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Transumbilical Breast Augmentation a Practical Review of a Growing Technique

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Transumbilical Breast Augmentation a Practical Review of a Growing Technique ORIGINAL ARTICLE Transumbilical Breast Augmentation A Practical Review of a Growing Technique William A. Brennan, MD, and Jacob Haiavy, MD These complication rates were comparable or less than other pub- Background: The transumbilical breast augmentation procedure lished methods of breast prosthesis implantation. has been described in the literature since 1993. This indirect route Conclusions: Transumbilical breast augmentation is a safe and for implant placement has received both criticism and praise over effective method for breast implant placement in selected patients. the years, without a comprehensive assessment of the procedure Patient satisfaction weighs heavily on implant location and postop- from the perspective of the patient. The growing patient demand for erative firmness and less on other variables. The procedure is the procedure, combined with the increased use by surgeons, associated with a complication rate comparable with other methods prompts a review of the procedure and a discussion of its pros and and finds itself growing in demand and popularity secondary to high cons, including tabulated patient satisfaction data. patient satisfaction. Methods: A retrospective chart review of 245 transumbilical breast augmentations performed by the second author from 2002 to 2004, Key Words: transumbilical breast augmentation, breast including the 1-year patient satisfaction surveys, is presented. Ad- augmentation surveys, endoscopic breast surgery ditionally, complications from the procedure are also tabulated and (Ann Plast Surg 2007;59: 243–249) compared with the complications published by our studies’ domi- nant implant manufacturer in their 1-year follow-up published data. The patients were asked to rate their postoperative pain, numbness, firmness, size satisfaction, rippling, and overall satisfaction. Data ransumbilical breast augmentation (TUBA) was de- were compiled and statistical analysis was performed using ␹2 Tscribed during a time in the surgical sciences when the methods. surgical endoscope was graduating from its use in gastroin- testinal medicine towards its use in the operating room for Results: The study revealed a strong negative correlation between 1 both the study parameters of prepectoral implant location and other purposes. This effort led to advances in every aspect of postoperative firmness and the survey result of overall satisfaction surgery, from the general surgeon’s laparoscopic cholecys- (P ϭ 0.0041). Conversely, numbness, pain, and rippling, long felt to tectomy to the neurosurgeon’s endoscopic approach to the be linked to satisfaction, were shown to have no statistical correla- cranium. It is not surprising that this avenue of surgical tion with satisfaction. A strong positive correlation with satisfaction guidance found application in the field of breast augmentation for 2 reasons: first because the acceptance of cosmetic pro- was seen with retropectoral (submuscular) implant location. The cedures was integrated with the resultant location and size of complications from transumbilical breast augmentation in our study the scar left behind by the procedure and second because this were hematoma ϭ 1 (0.4%), umbilical wound infection ϭ 8 (3.2%), acceptance was also entwined with the mandatory downtime deflation ϭ 3 (1.2%), tunnel seromas ϭ 5 (2.0%), asymmetry ϭ 10 ϭ associated with the procedures. Endoscopic guidance had (4.1%), capsular contracture 9 (3.7%), implant infection (0.0%). potential for reducing these concerns for the cosmetic patient. According to national surveys, breast augmentation continues to grow in popularity and acceptance, alongside Received September 13, 2006, and accepted for publication, after revision, cosmetic procedures in general.2,3,11 Patients, as well as November 28, 2006. surgeons, have always expressed a desire to have breast From *Surgical Arts of Beverly Hills, Inc., Beverly Hills, California, and augmentation follow a path of safety, efficiency, and cos- †Inland Cosmetic Surgery, Rancho Cucamonga, California. 1 The preliminary data from this study have been presented at the American metic appeal. Since Johnson and Christ published TUBA in Academy of Cosmetic Surgery Annual Meeting, Orlando, Florida, Jan- 1993, the procedure has been accepted, criticized, dissemi- uary 2006. nated, and occasionally modified in pursuit of this quest. Financial Disclosure and Products: Neither William A. Brennan, MD, nor Dowden4,5 and Caleel6 have contributed to the literature in Jacob Haiavy, MD, has any financial interest in the manufacturers or products mentioned in this manuscript. This manuscript was prepared multiple publications describing the TUBA procedure and without outside support from any corporate sponsor or affiliation. have described the procedures limitations, as well as advan- Reprints: William A. Brennan, MD, Surgical Arts of Beverly Hills, Inc., tages. This author expects that as this technique becomes 9401 Wilshire Blvd., Suite 1105, Beverly Hills, CA 90212. E-mail: more widespread in use, more surgeons will benefit from [email protected]. Copyright © 2007 by Lippincott Williams & Wilkins having practical clinical publications from which to draw ISSN: 0148-7043/07/5903-0243 their own conclusions. This publication will present the DOI: 10.1097/SAP.0b013e318030264f corresponding authors’ chart review of practice data from Annals of Plastic Surgery • Volume 59, Number 3, September 2007 243 Brennan and Haiavy Annals of Plastic Surgery • Volume 59, Number 3, September 2007 January 2002 to June 2004, wherein the TUBA procedure parameters tabulated in our study were age, implant size, was performed. Patient surveys were used in the generation implant location (retropectoral or prepectoral), implant vol- of follow-up information. ume, overfilling volume, operating room time, development of complications, and complications requiring reoperation. The questions asked of the patients on the survey forms 1 MATERIALS AND METHODS year after surgery were breast pain, sensory disturbance and All patients were seen in consultation in the office and percentage change from preoperative sensation, development assessed for their candidacy for breast augmentation. All of firmness, degree of rippling, satisfaction with size, as well patients had a detailed discussion of risks, benefits, and as overall satisfaction. A scoring system was devised to alternatives to surgery. All patients had alternate implant digitize each parameter on the patient survey. Breast pain was insertion techniques described and discussed. Patients were scored in a way that each breast could be assessed separately. excluded if they had extensive abdominal procedures in the A numeric score of 0-3 was given to each level of pain on the past, with scarring, severe flair rib, or significant chest-wall breast (0 ϭ no pain, 1 ϭ mild pain, 2 ϭ moderate pain, 3 ϭ deformity or tuberous breast anatomy. Detailed medical his- severe pain). A score of 0.5 was given if the patient’s reported tory, physical examinations, breast measurements, and appro- pain was unilateral. Sensory disturbances were categorized as priate laboratory data were obtained. All patients were given hypoesthesia or hypesthesia or no change based on the home sizing tasks to determine the optimal size for them- patient’s response. A score of 0.5 was given to each breast, selves. This exercise involved using a home measurement resulting in a range of Ϫ1.0 (bilateral hypoesthesia) to ϩ1.0 system that allowed the patients to create filling material for (bilateral hypesthesia) and “0” being no change in sensation. their undergarment which gave them the most appealing size. Firmness was scored by using a modified Baker classification Mammograms were recommended on women age 35 and system subjectively in the survey and allowing the patient to over or with a family history of breast cancer. During the choose from one of 4 categories, (1) no firmness present, initial consultation, standard breast measurements7 were (1.5) one breast is firm but not objectionable, (2) both breasts taken, and the information was used to craft recommenda- are firm but not objectionable, (2.5) one breast is firm but not tions to the patient regarding the appropriateness of the uncomfortable, (3) both breasts are firm but not uncomfort- procedure itself, as well as explaining criteria for making the able, (3.5) one breast is firm and uncomfortable, with pain, implant location decision. Patients who had breast thickness and (4.0) both breasts are firm and uncomfortable, with pain. measurements of 3 cm or greater were given the option of Only capsular contractures of Baker classification 3 and 4 are having their implants in either the prepectoral or retropectoral included as complications. Rippling was scored by asking the location. Patients who had small rib-cage anatomy generally patient if they had rippling that was visible (V) or palpable had high-profile implants recommended to avoid excessive only (P). Patient size satisfaction was scored according to projection in the lateral direction. The patients were seen the their response of “yes” if they were satisfied with their size or morning of surgery, preoperative photos taken, preoperative “no” if they wished they had chosen larger or smaller im- markings performed, preoperative checklists completed, and plants. Overall satisfaction was scored according to the scale the patients were then escorted to the surgery center. Anes- (0) not satisfied, (1) fairly satisfied, (2) satisfied, or (3) very thesia for all patients was general, with the majority utilizing
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