Transaxillary breast augmentation has been long misunderstood, perceived as being more technically difficult, taking longer to perform, and having higher risk of contracture and other complications. This chapter focuses on the nuances of incision location and design, pocket choice, and issues with device placement. The author has a long experience with endoscopic assistance, which adds a level of precision that allows for specific tissue preservation or release under direct vision. The theme of the chapter is that technical precision can be routinely accomplished with endoscopic assistance, that allows for outcomes with the transaxillary approach that can match outcomes seen with inframammary breast augmentation.
Key points
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Transaxillary breast augmentation allows for all plane and incision variant choices if endoscopic assistance is added.
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Endoscopic assistance allows for added precision and the ability to release or preserve specific tissue layers.
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Technical precision with transaxillary endoscopic breast augmentation is facilitated by prospective hemostasis and the minimization of blunt tissue manipulation.
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Ease of recovery from the transaxillary endoscopic approach results from the technical precision that allows for less tissue trauma, especially when compared with blunt dissection or balloon-based tissue stretching.
Abbreviation
| IMF | inframammary fold |
Introduction
The transaxillary approach to breast augmentation has the appeal of allowing for a breast implant to be placed with a hidden scar and no incision on the breast. A majority of plastic surgeons, however, has avoided the use of the transaxillary approach because of a perception that it is more technically demanding, may take longer to complete, and may be associated with a higher risk of capsular contracture, when compared with traditional inframammary breast augmentation. These reservations are not well founded, however, after review of the literature from the most experienced experts on transaxillary breast augmentation. In their article, “Evidence-Based Medicine: Augmentation Mammaplasty,” Lista and Ahmad suggested that the transaxillary approach was equal to the inframammary approach as the preferred incisions for breast implant placement. The purpose of this article is to review the aspects of transaxillary breast augmentation that have led to successful outcomes within the variations possible using the approach.
The initial reports of the transaxillary approach described the placement of a breast implant into a partial subpectoral pocket using mainly blunt dissection. ,, More recent reports, however, that have included 2 very large clinical experiences, have shown that the transaxillary approach to breast augmentation can be used with excellent outcomes. Gryskiewicz and colleagues published a 10 year experience with transaxillary nonendoscopic breast augmentation, using saline and gel implants in a partial subpectoral plane, and showed that patient satisfaction scores were significantly higher in patients with axillary incisions compared with inframammary incisions. Huang and Mills also reported excellent clinical outcomes and low complication rates in their 20 year experience using gel implants in a partial subpectoral pocket. These authors reported minimal use of endoscopic assistance in their large patient series.
The addition of endoscopic assistance to the transaxillary approach, as first described by Price and colleagues, allowed for direct visualization of the tissue layers to be released, helping to overcome the greatest limitation of the previous transaxillary approaches that were based on blunt technique with no tissue visualization. ,, The added visualization allowed for improved hemostasis, improved control of inframammary fold (IMF) level and shape, and the ability to precisely divide or preserve specific tissue layers according to the needs of each patient. This level of precision allows for tissue layers to be modified or preserved in the optimal combination with the implant chosen for placement. The added technical control afforded by endoscopic assistance to the transaxillary approach for breast augmentation has been reflected in multiple surgical technique and patient series reports. ,,,,,, Additionally, technical refinements have been described and demonstrated that allow for precise technical control to maintain or modify the level and shape of the IMF during implant placement using the transaxillary approach with endoscopic assistance. ,,,,,, This combined experience, with the improved technical control to modify the level of the IMF, suggests that the endoscopic approach for transaxillary breast augmentation has become an accepted standard for implant placement using a transaxillary incision.
Another important aspect of breast augmentation is the selection of the implant pocket. Several patient series have reported successful outcomes using the subfascial plane, but have featured the use of textured breast implants. ,,,, The prepectoral fascia has always been of interest to axillary implant surgeons and has its most thickness in the axillary area. Muhnoz and colleagues have published a recent report of a 25 year review of 1015 consecutive cases with a transaxillary approach. A subfascial pocket was used in all cases, with the aid of a fiberoptic retractor for direct visualization. Endoscopic assistance was added as needed in the patient series. The approach has also been updated over the clinical experience to incorporate the use of insertion sleeves, hybrid augmentation techniques with upper pole fat grafting, and use of Motiva (Establishment Laboratories, Costa Rica) nanotextured surface breast implants. Complication rates reported were low, both in primary and secondary patients. Conclusions relative to implant performance in the subfascial pocket are limited, however, by the addition of fat grafting to the upper pole in 69% of the primary cases. , The experience is important, however, to show overall excellent outcomes with the use of direct visualization in the transaxillary approach to breast augmentation in a very large clinical experience.
Surgical Technique: Transaxillary Breast Augmentation
The author is a strong advocate for the use of endoscopic assistance when the transaxillary approach is used for breast augmentation, due to the added technical control afforded by visualization of the specific tissue layers to be divided. Nuances of incision design and device placement will be covered in great detail, with the understanding that the tissue pocket creation and muscle release technique is unique to the combination of tissue type and implant chosen in each patient. The versatility of the endoscopic approach will be demonstrated, with the choice of partial subpectoral pocket and whichever derivative is preferred for a given patient, to prepectoral approaches with a pocket developed immediately deep to the prepectoral fascia, which is most thick at the area of the transaxillary incision. These approaches will be presented in detail, followed by a discussion of the nonendoscopic approach where the technique differs in the tissue-release phase of the procedure. ,,
Markings
Markings are routinely placed in the preoperative holding area with the patient in the sitting position, and include breast and chest wall width, tissue thickness, IMF position, IMF position planned, and exact incision location ( Fig. 1 A, B ). The anatomic chest midline and midbreast meridian at the IMF are marked with the patient in the sitting position and reconfirmed when the patient is supine, under anesthesia on the operating table.
( A , B ) ( A ) Preoperative frontal photo with breast and inframammary fold asymmetry. ( B ) Preoperative markings to lower the level of the inframammary fold, to correct the preoperative asymmetry and account for the dimensions of the breast implants to be placed.
Positioning
The patient is placed in a supine position with the arms secured onto armboards at 90°. The procedure is performed under general anesthesia with the aid of short-acting muscle relaxation. Draping is performed as with routine breast augmentation, except that the surgeon must be able to work above and below the shoulder on each side. The anesthesia machine is located at the head of the bed, also with enough space to allow for the surgeon to perform a majority of the procedure from a position above the shoulder, facing the endoscopic equipment at the foot of the bed. In addition to the endoscopic tower, all cautery and suction lines are directed toward the foot of the bed ( Fig. 2 ).
Patient is positioned with arms out, allowing room for surgeon to perform procedure from above shoulder. Note endoscopic tower at foot of operating room bed.
Equipment
The equipment used is that described by Price and colleagues, consisting of an endoscopic tower with monitor, endoscopic light source, recorder, and camera. The camera is mounted to a 10 mm downward angled endoscope that slides into an Emory Breast Retractor (Cardinal Health, Atlanta, GA) sheath with a grooved handle that holds the fiberoptic light cord. ,,, The author prefers the use of Dingman-Agris dissectors for blunt refinements if needed ,,, ( Fig. 3 A, B ).
( A , B ) ( A ) Endoscopic instruments. ( B ) Endoscopic setup with camera mounted to endoscope, light source above into endoscope, with cord held in groove in Emory Endoscopic Retractor (Cardinal Health).
Incisions
The incisions for the procedure differ depending upon whether saline, cohesive silicone gel, or highly cohesive silicone gel implants are to be used. All marks are carefully made to be confined within the axilla and within the hair-bearing skin. For small cohesive silicone gel or saline augmentation patients, an incision 2.5 to 3 cm is marked in the axillary apex, within an existing skin crease ( Fig. 4 A ). Occasionally, a dominant skin crease is long enough to permit a longer straight incision design. The cross mark is to facilitate correct alignment of the closure (see Fig. 4 B). Alternatively, for larger cohesive silicone gel augmentation, a boomerang-shaped incision design 4 to 5 cm in length is used. This incision design is recommended by the author for all device types as a good starting point to facilitate ease of use of the endoscopic equipment. It is important to note that a 3.5 cm incision can be made to function to a 4.5 to 5 cm length with appropriate use of a 4 prong skin hook routinely used by the author. The markings for this incision begin with a dot marked in the axillary apex. A line is then drawn anteriorly, in an existing skin crease, just short of the posterior boundary of the pectoralis major muscle. The posterior portion of the incision, beginning at the dot in the axillary apex, is marked in a posterior and slightly superior direction. This is the most versatile incision design, regardless of device type, based on the author’s long experience with the approach (see Fig. 4 C). Additional approaches that can be helpful include the choice of a modified hockey stick–shaped incision or an elongated S centered in the deepest skin crease, that can be used for the placement of large highly filled cohesive silicone implants, highly cohesive silicone gel implants or in patients who may have an especially narrow segment of hair-bearing skin in the axilla, regardless of the implant to be used (see Fig. 4 D).
( A–D ) ( A ) Short incision 2.5 to 3 cm, in existing crease, used for saline or small cohesive silicone gel or breast implants. ( B ) Silicone gel augmentation incision 4 to 5 cm, extending from mark in axillary apex, into extended dominant crease within hair-bearing skin. ( C ) Silicone gel incision 3.5 to 4 cm, angled based on mark in axillary apex, extended anteriorly within crease. Extended posteriorly at a superior angle in a posterior direction, allowing for the incision to function longer than its actual length. ( D ) Silicone gel incision 3.5 to 4 cm, with anterior and posterior curved extensions. This is most useful for placement of highly cohesive gel devices or for patients with especially narrow segments of hair-bearing skin in the axilla, regardless of device type to be placed.
These marks are usually made in the preoperative holding with the patient in a sitting position to insure proper incision placement behind the anterior axillary fold. The longer or angled incision designs are especially helpful for use in patients having cohesive gel devices or if the surgeon is early in use of the axillary approach to facilitate visualization in the early technical steps of the procedure. In the author’s experience, the shorter incision as used routinely for saline augmentation is visible for up to 6 months, as compared with 9 months for the longer incision options routinely used for silicone gel augmentation. These incisions are typically difficult to see by 1 year after the procedure ( Fig. 5 A–C ). In a reeent publication, Munhoz reported that 81% of patient ratings and 78.2% of observer ratings showed low to intermediate scar visibility, with high patient satisfaction. This report identified that tectured surface implants, implant volume over 350cc, and non-use of insertion sleeves each correlated with poor scar outcomes.
( A–C ) ( A ) Saline augmentation incision at 6 months. ( B ) Silicone gel augmentation incision at 6 months ( C ) Silicone gel augmentation incision in same patient as ( B ) at 2 years.
Initial dissection
After incision placement, the initial dissection is performed in an immediate subcutaneous plane, in an anterior direction using the electrocautery, until the lateral border of the pectoralis major muscle is reached. The skin flap created is thin, superficial to the axillary contents. Alternatively, scissor dissection is preferred for entry into the subpectoral space when using the shortest incision length for saline or small cohesive gel implant patients. Dissection in this superficial plane is important to prevent damage to the intercostobrachial nerve. The subpectoral space is then entered using facelift scissors, developing the plane between the pectoralis major and the pectoralis minor muscles. Alternatively, using the longer incision designs often needed for silicone gel device placement, a fiberoptic retractor is used to enter the subpectoral space under direct vision. Gentle blunt finger movement is used to provide additional limited dissection of the subpectoral space. This approach is uniformly used in the placement of silicone gel implants of all types, as the initial tissue tunnel that connects the incision to the subpectoral space must be larger to allow for the placement of most silicone gel devices as compared with saline implants. This distinction is important because saline implants are placed empty into the tissue pocket, and then filled with saline, as compared with silicone gel devices that are prefilled during the manufacturing process.
Dual Plane Approach
Pocket creation I: optical cavity creation
The subpectoral dissection is an important phase of the procedure that largely determines the ease of the endoscopic release of the pectoralis major muscle. Emphasis is placed on creation of a clear optical field in this initial space created between the pectoralis major and minor muscles. While the initial description of the endoscopic approach states preference for blunt dissection to the pectoralis major muscle at the IMF, the author prefers to avoid the occasional blood staining of tissue that can be seen with that approach using electrocautery with blended current. ,, The author prefers creation of the optical cavity by sharp endoscopic dissection, releasing the areolar plane just deep to the pectoralis major muscle ,, ( Fig. 6 ). This is accomplished by the initial placement of the Emory retractor (Cardinal Health) into the subpectoral space, followed by the placement of the endoscope through the retractor sheath following contact with defogging solution. The spatulated cautery rod, with a J-shape oriented outward in a lateral direction, is used for the dissection. Suction is attached to the posterior end of the cautery handle for smoke evacuation. This sequence is used for all endoscopic portions of the procedure. Orientation is maintained by identification of a rib, following which the tissue is released until the main body of the pectoralis major muscle is identified clearly in all areas to be addressed with the main muscle release ( Fig. 7 ).
