Disclosure 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.
Indications for endoscopic breast augmentation include the patient's desire for a remote incision and the absence of a well-developed inframammary crease to hide a crease incision below the horizontal visual axis.
Contraindications: Constricted lower pole A constricted lower pole with a short distance from the inframammary crease to the areola is significantly more difficult and can require radial scoring of the breast parenchyma. The potential exists for inferior implant displacement from overdissection (lowering) of the inframammary crease and superior implant displacement from underdissection of the inframammary crease. In experienced hands, the axillary approach can be used for this type of anatomy; however, use a cautious approach. Tubular breast The need for correction of the herniated areola and the scoring of the constricted lower-pole parenchyma makes the periareolar access incision most reasonable for this anatomy. Ptosis Pseudoptosis and grade 1 ptosis are possible with this technique, but this anatomy requires the lowering of the inframammary crease to the base of the vertical descent of the breast. This anatomy is not considered ideal for an initial experience and is subject to concerns of overdissection and underdissection of the inframammary crease. |
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Preoperative details: Preoperative considerations include accurate marking of the native and proposed placement of the inframammary crease. Mark the first axillary crease with a 2.5-cm incision well behind the anterior axillary line. Mark the mid line, proposed cleavage, and position of the partial myotomy. The myotomy should be approximately 2 cm lateral to the origins of the pectoralis muscle to avoid overdissection medially and the potential for synmastia. An example of preoperative markings is shown in Image 1. Intraoperative details: In the operating room, place the patient in the supine position with the arms on arm boards at approximately 80°. The author prefers to use an adherent drape at the inferior and lateral most aspect of the sterile field to secure the drapes to the patient during the procedure. Use a 1:10,000 epinephrine solution in the incision and at the position of partial myotomy. Take care when injecting the solution at the area of partial myotomy to prevent penetration of the chest wall. Perform the incision through the axillary position with a No. 15 blade. Place 2 skin hooks and perform vertical spreading through the subcutaneous tissues until the pectoral fascia is reached. Follow the undersurface of the upper skin flap to the fascia to avoid injury to the intercostal brachial nerve. Insert the index finger, identify the underside of the pectoralis, and perforate the fascia to allow access to the submuscular plane. Insert the endoscopic retractor, followed by the scope. The author uses the Emory-type retractor. Insert a 10-mm Hopkins rod endoscope within a sleeve in the retractor. After establishing the optical cavity, insert the endoscopic Bovie. Place low-wall suction on the endoscopic Bovie unit. Perform superior retraction with gradual enlargement of the pocket. Commonly, an assistant holds the retractor during dissection; however, the need for this assistance is diminished with experience. Constantly assess the internal position of the retractor with relation to the breast external anatomy by looking at the scope's transillumination through the skin and by watching the tissues move through the scope during manipulation of the external breast tissues. If necessary, several Angiocaths can be placed through the skin after superior retraction is performed to guide the myotomy during early experiences. The myotomy of the pectoralis muscle origin is usually performed from the 3- to 6-o'clock position approximately 2 cm off the chest wall. The dissection proceeds superomedially to inferomedially. Perform the inferior dissection with care to avoid overdissection. Also, avoid overdissection or underdissection medially. A complete myotomy and incision of the pectoral fascia is necessary to achieve marked improvement in cleavage; however, in thin patients with minimal breast coverage, this can lead to rippling medially. Underdissection medially can result in a lack of a defined cleavage and superolateral implant malposition. Thoughtfully determine the amount of inferior dissection needed to accommodate the dimensions of the implant chosen, based on the ideal transverse base diameter. In thin patients in whom a significant fold alteration is performed, the result can be a markedly palpable implant inferiorly. A bottom-heavy breast and possible inferior implant displacement can result from overdissection of the inframammary crease. Tapping of the inferior crease is a useful postoperative adjunct to set the crease during the postoperative period. Underdissection inferiorly can lead to superior implant displacement. An upper-pole strap can be useful postoperatively, especially in a breast with a tight lower pole, to set the implants in the lower part of the pocket. Remove the endoscope and Bovie, and insert a deflated saline implant. A smooth implant surface is chosen almost universally. Roll the edges toward the center, and insert the compact implant with the help of Army-Navy retractors. Take care to avoid dissection or implant placement below the pectoralis minor. The implant is then inflated. Carefully dissect the lateral pocket with the index finger to avoid overdissection or injury to the sensory nerves. Refinement of the inferior and medial pocket can be achieved further with a large urethral dilator or a Dingman dissector. Place the patient in the sitting position to verify implant position and volume requirements. Remove the fill tubes, and place the check caps. Close the axillary incisions with a layer closure followed by benzoin and a Steri-Strip. No drains are used. Postoperative details: Postoperative management is straightforward. Place dry gauze over the axillary wounds for 24 hours. The Steri-Strip remains until the suture is removed at 10 days to 2 weeks. The upper-pole strap is worn for several days to several weeks, depending on the tightness of the inferior pocket. Massage of the implant in the pocket is begun at 2 weeks.
Preoperative and postoperative photographs are shown in Images 2-3.
The predictability of the axillary approach has been enhanced greatly with the endoscope, and many surgeons continue to advocate this approach. Spear suggests that the endoscopic transaxillary augmentation mammoplasty has a higher incidence of implant malposition, and he does not embrace this technique. Unfortunately, all techniques have limitations. The key to successful breast augmentation surgery is to correctly interpret the patient's desires as applied to her anatomy and use the technique that predictably achieves the desired results.
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