TY - JOUR
AU - Dowden, Richard, V.
AB - Abstract Background: The transumbilical approach to breast augmentation has been described in the plastic surgery literature. However, the replacement of failed implants by way of the transumbilical approach has not been fully described. Objective: This article reports the instruments and surgical procedures used in breast implant replacement by way of the transumbilical approach. Methods: The initial operative steps for transumbilical breast implant replacement are identical to those previously described for transumbilical breast augmentation. However, instead of advancing the Johnson obdurator deep to the breast on the muscle or chest wall, as in the original procedure, it was elevated away from the chest wall with pressure sufficient to maintain contact with the capsule. A cutting cautery was used to open the capsule. The implant was punctured and nearly evacuated, and the position and orientation of the most accessible fold were assessed endoscopically. An endo-grasper was used to grasp the implant, which was then withdrawn. The interior of the pocket was examined and endoscopic capsulotomy was performed, if necessary, before insertion of the new implant. Results: Transumbilical breast implant replacement, including size decrease and modest size increase, has been performed on 28 breasts with no complications. Conclusion: Although primary transumbilical breast augmentation should be performed only by surgeons who have taken a formal training course, those surgeons who are already familiar with primary transumbilical augmentation can safely perform implant replacement by way of the navel without additional training. Transumbilical breast augmentation, first reported in 1993,1 has become an integral part of plastic surgery of the breast, and been incorporated into several textbooks.2–4 Most of the early misconceptions concerning the procedure have been dispelled,5 the operating room procedures have been detailed,6 a few simple technical modifications have been described,7 and the technique, including both prepectoral and subpectoral approaches, is being widely employed with success.8–12 It has been shown to be effective and safe for patients and implants when performed by a properly trained plastic surgeon who adheres to the key procedural guidelines.13, 14 Although replacement of failed implants by way of the transumbilical approach was mentioned by Caleel,8 the details of the technique have not been fully described. Patients seeking transumbilical breast augmentation often ask whether replacing their saline implants would require a new incision location and, consequently, a scar that might negate the benefit of the nearly imperceptible navel scar from the original operation. In actuality, prompt replacement of a failed saline implant through the navel is a straightforward procedure. This report describes the instrumentation and surgical details pertinent to performing such replacement safely and effectively. At the outset, it should be stressed that what is being discussed here is timely replacement of the original implant with the same size (or smaller) implant, not replacement with a much larger implant or major correction of capsular contracture. However, the techniques discussed here have been used for correction of minor degrees of capsular contracture, and therefore a modest implant size increase can also be performed by way of the navel. Although the navel can also be the route for replacement of deflated implants originally inserted through other incisions, I have not yet had a patient with another primary incision site request implant replacement by way of the navel and will not address that issue at this time. Materials and methods Instrumentation The surgical equipment includes all the standard trans-umbilical augmentation equipment, plus the following additional items (Figure 1): a gynecologic right-angle operating endoscope (eg, Karl Storz model 26034A [Tuttlingen, Germany] or equivalent), long endo-grasper forceps (eg, Ethicon Grasper model 5DSG; (Cornelia, GA) these need not pass through the endoscope), and a long insulated cautery tip, which one can easily fabricate from a long, thin metal tube within a thin plastic tube, both of which can be bought at any hobby shop. Figure 1 Open in new tabDownload slide The additional instruments needed for implant replacement by way of the navel. Top: Endo-grasper, which need not pass through the endoscope. Center: Right-angled operating endoscope. Bottom: Endoscopic needle aspirator. See text for details and sources. Figure 1 Open in new tabDownload slide The additional instruments needed for implant replacement by way of the navel. Top: Endo-grasper, which need not pass through the endoscope. Center: Right-angled operating endoscope. Bottom: Endoscopic needle aspirator. See text for details and sources. A means of evacuating the saline solution from the implants is also needed. Although it is possible to use an 18-gauge needle percutaneously, I prefer doing it endoscopically. For this I use a simple homemade aspirator made from a thin tube (again obtainable from a hobby shop) that has been sharpened at the tip. A standard aspirator (eg, Karl Storz model 26175P) may be used but is not long enough to be used through the endoscope, so the aspiration would have to be done blindly with that instrument. The operating room setup is the same as that used for transumbilical breast augmentation.6 Surgical procedure As is true of primary transumbilical breast augmentation, implant size was decided in advance. The markings, made before going to the operating room, while the patient was standing, were the same as those used for the equivalent procedure by way of any other incision, with the exception of marking the 2 tunnels from the navel to the nearest point on the inframammary crease. General anesthesia is my strong preference for this and most other breast procedures. The incision was made in the navel scar, then blunt spreading was performed to reach the fascia and continued a short distance toward each breast on the anterior surface of the rectus sheath. Although some surgeons infiltrate or tumesce the passageways with local anesthetic,15 I do not do so for either primary or replacement surgery by way of the navel. I have encountered no problems from scarring resulting from the earlier operation or from a prior abdominoplasty. Next, the Johnson obturator was advanced incrementally toward the breast in the usual manner. As with the transumbilical breast augmentation procedure, it was necessary to avoid the creation of any false passageways that would make insertion of the new implants difficult. In the original transumbilical breast augmentation technique, the surgeon normally advances the obturator deep to the breast on the muscle or chest wall, keeping the instrument parallel to the chest wall. But in an implant replacement procedure, that maneuver would create the passageway deep to the capsule, leading to a capsular opening that is too far posterior. Therefore, once the tip of the obturator reached the inframammary crease, the tip of the shaft was elevated away from the chest wall, with sufficient pressure to maintain close contact with the capsule. If the implant had completely deflated, upward traction on the breast was required to present the lower pole of the capsule at a right angle to the chest wall. Once the tunnel abutted the lower pole of the capsule, the obturator was withdrawn. The Johnson tube–obturator combination was advanced to the same position, the obturator was withdrawn, and the operating endoscope was used to confirm that the tube was right against the capsule. The Johnson right-angle dissector was passed up against the capsule, and a rotating sweeping motion was used to help separate the tissues from the capsule in a circular area about 3 cm in diameter. There are no differences in the replacement procedure between the prepectoral and subpectoral approaches because in subpectoral transumbilical augmentation, the fibers of origin are elevated from the ribs inferiorly. Normally the implant was placed in the original pocket. On one occasion, when performing a replacement for a patient with some capsular contracture, I elected to use the principle described by Hedon,16 in which the new implant pocket is created superficial to the anterior capsular surface. Therefore, before opening the capsule I elevated the obturator tip and passed it across the front of the capsule, creating the tunnel that would become the start of the new pocket. Although an instrument to assist in controlling which of the 2 planes the implant entered has been described by Rey,17 I had no difficulty passing the implant into the newly created pocket. In all my other cases, the implant was placed in the original pocket. Next, the cutting cautery was used to open the capsule. Short strokes and brief current times were used to prevent excessive tip heating that might damage the implant and interfere with the manufacturer's device analysis. I prefer to make an X-shaped capsular incision, with the 2 lines about 2.5 cm long, to avoid creating folds or flaps that might impede introduction of the new implants. During this capsulotomy, care must be taken to verify that no skin fold is in harm's way. The implant was punctured and nearly evacuated; a small amount of saline solution was left inside to ease deformation of the implant to a small cross-section for easy withdrawal through the tunnel. During deflation, it is important to press on the breast to mold the deflating implant into an elongated shape for easy withdrawal through the tunnel. The obturator was then reinserted into the tube and the 2 instruments advanced through the capsule into the pocket. The obturator was withdrawn, the endoscope reintroduced, and the cautery used to divide any remaining capsular bands or folds constricting the opening. Next the deflated implant was assessed, and note was made of the position and orientation of the most accessible fold. The endoscope was removed and the endo-grasper was used to grip the implant fold. With the implant held tightly, the grasper was pulled back until the implant lodges against the distal end of the tube, and then the tube, grasper, and implant were withdrawn together. Usually the implant can just be grasped and removed without using the tube (Figure 2). As in the original trans-umbilical breast augmentation procedure, no attempt is made to pass an implant through the tube. The process of implant evacuation and withdrawal is mostly intuitive and takes less time to perform than to describe. Figure 2 Open in new tabDownload slide The deflated implant is withdrawn with the endo-grasper. Note that it is not necessary to use either the Johnson tube or the endoscope during implant removal. Figure 2 Open in new tabDownload slide The deflated implant is withdrawn with the endo-grasper. Note that it is not necessary to use either the Johnson tube or the endoscope during implant removal. After the implant was removed, the interior of the pocket was examined and, if necessary, the insulated cautery instrument was used to perform a limited endoscopic capsulotomy under visualization, anywhere from about the 8 o'clock position through the 12 o'clock to the 4 o'clock position. Unlike the transumbilical breast augmentation procedure, in which the endoscope is used only intermittently to verify progress during the procedure but not while creating the pocket, such a capsulotomy procedure requires continuous monitoring with the endoscope and, as in any open capsulotomy, care to avoid penetration of the skin. For capsulotomy of the lower pole, between the 8 o'clock and 4 o'clock positions, the Baccari right-angled instrument is ideal. However, that technique necessitates cutting blindly, which entails a small risk of bleeding, unlike the initial procedure, in which no cutting is performed. More extensive transumbilical capsulotomy has been presented previously18 but is beyond the scope of this report. If larger implants are being inserted, or if considerable time elapsed since deflation, expansion of the pocket is necessary, whether or not a definite capsulotomy is required. As in the original transumbilical augmentation, the implant itself is never used for the expansion. I put in an expander with the same dimensions as the new implants and hydraulically expand the implant pockets. As in the original procedure, the shape of the enlarging pocket is monitored by means of external observation, with compression where appropriate. Transumbilical augmentation is very much a “what-you-see-is-what-you- get” procedure, in which pocket development is controlled with reference to the actual evolving breast shape. After removal of the expander, the pocket is inspected and hemostasis obtained. In a primary transumbilical augmentation, hemostasis within the pocket is rarely if ever needed because the pocket is created hydraulically. For the same reason, drains are not often needed. In cases involving implant replacement because of deflation or insertion of larger implants, the necessary capsular incision makes the need for cauterization or drains more likely. After the pocket was judged suitable, the new implants were prepared and inserted. During this, the implant was not pushed by, passed through or allowed to come into contact with any instrument whatsoever. The implant touched only the surgeon's gloved hand and the patient's sterile subcutaneous tissues. If internal capsulotomy had been performed, I usually placed drains (eg, round 10F) as far up as the inframammary crease (but not in contact with the implant) and brought them out through tiny incisions inside the navel. Recovery Recovery from transumbilical replacement was rapid, with the patient returning to usual activities within a day or two. Incisional pain was minimal because there was no tension on the incision site, but soreness occurred along the tunnel pathways, as did some pain at the site of the capsulotomies. Because the approach to the pocket was made from below, where there were no muscle fibers, there was neither muscle pain nor spasm postoperatively, even with subpectoral implants. Results My own experience with the transumbilical augmentation includes placement of implants in 1724 breasts since 1993. Of these, transumbilical implant replacement was performed in 36 breasts (Table). These procedures include 10 modest size increases (Figure 3) (with associated minor capsulotomies), 10 size decreases (twice for 1 patient), 12 deflations (7 involving valve failures in now-obsolete styles that were subsequently taken off the market for reasons of faulty valve design), and 4 elective replacements of the implant on the side opposite a leak. No complications occurred in any of these procedures. In addition to these procedures, I have performed 3 transumbilical capsulotomies without implant replacement; they will be reported separately. Also, in one patient a faulty-valved implant was replaced by way of the navel on the second postoperative day. Because no capsule had yet formed, that procedure was more like a primary transumbilical breast augmentation and is therefore not included here. Figure 3 Open in new tabDownload slide A, Preoperative view of a representative patient (number 19528 in Table 1). B, Postoperative view, 7 months after prepectoral transumbilical augmentation with 305-cc implants. C, View 1 year after transumbilical replacement of the original implants with 210-cc implants, 27 months after the original procedure. Figure 3 Open in new tabDownload slide A, Preoperative view of a representative patient (number 19528 in Table 1). B, Postoperative view, 7 months after prepectoral transumbilical augmentation with 305-cc implants. C, View 1 year after transumbilical replacement of the original implants with 210-cc implants, 27 months after the original procedure. Table Details of transumbilical breast implant replacement for 36 breasts in 19 patients Patient no. Patient ID Date of original implant surgery Implant type Reason for implant Date of revision Months elapsed since original augmentation Old size (cc) New size (cc) Implant plane Site of Implant failure 03587 AA 8-30-93 McGhan 60 Size increase 11-20-93 3 220 400 Prepectoral — “ “ “ Size increase “ “ 220 400 Prepectoral — 14463 HC 2-05-97 McGhan 68 Size decrease 5-06-97 2 265 200 Prepectoral — “ “ “ Size decrease “ “ 260 200 Prepectoral — 11326 TW 7-11-96 McGhan 60 Implant failure 11-20-97 16 230 236 Prepectoral Valve∗ 14463 HC 5-06-97 McGhan 68 Size decrease 2-04-98 9 200 150 Prepectoral — “ “ Size decrease “ “ 200 150 Prepectoral — 06917 KB 4-28-94 McGhan 60 Size increase 3-10-98 47 150 390 Prepectoral — “ “ Size increase “ “ 150 390 Prepectoral — 18297 MD 6-30-97 McGhan 60 Implant failure 8-17-98 26 385 390 Prepectoral Valve∗ “ “ Implant failure “ “ 385 390 Prepectoral Valve∗ 12720 KJ 10-17-95 Mentor 1600 Size increase 9-23-98 35 300 450 Prepectoral — “ “ Size increase “ “ 302 450 Prepectoral — 19528 MP 12-10-97 Mentor 1600 Size decrease 3-07-00 27 305 210 Prepectoral — “ “ Size decrease “ “ 305 10 Prepectoral — 01860 AS 4-10-93 McGhan 60 Size increase 8-22-00 88 345 560 Prepectoral — “ “ Size increase “ “ 330 60 Prepectoral — 14780 VB 6-13-96 McGhan 60 Implant failure 11-11-00 53 220 230 Prepectoral Valve∗ “ “ Elective replacement “ “ 230 230 Prepectoral 29199 AL 6-12-00 Mentor 1400 Size decrease 4-11-02 22 510 390 Prepectoral — “ “ Size decrease “ 22 490 390 Prepectoral — 35813 AL 8-29-02 McGhan 68 Implant failure 9-24-02 1 300 350 Subpectoral Valve∗ “ “ Size increase “ 1 280 330 Subpectoral — 19188 LH 8-20-97 McGhan 60 Implant failure 10-19-02 62 340 320 Prepectoral Valve∗ “ “ Implant failure “ 62 340 320 Prepectoral Hole∗ 25496 SM 5-26-99 McGhan 68 Size decrease 1-08-03 43 300 240 Subpectoral — “ “ Implant failure “ 43 300 240 Subpectoral Valve∗ 28703 SJ 3-13-00 Mentor 1400 Implant failure 1-14-03 34 690 690 Prepectoral Hole∗ 38104 JB 9-07-00 McGhan 68 Elective replacement 5-28-03 32 500 510 Subpectoral — “ “ Implant failure “ 32 500 510 Subpectoral Valve∗ 37556 PF 3-25-03 Mentor 1400 Size increase/capsulotomy 6-02-03 2 560 600 Prepectoral — “ “ Size increase/capsulotomy “ 2 560 600 Prepectoral — 09444 LM 6-07-95 Mentor 1800 Elective replacement 6-03-03 192 320 315 Prepectoral — “ “ Implant failure “ 192 310 305 Prepectoral Hole∗ 26010 RG 8-02-99 Mentor 1400 Implant failure 6-10-03 46 270 210 Prepectoral Hole∗ “ “ Elective replacement “ 46 270 210 Prepectoral — Patient no. Patient ID Date of original implant surgery Implant type Reason for implant Date of revision Months elapsed since original augmentation Old size (cc) New size (cc) Implant plane Site of Implant failure 03587 AA 8-30-93 McGhan 60 Size increase 11-20-93 3 220 400 Prepectoral — “ “ “ Size increase “ “ 220 400 Prepectoral — 14463 HC 2-05-97 McGhan 68 Size decrease 5-06-97 2 265 200 Prepectoral — “ “ “ Size decrease “ “ 260 200 Prepectoral — 11326 TW 7-11-96 McGhan 60 Implant failure 11-20-97 16 230 236 Prepectoral Valve∗ 14463 HC 5-06-97 McGhan 68 Size decrease 2-04-98 9 200 150 Prepectoral — “ “ Size decrease “ “ 200 150 Prepectoral — 06917 KB 4-28-94 McGhan 60 Size increase 3-10-98 47 150 390 Prepectoral — “ “ Size increase “ “ 150 390 Prepectoral — 18297 MD 6-30-97 McGhan 60 Implant failure 8-17-98 26 385 390 Prepectoral Valve∗ “ “ Implant failure “ “ 385 390 Prepectoral Valve∗ 12720 KJ 10-17-95 Mentor 1600 Size increase 9-23-98 35 300 450 Prepectoral — “ “ Size increase “ “ 302 450 Prepectoral — 19528 MP 12-10-97 Mentor 1600 Size decrease 3-07-00 27 305 210 Prepectoral — “ “ Size decrease “ “ 305 10 Prepectoral — 01860 AS 4-10-93 McGhan 60 Size increase 8-22-00 88 345 560 Prepectoral — “ “ Size increase “ “ 330 60 Prepectoral — 14780 VB 6-13-96 McGhan 60 Implant failure 11-11-00 53 220 230 Prepectoral Valve∗ “ “ Elective replacement “ “ 230 230 Prepectoral 29199 AL 6-12-00 Mentor 1400 Size decrease 4-11-02 22 510 390 Prepectoral — “ “ Size decrease “ 22 490 390 Prepectoral — 35813 AL 8-29-02 McGhan 68 Implant failure 9-24-02 1 300 350 Subpectoral Valve∗ “ “ Size increase “ 1 280 330 Subpectoral — 19188 LH 8-20-97 McGhan 60 Implant failure 10-19-02 62 340 320 Prepectoral Valve∗ “ “ Implant failure “ 62 340 320 Prepectoral Hole∗ 25496 SM 5-26-99 McGhan 68 Size decrease 1-08-03 43 300 240 Subpectoral — “ “ Implant failure “ 43 300 240 Subpectoral Valve∗ 28703 SJ 3-13-00 Mentor 1400 Implant failure 1-14-03 34 690 690 Prepectoral Hole∗ 38104 JB 9-07-00 McGhan 68 Elective replacement 5-28-03 32 500 510 Subpectoral — “ “ Implant failure “ 32 500 510 Subpectoral Valve∗ 37556 PF 3-25-03 Mentor 1400 Size increase/capsulotomy 6-02-03 2 560 600 Prepectoral — “ “ Size increase/capsulotomy “ 2 560 600 Prepectoral — 09444 LM 6-07-95 Mentor 1800 Elective replacement 6-03-03 192 320 315 Prepectoral — “ “ Implant failure “ 192 310 305 Prepectoral Hole∗ 26010 RG 8-02-99 Mentor 1400 Implant failure 6-10-03 46 270 210 Prepectoral Hole∗ “ “ Elective replacement “ 46 270 210 Prepectoral — Four of these patients underwent elective replacement of the implant on the opposite side. ∗ The 36 breast implant replacements were subsequent to 1724 implants inserted by way of the navel. The 10 modest size increases required capsulotomy; for the 10 size decreases, no capsule work was done. Seven of the 10 deflations occurred in implant styles that have since been discontinued because of faulty valve design. Open in new tab Table Details of transumbilical breast implant replacement for 36 breasts in 19 patients Patient no. Patient ID Date of original implant surgery Implant type Reason for implant Date of revision Months elapsed since original augmentation Old size (cc) New size (cc) Implant plane Site of Implant failure 03587 AA 8-30-93 McGhan 60 Size increase 11-20-93 3 220 400 Prepectoral — “ “ “ Size increase “ “ 220 400 Prepectoral — 14463 HC 2-05-97 McGhan 68 Size decrease 5-06-97 2 265 200 Prepectoral — “ “ “ Size decrease “ “ 260 200 Prepectoral — 11326 TW 7-11-96 McGhan 60 Implant failure 11-20-97 16 230 236 Prepectoral Valve∗ 14463 HC 5-06-97 McGhan 68 Size decrease 2-04-98 9 200 150 Prepectoral — “ “ Size decrease “ “ 200 150 Prepectoral — 06917 KB 4-28-94 McGhan 60 Size increase 3-10-98 47 150 390 Prepectoral — “ “ Size increase “ “ 150 390 Prepectoral — 18297 MD 6-30-97 McGhan 60 Implant failure 8-17-98 26 385 390 Prepectoral Valve∗ “ “ Implant failure “ “ 385 390 Prepectoral Valve∗ 12720 KJ 10-17-95 Mentor 1600 Size increase 9-23-98 35 300 450 Prepectoral — “ “ Size increase “ “ 302 450 Prepectoral — 19528 MP 12-10-97 Mentor 1600 Size decrease 3-07-00 27 305 210 Prepectoral — “ “ Size decrease “ “ 305 10 Prepectoral — 01860 AS 4-10-93 McGhan 60 Size increase 8-22-00 88 345 560 Prepectoral — “ “ Size increase “ “ 330 60 Prepectoral — 14780 VB 6-13-96 McGhan 60 Implant failure 11-11-00 53 220 230 Prepectoral Valve∗ “ “ Elective replacement “ “ 230 230 Prepectoral 29199 AL 6-12-00 Mentor 1400 Size decrease 4-11-02 22 510 390 Prepectoral — “ “ Size decrease “ 22 490 390 Prepectoral — 35813 AL 8-29-02 McGhan 68 Implant failure 9-24-02 1 300 350 Subpectoral Valve∗ “ “ Size increase “ 1 280 330 Subpectoral — 19188 LH 8-20-97 McGhan 60 Implant failure 10-19-02 62 340 320 Prepectoral Valve∗ “ “ Implant failure “ 62 340 320 Prepectoral Hole∗ 25496 SM 5-26-99 McGhan 68 Size decrease 1-08-03 43 300 240 Subpectoral — “ “ Implant failure “ 43 300 240 Subpectoral Valve∗ 28703 SJ 3-13-00 Mentor 1400 Implant failure 1-14-03 34 690 690 Prepectoral Hole∗ 38104 JB 9-07-00 McGhan 68 Elective replacement 5-28-03 32 500 510 Subpectoral — “ “ Implant failure “ 32 500 510 Subpectoral Valve∗ 37556 PF 3-25-03 Mentor 1400 Size increase/capsulotomy 6-02-03 2 560 600 Prepectoral — “ “ Size increase/capsulotomy “ 2 560 600 Prepectoral — 09444 LM 6-07-95 Mentor 1800 Elective replacement 6-03-03 192 320 315 Prepectoral — “ “ Implant failure “ 192 310 305 Prepectoral Hole∗ 26010 RG 8-02-99 Mentor 1400 Implant failure 6-10-03 46 270 210 Prepectoral Hole∗ “ “ Elective replacement “ 46 270 210 Prepectoral — Patient no. Patient ID Date of original implant surgery Implant type Reason for implant Date of revision Months elapsed since original augmentation Old size (cc) New size (cc) Implant plane Site of Implant failure 03587 AA 8-30-93 McGhan 60 Size increase 11-20-93 3 220 400 Prepectoral — “ “ “ Size increase “ “ 220 400 Prepectoral — 14463 HC 2-05-97 McGhan 68 Size decrease 5-06-97 2 265 200 Prepectoral — “ “ “ Size decrease “ “ 260 200 Prepectoral — 11326 TW 7-11-96 McGhan 60 Implant failure 11-20-97 16 230 236 Prepectoral Valve∗ 14463 HC 5-06-97 McGhan 68 Size decrease 2-04-98 9 200 150 Prepectoral — “ “ Size decrease “ “ 200 150 Prepectoral — 06917 KB 4-28-94 McGhan 60 Size increase 3-10-98 47 150 390 Prepectoral — “ “ Size increase “ “ 150 390 Prepectoral — 18297 MD 6-30-97 McGhan 60 Implant failure 8-17-98 26 385 390 Prepectoral Valve∗ “ “ Implant failure “ “ 385 390 Prepectoral Valve∗ 12720 KJ 10-17-95 Mentor 1600 Size increase 9-23-98 35 300 450 Prepectoral — “ “ Size increase “ “ 302 450 Prepectoral — 19528 MP 12-10-97 Mentor 1600 Size decrease 3-07-00 27 305 210 Prepectoral — “ “ Size decrease “ “ 305 10 Prepectoral — 01860 AS 4-10-93 McGhan 60 Size increase 8-22-00 88 345 560 Prepectoral — “ “ Size increase “ “ 330 60 Prepectoral — 14780 VB 6-13-96 McGhan 60 Implant failure 11-11-00 53 220 230 Prepectoral Valve∗ “ “ Elective replacement “ “ 230 230 Prepectoral 29199 AL 6-12-00 Mentor 1400 Size decrease 4-11-02 22 510 390 Prepectoral — “ “ Size decrease “ 22 490 390 Prepectoral — 35813 AL 8-29-02 McGhan 68 Implant failure 9-24-02 1 300 350 Subpectoral Valve∗ “ “ Size increase “ 1 280 330 Subpectoral — 19188 LH 8-20-97 McGhan 60 Implant failure 10-19-02 62 340 320 Prepectoral Valve∗ “ “ Implant failure “ 62 340 320 Prepectoral Hole∗ 25496 SM 5-26-99 McGhan 68 Size decrease 1-08-03 43 300 240 Subpectoral — “ “ Implant failure “ 43 300 240 Subpectoral Valve∗ 28703 SJ 3-13-00 Mentor 1400 Implant failure 1-14-03 34 690 690 Prepectoral Hole∗ 38104 JB 9-07-00 McGhan 68 Elective replacement 5-28-03 32 500 510 Subpectoral — “ “ Implant failure “ 32 500 510 Subpectoral Valve∗ 37556 PF 3-25-03 Mentor 1400 Size increase/capsulotomy 6-02-03 2 560 600 Prepectoral — “ “ Size increase/capsulotomy “ 2 560 600 Prepectoral — 09444 LM 6-07-95 Mentor 1800 Elective replacement 6-03-03 192 320 315 Prepectoral — “ “ Implant failure “ 192 310 305 Prepectoral Hole∗ 26010 RG 8-02-99 Mentor 1400 Implant failure 6-10-03 46 270 210 Prepectoral Hole∗ “ “ Elective replacement “ 46 270 210 Prepectoral — Four of these patients underwent elective replacement of the implant on the opposite side. ∗ The 36 breast implant replacements were subsequent to 1724 implants inserted by way of the navel. The 10 modest size increases required capsulotomy; for the 10 size decreases, no capsule work was done. Seven of the 10 deflations occurred in implant styles that have since been discontinued because of faulty valve design. Open in new tab Discussion Many surgeons who see no reason to use the transumbilical route for breast augmentation in the first place will naturally question the rationale for using the navel approach for implant replacement. A significant number of my patients tell me that if it were not possible to insert the implants without a scar on the breast or axilla, they would not go undergo augmentation. Most of my patients who undergo transumbilical breast augmentation say that if their implants leak, they would prefer that the replacement also be done by way of the navel if possible. I advise every patient seeking primary augmentation that if she chooses the transumbilical route, replacement by way of the navel will only be possible if it is done promptly after deflation, before the capsule has contracted. I also inform the patient that wherever she may be living at that time, she will need ready access to a surgeon comfortable with using the transumbilical approach. Conclusion Implant replacement by way of the navel should pose no difficulty for the surgeon familiar with transumbilical augmentation. In my opinion,13 to avoid poor results and potentially serious problems, primary transumbilical breast augmentation should be performed only by surgeons who have taken a formal training course. On the other hand, those plastic surgeons who are already experienced in primary transumbilical augmentation should be able to perform implant replacement by way of the navel without any additional training. They can be confident that the skills they mastered for the primary technique will also serve them well in the replacement of implants by way of the navel if they use the guidelines given here. They can then reassure patients undergoing transumbilical breast augmentation that implant replacement can also be performed by way of the navel. References 1 Johnson GW Christ JE The endoscopic breast augmentation Plast Reconstr Surg 1993 ; 92 : 801 – 808 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Johnson GW Dowden RV Breast augmentation: transumbilical retroglandular approach In: Fodor PB Isse NG, editors. Endoscopically Assisted Aesthetic Plastic Surgery St. Louis, MO : Mosby 1995 : 145 – 166 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 3 Johnson GW Dowden RV Breast augmentation: umbilical approach In: Ramirez OM Daniel RK, editors. Endoscopic Plastic Surgery New York : Springer 1995 : 156 – 175 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 4 Dowden RV Endoscopic breast augmentation In: Achauer BM Eriksson E Guyuron B Colema JJ, editors. Plastic Surgery: Indications, Operations, Outcomes Philadelphia, PA : Mosby 2000 : 2757 – 2767 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 5 Dowden RV Dispelling the myths and misconceptions about transumbilical breast augmentation Plast Reconstr Surg 2000 ; 106 : 190 – 194 . Google Scholar Crossref Search ADS PubMed WorldCat 6 Dixon P Dowden RV Connor P Klein C Transumbilical breast augmentation AORN J 2000 ; 72 : 615 – 630 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 7 Dowden RV Technical update on transumbilical breast augmentation Aesthetic Surg J 2000 ; 18 : 240 – 241 . OpenURL Placeholder Text WorldCat 8 Caleel RT Gray MW Perrott DH Transumbilical endoscopic breast augmentation: special considerations Int J Aesthetic Surg 1996 ; 4 : 33 – 35 . OpenURL Placeholder Text WorldCat 9 Wittenberg JM Leventhal M Transumbilical retroglandular breast augmentation: a review of 158 cases and a comparison with traditional approach Am J Cosmetic Surg 1998 ; 15 : 387 – 391 . OpenURL Placeholder Text WorldCat 10 Caleel RT Transumbilical endoscopic breast augmentation: submammary and subpectoral Plast Reconstr Surg 2000 ; 106 : 1177 – 1182 . Google Scholar Crossref Search ADS PubMed WorldCat 11 Pound EC Pound EC Transumbilical breast augmentation (TUBA) Clin Plast Surg 2001 ; 28 : 597 – 605 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 12 Songcharoen S Endoscopic transumbilical subglandular augmentation mammaplasty Clin Plast Surg 2002 ; 29 : 1 – 13 . Google Scholar Crossref Search ADS PubMed WorldCat 13 Dowden RV Keeping the transumbilical breast augmentation procedure safe Plast Reconstr Surg 2001 ; 108 : 1389 – 1400 . Google Scholar Crossref Search ADS PubMed WorldCat 14 Dowden RV Why the transumbilical breast augmentation is safe for implants Plast Reconstr Surg 2001 ; 109 : 2576 – 2579 . Google Scholar Crossref Search ADS WorldCat 15 Sudarsky L Experience with transumbilical breast augmentation Ann Plast Surg 2001 ; 46 : 467 – 472 discussion 472–473 Google Scholar Crossref Search ADS PubMed WorldCat 16 Hedon P Breast augmentation with anatomical cohesive gel implants: the world's largest current experience Clin Plast Surg 2001 ; 28 : 531 – 552 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 17 Rey RM Jr Transumbilical breast augmentation: a new instrument for changing implants from the subglandular to the subpectoral position Plast Reconstr Surg 2001 ; 107 : 1310 – 1311 . Google Scholar Crossref Search ADS WorldCat 18 Annual British Virgin Islands Plastic Surgery Workshop, Road Town, Tortola , January 2001 Author notes This work was previously presented at the British Virgin Islands Plastic Surgery Workshop, Road Town, Tortola, January 2001. © 2003 American Society for Aesthetic Plastic Surgery
TI - Transumbilical Breast Implant Replacement
JO - Aesthetic Surgery Journal
DO - 10.1016/S1090-820X(03)00202-4
DA - 2003-09-01
UR - https://www.deepdyve.com/lp/oxford-university-press/transumbilical-breast-implant-replacement-Jf3NoGX594
SP - 364
EP - 369
VL - 23
IS - 5
DP - DeepDyve
ER -