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Transumbilical Breast Augmentation

https://t.me/medicina_free

WithSaline andSilicone Implants

GabrielH.Patino

9.1 Introduction

9.1.1 Historical Background oftheProcedure

Dr. Gerald W.Johnson invented the Trans Umbilical Breast Augmentation (TUBA) under General Anesthesia using Saline Implants in October of 1991.

Dr. Gabriel H.Patino performed the rst known Trans Umbilical Breast Augmentation with saline implants under oral sedation and tumescent anesthesia with a modied Klein solution in 2004. He presented it at the American Society of Cosmetic Physicians meeting in 2014.

Dr Wen-Chi Huang performed the rst known Trans Umbilical Breast Augmentation under General Anesthesia using silicone lled implants with instruments and an endoscope for insertion in 2016. She reported an operating room time exceeding 3 h, signicant bleeding and implant rupture.

Dr. Gabriel H.Patino performed the rst known Trans Umbilical Breast Augmentation under General and Tumescent Anesthesia using Silicone implants manually, without instruments and without an endoscope on July 20,

2021. The procedure was done in under 1h with minimal bleeding and no implant rupture. He presented it at the American Academy of Cosmetic Surgery virtual meeting on February 1, 2021.

Ideal patient selection for this procedure

• Healthy female over 18 years old

• Ideally without breast ptosis

• Breast ptosis I and II can be improved with implants.

• Breast ptosis III mandates a breast lift.

• ASA class I or II

• Detailed complete pre-operative history and physical exam.

• Pre-operative medical and or psychiatric clearance if indicated.

• Pre-operative laboratory 1 week prior to surgery (CBC, CMP, UA, HCG) Pre-Operative EKG for patients over 45 or patients with risk factors

9.2 Important Steps Prior toUndertaking

theProcedure

• Patient tries on and selects her own implants (Placed within bra).

• Patient decides on the type of implant.

• Patient selects limits of nal ll volume (Saline Implants).

• Pre-operative worksheet is completed.

• Consent and Release form for personal choice of breast implant size is completed and signed by the patient.

• Prelled silicone implants cannot be inserted via the umbilicus (TUBA).

9.3 Short Discussion About Treatment/

Surgical Modalities

I have never used the endoscope. The proper plane is evident by the feel of the tissues and upon ination of the sizers by the tenting of the pectoralis major at the level of the axilla and the almond shape of the breast for submuscular placement. A rounder shape of the breast and no tenting of the pectoralis major is expected with the subglandular placement.

Supplementary Information The online version contains supplementary material available at

G. H. Patino (*) California Academy of Cosmetic Surgery, El Cerrito, CA, USA

https://doi.org/10.1007/978- 981- 99- 3726- 4_9.

9.4 Surgical Procedure: TUBA

Step 1: The Pre-operative markings are done with the patient in the standing position. The sternal notch is marked following its U shape. The sternal borders and inframammary folds

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G. H. Patino

Fig. 9.1 (a, b) Pre-operative marking of the midline, inframammary crease, and the dissection tracts

are marked. A mid sternal line is then drawn from the sternal notch to the mid portion of the superior umbilical hood. A line connecting the axillary apex to each side of the superior umbilical hood is then drawn (Fig.9.1).

Step 2: First-the inltration is done with the modied Klein solution (1000 ml of Normal Saline, 100 ml of 2% Lidocaine, 2 ml of 1:1000 Epinephrine, 10 ml of 8.4% Sodium Bicarbonate). The maximum dose of lidocaine for tumescent anesthesia is 55mg/kg. If Patient is under general Anesthesia, the maximum dose of lidocaine is 28mg/kg.

• The inltration is done with the Modied Klein solution

at the level of the inframammary fold at the intersection

of the markings for each tunnel. A 3mm incision is made

using a # 11 blade.

• Using a 3mm×15cm spray cannula to perform the hydro

Fig. 9.2 Submuscular inltration being undertaken using an inltrating needle and tumescent uid

dissection of the submuscular or subglandular pockets.

• Inltration under the muscle is evident by the lack of

resistance to the passage of the cannula, the almond shape

of the breast, and tenting of the pectoralis major at the

level of the axilla with progressive inltration.

• Subglandular inltration is noted by some resistance to the passage of the cannula, the round shape of the breasts, and no tenting of the pectoralis major at its insertion in the axillary area (Fig.9.2).

9 Transumbilical Breast Augmentation WithSaline andSilicone Implants

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• The tunnels are then inltrated in the subcutaneous fat plane between the rectus fascia and the skin being very careful to keep the inltrating cannula over the rib cage and advancing only 2.5–5.0cm at a time. Never direct the cannula toward the intra-abdominal or intrathoracic cavities.

• DO NOT USE NEEDLES WHEN INFILTRATING THE BREASTS.THIS CAN LEAD TO PNEUMOTHORAX RATHER USE INFUSION HANDLES WITH ON/OFF SWITCH (Fig.9.3).

Step 3: After the navel incision is made with a # 11 blade

all around the umbilicus, the subcutaneous tunnels are created with cone dissectors. The breast pockets are made initially with hydro dissection using the tumescent anesthesia and subsequently the pectoralis major attachments are detached using a right-angle blunt instrument. (Advancement should be done in 4–5cm increments at a time in order to prevent an improperly directed stroke from traveling any great distance (Fig.9.4)).

Step 4: The tunnel dissection is rst started from the

umbilicus using the cone dissector (Fig.9.5) and the breast is lifted for submuscular placement when the cone dissector is

Fig. 9.3 Infusion syringe and handle with control button

passed across the infra mammary fold. The breast is not lifted for subglandular placement.

Step 5: The test implants are prepared for insertion.

Once the pocket has been created either in the subglandular or submuscular plane, the adequacy is checked by using sizers (test implants) which can be lled by air. The test implants are inserted using Dr. Patino’s mammary implanter (Fig.9.6) (Author’s preference as it is safer and easier to do), the Johnson’s Endo tube or manual insertion.

The test implants are rst emptied of all air and folded in such a way that they form a cigar shape with simultaneous rolling from both sides. The tube to ll the air is kept in the center so that when the sizer is lled with air it unfolds (Fig.9.7).

The folded sizer (test implant) is now held with the Patino Mammary Implanter and placed in the pockets created (Fig.9.8).

Step 6: The test implants after placement are quickly inated with air using the closed inltration system provided by the implant manufacturer, to the patients’ desired size which has been discussed previously (Fig.9.9).

Step 7: The patient is then placed in the semi-fowler position to observe both the breasts for symmetry. Checking the implant pocket cranio-caudally and medio-laterally becomes very important along with conrming the position of NAC (nipple areola complex) which has to be centered on the implant. Once this is conrmed, the sizers are inated by 25% more and left in place to achieve hemostasis.

Step 8: The breast implants are now taken and readied for placement in the pocket by testing for air leaks in triple antibiotic solution (Bacitracin 50,000 Units, Cefazolin 1000mg and Gentamicin 80mg). Vancomycin can be used instead of Cefazolin for patients allergic to cephalosporins or penicillin.

Fig. 9.4 (a) Cone dissector with various cone shapes. (b) Right angled hockey stick dissector

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Fig. 9.5 The cone dissector to be inserted to create a track and dissect a pocket for placement of the implant

G. H. Patino

Fig. 9.7 The sizer being folded from both the sides so that it looks like a cigar

The Patino Mammary Implanter

Fig. 9.6 The Patino mammary implanter is used to place the sizer in the dissected pocket

Step 9: The test implant is now deated and immediately removed, one side at a time. The selected implant is inserted in the same way as the sizer and described in step 5 (Fig. 9.10). Once placed the implant is inated, this time using sterile saline to the desired amount (Fig.9.11), its position is checked and the connecting tube is pulled out. The saline should be lled using a closed system and a 3-way valve so that no air leaks into the implant thus preventing the feeling of sloshing.

Fig. 9.8 Patino Implanter being used to hold the rolled sizer

Fig. 9.9 The Sizers being inated using air to check adequacy of the

pocket size

9 Transumbilical Breast Augmentation WithSaline andSilicone Implants

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incision is closed with 4-0 Monocryl sutures. Steri-strips are applied, and an island umbilical dressing is placed. No drains are needed after this procedure. The pre- and postphotographs are shown which shows the natural shape that can be achieved using this technique (Figs.9.12, 9.13, 9.14,

9.15, and 9.16).

Fig. 9.10 The rolled implant is ready to be placed in the left breast. Note the sizer is still present in the right breast

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Step 10: The lling tubes are removed, and the umbilical

Fig. 9.11 Sterile saline being used to inate the breast implant using a 3-way valve

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9.5 Pre- andPost-Operative Pictures

G. H. Patino

Fig. 9.12 Pre- and post-operative photographs of a 23-year-old lady who underwent a transumbilical breast augmentation with Mentor 350ml Moderate plus prole subpectoral saline implants. Photograph taken 3 months after the procedure

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Fig. 9.13 Pre- and post-2 months after TUBA procedure in a 22-year-old female. The Mentor 350 ml moderate plus prole implants were placed in the submuscular plane