Can you please elaborate on the risks of transaxillary augmentation?

Most surgeons will say the transaxillary incision results in implants that are too high. However, this is only true if the augmentation is done blindly (without an endoscope). With the endoscopic technique, the inferior portion of the pectoralis muscle can be clearly visualized and released adequately, resulting in a very natural looking augmentation. There should really be difference in the ability to create cleavage with any incision choice. Endoscopic transaxillary breast augmentation is an advanced technique that requires specialized equipment, so many surgeons do not offer this option. Make sure to seek out someone who is comfortable with the endoscopic approach if you are considering augmentation via an armpit incision. Best of luck.Emile Brown, MD
Board Certified Plastic Surgeon, Johns Hopkins & Harvard Trained

Yes, the risks are greater as this results in 'high rising' breasts, among others.  The implant selection should be based on a combination of your desired size, soft tissue dynamics, breast base diameter and skin elasticity.  I recommend an in-office examination as well as a detailed discussion with a surgeon who you are comfortable with.   Finally, make sure your surgeon is a Double-Board Certified Plastic Surgeon certified by the American Board of Plastic Surgery (ABPS), a member of the American Society of Plastic Surgery (ASPS), a member of the American Society of Aesthetic Plastic Surgery (ASAPS), and a fellow of the American College of Surgeons (FACS).Best,Dr. DesaiBeverly Hills Institute for Aesthetic Plastic SurgeryHarvard Educated, Beverly Hills & Miami Beach TrainedDouble Board-Certified, Double Fellowship-Trained Beverly Hills Plastic Surgeon

I think a lot of surgeons are against transaxillary breast augmentation because they do not feel comfortable performing it or they even never tried or got train in performing it. I learned how to safely and successfully perform this type of breast augmentation over 25 years ago. Since then I augmented many thousands of breasts this way and this is my experience: it is my preferred way to do it (for a right candidate) my main reason is: why mutilate perfect beautiful woman's body if you can avoid it ? And there is really no downside, it is not true that are more complications, problems or capsular contractures than with any other way to do it. If surgeon is skilled and knows how to perform axillary breast augmentation results are very predictable. I would not be repeating this procedure for over 25 years if it would be causing problems. It would be insane since I sometimes have 10 patients /week and would ha to deal with a lot of unhappy women... And do not trust surgeons who tell you under the breast incision is great. Frequently, they are quite visible, stretched, dark, keloidal and quite annoying. Especially in small breasts that have no folds make these scars impossible to hide. Last time I performed inframammary incision is over 20 years ago. There is no need for that. Armpit incisions ALWAYS heal great and they are either invisible or look like a wrinkle in your armpit. And in my experience problems that people are describing are if anything less common that with other approaches.

Thank you for your question. Unfortunately, it is difficult to answer without a photo or in-person assessment. Please discuss these concerns with your chosen plastic surgeon. This way, you will be able to discuss your goals and concerns, and work out something that fits you best.  
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Regards, 

Hello,I perform both transax and inframammary breast augmentation surgery, and I can tell you that the safest route is the inframammary, when we look at risk of complications, especially capsular contracture (peri-areolar has the highest risk). The inframammary scar has a bad reputation that it doesn’t deserve from the perspective of cosmesis. 

Done correctly, the risks of transaxillary augmentation are typically the same as augmentation done through the inframammary and periareolar approach. This is some risk of injuring or traumatizing the nerves to the arm ( brachial plexus) , however this should be rare if the procedure is performed competently. The downside, in my opinion, is the difficulty in controlling the placement of the implant at the correct level, or inframmary fold. This results in the implants being "too high" . Scarring in augmentation is generally excellant and rarely a problem wherever the scar is. If you definitely do not want a scar on the breast, or under the breast, the transaxillary approach is a reasonable option. Consult an experienced surgeon that uses this approach and request to see their results.

When the discussion comes up in our consultation about location of incisions, i explain to the patient that the inframammary (below the breast) incision is the most direct approach to placement.  It allows direct visualization of the entire pocket and is a scar that typically heals well.  This is my go to location for implant insertion.  When an incision is placed in the axilla, generally they heal well, but if the scar is unsightly, it may be see in a bathing suit or sleeveless breast.  Incisions on the breast itself would not be visualized with clothing.

There is no single best incision for all breast augmentations, the decision is one of the many things you should discuss and determine with your board certified plastic surgeon during consultation and pre-op appointments.
The inframammary incision (under the breast) is the most commonly used nationwide. Advantage: Its technically easy to perform and generally well hidden. Disadvantage: If the implant settles down on the chest wall the scar could become visible in the bottom pole of the breast. I use this incision location mainly for large silicone implants.
The infraareolar incision (bottom half of the nipple perimeter) is the option I use most often when it is a good fit for the patient. Advantage: The scar fades very well and is the least noticeable of all of the options. Disadvantage: The biggest patient fear is loss of nipple sensation but I have found this to be a rare occurrence long-term. It can be more difficult to place a larger, silicone implant.
The axillary incision (armpit) is best suited for breasts that have little or not ptosis (drooping). Advantage: Ideal for having no scar at all on the breasts. Disadvantage: Some patients have noted pain in the axillary incision, but it is usually temporary. In some cases the placement of the implant can be a bit high (so surgeon experience is imperative) and again, this incision location does not lend itself well to a larger, silicone implant.
Every type of breast aug incision has its pros and cons and every case is unique. Your breast aug surgical choices, including incision location, should be individualized based on all of your case specifics and your aesthetic goals. It is a choice which should be made with careful consideration and guidance from your board certified plastic surgeon.
As far as achieving cleavage as a goal, there are several factors at play here, including your chest wall type. There are several decisions to make for a breast aug and describing the type of cleavage you are hoping to achieve (upper pole fullness, medial cleavage, both) helps your surgeon guide you through your implant surgery options.Keep learning and consulting until you are confident that you and your surgeon are on the same page and you understand all of the pros and cons for each of the options you've chosen for your breast aug surgery.Best wishes!

Thank you for your question and doing your homework on RealSelf.  There are advantages and disadvantages to each of the three main breast augmentation incisions.  I do not care for the transaxillary or peri-areolar incisions due to the higher bacterial concentrations in those areas and the higher risks for capsular contracture.  The transaxillary approach is remote from the breast pocket and it can be difficult to control precise pocket dimensions, especially if you have widely spaced breasts and will need some muscle dissection at the bottom of the pocket to optimize implant placement.  The inframammary crease incision is very versatile, can be done with as little as a 3.5-4 cm incision even with moderate size gel implants using the Keller funnel to deliver the implants, and allows the surgeon direct access to the pocket.  In addition, the inframammary crease incision is optimal for any subsequent revisions that need to be done for capsular contracture, implant rupture, size changes, etc.  My philosophy has always been, use one good incision for all of the implant related surgery needs rather than two or three suboptimal incision locations.  Best wishes on a great result and speedy recovery!

Dear mayo90,
I tend to prefer the periareolar incision because its the most well hidden. There is a natural border between the areola and the rest of the breast skin the hides the incision extremely well. You have to be completely naked to see it vs other incisions like transaxillary and inframammary are visible in clothing such as sleeveless shirts and bikini tops when extending your arms up. I've also noticed increased rates of bottoming out with inframmary incisions that is not reported. Transaxillary implants are always wide in appearance because the surgeon is not able to dissect medially enough to provide better cleavage. Ultimately, I can perform any of the incisions but I recommend the periareolar. There is no difference in sensation because the nerves that control nipple sensation come in laterally from the back and injury to them occurs when surgeons dissect to far laterally which is why transaxillary incisions have the highest nipple sensation disruption. There is no difference in breast feeding ability. One study did show a slight increase in capsular contracture with use of periareolar but that study was small and did not incorporate modern techniques such as below muscle placement, keller funnel usage and triple antibiotic irrigation. 
Daniel Barrett, MD

Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery