According to the American Society of Plastic Surgeons, breast augmentation or breast enlargement, was the most common body cosmetic surgical procedure performed in the United States in 2013. (over 290,000 performed) This surgery is done on an outpatient basis with most patients requiring minimal down-time before returning to every day activities. When choosing breast augmentation, patients need to consider the type of implant (saline vs silicone, textured vs smooth, shaped vs round), placement of the implant above or below the pectoralis major (“pec”) muscle, and the location of the incision.
The three most commonly used incisions for placement of breast implants are the peri-areolar (incision placed where the darker areolar skin and lighter breast skin meet), inframammary (incision placed in the fold of skin just below breast) and transaxillary (incision placed in the skin of the underarm area). While there are advantages and disadvantages to each of these incisional approaches, only the transaxillary incision allows placement of the breast implant without creating a scar on the breast itself.
The transaxillary breast augmentation method is performed with two different techniques. Traditionally, breast implants placed through an armpit incision were done without the surgeon being able to directly visualize the space in which the implant would ultimately sit, otherwise known as a blind technique. Despite the lack of direct visualization, complications such as bleeding, infection, and healing of the incision are very low and comparable to the other types of breast implant incisions.The most common problem after placing implants in this manner was poor positioning of the implant, although this can be seen with any type of approach.
Advances in technology and the development of minimally-invasive surgical techniques have given rise to the endoscopic transaxillary approach. The use of fiberoptic light sources, cameras and television monitors now allows plastic surgeons to see the space the implant will sit in as it is being created. Its one distinct advantage over a blind transaxillary approach is that the inferior end of the pectoralis muscle can be released and cauterized by direct vision.
The endoscopic transaxillary technique is similar to the more traditional, non-visualized way in that it has low rates of complications such as bleeding, infection, scarring around the implant and problems with healing of the incision. It does, however, differ in 3 distinct ways. First, it requires the use of specialized equipment that not every facility may have. Also, operation times are increased using this method, although this decreases the more times the surgeon has performed the operation. Finally, the rates of poor positioning seen with the more traditional, non-visualized method were reduced with using the endoscopic equipment, but not eliminated.
There are no studies that have ever directly compared the blind and endoscopic transaxillary techniques of breast augmentation. Intuitively, direct visualization would seem superior to a non-visualized instrumented pocket dissection, but the experience of the plastic surgeon may outweigh the need to see under the pectoralis muscle.
For the patient looking for augmentation while avoiding scars on the breasts, transaxillary breast augmentation is a safe and well-established approach. Both saline and certain sized silicone implants (500cc or under) may be used via this approach as well. Patient satisfaction is high when this approach is used and complication rates are comparable to both inframammary and peri-areolar incisions.
Dr. Riesa Monet Burnett
Dr. Barry Eppley
Indianapolis, Indiana