Introduction

Relative to conventional abdominoplasty, reverse abdominoplasty has been less frequently studied.^1–4 This is in part due to the fact that the reverse abdominoplasty technique necessitates an upper abdominal scar, and that most patients present with lower, rather than upper, abdominal laxity. In patients with relatively normal infraumbilical abdomen tissues who request that the lax epigastric tissues be addressed, or patients who are not candidates for conventional abdominoplasty because of previous subcostal incisional scars, reverse abdominoplasty may be the safer, better, or sole option.⁵

Using the augmentation mammaplasty by reverse abdominoplasty (AMBRA) technique, the upper abdominal pannus is repositioned as dual adipofascial flaps, which provide autologous tissue for augmentation mammaplasty by reverse abdominoplasty. The result is a volume increase of 150– 200 cm³ in the average patient, and greater than 300 cm³ increases in those with a more generous pannus. Though AMBRA was designed to address a small subset of patients who also desire breast enhancement, it has proven similarly valuable for reconstructive purposes in appropriately selected cases.

Preoperative Planning/Patient Selection

The key steps in determining a patient’s suitability for the AMBRA procedure are a careful evaluation of the soft tissues of the upper epigastrum and performing a “breast suspension” test (Fig. 11.1). The patient is asked to lift each breast with a cupped hand. This should restore an esthetic result to the upper abdomen and umbilicus. Some patients benefit from suction-assisted lipectomy to the lower abdomen for contouring. Other patients would be better served by a mini-abdominoplasty to address moderate skin laxity of the lower abdomen. These adjuncts can help optimize the final result of AMBRA, without undue added risk.

FIG. 11.1 Breast suspension test (A, B) to confirm suitability for AMBRA.

Surgical Technique

Based on the pedicle of the flap, AMBRA is categorized as either superiorly or inferiorly based. The preoperative markings do not differ between the two approaches.

These preoperative markings are conducted while the patient is standing upright, to delineate the inframammary folds, and breast markings for mastopexy are performed concurrently. Then the patient is placed supine to allow the surgeon to retract the excess upper abdominal tissues cephalad, which is an adaptation of the Lockwood technique.⁶ The redundant soft tissues of the upper abdomen are then folded over to mark the “safe” zone of skin excision that permits tension-free closure with the inframammary fold. This area can be de-epithelialized without sacrificing a tension-free closure of the upper abdominal–IMF wound (Fig. 11.2). This de-epithelialized tissue provides the bulk for each breast’s augmentation.

FIG. 11.2 Preoperative markings.

Peri- and Postoperative Care

At the conclusion of the case a thin layer of tissue glue is applied to the incisions. The wounds are taped vertically to reduce tension. A 15 cm (6 inch) cotton roll reduced to half its diameter is placed in the midline to splint the median raphe and tape is applied across the abdomen for support and dead space closure. No garment is used for the first 2 weeks, but the patient is retaped after postoperative visits.

Case Examples

A 70-year-old patient desired fuller breasts and superior and central abdominal tightening (Fig. 11.3A, B, C, D).

FIG. 11.3 A 70-year-old patient desiring fuller breasts and abdominal tightening.

Preoperative (A, C) and postoperative (B, D) photos.

The case example shown in Fig. 11.4 depicts a patient who had previous submuscular breast augmentation and was unhappy with her sagging epigastric soft tissues and breast appearance.

FIG. 11.4 Preoperative views (A, B, C) of a patient who had previous submuscular breast augmentation and was unhappy with her sagging epigastric soft tissues and breast appearance. Postoperative views (D, E, F) of same patient at 1 year are shown.

Complications and Their Management

Versus conventional abdominoplasty, the AMBRA scar is more difficult to conceal, but the normal venous, lymphatic and periumbilical arterial inflow to the flap are preserved. Moon and Taylor’s description of the periumbilical perforator network spurred the evolution of modern microsurgical breast reconstruction.⁷ Thus, the reverse abdominoplasty technique is forgiving, if the surgeon preserves the dominant central abdominal perforators and avoids venous and lymphatic compromise.

There is no risk for capsular contracture or other device-related problems with the AMBRA technique, and it provides a natural-feeling breast. Other techniques for autologous breast have been suggested to provide these same benefits versus synthetic implants.^8–13 However, augmentation mammaplasty by reverse abdominoplasty also provides concurrent abdominal contouring. The result can make for a dramatic improvement in selected patients. Admittedly, the AMBRA technique requires more operative time than its implant-based version. A major disadvantage of AMBRA is the required transverse epigastric scar, which encompasses both inframammary creases and crosses the midline in the presternal region. This scar has been surprisingly well tolerated by our patients, who might not otherwise be abdominoplasty candidates.

Conclusion

Augmentation mammaplasty by reverse abdominoplasty (AMBRA) may be a viable option for patients with upper abdominal skin laxity and adiposity who desire autologous tissue breast augmentation and/or mastopexy combined with reverse abdominoplasty. Those with previous breast reduction or with a long cholecystectomy scar may deserve special consideration as candidates for this procedure. AMBRA may also serve a unique role in breast reconstruction as an adjunct, alternative, or salvage procedure.

Introduction

A desire for combined cosmetic procedures, particularly the so-called “mommy makeover” has increased interest in perfecting techniques that safely and reliably result in a pleasing esthetic outcome. In our experience, in an appropriately selected patient population, we have frequently utilized the transabdominal breast augmentation (TABA) in the pursuit of these goals. Though TABA has been described before, these published reports have been limited by short-term follow up and small case series. In addition, the majority of these surgeons utilized general anesthesia, which differs from our experience. Often those patients who desire abdominoplasty are seldom nulliparous and have concomitant involutional breast volume loss and either resultant ptosis or pseudoptosis. These patients often request accompanying breast augmentation and we believe the combined procedure of breast augmentation via an abdominoplasty incision is a favorable approach in terms of minimizing incisions and can be safely performed without general anesthesia, thereby limiting postoperative nausea and vomiting.^14–18 The senior surgeon, R.J.Z., has the largest series to date of this technique and his procedure and management are illustrated here and elsewhere.¹⁹

Preoperative Planning/Patient Selection

Appropriate patients are those who qualify for conventional abdominoplasty, have no previous breast or superior abdominal violation, have either minimal ptosis (Grade I) or pseudoptosis, and are requesting simultaneous abdominoplasty and bilateral breast augmentation. Smoking cessation should be required longer than 4 weeks preoperatively and indefinitely post procedure.

Marking and Anesthesia

Patients are marked in the preoperative holding area for a low transverse abdominal incision. Surgery is then preferably performed under monitored anesthesia care (MAC) with use of a combination of propofol and ketamine. Further anesthesia is executed with the patient placed in the prone position for posterior intercostal nerve blocks to T4–T12, using a combination of 1% lidocaine with 1 : 100 000 epinephrine (adrenaline) and 0.5% Marcaine. The patient is then rotated to a supine position for placement of T2–T3 intercostal nerve blocks in the posterior axillary line and bilateral ilioinguinal nerve blocks. The local anesthetic is then diluted and injected into the breast periphery and medial intercostal perforators of the breast mound.

Surgical Technique

A conventional abdominoplasty flap dissection is performed. Tunnels are created to reach the inframammary fold, at which point blunt finger dissection is used to create a subpectoral pocket. The pocket is further defined using a Snowden Pencer™ balloon dissector (Fig. 11.5). A hockey stick dissector is frequently used for further pocket definition.

FIG. 11.5 Picture of dissector in patient.

Following adequate pocket creation, the implants are positioned. The patient, who has been secured to the bed, is placed in a sitting position to evaluate for symmetry and any further adjustments are made at that time. After achievement of optimal symmetry, the inframammary tunnels are occasionally partially closed with permanent sutures. Additionally, external bolster sutures on Xeroform pledgets may be used to further define the inframammary fold. Conventional abdominoplasty then continues with removal of excess skin and fascial plication from the xiphoid to the pubic symphysis with interrupted and running permanent sutures. Often, the supraumbilical flap is judiciously liposuctioned for contouring of the midline raphe. The umbilicus is then inset. For further postoperative pain relief, Marcaine is injected into bilateral rectus muscles intraoperatively. Two JP drains are placed and brought out in the mid-suprapubic region. Finally, the abdominoplasty incision is closed in multiple layers.

The patient shown in Fig. 11.6 demonstrates significant preoperative rectus diastasis after two large pregnancies. The patient in Fig. 11.7 underwent a floating abdominal technique; note her involutional loss of breast volume preoperatively.

FIG. 11.6 This patient had a significant rectus diastasis after two large pregnancies preoperatively (A). (B) Postoperative results.

FIG. 11.7 This patient (A) underwent a floating umbilical technique; notice the inconspicuous abdominal scars (B).

The patient shown in Fig. 11.8 had significant preoperative lower abdominal adiposity which is improved significantly after TABA with a pleasing feminine hourglass shape.

FIG. 11.8 Preoperatively (A), this patient had significant lower abdominal adiposity. Improved contour and hourglass shape is displayed postoperatively (B).

Box 11.2 gives hints for optimizing outcomes.

Peri- and Postoperative Care

At the conclusion of the case, a 15 cm (6 inch) cotton roll reduced to half its diameter is applied to the supraumbilical median raphe for further contouring. Pertinent postoperative care is limited to utilizing Medipore™ tape to abdominoplasty incision and for further definition of the breast mound for 3 months for scar management.

Complications and Their Management

The greater part of complications are related to the distal abdominoplasty flap and are managed nonoperatively. The common complications related to this procedure include: peri-incisional wound complications, seroma, hematoma, and cellulitis. Uncommon complications are those related to breast augmentation, including symptomatic capsule formation and implant malposition.

Further retrospective examination of our patients revealed the greater majority of adverse events were in patients who had comorbidities. Many of the complications in our patient series were in patients who were defined as overweight, obese, or were smokers.

Conclusion

Transabdominal breast augmentation, in the properly selected candidate, is an excellent choice for patients requesting both abdominoplasty and breast augmentation. The procedure is an outpatient procedure and tolerated very well under MAC anesthesia with nerve blocks. The significance of this combined procedure is the addition of the breast augmentation to the already planned abdominoplasty with the benefit of eliminating the breast incision. Morbidity is minimal and complication rates parallel those of published reports for abdominal contour procedures in females. There are distinct advantages to the use of this technique in this re-emerging silicone breast implant era. These include complete lack of breast incisional scarring, elimination of implant trauma during placement due to wide access of the breast pocket and marginal symptomatic capsular contracture sequelae.