Armpit approach for implant exchange? (Photo)

Question

I hate my ugly scars that are on my actual breast. I know most doctors would want to re Cut me and position the scar low in the fold which I would like. But my skin is tight. The scar looks better when I pull my skin down towards the crease. I want I go bigger and do treatments to lessen my current scars. But I want to use the armpit approach to go bigger any thoughts? I think re cutting my scar to lower it is just going to make it look worse. Unless this is an easy revision doctors guarantee?

Leland Deane, MD, FACS · Answer

Thank you for your question. My answer is somewhat general, based on your photos. I see that your scars are flat, but they are more prominent because your implants are large, you are over dissected, and the breasts have a 'bottomed out' shape (although views are a little difficult to assess). Going to a larger implant, in my opinion, will make things worse. As for 'armpit scars', those of us who trained in a time when they were used frequently can tell you that there are problems with those scars as well (especially visibility, and cutaneous nerve issues) and that approach is not recommended for most secondary surgeries. 
I hope this helps. Be careful before doing any secondary surgery and seek an experienced surgeon.

Donovan Rosas, MD · Answer

It is best to use the scar you have for revisionary surgery. Every new scar adds to your scar burden.

Additionally, the trans-axillary approach is very limiting. It is difficult on primary surgery and even more difficult on second approach. Technically speaking, that approach is reserved for saline implants.

My recommendation is to re-use the original access incision.

As always, discuss your concerns with a board certified plastic surgeon (ABPS).

Gianfranco Frojo, MD · Answer

This happens when the original scar is placed in the native inframammary fold. As the implant exerts its forces on the breast, the lower pole stretches and the inframammary scar can eventually end up on the now new lower pole skin. The key is to properly plan the incision based on the implant that is being placed and also based on the breast's native measurements. This is a common issue. You can performed a horizontal lenticular (like an ellipse) to remove the excess skin between the scar and the breast fold. You basically need to see a very experienced American Board of Plastic Surgery certified surgeon with extensive breast surgery experience.

Daniel Barrett, MD · Answer

Dear evangeline jamie,
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, MDCertified, American Board of Plastic SurgeryMember, American Society of Plastic SurgeryMember, American Society of Aesthetic Plastic Surgery

Kayla Humenansky, DO · Answer

Your scars are healing very nicely. I am not sure how far out you are from your procedure, but scars can take up to a year to fade and augmentation scars are often imperceptible once mature. Only saline breast implants can be placed via an axillary approach (through the armpit) and this would leave additional scars. To avoid placing any additional scars, I would use the scar that is already present regardless of attempting to lower the scar to the fold. Attempts at recreating a fold can also be accomplished internally without additional scarring on the breast. Additionally, you'll want to keep in mind the diameter of your chest wall and skin stretch when considering a larger breast implant, as these can be limiting factors. Ultimately, I would make sure you're going to a board certified plastic surgeon and discussing all of your concerns to get the best possible outcome.

Azita Madjidi, MD, MS, FACS · Answer

Large silicone implants cannot go through an armpit approach because they get damaged during the insertion. Old implant either, cannot be pulled up there. So the best solution and the most precise, is going through your old scars and not creating more scars. Scars cannot be erased but can be put in a place that they do not show in natural position.

Harry T. Haramis, MD, FACS · Answer

Unfortunately, over time, implants can drop below the fold making the scar rise above the fold. This also causes more lower fullness than upper.

A bigger implant may make this worse, even with lifting the pocket/fold to have the scar in the crease. This can be difficult to maintain over time and not recommended via armpit.

Since you already have faint scars, in my experience, reuse the same incision, but need to address the lower poles and folds. This will also give more upper fullness since the implants will be higher.

Any breast implant revision surgery has risks, limitations, potential for complications, etc.

An exam and consultation with your/a plastic surgeon is recommended to further discuss your best options and expectations.

Camille Cash, MD · Answer

For the best result I recommend using the incision in the inframammary fold.  This allows your surgeon to visualize the space and seat the implant properly. It makes sense since you already have the incision.  Treatments can be started early to encourage favorable scar healing.

Connie Hiers, MD, FACS · Answer

You are bottoming out now so you should not go bigger. No, the axillary incision cannot be used for large implants and risks are increased with that incision. what would be best if to tighten your inferior pocket and go with something smaller that your tissue will support.

Darryl J. Blinski, MD · Answer

Based on your photos, I agree using a larger axillary or armpit incision to do. The exchange is better than trying to revise or lower the memory crease scar. Expect me to be $10,000.

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