Breast Augmentation With Implant— Transaxillary Approach

Introduction

Breast augmentation, according to the most recent procedural statistics data from the American Society for Aesthetic Plastic Surgery, continues to have increased popularity as the most common surgical procedure in the United States and was performed in more than 330,000 women in 2017. The most common incision access used is the inframammary approach worldwide, based largely a long-existing bias that this approach is most simple to perform with the best ability to accomplish consistent results.

There is an evolving body of literature, however, that suggests that the transaxillary approach can be performed with results that are comparable in terms of consistent and predictable outcomes, with the advantage of the avoidance of an incision on the breast for primary breast implant placement. In their recent literature review for outcomes-based analysis for breast augmentation, Lista and Ahmad suggest that the transaxillary approach is preferred equally to the inframammary approach for breast implant placement. Numerous additional studies have reported excellent and predictable outcomes using the transaxillary approach with several variations of technique.

This chapter discusses the author’s preferred technique for transaxillary breast augmentation with the aid of endoscopic assistance. ^, This includes a discussion of rationale for this approach and an emphasis on specific aspects of technique that allow for consistent technical control and outcomes that equal the more universally popular inframammary approach.

Indications and Contraindications

The author views any patient who is a candidate for breast augmentation as a candidate for the transaxillary approach. The deciding factor on whether this approach is used becomes an issue of patient choice. An important aspect of this choice by the patient comes down to correct information relative to the transaxillary approach, because many surgeons claim to offer the approach and then criticize it, often based on a lack of experience or just because they do not prefer the approach, to then offer only the inframammary approach with which they may be more comfortable.

After an explanation of the technique, how it works, and that the addition of the endoscope allows for precise technical control in the author’s hands that makes the procedure identical to the inframammary approach in terms of the internal cuts made, the patient can then select her preferred approach. The only difference between the axillary approach, in the technique of the author, is the set of instruments used to create the partial subpectoral pocket. The patient selects the transaxillary approach if she prefers that her breast implants be placed with no incisions on the breast.

An issue that can be confusing is whether certain tissue types represent contraindications to the transaxillary approach. The author uses the approach in any patient who is otherwise an appropriate candidate for breast augmentation. This applies to patients with all tissue types and who request any type of breast implant device used by the author in his clinical practice. This also applies to patients who have minimal ptosis, after a detailed explanation and distinction from patients who have significant ptosis and require a breast augmentation with mastopexy.

Preoperative Evaluation and Special Considerations

The main issues for preoperative evaluation include the preference of incision location, accurate education relative to the choice of incision relative to the technique for pocket creation, and an assessment of tissue type with the resultant discussion of whether the patient can achieve the outcome desired should her tissue position be low as a result of mammary ptosis. This issue is emphasized because of the large subgroup of patients in the author’s revision practice from outside who had ptosis addressed by breast augmentation with subsequent dissatisfaction with the position and appearance of the augmented breast because a mastopexy was not pursued.

There are several important issues relative to incision location that should be understood. The transaxillary incision, when properly placed within the hair-bearing skin, will almost always heal in a way that is difficult to see postoperatively. The timing of the incision becoming difficult to see may vary to some degree based on the ethnicity of the patient, with the longest maturation time frames noted in Asian, Hispanic, and red-haired Caucasian patients. The author informs his patients that the incisions usually are difficult to see by 1 year, with distinct improvement seen at 4 months.

The author has performed the transaxillary approach routinely in patients who are avid tennis players, entertainers, and cheerleaders for major conference sporting events who usually have no issues as long as there have been appropriate expectations created through patient education. These patients can elect the inframammary approach or the axillary approach, then, if they prefer to have their implants placed with no incisions on their breasts. The periareolar approach is not currently offered on a routine basis by the author unless requested by a patient.

Surgical Technique