Philadelphia -- Expanding incision sites to include areas of the abdomen for breast augmentation endoscopy offers the same advantages as umbilical entry over other approaches, said Peter Cheski, M.D., at the AACS Symposium on Body Augmentation and Contouring.
The incision site for TUBA (transumbilical breast augmentation) is through the umbilicus. "Because I've expanded it to a number of different areas, I now more commonly refer to it as 'transabdominal' augmentation." Either approach offers less scarring and recovery time over other, more traditional methods, he said.
Abdominal entry may be through an old C-section scar in the suprapubic region. Likewise, if the patient has a scar from hernia repair or gallbladder or appendix operations, Dr. Cheski may elect to enter through the old scar as opposed to placing a new scar in the umbilicus.
Patient has the last say
The decision to use an alternate abdominal site is usually driven by patent desire. "Some patients have a very small or an 'outie' belly button or other anatomical consideration where they really don't want their belly button altered. Also, fairly regularly, I see patients who have a phobia about people touching their belly buttons."
Hernia or recurrent infections from a belly button ring may be medical contraindications to umbilical entry. He also uses the abdominal approach for patients seeking abdominoplasty with breast augmentation.
"We raise the abdominoplasty flap all the way up to the costal margin. We use the transumbilical instruments to tunnel from the superior lateral aspect of the flap to the subpectoral pocket," he said.
But roughly 90 percent of his augmentations use the transumbilical approach, making an incision just under the hood of the belly button. "We tunnel on the left and right side in the subcutaneous plane and then pierce through the inframammary crease and place a dissector at the lateral border of the pectoralis major muscle." A submuscular pocket is created using specially designed dissectors. "One of the keys to good pocket shape is control and proper shaping of the inframammary crease," he added.
When that is completed on both sides, a sizer is placed in the pockets and over-inflated to 150 percent to 200 percent of the anticipated fill volume.
"Because you're really stretching things, you can see any irregularities and then further dissect them," said Dr. Cheski. Any small capillary bleeders that might be slightly oozing are also tamponaded with the pressure.
Since the sizer is disposable, damage from instruments is not a problem. He sizes the patient by seating her in different positions. "Some patients like the implant a little higher up, with more superior fullness. Some people like a little more sloping, anatural shape of the breast. And some patients like a breast that is even more sloping with the nipple riding higher on the breast; we can control all of those positions to some degree."
A small and then a large bullet-tipped dissector is used that is similar to a liposuction cannula with a spreading bullet at the end to open a pocket from the umbilicus to the submuscular pocket. Blunt hockey-stick-shaped dissectors are placed under the muscle to sweep the muscle up off the chest. "The blunt dissector will not detach the muscle medially nor will it release the inframammary crease," he said.
Another hockey stick dissector with 2-mm serrations is used to lower, control, and shape the inframammary crease. The tissue at the inframammary crease is engaged and the pocket is seesawed back and forth so it can only lower the inframammary crease 2 mm to 3 mm at a time. "You don't overdrop the crease and you have nice control over where that crease is going to be," he said.
The sizer is then removed and the corresponding implant is chosen. Implants are rolled up like a cigar and passed with the aid of a tube through the umbilicus and then inflated once in place. "I tend to use a regular-profile implant and over-inflate it slightly. But I am using more of the high-profile implants to a minimum-fill volume. I find the physics of their side-wall is better and result in less rippling. I don't want to over-inflate because then you get too much anterior projection and a more narrow implant."
Show me the scar
Advantages of a transabdominal breast augmentation include no scar on the chest or breast whatsoever, with less risk of loss of sensation to the nipple. There is also less interference with mammograms than with the periareolar approach because there is no scarring in the breast tissue. And because the procedure is sub-muscular, the breast gland and, thus, breast-feeding, are conserved.
Advantages add up
Pain and recovery are improved with the transabdominal approach as well, claimed Dr. Cheski, and he believes there is less capsule contracture. Perhaps, he added, because any collections of blood or serosanguinous fluid are drained with a gravity--dependent drain through the umbilicus. "Fluid remaining around the breast implant can form a hard crust on the implant that can contribute to capsule contracture," he theorized. Since breast tissue is not violated, staphylococcus from the breast ducts is not injected into the pocket. Minor low-grade infection may be a contributing factor to the complication.
However, Dr. Cheski is pleased with his patient outcomes. Of the last 800 cases, including 18 with abdominoplasty, there was capsule contracture in eight patients, two that required further surgery. Rippling occurred in eight patients and, in nine, deflations that required removal and replacement of the implant. None of these occurred within the first two months of surgery. One patient required a scar revision after surgery, and three patients required a mastopexy later.
"In all nine of the cases that had a deflation we were able to go back through our primary incision," whether the umbilicus or another abdominal area, he said. For capsule contracture, "We have done a capsulotomy through the belly button, although it's more difficult than the areolar approach." When doing mastopexy, you lose the cosmetic advantages that are evident with the transumbilical/transabdominal approach. "So, typically, I would just do the implant through the areola," he said.