Cosmetic A System for Breast Implant Selection Based on Patient Tissue Characteristics and Implant–Soft Tissue Dynamics John B. Tebbetts, M.D. Dallas, Texas

This system evolved from compiling and reviewing measurements and results from 330 primary breast augmentations from 1996 to 1999, including round and anatomic implant types with smooth shells and two different textured shells. The TEPID system was then used concurrently with the previous dimensional system for patient tissue evaluation and preoperative implant selection in 627 consecutive primary augmentation cases over a 3-year period from January of 1998 to January of 2001. Implant selection that did not comply with the parameters of the system was necessary in only eight cases. The TEPID system is a simple, efficient, and clinically practical method that allows surgeons to base implant selection on clinically quantifiable, individual patient tissue characteristics. (Plast. Reconstr. Surg. 109: 1396, 2002.)

Primary breast augmentation patients have widely varying characteristics of their breast envelope, parenchyma, and adjacent tissues. When preoperative breast implant selection does not specifically address critical soft-tissue parameters individual to each patient, risks of complications increase. Complications that occur from failure to reconcile a patient’s wishes for breast size with her individual tissue characteristics include skin stretch and thinning, ptosis, atrophy of parenchyma, implant edge or shell visibility, implant edge or shell palpability, visible traction rippling, “bottoming” deformities, and lateral implant displacement with widening of the intermammary distance. Previous dimensional systems address implant parenchyma base width relative to implant base width, but no published system adequately addresses or attempts to quantitate the third dimension, tissue stretch, that is critical to estimate amount of fill necessary in a wide range of breast and tissue types. This system addresses the tissue characteristics (T) of the envelope (E), the parenchyma (P), and the implant (I), and the dynamics (D) of implant and filler distribution that affect soft tissues. The acronym TEPID summarizes the key factors that determine aesthetic results and occurrence of problems and reoperations following breast augmentation. This simple, efficient, and clinically practical system focuses on only three tissue measurements to estimate implant volume required to fill each patient’s existing breast envelope, on the basis of her individual tissue characteristics: base width of the parenchyma, anterior pull skin stretch, and areola- and/or nipple-to-inframammaryfold distance measured under maximal stretch. The surgeon then adjusts initial volume to address differences in degree of skin stretch (anterior pull skin stretch) and contribution of the patient’s existing parenchyma to stretched envelope fill, and to address differences in implant dimensions and filler distribution dynamics. To base decisions of implant pocket location on quantifiable softtissue coverage thickness, the system measures soft-tissue pinch thickness of the upper pole and at the inframammary fold. Surgeon time required to measure, estimate, and make preoperative implant selection decisions is less than 5 minutes.

Breast implant interactions with patients’ tissues (implant–soft tissue dynamics) profoundly affect short- and long-term results in breast augmentation. Risks of complications such as skin thinning, subcutaneous tissue and parenchymal atrophy, ptosis, visible implant edges, increased implant palpability, visible traction rippling, and asymmetry relate directly and indirectly to implant–soft tissue dynamics. Rates of reoperation to remedy those complications1,2 evidence a need for implant selection guidelines that address patient tissue characteristics. Tissue characteristics (T) of the envelope (E), parenchyma (P), and implant (I), and the dimensions and fill distribution dynamics (D) of the implant are essential parameters that affect aesthetic results, compromises, complications, and reoperations. The acronym TEPID is useful to remember these five important considerations when selecting an implant

Received for publication July 5, 2001; revised September 4, 2001. Dr. Tebbetts is a consultant to and receives financial benefits from McGhan Medical Corporation, manufacturer of two of the types of breast implants mentioned in this article.

1396

Vol. 109, No. 4 /

1397

SYSTEM FOR BREAST IMPLANT SELECTION

on the basis of individual patient tissue characteristics and implant–soft tissue dynamics. More than 53 tissue and surgeon factors (Table I) can affect a breast augmentation result. No clinically practical system for implant selection can address all of these factors, and currently no practical methods exist to quantitate many of these factors. For a system of measurement and implant selection to be clinically practical, it must be simple and efficient, addressing key parameters to suggest a volume required to adequately fill the breast envelope that the surgeon can then modify according to additional clinical considerations and preferences. The three parameters that most affect required fill volume are the base width of the breast, the amount that the skin of the breast stretches anteriorly under stress, and the contribution of the existing breast parenchyma to optimal, stretched envelope fill. The TEPID system is based on these parameters, and includes additional parameters that quantitate the thickness of soft-tissue coverage over the

implant that can dramatically affect long-term results and occurrence of complications. A PREVIOUS DIMENSIONAL SYSTEM

In 1994, the author introduced a dimensional system of implant selection and operative planning to assist surgeons in selection and operative planning for anatomic implant products.3 Although this system has been used by a large number of surgeons worldwide for the past 7 years, it has three limitations: (1) it does not address each patient’s individual tissue stretch characteristics; (2) it prioritizes a patient’s desired aesthetic results (including width of the intermammary distance or cleavage) above long-term soft-tissue coverage considerations that affect complication and reoperation rates; and (3) it does not apply to a wide range of implant product types and shapes. In addition, some surgeons felt that the previous system was excessively complicated and involved an excessive number of measure-

TABLE I Tissue and Surgeon Factors Affecting Implant Soft-Tissue Dynamics, Aesthetic Results, and Implant Shape and Shell Characteristics Postoperatively

Clinical and Tissue Factors

Genetic factors Hormonal factors Pregnancy history Nursing history Age Medications (especially birth control pills and hormones) Skin thickness Skin compliance Breast parenchyma Amount Base width Height Consistency Attachments to pectoralis Attachments to serratus Attachments to deep subcutaneous fascia Capsule Thickness Compliance Degree of contracture Age of capsule Attachments to pectoralis Attachments to serratus Pectoralis major muscle Thickness Compliance Degree of contraction Degree of passive tension Size of periprosthetic pocket Shape of periprosthetic pocket Patient arm position Patient degree of pectoralis contraction (passive or active) Implant fill volume Air in implant

Surgeon Factors

Incision approach Parenchymal dissection Location Extent Pocket dissection method Pocket dissection technique Degree of tissue trauma Bleeding intraoperatively Blood remaining in tissues Blood remaining in pocket Pocket dimensions Pocket dissection plane—submammary or subpectoral Division of pectoralis origins Location Extent Method of implant fill Implant insertion method Implant positioning method Tissue closure method Postoperative bandaging methods Postoperative implant motion exercises Postoperative activity regimen Postoperative drug regimen

1398

PLASTIC AND RECONSTRUCTIVE SURGERY,

ments. The TEPID system addresses these limitations and considerations. TISSUE PARAMETERS

AND

FILL VOLUME

Characteristics of the tissue components of the breast—skin, subcutaneous tissue, breast parenchyma, and attachments of parenchyma to surrounding structures— differ significantly from patient to patient. Three quantifiable parameters are key to estimating optimal fill of a breast envelope for augmentation: (1) the base width of the existing breast parenchyma (or breast), (2) the degree of stretch that is present in the patient’s breast envelope, and (3) the amount of existing parenchyma and its contribution to stretched envelope fill. The degree to which the skin envelope of the breast stretches is one of the most important and most over-

April 1, 2002

looked of the parameters that determine the amount of fill required to adequately fill the skin envelope for an optimal augmentation result. Envelope stretch varies with genetic characteristics, age, pregnancy, nursing, hormonal factors, breast size, previous implant size (if applicable), and other factors. An envelope previously stretched by pregnancy, nursing, or a breast implant requires adequate volume to fill the stretched envelope to produce adequate upper fill. Inadequate fill results in a concave or flat upper breast. A tight, nulliparous envelope, in contrast, is usually much less compliant or “stretchy” compared with a multiparous envelope, and hence requires less volume for optimal fill of the envelope. When excessively large volumes are forced into a nulliparous or relatively noncompliant envelope to produce a specific result, mechanical forces stretch and thin the skin and subcutaneous tissue and apply pressure to parenchyma, subcutaneous tissue, and even the thoracic cage that can cause atrophy of these tissues over time. DEFINING OPTIMAL FILL

FIG. 1. Base width of the existing breast parenchyma. When measuring, be absolutely sure that breast tissue is underlying the tips of the calipers— err on the side of an excessively narrow measurement to best ensure adequate coverage over implant edges.

If optimal aesthetics and minimal risks and reoperations are priorities, optimal breast fill for augmentation is a volume (considering individual patient tissue characteristics) that produces adequate but not excessive upper pole fill to produce the desired aesthetic result without introducing excessive weight and implant– soft tissue dynamics factors that compromise tissues long-term. From a simplistic perspective, if a funnel were present in the upper

FIG. 2. (Left) Anterior pull skin stretch. Pull the periareolar skin to maximal stretch and mark with the index fingernail. (Right) Release the skin and caliper measure from the fingernail marker back to the original position of the periareolar skin.

Vol. 109, No. 4 /

1399

SYSTEM FOR BREAST IMPLANT SELECTION

FIG. 3. Soft-tissue pinch thickness of the upper pole quantitates the thickness of skin and subcutaneous tissue superior to the breast parenchyma. The surgeon isolates the breast parenchyma inferiorly and measures firm pinch thickness of skin and subcutaneous tissue only, avoiding incorporating pectoralis major muscle in the pinch.

breast, as fluid pours into the funnel to fill the envelope, the lower envelope fills first, then expands anteriorly until it reaches its “stretch limit.” The upper pole fills last, and the aesthetics of the upper pole are controlled by the amount of fill and the subsequent degree of stretch of the lower pole tissues. Inadequate fill results in a concave upper pole. An amount of fill that produces slight convexity of the upper pole usually results in a natural appearing yet full upper pole after skin stretch in the first 3 to 6 months postoperatively. Excessive fill produces more and longer term bulging of the upper breast desired by some patients, but inevitably adds additional weight that ultimately causes more lower pole stretch and subsequent

FIG. 4. Soft-tissue pinch thickness at the inframammary fold quantitates the thickness of skin and subcutaneous tissue at the inframammary fold. If this thickness is less than 0.4 cm, the surgeon can elect to add additional soft-tissue coverage by leaving pectoralis major muscle origins intact along the inframammary fold.

loss of upper fill, and risks traction rippling deformities. PRINCIPLES

ON

WHICH

THE

SYSTEM IS BASED

The following observations derived from a 21-year clinical experience in breast augmentation using every type of breast implant available during that time are the basis for this system: 1. Optimal soft-tissue coverage (both shortterm and long-term) is the highest priority to avoid compromises, complications, and reoperations. Optimal long-term soft-tissue coverage considerations should always take priority over any other aesthetic considerations. 2. Optimal aesthetic results require adequate but not excessive fill of each patient’s breast envelope, individualized according to genetic tissue characteristics, history of previous envelope stretch, current stretch characteristics of the envelope, and projected future stretch characteristics. 3. Inadequate fill of any patient’s envelope will result in less fill of the upper breast. 4. Excessive fill of any patient’s envelope will produce excessive fullness or bulging of the upper breast that may or may not decrease over time, depending on patient tissue characteristics, implant size and characteristics, capsule characteristics, and many additional factors. Any volume greater than the volume required to opti-

1400

PLASTIC AND RECONSTRUCTIVE SURGERY,

April 1, 2002

FIG. 5. Nipple-to-inframammary-fold distance measured under maximal stretch. Marker dots at the nipple and inframammary fold increase the accuracy of the measurement. Hold the tip of a tape measure at the nipple, stretch the nipple and lower pole skin superiorly under maximal stretch, and measure the distance between the dots. The same method measures the areola-toinframammary-fold distance.

added, the greater and more rapid the stretch, other factors being equal. 6. The breast envelope is three-dimensional, and the critical parameters for estimating the volume required for optimal fill are base width of the existing parenchyma (and envelope), the degree of anterior stretch of the existing envelope, and the contribution of the existing parenchyma to the optimal fill volume for that envelope.

mally fill the upper breast for a natural appearance adds excess weight to the breast and increases the amount of tissue stretch and thinning that will occur in the lower breast envelope over time. 5. Regardless of the volume or type of implant placed in the breast, upper fill will decrease over time as the lower pole envelope stretches (in the absence of capsular contracture). The larger the volume

TABLE II Tissue Parameters and Implant Selection Form from Patient Chart*

Clinical Breast Measurements L/R (cm)

Base width

APSSMaxStr STPTUP STPTIMF A/N:IMFMaxStr PCSEF% IDFDD Patient request Total estimated implant volume, estimating the optimal level of the inframammary fold relative to the nipple If total estimated volume above is: Set new IMF at:† A:IMF distance (cm) N:IMF distance (cm)

Estimating Desired Breast Implant Volume Based on Breast Measurements and Tissue Characteristics

Base width parenchyma (cm) Estimated initial implant volume (cc) If APSS ⬍ 2.0, ⫺30 cc If APSS ⬎ 3.0, ⫹30 cc If APSS ⬎ 4.0, ⫹60 cc If N:IMF ⬎ 9.5, ⫹30 cc If PCSEF ⬍ 20%, ⫹30 cc If PCSEF ⬎ 80%, ⫺30 cc

10.5

11.0

11.5

12.0

12.5

13.0

13.5

14.0

14.5

15.0

200

250

275

300

300

325

350

375

375

400

200

250

275

300

325

350

375

400

5.0 7.0

5.0 7.0

5.5 7.5

6 8

6 8

6.5 8.5

7.0 9.0

7 9.5

* The TEPID System, copyright 2001, John B. Tebbetts, M.D. APSS, anterior pull skin stretch; MaxStr, maximum stretch; STPTUP, soft-tissue pinch thickness of the upper pole; STPTIMF, soft-tissue pinch thickness at the inframammary fold; A/N:IMFMaxStr, distance from areola and/or nipple to inframammary fold measured under maximal stretch; PCSEF%, parenchyma contribution to stretched envelope fill percent; IDFDD, implant dimensions and filler distribution dynamics; IMF, inframammary fold. † Either of the two listed alternatives, measured under maximal stretch.

Vol. 109, No. 4 /

1401

SYSTEM FOR BREAST IMPLANT SELECTION

TABLE III Tissue Measurements and Implant Selection for the Patient in Case 1*

Clinical Breast Measurements L/R (cm)

Base width

APSSMaxStr STPTUP STPTIMF A/N:IMFMaxStr PCSEF%

12.0

1.5 1.2 1.3 4.5/6.5 70%

Estimating Desired Breast Implant Volume Based on Breast Measurements and Tissue Characteristics

Base width parenchyma (cm) Estimated initial implant volume (cc) If APSS ⬍ 2.0, ⫺30 cc If APSS ⬎ 3.0, ⫹30 cc If APSS ⬎ 4.0, ⫹60 cc If N:IMF ⬎ 9.5, ⫹30 cc If PCSEF ⬍ 20%, ⫹30 cc If PCSEF ⬎ 80%, ⫺30 cc

IDFDD Patient request Total estimated implant volume, estimating the optimal level of the inframammary fold relative to the nipple If total estimated volume above is: Set new IMF at:† A:IMF distance (cm) N:IMF distance (cm)

10.5

11.0

11.5

12.0

12.5

13.0

13.5

14.0

200

250

275

300

300

325

350

375

⫺30

270

200

250

275

300

325

350

375

5.0 7.0

5.0 7.0

5.5 7.5

6 8

6 8

6.5 8.5

7.0 9.0

* The TEPID System, copyright 2001, John B. Tebbetts, M.D. For definition of abbreviations, see Table II. Implant selected: Mentor Siltex Round; volume: 275⫹25/275 cc; base width: 12.3 cm. † Either of the two alternatives listed, measured under maximal stretch.

7. Implant design, shell characteristics, fill volumes, and filler-shell interactions and dynamics affect implant–soft tissue dynamics and the ultimate shape of the implant and distribution of filler within the breast. 8. When the base width of the implant selected exceeds the base width of the patient’s existing breast parenchyma (depending on im-

plant shape, shell characteristics, fill, and dynamics), the patient should be informed and accept that edges of the implant may be covered only by skin and subcutaneous tissue, increasing risks of edge visibility, palpability, and traction rippling. 9. A clinically practical system for implant selection should address all currently available

FIG. 6. Preoperative and 6-month postoperative views of the patient in case 1.

1402

PLASTIC AND RECONSTRUCTIVE SURGERY,

April 1, 2002

TABLE IV Tissue Measurements and Implant Selection for the Patient in Case 2*

Clinical Breast Measurements L/R (cm)

Base width

APSSMaxStr STPTUP STPTIMF A/N:IMFMaxStr PCSEF%

15

3.8 1.3 0.8 7/10 40%

Estimating Desired Breast Implant Volume Based on Breast Measurements and Tissue Characteristics

Base width parenchyma (cm) Estimated initial implant volume (cc) If APSS ⬍ 2.0, ⫺30 cc If APSS ⬎ 3.0, ⫹30 cc If APSS ⬎ 4.0, ⫹60 cc If N:IMF ⬎ 9.5, ⫹30 cc If PCSEF ⬍ 20%, ⫹30 cc If PCSEF ⬎ 80%, ⫺30 cc

IDFDD Patient request Total estimated implant volume, estimating the optimal level of the inframammary fold relative to the nipple If total estimated volume above is: Set new IMF at:† A:IMF distance (cm) N:IMF distance (cm)

11.5

12.0

12.5

13.0

13.5

14.0

14.5

15.0

275

300

300

325

350

375

375

400 ⫹30

430

275

300

325

350

375

400

5.5 7.5

6 8

6 8

6.5 8.5

7.0 9.0

7 9.5

* The TEPID System, copyright 2001, John B. Tebbetts, M.D. For definition of abbreviations, see Table II. Implant selected: Mentor Round Smooth; volume: 425 ⫹50/450 cc; base width: 14.2 cm. † Either of the two alternatives listed, measured under maximal stretch.

implant shapes, shell characteristics, and filler materials. Addressing individual characteristics of specific implant devices requires additional surgeon expertise and knowledge of implant–soft tissue dynamics. 10. To be clinically practical, any system of patient measurements and applying those measurements to implant selection must be reproducible and efficient, requiring no more than 5 minutes to complete the entire measurement and implant selection process. Some surgeons may feel that a system that requires less than 5 minutes is excessively complex. 11. Current designs of round, saline implants filled to current manufacturers’ recommended fill ranges have similar fill distribution dynamics to current and previous round, silicone gel–filled implants. The upper pole of all of the above-mentioned implants collapses somewhat when the implant is upright because of the degree of filler volume relative to the mandrel volume of the implant. 12. Current designs of full height anatomic implants, McGhan Styles 468 saline-filled implants filled within manufacturer’s recommended range and full and reduced height 410 cohesive gel-filled implants, are intended to eliminate upper shell collapse or shell folding with the implant upright.

The fill volume of the Style 468 saline implant is a higher percentage of mandrel volume compared with the Style 410 to prevent upper shell collapse with a noncohesive filler; hence, the two implants differ from each other and from other implants in their dimensions and filler distribution dynamics. MEASUREMENTS

AND

METHODS

This simple system requires only five clinical measurements and a total surgeon time of less than 5 minutes to estimate desired implant volume: (1) base width of the existing breast parenchyma, (2) anterior pull skin stretch, (3) soft-tissue pinch thickness of the upper pole, (4) soft-tissue pinch thickness at the inframammary fold, and (5) nipple-to-inframammaryfold distance under maximal stretch. The surgeon must also estimate the existing parenchyma’s contribution to stretched envelope fill as a percent of final desired volume, and consider implant dimensions and filler distribution and dynamics for the implant selected. To measure base width (Fig. 1), view the breast from anteriorly and, using calipers, measure the width of the breast parenchyma from a point medially where the breast mound begins its upward slope to the lateral border of the breast. This is a linear measurement, not a measurement over a curve. The purpose of this

Vol. 109, No. 4 /

1403

SYSTEM FOR BREAST IMPLANT SELECTION

FIG. 7. Preoperative and 13-month postoperative views of the patient in case 2.

measurement is to estimate breast parenchymal width available to cover the implant. The width of the breast parenchyma is slightly less than the width of the visible breast mound viewed anteriorly because of the thickness of subcutaneous tissue overlying the parenchyma medially and laterally. It is preferable to have the parenchyma base width measurement 0.5 cm too narrow rather than 0.5 cm too wide to best ensure adequate coverage of implant edges medially and laterally when selecting implant width or volume. To measure anterior pull skin stretch (Fig. 2), grasp the areolar skin medially and stretch it maximally anteriorly. Holding a fingernail at that anterior location, release the skin and caliper measure from the fingernail back to the skin of the unstretched areola. To measure soft-tissue pinch thickness of the upper pole (Fig. 3), isolating the breast parenchyma inferiorly, pinch firmly and caliper measure the thickness of skin and subcutaneous tissue superior to the breast parenchyma. Similarly, pinch firmly to measure soft-tissue pinch thickness at the inframammary fold (Fig. 4). Measure the preoperative nipple-to-inframammary-fold distance under maximal stretch (Fig. 5) by placing a dot at the existing inframammary fold and at the middle of the nipple on its medial border. Place the tip of a flexible tape measure exactly on the nipple dot, lift, stretch the lower pole skin maximally upward,

and measure to the dot at the inframammary fold. If desired, repeat the measurement from a dot at the lower areolar border to measure areola-to-inframammary-fold distance under maximal stretch. ESTIMATING PERCENT FILL OF THE STRETCHED ENVELOPE BY THE EXISTING PARENCHYMA

Parenchyma contribution to stretched envelope fill is an estimate of the percent of the stretched envelope that will be filled by the existing breast parenchyma. The surgeon can simultaneously demonstrate approximate breast size to the patient while estimating the parenchyma contribution to stretched envelope fill. After measuring anterior pull skin stretch by maximally stretching the skin anteriorly, the surgeon can cup the fingers around the lower pole of the existing breast, anterior to the skin an amount equal to the anterior pull skin stretch. This visual aid helps the patient visualize the fill of the lower breast that approximates their individual degree of tissue stretch. Holding a fingernail at the nipple position anterior to the existing nipple by an amount equal to anterior pull skin stretch, the surgeon can demonstrate approximate upper fill by holding a pen or other straight-edge object connecting the new nipple position with the chest wall superiorly. Finally, the surgeon envisions the stretched envelope size demonstrated to the patient by these maneuvers, and

1404

PLASTIC AND RECONSTRUCTIVE SURGERY,

April 1, 2002

TABLE V Tissue Measurements and Implant Selection for the Patient in Case 3*

Clinical Breast Measurements L/R (cm)

Base width

APSSMaxStr STPTUP STPTIMF A/N:IMFMaxStr PCSEF%

Estimating Desired Breast Implant Volume Based on Breast Measurements and Tissue Characteristics

11.5

2.2 1.2 0.7 4.5/6R 5/7L 70%

IDFDD

Base width parenchyma (cm) Estimated initial implant volume (cc) If APSS ⬍ 2.0, ⫺30 cc If APSS ⬎ 3.0, ⫹30 cc If APSS ⬎ 4.0, ⫹60 cc If N:IMF ⬎ 9.5, ⫹30 cc

10.5

11.0

11.5

12.0

12.5

13.0

13.5

14.0

200

250

275

300

300

325

350

375

If PCSEF ⬍ 20%, ⫹30 cc If PCSEF ⬎ 80%, ⫺30 cc Noncohesive filler, full height implant, no upper shell collapse upright

Patient request Total estimated implant volume, estimating the optimal level of the inframammary fold relative to the nipple If total estimated volume above is: Set new IMF at:† A:IMF distance (cm) N:IMF distance (cm)

⫺30

245

200

250

275

300

325

350

375

5.0 7.0

5.0 7.0

5.5 7.5

6 8

6 8

6.5 8.5

7.0 9.0

* The TEPID System, copyright 2001, John B. Tebbetts, M.D. For definition of abbreviations, see Table II. Implant selected: McGhan Style 468 Textured Anatomic; volume: 230 –240/240 cc; base width: 10.5 cm. † Either of the two listed alternatives, measured under maximal stretch.

the parenchyma contribution to stretched envelope fill is the approximate percentage of that stretched envelope that is filled by the patient’s existing parenchyma. This estimate is only pertinent if the percent fill is less than 20 percent (almost no breast parenchyma) or more than 80 percent (envelope stretches minimally and is already almost completely full of parenchyma evidenced by a full upper breast in lateral and oblique views). The surgeon records pertinent breast measurements on a form similar to that shown in Table II while examining the patient; the surgeon then uses this form to estimate desired implant volume for the patient’s tissue characteristics. The entire process of measuring and defining desired implant volume requires less than 5 minutes. DETERMINING IMPLANT VOLUME COVERAGE

AND

SOFT-TISSUE

The surgeon next uses Table I in the following manner to estimate desired implant volume: 1. Locate the patient’s parenchyma base width in the top row of the table. The initial estimated volume of the implant

based on the width of the breast is listed in the cell immediately below. Modify this initial volume according to tissue stretch parameters below. 2. If anterior pull skin stretch is less than 2.0 cm, subtract 30 cc from the initial volume indicated (very tight envelope). If anterior pull skin stretch is greater than 3.0 cm, add 30 cc to the initial volume indicated (moderately compliant envelope). If anterior pull skin stretch is greater than 4.0 cm, add 60 cc to the initial volume indicated (markedly compliant envelope). 3. If nipple-to-inframammary-fold distance under maximal stretch is greater than 9.5 cm (measured under maximal stretch), add an additional 30 cc to the initial volume indicated (an indicator of marked amount of skin in the lower breast envelope, e.g., in a markedly glandular ptotic breast, requiring additional fill volume). 4. If the parenchyma contribution to stretched envelope fill is less than 20 percent, add 30 cc to volume indicated (virtually no breast parenchyma present preoperatively). If the parenchyma contribution to stretched envelope fill is greater than 80

Vol. 109, No. 4 /

1405

SYSTEM FOR BREAST IMPLANT SELECTION

FIG. 8. Preoperative and 12-month postoperative views of the patient in case 3.

percent, subtract 30 cc from volume indicated (envelope already filled with parenchyma preoperatively). 5. Implant dimensions and filler distribution dynamics is a variable volume that the surgeon can add or subtract to compensate for specific implant dimensions and filler distribution dynamics for different implant shapes and filler materials. For example, if any implant is filled with a noncohesive filler adequately to prevent upper shell collapse with the implant supported upright, subtract 30 cc from the initial estimated fill volume because that implant will maintain more upper fill in the breast with less volume. Failure to address this specific filler distribution dynamic can result in an excessively full upper breast. Each specific style, size, and model of implant has specific dimensions and filler distribution dynamics that vary according to implant dimensions (size), filler characteristics, shell characteristics, shell-filler interactions, shell shape, and other factors. A detailed discussion is beyond the scope of this article and will be addressed in future communications. 6. Add or subtract indicated volumes to or from the initial suggested volume to calculate total estimated implant volume. 7. Modify total estimated implant volume according to special patient requests and sur-

geon-identified factors and confirm in informed consent documents. 8. To determine optimal level of the inframammary fold relative to the nipple, calculate the final estimated implant volume. In the row beneath, locate that volume, and in the column directly beneath it is the desired new areola- or nipple-to-inframammary-fold distance under maximal stretch for that base width implant. If the preoperative areola- or nipple-to-inframammaryfold distance under maximal stretch is as long or longer than the measurement listed for new desired areola- or nipple-toinframammary fold-distance under maximal stretch, use the preoperative measurement and leave the inframammary fold located in its preoperative position. If the preoperative areola- or nipple-to-inframammary-fold distance under maximal stretch is shorter than the distances listed in Table I, mark the desired areola- or nipple-to-inframammary-fold distance under maximal stretch fold beneath the existing fold, always measuring under maximal tension. Then, draw in the desired new fold beneath the preexisting fold, adjusting fold configuration as necessary to optimize fold shape. Either nipple- or areola-toinframammary-fold distance under maximal stretch is appropriate and accurate, except in unusual cases with dispropor-

1406

PLASTIC AND RECONSTRUCTIVE SURGERY,

April 1, 2002

TABLE VI Tissue Measurements and Implant Selection for the Patient in Case 4*

Clinical Breast Measurements L/R (cm)

Base width

14.0

APSSMaxStr STPTUP STPTIMF A/N:IMFMaxStr PCSEF%

4.3 1.8 1.0 7/9 30%

IDFDD

Estimating Desired Breast Implant Volume Based on Breast Measurements and Tissue Characteristics

Base width parenchyma (cm) 11.5 Estimated initial implant volume (cc) 275 If APSS ⬍ 2.0, ⫺30 cc If APSS ⬎ 3.0, ⫹30 cc If APSS ⬎ 4.0, ⫹60 cc If N:IMF ⬎ 9.5, ⫹30 cc If PCSEF ⬍ 20%, ⫹30 cc If PCSEF ⬎ 80%, ⫺30 cc Noncohesive filler, full height implant, no upper shell collapse upright

Patient request Total estimated implant volume, estimating the optimal level of the inframammary fold relative to the nipple If total estimated volume above is: Set new IMF at:† A:IMF distance (cm) N:IMF distance (cm)

12.0 300

12.5 300

13.0 325

13.5 350

14.0 375

14.5 375

15.0 400 ⫹60

⫺30

405

275

300

325

350

375

400

5.5 7.5

6 8

6 8

6.5 8.5

7.0 9.0

7 9.5

* The TEPID System, copyright 2001, John B. Tebbetts, M.D. For definition of abbreviations, see Table II. Implant selected: McGhan Style 468; volume: 380 – 400/400 cc; base width: 12.5 cm. † Either of the two listed alternatives, measured under maximal stretch.

tionately large areolas in which nipple-toinframammary-fold distance under maximal stretch is a more appropriate measurement. 9. Adjust final areola- or nipple-to-inframammary-fold distance under maximal stretch measurements according to any mitigating clinical parameters and dynamic tissue factors affecting the implant and implant type. For example, if pectoralis major origins are left intact along the inframammary fold in a subpectoral augmentation, additional pressure of the muscle often prevents the lower edge of the implant from resting at the most inferior aspect of the pocket. In these cases, the surgeon may need to lower the fold an additional 0.5 to 1.0 cm to compensate, depending on the projection and shell surface characteristics of the implant. 10. If soft-tissue pinch thickness of the upper pole is less than 2 cm pinch thickness of skin and subcutaneous tissue superior to the breast parenchyma in the upper pole, consider placing the implant partially subpectorally or dual plane to optimize softtissue coverage4 superiorly. 11. If soft-tissue pinch thickness at the inframammary fold is less than 0.4 mm, consider leaving inferior origins of the pectoralis major muscle intact along the

inframammary fold and lowering the pocket an additional 0.5 cm to compensate for the additional pressure of the muscle on the implant lower4 pole. CLINICAL EXPERIENCE

This system evolved from compiling and reviewing measurements and results from 330 primary breast augmentations from 1996 to 1999, including round and anatomic implant types with smooth shells and two different textured shells. The TEPID system was then used concurrently with the previous dimensional system for patient tissue evaluation and preoperative implant selection in 627 consecutive primary augmentation cases over a 3-year period from January of 1998 to January of 2001.5,6 Implant selection that did not comply with the parameters of the system was necessary in only eight cases. Three of these cases had breast base width greater than 15 cm, and five cases involved very narrow breasts with a base width of less than 10.5 cm, including constricted lower pole and tubular breasts. CASE EXAMPLES

The following case examples illustrate the use of the system within patients with widely varying tissue component characteristics and with round and anatomic implants.

Vol. 109, No. 4 /

1407

SYSTEM FOR BREAST IMPLANT SELECTION

FIG. 9. Preoperative and 8-month postoperative views of the patient in case 4.

Case 1 This patient is 28 years old, gravida 1 para 1, 6 feet 0 inches tall, with a medium frame, who was A cup before pregnancy, enlarged maximally to B cup, currently wears 34 B cup bra, requests augmentation to 34 C/D cup, and requests round, textured surface saline-filled breast implants. The breasts have an extremely tight skin envelope despite the patient’s previous pregnancy. Tissue measurements and implant selection are listed in Table III, and the patient’s preoperative and 6-month postoperative photographs are included in Figure 6.

Case 2 This patient is 40 years old, gravida 3 para 2, 5 feet 3 inches tall, with a medium frame, who was C cup before pregnancy, enlarged maximally to DD cup, currently wears a 34 C cup bra, requests augmentation to 34 D/DD cup to adequately refill her envelope, and requested round, smooth surface saline-filled breast implants. The breasts are extremely wide and have an extremely loose and markedly stretchable skin envelope. Tissue measurements and implant selection are listed in Table IV, and the patient’s preoperative and 6-month postoperative photographs are included in Figure 7. The tissue dimensions, stretch characteristics, and implant fill dynamics of her desired implant mandated a large implant for adequate fill of the existing envelope to achieve adequate upper pole fill. Because of the size of the implant required, the patient signed detailed preoperative informed consent documents of the potential stretch effects and necessity of future surgery resulting from this size implant.

Case 3 This patient is 28 years old, gravida 1 para 1, 5 feet 7 inches tall, with a small frame, who currently wears a 34 AA-A cup bra, who requests augmentation to 34 B/C cup and requests anatomic, textured surface saline-filled breast implants. The breasts have an extremely tight skin envelope despite the patient’s previous pregnancy. Tissue measurements and im-

plant selection are listed in Table V, and the patient’s preoperative and 6-month postoperative photographs are included in Figure 8.

Case 4 This patient is 37 years old, gravida 4 para 2, 5 feet 4 inches tall, with a medium frame, who was B cup before pregnancy, enlarged maximally to D cup, currently wears a 34 C cup bra, requests augmentation to 34 D/DD cup, and requests anatomic, textured surface saline-filled breast implants. The breasts have an extremely loose and markedly stretchable skin envelope. Tissue measurements and implant selection are listed in Table VI, and the patient’s preoperative and 6-month postoperative photographs are included in Figure 9. The tissue dimensions, stretch characteristics, and implant fill dynamics of her desired implant mandated a large implant for adequate fill of the existing envelope to achieve adequate upper pole fill. The implant she desired is filled with a noncohesive filler, but the manufacturers’ recommended fill volume is adequate to prevent upper shell collapse and folding when the implant is upright; hence, 30 cc was subtracted from initial estimated volume required. Because of the size of the implant required to adequately fill the envelope, the patient signed detailed preoperative informed consent documents of the potential stretch effects and necessity of future surgery resulting from this size.

RESULTS

In 627 consecutive primary breast augmentation cases, the TEPID system of tissue evaluation and implant selection proved reliable and extremely beneficial to preoperative evaluation and implant selection on the basis of the following data: total cases in which more than one implant size was ordered (six); cases in which implant sizers were required intraop-

1408

PLASTIC AND RECONSTRUCTIVE SURGERY,

eratively (zero); cases in which implant size change was required intraoperatively (two); reoperations required for size change during the 3 years of the study (two); and cases in which the surgeon overruled the recommendations of the system (eight). DISCUSSION

This system for estimating desired implant volume and assessing adequacy of soft-tissue coverage is designed to be clinically practical, efficient, and cost effective, so that any surgeon who has access to a tape measure (enhanced by a caliper, which is not absolutely necessary) can use it. This report does not scientifically document the superiority of this system over other systems, but the author is unaware of any other published systems that attempt to quantitatively address soft-tissue stretch and soft-tissue thickness, both critical factors in optimal preoperative decision-making and planning in primary breast augmentation. The measurements in the system may vary slightly with different surgeons’ measuring techniques, but rapidly become consistent, predictable, and reproducible. Each surgeon can adjust specific volumes added or subtracted for the tissue variables on the basis of personal experience and personal measuring methods. The most important goal of the system is to address the most critical tissue factors that vary from patient to patient and that affect long-term outcomes, requiring only three measurements to estimate desired implant volume, and two measurements to address soft-tissue coverage of the implant. Once familiar with the system, any surgeon can complete all measurements and preoperative decisions in less than 5 minutes. Implant–soft tissue dynamics are a major determinant of long-term results, complications, and reoperation rates. Implant selection should be derived from more than a patient’s subjective desires regarding cup size or by inserting various devices into test bras. Neither of these methods addresses any of the variables inherent to the patient’s tissue characteristics, variables that are critical to the accuracy and predictability of results and occurrence of complications necessitating reoperation. Surgeons cannot accurately and scientifically evaluate any surgical technique or implant without addressing the tissue variables of the environment in which the device or technique is used. The very basic variables addressed in this system will undoubtedly expand

April 1, 2002

in the future and become more accurate as surgeons develop clinically practical and costeffective technologies for quantitating tissue characteristics. Limitations of the system include wide base width breasts (⬎15 cm) and exceedingly narrow base width breasts (⬍10.5 cm), including tubular breasts and some severely constricted lower pole breasts. In these specific types of breasts, the surgeon must incorporate parameters in addition to those included in this system when selecting the appropriate implant. This system functions well for selecting round or anatomic implants with smooth or textured shells in a wide range of breast types. The system provides basic guidelines and parameters—a first step toward a greater clinical understanding and application of the many tissue factors that affect results. No system can supplant surgeon judgment and experience. The TEPID system is designed to provide a framework and basic methods to attempt to quantitate tissue coverage over an implant, estimate volume needs on the basis of base width of the existing parenchyma and envelope stretch characteristics, and provide guidelines for setting nipple-to-inframammary-fold distance. The system also provides an excellent framework for review, discussion, and analysis of case results, taking into account individual patient tissue characteristics, and provides quantifiable guidelines for adequate tissue coverage superiorly and at the inframammary fold. The effects of various implant devices long-term cannot be credibly discussed or scientifically reported without addressing patient tissue characteristics quantitatively. Future systems need to address as many of the factors listed in Table I as possible if we are to truly understand and apply implant–soft tissue dynamics to the selection of techniques and implants that benefit patients. John B. Tebbetts, M.D. 2801 Lemmon Avenue West Suite 300 Dallas, Texas 75204 [email protected] REFERENCES 1. Mentor Corporation. Saline-Filled Breast Implant Surgery: Making an Informed Decision. Santa Barbara: Mentor Corporation, 2000. Pp. 11–19. 2. McGhan Medical Corporation. Saline-Filled Breast Implant Surgery: Making an Informed Decision. Santa Barbara: McGhan Medical Corporation, 2000. Pp. 10 – 18.

Vol. 109, No. 4 /

SYSTEM FOR BREAST IMPLANT SELECTION

3. Tebbetts, J. B. Dimensional Augmentation Mammaplasty Using the BioDimensional System. Santa Barbara: McGhan Medical Corporation, 1994. Pp. 1–90. 4. Tebbetts, J. B. Dual plane breast augmentation: Optimizing implant-soft tissue relationships in a wide range of breast types. Plast. Reconstr. Surg. 107: 1255, 2001. 5. Tebbetts, J. B. Achieving a predictable 24-hour return

1409 to normal activities following breast augmentation: Refining practices using motion and time study principles. Part I. Plast. Reconstr. Surg. 109: 273, 2002. 6. Tebbetts, J. B. Achieving a predictable 24-hour return to normal activities following breast augmentation: Patient preparation, refined surgical techniques and instrumentation. Part II. Plast. Reconstr. Surg. 109: 293, 2002.