New York — A limited population of abdominoplasty patients who also desire breast augmentation can have the procedures performed together without scars on or around the breast.
New York plastic surgeon Steven Wallach, M.D., says the combined procedure, transabdominoplasty breast augmentation (TABA), prevents the need to make an incision on or near the breast because the breast augmentation is approached through the abdominoplasty incision.
"This is done by extending the abdominoplasty undermining through two small tunnels - one on each side of the chest - which affords the surgeon easy access to the chest," says Dr. Wallach, assistant clinical professor of plastic surgery, Albert Einstein College of Medicine, and attending physician, Lenox Hill Hospital and Manhattan, Eye, Ear & Throat Hospital, New York.
"This is obviously for a limited patient population," he tells Dermatology Times, "but the clear advantage is that for a patient who wants both breast augmentation and an abdominoplasty, it limits the need for additional incisions on or near the breast."
Patient selection Dr. Wallach says the ideal candidate would have no more than first-degree breast ptosis and a short distance (2 cm to 4 cm) between the rib cage and the inframammary fold requiring dissection.
"Most patients with second- or third-degree breast ptosis would probably benefit more from a combination of augmentation and mastopexy than from TABA, and patients better suited for mini-abdominoplasty or modified abdominoplasty may not provide adequate exposure for creation of the tunnels necessary for implant insertion," he says.
Technique Dr. Wallach describes his own technique as follows:
First, he designs and marks the abdominoplasty incision. He then marks the inframammary folds bilaterally and the tunnels (4 cm to 6 cm wide) for implant insertion from a line lateral to the xiphoid and cephalad toward the central inframammary fold.
Next, he infiltrates the tunnels with 10 mL of 1 percent lidocaine with 1:100,000 epinephrine to minimize bleeding and tissue staining during tunnel dissection.
After elevating the abdominal flap, he excises the redundant abdominal pannus. He explains that the surgeon can determine the amount of tissue to remove by flexing the operating table and using a "vest over pants" technique.
"Removal of the redundant tissue," he says, "makes the superior abdominal flap less cumbersome and easier to retract during dissection of the tunnels."
Dr. Wallach creates the implant tunnels - usually 6 cm to 8 cm long - by elevating the soft tissue at the level of the anterior rectus sheath in a manner similar to raising the abdominal flap during an abdominoplasty or during a pedicled transverse rectus abdominis muscle breast reconstruction.
"It is essential to keep the two tunnels separate to avoid the development of symmastia," he warns. "It is also important to know when the dissection crosses the infra-mammary fold; you can determine this by visualizing the breast parenchyma or pectoralis fascia and confirm it externally on the chest skin by means of palpation and checking the inframammary markings."
To create a subglandular pocket, he retracts the pectoralis downward while carrying the dissection superficial to the muscle fascia.
For partial subpectoralis muscle placement, he divides the inferomedial muscle fibers, as with other techniques.
"Initially, I designed the pocket just lateral to the center of the breast meridian because it was easier to access the lateral border of the pectoralis muscle. However, this made it more difficult to divide the inferomedial pectoralis muscle fibers under direct vision," he explains. "I have moved the dissection just medial to the central breast meridian to get direct exposure to the pectoralis muscle fibers that require detachment."