Excerpt from Breast Augmentation, Endoscopic Assisted

Synonyms, Key Words, and Related Terms: transaxillary approach, breast augmentation, transaxillary endoscopic augmentation mammoplasty, breast enlargement, breast enhancement, endoscopic breast enlargement, endoscopic breast enhancement, endoscopic breast augmentation, mammoplasty, breast implants, breast revision

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The trend in plastic surgery to minimize scarring by remote placement of access incisions is embodied in the transaxillary endoscopic augmentation mammoplasty. The incision is hidden within the axilla, in the first axillary crease, and is generally invisible even with the arm raised. The surgical control gained with the use of the endoscope has resulted in more consistent results, which have renewed enthusiasm for the axillary approach.

History of the Procedure: The transaxillary approach to breast augmentation was described by Troques in 1972 and Hoehler in 1973. Besides the obvious advantage of the hidden incision, this approach facilitated direct access to the subpectoral plane. With this technique, the inframammary crease was altered and the origin of the pectoralis muscle was dissected blindly, accounting for a significantly higher incidence of implant malposition. The limited exposure of the blind technique did not allow complete division of the prepectoral fascia, resulting in the tendency of high-riding implants or the double-bubble appearance of the inframammary crease.

The advent of endoscopic plastic surgery in the 1990s allowed the application of the endoscope to breast surgery. The Emory group reported their experience with endoscopic breast augmentation through an axillary incision in 1993 using a specialized retractor and an air-filled optical cavity (Eaves, 1993). Ho reported a technique that used glycine irrigation to create a liquid-filled optical cavity, although he now also uses a specialized retractor and an air-filled optical cavity. The increased control resulting from direct visualization of the dissection obviated many of the previous downfalls of the blind axillary approach. Howard demonstrated the benefits of the endoscope with the axillary approach by decreasing the incidence of implant malposition from 8.6% to 2% when the endoscope was used.

Endoscopic transaxillary augmentation mammoplasty is now a widely used technique and has withstood the test of time. However, the learning curve is significant, and more straightforward cases should be considered during the initial experience. The axillary approach has limited application in secondary cases.

Clinical: The importance of the initial consultation cannot be overemphasized. Discuss the 4 possible access incisions with the patient. Present the periareolar, inframammary crease, umbilical, and axillary incisions in a nonbiased manner, and assess the patient’s enthusiasm for the axillary incision. Discuss the potential complications of breast augmentation, emphasizing those complications unique to the axillary approach. Discuss implant malposition, axillary hematoma, temporary axillary banding, and lymphadenopathy. Finally, discuss the possible need for an additional inframammary crease incision to treat some complications.

Perform a physical examination. Describe the location of the axillary incision, and draw the position and size of the axillary incision with a surgical marker. Pay particular attention to the distance from the areola to the inframammary crease and the transverse diameter of the breast. Assess the ideal transverse diameter of the breast, with a dimensional approach used to select implant size and direct fold adjustment. The need to lower the inframammary fold 1-2 cm is common; however, more than 3 cm should alert the physician to the presence of a constricted lower pole and the need for parenchyma alteration, which can be more straightforward with another approach. The ideal patient has a distance of 5-6 cm from the areola to the inframammary crease and therefore requires less inferior dissection