Review Article

Decisional pathways in breast augmentation: how to improve

outcomes through accurate pre-operative planning
Maurizio B. Nava 1,2, Nicola Rocco 3, Gianfranco Tunesi 4, Giuseppe Catanuto 5, Alberto Rancati 6,
Julio Dorr7
1
Valduce Hospital, Como, Italy; 2Department of Plastic Surgery, University of Milan, Milan, Italy; 3Department of Clinical Medicine and Surgery,
University of Naples Federico II, Naples, Italy; 4Private Practice, Milan, Italy; 5Multidisciplinary Breast Unit, Azienda Ospedaliera Cannizzaro,
Catania, Italy; 6Chief Oncoplastic Surgery Instituto Henry Moore, University Of Buenos Aires, Buenos Aires, Argentina; 7University of Buenos
Aires, Buenos Aires, Argentina
Contributions: (I) Conception and design: MB Nava, A Rancati; (II) Administrative support: N Rocco; (III) Provision of study materials or patients:
MB Nava, A Rancati; (IV) Collection and assembly of data: N Rocco, G Catanuto; (V) Data analysis and interpretation: J Dorr; (VI) Manuscript
writing: All authors; (VII) Final approval of manuscript: All authors.
Correspondence to: Alberto Rancati. Chief Oncoplastic Surgery Instituto Henry Moore, University of Buenos Aires, Buenos Aires, Argentina.
Email: [email protected].

Abstract: Breast augmentation is the most commonly performed surgical procedure in aesthetic plastic
surgery. Accurate pre-operative planning is crucial to obtain the best outcomes. We present our planning
method deriving from a more than 30-year experience in aesthetic breast surgery, matching together patients
tissues’ characteristics and patients’ wishes. We schematized our planning method in an easy-to-use flow
diagram to help the decisional process in breast augmentation.

Keywords: Breast augmentation; breast implants; pre-operative planning

Submitted Oct 29, 2016. Accepted for publication Feb 10, 2017.
doi: 10.21037/gs.2017.03.01
View this article at: http://dx.doi.org/10.21037/gs.2017.03.01

Introduction 2% to 20.6% (7).

Many techniques aiming to refine the pre-operative
Breast augmentation is the most commonly performed
decisional process in breast augmentation have been
surgical procedure in aesthetic plastic surgery (1,2).
developed in the last 10 years, leading to a significant
Accurate pre-operative planning is crucial to obtain the
reduction of re-operation rates (8-10).
best outcomes and to reduce re-intervention rates. Lower re-intervention rates are associated with the
The entire decisional process in breast augmentation application of tissue-based planning methods, decisional
was initially determined exclusively by patient’s wishes and systems matching implants to patient’s tissues and breast
surgeons’ preference, being the choice of implant size, dimensions (11-14).
type of implant, implant position and type of incision an A national survey conducted among consultant plastic
arbitrary decision. surgeons in United Kingdom showed how two schools
This led to high re-intervention rates for patient’s of thought have emerged among the recent attempts to
dissatisfaction with implant size and other post-operative rationalize the choice of breast implants: those relying
complications (3-5). on standardized measurement systems and those that are
Tebbetts described four main areas of post-operative guided by volume. The survey showed that over one third
issues after primary breast augmentation and dissatisfaction of surgeons take an intermediate approach using different
with implant size was one of them (6), the rate of requests forms of breast measurement (most commonly breast base)
for change of implants purely for size issues ranging from in combination with volumetric external sizing (15).

© Gland Surgery. All rights reserved. gs.amegroups.com Gland Surg 2017;6(2):203-209

204 Nava et al. Decisional pathways in breast augmentation

process in breast augmentation based on skin and soft tissue

characteristics, breast and chest wall size, breast shape and
patient’s wishes.
SN-N When planning a breast augmentation, the surgeon will
assess implant size, implant type, implant pocket position
Line between the “hands” lines
and incision location and each decision will strongly impact
A
on final outcomes.
Desire clivage
Chest wall width B The entire decisional process could be based on
Present breast width A: eIMF distance

B: New IMF fold and incision

objective and quantifiable data deriving from patient’s tissue
Desired breast width
Four pinch thickness (5 cm from inferior characteristics or arbitrary choices deriving from surgeon’s
medial lateral superior border of areola)
central for projection preference or patient’s specific requests.
Figure 1 Key measurements in the pre-operative planning of We must pursue evidence-based surgery and to achieve
breast augmentation. predictable outcomes with low re-operation rates, we have
to build our results on objective data.

We present our planning method deriving from a

Assessing implant size and type
more than 30-year experience in aesthetic breast surgery,
matching together patients tissues’ characteristics and Several dimensional systems have been developed to pre-
patients’ wishes. operatively assess implant size in breast augmentation, one
We schematized our planning method in an easy-to- of the most commonly used being the BioDimensional
use flow diagram to help the decisional process in breast System licensed by Inamed Corporation in 1994 (16),
augmentation. later evolved in the TEPID system, a planning method
prioritizing long-term outcomes and minimizing re-
intervention rates (17).
How to guide decisional processes in breast
We firmly believe methods to assess implant size should
augmentation
put together patient’s wishes with tissue characteristics,
We firmly believe a scientific and rigorous approach towards making women understand the real possibilities of their
breast augmentation to be mandatory in order to obtain tissues and the limits of the achievable outcomes, basing on
good outcomes, long-lasting results, low complication and objective, quantifiable measurements.
re-intervention rates and high women’s satisfaction levels. Final breast shape will depend on coverage tissue (breast
A rigorous approach starts with an accurate first skin, glandular parenchyma and fat) characteristics and
consultation, listening to patient’s wishes, analyzing skin implants.
and soft tissues characteristics, the size of the chest wall and After an objective definition of specific patient’s
the breast and breast shape, always remembering that if you parameters [chest wall width, base width of the existing
fail to plan, you plan to fail. breast, nipple-to-inframammary fold (IMF) distance under
After accurate planning and shared decision making, a maximal stretch, medial, lateral, superior and central pinch
properly performed surgery with a complete knowledge of thickness of the existing tissues, clivage, sternal notch to
the devices we are using, with a correct and standardized nipple distance], the surgeon will be able to choose the best
follow-up will be next drivers towards the best and long- width, height and projection of the implant (Figure 1).
lasting results in breast augmentation. Dimensions will determine volume and not vice versa.
We always have to balance the wishes of the patient The surgeon will be able to assess breast volume,
with her tissue characteristics, identifying potential desired classified in very small/small/medium.
result/soft tissue mismatch. When the patient’s wish is In case of medium-sized breasts, ptosis will be also
recognized to be not achievable, further consultation and assessed according to Regnault classification (18). Minimal
patient education is mandatory. Very useful tools to enhance ptosis (Regnault I) can be solved with the correct use of
patient understanding of the achievable results during the extra projected high cohesivity anatomical implant (Allergan
consultation are represented by the external sizers. Style 510, Irvine, CA, USA); or corresponding CPG model
We developed a planning method to guide the decisional 333 Anatomical implants (Mentor Inc., Texas, USA). In

© Gland Surgery. All rights reserved. gs.amegroups.com Gland Surg 2017;6(2):203-209

Gland Surgery, Vol 6, No 2 April 2017 205

C D

Figure 2 Dual plane breast augmentation with Allergan Style 510 Dual Gel implants (width 12 cm; height 11.1 cm; volume 290 cc). Pre-
operative view (A); 1 year (B); 3 years (C) and 6 years (D) follow-up.

case of moderate ptosis (Regnault II), an adjunctive round- The surgeon will also consider patient’s wishes. Women
block mastopexy will help obtaining the best outcome. If asking for a full-filled upper pole will be offered an Extra-
facing a severe ptotic breast (Regnault III), a Wise (inverted Projected Style 410 Cohesive Gel Implant (Allergan, Irvine,
T) pattern mastopexy could be considered together with CA, USA). Women wishing a sweeter upper pole will be
the augmentation. Simultaneous breast augmentation offered an Extra-Projected Style 510 Dual Gel implant
and mastopexy could represent one of the most difficult (Allergan, Irvine, CA, USA) (Figure 2); or corresponding
procedures in aesthetic breast surgery if not accurately pre- CPG model 333 anatomical implants (Mentor Inc., Texas,
operatively planned and meticulously performed. In case USA). If desiring a soft breast, the surgeon will consider
of augmentation mastopexy, we suggest the surgeon to a Low, Medium or Full Projected Style 410 Soft Touch
consider round implants use if not completely confident Gel implant (Allergan, Irvine, CA, USA) (Figures 3,4); or
with anatomical implants. When needing adjunctive corresponding CPG model 322-332 Anatomical implants
procedures to lift the breast we strongly advice trying to (Mentor Inc., Texas, USA).
minimize implant contamination during the surgery. Even though we could obtain good outcomes with both

© Gland Surgery. All rights reserved. gs.amegroups.com Gland Surg 2017;6(2):203-209

206 Nava et al. Decisional pathways in breast augmentation

A B

Figure 3 Dual plane breast augmentation using Allergan Style 410 MM Soft Touch gel implants (volume 215 cc). Pre-operative view (A);
post-operative follow-up at 8 years (B).

A B

Figure 4 Dual plane breast augmentation using Allergan Style 410 FF Soft Touch implant (Width 11.5 cm; height 12 cm; volume 290 cc).
Pre-operative view (A); post-operative follow-up at 6 years (B).

round and anatomical implants in women with a good breast of the level of the new IMF appears mandatory. Several
tissue coverage, we prefer anatomical implants. They help methods have been described in order to define the level
enhancing cosmetic results, allowing long-lasting results of the new IMF, as the ICE principle (22) or the method
and remain mandatory in challenging situations, when reported by Tebbetts with the TEPID system (17). Other
correcting congenital malformations, when considering authors prefer to calculate the position of the new IMF
breast augmentation in very thin patients or patients with adding the half parenchymal thickness to the implant’s
low/moderate breast ptosis (19,20). lower ventral curvature. This new IMF calculation method
has been validated with Allergan implants (Irvine, CA, USA)
and we actually do not know if it could be extended to other
Assessing implant pocket location and IMF
types of implants.
positioning
Our preference for new IMF positioning derives from an
The surgeon will then assess skin and soft tissue extension of Tebbetts’ method: the new IMF position will
characteristics, through the soft-tissue medial, lateral, be calculated adding the half of the width of the implant
superior and central pinch thickness. to a measure deriving from the patient’s tissue stretching:
If upper pole pinch thickness less than 2 cm (medium/ if low tissue amount we will add 1 cm, if moderate tissue
poor soft tissues), he will consider a dual-plane technique to amount less than 1 cm, if good tissue amount no further
ensure good tissue coverage (21). addings will be considered.
In case of very good soft tissues (upper pole pinch Our decisional process in breast augmentation is
thickness more than 2 cm), the surgeon will choose a sub- summarized in the breast augmentation flow-diagram
fascial breast augmentation. (Figure 5).
Our preference for incision location is at the IMF, in
order to minimize implant contamination. However incision
Discussion
location will be defined in relation with patient’s wishes,
surgical skills trying to reduce tissue trauma and trade-offs. We firmly believe that the best outcomes in breast
When considering an incision at the IMF, the estimation augmentation could be achieved only through a standardized

© Gland Surgery. All rights reserved. gs.amegroups.com Gland Surg 2017;6(2):203-209

Gland Surgery, Vol 6, No 2 April 2017 207

Chest wall width Assess skin and Good/poor

Assess volume Very good
implant width soft tissue

Full filled upper 410 XP Allergan

pole CPG 333 Mentor

Small/very small Yes

Patient wishes Sweet upper pole 510 XP Allergan

Soft breast ST L M or F Allergan

CPG 322 Mentor
NO

Yes
Small/medium size Assess ptosis Nil

Round block
+
Good/poor 410 - 510 XP or F M
Moderate Allergan
Dual plane CPG 323 Mentor

Severe T inverted mastopexy

Very good
round implant
Sub fascial

Figure 5 The breast augmentation flow diagram.

pre-operative planning of the surgery, a complete knowledge tissues, implant filler characteristics and implant shell-filler
of the available devices, the application of an impeccable interactions. When using non-form stable implants, the
surgical technique and a scheduled follow-up. height of the device is difficult to measure accurately so
The pre-operative planning should derive from a balance implant width and projection remain the most significant
of patient’s tissue characteristics and patient’s wishes. parameters.
Quantifiable, objective parameters should drive decisions Accurate measurements, but also impeccable surgical
for implant choice and implant pocket position, but the technique and standardized follow-up. Our recommended
patient’s desire could further define the final outcome follow-up starts at 1 week, changing drapes and then
if the surgeon has clear in his mind the whole available maintaining paper tape on the surgical scars for 2 months,
“armamentarium” for a “scientific” breast augmentation. avoiding strong muscular exercise for three months,
Pinch thickness to guide decisions about implant wearing post-surgical bras day and night for 2 months and
coverage and pocket location, chest wall width, breast base then only at night for 1 more month. Clinical evaluation
width, nipple-to-IMF distance, skin stretch to drive implant will be performed at first, second, sixth month after surgery
volume assessment and still arithmetics to define new IMF and then yearly together with breast imaging.
position. The decisional algorithm we developed, graphically
Objective measurements will help obtaining long-lasting summarize the complex process behind a breast
results and fulfilling women’s desires, significantly reducing augmentation and aims to help standardizing decisions,
re-intervention rates. basing on quantifiable parameters and abandoning arbitrary
When considering a specific volume, implant width and subjective assessments methods.
will be the most important parameter, but the surgeon Evidence-based surgery aiming to evidence-based
has to take into full account the height of the implant as outcomes mandatory requires scientific analysis of the
well, depending on the characteristics of the overlying decisional pathways.

© Gland Surgery. All rights reserved. gs.amegroups.com Gland Surg 2017;6(2):203-209

208 Nava et al. Decisional pathways in breast augmentation

We developed our decisional algorithm using Allergan Footnote

implants, or Mentor (Mentor Inc., Texas, USA), but it could
Conflicts of Interest: The authors have no conflicts of interest
be easily adapted to any form-stable breast implant by a
to declare.
skilled user of other types of implants.
Most implant manufacturers actually offer a wide choice
of implant device dimensions potentially enabling surgeons References
to obtain any result a woman could wish.
1. American Society of Plastic Surgeons. 2015 Plastic Surgery
Long lasting results will derive from the best interactions
Statistics. Accessed August 2016. Available online: https://
between the implant and the patient’s tissues: excessive
www.plasticsurgery.org/news/plastic-surgery-statistics?sub
volumes and excessive projections or the wrong implant
=2015+Plastic+Surgery+Statistics
pocket position derive from wrong interactions between
2. ISAPS International Survey on Aesthetic/Cosmetic.
implants and patient’s tissues. Surgeon’s aim should be to Accessed August 2015. Available online: http://www.isaps.
tailor the breast augmentation on each single woman. org/Media/Default/global-statistics/2016%20ISAPS%20
The optimal breast augmentation remains a team work Results.pdf
in which the surgeon should offer the best pre-operative 3. Adams WP Jr, Teitelbaum S, Bengtson BP, et al.
patient education with patient decision support devices and Breast augmentation roundtable. Plast Reconstr Surg
really informed consent processes (6,23). 2006;118:175S-187S.
The proposed algorithm while standardizing decisional 4. Bengtson BP. Complications, reoperations, and revisions
pathways, at the same time provides the great opportunity in breast augmentation. Clin Plast Surg 2009; 36:139-56.
for the surgeon to consider patients’ requests that will 5. Jewell ML, Jewell JL. A comparison of outcomes involving
definitively determine the final outcome. highly cohesive, form-stable breast implants from two
We would like to underline how the breast augmentation manufacturers in patients undergoing primary breast
decisional process remains a complex choice: only pursuing augmentation. Aesthet Surg J 2010;30:51-65.
a standardized decisional process, performing an accurate 6. Tebbetts JB. An approach that integrates patient education
surgery aiming to reduce trade-offs and minimizing and informed consent in breast augmentation. Plast
contaminations (that does not necessarily mean longer Reconstr Surg 2002;110:971-8.
operative times), with a tight-knit and “oiled” surgical team, 7. Berry MG, Cucchiara V, Davies DM. Breast augmentation:
we could aspire to obtain the best, tailored and long-lasting part III--preoperative considerations and planning. J Plast
results. Reconstr Aesthet Surg 2011;64:1401-9.
All aesthetic breast surgeons should analyze their 8. Bengtson BP, Van Natta BW, Murphy DK, et al. Style 410
own practice in order to standardize measurements and highly cohesive silicone breast implant core study results at
understanding exactly how measurements determine 3 years. Plast Reconstr Surg 2007;120:40S-48S.
implant size and how the type of implant impacts on 9. Maxwell GP, Van Natta BW, Murphy DK, et al. Natrelle
measurement techniques in their experience. style 410 form-stable silicone breast implants: core study
Moreover aesthetic breast surgeons should assess results at 6 years. Aesthet Surg J 2012;32:709-17.
post-operative complications, re-intervention rates and 10. Maxwell GP, Van Natta BW, Bengtson BP, et al. Ten-
reasons for re-operation and patient-reported outcomes. year results from the Natrelle 410 anatomical form-
A national register with compulsory reporting of all breast stable silicone breast implant core study. Aesthet Surg J
augmentations with implants and outcomes data would 2015;35:145-55.
help making a complete picture about different methods 11. Tebbetts JB, Adams WP. Five critical decisions in breast
of pre-operative planning and their impact on patients’ augmentation using five measurements in 5 minutes: the
outcomes (24,25). high five decision support process. Plast Reconstr Surg
2005;116:2005-16.
12. Tebbetts JB. Achieving a zero percent reoperation
Acknowledgements
rate at 3 years in a 50-consecutive-case augmentation
None. mammaplasty premarket approval study. Plast Reconstr

© Gland Surgery. All rights reserved. gs.amegroups.com Gland Surg 2017;6(2):203-209

Gland Surgery, Vol 6, No 2 April 2017 209

Surg 2006;118:1453-7. 20. Tebbetts JB, Teitelbaum S. High- and extra-high-

13. Adams WP. The High Five Process: tissue-based planning projection breast implants: potential consequences for
for breast augmentation. Plast Surg Nurs 2007;27:197-201. patients. Plast Reconstr Surg 2010;126:2150-9.
14. Adams WP Jr. The process of breast augmentation: four 21. Tebbetts JB. Dual plane breast augmentation: Optimizing
sequential steps for optimizing outcomes for patients. Plast implant-soft tissue relationships in a wide range of breast
Reconstr Surg 2008;122:1892-900. types. Plast Reconstr Surg 2006;118:81S-98S; discussion
15. Holmes WJ, Timmons MJ, Kauser S. Techniques used 99S-102S.
by United Kingdom consultant plastic surgeons to select 22. Mallucci P, Branford OA. Design for Natural Breast
implant size for primary breast augmentation. J Plast Augmentation: The ICE Principle. Plast Reconstr Surg
Reconstr Aesthet Surg 2015;68:1364-9. 2016;137:1728-37.
16. Tebbetts JB. Dimensional Augmentation Mammaplasty 23. Adams WP Jr, Small KH. The Process of Breast
Using the BioDimensional System. Santa Barbara, Calif.: Augmentation with Special Focus on Patient Education,
McGhan Medical Corporation, 1994:1-90. Patient Selection and Implant Selection. Clin Plast Surg
17. Tebbetts JB. A system for breast implant selection based 2015;42:413-26.
on patient tissue characteristics and implant-soft tissue 24. Cooter RD, Barker S, Carroll SM, et al. International
dynamics. Plast Reconstr Surg 2002;109:1396-409. importance of robust breast device registries. Plast
18. Regnault P. Breast ptosis. Definition and treatment. Clin Reconstr Surg 2015;135:330-6.
Plast Surg 1976;3:193-203. 25. Nahabedian MY. Discussion: international importance
19. Largent JA, Reisman NR, Kaplan HM, et al. Clinical trial of robust breast device registries. Plast Reconstr Surg
outcomes of high- and extra high-profile breast implants. 2015;135:337-8.
Aesthet Surg J 2013;33:529-39.

Cite this article as: Nava MB, Rocco N, Tunesi G, Catanuto G,

Rancati A, Dorr J. Decisional pathways in breast augmentation:
how to improve outcomes through accurate pre-operative
planning. Gland Surg 2017;6(2):203-209. doi: 10.21037/
gs.2017.03.01

© Gland Surgery. All rights reserved. gs.amegroups.com Gland Surg 2017;6(2):203-209