Combined abdominoplasty and breast enlargement by autologous tissue transfer or transabdominal implant placement

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Chapter 11 Combined abdominoplasty and breast enlargement by autologous tissue transfer or transabdominal implant placement

A Augmentation Mammaplasty by Reverse Abdominoplasty

Introduction

Relative to conventional abdominoplasty, reverse abdominoplasty has been less frequently studied.14 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.

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.

Superiorly Based Augmentation Mammaplasty by Reverse Abdominoplasty

The procedure begins with de-epithelializing the “safe zone”, taking care to preserve as much dermis as possible. Dissection is continued, beneath the dermis one centimeter above the inferior border of the safe zone, and then deepened to the level of Scarpa’s fascia, depending on the desired thickness of the flap. Dissection proceeds to a level just cephalad to the umbilicus, where it is directed down to the rectus abdominis fascia. The de-epithelialized zone is divided into halves, and a subglandular pocket is undermined beneath each breast. The AMBRA flaps are then folded into these pockets. The flaps are reflected inferiorly until plication of the rectus is completed, and the patient is raised to a seated position on the operating table. The breasts, once augmented by the AMBRA flaps, can be assessed for position, projection, and symmetry and adjusted as necessary.

The patient is returned to a fully supine position, and with cephalic tension on the flap, the de-epithelialized border of the skin apron is anchored to the perichondrium, periosteum, and deep fascia along the lower border of the breast. A nipple–areola complex located slightly lower on the breast mound (1 to 2 cm) than ideal, to allow for lower pole descent, is preferred. The edge of the abdominal skin flap is then reinforced along its entire length with sutures to the periosteum. The central midline supraumbilical abdominal area is then liposuctioned to emphasize the median raphe. The closure of upper and lower wounds is the same except that Scarpa’s fascia is approximated in the lower abdominal closure, followed by dermal closure (Box 11.1).