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TUBA: Transumbilical Breast
https://t.me/medicina_free
Augmentation
EhabAkkary andRobertShumway
8
8.1 Introduction
Breast augmentation (BA) is one of the most common procedures performed in cosmetic surgery. The procedure comprises enhancing the volume of the breast using implants
(saline or silicone), autologous fat transfer and aps. In this
chapter, we will focus on BA using implants. Silicone
implants are more widely used than saline implants for many
reasons including the feel of the breast, less sloshing as well
as a more natural feel and the absence of a valve that might
cause deation if it malfunctions. However, saline implants
are still appealing to many patients as saline implants are
usually cheaper than silicone, some patients are concerned
about silicone implant rupture with a possibility of silicone
migration and granulomas, and one of the very important
reasons is the ability to place saline implants, via transumbilical approach, without placing any scars on the breast.
In the eld of cosmetic surgery, we always strive to hide
our incisions and create scars that are barely visible.
Transumbilical BA (TUBA) represents a distinctive approach
where patients can achieve BA without having any scars
placed on the breast. The common approaches for implant
placement are via: Inframammary crease (IMC), periareolar,
and transaxillary. TUBA is a procedure that has not been
widely accepted by many surgeons likely because of the
need for different skill set in addition to the usual surgical
skills needed for placement of breast implants, the need for
endoscopic skills and extra equipment. Dr Robert Shumway,
the senior author on this chapter has recently published the
Supplementary Information The online version contains supplementary material available at
E. Akkary (*)
Akkary Surgery Center, Morgantown, WV, USA
e-mail: eakkary@yourdreambody.com
R. Shumway (
Shumway Cosmetic Surgery and Laser Institute University
Center Ln, San Diego, CA, USA
*)
https://doi.org/10.1007/978- 981- 99- 3726- 4_8.
largest TUBA series to date. In this chapter, we will focus on
the standardized approach Dr Shumway utilizes for this procedure, it will be referred to as “Shumway TUBA Protocol.”
8.2 Historical Background
oftheProcedure
The rst TUBA procedure was reported by Johnson and
Christ in 1993. Technical modications were proposed by
Dowden and Caleel 7 years later stressing on the importance
of using blunt instruments and avoiding aggressive dissections with the TUBA instruments. They also presented a very
important principle in TUBA procedure which is avoiding
angling the instruments towards the abdominal or thoracic
cavity which can be easily overlooked during TUBA surgery
(Johnson and Christ 1993; Dowden 2000; Caleel 2000).
The 1990s were the Golden years for TUBA because of
the FDA withdrawal of the silicone implants from the
U.S.Market. This led to saline implants being the only available implant for BA.Naturally, TUBA cases increased during that time. As silicone implants got reintroduced into the
U.S.Market, the number of saline implants decreased, and
TUBA cases subsequently declined. However, TUBA still
represents an excellent option for patients and need to be part
of the discussion with patients when they come for consultation for breast implants. Making patients aware of the different types of implants and approaches is part of the informed
consent process and proper medical care. If the surgeon does
not recommend TUBA or does not perform it, this has to be
disclosed to the patient so the patient can make a proper
informed consent.
In my practice, only small fraction of patients gets saline
implants but 100% of the patients receive information about
saline and silicone implants and the different approaches
with the advantages and disadvantages of each including the
TUBA approach. As different surgical specialties evolve and
develop minimally invasive techniques, this should not be
different in cosmetic surgery. The less incisions the better,
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
M. Thomas, J. D‘silva (eds.), Manual of Cosmetic Medicine and Surgery, https://doi.org/10.1007/978-981-99-3726-4_8
93
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E. Akkary and R. Shumway
the smaller the incisions the better and the farther the incision
is from the implants the better. These basic surgical principles should prompt many physicians to consider adding
TUBA to their practice. The relatively low number of TUBA
surgeons is reected in the surgical literature with relatively
low number of publications about the procedure.
Another important topic to discuss when it comes to
TUBA is the off-label nature of the procedure (Guidance for
Industry and FDA Staff 2006). This is another reason that
leads to some surgeon’ hesitation to introduce TUBA to their
practice. Therefore, it is reasonable to look at the historical
background of this issue and fully understand it before performing the procedure. Some people, even healthcare providers, are confused about the term “off-label” thinking it
means the procedure is illegal or prohibited by law. This is
entirely false. Physicians can use medications and products
in an “off-label” fashion as long as they follow proper guidelines, medical and surgical principles. The patient must be
informed about the off-label nature of the treatment.
The reasons TUBA was considered off-label are interesting and stemmed from poor understanding of the procedure
by some physicians early on. In general, any variation from
a company’s drug or device application to the U.S.Food and
Drug Administration (FDA) would render the use off-label.
The original industry application to the FDA included the
more commonly used approaches; inframammary, periareolar, and transaxillary. Therefore, any other approach would
fall under the “off-label” category. To put this into perspective, if the patient has previous scar on the breast from a
breast biopsy and this scar was used to place the implant,
then this would be considered “off-label” because using an
old scar was not included in the FDA application. Placing an
implant through an old scar, TUBA or via transabdominal
approach during an abdominoplasty (also known as transabdominal breast augmentation or TABA) normally does not
void the warranty of the implant by the manufacturer.
However, previous statements by the implant manufacturers
led to some confusion about the warranty when implants are
placed through TUBA.
The statements recommended against the use of endoscopy when performing breast implants and naturally this
would lead to recommendation against TUBA as endoscopy
is commonly used during this procedure especially in the initial cases. The misleading and confusing statements occurred
because of the lack of knowledge about TUBA during an
FDA hearing. Before we get into what occurred in this hearing, it is important to mention that recommending against the
use of endoscopy in breast implants simply contradicts with
the “on-label” use of endoscopy while placing the implants
via transaxillary approach. This obviously shows that the
statement by the manufacturers against TUBA were wrong
and confusing. Historically, to our knowledge, the companies have not been denying warranty for implants that were
placed via TUBA approach.
Therefore, what happened during the FDA hearing
approximately 20 years ago? TUBA was discussed briey in
this meeting. There were two plastic surgeons that were present during the hearing who did not have adequate knowledge
about the procedure. The FDA committee members were
told that the implants are “shoved in through an endoscope.”
This clearly reects the lack of knowledge of the surgeons
who attended the hearing and clearly shows that they had not
even seen a single TUBA case or an endoscope. The endoscope is a solid structure, and the implant cannot be placed
inside the endoscope. Obviously, this false statement and
misrepresentation of the procedure led to the result of TUBA
being off-label (Dowden 2008; Dowden etal. 2002).
It is imperative to clarify that off label use of a medical
device is legal (except if said treatment is specically prohibited). The Federal Food, Drug, and Cosmetic Act allowed
Physicians the off-label use of any approved, legally marketed medical device. The 1997 FDA Modernization Act
allows the same (https://www.fda.gov/; Akkary etal. 2019).
8.3 Classication
TUBA can be classied into subglandular or subpectoral
based on pocket creation and implant placement. Dr.
Shumway published the largest series to date at the American
Journal of Cosmetic Surgery comparing both types. This was
a retrospective study of all TUBA cases performed by Dr.
Shumway. The study included 2263 patients (4526 saline
breast implants). The data extended over two decades from
1994 to 2017. All patients were females, no gender transformation operations were included in the study. Average age of
the patient on the day of surgery was 28 years old. All procedures were performed under monitored IV sedation with
tumescence anesthesia in a certied surgery center. Patients
were divided evenly between the subglandular and subpectoral arms of the study. There was only one conversion to periareolar approach early on during the initial experience. The
study showed low incidence of complications and high
patients’ satisfaction. Five cases (0.2%) of postoperative
hematoma were encountered, 4 of them were in the subpectoral aspect, there were no seromas in the breast, abdominal
wall or umbilicus. 5% capsular contracture was recorded
during a 2-year follow-up. Only three patients had supercial umbilical wound infection that was easily treated by
antibiotics and local wound care and no altered nipple sensation was encountered. The study showed very high patient
satisfaction (Akkary etal. 2020) (Table8.1).
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Table 8.1 Dr. Shumway’s experience with TUBA
Total Subglandular Subpectoral
Number of patients 2263 patients (4526 implants
Number of conversions to another
approach (periareolar)
Postoperative hematoma 5 (0.2%) 1 (0.04%) 4 (0.16%)
Postoperative seroma 0 (0%) 0 (0%) 0 (0%)
Postoperative abdominal wall seroma 0 (0%) 0 (0%) 0 (0%)
Average postoperative follow-up 2 years 2 years 2 years
Grade III, IV capsular contracture 113 (5%) 68 (3%) 45 (2%)
Supercial umbilical wound infection 3 (0.14%) 1 (0.04%) 2 (0.1%)
altered nipple sensation 0 (0%) 0 (0%) 0 (0%)
Patient satisfaction (1–10) 9 9 9
placed)
1 (0.04%) 0 (0%) 1 (0.04%)
1064 (47%) 1199 (53%)
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8.4 Examination andConsultation
Process
TUBA evaluation does not signicantly differ from evaluation for any other approach of BA.Detailed history is taken
focusing on personal and family history of breast disease,
gynecologic and breast-feeding history, personal and family
history of breast cancer, any signicant systemic disease and
use of medications including anticoagulants. Further examination of the breast includes inspection, palpation, examination of the breast for asymmetry, ptosis, any pathology
including but not limited to lumps, discharge or bleeding per
nipple, axillary lymphadenopathy, and any bony deformities.
It is important to perform a thorough abdominal examination
focusing on ventral, incisional or umbilical hernias when
planning TUBA.The following measurements are taken during our evaluation:
1. The distance from the sternal notch to the nipple
2. The distance from the mid-clavicle to the nipple
3. Intermammary distance
4. Inter-nipple distance
5. Breast width
6. Distance from the nipple to the inframammary crease on
superior stretch
7. Areolar dimensions
8. Distance from the sternal notch to the navel
9. Pinch test of the superior pole of the breast
10. Band, bust, waist and hip measurements.
We perform thorough consultation with the patients and
educate them about the different methods of BA, the different types of implants and the different approaches to place
breast implants. This is done during the initial consultation
process. Patients are then given educational material to take
home and are encouraged to contact the ofce with any
questions.
The patients are then brought back for a preoperative visit
with the surgeon and the procedure is again discussed in
depth and their knowledge and understanding is assessed.
All patients are requested to have a preoperative mammogram if they did not have one within a year. If patients decline
to have a mammogram, they are asked to sign an informed
refusal consent. I ask the patients to handwrite parts of the
consent, these include the size and prole of the implant,
saline or silicone, smooth or textured, round or anatomical,
above or below the muscle, the incision approach, if a breast
lift is being performed at the same time, and the type of anesthesia (oral anxiolysis, IV sedation, general anesthesia).
8.5 Shumway TUBA Protocol
On arrival to the Surgery Center on the day of surgery, an
updated history and physical and urine pregnancy test are
obtained. The procedure is again discussed and conrmed
with the patient. Preoperative pictures are taken, and preoperative markings are done with the patient in standing
position.
In addition to the standard preoperative markings for BA,
additional markings are made for the tunnels that extend
from the umbilicus to the breast. Based on the type of implant
placement, subpectoral or subglandular, the line from the
umbilicus to the breast differs. If the implant will be placed
in a subglandular plane, the line is drawn from the umbilicus
to the medial aspect of the breast (medial to the nippleareolar complex (NAC)). If the implant will be placed in a
subpectoral plane, the line is drawn from the umbilicus to the
lateral aspect of the breast (lateral to the NAC).
Tumescence is prepared at double strength the standard
Klein solution (0.2% lidocaine concentration and 0.0002%
Epinephrine). The patient is placed on the bed in supine position with the arms extended at 90° angle over arm boards.
The patient is monitored throughout the procedure with non-
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E. Akkary and R. Shumway
invasive hemodynamic monitoring, three lead EKG, and
pulse oximetry. The procedure is done under monitored IV
sedation. I routinely use Bispectral Index monitor (BIS)
(Medtronic, Minneapolis, MN, USA) to assess the level of
sedation and electromyography (EMG). After IV sedation,
the patient is prepped and draped in the standard surgical
fashion and tumescence is started.
Proper tumescence technique is key when performing
TUBA.The surgeon must ensure the placement of the tumescence solution into the proper planes to decrease the risk of
bleeding during TUBA procedure. Shumway TUBA Protocol
proposes a slightly different tumescence technique based on
the pocket placement.
The nature of the pectoralis major muscle attachment is
important to keep in mind when performing TUBA. The
muscle is attached rmly to the ribs and the sternum medially but loosely attached to the serratus anterior and external
oblique laterally. This is an important point when performing
TUBA in terms of tumescence infusion and pocket creation.
When lifting the breast up, the muscle has very limited
mobility medially but more mobility laterally. Therefore, in
subglandular pocket placement, the access is medial to the
NAC since lifting the breast up essentially leaves the muscle
in place and the plane between the breast tissue and the muscle can be accessed at a horizontal plane parallel to the chest
wall above the muscle. While, in subpectoral pocket placement, the access is lateral to the NAC since lifting the breast
up essentially tents the muscle away from the chest wall and
the plane between the muscle and chest wall can be accessed
at a horizontal plane parallel to the chest wall below the
muscle.
8.5.1 Tumescence Infusion inSubglandular
Pocket Placement
• Tumescence infusion pump is used that is connected to
tumescence tubing and 20-gauge spinal needle.
Tumescence infusion cannulas are not used in this
setting.
• Inltrate tumescence into the umbilicus and the subcuta-
neous tunnels following the preoperative markings.
• 500mL of tumescence is infused into each breast (tumes-
cence volume may vary per patient based on the pocket
size. Also, we recommend infusing more tumescence in
the initial TUBA cases if needed).
• The breast is gently lifted up and percutaneous tumes-
cence injection is done using the 20-gauge spinal needle
medial to the NAC at a horizontal plane over the muscle
medially.
• Always keep the needle in a horizontal plane to avoid
injury to the lung or pleura.
• Keep infusing tumescence until the breast is lifted up
medially then switch to the lateral portion of the breast.
• Gently lift the breast up and access the subglandular plane
in the same fashion. Avoid excessive tension on the breast
as this will lead to tenting the muscle and the tumescence
can be erroneously infused into the subpectoral plane.
8.5.2 Tumescence Infusion inSubpectoral
Pocket Placement
• Tumescence infusion pump is used that is connected to
tumescence tubing and 20-gauge spinal needle.
Tumescence infusion cannulas are not used in this
setting.
• Inltrate tumescence into the umbilicus and the subcutaneous tunnels following the preoperative markings.
• 250mL of tumescence is infused into each breast (tumescence volume may very per patient based on the pocket
size. Also, we recommend infusing more tumescence in
the initial TUBA cases if needed).
• Lift the lateral edge of the pectoralis muscle close to the
axilla. Access the subpectoral plane in this area with the
20-gauge spinal needle while keeping the muscle lifted at
all times and going at a horizontal or slightly inclined
plane pointing up to avoid violation of the pleural cavity.
• Start with infusion of tumescence volume laterally to start
lifting the muscle then slowly advance your needle medially while keeping the muscle lifted and keeping the needle at a horizontal plane or slightly inclined plane pointing
up to avoid violation of the pleural cavity.
• After the superior pole is inltrated in the retro pectoral
plane, change the needle into an inferomedial direction
keeping the same planes as above.
• Remove the needle and then place it medially (from the
inferior aspect of the breast pointing the needle towards
the head of the patient) in a horizontal plane parallel to the
rib cage to inltrate the muscle and the retro pectoral
plane at the medial attachments.
• The inferomedial attachments of the muscle are then inltrated (from the inferior aspect of the breast pointing the
needle towards the head of the patient) in a horizontal
plane parallel to the rib cage to inltrate the muscle and
the retro pectoral plane.
Proper tumescence infused into the correct planes is very
important to have a smooth TUBA procedure. It is imperative, especially during the initial TUBA cases, to conrm the
presence of adequate volume of tumescence in the correct
plane endoscopically as will be discussed later in this
chapter.
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8.6 After Tumescence, the Protocol
Consists oftheFollowing Steps
1. Umbilical incision
2. Abdominal wall tunnel creation
3. Pocket creation
4. Implant placement
5. Umbilical closure
6. Postoperative compression
8.6.1 Umbilical Incision
• Implementing meticulous technique while performing the
umbilical incision in TUBA creates an aesthetically pleasing navel after the procedure.
• A 3-cm incision is made using ten scalpel blades (Fig.8.1).
• The abdominal wall is lifted up above the umbilicus and
the incision is made under the superior umbilical fold
using the scalpel held in a horizontal direction.
• This technique helps in keeping the incision within the
umbilical ring and therefore allows for a virtually scarless
surgery as this incision is not seen. Also, it avoids injury
to the umbilical stalk.
8.6.2 Abdominal Wall Tunnel Creation
• Mayo scissors are introduced through the umbilical inci-
sion and used to dissect the umbilical tunnel following the
preoperative markings.
• The tunnel aims towards the lateral portion of the breast if
a subpectoral pocket has to be created and towards the
medial portion of the breast if a subglandular pocket will
be created.
Fig. 8.1 Umbilical incision
• The plane of dissection should be at the anterior rectus
fascia or in the subcutaneous tissue if there is enough fatty
tissue in the anterior abdominal wall.
• Very supercial dissection in the subdermal plane should
be avoided to avoid skin injury, scarring and
irregularities.
• Creating the tunnel bilaterally will leave a bridge of subcutaneous tissue in the supraumbilical area between both
tunnels. We routinely incise this bridge with Mayo scissors to enable easy introduction of the TUBA instruments
into the subcutaneous tunnels.
• Endoscopic visualization using a 10mm/0 or a 10mm/30°
scope is used to conrm proper tunnel dissection above
the rectus sheath fascia.
8.6.3 Pocket Creation
8.6.3.1 Subglandular TUBA
• The preoperative marking should represent a line extending from the umbilicus to medial to the NAC.
• Another important principle to keep in mind, when performing TUBA procedure, is consistently using a single
access point (SAP) as detailed below.
• The initial access to the planned pocket should be with the
pointed bullet dissector.
• The bullet dissector is introduced from the umbilical incision into the subcutaneous tunnel then it should precisely
follow the preoperative line marking connecting the
umbilicus to the medial aspect of the breast.
• The breast is lifted gently up, this leaves the muscle rmly
attached to the sternum and the ribs medially and then the
pointed bullet dissector is pushed through the inframammary fold (IMF) into the subglandular plane. At this
point, there is one opening in the IMF that occurred from
introducing the bullet dissector.
• This one opening should represent the SAP to all the
instruments that will be introduced into the pocket from
this point on. The reason being that it is important to avoid
accessing the pocket from multiple points at the IMF as it
can eventually weaken the IMF and cause bottoming out
of the implant.
• The TUBA instrument set (Fig.8.2) has bullet dissector
and round heads of different sizes. At this stage, the
pointed head is removed, and the round bullet head is
placed on the long handle.
• The round bullet dissector is then placed from the umbilical incision into the subcutaneous tunnel then through the
SAP into the pocket and used to dissect the pocket using
repetitive gentle stroking motions separating the glandular tissue from muscle and following the preoperative
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E. Akkary and R. Shumway
a
• Endoscopic visualization using a 10mm/0 or a 10mm/30°
scope is used during the different steps of the pocket creation to conrm proper pocket dissection and
hemostasis.
8.6.3.2 Subpectoral TUBA
• The preoperative marking should represent a line extending from the umbilicus to lateral to the NAC (Fig.8.3).
• Another important principle to keep in mind when performing TUBA procedure is consistently using a single
access point (SAP) as detailed below.
• The initial access to the planned pocket should be with the
pointed bullet dissector.
b
• The bullet dissector is introduced from the umbilical incision into the subcutaneous tunnel then it should follow
precisely the preoperative line connecting the umbilicus
to the lateral aspect of the breast (Fig.8.4).
• The breast is lifted rmly up, this tents the muscle laterally away from the ribcage and then the pointed bullet
Fig. 8.2 (a, b) TUBA instruments
markings to avoid over dissection of the pocket. We start
with the smallest bullet size then gradually increase to the
largest one.
• If the IMF needs to be lowered, then this is achieved using
the hockey stick TUBA dissector. This dissector is introduced from the umbilical incision into the subcutaneous
tunnel then through the SAP into the pocket.
• The hockey-stick is then used to pull down on the IMF
attachments in short repetitive strokes.
• A very important safety tip while using the hockey-stick
is to avoid pointing the instrument down towards the back
of the patient as this can cause injury to the ribs and/or
violation of the pleural space. The hockey-stick should
point only at 0°, 90° up or 180° to the horizontal plane.
This simply means that the tip of the instrument can point
to the right or left or up (towards the ceiling) but never
down (towards the oor).
• We also avoid lateral dissection of the pocket using the
hockey-stick as this can cause T4 injury and subsequently
altered nipple sensation. Lateral dissection is done with
the bullet dissectors.
• All instruments are kept at a horizontal plane to avoid thoracic injury.
Fig. 8.3 Markings for subpectoral TUBA.Notice the line connecting
the navel to the breast is aiming towards the lateral aspect of the nippleareolar complex
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Fig. 8.4 Bullet dissector used to dissect the tunnel and incise the IMF
lateral to the NAC
dissector is pushed through the IMF into the subpectoral
plane. At this point, there is one incision in the IMF that
occurred from introducing the bullet dissector.
• This one incision should represent the SAP to all the
instruments that will be introduced into the pocket from
this point on. The reason it is important to avoid accessing
the pocket from multiple points at the IMF is that this can
eventually weaken the IMF and causing bottoming out of
the implant.
• The TUBA instrument set has bullet dissector round
heads of different sizes. At this stage, the pointed head is
removed, and the round bullet head is placed on the long
handle.
• The round bullet dissector is then passed from the umbilical incision into the subcutaneous tunnel through the SAP
into the pocket and is used to dissect the pocket using
repetitive gentle stroking motions separating the muscle
from the rib cage following the preoperative markings to
avoid over dissection of the pocket. We start with the
smallest bullet size then gradually increase to the largest
one.
• The inferomedial attachments of the pectoralis major
muscle are freed using the hockey stick TUBA dissector.
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Fig. 8.5 Mobilizing the inferomedial attachments of the Pectoralis
major muscle using the hockey stick dissector
This dissector is introduced from the umbilical incision
into the subcutaneous tunnel then through the SAP into
the pocket (Fig.8.5).
• The hockey-stick is then used to pull down on the attachments in short repetitive strokes.
• Similar technique is used if the inframammary fold needs
lowered.
• A very important safety tip while using the hockey-stick is to
avoid pointing the instrument down towards the back of the
patient as this can cause injury to the ribs and or violation of
the pleural space. A hockey-stick should point only at 0°, 90°
up or 180° to the horizontal plane. This simply means that
the tip of the instrument can point to the right or left or up
(towards the ceiling) but never down (towards the oor).
• We also avoid lateral dissection of the pocket using the
hockey-stick as this can cause T4 injury and subsequently
altered nipple sensation. Lateral dissection is done with
the bullet dissectors.
• All instruments are kept at a horizontal plane to avoid thoracic injury.
• Endoscopic visualization using a 10mm/0 or a 10mm/30°
scope is used during the different steps of pocket creation
to conrm proper pocket dissection and hemostasis.
8.6.4 Implant Placement
• The TUBA set has two different types of mammotubes,
short and long. This is to help the surgeon choose the
mammotube suitable for the patient based on their height
and preoperative measurements.
• The mammotube is introduced through the umbilical incision into the subcutaneous tunnel then through the SAP
into the pocket.
• 60 mL syringe is then used to irrigate the pocket with
antibiotic irrigation via the mammotube. Multiple ush-
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ings of the solution are undertaken based on the size of
the pocket. The antibiotic irrigation is then left to drain
passively through the tube.
• Examination of the passively drained uid is important to
ensure hemostasis. If there is any fresh red blood identied, applying rm external pressure on the pocket is performed followed by endoscopic visualization to conrm
hemostasis. If this is not successful, we recommend conversion to a periareolar or inframammary approach.
• After antibiotic irrigation and conrming hemostasis, the
tissue expander is then folded and placed into the mammotube and then the mammotube is used to introduce the
tissue expander through the umbilical incision into the
subcutaneous tunnel then through the SAP into the pocket
(Fig.8.6).
• At this point, the expander is placed in the pocket while
the catheter connected to the valve of the expander
emerges out of the end of the mammotube at the
umbilicus.
• The surgeon then must hold the breast with the tissue
expander in place rmly and then gently pull out the
mammotube. Now, the expander catheter should be
emerging from the umbilicus.
Fig. 8.6 Placement of the tissue expander through the tunnel into the
pocket using the mammotube
E. Akkary and R. Shumway
Fig. 8.7 Inating the tissue expander with air
• The expander is then inated with air to conrm proper
pocket dissection. After this is conrmed, the expander is
then lled with extra 50–100mL of air over the size of the
implant and left in place to ensure hemostasis (Fig.8.7).
• Make the patient sit up at this point to conrm proper
positioning and adequate pocket dissection. After conrmation, the patient is then placed back in the supine
position.
• The tissue expander is then deated and removed by gently applying traction on the catheter at the umbilicus while
massaging the expander out of the breast at the same time.
It is very important to avoid aggressive traction on the
catheter as this might dislodge the catheter from the tissue
expander.
• Irrigate the pocket with antibiotic solution again following the same technique mentioned above.
• Gloves are changed and a no-touch technique is implemented to place the implant.
• The implant is placed in a bowl with antibiotic solution.
• The saline implant is then folded and placed into the
mammotube and then the mammotube is used to introduce the implant through the umbilical incision into the
subcutaneous tunnel then through the SAP into the pocket
(Fig.8.8).
• At this point, the implant is placed in the pocket while the
catheter connected to the valve of the implant emerges out
of the end of the mammotube at the umbilicus.
• The surgeon then must hold the breast with the implant in
place rmly and then gently pull out the mammotube.
Now, the implant catheter should be emerging from the
umbilicus.
• The implant is then lled with saline to the desired volume and its position conrmed by making the patient sit
up.
• After conrmation, the catheter tubes connected to the
implant are disconnected from the implants by pulling the
catheters as they emerge from the umbilicus.
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a
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Fig. 8.9 Umbilical closure
b
c
Fig. 8.8 Preparation and placement of the implant
8.6.5 Umbilical Closure
• The umbilical incision and subcutaneous tunnels are irrigated with antibiotic solution.
• We routinely excise the adipose tissue under the superior
umbilical ap leaving 1–2 cm of subcutaneous tissue
under the dermis. This technique creates a deeper and aesthetically pleasing umbilical hooding.
• The incision is then closed using 3-0 chromic sutures in
an interrupted subcuticular fashion. We avoid tight clo-
sure to allow for tumescence drainage through the umbilical incision (Fig.8.9).
• Cotton ball and Tegaderm dressing are then applied on the
umbilicus.
8.6.5.1 Postoperative Compression
• A soft compression bra with upper compression strap is
used to squeeze the implants downwards.
• Two Ace wraps are used to compress the trunk to decrease
the risk of seroma formation in the subcutaneous abdominal wall tunnels.
8.7 Short Discussion
While BA is one of the most common procedures performed
in the eld of cosmetic surgery, TUBA has been an underutilized procedure. The surgery was introduced in 1993 by
Johnson and Christ then was modied by Dowden and Caleel
in 2000 focusing on using blunt objects and avoiding aggressive TUBA instrument drives (Johnson and Christ 1993;
Dowden 2000; Caleel 2000). The initial report by Johnson
and Christ studied 91 patients and conrmed successful procedure without signicant bleeding. There was less chest
discomfort and there was temporary abdominal wall swelling (Johnson and Christ 1993). Dowden published his results
with 1307 TUBA procedures conrming the surgery to be
safe with low incidence of complications. Capsular contracture was encountered in 0.2% of patients and altered nipple
sensation in 0.8% of patients. He encountered tunnel seroma
in 1.5% of patients and this was easily treated in the ofce by
aspiration (Dowden 2000). Dowden’s role in explaining the
off-label nature of TUBA and his publication about what
occurred in the FDA hearing, as mentioned earlier in this
chapter, shed the light on a very important historical event
that every surgeon should know before performing TUBA
(Dowden etal. 2002).
While TUBA was designed to exclusively place saline
implants and this was considered one of the disadvantages of
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E. Akkary and R. Shumway
this procedure since silicone implants cannot be placed,
there was a recent publication from South Korea where the
authors presented their experience with subpectoral silicone
implant placement. The implants did not exceed 300 mL in
volume and there was 11% incidence of periumbilical hematoma. Also, one of the limitations of the study was the short
duration of follow-up (9 months) as one would be curious to
know if the extensive manipulation of the implant through
the small subcutaneous tunnel would damage the implant
and cause higher incidence of implant rupture on long term
follow-ups (Lee etal. 2014).
As mentioned, one of the relative disadvantages of TUBA
is the need for endoscopy. However, a study by Scarlett and
Borsand showed that endoscopy does not need to be used
routinely in TUBA.The use of endoscopy was related to the
level of comfort and experience of the TUBA surgeon. The
authors recommended that surgeons use endoscopy in their
initial cases (Scarlett and Borsand 2004).
Our recently published study demonstrated the safety and
high patients’ satisfaction of TUBA in 2263 patients (Akkary
etal. 2020). Other studies showed similar results. Brennan
and Haiavy published their experience with 245 TUBA cases
in 2007, this was a retrospective study that showed high
patients’ satisfaction. It was noted that satisfaction was
higher with subpectoral implants over subglandular implants
(Brennan and Haiavy 2007). Safety of TUBA was again
demonstrated in multiple studies as Caleel’s (Caleel etal.
1996), Johnson’s (Johnson and Dowden 1996), and
Wittenberg’s (Wittenberg and Leventhal 1998).
8.8 Complications
Complications of TUBA include seroma, hematoma, asymmetry, capsular contractures, altered nipple sensation,
implant exposure, and wound infection. Specic complications related to TUBA include abdominal wall seroma or
hematoma, skin irregularities of the abdominal wall or
umbilical wound complications. Overall TUBA is a safe procedure in the hands of trained surgeons and the incidence of
complications is low and comparable to other breast augmentation approaches (Akkary etal. 2020; Caleel etal. 1996;
Johnson and Dowden 1996; Wittenberg and Leventhal 1998).
8.9 Pearls ofWisdom
• TUBA is an underutilized procedure that can be safely
implemented into surgeons’ practices after proper train-
ing and proctoring.
• Understand the nature and history of the off-label catego-
rization of TUBA and disclose it to the patient.
• Standardizing TUBA is essential to optimize outcomes.
• Examine the patient’s abdomen preoperatively for
hernias.
• The subcutaneous tunnels need to be created just above
the rectus muscle. Very supercial tunnels can cause skin
irregularities and scarring of the abdominal wall.
• Understanding the anatomy of the pectoralis major muscle attachments is very important when performing
TUBA. The muscle is rmly attached medially and
loosely attached laterally.
• Pocket dissection for subglandular TUBA is started
medially.
• Pocket dissection for subpectoral TUBA is started
laterally.
• Always apply the principle of SAP when performing
TUBA to avoid weakening the IMF.
• Do not use the hockey-stick dissector lateral to the NAC
to avoid T4 injury.
• Never point the hockey-stick down towards the oor as
this might violate the pleural space.
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