BREAST AUGMENTATION: THE BELLY BUTTON APPROACH

The belly button approach, also known as Transumbilical Breast Augmentation (TUBA), has been in use since 1991.  Dr. Friedman is one of only a few surgeons in Northern California offering this approach and has been successfully utilizing this technique at The Cosmetic and Reconstructive Surgery Center since 1996.  This is an endoscopic approach, meaning that only a very small incision inside the belly button is used for implant placement.  This results in virtually no visible scarring (the scar is inside the belly button).  Because there is no other cutting, there is only a tiny amount of bleeding (generally one to two tablespoons) and therefore less bruising and far less pain as compared to the other approaches used in breast augmentation.

Our experience is that there are lower rates of complications with this approach.  For example, nipple sensation loss with the standard approach is two to three percent of patients.  With the belly button approach, it is less than one percent.  Bleeding or hematoma occur in one to three percent of patients with a standard approach, yet with the belly button approach, it’s less than one percent.  Infections occur in one to three percent of standard approaches, while our rate with the belly button approach is less than one half of one percent.  Patients also experience a lesser chance of hardening.

A big advantage for women considering pregnancy in the future is that the breast tissue is not harmed in any way with the belly button approach.  The implant is simply slid under the breast tissue.  No breast tissue or ducts to the nipple are cut or disturbed in any way.

Recovery is far easier and far more rapid with the belly button approach.  With standard approaches, it is common for patients to have moderate to severe pain the first one to three weeks.  With the belly button approach, the pain lasts, on average, three to five days.  It is generally mild to moderate, and patients are ready to resume normal, non-strenuous activities within five to seven days.

Patients often ask how this procedure can be done.  Briefly, a small incision is made inside the rim of the navel.  A tunnel is made through the subcutaneous fat under the skin and above the abdominal muscles (no body cavities are entered).  A long instrument is used to create a pocket for the implant, either under the pectoralis muscle (most common) or under the breast tissue.  The empty implant, with fill-tube attached, is rolled up and pushed up the tunnel and into the pocket.  The implant is then filled with sterile salt water (saline solution).  The fill-tube is then removed which automatically seals the valve.  The navel incision is closed with absorbable sutures, and a small drain is placed in the belly button.

THE FIRST THREE WEEKS AFTER SURGERY

DAY ONE TO DAY THREE:
You will experience mild to moderate bruising, mild to moderate swelling, and drainage via the belly button, decreasing on day two or day three.  Change the abdominal pads as needed.  Under the pad is gauze, and under the gauze is the drain.  Do not touch the drain.   Some patients will have the drain removed day two or day three.  Patients who have their implants placed under the muscle will have more drainage and more discomfort.  You should ice continuously for 48 to 72 hours.  Take three Arnica tablets under the tongue every three hours.  Day three after surgery, the second bra may be removed and the Ace wrap may be loosened.  Activity: Sitting and minimal walking.  You should not be doing any bending, lifting, straining, or exercising during this time.

DAY FOUR:
The discomfort is minimal but present (under the muscle placement may still have moderate discomfort).  The swelling continues to go down but is still present (more swelling with under the muscle placement).  Drainage is minimal.  If the drain is still in, it will be pulled out today, tomorrow or on day six.  If the drain was taken out yesterday, then you can shower, but do not bathe for one week after the drain has been removed.  The gauze may be removed one day after removing the drain. Activity: Sitting and minimal walking, and still no bending, lifting, straining, or exercising.

DAY FIVE:
The discomfort is still decreasing but present.  The swelling continues to go down but is still present.  Drainage is minimal if the drain is still in or if it was taken out yesterday.  If the drain is still in, it will be pulled out today or tomorrow.  If the drain was taken out yesterday, then you can shower, but do not bathe for one week after the drain has been removed.  The breasts are slightly swollen, more so if implants are under the muscle.  Activity: Sitting and minimal walking, and still no bending, lifting, straining, or exercising.

DAY SIX TO DAY 21:
The discomfort in the breast is going away but there are still sore spots.  The swelling goes down daily.  As activity increases, the breasts may become more swollen and discomfort may increase.  You are still restricted in activity, and if swelling and discomfort increase, you are doing too much. Activity: Sitting and minimal walking, and still no bending, lifting, straining, or exercising.  You may resume normal activities and exercise three to four weeks after surgery. 

Frequently Asked Questions About Breast Enlargement

What is the belly button approach (Transumbilical Breast Augmentation or TUBA)?

The belly button approach has been in use since 1991. This is an endoscopic approach meaning that only a very small incision in the belly button is used with practically no visible scar (except inside the belly button).  Because there is no other cutting and only small scopes are used to perform the procedure, patients experience much less discomfort and are back to non-strenuous activities much sooner. Our experience has shown a much lower rate of bleeding (hematoma), less hardening, much lower infection rate, and much less sensation loss.

Are there drawbacks to having larger breasts?

The benefits of breast enlargement are well known and easy to understand.  Most of them relate to greater ease of finding clothing that fits well, without the need for internal padding or special lingerie.  Women contemplating enlargement need to consider that there are some drawbacks to larger breasts and implants.

Larger breasted women:

• need to wear a bra most of the day
• need support during strenuous exercise
• may not enjoy sleeping on the stomach
• may get unwanted attention from men
• may encounter envious treatment by other women
• may get more sag over the years
• may be able, in certain instances and positions, to see or feel the implants

What are the implants made of?

Breast implants are made of medical silicone, a soft, rubbery material, filled with salt water or silicone gel.  Silicone gel implants require a modified umbilical approach if the patient wishes to have breast augmentation through the belly button, which results in a small scar on the underside of the breast, on the areola.

What is the difference between placing implants in front of vs. behind the pectoralis muscle?

The primary difference between placing implants in front of the muscle vs. behind the muscle is the type of "look" that the breasts have.  In front of the muscle, the implant gives a distinct line, which extends up over the top of the breast.  If patients are not at least a full “B” cup to begin with, then a “stuck-on” look may occur.  Behind the muscle placement often yields a more natural look with softer transitions between the implant and the chest wall. The degree to which the placement affects the final result depends upon several factors, including:

• The larger the change in size, the greater the impact of  placement.
• The heavier and larger breasted a woman is to begin with, the less the impact of the different placements.

When is it important to place the implants behind the muscle?

• When the patient is a “B” cup or smaller, the muscle is needed to help cover the implant. 
• When a patient wants to go to a large size (a full “C,” “D” or larger), has little breast tissue, and thin skin and subcutaneous tissue, then behind the muscle is best.
• When the patient desires a more natural look, submuscular placement is recommended.
• In most instances, the submuscular placement yields a better look over many years.  For this reason, well over 90% of our patients over the past 20 years have had implants placed in the submuscular position.

What are the disadvantages to placing the implant behind the muscle?

• More discomfort post-operatively for the first week
• Breast movement associated with contraction of the pectoralis muscle (50% of patients)
• Longer recovery with more initial discomfort

Can salt-water implants harden?

The hardening that can occur is due to excess scar tissue formation and contraction of that tissue around the implant.  If this occurs, another operation may be required to remove the scar tissue.  Our rate of hardening over the past 20 years with saline implants is about three to four percent.

What is the expected product life of the implant?

An estimate for the product life is 10-15 years.  This is true of both saline and silicone implants.  Implants do not need to be changed unless there is a deflation. There is a three to four percent rate of deflation in the first 10 years. The implants are guaranteed by the manufacturer for life and against defect for up to 10 years.   While at anytime in your life you may obtain a replacement, the manufacturer will pay for the operating room fee within the first 10 years should a deflation occur and the extended warranty is in effect.

Is it true the replacement of implants is fairly minor?

For removal and replacement of implants, the answer is “yes.”  The major part of the original operation is the creation of the pocket.  When replacement is needed, the pocket is still there, so all that is needed is to open the pocket, take the present implant out, and put the new one in.  With saline implants, this can be accomplished in most patients through the belly button.  Silicone implants require a nipple or inframammary incision.

Can a woman breast-feed after breast augmentation?

Particularly with the belly button approach, the breast tissue and ducts are not disturbed, cut, or affected.  The procedure literally takes place under all of the breast tissue, without needing to go through it.  There is no evidence that silicone from the implant shell enters the milk.  When silicone implants are placed using the modified belly button approach combined with a small inframammary incision, the disturbance to the breast tissue is minimal, and in the majority of instances, will preserve the ability to breast-feed without difficulty.

Can implants achieve some lifting of sagging breasts?

Although implants do not lift up a sagging breast, they do help mildly sagging breasts to appear less saggy.  They do this in two ways:

• Implants take up some of the slack in loosened skin thereby increasing the volume and decreasing the saggy look.
• Implants, to a mild extent, rotate the lower portion of the breast upward making the breasts appear less saggy.

For moderate or severe sagging, a lifting procedure or a lifting procedure with implants is performed.

Do breasts with implants experience sagging over time?

All breasts relax as time passes, because the weight stretches the skin, elasticity is lost with age, and the amount of breast tissue often decreases as the person gets older.  These three factors mean that breasts can be expected to relax and sag whether or not there are implants.  The implants add some weight to the breast, which may increase the rate of relaxation, and yet implants and surrounding scar tissue can provide some internal support for the breasts.  The overall result is that usually the breasts sag less than they would have if they had grown to that same size on their own, and yet somewhat faster than if they were left their original smaller size.

What are the advantages and disadvantages of silicone implants?

Advantages:  Silicone implants are softer than saline implants.  How much difference in softness depends upon the amount and density of breast tissue present, skin thickness, and amount of subcutaneous tissue.  There is less rippling visible on the skin with silicone implants.

Disadvantages:  With silicone implants, a scar is required on the skin of the breast or on the areola.  The scars heal well but are generally still slightly perceptible.  When a silicone-filled implant fails or breaks, it is not readily apparent, with the first sign often being hardening of the breast.  This is due to the body’s natural response to silicone gel, which forms scar tissue to “wall off” the silicone from the body.  It can be a tedious operation to remove the gel from the breast pocket, and one cannot generally remove the microscopic amounts of silicone.  This can, in some instances, lead to hardening again, even with a new implant.

Saline or Silicone:  Which is better for me?

Most of the breast augmentation procedures we perform are using saline implants with the belly button approach.  Overall, there are slightly fewer complications with the belly button approach than with all other approaches.  Healing time, discomfort, and lack of a visible scar are the advantages.  Saline implants are also soft but not as soft as silicone.  If your are very concerned with the softness and do not mind a slightly higher rate of complications (.5 – 2%), a higher rate of each of the possible complications, as well as a greater possibility of hardening many years down the road, then silicone is for you.  If you want a quicker, less painful recovery with no visible scar and you don’t mind a slightly firmer implant, then saline is the better choice.

COSMETIC SURGERY & RECONSTRUCTIVE SURGERY CENTER IN LAFAYETTE, CALIFORNIA

Our goal is to provide a safe, tasteful and comfortable environment for our patients and an efficient and enjoyable space in which to work. Within the surgery center are rooms for consultation and examination, modern operating suites, and a comfortable recovery area. Locating in Lafayette brings the comfort, safety and convenience of an office surgery center to a very beautiful setting. Residents in the Lamorinda region are now within five to ten minutes of the quality of care that they expect. A fifteen to thirty minute drive is all that is required to reach the Surgery Center from most areas of Contra Costa County and Berkeley. We are about an hour from San Francisco, Marin and the South Bay.