Natural Looking Breast Implants with Transaxillary Incision?

I see many photos of underarm incision for breast implants, and the implant placement looks oddly high and often misplaced. Also, many surgeons won't use this incision.

Is it possible to get a natural look with the underarm incision for silicone breast implant? I am a first time patient, size A, looking to increase to full B.

 

Doctor Answers (15)

Natural breast augmentation result possible with Transaxillary Incision

+4
For some patients this incision is ideal and can provide very natural looking results. Be sure to ask for many  photos of  patients who have had their implants placed through this incision, and then speak with some patients and what their experience is like.  

A surgeon with expertise at transaxillary (through an underarm incision) breast augmentation should be capable of producing natural-appearing results with that approach.  Insist on seeing a large number of 'before and after' photos of your surgeon's transaxillary breast augmentation results (including the surgical scars) before you agree to have that surgeon place your breast implants via that approach.

Some patients have a starting point that makes it challenging to achieve an ideal result through an underarm area incision.  Both of the 'before and after' images you attached show patients with a very low NAC (nipple-areola complex) position on the breast mound, and I almost never offer a trans-axillary approach to those patients.  The first patient has almost no lower pole breast tissue preoperatively, and needs to have her inframammary fold (IMF) lowered significantly to achieve a natural-appearing implant position.  I only do this (significant lowering of the IMF) through an IMF incision.  

The second patient has a very low NAC position preop and appears to need a lift in addition to augmentation. Both of these patients' preoperative breast types are a setup for a distinctly unnatural postop appearance when the surgery is performed through an underarm incision, and unfortunately that is the result that both of them got.  So the axillary approach is not for every patient (or surgeon).  

Another mistake that is often made through the axillary approach is non-release or inadequate release of the inferior origin of the pectorals major muscle.  If the inferior origin is not released, then the pec major muscle holds the implants high and prevents them from settling into a natural position.



Raleigh-Durham Plastic Surgeon
4.5 out of 5 stars 40 reviews

Absolutely! Transaxillary Subfascial approach with highly cohesive Natrelle 410 or Sientra implants is the way to go!!!

+3

Absolutely! Transaxillary approach with highly cohesive Natrelle 410 or Sientra implants is the only way to go!!!


The transaxillary approach is very misunderstood.  It is much more difficult and technically demanding then directly accessing the breast through an infra-mammary approach or through the nipple.  This is the main reason that most surgeons think it is too difficult or frankly impossible.  As far as riding high, this is technical error.  The entry dissection through the armpit has to be done thoughtfully.  The lymphatics that drain the breast are nearby and should not be disrupted for the future possibility of cancer staging/lymph node detection.  To avoid the lymphatics, one must stay high and avoid traversing the surgical axilla.  If this is done, there is geometric isolation between the entry dissection and the implant pocket and the implant cannot ride into this area.  The second reason that implants may ride high is that it is more technically demanding to develop an accurate and well designed inferior pocket.  Most of these problems occur when an endoscope is used and the actual placement on the body is overlooked in favor of concentrating on the endoscopic monitor.

 

 

In my opinion it just does not make sense to place a scar on the breast in an aesthetic elective procedure unless a lift is needed.  For primary augmentations with class I-II ptosis I exclusively use the transaxillary Cold-Subfascial Breast Augmentation TM.  What this means is that I access the interface of the pectoral fascia and pectoralis major muscle through the axilla (arm pit) and carefully dissect the fascia from the muscle.  The implant goes under the strong supportive fascia and above the muscle.  This is VERY different from "above the muscle" or subglandular techniques which typically do not fare well.  The fascia not only shapes the breast beautifully but the muscle is out of the picture allowing the breast implant to sit naturally more medially than dual plane techniques and it also offers the implant lasting support to prevent bottoming out and undesirable changes.  Live surgical videos have been published on the technical aspects of the Cold-Subfascial Breast AugmentationTM where the delicate dissection can be observed. 

Even the product representatives may believe that transaxillary placement is too difficult or impossible but these beliefs are remnants from early experience decades ago with saline transaxillary augmentation with a 2-3 cm incision.  The reality is that an endoscope it not necessary and the axillary incision heals and nearly disappears in most women and a larger incision in the axilla can be shortened and hidden with suture technique.

Rian A. Maercks, MD
Miami Plastic Surgeon
5.0 out of 5 stars 31 reviews

An experienced surgeon can make breasts look natural through a transaxillary incision

+3

Unless the breasts have some pre-exisiting ptosis (droop) prior to the breast augmentation, there should be no reason why breast augmentation performed through a transaxillary (armpit) incision should not look natural.

You mentioned in your question, that often they look to high when you see before and after pictures of augmentation performed through the transaxillary approach.

This is a common mistake with the transaxillary approach. The surgeon must have the experience to know to initially place the implants slightly lower through the transaxillary approach then through the peri-areolar or inframammary approach. When properly performed, implants can look perfectly natural through the transaxillary incision.

Lane Smith, MD
Las Vegas Plastic Surgeon
4.5 out of 5 stars 27 reviews

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Trans axillary breast implant are great, it depends on the surgeons experience.

+2

While over the past few years I have come to prefer peri areolar incisions and the placement of textured silicone gel implants there is no question that in a surgeon who has mastered the technique trans axillary sub muscular implants will give marvelous results in almost all patients. In fact if I am going to use saline implants and over 80% of my patients choose these, probably for cost factors, I routinely use the trans axillary sub muscular technique. The claim that they will be too high and too far apart is simply incorrect in a good surgeons hands. So again what ever technique you choose make sure you see the surgeons pre and post op photos to assure your self that the results the surgeon plans for you are the same as what you are looking for.

Two exceptions to trans axillary sub muscular implantation in my hand are when they are done in conjunction with a breast lift and when the patient presents with tuberous breasts. Tuberous breasts are those with very small base diameters, deficient inferior breast tissue and they tend to drop off the chest like Snoopy the dog's nose. With these I feel I need to use gel filled implants behind the breast and not behind the muscle.

Carl W. 'Rick' Lentz III, MD
Orlando Plastic Surgeon
5.0 out of 5 stars 11 reviews

Transaxillary approach gives excellent results in augmentation

+2

Transaxillary augmentation is an excellent approach to augmentation in those individuals who are more comfortable with a scar that is off the breast. The incision in placed high in the crease under the arm and the implant slid down into a submuscular position.

This approach was very popular several years ago and has not received the attention today that it deserves. There should be no difference in the augmentation result when comparing the underarm approach, around the nipple, or a breast fold or inframammary incision. All simply provide access through which an appropriate pocket is made to accommodate the selected breast implant. Augmentation through each approach may be done well, or done poorly. Surgeons who do not use this approach may not be comfortable with it or be able to do it well and rely on what they feel is a more "direct" incision.

All incisions do fade, however you should be able to have an excellent augmentation through a transaxillary incision and avoid a breast scar if you wish.

Best of luck,

peterejohnsonmd

Peter E. Johnson, MD
Chicago Plastic Surgeon
4.0 out of 5 stars 28 reviews

Experience

+1
Important to look for someone with experience. Those who do not do many can wind up frustrated with this surgery and not completely release the muscle attachments leading to high riding implants. This approach more expertise. The scar is hardly visible and heals well in almost all patients. Especially in those pts with little to no breast tissue where the incision can be highly visible along the fold. 

Patrick Hsu, MD, FACS
Houston Plastic Surgeon
5.0 out of 5 stars 12 reviews

Is It Possible To Get A Natural Looking Silicone Breast Augmentation Through A Transaxillary Incision?

+1
Many excellent Board Certified plastic surgeons around the country do silicone breast augmentations through the armpit.  The use of an endoscope in transaxillary breast augmentations increases the surgeon's ability to see and stop bleeders that could later lead to a hematoma or capsular contracture or both.  
Transaxillary incisions make it incredibly easy to go underneath the pectorals muscle, and sub pectoral implants look more natural and have a history of getting less capsular contractors.  Creating a dual plane augmentation is also incredibly easy with an armpit incision, therefore covering the upper portion of the implant with the pectoralis muscle and allowing the lower portion to be outside the muscle, giving the patient a teardrop appearance without using teardrop implants which can rotate.
I personally have placed hundreds of implants 600-800 ccs in size through the armpit using the Kellar funnel.  The Kellar funnel is an ingenious invention eliminating non-pathogenic bacteria hitchhiking a ride through the armpit, down into the implant pocket, and therefore increasing the chance of capsular contracture. 
All in all, you are very smart to consider a transaxillary approach for a silicone breast augmentation, and considering the size implant you desire, you should have a very small incision (approximate 4 cm), and because the normal creases of the armpit are called Langer's lines, the scar should be relatively invisible.  Don't forget, no one, not even your mother, has intentionally looked under your armpits. 

S. Larry Schlesinger, MD, FACS
Honolulu Plastic Surgeon
5.0 out of 5 stars 200 reviews

You can have a very natural look from the transaxillary approach.

+1

Your observation of asymmetry and high position is exactly why I hesitated back in the middle 80's.  Whenever I saw a presentation, they were cockeyed and often high.  I thought there were inherent procedure difficulties that caused this.  But after I tried it, I realized that it was not a procedure problem but a problem with the surgeon.  Some picked the wrong candidate, anatomically.  But mostly it was the surgeon not making an adequate pocket and paying attention to details such as sitting the patient up to check position and symmetry before closing.  An advantage of this technique I have seen over the years is the lack of "bottoming out" over time, probably due to less disruption of the tissues at the fold when making the pocket.

Myles Goldflies, MD
Bellevue Plastic Surgeon
4.0 out of 5 stars 5 reviews

Transaxillary approach for gel implants

+1

You are very observant. The biggest problem with transaxillary placment is the  malposition of the implants usually too high. This approach was much easier with saline implants. Now with gels, the incision has to be made larger to accomodate the implant.

Steven Wallach, MD
Manhattan Plastic Surgeon
4.5 out of 5 stars 17 reviews

Consider endoscopic transaxillary approach

+1

There are many approaches used for breast augmentation. The trans-axillary approach is especially appealing since it avoids incisions in and around the breast.

However, the only way to safely and precisely perform a breast augmentation through the axilla is to use an endoscope. In this way the pocket can be clearly visualized and proper implant placement can be achieved.

Many doctors are not comfortable with the use of the endoscope. They either do not perform this procedure or use blind, blunt dissection to create the pocket. This can result in asymmetry and high placement of the implant,

The pictures you have seen likely represent poor pocket dissection using a blind approach.

Keep in mind that generally the largest silicone implant that can be placed through the armpit is about 250cc. If you desire a larger implant, then you may have to consider a saline implant.

Good luck with your procedure.

A. Peter Salas, MD
Manhattan Plastic Surgeon
3.0 out of 5 stars 1 review

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.