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The History of the High Five® Measurement System

The History of High Five® and Objective Tissue Based Implant Selection Systems in Dallas, TX

Implant size selection is one of the most important decisions for every breast augmentation patient and her surgeon. Implant size selection not only affects the appearance of the breast, but more importantly, implant size directly impacts every patient’s risks of additional reoperations, permanent, negative changes that can occur to their tissues, and the risks of permanent breast deformities that are uncorrectable by any type of surgery. If the implant is not properly sized to each patient’s specific tissue dimensions and characteristics, negative effects (many irreversible) on tissues are almost inevitable.

The High Five Measurement System® Executive Summary

If you want the short story essentials, here they are. The details are included for further reading if you want to be educated to another level.

Breast Augmentation Dallas

Figure 7-1

  • The decision of implant size not only determines the “look” of your breasts.
  • Implant size and dimensions determine your risks of reoperations in the future
  • Implant size and dimensions determine whether you will have uncorrectable breast deformities in the future
  • Surgeons can’t predictably produce what they and patients can’t define…cup size.
  • Selection of implant size using pictures guarantees that sizing will not be objective and optimal.
  • There is a correct amount of fill for every breast, depending on the dimensions and stretch characteristics of each individual patient’s breast tissues…we can measure those things, and use objective, scientific processes to make decisions instead of choosing based on subjective patient and surgeon opinions.
  • Either you get a correct amount of fill determined by objective measurements and scientific methods, or you get an ugly or overfilled breast that causes the risks, tradeoffs, and uncorrectable deformities that have continued to occur for four decades.
  • It’s your decision. Trust and request the only scientifically validated, objective system for selecting implant size, the High Five® System, or choose to use one of the outdated, less accurate, subjective systems that have a track record of greater risks and tradeoffs.


The High Five® System for Breast Implant Measurement:

Dallas TX Breast Augmentation

Figure 7-2

  • Is derived from more than 20 years of extensive measurement data from a wide range of patients and breast types
  • Is the only objective, scientifically validated system based on each individual patient’s tissue dimensions and stretch qualities
  • Is the only system that has been peer reviewed and published in the most respected professional journal in plastic surgery, Plastic and Reconstructive Surgery Journal.
  • Has been used worldwide by highly selective and demanding surgeons who treat patients scientifically instead of subjectively.
  • Is the only implant selection system in history that has ever produced a zero percent reoperation rate in a series of patients from within an independently monitored FDA PMA study.
  • Is highly accurate and predictable, and has virtually eliminated risks of additional reoperations for size exchange.
  • Enables surgeons to plan your breast augmentation extremely precisely, avoid wasting time, avoid giving you unnecessary and excessive drugs, avoid prolonging your operation unnecessarily, and avoid using implant sizers during surgery that cause increased tissue trauma and increased bacterial contamination of the implant pocket from repeated insertion and removal (increasing risks of capsular contracture and infection).
  • Is so unique and effective that it is trademarked.


Traditional and outdated methods of breast implant size selection…and the reasons…

Before Breast Augmentation

Figure 7-3

To understand the reasons and logic behind state-of-the-art, objective, scientific, tissue based systems for implant selection like High Five®, it is important to understand why other methods are illogical, outdated and suboptimal.

Like all decisions, the quality of the decision about implant size is directly related to the amount of education a patient receives, the knowledge base she builds using the information she is given, and the manner in which her surgeon assists her with decision processes. Unfortunately, many surgeons are more focused on giving the patient anything she may think she wants in order to sell an operation, compared to educating the patient with the scientifically proved facts. Although a patient may think she knows what she wants, it is most important to understand the consequences of her choices (what she is really likely to get long term).

Patients who are not optimally educated by their surgeon shop for breast augmentation in the same manner they shop for other items….hear a recommendation, see what a friend has, browse the Internet for before and after pictures, stuff test implants into a bra, look at pictures or bring pictures to their surgeon, and then form an opinion about what size implant they want. While all of these methods are commonly used even today, all of them produce at best, average results and unnecessarily high rates of reoperations and uncorrectable deformities. The best results and lowest reoperation and permanent deformity rates published in the medical literature require a more sophisticated, objective, scientific approach that is individualized for each patient.

No patient or surgeon can define bra cup size, yet cup size is commonly used to determine implant size selection. No bra has any characteristics that match the tissues of any patient’s breast, yet surgeons and patients continue to select a desired bra cup and size and stuff test implants into the bra to define implant size for augmentation. Any picture or image, even 3D imaging, is totally subjective—the patient and surgeon each form opinions about what they see, opinions that are always different, and yet the surgeon assures the patient that they can have something that is similar to the picture. These outdated, subjective methods may give patients a feeling of comfort in their shopping decision, but these methods do not deliver optimal long-term outcomes that are safest for patients.

Let’s start with some facts about breast implant size and fill…

Simply put, here are some facts:

The key to achieving an optimal aesthetic result is putting exactly the right amount of fill in the existing skin envelope of the breast. There is a correct and optimal amount of fill for every breast based not on subjective opinions, but based on objective measurements of the size and stretch of each patients breast skin envelope.

Not enough volume (size) in your implants gets you the following:

  • More fill in the lower breast, not enough fill in the upper breast…a…
  • Rock in a sock appearance
  • Ugly.


Too much volume (size) in your implants (regardless of the reason you may think you want it) gets you the following:

Before and After Breast Augmentation Dallas

Figure 7-4

Excessive upper breast fill

  • A breast that looks more like a basketball than a breast
  • Excessive stretch of your skin over time as you age
  • Thinning of your breast skin due to pressure of an excessively large implant
  • Thin skin over a breast implant equals disaster in appearance, including…
  • Visible implant edges
  • Visible rippling
  • Pressure shrinkage of breast tissue (atrophy) that can take away the ability to nurse, and expose the implant due to inadequate soft tissue coverage
  • Destroy soft tissue coverage, creating the ultimate “implanted” look where the implant and its edges are so visible that the breast looks like an implant under skin only
  • Skin stretch that produces excessive breast sagging—the National Geographic look
  • Permanent, uncorrectable changes in your tissues that no surgeon or surgical procedure can improve
  • If surgeons attempt additional procedures with these stretched, thin, compromised tissues, complication rates can skyrocket, with non-healing wounds, exposed implants that must be removed, and tissues that won’t support the weight and pressure of even a smaller implant


Take a much closer look at the two lists above, and it will be obvious that the worst decision any patient and surgeon can make is to destroy patient tissues with excessively large implants. But it happens every day. Why? Because surgeons don’t educate their patients. Surgeons rarely say, “No” at the risk of losing an operation. And patients would rather shop according to their own rules if they aren’t optimally educated…instead of relying on scientifically proved methods that unquestionably deliver superior and safer results.

How did the High Five Measurement System® develop?

High Five Breast Implant Measuring

Figure 7-5

During my residency training as a plastic surgeon, I was taught to use pictures, bra stuffing… all the traditional methods of implant size selection. I used those methods for almost a decade, but gradually, as I reexamined my patients a few years following breast augmentation, it became painfully apparent to me that like many things in life, you can’t necessarily have whatever you want, unless you are willing to deal with the consequences. I began to see patients who had requested excessively large implants return with deformities I could not correct. Together, even meaning well in our initial decisions, we had chosen implant size that inevitably and negatively compromised patients’ tissues.

Two decades ago, it seemed obvious to me that if we could fly to the moon, we should be able to define systems that would make a breast look its best, but at the same time, minimize risks and protect every patient’s tissues from negative effects of a medically unnecessary device…a breast implant. It also seemed obvious that for every breast, there should be a correct and optimal amount of fill that would produce beautiful results, but without damaging tissues. The problem was to define an objective system that could be scientifically verified, and then get patients and surgeons to apply such a system.

Beginning in 1984, almost three decades ago, I began to perform a large number of measurements on every patient’s breast prior to augmentation, and repeated those measurements at intervals following surgery. As I followed the patients over months and years, the serial measurements for the first time gave me objective answers to the many, complicated effects that breast implants have on patients’ tissues. After accumulating tens of thousands of measurements, in 1993, about the time I developed the world’s first highly cohesive, shaped breast implant, I also became familiar with methods of computer analysis that could take the measurement data I had accumulated and provide key answers for the foundation of a measurement system based on patients’ tissues that could be applied to all breast implants.

The computer analysis was structured to answer specific questions:

Which specific measurements best predicted that a patient would have:

The best aesthetic results compared to other patients, maintained for the longest time

  • The least risk of having a complication or reoperation
  • The leas risk of having a reoperation for size exchange
  • The least risk of having any reoperation
  • The least risk of negative tissue effects from an implant
  • The least risk of permanent tissue deformities
  • Essentially, we were asking, “What five measurements most accurately defined an implant size that gave the best aesthetic results, the longest term best results, and with the least risks of reoperations and permanent tissue deformities?”


The answers from this extensive analysis of data gave us the answers we needed to then design the first objective measurement system for breast augmentation that incorporated not only width and nipple to fold measurements, but stretch measurement as well. This sytem was named the TEPID™ System, and it addresses the tissue characteristics (T) of the skiin envelope (E), the breast tissue (parenchymna P), the implant (I), and the dynamics (D) and filler distribution that affects the soft tissues and appearance of the breast. This system was published in Plastic and Reconstructive Surgery Journal in April, 2002.

  1. Tebbetts, JB. A system for breast implant selection based on patient tissue characteristics and implant-soft tissue dynamics. Plast. Reconstr. Surg.109 (4): 1396-1409, April, 2002.


A measurement system alone is not enough. Measurements are only useful if surgeons know how to use those measurements in an optimal sequence of decision processes. Many surgeons may take measurements, but unless those measurements are applied to very specific steps in a specific decision process, the measurements are virtually useless. Very soon after the TEPID™ system was published, it became apparent to me that surgeons were not following the TEPID™ system to the letter, often taking some measurements and ignoring others. And many surgeons would take the measurements, but then ignore the rules the measurements set, in essence cheating on the system in order to allow patients to have anything they might dream up instead of adhering to the safest system.

In order to more clearly define what was necessary for surgeons to do if they expected to achieve the results we had proved using TEPID™ and our decision systems, I decided to incorporate the TEPID measurement system into a more comprehensive system of decision processes that clearly and concisely defined how to use the measurements in a specific sequence of specific decisions, including not only implant size, but implant pocket location to assure optimal soft tissue coverage of the implant, and other surgical planning factors including incision location. This more comprehensive decision support system with TEPID measurements incorporated became the High Five® System, and it was published in Plastic and Reconstructive Surgery Journal in December of 2005. Dr. Bill Adams had used the system extensively since I first developed and shared it with him, so I invited him to coauthor the paper with me and include his patient experience as well.

Tebbetts JB and Adams WP. Five critical decisions in breast augmentation using 5 measurements in 5 minutes: The high five system. Plast.Reconstr.Surg.116(7), 2005-16, Dec 2005.

More than a decade after TEPID was published, no other objective measurement system has been validated or published. High Five™ continues to be refined, and is clearly the most scientific, predictable, and objective system for objective determination of implant size and operative planning for breast augmentation. I have personally used the system or its precursors for more than two decades, and for more than a decade, I have not changed the size of an implant in the operating room from the size recommended by TEPID™/High Five™. During that time, I have published the lowest complication and reoperation rates in the history of plastic surgery, and done so in an independently monitored FDA PMA study. No other system and no other surgeon can make that claim.

The most rewarding aspect of rigidly following High Five™ is seeing what it does for patients, allowing them to enjoy out to dinner the evening of augmentation, full normal activity withing 24 hours or less, outstanding aesthetic results, and the least risks of complications, reoperations, and uncorrectable deformities. That’s why we believe so strongly in High Five™, and why the best informed patients believe in the system as strongly as we believe in it….because no other system or method delivers a comparable level of outcomes.

Why don’t more plastic surgeons use High Five™?

We hear this question frequently. The simple answer is “Because patients don’t demand that surgeons use it. Absent patient demand, surgeons simply do not have adequate incentive to change, progress, and invest time and money to learn more sophisticated methodologies.” More than a decades since all of these more sophisticated processes were published in the most respected journal in plastic surgery, a small percentage of surgeons have made the commitment to learn and apply High Five™.

As long as patients continue to accept and even promote bra stuffing and pictures for implant selection, and also accept days to weeks to return to normal activities, only a small group of committed plastic surgeons will rigidly apply High Five and deliver 24-hour return to normal activities.

If patients want to experience state-of-the-art in every aspect of breast augmentation, then patients must demand more and not accept three decades old methods of implant selection, surgical technique, and prolonged recovery.

After more than a decade, my personal opinions about why more surgeons don’t apply TEPID and High Five to the letter are the following:

  • When surgeons can make the same amount of money using three decades old techniques and decision making processes, and patients don’t demand more, there is no incentive for a majority of surgeons to change.
  • A surgeon may be too involved with other things to take the time to read and study the published scientific literature…or simply doesn’t care to take the time.
  • A surgeon may think that his or her results are already good enough, even when FDA PMA data clearly show that the average surgeon has up to a 25% reoperation rate in just 3 years, with high rates of reoperation for implant size exchange and other complications, and significant rates of uncorrectable tissue deformities.
  • A surgeon may use a few measurements, but the surgeon’s ego says that not all of the details of High Five are necessary, and some of the surgeon’s subjective opinions (not scientifically validated) are more important. The High Five “recipe” does not work optimally if a surgeon “cheats on” or modifies the system.
  • The High Five System sets rules. At times, rules say “No. We can’t do that.” Surgeons as a group never like to say “No” to any patient, because telling a patient what she may not want to hear usually risks the surgeon losing the patient and the revenue from her operation.
  • Thorough patient education is required to help patients understand the incredible benefits of a scientific, objective system like High Five, because in order to use High Five, a patient must become comfortable with a scientific alternative that may ask her to compromise her traditional shopping techniques of bra stuffing, before and after pictures, and imaging. Many surgeons do not want to spend the time necessary to educate patients to this level if they can sell an operation using older methods that are quicker.


Why am I so rigid about requiring High Five™?

I am a perfectionist and I I know what is possible for patients. I want to deliver unquestionably the best and most predictable breast augmentation results and the most rapid recovery and lowest reoperation rates in the world.

  • My track record speaks for itself. I have improved my treatment of patients consistently over my career by developing better systems, methods, and techniques.
  • I have learned that when I cheat on any system for any reason, results are compromised and patients (even those who ask me to compromise and cheat) incur risks, reoperations, and uncorrectable deformities. Those consequences are unacceptable to me.
  • I have worked for more than three decades to achieve the level of what I deliver today and to establish a scientifically validated (not opinion based) track record.
  • I am not willing to go backward and deliver less to even a single patient. If our systems and approach are not well matched to a patient, I am not the right surgeon to perform that patient’s breast augmentation. Other surgeons may choose to do less and compromise for various reasons, but that is at least one reason why their track records do not match mine.


Dallas Plastic SurgeonRead more about Dr. Tebbetts’ High Five Measurement System® for Breast Augmentation

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The Best Breast

John B. Tebbetts, M.D., is a plastic surgeon in Dallas, Texas, specializing in primary breast augmentation. Dr. Tebbetts has revolutionized the landscape of breast implant surgery through his 24 Hour Recovery® and High Five Measurement® System.

As a premier plastic surgeon in Dallas, Dr. John Tebbetts has an unmatched track record among breast augmentation surgeons. Dr. Tebbetts developed the High Five Measurement® System which allows a woman’s body to choose breast implant size for her. His breast augmentation 24 Hour Recovery® has changed the way women expect to recover after breast augmentation. Dr. Tebbetts’ method means women can routinely have breast implant surgery in the morning and be out shopping the in afternoon.

Dr. John Tebbetts regularly produces breast augmentation video content. His practice blog, The Best Breast Blog, focuses on breast augmentation patient education. It is published weekly with the latest news about breast implants, both saline and silicone implants, and answers to the most frequently asked breast surgery related questions.

Dr. John Tebbetts is the only surgeon to have a proven zero percent reoperation rate in consecutive FDA PMA studies. View the results of his case studies and before and after breast implant photos on this website.

To have the best breast implants in Dallas, contact Dr. John B. Tebbetts’ office by calling (214)220-2712 or filling out a contact form.