by William A. Brennan, M.D., F.A.C.S.
Surgical Arts of Beverly Hills
http://www.surgicalart.com/

Mark Twain wrote in A Connecticut Yankee in King Arthur's Court in 1889: "she was wise, subtle, and knew more than one way to skin a cat".

There's also more than one way to insert breast implants.

Some doctors, like me and my partner, insert implants through the patient's belly button in a procedure known as TransUmbilical Breast Augmentation. Virtually everybody refers to it simply as the TUBA approach.

Breast Implants

Inserting breast implants through the navel has been written up in physician journals since 1992. Moreover, it's been praised and criticized by physicians, but not much has been heard from the women who have asked for a TUBA.

So, my partner Jacob Haiavy, M.D., and I volunteered the medical charts of 245 of his, Dr. Haiavy's, patients who had the procedure from 2002 to 2004. We concentrated on the one-year patients' satisfaction survey and looked for complications resulting from the procedure.

(Physicians can read the entire article at Ann Plast Surg 2007;59(3): 243-249, September, 2007.)

Then, we compared our findings to what other TUBA specialists have found among their patients. The satisfaction survey asked about post op pain, numbness, firmness, size satisfaction, rippling and the patients' overall level of satisfaction.

Incision Decision

In case you don't already know, here is the difference in the TUBA method: Until about 14 years ago, surgeons had a choice of inserting implants through the armpit, making an incision within the areola (the dark area surrounding the nipple,) or making an incision under the breast where the mammary gland meets the chest wall.

The presurgical markings -- as well as the before and after results --
are shown on this patient whose after pictures were taken one year
after her TUBA procedure. (Photos, courtesy of Leonard Grossman, M.D.)

Surgeons can also place the implant on top or below the chest muscles. All approaches have various complications and drawbacks. For instance, if the implant is placed on top the pectoral muscles, it tends to have less support and becomes unrealistically firm.

Then, the surgical endoscope came along. The endoscope is a slim, lighted device with a tiny camera and equally tiny surgical tools that allows surgeons to see and work under a patient's skin. It's all the thickness of a pencil so it fits inside the patient without disturbing much tissue, and that means quicker healing.

In cosmetic plastic surgery, two things are very important to patients: Scarring and "down time" to allow for recovery. Plastic surgeons found that the endoscope reduced both.

Saline Implants

In 1993, surgeons started making tiny incisions in the belly button, and making two, small tunnels up to each breast. The implants were -- and still are -- rolled up like a cigar. Then, using specially designed tools that could reach from the naval to the chest -- inserted the implant into a space we create called the "pocket." Once in place, the implant is filled with a saline solution.

Our breast implant subjects ranged in age from 18 to 64 with the average age being 31. After one year, we asked if the patients had:

• Breast pain
• Firmness in one or both of the breasts

Those are important questions because the answers tell us if, and how much, capsular contracture -- a scarring effect -- has taken place inside the breast. We also asked about rippling -- that is, if creases and folds in the implant could be seen through the skin of the breast. And, we wanted to know how happy the patient was with her size as well as her overall level of satisfaction.

Of things that could, and do, go wrong, here's the experience of the 245 TUBA patients:

• Hematoma -- 1 ("Hematoma" is a pool of blood under the skin that results in a large bruise.)
• Umbilical incision infection -- 8 (The incision inside the belly button became infected.)
• Deflation of the implant -- 3 (The implant leaked and became flat.)
• Tunnel seroma -- 5 (A collection of pale yellow fluid collected in the tunnel leading from the belly button to the breast pocket.)
• Asymmetry -- 10 (The breasts were different sizes.)
• Capsular contracture -- 9 (Scarring inside the breast took place.)
• Implant infection -- 0

Patients who opted for the TUBA procedure liked the idea of moving the incision from or near the breast down to the belly button. The study results showed our subjects' complications were either at, or below, the level of other insertion techniques.

The study also revealed that 86.5 percent of the patients were happy with their breast size. Of the others, 11 percent wished they had gone bigger while only 2.5 percent wished they had gone smaller.

We also like to think the high satisfaction rate was partly due to our home sizing service. Before the operation, we give our TUBA patients materials they can use to create artifical implants to wear under their clothing for a few days to get used to the new look.

The TUBA training is a complex issue but for some surgeons, a week long course with cadaver training is sufficient. For others, dedicated time training with an experienced surgeon is necessary. I personally found myself continuing to learn little nuances way into my 50th and 100th cases. I had the benefit of training with Dr. Haiavy who has 10-15 TUBA procedures a month. The bottom line is that this technique is perhaps the most challenging of all the methods but well worth learning.

So, if you are considering a surgeon who offers the technique, a fair question to ask is: "Doctor, how many times have you performed the TUBA procedure and how many times do you do it a month?"

In my opinion, surgeons should also tell patients that alternate sites on the body exist for an alternate incision that may be used if there are unforeseen difficulties placing the implants with the TUBA method.

Nipple, Breast and Areola

Surgeons should also tell their patients the majority of TUBA patients can expect brief changes in nipple, breast and areola sensations. But those changes will improve with time after the operation.

Overall, the procedure takes less time and causes less bleeding than other methods because we use not sharp, but blunt, instruments to reach and work under the breast. The endoscope allows us to check the passage of the instruments as the belly button-to-breast tunnel is made.

Patients also seem to have less postoperative pain than what is experienced in other implant techniques.

Typical TUBA Patient?

A women who wants a larger breast size for whatever reason and with no scarring is the typical patient. The operation is not intended for women with abnormal chests because it makes the easy passage of long, straight instruments more difficult.

William A. Brennan, M.D., F.A.C.S.

Additionally, women who have had an abdominoplasty (a tummy tuck) or liposuction in the stomach may not be good candidates. We would also be concerned about any procedure which has lead to fibrosis and scarring of the stomach or thoracic (the section of your body between the neck and the stomach.) area.

So, after our study and after reading other studies on the same topic, the bottom line is: the procedure is growing in popularity and is safe and effective when the right patients are selected.

How satisfied the patient will be depends on how the breasts look and if they become unnaturally hard.

Many surgeons -- including myself -- believe that vigorous breast exercises like pushing the breasts up, down and inward can reduce or eliminate the chance of capsular contracture. I have seen the exercises reduce the capsular contracture once it was diagnosed. This subject is controversial, however.

William A. Brennan, M.D., F.A.C.S. is the only neurosurgeon in California with training in cosmetic surgery.