Thanks for your question. We almost exclusively use a transaxillary incision for our breast augmentations. I feel an endoscopic technique is absolutely essential. The endoscope is a surgical telescope that allows a surgeon to see exactly what he is doing. This, with endoscopic surgical instruments allows for the surgery to be done precisely, accurately and without bleeding.
If the surgery is not done in this manner, I feel the risk that implants are placed incorrectly is higher. Some surgeons will use a non-endoscopic approach, using blunt dissection which is done blindly. Bleeding is not controlled and I feel complications such as incomplete muscle release and asymmetry of the implants are more likely.
It is completely possible to get a natural look with an armpit incision, which heals very well and in most cases is invisible. Please look at our before and after gallery. All cases were done in this manner.
Shim Ching, MD
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.
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.
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.
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.
The armpit incision (transaxillary supectoral augmentation) is my preferred method of doing a breast augmentation, and I have done many thousands of these operations through the armpit. It is a favorite of patients because there is no incision on the breast and it can look extremely natural. Experience is the most important factor in getting a great result. Frequently when I see patients asking for a revision of their implants, and their surgeon has used that approach, I find that the pocket was not dissected low enough at the first operation. This is a common problem if the surgeon is not well versed in this approach. Of course there are nuances from every approach, but it takes more experience with the armpit approach than any other. Of course the first thing is to find a Board Certified Plastic surgeon, one that is a member of the American Society for Aesthetic Plastic Surgeons who does more cosmetic or aesthetic surgery in his practice is even a better choice.
Trans-axillary breast augmentation is becoming an increasing popular method for breast augmentation as
technology continues to improve. There are several misconceptions about axillary breast augmentation.
First of all both saline and silicone implants can be used with this method. Many patients and surgeons that do not commonly perform this surgery don’t know that a silicone implant can be placed from an
axillary incision. The use of the Keller funnel allows a variety of implants to be placed through the axilla easily.
Secondly, the incisions in the axilla is just as small as it would be if it was placed around the nipple or under the breast. The incision is well concealed in one of the natural arm creases in the axilla.
Thirdly the use of the endoscope has made the procedure very precise as the entire breast pocket is created under direct vision. This method has become very popular in Miami where I first practiced and now I commonly perform this procedure here in Austin Texas as it avoids putting any incisions on the breast, thus decreasing the chances of altering nipple sensation.
Please consult your board certified plastic surgeon to help guide you through your breast augmentation process.
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.
A variety of
incision options are currently available for breast augmentation surgery.Each of these incisions offers advantages and
The transaxillary approach utilizes
an incision in the armpit.Incisions in
the armpit are well-hidden, but there is the potential for implant malposition
and superiorly positioned implants with this approach.
For this reason, it’s important that
the procedure be performed by a plastic surgeon with experience with this technique.Under these circumstances, the results can be
excellent and the breasts can ultimately look very natural.
Natural results are achieved with the transaxillary approach using gummy bear silicone gel implants. The key is to make the pocket for the implant low so that the implants don't sit too high. A surgeon experienced with this approach knows how to make the pocket low enough to avoid this problem.