Breast Augmentation

Saline vs.

• Are filled after they are placed in the body which allows for smaller, less invasive incisions to be used.
• Lower rate of capsular contraction (see under silicone).
• Can be used with the TUBA method.
• The implant size c be adjusted intraoperatively during placement, unlike silicone implants which are pre-filled.
• Are considered safer because saline is essentially water, so there are no concerns of tissue reaction if an implant leaks or ruptures.
• Usually slightly overfilled to minimize ripples along implant edges and to prevent folding. This makes the implant feel a bit firmer.

Silicone

• More natural feel and appearance.
• Can be used with the Trans-Axillary method.
• Less tendency to “ripple”.
• Slightly higher rate of capsular contraction that may cause distortion and hardening of the implant.
• The implants are pre-filled requiring a larger skin incision, unlike the TUBA method. When placing gel implants, we hide the scar in the armpit.

Implants may be placed between the gland and the chest muscles or underneath the pectoralis muscles. Location choice is determined based on the need for adequate soft tissue necessary to minimize visibility of implant edges.

Subglandular vs.

• Placed under the gland and on top of the pectoralis major muscle.
• For those patients who have sufficient breast and subcutaneous tissue, results are more natural.
• Requires less dissection, is less traumatic and, therefore, results in quicker recovery.

Submuscular

• Provides slightly more soft-tissue for implants placed underneath the pectoralis major muscle. However, we believe this advantage is quite over-rated.
• Typically, the muscle is detached from the lower ribs and does not cover the lower portion of the implant.
• Because some muscle attachments are disrupted, this placement is more traumatic and may increase recovery time.
• Because the implant is partially placed beneath a powerful muscle, it will temporarily change shape with vigorous contraction of the pectoralis. This deformation is minimal but may be noticeable to the patient during vigorous exercise.

Generally, the larger the implant, the more obvious it will be and the more it will sag over time.

Breast implant size is a personal decision determined by patient desire and what the patient’s tissues can accommodate. The amount of soft tissue coverage is key to determining how large an implant is reasonable.

We use a system of objective measurements to determine a reasonably sized implant for each patient. We ask patients to participate in this process by determining the approximate size she wants.

We have a great deal of experience performing surgery using local anesthesia with intravenous sedation. Your surgery will be performed at Bozeman Health Deaconess Hospital.

Trans-Umbilical Breast Augmentation (TUBA) uses saline implants that are placed under the breasts through the navel using an endoscopic approach, leaving an essentially invisible scar hidden in the navel. There is absolutely no scarring on or around the breasts.

Advantages of this procedure include:

• A single, inconspicuous scar deep within the navel
• Less invasive and therefore, less breast trauma
• Minimal bleeding
• Faster recovery

Less risk of injury to the sensory nerves of the nipple and breast

Common misconceptions about transumbilical breast augmentation (TUBA)?

The most common myths concerning transumbilical breast augmentation were summarized and dispelled in an article published in the official journal of the American Society of Plastic Surgery* as paraphrased below:

It is too difficult to dissect all the way up there.
The pocket is created not by dissection, but by expansion. There is no cutting behind or in the breast. Pocket creation is actually easier than using any other method.

There are too many complications.
The original study showed a lower complication rate than with other methods. There is also less bleeding compared to other methods.

The surgeon cannot control bleeding.
There is a remarkable absence of bleeding with TUBA and rarely any bleeding at all to control. However, doing so presents no problem by visualizing the implant pocket through an endoscope.

The surgeon cannot position the implants properly.
Because the surgeon sees the exact shape of the breast and position of the implant during the expansion phase, there is no guesswork in implant positioning.

Pushing implants through the tube damages them.
Implants are not pushed through a tube. The implant is seated on the end of a tube used to push implants into position.

The technique leads to visible track deformities on the abdomen.
The author saw no visible track deformity in seven years performing TUBA.

Using the implant as an expander can damage the implant.
This is the most understandable of the misconceptions. Originally, the implant itself was used as an expander, putting it under excessive stress. This has not been done since 1992. Instead, a separate expander step has been incorporated into the technique.

Using the transumbilical technique will void the warranty on the implant.
This is patently untrue. We have verified with implant manufacturers that this technique does not void the warranty.

It is a blind technique.
This has no significance in actual practice. Tissue expansion, rhinoplasty and liposuction are all "blind" techniques that are well-accepted, performed frequently and have low complication rates. Moreover, the transumbilical technique is the only one of these "blind" approaches in which the operative site is inspected with an endoscope, so is not truly blind.

The technique increases the risk of implant failure.
This is untrue in both practice and theory.

The technique is only suitable for prepectoral placement.
This was initially true. However, instrumentation and techniques for subpectoral placement have been available for some time.

Removal of the implant cannot be done through a transumbilical incision.
The saline implants are easily removed through the navel.

Disrupting the abdominal muscles causes excessive pain.
Abdominal muscles are not disrupted in any way. The entire procedure is performed above the anterior rectus fascia in the subcutaneous plane. One noteworthy feature of the transumbilical procedure is that it is less painful than other methods and results in quicker recovery.

The technique cannot be performed if the patient has an umbilical hernia.
The original article cited "abdominal hernia" as a possible contraindication to transumbilical augmentation. In fact, an umbilical hernia can be repaired at the same time.

The implant must pass between the abdominal organs.
The transumbilical procedure is entirely subcutaneous and does not involve abdominal organs or muscles.

The technique cannot be performed if the patient has a navel ring.
Navel rings have proven no obstacle. Some surgeons prefer the ring to be removed during the procedure and reinserted afterward; others prefer to leave them in place or even use them to aid in elevation.

Going through the navel will cause infections.
No surgical procedure can be free of the possibility of infection. The author has seen no infections with the transumbilical procedure; but has seen them with other methods of augmentation. Infection is very unlikely. With the incision so remote from the implant, even a wound infection would be unlikely to reach the implant.

The surgeon cannot control the plane of the implants.
The endoscope is used to verify that the implant is in the proper plane relative to the pectoralis muscle.

Using a drain would require a breast incision anyway.
Most surgeons performing transumbilical augmentations have not used drains. Thin, round drains may be used through the navel and so no breast scarring. At Bozeman Health Cosmetic Surgery, we have rarely found drains to be necessary.

*Dowden, R. V. Dispelling the Myths and Misconceptions about Transumbilical Breast Augmentation. Plastic & Reconstructive Surgery. Volume 106(1), July 2000, pp 190-194