Outline

The use of the transaxillary incision has enabled augmentation mammoplasty with a scarless breast. However, the classic technique has been associated with high rates of asymmetry, malposition, and high riding implants. With the addition of endoscopic assistance, retropectoral pocket visualization and better control of the lower pole has been facilitated. Nevertheless, pitfalls in patient selection and technique abound. In this study, the authors experience with endoscopic transaxillary breast augmentation is reviewed, with particular attention to both the anatomic characteristics associated with favorable and unfavorable outcomes and technical nuances that have improved aesthetic results. One hundred and ninety-seven endoscopic transaxillary breast augmentations were performed during this study. All patients underwent augmentation with saline implants, with a mean volume of 298 mL. Preoperative pseudoptosis or grade I ptosis was present in 14 patients, and 4 patients had mild or moderate tuberous deformity. Thirty-four patients had short lower pole anatomy, with areola-to-inframammary crease length of <=3.5 cm. There were 19 patients identified with pectoralis major hypertrophy resulting from strength training. One patient (0.5%) required conversion to an open technique for control of bleeding. Three patients (1.5%) required intraoperative conversion to an open technique for inadequate implant position and breast shape (2 with tuberous deformities and 1 with ptosis). Seven patients (3.5%) underwent revision for malposition (5 superior and 2 inferior). There were no infections, seromas, postoperative hematomas, or significant encapsulations. Patient selection is of paramount importance in minimizing complications and optimizing the results of endoscopic-assisted transaxillary breast augmentation. Patients with deficient lower breast poles, sharply defined inframammary creases with short areola-to-fold distances, pectoralis major muscular hypertrophy, ptosis or pseudoptosis, and any form of tuberous breast deformity should be identified carefully and considered judiciously. Technical refinements that maximize safety and improve the aesthetic results with endoscopic-assisted transaxillary breast augmentation are described.

Breast augmentation is currently the most common aesthetic surgical procedure in the United States, with >310,000 cases performed in 2009.1 Prospective patients, through access to myriad web-based information portals, pervasive media exposure, and increasing public acceptance and awareness, have become progressively savvy with regard to breast augmentation techniques and the ability to achieve breast enhancement with a “scarless breast.” This has further fueled plastic surgeons' inexorable pursuit of breast augmentation techniques and modifications that maximize aesthetic results and safety while minimizing irregularities and complications.

The transaxillary breast augmentation technique has facilitated both submuscular implant placement and the absence of visible scars on the breast. First described by Hoehler 2 in 1972, the transaxillary approach provides the advantages of inconspicuous access incisions and scars within the folds of the axillae, ready access to the subpectoral plane, and maintenance of an inviolate breast gland and lactiferous ductal system.2–6 Although providing obvious technical benefits, the classic transaxillary technique has been frequently associated with contour deformity, asymmetry, and implant malposition because visualization of the region of the inframammary fold, and surgical control thereof, is limited.7–10 The blind release through blunt dissection of the inferior fibers of the pectoralis major muscle can result in an irregular or inadequate expansion in the lower pole, with consequent breast contour deformity and often high riding implants.

The advent of minimally invasive endoscopic techniques has substantially improved the transaxillary approach to breast augmentation.11–18 The application of endoscopic instrumentation has facilitated clear retropectoral pocket visualization, more meticulous hemostasis, precise electrocautery division of muscle fibers (supplanting blunt avulsive maneuvers), and improved control of the inframammary fold region and lower pole of the breast.

Patient selection is of paramount importance in optimizing the outcome of transaxillary breast augmentation. In patients with hypomastia with nonptotic, symmetric breasts with well-defined inframammary crease and lower pole anatomy, endoscopic transaxillary breast augmentation (ETBA) is ideal. However, there is a dearth of information regarding this technique's suitability in more challenging anatomic scenarios, which include patients with ptosis, tuberous deformities, asymmetry, and those with hypertrophy of the pectoralis major muscle because of zealous strength training. In this study, the authors' experience with patients treated with ETBAs is reviewed, with particular focus on the anatomic characteristics associated with favorable and unfavorable outcomes and technical nuances that have improved aesthetic results.

From 1995 to 2009, 197 ETBAs were performed in 197 women with glandular hypomastia; 193 cases were bilateral and 4 unilateral. Mean age was 34 years (range, 20–50 years), with mean follow-up of 3.6 years (range, 11 months–7 years). All patients underwent augmentation with saline implants, with a mean volume of inflation of 298 mL. Postoperative follow-up visits were conducted in the weeks immediately after surgery, at 3 months, 6 months, 12 months, and yearly thereafter. All data were reviewed retrospectively.

All patients are marked in the standing or seated upright position preoperatively. The existing inframammary crease is delineated, as is the lateral border of the pectoralis major. With manual pinch-distraction of the lower pole skin, the anticipated “new” inframammary crease line is identified and marked for reference. Within the hair-bearing axilla, a dominant natural crease is identified beneath the apex of the axillary vault. Defined by passively adducing and abducting the arm, the creases are easily identified and marked. If 2 dominant creases are identified, the more caudal is selected. Incisions are marked between 2.5 and 3.0 cm in length and ~1 to 2 cm posterior to the lateral border of the pectoralis major muscle and anterior axillary fold to preclude exposure with arms held in repose (Fig. 1).

All procedures are performed under general anesthesia. Patients are positioned with arms abducted at 90 degrees and the head of bed elevated to 15 degrees. The regions of the breast lower pole between the premarked existing inframammary crease and the anticipated crease, lateral borders of the pectoralis major, and marked incision lines are injected with 0.5% Xylocaine solution with epinephrine.

After skin incision, the lateral pectoral fascia is incised with electrocautery identifying the posterolateral border of the pectoralis major muscle. Dissection immediately beneath the pectoralis muscle with a lighted retractor under direct vision is carried out, clearly identifying the retropectoral plane. Limited blunt dissection, first digital and then using a Dingman dissector,6 is then used to gently develop the upper one-third to one-half of the retropectoral pocket. Cool or cold triple-antibiotic-saline irrigation is liberally administered using a soft-tipped catheter. An Emory endoscopic retractor (Snowden-Pencer Corporation, Tucker, GA) is then inserted. A 10-mm 30-degree endoscope is used to visualize the pocket, continuing the subpectoral dissection with monopolar cautery to the lower pole while achieving meticulous hemostasis. Care is taken to preserve all medial fibers of the origin of the pectoralis major muscle, particularly the inferomedial fibers at their junction with the inframammary fold line. This point marks the location of the commencement of inferior muscle division. The pectoralis muscle and prepectoral fascia are then divided from this medial point to the lateral muscle border, approximating the 4 O'clock to 8 O'clock position on each breast, with monopolar cautery. Muscle division is carried out ~1 cm above the chest wall and the visualized caudal origins of the pectoralis muscle. The limit of muscle and fascial division is the visualization of subcutaneous fat, at which point monopolar cautery dissection is completed (Fig. 2). The Dingman instrument is used to gently dissect the inferolateral aspect of the pocket to minimize potential cautery trauma to the fourth and fifth intercostal nerves. When required, particularly in cases with short inframammary fold-to-areolar dimensions, additional gentle caudal dissection with the Dingman dissector is carried out.

Saline sizers were used in all cases to determine the optimal fill volumes and to achieve intraoperative expansion of the tissues as indicated. The back of the operating table is elevated maximally, and the table then placed in reverse Trendelenburg position to approximate a seated upright orientation. Sizers are overinflated to twice the anticipated final fill range and are then deflated to desired volume. Any residual contour imperfections are identified, and final modifications are made with gentle adjustments with a Dingman dissector. When such gentle dissection is insufficient at achieving appropriate lower pole shape, it is often an indication that the muscle division was incomplete, and additional release of muscle and prepectoral fascia with the endoscope and monopolar electrocautery to completely visualize the subcutaneous tissues is required. After sizer removal and irrigation with cool antibiotic saline solution, the pocket is inspected with the endoscope and hemostasis is confirmed.

Saline implants were inserted in all cases. Textured round saline implants were used during the first year of the study, and smooth round saline implants were used exclusively in all subsequent cases.

The lateral pectoral fascia, subcutaneous planes, and deep dermis are reapproximated with 3-0 or 4-0 absorbable suture, and the skin ultimately closed with running intradermal 4-0 absorbable suture. Sterile gauze dressings are applied to the incision lines, and a supportive brassiere is placed.

In 197 women treated, all had glandular hypomastia. Preoperative pseudoptosis or grade I ptosis 19 was present in 14 patients, and 4 patients had mild or moderate tuberous deformity. Thirty-four patients had short lower pole anatomy, with areola-to-inframammary crease length of <=3.5 cm. There were 19 patients identified with preoperative pectoralis major hypertrophy resulting from strength training.

Four patients (2%) required intraoperative maneuvers with additional breast incisions. Of these, 3 patients (1.5%) required intraoperative conversion to an open technique for inadequate breast shape, and 1 patient (0.5%) required conversion to an open technique for control of hemorrhage. Of the 3 in whom shape considerations necessitated the technical changes, 2 were tuberous deformities, and 1 demonstrated mild preoperative ptosis. During the endoscopic transaxillary augmentation procedure, the 2 tuberous deformity cases were found to have unacceptable lower pole expansion in addition to areolar herniation and required periareolar incisions for glandular scoring and control of the areolar diameter. The preoperative ptosis case was insufficiently corrected with the subpectoral transaxillary augmentation alone, and a periareolar mastopexy adequately addressed the residual ptosis. Aesthetic results and patient satisfaction were high, and no additional procedures were required. In the single case where bleeding was the stimulus for an additional breast incision, suture–ligature hemostasis was achieved, controlling a recalcitrant bleeding internal mammary artery perforator using an inframammary counter-incision. No additional procedures were required.

Postoperatively, 3 patients (1.5%) experienced mild superficial upper extremity thrombophlebitis, 4 patients (2%) developed hypertrophic scars, 2 patients (1%) noted nipple-areolar sensory loss, and 1 patient (0.5%) developed unilateral hypoesthesia of the proximal-medial arm. All cases of superficial thrombophlebitis resolved within 30 days after conservative treatment with warm soaks and daily aspirin. The hypertrophic scars were mild in all cases, and none elected any treatment whatsoever. The 2 cases of unilateral nipple-areolar insensitivity and the case with unilateral arm hypoesthesia were unresolved after 12 months. In each case, patients had little or no concerns, and satisfaction was high.

There were 7 cases (3.5%) of persistent breast malposition requiring reoperation, 5 were superiorly positioned, and 2 were inferiorly positioned. There were 19 cases (9.6%) identified by the authors to demonstrate superposition, or “high-riding” implant malposition early and at 3 months postoperative. Early treatment of the superiorly positioned cases included displacement exercises and massage and external elastic banding of the upper poles. Of the 19 cases, 14 had resolved to patient and surgeon's satisfaction at 6 months. The 5 cases (2.5%) of superior malposition were corrected surgically with additional inferior pole release and intraoperative sizer expansion using the transaxillary endoscopic technique, all with satisfactory results. Two cases (1%) were inferiorly malpositioned or “bottomed out.” Both cases required reoperation and reestablishment of the inframammary fold with internal capsulorrhaphy; one was corrected through an areolar incision and the other through an inframammary crease incision.

Nine patients (4.6%) ultimately requested size change (8 desired larger and 1 smaller). There were 4 cases (2%) of implant leak/deflation identified during the follow-up period. All removal-and-replacement procedures were performed successfully with transaxillary endoscopic technique.

There were no infections, seromas, postoperative hematomas, or significant encapsulations.

By obviating the need for a scar on the breast, transaxillary breast augmentation has enjoyed popularity over >3 decades. In comparison with an areolar approach in which scars are in most cases subtle but nevertheless always visible, and with the inframammary approach, wherein scar placement is often challenging and the visibility of which is guaranteed, the direct access to the retropectoral plane through largely inconspicuous incisions has been among the clear advantages of the transaxillary augmentation technique.2–6 Despite its benefits, the classically described transaxillary augmentation also has clear limitations. The advantage of incisions made more proximate to the breast lower pole using areolar or inframammary fold incisions is the provision of direct visualization of the inferior origins of the pectoralis major muscle, facilitating muscle division, pocket control, hemostasis, and implant placement, which has been previously impossible with the transaxillary approach. When the inferior breast is addressed in a “blind” fashion, muscle and fascia cannot be meticulously addressed, surgical control is by definition sorely limited, and contour deformity, asymmetry, and implant malposition are seen commonly.7–10

Combining endoscopic visualization and technique with the transaxillary approach, intraoperative control and postoperative results have been improved dramatically.11–18 Whereas the lower pole was previously addressed by blind, blunt “sweeping”2–6 or avulsive techniques, the transaxillary endoscopic approach has enabled clear visualization, meticulous hemostasis, and precise division of muscle fibers, and thereby superior control of the pocket, increased safety, and improved breast shape.

Since the earliest reports of ETBA by Ho 11 and others,12–18 many plastic surgeons have become increasingly facile with endoscopic instrumentation and technique. In our experience, after having achieved a high level of comfort and facility with the techniques, we have found during the past 15 years that the true challenges lie predominantly in patient selection.

In patients with glandular hypomastia with symmetric breasts, well-defined inframammary creases and lower pole anatomy and no ptosis, ETBA is ideal (Figs. 3A–F, 4A–F). In patients with severe hypomastia with short lower pole dimensions and ill-defined creases, ptosis, tuberous deformities, asymmetry, and those with hypertrophy of the pectoralis major muscle because of zealous strength-training, the indications for ETBA have been less clear. In the index cases in our experience, our selection criteria for potential patients for the endoscopic transaxillary approach was identical to the criteria for those who would also have been considered candidates for either an areolar or an inframammary crease approach. Patients who were selected had mammary hypoplasia without ptosis or asymmetry who requested breast augmentation with a scarless breast. As our skill with the technique grew, patients with pseudoptosis and mild ptosis were included because were those with marked muscle hypertrophy or constricted lower breast poles.

During the first 10 months of the study, we noted contour deformities after ETBA in the patients with pseudoptosis and mild ptosis, manifest as a lack of effacement or expansion of the relative excess preexisting lower pole skin and glandular tissue, and in patients with short lower pole anatomy and pectoralis major hypertrophy, demonstrating flattened lower breast poles with poor convexity and high-riding implants. Despite what was felt in these early problematic cases to be adequate electrocautery division of the pectoralis major muscle and prepectoral fascia, each was associated with under-expansion of the lower poles, particularly in the cases of the more unyielding, constrictive, and hypertrophied pectoralis major muscle.

After the identification of these problems during the first 10 months of the series, we began using an intraoperative maneuver that produced substantial improvements in breast aesthetics, particularly in cases of more challenging lower pole restrictive anatomy. Because saline sizers had been used previously for the establishment of optimal final implant fill volumes, we then began overfilling the sizers to intraoperatively stretch the thickened, overdeveloped muscle and underdeveloped lower pole soft tissue. By overinflation to approximately twice the anticipated final fill volume and maintenance of the expansion for up to 20 minutes, consistently improved postoperative breast aesthetics were achieved. After the institution of this maneuver at the end of the first year of our experience, it has been used in all subsequent cases.

The results of intraoperative expansion with a saline sizer are by no means suggested to approximate the clinical effects of staged mechanical tissue expansion. Whereas the latter process is associated with increased mitosis, cellular hyperplasia, and skin generation over time,20–23 the immediate effects of the sizer hyperinflation are directed toward “tissue relaxation.” Sasaki 24 described rapid intraoperative tissue expansion as a 1-stage alternative to the traditional multistage process, which has subsequently been used in a variety of surgical scenarios and anatomic regions 25–27 with the mechanism of action felt in part to be related to the rupture of interlinked dermal collagen fibers and the realignment of collagen and elastin fibers.24,28 Expansions of 0.5 to 2.5 cm,24 or 15% to 20%27 have been reported. In our series, we have noted immediate intraoperative increases of nipple areolar-to-inframammary fold distances from 3.5 cm to 5–6 cm.

The pectoralis major muscle, mammary gland, soft tissue, and skin relaxation that is achieved during ETBA may also be related to the disruption of suspensory ligaments that join the deep layers of the superficial fascia of the breast (including Cooper's ligaments) to the investing fascia of the pectoralis major muscle (prepectoral fascia). This is advantageous in cases of deficient lower pole anatomy and pectoralis major hypertrophy as well as in pseudoptosis and mild ptosis. Clearly in the setting of more significant grade II or grade III ptosis,19 incisional mastopexy techniques are most often indicated. In pseudoptosis or mild ptosis (grade I), more limited incisions may be acceptable for breast augmentation and correction. However, dual plane 29 pocket development and liberation of the fibro-ligamentous attachments of the anterior investing fascia of the pectoralis major muscle from the gland are often required to optimize lower pole breast shape. When creating a transaxillary endoscopic-assisted pocket plane beneath the pectoralis major muscle, after inferior muscle division, it is not technically feasible to develop an appropriate dual plane with continued anterior pectoral dissection between the muscle and the gland. However, we feel that intraoperative expansion approximates dual plane maneuvers by encouraging increased separation of the fibrous attachments between the caudal pectoralis fascia and the inferior pole of the gland (Fig. 4A–F). Although seemingly counterintuitive, expansion in the presence of mild lower pole skin and soft tissue laxity aids in the liberation of the fascial attachments of muscle to gland and facilitates improved lower pole breast shaping. Similarly, Barnett 30 has described disrupting the pectoral fascia and “sweeping” the caudal parenchyma digitally during transaxillary subpectoral augmentation in women with ptosis. However, these maneuvers were performed in the absence of endoscopic visualization and control. Although there have also been reports of endoscopic transaxillary augmentation at the subfacial and subglandular planes,31–34 our experience has been limited solely to the subpectoral approach because we find the protective advantages of the subpectoral plane in conjunction with the technical maneuvers described to be quite versatile in a variety of settings and to yield safe and predictable aesthetic results.

In this study, 3 patients (1.5%) required intraoperative conversion to an open technique for inadequate breast shape, 2 of whom were tuberous deformities, and 1 demonstrated preoperative ptosis. Two of 4 cases (50%) judged preoperatively to have tuberous deformity were insufficiently addressed with ETBA. Accentuated areolar herniation, persistent inferior pole constriction, asymmetry, and poor breast shape necessitated periareolar incisions for glandular scoring and control of the areolar diameter and breast shape. Meara et al 35 have described a 3-tiered classification system for tuberous breast deformities and highlight the treatment principles that may include augmentation of breast volume, lowering of the inframammary fold, increase of the skin envelope, expansion of the constricted base, and reduction of areolar herniation and size. In our series, all tuberous deformities were mild (type I). However, the volume augmentation, inframammary fold position adjustment, and skin expansion were unsuccessful in achieving pleasing breast shape in 2 of 4 patients treated. In tuberous breast deformity, the high probability of asymmetry and contour problems of any isolated subpectoral approach combined with the frequent need for direct glandular and areolar maneuvers should inspire great caution when considering ETBA. We have abandoned this technique for the treatment of even mild tuberous breast deformity.

In the case of preoperative ptosis that was insufficiently corrected with ETBA alone, a periareolar mastopexy adequately addressed the residual ptosis. The ptosis preoperatively was considered moderate (grade II) and would have in retrospect been difficult to correct with any limited incision subpectoral or dual plane approach. In all other cases with pseudoptosis and grade I ptosis in this series, satisfactory correction was achieved with ETBA. Nevertheless, the endoscopic transaxillary approach should be selected carefully in cases with any ptosis, particularly for those surgeons who have not yet reached the peak of the learning curve for this technique. When one feels that a more carefully defined dual plane pocket location is required, inframammary fold or areolar access is encouraged.

There were 19 cases (9.6%) identified by the authors to demonstrate “high-riding” implant malposition early and at 3 months postoperative, the majority of which 14 responded well to conservative measures by 6 months. The 5 unresolved cases (2.5%) of superior malposition were corrected surgically with additional inferior pole release and intraoperative sizer expansion using the transaxillary endoscopic technique, all with satisfactory results. The 2 cases (1%) that were inferiorly malpositioned, or “bottomed out,” required reconstruction of the inframammary folds with internal capsulorrhaphy. Given the technical demands of inferior pole suturing of anterior capsule to posterior capsule and periosteum, the transaxillary approach was not attempted. One was corrected through an areolar incision and the other through an inframammary crease incision.

Postoperative complications were predominantly mild. There were no infections, seromas, hematomas, or encapsulations. Three patients (1.5%) experienced mild superficial upper extremity thrombophlebitis that resolved within 1 month with conservative treatment. Four patients (2%) developed hypertrophic scars that were considered mild in all cases and none required treatment. Sensory disturbances were infrequent, with 2 instances (1%) of nipple-areolar sensory loss and one (0.5%) of unilateral hypoesthesia of the proximal-medial arm did that did not completely resolve after 1 year. In each case, patients had little or no concerns, and overall satisfaction was high. Electrocautery dissection in the lower-outer quadrant is limited, and gentle blunt dissection is used to minimize injury to afferent nerves to the nipple areolar complex. In the axilla, subcutaneous dissection is performed from the incision line to the pectoral border and lateral pectoral fascia in the subcutaneous plane to avoid injuries to the intercostobrachial nerve.36

We have found that patients who desire volume change can be safely and effectively treated using the endoscopic transaxillary approach. Retrieval of the implants through the axillary incision has been simple. When replacing saline implants, ease of explantation is facilitated by displacement of the implant toward the axilla and deliberate deflation of the implants. Treatment of capsular contracture has been reported with the endoscopic transaxillary approach.37 Although we have not had occasion to perform capsulectomy using this approach (in the absence of contractures in this series), capsulotomies can be safely and effectively performed using the transaxillary endoscopic technique to improve lower pole contour.

Breast augmentation using the endoscopic-assisted transaxillary approach is safe and effective for a variety of body types and breast anatomy. However, patient selection is of paramount importance in minimizing complications and optimizing aesthetic results. Patients with glandular hypomastia with symmetric breasts, well-defined inframammary creases and lower pole anatomy and no ptosis are ideal candidates. Patients with deficient lower breast poles, poorly defined inframammary creases with short areola-to-fold distances, pectoralis major muscular hypertrophy, and pseudoptosis or mild ptosis can also be considered for ETBA using the techniques described herein. Those with any form of tuberous breast deformity or tuberous-ptosis should be identified carefully, and considered judiciously, because postoperative shape anomalies are common.

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Key Words: transaxillary endoscopic breast augmentation; breast implants; armpit incision; axillary breast augmentation; endoscopic assisted breast augmentation; breast enlargement with endoscope