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re-operation rates during 3 years in the Federal DrugAdministration multiple pre-market approval (PMA)studies have been 15% to 20% and reflected thisunscientific/arbitrary approach. Recent advances intissue-based planning have demonstrated not only asimplified method of planning but also one thatmatches implants to patient’s tissues and breastdimensions and has produced much lower re-opera-tion rates. The most recently described tissue-basedplanning system is the High Five™ process (Tebbetts& Adams, 2005). The High Five process was devel-oped more than 15 years ago and this third-generationsystem codified the five most important decisionssurgeons make during the pre-operative planningphase that affect patient outcomes.

Accurate planning is not unique to breast aug-mentation but is relevant in all professions andresults in a degree of success with examples includ-ing business ventures or sporting endeavors. Sur-geons often ask, “How do I pick the implant?”“What implant gives the best results?” and “Whatimplant do patients like best?” The truth is that it isnot about the implant, but rather the process(described above). In fact, in a recent FDA implantPMA hearing, although the devices were discussed,the next most visible concerns were regarding com-plications in patient re-operation rates.

The bottom line is about “wishes versus tissues,”or in other words, patients wish they looked like thisactress or this model on the cover of a magazine, orwish they had breasts the same size as their friend,which may be a totally different body type; however,what really matters is their tissues, and to assessthese objectively and to match the implant to the tis-sues specifically. The process of breast augmentationholds true for all implant types. It determines the re-operation rates, the patient’s experience and recov-ery, and ultimately the growth of one’s practice inbreast augmentation.

Despite popularity, breast augmentation has notadvanced significantly in 20 years. The re-operation

data for breast augmentation has been excessive at 15%to 20% in every Federal Drug Administration pre-marketapproval study for the past 15 years. Recently, a more sci-entific approach to breast augmentation has described atrue process approach to this procedure. One element, tis-sue-based pre-operative planning, has been shown toreduce re-operation rate to less than 3% in publishedpeer-reviewed studies. The High Five™ process was pub-lished in 2005 and codifies the 5 most important pre-operative decisions made during a breast augmentationprocedure. Application into clinical practice of this plan-ning system is discussed.

Breast augmentation has recently been reported tobe the most common surgical procedure in plasticsurgery (American Society for Aesthetic PlasticSurgery, 2007). Within the past 5 years, the disci-pline of breast augmentation has been recognizednot as a surgical procedure but as an actual processthat involves four subprocesses (Adams, 2007):

1. Patient education2. Tissue-based pre-operative planning3. Refine surgical technique4. Define post-operative care

Tissue-based pre-operative planning is essential toobtain reproducible results in breast augmentationwhile minimizing the re-operation rate. Althoughhistorically surgeons have subjectively performed pre-operative planning in the past 15 years, the

The High Five™ Process: Tissue-BasedPlanning for Breast AugmentationWilliam P. Adams Jr., MD

William P. Adams Jr., MD, is in private practice in plastic surgeryin Dallas, Texas. He also serves as an Associate Clinical Professorof Plastic Surgery at the University of Texas Southwestern MedicalCenter in Dallas, Texas.Address correspondence to William P. Adams Jr., MD, 2801 LemmonAve West, Suite 300, Dallas, TX 75204 (e-mail: BA@dr-adams.com).

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prioritized the desired result of the patient or sur-geon over the tissue. The TEPID system was prima-rily a tool to determine tissue-based implant volume.In the current third-generation High Five process,the five critical pre-operative decisions that deter-mine outcomes were codified and put into a simpleeasy-to-follow process for patient assessment thatcan be performed in less than 5 minutes.

THE HIGH FIVE PROCESS: HOW IT WORKSIN CLINICAL PRACTICE

The five critical decisions in the High Five processinclude:

1. Implant coverage/pocket planning2. Implant size/volume

The concepts of tissue-based planning are wellestablished in the plastic surgery literature. In pub-lished and peer-reviewed series, as well as nationalpresentations in the last 2 years, there are more than2,500 primary breast augmentation procedures(Bengtson, 2005; Jewell, 2005; Tebbetts & Adams,2005) performed with similar concepts in tissue-based pre-operative planning, with re-operation ratesof less than 3% with 6–7 years follow-up, in com-parison with the re-operation rate of 15% to 20% in3 years in all the PMA studies in the past 15 years.

The immediate predecessor to the High Fiveprocess was a tissue-based planning system devel-oped by Tebbetts (Tebbetts, 2002). This was the firsttissue-based system of its kind, as it prioritized thetissues of the patient as the most important factor.This is contrary to previous generation systems that

Figure 1. High Five planning sheet.

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3. Implant type4. Infra-mammary fold (IMF) position5. Incision

For purposes of simplicity, all of the details ofthe High Five process are not reviewed in thisoverview; however, the basics are described. TheHigh Five process has been found to be safe andsimple. It leaves the control totally up to the sur-geon and gets the surgeon “on base.” The process isapplicable to all implant types including gel, highlycohesive form-stable gel, and saline implants. It iseffective and proven as described above, and, mostimportantly, it is transferable, meaning that sur-geons, residents, patient coordinators, and evenpatients have successfully used this system toobjectively select implants appropriately for a givenpatient’s breasts.

All the details may be found in Tebbetts andAdams (2005). However, there are four primarymeasurements:

1. Pinch thickness in the superior pole of the breast.2. Base width.3. Skin stretch.4. Nipple to IMF on stretch.

The High Five tissue analysis and operative plan-ning sheet can be used to summarize the findings ofthe measurements and to make decisions (Figure 1).

Case Example

This 31 year-old woman desires breast augmentation.Her critical measurements are shown in Figure 2.

Coverage. This is the most important decisionbecause it is very difficult to correct the outcomes ofan inadequate implant coverage. This decision is pri-marily based on the pinch thickness in the upper pole.If pinch thickness is less than 2 cm, a subpectoral ordual plane-type pocket plan is advisable to maintainadequate coverage over the implant, particularly in thelong term. If the pinch thickness in the upper pole ismore than 2 cm, preferably more than 2.5–3.0 cm, asubglandular pocket plane may be considered. How-ever, it is in the author’s practice to generally placemost implants under the muscle given the trade-offs ofthe subglandular versus the subpectoral position(Figure 3).

Implant volume. Implant volume is determined bythe High Five nomogram, which is provided in thesystem. The base width is measured as demonstrat-ed in the planning sheet. There is an initial implantvolume associated with a given base width. Next,adjustments of the implant volume are made on thebasis of the skin stretch and the amount ofparenchyma present. Adjustments may also be madeon the basis of patient requests, whether a patient isasking for larger or smaller size breast. These valuesare totaled and a net estimated volume to optimallyfill the given breast envelope is obtained (Figure 4).

Implant type. The implant type is selected on thebasis of patient’s request and surgeon’s recommen-dation. The implant volume discussed in the previ-ous section is used as a reference. The implant specsheets may be reviewed and the patient’s base widthis selected on the basis of an implant that is similaror slightly less in width in comparison with thepatient’s base width of similar volume as calculatedin Step 2 (Figure 5).

Selection of the optimal IMF position. This is cal-culated on the basis of some consistent relation-ships between the width of the breast and the nip-ple-to-fold length. It is important to know where theIMF will be placed post-operatively. When using theIMF incision, this information allows the surgeon to

Figure 3. The superior pole pinch (SPP) is 2.5. A dual plane 1 is selected.

Figure 2. Anteroposterior (AP) view of patient. Measure-ments: superior pole pinch (SPP) � 2.5; base width (BW) �12.5; skin stretch (SS) � 1.5; and nipple-to-infra-mammaryfold (N:IMF) ratio � 6.5.

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sion is the least important of all five and is againbased on patient’s request, surgeon’s recommenda-tion, and surgeon’s skills set (Figures 7 and 8).

Using this system, all important pre-operativedecisions may be made in approximately 5 minutes,allowing the surgeon to very reproducibly match theimplant to the given patient’s breast tissues anddimensions. This allows for several important

place the incision directly in the post-operative IMF.The High Five system provides these relationshipsand can simply be followed on the basis of themeasurements. The details can be found in Tebbettsand Adams (2005) (Figure 6).

Incision. The final decision is the incision.Although this is frequently talked about, the inci-

Figure 4. Base width (BW) is 12.5 for an initial implant volume of 300 ml. A reduction of 30 ml is done for a tight breastenvelope, indicated by a skin stretch (SS) of less than 2 (1.5 in this case). The total represents the optimal fill volumefor that individual breast tissue type.

Figure 5. The desired volume (Step 2) is 270 ml. The implant specification sheets are reviewed. The patient desired around silicone gel implant. The Inamed/Allergan Style 10, 15, and 20 implant sheets are depicted. The best match of animplant about 270 ml with a base diameter of 12.5 cm or less is chosen (Style 10, 270 ml, base width � 12.2).

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outcomes that include allowing the surgeon to go tothe operating room with all of the important deci-sions made in advance. This allows the third step (theoperative technique) of the process of breast aug-mentation to proceed in a very logical fashion.

CONCLUSION

The High Five process allows the surgeon to makeall important decisions that determine outcomespre-operatively. Included in this system is a tissue-based system for selecting breast implant size tomatch the implant to the given patient’s breast tis-sues and dimensions. Using this type of planning,patient outcomes including re-operation rates andrecovery have been optimized. Over time, surgeonswill find the use of this system very advantageousfor delivering optimal results to their patients.

REFERENCESAdams, W. P. (2007). The process of breast augmentation.

Manuscript submitted for publication.American Society for Aesthetic Plastic Surgery. (2007). Amer-

ican Society for Aesthetic Plastic Surgery statistics. LosAlamitos, CA: Author.

Bengtson, B. (2005). Experience with 410 implants. Presentedat the American Association of Aesthetic Plastic SurgeryMeeting, New Orleans.

Jewell, M. (2005). Experience with From Stable Cohesive GelImplants. Presented at S8 Breast Education Course.American Association of Aesthetic Plastic Surgery Meet-ing, New Orleans.

Tebbetts, J. B. (2002). Breast implant selection based onpatient tissue characteristics and dynamics: The TEPIDapproach. Plastic and Reconstructive Surgery, 190(4),1396–1409.

Tebbetts, J. B., Adams, W. P., Jr. (2005). Five critical decisionsin breast augmentation using five measurements in 5 min-utes: The High Five decision support process. Plastic andReconstructive Surgery, 116.

Figure 6. Determining the infra-mammary fold (IMF) position with objective data.

Figure 7. Incision and key factors.

Figure 8. Final post-operative result at 1 year.

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