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Final Review
• Abdominoplasty is one of the most
demanded procedures after pregnancy.
• Mastering anatomy is key to performing
a safe procedure.
• Correct selection of patient ensures better outcome.
• Correction of rectus diastasis may
improve lower back pain.
• Placement of scar is probably the most
important technical issue.
• Patient satisfaction is usually very high.
• Long-lasting results are achieved as
long as patient’s weight is unmodied.
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Simultaneous Correction
https://t.me/medicina_free
ofPostpartum Breast/Belly
Badness Utilizing TABA
RichardJ.Zienowicz andErcanKaracaoglu
26
Take-Home Points
The most common contour changes after pregnancy are seen in breast and tummy including
both anks and lateral breast areas.
• Mommy makeover has two procedures combined in one surgery: breast contouring and
abdomen contouring.
• TABA (transabdominal breast augmentation)
and abdominoplasty combined surgery
through an abdominoplasty incision is a satisfactory option for mommy makeover.
• TABA is preferred in the pursuit of minimizing incisions and maximizing aesthetic results
in one single procedure.
26.1 Introduction
Contour changes and deformities of the breast
and abdominal wall after pregnancy are common.
Breast contouring and abdominoplasty are surgeries that make signicant improvement in body
contour of women in her post-maternity period. It
is widely known as mommy make over.
R. J. Zienowicz (*)
Division of Plastic Surgery, Brown University, School
of Medicine, Alpert Medical School,
Providence, RI, USA
E. Karacaoglu
Department of Plastic Surgery, Bahcesehir University,
School of Medicine, Istanbul, Turkey
Mommy makeover has two procedures combined in one single surgery: breast contouring
and abdomen contouring. Breast contouring after
pregnancy is a fruitful and effective procedure in
which the excess skin and ptotic breast tissue are
removed and the contour, mount of the breast
restored and regained. Even a better shape, volume, and contour can be achieved with this breast
surgery. Tummy contouring after pregnancy is
also a signicant surgery in which the excess skin
and fat are removed, and the muscle and fascia
layers, i.e., so-called myoaponeurotic layers, are
tightened, shaped, and repositioned.
It has been proved that abdomen and breast
contouring increases the self-esteem, the quality
of life, and self-image. This combined surgery
also increases a woman’s condence in sexual
encounters.
TABA (transabdominal breast augmentation)
and abdominoplasty combined surgery through
an abdominoplasty incision is a favorable technique. We prefer transabdominal breast augmentation in the pursuit of minimizing incisions and
maximizing aesthetic results in one single procedure. Indications, technique, post-op management, and pearls and pitfalls regarding this
technique will be found in detail here in this
chapter [1].
The technique of transabdominal placement
of breast implants was rst described by
Hinderer in 1975 in a single case report [2].
There had been subsequent published reports
© Springer Nature Switzerland AG 2023
M. Gomes-Ferreira, J. Olivas-Menayo (eds.), Post-maternity Body Changes,
https://doi.org/10.1007/978-3-030-43840-1_26
435
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R. J. Zienowicz and E. Karacaoglu
with short- term follow-up [3]. All of these combined techniques were done under general
anesthesia [3–7]. Here, in this chapter, we will
be presenting our experience with monitored
anesthesia care in an ambulatory setting using
propofol, ketamine, and intercostal nerve
blocks [8–12].
26.2 Patient Selection
There are two patient populations that are candidate for combined TABA and abdominoplasty.
The rst group is the patients who gave birth
and desire abdominoplasty and have concomitant involutional breast volume loss. Patients
who request a combination of breast augmentation and abdominoplasty in one single surgery
are optimal candidates. The second population
is patients who seek abdominoplasty with combined breast augmentation and has moderate
skin laxity after weight loss of 25 to 50 kg.
TABA can be used effectively in this group of
patients as well, if ptosis is not severe (Grade 1
and occasionally Grade 2 ptosis and
pseudoptosis).
Patients are required to qualify for full
abdominoplasty and bilateral breast augmentation. Patients who already had a signicant previous breast surgery and upper abdominal
surgery are not considered good candidates for
this surgery. Similarly, patients with signicant
breast ptosis (some of the Grade 2 ptosis and all
Grade 3 ptosis) are not candidate for this combined surgery.
Patients should quit smoking at least 4weeks
before surgery. Smoking should not be allowed
until full recovery is established.
26.4 Anesthesia
Majority of surgeries can be performed under monitored anesthesia care in the outpatient setting.
Briey, the technique for monitored anesthesia
care is induction with a combination of propofol
and ketamine followed by nerve blocks. Nerve
blocks are as follows: posterior intercostal block
from T4 to T12 using a combination of lidocaine,
epinephrine and bupivacaine, and anterior intercostal block of T2 and T3in the posterior axillary line
and bilateral ilioinguinal nerve blocks. Patients are
also given a strong antiemetic combination including metoclopramide, droperidol, and ondansetron.
Patients receive propofol, fentanyl, ketamine, and
midazolam as needed during the operation.
26.5 Surgical Technique
Surgery begins with conventional abdominoplasty ap dissection. Umbulicus is freed.
Dissection ends up at arcus costarium (Fig.26.1).
A funnel-shaped tunnel 8–10cm long is made
with distal openings at the inframammary fold. A
4cm wide opening is created with electrocautery to
pass through the inframammary fold. This last
opening is made to allow the passage of a gel lled
or saline implant. Electrocautery is also used to free
up the lower insertion of pectoralis major muscle.
26.3 Marking
The conventional marking for a low bikini incision is performed with the patient in the standing
position. Both inframammary folds (IMF) are
marked.
Fig. 26.1 Intraoperative image of transabdominal breast
augmentation approach. Surgery begins with conventional
abdominoplasty ap dissection
26 Simultaneous Correction ofPostpartum Breast/Belly Badness Utilizing TABA
https://t.me/medicina_free
symphysis with interrupted and running permanent sutures is done. Excess skin is removed. For
further postoperative pain relief, bupivacaine is
injected into the bilateral rectus sheaths just lateral to the suture plication. Two Jackson–Pratt
drains are placed and brought out in the midsuprapubic region. Finally, the lower abdominal
skin is closed in layers using absorbable barbed
sutures while umbulicus inset is completed. Final
adjustment can be made with liposuction cannulas. This nal touch is made for both anks, upper
Fig. 26.2 Intraoperative image of transabdominal breast
augmentation approach. Once the subpectoral plane is
entered, a balloon dissector is introduced and inated to
develop the pocket for implant placement. Further pocket
dissection is performed with a hockey-stick dissector
abdomen, and for any area that adipose tissue
thickness is not homogenous or redundant.
26.6 Postoperative Care
437
Further dissection is done bluntly with nger.
Finger dissection helps to enter the subpectoral
space with simultaneous distraction on the breast
tissues to help elevate the pectoralis major muscle away from the chest wall. A Snowden–Pencer
balloon dissector is then inated to 600 cc to
dene the subpectoral pocket, with further adjustments made with a hockeystick dissector and
blunt nger dissection as necessary (Fig.26.2).
After adequate pocket creation, the implant is
placed. To minimize trauma during implant insertion, a Keller Funnel device can be used. This can
be especially helpful for textured implants.
Implants may be placed above the muscle to
address a greater degree of ptosis. But our preference is subpectoral placement unless otherwise
indicated.
The patient is placed in the sitting position to
assess and evaluate for symmetry and further
adjustments are made while the patient is still in
sitting position. After further adjustment, the
inframammary tunnels are partially closed with
permanent suture of no. 1 Maxon (Covidien,
Manseld, MA.USA) In addition, external bolster sutures of 0-Prolene (Ethicon, Inc.,
Somerville, N.J.USA) on Xeroform (Covidien,
Manseld, MA.USA) pledgets are used to further dene the inframammary fold.
After breast augmentation is completed, procedure continues with conventional abdominoplasty. Fascial plication from the xiphoid to pubic
After dressing application, the patients are sent to
the recovery room. Patients are traditionally discharged to home after appropriate monitoring
unless they had extensive additional procedures
warranting inpatient admission.
Patients with following comorbidities might
be evaluated for inpatient admission:
• Patients with body mass index (BMI) over
30kg/m
2
• Diabetic patients (especially insulindependent patients)
• heavy smokers
During postoperative visits, patients are
instructed in appropriate taping and breast bandeau wear, if indicated.
26.7 Complications
Complications can be classied as abdominoplasty and breast related.
The most common abdominoplasty-related
complication is wound complications in the distal end of abdominoplasty ap. Minor wound
dehiscence might be seen. These wound problems are simply managed with ofce-based
wound care. Other complications are hematoma
and seroma. Breast-related complications are
double- bubble, implant malposition in the sub-
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R. J. Zienowicz and E. Karacaoglu
glandular plane, capsular contracture (including
Baker grade 3). Overall, our minor complication
rate is 21.9%.
Major complications are seen in patients with
comorbidities such as patients with body mass
index (BMI) over 30 kg/m2, diabetic patients
(especially insulin dependent patients), heavy
smokers. Overall, major complication rate is 7%
in our daily practice for TABA cases.
Key Points
• Transabdominal breast augmentation in the
properly selected candidates is an excellent
choice for those who desire both abdominal
and breast rejuvenation.
• It is an outpatient procedure and is tolerated
very well under monitored anesthesia care
with nerve blocks.
• The elimination of the additional incision,
especially on the breast, where telltale scar
hypertrophy can occur, is a distinct
advantage.
• The procedure also allows for superior reposi-
tioning of the inframammary fold with simple
suture placement.
• Natural gravitational drainage of the breast
dissection site into the abdominoplasty region
helps to prevent blood and serum accumula-
tion within the implant pocket.
• A true no-touch technique where the inserted
breast implants never come in contact with
skin ora may lead to overall decreased cap-
sular contracture development by circumvent-
ing bacterial contamination associated with
biolm production.
• The symptomatic capsular contracture rate is
minimal (0.8%)
• The majority of complications is minor and
can be managed in the ofce setting.
Complication rates paralleled those of prior
published reports for abdominal contour pro-
cedures in women.
Pearls and Pitfalls
• The majority of cases (94%) can be performed
under monitored anesthesia care with inter-
costal nerve blocks.
• Operative time is approximately 2.5h.
• There is denitely a learning curve.
• Implants are placed in almost 95% of cases in
subpectoral plane, and predominantly gellled implants (almost 70%) are preferred.
• The average implant placed is 350cc.
• TABA lets to combine additional procedures
at the same operative setting. The most commonly requested additional procedures are
suction-assisted lipectomy, fat grafting, scar
revisions, nipple reduction, and purse stringing of the areola.
26.8 Conclusion
After a single case report by Hinderer in 1975,
there have been only very few case series over the
ensuing decades examining the safety, efcacy,
and outcomes of transabdominal breast augmentation [2–7]. Our large series published in 2017
highlights the benet of breast augmentation
delivered through an abdominal route combined
with abdominoplasty through a single incision
for subpectoral or subglandular placement of
either silicone or saline prostheses [1]. This is the
largest reported series of transabdominal breast
augmentation to date, providing long-term follow-up in a diverse population. We experienced
that the procedure is a safe, straightforward technique with excellent patient outcomes in the
appropriately selected population.
It is worthy to underline the importance of
ideal candidate. Ideal candidate is a healthy, minimally to moderately ptotic patient who has completed birth-giving and is eligible for both breast
augmentation and abdominoplasty. Patients, who
are either postpartum or do not desire children,
are candidate for this combined surgery.
Patients who had large-scale weight loss (25–
50kg) either through laparoscopic gastric bypass
or through intensive lifestyle modication can
also be considered good candidates for this
procedure.
For the subset of patients who undergone gas-
tric bypass operation, the concerns for nutritional
decits should be addressed preoperatively. It
should be emphasized that there is no association
with any documented major or minor complica-
26 Simultaneous Correction ofPostpartum Breast/Belly Badness Utilizing TABA
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439
tions in this specic patient subset [13]. Patients
with abdominal laxity and minimal ptosis, who is
done with childbearing and without medical
Fig. 26.3 Patient: A
38-year-old woman with
a history of hypomastia
and two prior
pregnancies presenting
with lower abdominal
skin laxity and moderate
ptosis. Procedure: This
patient underwent
transabdominal breast
augmentation,
abdominoplasty, and
suction assisted
lipectomy to the anks
and thighs with
subpectoral placement
of 450-cc implants
bilaterally. (Left)
Preoperative images.
(Right) Postoperative
result at a follow-up
appointment 21months
after the operation
comorbidities, can achieve good outcomes with
TABA and abdominoplasty combined surgery
(Figs.26.3, 26.4, 26.5, and 26.6).
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R. J. Zienowicz and E. Karacaoglu
Fig. 26.4 Patient: A 55-year-old woman with a history of
umbilical hernia repair, C section delivery, and three prior
pregnancies presenting with bilateral hypomastia and
lower abdominal skin laxity. Procedure: The patient
underwent transabdominal breast augmentation and
abdominoplasty in addition to suction-assisted lipectomy
Abdominoplasty wound complication rates
are parallel to standard rates [14–16] Hensel etal.
reported an overall complication rate of 32% for
abdominoplasty [15]. Our major complication
rate is 7.0% and our minor complication rate is
21.9%. The existing literature also delineates an
increased risk of complications in smokers, diabetics, and obese patients [16].
Combined procedures, i.e., breast surgery and
tummy surgery, in one single stage has been a
subject of debate. But combined standard cosmetic breast and abdominoplasty procedures
have been previously shown to be good [17]. The
majority of complications is at the abdominoplasty site and parallel to the complication rate of
abdominoplasty alone. Davison etal., Grazer and
Goldwyn have reported higher rates of deep
and fat grafting to the central chest. The patient underwent
subpectoral placement of smooth, round, high-prole
saline implants; 320-cc implants were inserted bilaterally.
Shown here are images obtained preoperatively (left),
1 year postoperatively (center), and 10 years
postoperatively (right)
venous thrombosis and pulmonary emboli after
abdominoplasty [18, 19]. We have a lower deep
venous thrombosis rate and no pulmonary
embolus case. It may be related to performing
our surgeries in the outpatient setting and having
the patients immediately ambulated [12]. The
advantages of early ambulation after surgery are
widely known in the plastic surgery literature
[20, 21]. We believe that the type of anesthesia
we used and its help to motivate our patients for
early mobilization and nally our early mobilization helps to minimize deep venous thrombosis
risk.
Breast complication rates are signicantly
lower than that of the abdominoplasty. It is clear
that there is an open drainage of the implant
pocket into the abdominoplasty area. This aids in
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