Transaxillary Endoscopic Breast Augmentation

Transaxillary Endoscopic Breast Augmentation in an approach to breast enlargement that allows for your breast implants to be placed with no incisions on your breasts. The technique utilizes a small incision in the top of the armpit that is first used to place an endoscope, or tiny camera, that allows for precise creation of a tissue pocket with optimal control and visualization all steps of the procedure. After creation of the tissue pocket internally, saline or silicone gel implants can be placed, depending upon your preference. Recovery from the procedure is identical to any other approach for breast augmentation, except that the early postoperative soreness associated with the incision location will be in the armpit. 

The ideal candidate for endoscopic transaxillary breast augmentation wants a hidden scar and a short recovery period. She has a small areola and a poorly defined inframammary fold. Contradictions to this approach include tuberous breasts with a protruding areola, significant breast asymmetry, and/or moderate to major ptosis. 

Preparation Prior To Surgery: 

 Medical history assessment (any allergies, serious medical condition and all 

medications taken both prescribed and non-prescribed), physical 

examination, and laboratory tests will be performed during consultation. 

 Avoid smoking   for about 3-4 weeks prior to surgery, as nicotine interferes 

with circulation and will greatly affect healing process. 

 Stop drinking alcohol, a week before the surgery and throughout your 

recovery period. 

 Taking any medications should be avoided such as hormones, anticoagulants, 

anabolic steroids and supplements at least 4-6 weeks to prevent complicating 

medical factors prior to surgery, and also avoid taking aspirin, anti- 

inflammatory drugs and herbal supplements as they can increase bleeding. 

During the procedure: 

Usual preoperative markings were made with the patient in the upright position. The incision was located high in the axilla, in the shape of an arc, following a crease, in the hair-bearing area. Depending on the size of the implant, the length of the incision ranged from 4.5 to 5.5 cm. The operation was performed with the patient under general anesthesia, with antibiotic prophylaxis provided at induction. The patient was supine with her arms at 90 degrees. The entire table was tilted about 15 degrees, so that the manubrium tended to be horizontal. This position facilitated manipulation of instruments while elevating the tissues and also protected the chest wall from inadvertent penetration. The endoscopic cart was placed at the foot of the table, and the patient was prepared and draped in such a manner that the surgeon and the assistant were free to move around the arm from the axilla to the head. The standard instrumentation included an endoscopic retractor, a 10-mm endoscope, and various dissecting cauteries. Injections of methylene blue through the different anatomic planes were of great value in the dissection of the pocket at the inframammary fold, particularly in those cases where some difficulty was anticipated concerning the precise limits of the pocket. It was advisable to inject perpendicularly and retrograde from bone to skin to avoid any chest wall penetration. Once the skin incision was made, the subcutaneous fat was crossed, using the cautery to expose the lateral border of the pectoralis major. This was easily accomplished from the upper part of the incision (the first 2 cm in the anterior portion). With the help of two smooth retractors, the incision was moved anteriorly to give direct access to the muscle. Approaching the area in this way helped to protect the intercostobrachial nerve. 

The dissection then progressed several centimeters caudally and posteriorly to create an adequate tunnel for insertion of the implant. It was sometimes necessary to ligate the lateral mammary artery. All the fatty tissues were pulled down toward the operator to complete the exposure. The lateral pectoral bundle, which almost always crosses the area to enter the intermuscular space, was preserved whenever possible. 

There were 3 options for selecting the most appropriate type of pocket for each patient. The strictly subglandular pocket, the most superficial, was initiated on top of the pectoral fascia. Ideally, scissor dissection helped to separate and elevate the axillary tail of the gland, allowing for smooth coverage of the implant. Then the dissection progressed downward, bluntly, for about 10 cm, and the endoscope was inserted. Given the classical anatomy of the retroglandular “space.” This should be easy, but was not in every case. The undersurface of the gland was often irregular and adhered, so that no clear plane appeared. Nevertheless, this did not prevent development of the pocket. When the endoscope was inserted, some fat was often present so that an effort was required to reach the superficial fibers of the pectoralis major. In the lower portion of the dissection, from the nipple to the inframammary fold, electrocoagulation was performed on the vertical musculoglandular and cutaneous vessels. There were many fibrous adhesions that had to be freed to open the pocket correctly. 

From a surgical standpoint, the so-called subfascial plane was cleaner and more easily accessed. (This plane is commonly used in modified radical mastectomies.) Once the fascia was elevated at the lateral border of the muscle, blunt dissection progressed for 10 cm, and the endoscope was then inserted. Some changes were noted during the progression between the fascia above and the muscle below. The muscle fibers, once dark and clearly individualized, became lighter and less differentiated as they mixed with the prepectoral fascia. This was particularly evident in the medial portion of the dissection, where the muscle has its foremost insertions. To develop this pocket up to or below the inframammary fold, the fascia was crossed superficially to change planes and progress in the subglandular plane. Consequently, this pocket was both subfascial and subglandular; it was a subfascioglandular pocket. To obtain a true subfascial pocket, it was necessary to continue medially beneath the anterior sheath of the rectus abdominis (potentially a bleeding area), and laterally beneath the extended pectoral fascia (a source of constriction of the lateral lower pole of the augmented breast 

The third option was the so-called subpectoral pocket. It was important to visualize the lateral borders of both pectoralis muscles and protect the lateral pectoral bundle. This helped to avoid unnecessary damage to the lateral pectoral nerve and vessels and prevented inadvertent penetration of the pectoralis minor, which could be sources for bleeding and could present technical difficulties for the surgeon at the beginning of the procedure. Once the correct plane was recognized, blunt dissection was carried out with the index finger in a gentle sweeping motion. Some resistance appeared quickly, caused by digitations from the accessory line of insertion of the pectoralis major. It was then advisable to shift to the endoscope and cautery to avoid unnecessary bleeding when tearing the muscle fibers. This endoscopic submuscular dissection progressed in a dry and clean space. Preventive hemostasis was efficient, and the main line of insertions was readily accessible. At this point, the muscle fibers were divided from medial to lateral, leaving a stump of muscle attached to the chest wall to prevent chest wall penetration and allow for easier hemostasis. In addition, once the prepectoral fascia was divided at the corresponding level, the next space was opened slightly above or at the inframammary crease. The division of the pectoral fascia was continued laterally to open the extended pectoral fascia. 

Possible Risks and Complications: 

  • Complication rates for these procedures are comparable with other techniques for breast augmentation. [14] 
  • Implant malposition: Most implant malpositions are related to superior displacement; however, inferior displacement with bottoming out is more difficult to treat. Inadvertent subpectoral implantation has been reported in the transumbilical approach. This occasionally cannot be corrected remotely and requires an inframammary incision. 
  • Axillary banding: Fibrous banding across the axillary incision is believed to be either lymphatic channels or thrombophlebitis  
  • Hematoma: Although meticulous hemostasis is one of the benefits of the endoscopic approach, axillary hematoma has been described, although rarely. 
  • Capsular contracture 

Recovery Period:  

Postoperative management is straightforward with both methods. Place dry gauze over the respective wounds for 24 hours. Steri-strips remain until the suture is removed at 10 days to 2 weeks. An upper-pole strap is worn for several days to several weeks, depending on the tightness of the inferior pocket. This forces the implant in an inferior direction. Massage of the implant pocket is begun at 2 weeks.