TUBA-BREAST AUGMENTATION REVISITED

Approximately one year ago in this column, I gave our readers a basic primer for the insertion of breast implants in TG Breast Augmentation. But appearing in the same issue of TG Forum was the personal experience of a member who had a Trans Umbilical Breast Augmentation (TUBA), which I had not covered. So now for completeness, I shall discuss TUBA, which may not be the best approach to the MTF breast, but is obviously available. In the practice of surgery, it is best to do what you know best and carefully evaluate new procedures as they become available. There is no doubt that endoscopic and laparoscopic surgery have revolutionized gall bladder and kidney surgery. But each new procedure brings with it a learning curve of complications and refinements as to which patients are best served with this new technique.

Trans Umbilical Endoscopic Breast Augmentation was first described by Drs. Johnson and Christ in 1993 in their series of 91 patients implanted with inflatable saline breast implants. A long tunnel below the skin allowed blunt instruments to reach the upper middle part of the breast from the belly button. The description of the procedure clearly states that any instrumentation that comes in contact with the implant on insertion may tear or weaken the envelope. But as surgeons tried to emulate their work, a high rate of post implant leakage and deflations occurred. Their detractors were many for that reason and other surgical issues, so that the procedure never gained a following except among a few surgeons across the country who persisted and refined their techniques.

The desire for TUBAs is patient-driven since there is only a small hidden belly button incision, a quicker recovery time, reduced postoperative pain and reduced operating time. But Plastic Surgeons argued that the tissue was dissected blindly, bleeding could not be controlled, the placement was inexact, and the end result was cosmetically asymmetrical in many cases. Initially this procedure was reserved for people with some existing breast tissue and all insertions were placed just below the glandular tissue not the muscle as described in my earlier article. This basically eliminated its use for TS’s because of the thin masculine chest. In 1997 a submuscular approach was described and now can be used where there is less than 1 inch of existing breast tissue.

With each new technique came new problems. The technique is the same as that performed in the Trans axillary subpectoral endoscopic implants used for TS’s, but the implantation distance is doubled. Bleeding may be increased or decreased depending on who you believe, but there is no question that the placement is higher than normal on the chest and must descend to a normal position with time. A saline expander is inflated to dissect the submuscular pocket and then removed, so that the surgeon gets some idea of his position before implantation of the actual prosthesis. In rare instances where the expander will not come out, the procedure must be converted to an open incision. In most cases the implant is massaged into position instead of being fixed in place. As the muscle will compress the rounded implant, it is normally filled to twice its expected volume so that the expanded breast volume will protrude properly. Now with the advent of visual endoscopic instruments, inspection of the cavity is routinely used with cautery for blood control if necessary. General anesthesia with muscle relaxants are required for this approach. In some cases bleeding and serum may fill the subcutaneous tunnels, but this is not cause for alarm as it may be aspirated with a needle postoperatively if it does not disappear on its own. The operating time is usually one hour. Light compression dressings are applied and the patient may return home the same day.

In May 2000 the FDA approved the use of inflatable saline implants, but did not include endoscopic axillary or umbilical augmentation procedures. The FDA required that manufacturers do not recommend these procedures in their literature because there was not enough data available. Despite this off-label use, implant manufacturers say they will honor their free lifetime warranties of the implants. The number of subpectoral TUBA’s that have been done is hard to ascertain, but certainly they are only a small fraction of the total number of implants being performed today. Finding a surgeon who has trained extensively in this technique and has experience with implantation in the male chest is your best chance of having a TUBA performed successfully. The decision is now yours, if this is in your future.

Best of Luck in Your New Future,
Cerise Richards, M.D.