Patient Self-Assessment and Measuring Techniques
Are measurements really necessary, and are patient outcomes better with defined decision processes?
While plastic surgery is partially art, optimal results with minimal risks, rapid recovery, and minimal reoperations require that surgeons use art after they apply science, not in lieu of science. The scientific method is based on using objective, measurable data to test a theory or hypothesis. Absent objective data, methods are not scientific; instead, the methods are simply opinions. To determine whether results based on opinions are better compared to results based on scientifically tested and valid methods, it is important for you as a patient to consider data on results that have been scientifically peer reviewed and published in indexed medical journals.
Optimal results and outcomes with minimal reoperations require that you and your surgeon make optimal decisions before your augmentation. For the past three decades, surgeons and patients have based most of their decisions on subjective parameters, such as cup size (which no surgeon or patient can define), terms such as thin (How thin is thin?), and terms such as tight skin (How tight is tight?). To determine implant size, many surgeons allow patients to judge size by pictures (inaccurate unless the picture measures breast width and skin stretch). Other surgeons allow patients to purchase a bra of the size they desire and place test implants into the bra to determine the size implant to place during the augmentation (ignoring a basic fact that the width and stretch of the bra never match the width and stretch characteristics of the patient’s breast). Many of these methods allow patients to define their wishes and then force their desires on their tissues whether or not the desires consider the dimensions and characteristics of their tissues. When patient and surgeon force tissues to a desired result instead of defining realistic limits of what each individual patient’s tissues will safely allow, irreversible tissue compromises and uncorrectable deformities can result. These compromises can include skin thinning, shrinkage and loss of breast tissue, visible implant edges, visible traction rippling, excessive sagging of the breasts, implant malpositions, and even chest wall deformities.
Traditionally, many surgeons have resisted using measurements, instead preferring to rely on their “aesthetic eyes” to make decisions. Decisions based on subjective parameters without objective measurements contributed to an unenviable track record of an average 17 percent reoperation rate within just three years following augmentation in FDA studies.1,2
During the past seven years, we have developed more objective methods of assessing the dimensions and tissues of the breast. Instead of using terms like small, big, tight, loose, proportional, cup size and other terms that are subject to wide differences in interpretation and cannot be studied scientifically, we now rely on a few very specific, objective measurements and defined decision processes to make critical decisions before augmentation.3,4 A key question is whether these more objective methods using simple measurements and defined decision processes actually improve patients’ outcomes and reduce reoperation rates. Instead of a 17 percent reoperation rate in just three years following augmentation,1,2 these new methods3,4 have enabled us to reduce reoperation rates to only 3 percent up to seven years after augmentation in 1,664 patients,5,6,7 and for the first time in history, to document a zero percent reoperation rate in fifty consecutive breast augmentation patients at three years following augmentation in an FDA study.8 Combined with redefined surgical techniques, these processes have enabled more than 80 percent of our patients to be out to dinner the evening of surgery, and 96 percent to return to full, normal activities within twenty-four hours following their breast augmentation.7
Decisions based on subjective terms and methods had a 17 percent reoperation rate in just three years.
Decisions based on objective measurements and defined decision processes CaN and HaVe beeN tested scientifically.3,4,5,6,7,8
Decisions based on objective measurements and defined decision processes produced a 3 percent overall reoperation rate at up to seven years, and a zero percent reoperation rate at three years postop.
Can and Should Patients Measure Themselves?
Patient measurements should never replace measurements and decision-support by an expert, board-certified plastic surgeon. Based on our experience and testing self-measurement techniques in many of our patients, we are convinced that interested, motivated, intelligent patients are completely capable of performing basic measurements on their breasts and applying basic decision-making processes to help establish safe, realistic expectations.
Every patient who performs self-measurements should thoroughly understand that her measurements will likely never exactly match her surgeon’s measurements, and that fact should not disturb any patient. Measurements vary even among surgeons, but each individual surgeon’s or patient’s measurements become very consistent with repetition. Your surgeon will likely make more measurements than you make and will likely interpret the measurements differently and with more depth due to training and experience.
Our experience with patients measuring themselves has been overwhelmingly positive provided the patient understands the principles described above and provided the patient understands that patient measurements are always less comprehensive and somewhat less accurate compared to surgeon measurements. When surgeons and patients formerly e-mailed us with questions, we relied on photographs to try to help with answers or advice. Today, we rely totally on measurements, because we know how misleading photographs can be and realize that photographs convey very little or no information about the actual dimensions and tissue stretch of a breast—critical factors in every breast augmentation.
An obvious question is “How accurate and useful are patient measurements and decisions compared to surgeon measurements and decisions?” We tested a series of patients by combining our thorough and repetitive patient education processes described earlier in the book9 with basic measurement techniques and decision methods and found that in 90 percent of cases, the patients’ measurements and preliminary choices required absolutely no change in basic preoperative decisions by the surgeon. While the patient’s measurements varied slightly in every case from the surgeon’s measurements, the variations did not significantly affect the ultimate decisions of the surgeon. These findings surprised us and convinced us that many patients, adequately informed and motivated, are capable of performing basic self-measurements and making preliminary assessment decisions with remarkable accuracy.
Basic Measuring Tools
In order to perform basic measurements on your breast, you will need a flexible cloth or plastic tape measure that is marked in both inches and centimeters. Most sewing, fabric, or crafts stores and some hardware stores stock these types of tape measures, and many are very inexpensive. If you happen to have access to a set of calipers, they can be helpful but are not essential. In addition, you will need a ballpoint pen or washable marker to place dots on your breast at key measuring points.
A measuring kit that we assembled for our out-of-town patients (Figure A1-1) includes a caliper, measuring tape, and DVD with instructions for measuring. This kit is available on www.amazon.com or by calling our office. (Search for breast measurement kit and DVD.)
Key Measurements and Measurement Techniques
Measuring the Thickness of Your Upper Breast Tissues
One of the most important priorities in breast augmentation is choosing an implant pocket location that assures optimal soft-tissue coverage over your implant for your entire lifetime. Your tissues are likely to become thinner with age, and thin tissues overlying any portion of a breast implant can allow visible implant edges, visible rippling, and excessive stretch that may be uncorrectable. Subjectively assessing whether you appear thin is inaccurate and inadequate. Making optimal decisions about implant pocket location requires objective measurements of tissue thickness.
The most accurate and effective method for determining the thickness of tissues that will lie over the upper portion of your breast implant is to measure tissue thickness in the upper breast using a simple pinch test and measuring with your caliper.
With one hand, gently grasp the mass or your breast tissue and pull it downward toward your feet to assure that you are not grasping breast tissue when you perform the pinch tissue measurement in the upper breast (Figure A1-2, A). With the opposite hand, open your thumb and index finger about an inch-and-a-half apart, then grasp the skin and underlying fat above the breast tissue, pinch firmly, and measure the thickness of the pinched tissue with the caliper (Fgure A1-2, B). It is important to avoid starting with your fingers extremely wide apart and pushing hard against the chest wall as you pick up tissues because you may tend to include the underlying pectoralis muscle in your measurement.
Measuring the Base Width of Your Breast
The most accurate method for measuring the base width of your breast is to use a caliper, but if you do not have a caliper available, you will be able to make an approximate measurement with your tape measure.
While standing in front of the mirror, look at the cleavage area between your breasts. You’ll notice a flat area between the breasts. Try to locate a point where this flat area first begins to slope upward onto your breast mound, and place a dot at the beginning of the upslope of the breast mound.
While looking in the mirror, visualize the line that forms the outside curve of your breast directly across the breast from the dot you placed in the cleavage area. You will be measuring from the dot in the cleavage area straight across to the outside border of the breast mound to determine the base width of the breast mound (Figure A1-3). The measurement should be a straight-line measurement, not a measurement over the curve of the breast.
If you are using a tape measure in order to get a straight line measurement, you’ll need to hold the tip of the tape measure in front of your chest locating the tip directly over the dot you placed in the cleavage area. Stretch the tape directly across in front of your breast, not touching your breast, and note the number on the tape where the outer profile line of your breast crosses behind the tape. This measurement from the beginning of the upslope of the breast in your cleavage area to the visible outer boundary of the breast is the base width of the breast mound.
Perform this measurement three times and record the three measurements, then average the measurements.
| Measurement #1 | Measurement #2 | Measurement #3 | Average |
|---|---|---|---|
| (base width) | (base width) | (base width) | (base width) |
Measuring the Nipple-to-Inframammary Fold Distance
While standing in front of a mirror, gently lift your breast, and locate the crease or fold beneath the breast. This is the inframammary fold. Using a ballpoint pen or marker, place a small dot exactly in the fold beneath your breast on a line directly beneath your nipple, near the six o’clock position of the fold (Figure A1-4, A).
Release your breast, and place a second dot exactly beside the midpoint of your nipple on the skin of the areola (the pigmented skin surrounding the nipple).
Place the tip of a flexible tape measure on the dot you just placed beside the nipple. With one hand, push the tip of the tape measure toward your back to hold it in place, and use the same hand (pushing backward and upward) to lift your breast upward toward your collar bone. This puts the skin between the nipple and the fold beneath your breast under maximum stretch. Pull the tape measure straight downward past the dot you placed in the fold under your breast, and read the nipple-to-fold distance on the tape at a point immediately beside the dot you placed in the fold (Figure A1-4, B). If you have someone who can help you, you can lift the breast and stretch the skin while they make the measurement.
Perform this measurement three times and record the three measurements, then average the measurements.
| Measurement #1 | Measurement #2 | Measurement #3 | Average |
|---|---|---|---|
| (nipple to fold) | (nipple to fold) | (nipple to fold) | (nipple to fold) |
Measuring Skin Stretch
Measuring skin stretch is somewhat more difficult compared to the previous measurements, and your surgeon will be able to more accurately repeat this measurement during your consultation. Nevertheless, you should be able to perform a very basic measurement that can provide useful information. A caliper is almost essential to perform this measurement accurately.
Pick up your caliper in your right hand (or in your left hand if you are left handed) and hold it in the palm of your hand leaving your thumb and index finger of the same hand free to grasp the skin of your areola.
Grasp the skin of your areola immediately adjacent to the nipple and pull if straight forward away from your chest as far as you can possibly force it to go (see Figure A1-5, A). Use the fingernail of your opposite hand to mark the maximum point of skin stretch forward, and while holding the fingernail in the air to mark the point, release the skin and measure from the fingernail marker back to the relaxed skin of the areola on the chest (see Figure A1-5, B). This distance represents the maximum forward (anterior) pull—skin stretch of your breast. Perform this measurement three times and record the three measurements, then average the measurements.
| Measurement #1 | Measurement #2 | Measurement #3 | Average |
|---|---|---|---|
| (skin stretch) | (skin stretch) | (skin stretch) | (skin stretch) |
Using Your Measurements to Make Preliminary Decisions
The measurements you have made can help you better understand options for implant size and implant pocket location that minimize your risk of reoperations, tissue compromises, and uncorrectable deformities in the future. If you understand that the caliper and tape measure are impersonal and totally objective, understanding the limitations that measurements can point out to you can be invaluable as you and your surgeon make critical decisions for your augmentation.
Before we discuss how to use measurements to help make decisions, you should clearly understand that the final decisions you and your surgeon make will depend on additional measurements and other factors that are individual to each patient. The information we will provide is general and is not intended to be definitive, but to provide a framework for you to better understand tissue limitations based on tissue measurements. The principles of using measurements to make important decisions in augmentation are derived from peer-reviewed scientific studies that we have published.3,4 These are the same principles used by surgeons who are delivering 24-hour return4,7 to normal activity and 3 percent or lower reoperation rates at up to seven years following augmentation.5,6,7,8
Choosing a Pocket Location to Optimize Tissue Coverage of Your Implants
The highest priority decision in breast augmentation is choosing a pocket location and using surgical techniques to provide optimal, maximal soft-tissue coverage over your implants for your entire lifetime. This is the highest priority decision in the high five priority decisions that surgeons use in the High Five Decision System4 to minimize risks of uncorrectable deformities, such as implant edge visibility, visible rippling or wrinkling, and irreversible tissue thinning. These uncorrectable deformities and tissue compromises are almost totally avoidable by making simple decisions about pocket location that are based on objective measurements instead of subjective opinions and by making choices that maximize tissue coverage over your implants instead of choosing options that may or may not be adequate as you age and your tissues become thinner.
Table A1-1 is a flowchart that uses your measurement of the tissue thickness above your breast tissue (soft tissue pinch thickness of the upper pole or STPTUP) to help you select the best option for implant pocket location to assure optimal long-term coverage over your implant.
If the soft-tissue pinch thickness you measured above your breast tissue was less than 2 cm thick, to minimize risks of reoperations and uncorrectable deformities, you should choose an implant pocket location that provides additional muscle coverage over the upper and middle portions of your implant.
Two options for pocket location that add muscle coverage include a traditional retropectoral pocket, and the newer, dual-plane pocket that provides muscle cover in the upper breast while minimizing trade-offs associated with the traditional submuscular pocket. (For more detailed information on pocket locations, see chapter 6.)
If your pinch thickness measurement above your breast tissue was greater than 2 cm, placing the implant behind breast tissue (submammary) or behind breast tissue and a thin layer of fascia (subfascial) are also reasonable options. With the development of the dual-plane pocket option that minimizes trade-offs of the traditional submuscular pocket location, more and more patients are asking, “Why not just be as safe as possible and provide muscle cover over the upper and middle portions of the implant?” More and more, we agree with them. Our peer-reviewed and published scientific studies indicate the dual-plane pocket location has the lowest reoperation rate and a zero rate of uncorrectable compromises. No other published studies currently match the track record of the dual-plane pocket location.3,4,5,6,7,8
Implant size (volume) options-Using base width, stretch, and nipple-to fold measurements
Table A-2 is a simplified version of the decision process table from our peer-reviewed and published TEPID™ and High Five systems. To use the table to estimate an approximate implant volume based on the width and stretch of your tissues, perform the following steps:
| Base Width | Base Width (cm) | 10.5 | 11.0 | 11.5 | 12.0 | 12.5 | 13.0 | 13.5 | 14.0 | 14.5 | 15.0 |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Estimated Volume (cc) | 200 | 250 | 275 | 300 | 300 | 325 | 350 | 375 | 375 | 400 |
Table A-2
- In the far left column of the table, enter the measurements you performed in the following spaces: pinch thickness in the STPTUP space, base width in the BW space, skin stretch in the APSS (anterior pull skin stretch) space, and nipple-to-fold measurement in the N:IMF space.
- In the top row of the table, locate the base width average measurement of your breast.
- Immediately beneath the base width measurement, the table lists an approximate starting implant volume for your base width. This volume is a starting volume that will be adjusted depending on the correlation of your other measurements with your surgeon’s measurements.
- The suggested volume from c) above also depends on the degree of skin stretch in your breast. If your skin stretch is less than 2 cm, subtract 30cc from the volume suggested by your base width. If your skin stretch is greater than 3 cm, add 30cc to the suggested volume, and if your skin stretch is 40cc, add 60cc to the suggested volume. These volumes are all approximate and will depend on you and your surgeon’s assessments and discussion.
References
1 U. S. Food and Drug Administration. Product labeling for Mentor and Allergen/Inamed core studies of saline implants. http://www.fda. gov/cdrh/breastimplants/labeling/mentor_patient_labeling_5900.html. Accessed: January 1, 2007, FDA web site updated November 17, 2006..
2 U. S. Food and Drug Administration. Product labeling for mentor and Allergan/Inamed core studies of conventional silicone gel implants. http:///www.fda.gov/cdrh/breastimplants/labeling.html. Accessed: December 5, 2006, FDA web site updated Nov 17, 2006.
3 Tebbetts, J. B. A system for breast implant selection based on patient tissue characteristics and implant-soft tissue dynamics. Plast. Reconstr. Surg. 109(4): 1396-1409, 2002.
4 Tebbetts, J. B., and Adams, W. P. Five critical decisions in 1. U. S. Food and Drug Administration. Product labeling for Mentor and Allergen/Inamed core studies of saline implants. http://www.fda.gov/cdrh/breastimplants/labeling/mentor_patient_labeling_5900.html. Accessed: January 1, 2007, FDA web site updated November 17, 2006..
5 Tebbetts, J. B. Patient acceptance of adequately filled breast implants. Plast. Reconstr. Surg. 106(1): 139-147, 2000.
6 Tebbetts, J. B. Dual-plane (DP) breast augmentation: Optimizing implant-soft tissue relationships in a wide range of breast types. Plast. Reconstr. Surg. 107: 1255, 2001.
7 Tebbetts, J. B. Achieving a predictable 24-hour return to normal activities after breast augmentation, part II: Patient preparation, refined surgical techniques and instrumentation. Plast. Reconstr. Surg. 109: 293-305, 2002.
8 Tebbetts, J. B. Achieving a zero percent reoperation rate at 3 years in a 50 consecutive case augmentation mammaplasty PMA study. Plast. Reconstr. Surg. 108(6): 1453-1457, 2006.
9 Tebbetts, J. B. An approach that integrates patient education and informed consent in breast augmentation. Plast. Reconstr. Surg. 110(3): 971-978, 2002.