This document outlines the process and philosophy for primary breast augmentation. It discusses goals of creating a natural breast while minimizing risks. It describes the consultation process including discussing alternatives and pre-operative planning using measurements to determine optimal implant size and position. The surgical technique is explained focusing on minimizing blood loss and ensuring implant placement. Post-operative care aims to return patients to activity quickly and safely. Follow-up appointments assess healing and results. Throughout, the focus is on having a clear plan and meeting patient expectations to achieve good outcomes.

1. PRIMARY BREAST
AUGMENTATION
Nina S. Naidu, MD, FACS

2. Philosophy and Goals
• to create a natural-appearing breast which fills
the patient’s tissues adequately
• to minimize the risk of complications which
can result from placing a medical device into a
patient for cosmetic reasons
• to improve the body image and self-esteem of
the patient

3. Initial telephone call/internet inquiry
Goal: to get the patient into the office
• Respond to patient’s call/email immediately
• Send written information about procedure
• Initial consultation scheduled: 45-60 minutes
• Second consultation scheduled if patient
wishes to proceed with surgery: 45 minutes
for photos, implant sizing, paperwork,
additional questions

4. Initial Consultation
1. Brief history of breast augmentation
• Do implants cause disease: breast cancer,
connective tissue diseases, interference with
mammography
• Breast implant technology: saline vs silicone
• History of silicone moratorium

5. Initial consultation (con’t.)
2. Summarize the alternatives
• incision: infra-mammary, peri-areolar, transaxillary
• location: subglandular vs subpectoral
• implant type: silicone vs saline, smooth vs
textured, round vs anatomic
• size: do not guarantee a cup size!

6. Pre-operative planning
• Goal: to have a clear surgical plan prior to
surgery
-eliminates the need to use sizers
-eliminates second-guessing on the OR table
-decreases operative time
-provides more predictable results

7. Preoperative planning: High Five
Tissue Analysis (Tebbetts)
1. Implant coverage: select a pocket location which
will optimize soft tissue coverage
2. Implant volume: select implant volume to
produce optimal envelope fill (TEPID™)
3. Implant dimensions and type: selecting specific
implant characteristics
4. Infra-mammary fold location: estimate desired
postoperative infra-mammary fold position
5. Incision location: select desired incision location

8. 1. Implant coverage (pocket location)
• 1. subglandular:
– implant is exposed to breast
tissue
– soft tissue coverage is
decreased
– less risk of implant distortion
• 2. subfascial:
– above muscle to avoid muscle
distortion
– fascia provides additional
layer of coverage of implant
– Graf, Plast Reconstr Surg
2003; 111: 904-908.

9. 1. Implant coverage (pocket location)
•
•
3. subpectoral:
– complete muscular coverage of implant
– protection from breast bacteria
– possible implant displacement from muscle
– decreased incidence of capsular contracture
(Vazquez, Aesthet Plast Surg 1987; 11: 101105)
4. dual-plane: partial subpectoral placement
– I: divide muscle across IMF
– II: divide muscle and separate overlying
parenchyma up to inferior border of NAC
– III: divide muscle, separate parenchyma up to
nipple or superior border of NAC
– Tebbetts: Plast Reconstr Surg 2001; 107: 12551272.

10. Dual-plane breast augmentation
(Tebbetts)

11. 2. Implant volume
TEPID™ System measurements
– BW: base width of existing breast parenchyma
– APSS: anterior pull skin stretch
– STPTUP: soft tissue pinch thickness of upper pole
– STPTIMF: soft tissue pinch thickness at IMF
– N-IMF: nipple-inframammary fold distance under
maximal stretch
– PCSEF: parenchyma’s contribution to stretched
envelope fill

12. Pre-operative measurements
(Tebbetts: Plast Reconstr Surg 2005; 116: 2005-2016)
Base Width
APSS (anterior pull skin stretch)

13. Pre-operative measurements
(Tebbetts: Plast Reconstr Surg 2005; 116: 2005-2016)
STPTUP & STPTIMF
N-IMF

14. Pre-operative measurements
(Tebbetts: Plast Reconstr Surg 2005; 116: 2005-2016)
PCSEF (parenchyma contribution to stretched envelope fill)

15. Determining the optimal size: TEPID™
system
Base
width
(cm)
APSS
STPTUP
STPTIMF
N:IMF
PCSEF
Base width
parenchyma
(cm)
Estimated
initial implant
volume (cc)
If APSS < 2.0, 30 cc
If APSS > 3.0,
+30 cc
If APSS > 4.0,
+60 cc
If N:IMF > 9.5,
+ 30 cc
If PCSEF <
20%, +30 cc
If PCSEF >
80%, -30 cc
Estimated
implant
volume
For each
volume
indicated
Set new IMF
at N:IMF (cm)
10.5
11.0
11.5
12.0
12.5
13.0
13.5
14.0
14.5
15.0
200
250
275
300
300
325
350
375
375
400
200
250
275
300
325
350
375
400
7.0
7.0
7.5
8
8
8.5
9.0
9.5

16. 3. Implant dimensions and type
• a. shape: round versus
anatomic
-no difference in shape with
round vs anatomic implants in
upright position (Hamas,
Aesthetic Surg J 1999; 19: 369374)
• b. profile: low versus
medium versus high
-potential negative effects of
high and extra-high profile
implants (Tebbetts, Plast
Reconstr Surg 2010; 126:
2150-2159)

17. 3. Implant dimensions and type
c. fill: silicone vs saline
– more natural feel of
silicone; lower rates of
rupture, asymmetry,
malposition (Spear,
Aesthetic Surg J 2010; 30:
557-570)
d. surface: textured vs smooth
-no difference in rate of
capsular contracture b/t
textured and smooth implants
when placed in the
submuscular position (Kjoller
2001, Ann Plast Surg 47: 359366)

18. 4. Infra-mammary fold location
Base
width
(cm)
APSS
STPTUP
STPTIMF
N:IMF
PCSEF
Base width
parenchyma
(cm)
Estimated
initial implant
volume (cc)
If APSS < 2.0, 30 cc
If APSS > 3.0,
+30 cc
If APSS > 4.0,
+60 cc
If N:IMF > 9.5,
+ 30 cc
If PCSEF <
20%, +30 cc
If PCSEF >
80%, -30 cc
Estimated
implant
volume
For each
volume
indicated
Set new IMF
at N:IMF (cm)
10.5
11.0
11.5
12.0
12.5
13.0
13.5
14.0
14.5
15.0
200
250
275
300
300
325
350
375
375
400
200
250
275
300
325
350
375
400
7.0
7.0
7.5
8
8
8.5
9.0
9.5

19. 5. Incision location
• 1. infra-mammary: excellent
visualization and control;
decreased incidence of capsular
contracture (Wiener, Aesthet
Plast Surg 2008; 32: 303-306)
• 2. peri-areolar: very good
exposure, but more exposure of
implant to endogenous breast
bacteria
• 3. trans-axillary: good
visualization with endoscope;
limited to smaller gel implants
• 4. trans-umbilical: blind
dissection; limited to saline
implants

20. Pre-operative
markings
1) Mark midline
2) Mark medial
perforators 1.5 cm off
midline
3) Mark current IMF
4) Mark new IMF
5) Mark incision (4-5 cm)

21. Operative sequence
Goals: minimize blood loss,
work efficiently
1. Initial incision and
dissection to pectoralis
fascia
2. Entering the subpectoral
space, leave 1 cm cuff
-lift anteriorly with retractor;
the muscle which tents is
pectoralis and can now
be entered safely

22. Operative sequence
3. Sequence of pocket
dissection
-preserve all medial
origins of the
pectoralis muscle
-dissect inferiorly,
medial, lateral, superolateral, and finally
supero-medial

23. Operative sequence
4. Re-inspection and pocket irrigation
-check for hemostasis
-triple-antibiotic (cefazolin, gentamycin, Bacitracin)
irrigation (Adams, Plast Reconstr Surg 2006; 117: 30-36)
5. Implant placement and positioning
-insert implant, lengthen incision if necessary
-run a finger over top and bottom of implant to ensure sitting
smoothly without folding
6. Incision closure and dressing
-3-0 Monocryl running for fascia
-5-0 Monocryl subcuticular for skin
-Steri-strips for dressing

24. Post-operative Care
• Goal: to return patients to regular activity as
quickly and as safely as possible
– No special bras, no drains, no pain pumps, no
compression dressings
– Patients are permitted to shower and perform
most activities that evening, including light lifting
– No aerobic activity and no sex for two weeks

25. Follow-up visits
•
•
•
•
•
•
5-6 days postop
6 weeks
3 months
6 months: photos taken
1 year
Yearly thereafter

26. KN: 28yo, G0P0, A → full C

27. KN: pre-operative planning
Base
width
(cm)
R/L
Base width
parenchyma (cm)
10.5
11.0
11.5
12.0
12.5
13.0
13.5
14.0
14.5
15.0
Estimated initial implant
volume (cc)
200
250
275
300
300
325
350
375
375
400
APSS
13/
12.
5
1/1
-30
-30
STPTUP
1/1
If APSS > 3.0, +30 cc
STPTIMF
1/1
If APSS > 4.0, +60 cc
N:IMF
6/6
If N:IMF > 9.5, + 30 cc
+30
+30
300
325
PCSEF
If APSS < 2.0, -30 cc
If PCSEF < 20%, +30 cc
If PCSEF > 80%, -30 cc
Estimated implant
volume
For each volume
indicated
Set new IMF at N:IMF
(cm)
200
250
275
300
325
350
375
400
7.0
7.0
7.5
8
8
8.5
9.0
9.5

28. KN: style 15 304 cc smooth round
silicone, infra-mammary, dual-plane I

29. SG: 29 yo, G3P2, B → C

30. SG: pre-operative planning
Base
width
(cm)
R/L
Base width
parenchyma (cm)
10.5
11.0
11.5
12.0
12.5
13.0
13.5
14.0
14.5
15.0
Estimated initial
implant volume (cc)
If APSS < 2.0, -30 cc
200
250
275
300
300
325
350
375
375
400
APSS
13/1
3
1/1
STPTUP
1/1.5
If APSS > 3.0, +30 cc
STPTIMF
1/1.5
If APSS > 4.0, +60 cc
N:IMF
5.5/6
If N:IMF > 9.5, + 30 cc
PCSEF
-30
If PCSEF < 20%, +30 cc
If PCSEF > 80%, -30 cc
Estimated implant
volume
For each volume
indicated
Set new IMF at N:IMF
(cm)
295
200
250
275
300
325
350
375
400
7.0
7.0
7.5
8
8
8.5
9.0
9.5

31. SG: style 15 286 cc, smooth round
silicone, infra-mammary, dual-plane I

32. PG: 33 yo, G2P2, A → full B

33. PG: pre-operative planning
Base
width
(cm)
R/L
Base width
parenchyma (cm)
10.5
11.0
11.5
12.0
12.5
13.0
13.5
14.0
14.5
15.0
Estimated initial
implant volume (cc)
If APSS < 2.0, -30 cc
200
250
275
300
300
325
350
375
375
400
APSS
12.5/
12
1.5/2
STPTUP
1/2
If APSS > 3.0, +30 cc
STPTIMF
2/2
If APSS > 4.0, +60 cc
N:IMF
5/5
If N:IMF > 9.5, + 30 cc
PCSEF
-30
If PCSEF < 20%, +30 cc
If PCSEF > 80%, -30 cc
Estimated implant
volume
For each volume
indicated
Set new IMF at N:IMF
(cm)
200
250
275
300
325
350
375
400
7.0
7.0
7.5
8
8
8.5
9.0
9.5

34. PG: style 15 286 cc, smooth round
silicone, infra-mammary, dual-plane I

35. ES: 37 yo, G3P2, A → C

36. ES: pre-operative planning
Base
width
(cm)
R/L
Base width
parenchyma (cm)
10.5
11.0
11.5
12.0
12.5
13.0
13.5
14.0
14.5
15.0
Estimated initial
implant volume (cc)
If APSS < 2.0, -30 cc
200
250
275
300
300
325
350
375
375
400
APSS
14/1
4
3/3
STPTUP
2/2
If APSS > 3.0, +30 cc
STPTIMF
2/2
If APSS > 4.0, +60 cc
N:IMF
5/5.5
If N:IMF > 9.5, + 30 cc
PCSEF
+30
If PCSEF < 20%, +30 cc
If PCSEF > 80%, -30 cc
Estimated implant
volume
For each volume
indicated
Set new IMF at N:IMF
(cm)
405
200
250
275
300
325
350
375
400
7.0
7.0
7.5
8
8
8.5
9.0
9.5

37. ES: style 15, 397 cc, smooth round
silicone, infra-mammary, dual-plane I

38. Conclusions
• Have clear goals in mind at every step of the
process: consultation, pre-operative, intraoperative, post-operative
• Make sure that you and the patient have the
same expectations
• Use a systematic approach that works for you,
this will allow you to achieve better and more
predictable results

39. NINA S. NAIDU, MD, FACS
PLASTIC & RECONSTRUCTIVE SURGERY
(212) 452.1230
www.naiduplasticsurgery.com