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9 Transumbilical Breast Augmentation WithSaline andSilicone Implants
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Fig. 9.15 (continued)
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G. H. Patino
Fig. 9.16
Twelve months post-submuscular implant in a multiparous woman
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Fig. 9.16 (continued)
115
9.6 Prevention andManagement
ofComplications
• Death can be prevented by doing a very complete pre-
operative evaluation, not using general anesthesia, not
operating in high-risk patients, check all of the patients’
medications and supplements and stop those that may
cause drug interactions or may cause bleeding 2 weeks
before and 2 weeks after surgery. Complete a pre-
operative report with airway and ASA assessment, lido-
caine dose, etc.
• Lidocaine toxicity can be prevented by limiting the maxi-
mum dose of lidocaine to 55mg/kg and be aware of lido-
caine interactions. Inltrate with cannulas instead of
needles.
• Thromboembolic disease can be prevented by not using
general anesthesia or paralyzing agents. Use anti-embolic
compression devices on all patients. Give specic instruc-
tions for the patient not to travel by air or ground for more
than 2.5h for 2.5 months after the procedure. Post-pone
surgery for after 8-weeks post-partum. Identify risk fac-
tors (Personal or family history of thromboembolism,
contraceptives, smoking, cancer)
• Bleeding can be prevented by using tumescent anesthesia
and stopping medications, vitamins, herbs, and supple-
ments in the list 2 weeks before and 2 weeks after surgery.
Identify a personal or family history of easy bruising or
bleeding.
• Infection can be prevented by having the patient follow
the instructions, using antibiotics as prescribed, not shaving the breasts and using the TUBA approach.
• Pneumothorax, hemothorax, injury to other organs can be
prevented with proper surgical technique.
• Capsular contracture can be minimized by massage, soaking the implants in triple antibiotic solution, using powder
free gloves and using the TUBA approach.
• Implant malposition can be prevented with proper surgical technique and the use of the Patino mammary
implanter or an endoscope.
• An Accredited surgical facility is highly recommended.
• Hospital transfer agreement with a nearby hospital is
recommended.
• Have all airway and resuscitation equipment and medications available and ready to use by an experienced qualied physician.
• Use only mild oral sedation. Do not use moderate or deep
sedation. It is not needed and can lead to complications. If
deep sedation is used, it should be administered by an
anesthesiologist or CRNA.
• Have IV access available in all patients. Chest tubes must
be available and ready to use by an experienced
physician.
• Every patient must meet discharge criteria reviewed and
signed by the surgeon.
• Over ination by 100 or 150% is advocated by some surgeons, I do not recommend it because over ination may
be unpredictable and may over distend unintended areas.
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9.7 Trans Abdominal Silicone Breast
Augmentation: TASBA
The surgical procedure for the Trans Abdominal Silicone
Breast Augmentation is similar in nature to Steps 1–8,
described above with minor differences. Once the sizers have
been placed the breast dissection is completed and the
abdominal procedure is started.
Step A: After the Test implants are inserted, the abdominal ap is raised all the way to the costal margins bilaterally
and the tunnels are enlarged to approximately 7cm distally
and 5 cm proximately at the inframammary fold level
(Fig.9.17).
Step 2: Using a large Deaver retractor while the patient is
paralyzed by the Anesthetist, the assistant lifts the Deaver
vertically while the surgeon inserts the Silicone implants
using a no touch technique with the Keller funnel (Fig.9.18).
The Author does not close the inframammary opening but
instead advises the patient not to massage the breasts for the
rst week in order to minimize the risk of the implants
migrating into the area under the abdominal ap. The author
has not had any cases of implant migration using this technique (Figs.9.19, 9.20, 9.21, and 9.22).
G. H. Patino
Fig. 9.18 Deaver retractor being used to retract the opening and the
silicone implant is being placed in the pocket
Fig. 9.17 The access to the
submuscular pocket has been
exposed through the
abdominoplasty incision
Widening the access to the
Implant pocket
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Fig. 9.19 Twelve months post-submuscular implant in a multiparous woman who underwent abdominoplasty along with breast augmentation
through a transabdominal approach
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G. H. Patino
Fig. 9.20 Three months post-submuscular implant in a lady who underwent abdominoplasty along with breast augmentation through a transabdominal approach
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Fig. 9.21 3 weeks post-submuscular implant in a lady who underwent an extended abdominoplasty along with a breast augmentation through the
transabdominal approach
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G. H. Patino
Fig. 9.22 Twelve months post-submuscular implant in a patient who came in for abdominoplasty and breast augmentation
9.8 Transumbilical Silicone Breast
Augmentation (TUSBA)
9.8.1 Surgical Procedure
The surgical procedure for Transumbilical Silicone Breast
Augmentation is similar in steps 1–8 as discussed above
with minor differences.
Step 1: The belly button incision that is made using the
#11 blade is 6cm versus a 3cm incision and instead of the
incision been limited to the superior umbilical hood it
extends all the way to the inferior umbilical hood in a circumferential manner. Occasionally when larger implants
have to be used, the incision may need to be extended for 1
or 2 cm to the infraumbilical midline in order to facilitate
insertion of the silicon implant.
Step 2: The subcutaneous tunnels are created in the same
way, but during TUSBA, they are more lateral to prevent
them from connecting to each other. The tunnels are also
wider (5 cm at the level of the inframammary folds, then
increased to 7cm at 5cm intervals so that it is 12cm in the
mid portion, decreasing to 7cm and then down to 5cm at the
level of the superior umbilical hood) to ensure that the silicone implant is able to pass through the Keller funnel
(Fig.9.23).
Step 3: Once the test implants are inserted with the
described technique using the Patino mammary implanter.
The test implants are deated by 100ml and pushed down
manually through the inframammary fold internal opening
into the tunnels where they are reinated by 100 or 200ml in
order to assist with the soft expansion of the tunnels. The test
implants are then deated to the actual desired silicone
implant size selected by the patient and pulled out through
the umbilical incision. The test implants (Sizers) are then reinserted fully inated via the umbilical incision using the
Keller funnel. This process may need to be repeated as many
times as needed until the test implant can go in and out of the
subpectoral or subglandular pocket easily prior to proceeding with the insertion of the silicone implants using the
Keller funnels as described. It is important to remember that
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121
the test implant is always pushed down manually into the
tunnels only when it has been deated by 100mL, but, when
the test implant is advanced into the subpectoral or subglandular pockets, it is inserted at its full desired nal ination
corresponding to the patient’s desired silicone implant size.
5cm
12 cm
Fig. 9.23 Width of the soft tissue tunnel through which the silicone
breast implant has to pass when placed through the umbilicus
5cm
Step 4: Inserting the silicone implant is done using a “no
touch” technique with the Keller funnel. This technique also
decreases the risk of infection. The silicone implant is
soaked in triple antibiotic solution. Unlike the saline
implants which are inserted using the Patino Mammary
implanter, the silicone implants are inserted manually using
the two Keller funnel technique described by the author.
One Keller funnel is inserted in the tunnel, leading up to one
breast, using the Patino mammary implanter. Snowden or
Army Navy retractors are used at the umbilical incision site.
The Keller funnel is secured between the retractors and the
skin. As the retractors are lifted, vertically, the silicone
implant is inserted with a Keller funnel into the second
Keller funnel previously inserted into the tunnel. The silicone implant is then advanced manually through the tunnel
into the subpectoral pocket while the assistant lifts the pectoralis major muscle. This maneuver is not necessary for the
insertion of subglandular implants. The same process is then
repeated on the other breast. If the implant is ruptured during insertion, the implant and any silicone spillage is usually
contained and removed as the Keller funnel is removed
(Fig.9.24a–c).
a
b
c
Fig. 9.24 (a) The Silicone implant is being prepared for placement through the umbilical incision. (b) The Implant is seen in the tunnel in the
anterior abdominal wall. (c) It is now being squeezed into the subglandular pocket
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G. H. Patino
Last step is to close the umbilical incision with a 4-0
Monocryl suture. Steri-strips and an island umbilical dressing are placed, like the TUBA.No drains, again, are needed
for this technique. The nal results look very natural
(Fig.9.25).
Fig. 9.25 Transumbilical placement of silicone implants in a young lady who did not want any scars in the breasts or armpits
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