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re-operation rates during 3 years in the Federal Drug
Administration multiple pre-market approval (PMA)
studies have been 15% to 20% and reflected this
unscientific/arbitrary approach. Recent advances in
tissue-based planning have demonstrated not only a
simplified method of planning but also one that
matches implants to patients tissues and breast
dimensions and has produced much lower re-opera-
tion rates. The most recently described tissue-based
planning system is the High Five process (Tebbetts
& Adams, 2005). The High Five process was devel-
oped more than 15 years ago and this third-generation
system codified the five most important decisions
surgeons make during the pre-operative planning
phase that affect patient outcomes.
Accurate planning is not unique to breast aug-
mentation but is relevant in all professions and
results 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 What
implant do patients like best? The truth is that it is
not about the implant, but rather the process
(described above). In fact, in a recent FDA implant
PMA 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 this
actress or this model on the cover of a magazine, or
wish 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 assess
these objectively and to match the implant to the tis-
sues specifically. The process of breast augmentation
holds true for all implant types. It determines the re-
operation rates, the patients experience and recov-
ery, and ultimately the growth of ones practice in
breast augmentation.
D
espite popularity, breast augmentation has not
advanced significantly in 20 years. The re-operation
data for breast augmentation has been excessive at 15%
to 20% in every Federal Drug Administration pre-market
approval study for the past 15 years. Recently, a more sci-
entific approach to breast augmentation has described a
true process approach to this procedure. One element, tis-
sue-based pre-operative planning, has been shown to
reduce re-operation rate to less than 3% in published
peer-reviewed studies. The High Five process was pub-
lished in 2005 and codifies the 5 most important pre-
operative decisions made during a breast augmentation
procedure. Application into clinical practice of this plan-
ning system is discussed.
Breast augmentation has recently been reported to
be the most common surgical procedure in plastic
surgery (American Society for Aesthetic Plastic
Surgery, 2007). Within the past 5 years, the disci-
pline of breast augmentation has been recognized
not as a surgical procedure but as an actual process
that involves four subprocesses (Adams, 2007):
1. Patient education
2. Tissue-based pre-operative planning
3. Refine surgical technique
4. Define post-operative care
Tissue-based pre-operative planning is essential to
obtain reproducible results in breast augmentation
while minimizing the re-operation rate. Although
historically surgeons have subjectively performed
pre-operative planning in the past 15 years, the
The High Five Process: Tissue-Based
Planning for Breast Augmentation
William P. Adams Jr., MD
William P. Adams Jr., MD, is in private practice in plastic surgery
in Dallas, Texas. He also serves as an Associate Clinical Professor
of Plastic Surgery at the University of Texas Southwestern Medical
Center in Dallas, Texas.
Address correspondence to William P. Adams Jr., MD, 2801 Lemmon
Ave West, Suite 300, Dallas, TX 75204 (e-mail: [email protected]).
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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 simple
easy-to-follow process for patient assessment that
can be performed in less than 5 minutes.
THE HIGH FIVE PROCESS: HOW IT WORKS
IN CLINICAL PRACTICE
The five critical decisions in the High Five process
include:
1. Implant coverage/pocket planning
2. Implant size/volume
The concepts of tissue-based planning are well
established in the plastic surgery literature. In pub-
lished and peer-reviewed series, as well as national
presentations in the last 2 years, there are more than
2,500 primary breast augmentation procedures
(Bengtson, 2005; Jewell, 2005; Tebbetts & Adams,
2005) performed with similar concepts in tissue-
based pre-operative planning, with re-operation rates
of less than 3% with 67 years follow-up, in com-
parison with the re-operation rate of 15% to 20% in
3 years in all the PMA studies in the past 15 years.
The immediate predecessor to the High Five
process was a tissue-based planning system devel-
oped by Tebbetts (Tebbetts, 2002). This was the first
tissue-based system of its kind, as it prioritized the
tissues 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 type
4. Infra-mammary fold (IMF) position
5. Incision
For purposes of simplicity, all of the details of
the High Five process are not reviewed in this
overview; however, the basics are described. The
High Five process has been found to be safe and
simple. It leaves the control totally up to the sur-
geon and gets the surgeon on base. The process is
applicable to all implant types including gel, highly
cohesive form-stable gel, and saline implants. It is
effective and proven as described above, and, most
importantly, it is transferable, meaning that sur-
geons, residents, patient coordinators, and even
patients have successfully used this system to
objectively select implants appropriately for a given
patients breasts.
All the details may be found in Tebbetts and
Adams (2005). However, there are four primary
measurements:
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 of
the 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 decision
because it is very difficult to correct the outcomes of
an 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 or
dual plane-type pocket plan is advisable to maintain
adequate coverage over the implant, particularly in the
long term. If the pinch thickness in the upper pole is
more than 2 cm, preferably more than 2.53.0 cm, a
subglandular pocket plane may be considered. How-
ever, it is in the authors practice to generally place
most implants under the muscle given the trade-offs of
the subglandular versus the subpectoral position
(Figure 3).
Implant volume. Implant volume is determined by
the High Five nomogram, which is provided in the
system. The base width is measured as demonstrat-
ed in the planning sheet. There is an initial implant
volume associated with a given base width. Next,
adjustments of the implant volume are made on the
basis of the skin stretch and the amount of
parenchyma present. Adjustments may also be made
on the basis of patient requests, whether a patient is
asking for larger or smaller size breast. These values
are totaled and a net estimated volume to optimally
fill the given breast envelope is obtained (Figure 4).
Implant type. The implant type is selected on the
basis of patients request and surgeons recommen-
dation. The implant volume discussed in the previ-
ous section is used as a reference. The implant spec
sheets may be reviewed and the patients base width
is selected on the basis of an implant that is similar
or slightly less in width in comparison with the
patients base width of similar volume as calculated
in 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 the
IMF will be placed post-operatively. When using the
IMF 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-mammary
fold (N:IMF) ratio 6.5.
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sion is the least important of all five and is again
based on patients request, surgeons recommenda-
tion, and surgeons skills set (Figures 7 and 8).
Using this system, all important pre-operative
decisions may be made in approximately 5 minutes,
allowing the surgeon to very reproducibly match the
implant to the given patients breast tissues and
dimensions. This allows for several important
place the incision directly in the post-operative IMF.
The High Five system provides these relationships
and can simply be followed on the basis of the
measurements. The details can be found in Tebbetts
and 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 breast
envelope, indicated by a skin stretch (SS) of less than 2 (1.5 in this case). The total represents the optimal fill volume
for that individual breast tissue type.
Figure 5. The desired volume (Step 2) is 270 ml. The implant specification sheets are reviewed. The patient desired a
round silicone gel implant. The Inamed/Allergan Style 10, 15, and 20 implant sheets are depicted. The best match of an
implant 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 to
the operating room with all of the important deci-
sions made in advance. This allows the third step (the
operative technique) of the process of breast aug-
mentation to proceed in a very logical fashion.
CONCLUSION
The High Five process allows the surgeon to make
all important decisions that determine outcomes
pre-operatively. Included in this system is a tissue-
based system for selecting breast implant size to
match the implant to the given patients breast tis-
sues and dimensions. Using this type of planning,
patient outcomes including re-operation rates and
recovery have been optimized. Over time, surgeons
will find the use of this system very advantageous
for delivering optimal results to their patients.
REFERENCES
Adams, 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. Los
Alamitos, CA: Author.
Bengtson, B. (2005). Experience with 410 implants. Presented
at the American Association of Aesthetic Plastic Surgery
Meeting, New Orleans.
Jewell, M. (2005). Experience with From Stable Cohesive Gel
Implants. Presented at S8 Breast Education Course.
American Association of Aesthetic Plastic Surgery Meet-
ing, New Orleans.
Tebbetts, J. B. (2002). Breast implant selection based on
patient tissue characteristics and dynamics: The TEPID
approach. Plastic and Reconstructive Surgery, 190(4),
13961409.
Tebbetts, J. B., Adams, W. P., Jr. (2005). Five critical decisions
in breast augmentation using five measurements in 5 min-
utes: The High Five decision support process. Plastic and
Reconstructive 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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