Surgery Spotlight: Trans-Abdominal Breast Augmentation (TABA)-Surgery Spotlight: Trans-Abdominal Breast Augmentation (TABA)

Surgery Spotlight: Trans-Abdominal Breast Augmentation (TABA)

Video Transcription

Hi, I'm Rick Zenowitz. I'm an Associate Professor at Brown University in Plastic Surgery. What  this operation does, and it's called TABA, Trans Abdominal Breast Augmentation, is take the biggest route that you could possibly put an implant through with the least amount  of skin touch, insert the breast implants in under the muscle, or above if you choose to, but I think under the muscle is generally the better way, and end up with a capsule  contracture rate that is the lowest reported ever. We, fortunately, just had our paper accepted by the White Journal, and it's less than 1%. It's about 0.8%, 0.78%, I believe.  Why is that? Well, because it's a no-touch technique. You're putting the implant in through the abdominal opening, so there's no contact at all with skin, and number two, the pocket  from the breast is draining into the abdomen, so there's no chance of collection of seroma or hematoma around the implant. So we strongly believe that that's what's contributing to  So today's patient is a professional, wanted to be a little smaller than I thought would be ideal for her, but still turned out to be, I think, a reasonable size for her, and  she chose saline implants. Now, we use about 95% silicone today, but in the early days  when silicone wasn't as available, I was certainly using a lot of saline, and saline works beautifully. So, without further ado, TABA.  So one of the things that we can notice right here is that we've got a considerable diastasis. When Leslie turns this way right here, you can see how this part really just bulges so  much, and there's considerable laxity right here to the bottom. So we're going to be fixing that on the inside. What I like to do first is she's going to just hold her tummy right  here and I'll pull straight up. So that gives me a good line for the midline. I'm going to mark the midline in line with the pubic mound. This is basically just for orientation  purposes. And then you can see the old fan and steel incision right here. We're going to go below that because we want to get rid of that. So we're going to stay on the low  side right here, which will be concealed by bathing suit wear. And we'll start off with a conservative marking like this. And then you can relax now. And then for orientation  purposes, you can see right here in the middle of the xiphoid area, xiphoid, and we're going to just mark, for orientation purposes again, just the midline. That's going to help us  later on to line up the umbilicus where we want it to end up. You can see that her breast mound position is fairly ideal. We've got a little bit of hypoplasia on this side. This  part of the chest wall projects a bit more than this side. So we are going to compensate by using a one size larger implant on this side. She's chosen, and she's a very educated  person, to use saline implants. And she has her own specific reasons for that. So the saline implants give us a little bit more largesse to adjust volumes as well. I am not  going to mark any folds because I find that marking right here is only going to distract the appearance on the table. She'll be seated and will be able to see everything for ideal  purpose of marking. Here, I think we're just going to go a little tiny bit lower right  there. Okay, and that should do it. Kind enough to have Dr. Steven Pinero, who is a Mass General  trained outstanding anesthesiologist, who's already done some paravertebral blocks here that basically just makes things a little bit easier for us going through this so that  the patient will be really comfortable. But we're going to start approximately about the T5 level and we're going to go down until we get to T12 with paravertebral blocks. And  the purposes of these, certainly one is going to be for analgesia, but also for hemostasis  because it really curtails the amount of inflow from the intercostal arteries. So right here we can transfix each rib. Watch this, boom. I am on the rib right now and then I just  walk it right down to the lower edge and I put in two cc's. So I'm not even at, it's  a diffusion block. There's no chance of intra-arterial injection. So again, hitting the rib, walking  it to the lower edge with your finger and then putting in two cc's. I've got to get a little bit lower right there. Boom. And it's amazing how easy, especially on patients  like this, it is so easy to inject because the ribs are right there on the surface. So we're using a mixture here of 1% xylocaine with epinephrine mixed with a quarter percent  marcaine plain. If you look right now, you can see the degree of diastasis recti that this young woman has. I mean, this is her umbilicus and I'm putting my finger, and you  can see the pulsation on my finger, I believe. If you look at that right now, and that is her aorta. So there's really nothing in between there because the rectus sheath has been so  attenuated by pregnancy that there's a big space and that's why she bulges. I use plain only around the umbilicus because we don't want any problem with circulation in the center  of the flap. So that's just plain. And then we're going to use our regular combination for the incision down below. You can see the old fan and steel incision that we're going  to be excising. And then we'll also do some ilioinguinal blocks. So we get to this level  and we put in about 5 cc's right where the ilioinguinal nerve makes its course. Lastly,  I'm going to put some along the medial borders here so that we get the medial intercostals.  A little bit higher level of the ribcage right here and then a little in the pectoralis major  and then a little bit in the middle. Typically in 95% of our patients, at least, we're using silicone gel implants and I use a Keller funnel to introduce all of those. The patient  had specific reasons for wanting saline implants today so we're going to be using saline, which  obviates the need for a Keller funnel because they are inserted as a little cigar rolled up through a small opening. And we'll show you how that works. One of the things that  we're going to be doing is we're going to be using a silicone gel implant. And we're going to be using a silicone gel implant. And we're going to be using a silicone gel  implant. And we're going to be using a silicone gel implant. And we're going to be using a  through a small opening. And we'll show you how that works. One of the things that I cannot tell you exactly how we're going to handle it just yet, it really depends on how much  translocation we get of this area inferiorly to decide what we're going to do with the actual umbilicus. We may need to make a new umbilicus completely because there is a little  hernia here. But often times what I do is float, so take this as one unit, leave the umbilicus intact, attached to the abdominal apron, pull everything down and then sometimes  we will take a piece of dermis and fat right here as a dermal fat graft and graft behind this area if it's attenuated down here and we still need to have that filled up. And  sometimes we will just incise it and close it as a little straight line down in the lower hypogastrium. If you look at this, this is not a straightforward case. So she's got an  umbilical hernia here, she's got a massive diastasis. What I'm thinking about doing is  if you look, when I pull in this direction here, I am very close to getting this all excised. However, I may have a few centimeters that would be tight and I would rather give  her a low scar if I can. So I'm going to raise this right off of the umbilical stalk and then when we go in and repair the diastasis, the hernia will be repaired and we will make  a new umbilicus for her at some point, okay? And what you want to do here is you want to preserve a little umbilical stalk but not too much. You can see what we're doing now  is preserving a stalk of umbo, which is what will be lining the lower part of the umbilical  inset ultimately. So keeping this short is important and it will still give her a beautiful  umbilicus and we'll show you how that works. One of the things that is really helpful here is to make sure that we separate this nicely from the dissection. I'm staying wide here.  So I'm just separating the stalk from the surrounding tissues and what that does is it makes the eventual elevation of the abdominal flap so much easier because the umbilicus  is just sitting in the breeze. So we'll start with a little bit shorter scar. We may have to make it longer later on and we're going to cut immediately as opposed to the way that  a lot of abdominoplasties are taught, we're going to be cutting right where we want this scar to end up. So we don't want to leave extra fat behind and you can see how thin  she is to begin with. If you can see right here, we're already onto abdominal fascia here. Beautiful abdominal fascia. Very thin. This is always the most difficult part to  gain good anesthesia. So Dr. Pinheiro, I can assure you, has titrated up his level of ketamine to help us here to get through this little bit difficult area to anesthetize. Once we  get into the intercostal zone then it's not such an issue. What we try to do, and I think  we can give Carlos Hubel a shout out and Rafael de la Plaza for telling us to leave more tissue  down on the rectus sheath, which again leaves lymphatics. What I'm doing is I'm going right  now through an old phantosteel scar so that's why it looks like this. But now we're going to  try and leave a little bit of fat on the fascia. The assistant, all the residents learn right up  front that if we cut this flap now, so she's feeling where the end of the lower abdominal  incision is, and she's going to cut to that level. A little bit more. And it just makes it easier  for us to dissect now. And so what I'm doing is I'm protecting that umbilicus from any injury.  And there's the old stalk of the umbilicus right there that everybody can see. And it really is  not so much a hernia as a diastasis. If you get all the bleeders on the way in, the chances of you  having a problem later on, especially if we have to use Lovenox, which is becoming more  de rigueur for the age group that we're doing this for, we want to be pretty certain that we've  gotten excellent hemostasis throughout. This is the edge of the rectus muscle on both sides. It is  enormously wide right here. And again, it's under no distension, so imagine when she's standing up  how much that actually stretches out. We've reached the costal margin right now, so the dissection  now is going to be, if you look right here, I'm just easily going to the level of the inframammary  fold that we proposed to use. I'm just going to bluntly make those tunnels right here now, because  we don't really need to do a lot of undermining, and that will preserve more blood supply. So we're just going to enlarge the entrance of those tunnels a little bit right now.  When we take the breast envelope and we pull up, I apologize, I've had a C7, T1, and T1, T2  disc herniation, so my left hand's a little bit weak, so I'm going to ask Bella to pull up on this.  Pull up a little bit harder. And then what I'm doing right now is I'm getting easily underneath the pectoralis major muscle with just blunt dissection.  Okay, almost there. Perfect. So I am underneath the pectoralis major muscle now. So what we're going to do now is, this is a Snowden-Pencer balloon dissector. For this application,  typically we use a 600cc balloon, and they are round. Unfortunately they are on back order for six  months, so what we have is a transaxillary balloon. It will suffice, it will work nicely anyway.  But what we're going to do is we're going to use it in the opposite direction. We're going to put the  side on the left because you'll see there's a blunt side that will not over-distract the section on this side.  So I'm going to just lift up like this, I'm going to slide in, I'm in. Okay, now we're ready. Bell? Yep.  And she's going to inflate this. Okay, go. Okay, that should be good. Good, okay, good. That was 20, so that's 600cc of distention.  I'm going to relax that. And then what I'm going to do is I'm just going to go in myself and I can feel the pocket  itself. I just want to make sure that it's properly situated. And I'm just releasing a little bit along the  inframammary fold. So I'm just going to put this in on the opposite side and we'll do the left on this side.  I just want to make sure.  Slide it right in.  Perfect, keep going down and in. Beautiful.  Okay, good. Now if you wouldn't mind pumping it up again, close that off.  We'll do the same, 600, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, perfect, ok good, relax, good.  This is a paddle dissector, all I'm doing is just introducing this so that I can just make sure that we have enough release in the lower pole right here.  And this can be used with the implant in place as well.  So now we're going to take this, put it right on top, remove this, so then we introduce the tube into the middle, it screws right in,  and then you deflate it on top of this cone so it really, really deflates it beautifully, and then I roll it into a cigar shape.  Ok, and then we're going to do the same thing on the other side, roll it into a cigar shape.  Let me just make sure this is all empty, good, put that on, suck all the air out, now detach it, good, beautiful. Ok, so this is going in, and let's start filling.  So I'm going to squirt triple antibiotics into the pocket as well. That's filled to 300. Ok, so let's go up to 330, another 30.  She does not want to be too big, so we're going to stop there, we'll fill the other one. Beautiful. Can we begin filling please?  So the paddle right here, just a little bit of tweaking right here. There's the roundness back. We're going to just tape right across right here.  We only have an opening about this big on there to get that in, so we're going to just tape that fold and it'll be beautiful. See how small that space is right there?  And if I push on the implant, it is not coming out of the hole because the arc of it is too big to allow for that to happen.  So with a little bit of tape, that's going to hold it just where it is, and it will seal perfectly.  If the implant tends to come down, then you can put a nice suture in there, and I've done that before on video, but we don't need to do that today. So now let's fix our diastasis.  And what we're going to do is we're going to do a, let me just mark where my umbo is, so we don't lose the umbo later on. We're going to use Interrupteds.  So Maxon is an absorbable, phenomenal coefficient of friction. It just ties so well.  And I like to use power pads, which if you look at them, they have this beautiful tying platform, so it grabs the needle so well.  And then once we do this, we will anesthetize the area with some Marcane so that she doesn't wake up in pain.  This is what happened during pregnancy. In order to accommodate the fetus, the body stretched out and allowed that part, as opposed to the muscles. This is pure fascia.  See how loose it is? So now by putting the muscles together, we're restoring the natural carrying position of both muscles.  And it'll never separate again, ever. Unless she had another pregnancy.  For just about everybody, if they're ever intending on having another child, it would not be the smartest thing to do this.  Because you're basically going to stretch out your repair, and why waste the effort? Do it once you're done with your last child. These are all Interrupteds. They're very strong.  They will last probably six months tensile strength while this is healing. So that even if she's doing hard exercise, I can, I've done a test on her.  I can, I've done a New England Patriots lineman, and he was hitting the sled after six weeks and never had a problem. These work beautifully. This is the first layer.  We're going to use V-Lock after that, and I'll show you that in a minute.  I'm going right back through old scar now. This is our old fan and steel area. So it's really dense scar.  I hope everybody appreciated that we used different size implants because her chest wall was more pronounced, more projecting on the left side.  So we used a smaller implant by 25 cc's on that side. It looks to me from the base that her projection is pretty similar now.  Even though the implant is not particularly, it's not much more projecting. It just seems to have been enough to restore more symmetry.  V-Lock.  Made by Covedian. So it's a barbed suture, and if you look at the end, it has a loop. So it's not, it's knotless. So I will start.  My umbilicus is actually right here where I've marked, and I'm going to start right at that side, and then Bella will do another one going in that same opposite direction.  So once again, we don't have to do any knotting. We just engage that suture as a loop, and it's beautiful because especially around the umbilicus,  it doesn't create a bulky knot that can, see how it just disappears?  So now the suture is phenomenal because as it goes across, it engages the tissues and it holds. It doesn't reel back because of those little barbs on the end.  I have no interest in the company, and we will also be using,  the other competitor is Quill, and we'll be using that, which is somewhat identical. They're both barbed sutures, just different manufacturers.  But I find them to be a tremendous addition to our armamentarium.  So I've already gone all the way up, and now I'm going to go backwards and get a third layer.  So this is a three-layer closure,  with heavy suture that is quite strong, and will last approximately six months.  And we're good, so we'll close that, and then we'll close that as a straight line. So, can everybody appreciate how this is now rock solid?  It is just, there's nothing left. I'm pushing with all this force and nothing's bouncing. It's very strong. This is what we use now to take the zing out of what we've done.  It will make a huge difference.  Let me just go paramedian, all the way up and down.  So we put the drains right at the very bottom, where they can't compromise circulation. Ordinarily, again, I lipo everybody here, but she's so thin to begin with,  that I'm a little bit loathe to do too much. I'm only going to do a little bit right here, just to indent that just a little bit right there.  This is to create the median raffae.  You can see how that just shapes that better.  What I need to do now is to centralize the umbilicus. So I know where it is because we've marked it before, and we've left that opening.  Remember what we left behind. It wasn't a lot.  In order to identify the midline of the umbilicus, what somebody can do is, you take the bovie, put it right in the sternal notch, carry it down to the middle of the mons.  So we can see that the umbo is exactly where it belongs, right?  By plumb lining, it's perfectly straight. So now we're going to just set it into this pre-marked line that we did.  So now what I'm doing is I'm pulling this down to a spot where I feel like I want that to sit. And then we'll get a bite of the dermis, just inside.  Perfect.  That's awesome. So what that's doing for us is it's showing us exactly where we want to put the umbo. And it's foolproof. I've tried a thousand different techniques.  This works beautifully every time. So we look and we see, how close is it to the actual umbo? And it's very close. This is the actual umbo.  So I'm going to make it just maybe about five millimeters lower than that. So what we'll do is we'll make a little tiny incision right below that. We don't need a big one.  I'm going to defat this area slightly.  Forcep.  And that will create a little depth for us.  Good. Okay. And now what we do is we sew the umbilicus into the fascia. And that spreads it out a little bit. So now that goes into and out.  We grab it.  We sew it to the skin.  And she goes back in.  We take the other end.  We introduce it through here.  And then tie it. And it is also another kind of foolproof way of locking it to the fascia.  Cut it with a little tiny tail. Now when she tightens that up, you'll see how it just, it causes a nice indentation. And this is as skinny an abdominal wall as you're going to see.  So if we can get a little bit of an innie, then that's wonderful.  But there we go. Okay.  Boom. Okay, good.  Nice bevel.  Bovy. So now here, we want to leave all the fat at least up to the transition zone.  She's so thin that there's not much, we want to make sure that we get no extra fat here.  And they often feel it out laterally here at this later closing because we haven't really anesthetized that as well.  We've just left it so that there's no extra fat. And when we close it, it's absolutely flat. That's what every patient is hoping for. They all read about dog ears and trusses.  If there's a hint of a dog ear, they're going to complain. So we're just going to put a couple of tool monocles before we do our O maxon closure.  And that's just to take the tension off. So we're getting scarpas here.  And aligning things nicely.  We're going to go with the oak quill now.  And these are separate. So we'll just close our scarpas with these.  These are also knotless sutures, you can see. So it's a beautiful closure technique. And we're using these in the deep tissues to close scarpas fascia.  It takes all the tension off of the wound. So that basically you have a three-layer closure.  If we were going to do it by hand,  if we were going to do it by everybody else's technique, the incision would be here. This is where the incision would end up, right here.  Because they would cut the umbilicus out right at that level. So you would have this scar coming right across here. So you have this space between the umbilicus.  When we're done, and this is all closed up nicely, you'll see how this can disappear. And it's not hard to hide in a bathing suit. I leave these last couple of staples in,  just for the first week, because it maintains the perfect end closure. We're going around them. This is all we need to do to define the fold, on both sides, while it heals.  And I will tell you, and Bella will vouch for this, I usually liposuction aggressively right here in the midline, but her skin was so thin that I thought it was a risk  to perfusion to the middle of the abdomen, so I did not do it today. Usually I like to have a nice sub-durable plexus there, and she didn't have it, so I didn't want to do that.  This is a professional, and she did not want to be large. That was her biggest thing, was just subtle, subtle breasts. And I think that's what we gave her,  but far better symmetry. I will also tape over here a little bit, but you can see our perfusion is all beautiful, all the way through. Once again, if we had done it the other way,  here's where the scar would have been, because that's where the umbilicus ends, right there. So, we finished our tablet today, and all I can tell you is I was ecstatic  with how everything went. This was a patient who is extremely thin, probably has about, at the most, a centimeter of fat behind her abdominal skin flap.  We did our very best to leave a little bit of fat on the fascia afterwards to try and decrease the chance of seroma formation. I think her implants were, by and large,  a nice choice for her, and I think she's going to be very happy with those. You're going to see a difference with this technique over virtually every other abdominoplasty technique,  because we close the old umbilical site as a little straight line in the lower abdomen, rather than create a big, high, horizontal scar  that is unsightly and can't be hidden in any beach wear.  ♪♪♪

Video Summary

Dr. Rick Zenowitz, an Associate Professor at Brown University, discusses a specialized surgical procedure called Trans Abdominal Breast Augmentation (TABA). This approach involves inserting breast implants via the abdominal route, minimizing skin contact and subsequently reducing the risk of complications like capsule contracture to as low as 0.78%. The technique also allows for the breast pocket to drain into the abdomen, reducing the risk of seroma or hematoma. During the surgery, a patient opted for saline implants, which are adjusted and inserted in a way that maintains symmetry and a natural appearance. The procedure includes addressing abdominal diastasis, using techniques that minimize visible scarring. Dr. Zenowitz's approach is meticulous, involving various innovative methods and tools such as paravertebral blocks for analgesia and hemostasis, and barbed sutures for a secure closure. This comprehensive technique aims to achieve minimal visible scarring, high satisfaction in aesthetic results, and a quick recovery, highlighting the benefits and advancements of plastic surgical methods.

Asset Caption

Richard Zienowicz, MD, demontrates a trans-abdominal breast augmentation (TABA) using saline implants, as well as an abdominoplasty. Dr. Zienowicz describes the preoperative markings, anesthesia and each step of the TABA and abdominoplasty procedures. Also, Dr. Zienowicz discusses the advantages of creating a lower abdominal scar. The video concludes with photographs taken three months postoperatively.

Surgeon Richard Zienowicz, MD

Disclosure All ASPS staff members managing this activity have no relevant financial relationships or affiliations to disclose. All identified conflicts of interest have been resolved and the educational content thoroughly vetted by ASPS for fair balance, scientific objectivity, and appropriateness of patient care recommendations. The ASPS also requires faculty/authors to disclose when off-label/unapproved uses of a product are discussed in a CME activity or included in related materials. This product is not certified for CME.

Keywords

Surgical Videos

Surgery Spotlight

Breast

Richard Zienowicz MD; Memben

Trans Abdominal Breast Augmentation

TABA

capsule contracture

abdominal diastasis

paravertebral blocks

barbed sutures

plastic surgery advancements