Why don’t more PS use the transaxillary breast augmentation using endoscopy technique?

The transaxillary approach involves making an incision in the armpit. The pocket for the implant can be dissected blindly and bluntly with special instruments. It can also be dissected with an endoscope and electrocautery under direct vision. The endoscope allows visualization of bleeding vessels that can be directly controlled. Reported disadvantages include poor pocket visualization and control, which is largely dependent upon surgeon comfort with the procedure and the number of procedures performed through this approach. The scar in the hairbearing area of the axilla may cause shaving difficulties. If removal of the implant is necessary in the future due to implant rupture or capsular contracture, an incision on the breast mound, either periareolar or inframammary, may be necessary.

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.

Many plastic surgeon, including myself, have tried the transaxillary breast approach at some time in their practice.  I think most who have tried it eventually realize it has no great advantage over other incisions.  The surgeon doesn’t have as much control or visualization. If you really wanted it done that way I’m sure you could find surgeons willing to do it, but I suspect most will try to talk you out of it.

A well-planned breast augmentation using an infra-mammary incision should have the resultant scar in the infra-mammary fold itself - its basically invisible in that position. Check out my before/after photos and see what you think. Most PS do not perform trans-ax breast augmentation because of the implant malposition and capsular contracture issues associated with this procedure.

 I know sometimes this forum can be so confusing but there are so many different approaches. I’m going to give you the exact opposite of Dr. Young. I have been doing the transax endoscopic  approach for 20 years and would not continue to do so if there were the problems mentioned. Let me give you the advantages !1.  I believe there is more discomfort for the first 2 to 3 days doing your hair but that is about it. The majority of your discomfort comes from the implant being under your muscle. Within five or six days patients are back doing what they want to do. 2. The scar in most cases is imperceptible. I hide it in a small crease in the under arm and it works great. I have seen horrible scars with an M for memory approach that are visible when the swimsuit rides up but anyone can have a bad scar.3.  Many revisions can still be done through the under arm. I can add saline to an implant, adjust a pocket lower, fix mild capsular contracture, remove a ruptured implant and exchange it, exchange silicone or saline and I can insert up to 550 mL through the under arm (I’ve done 600 mL but it was a struggle!) 4.  It is true that if the camera is not used, transaxillary does have a tendency for implants to ride high and wide. But using the camera changes all of that. 5. I like the incision being far away from the implant. With inframammary I’m always nervous if there is a wound infection that the implant is sitting right there.6.  I do not see an increased incidence of loss of sensation of the nipple. In fact most patients get a little hypersensitive for several months and then return to normal.  I also do not see a higher incidence of capsular contracture. I do have my patience massage and I use the Keller funnel. 7.  The operative time is very short usually wheels in wheels out around one hour. 8. I believe there is a lower risk of bottoming out because the supportive tissues under the breast are not disturbed as they might be with under the breast  incisions  9.  Remember the three main incisions used are all acceptable and it really depends on the patient and Dr. comfort but again after 20 years I love it and so did my patients. 

I offer transaxillary breast augmentation however most patients choose an inframammary or periareolar scar.  Like you mentioned, most revisions can't be done through the transaxillary approach.  It's also a more painful recovery, longer scar and higher chance of the implants sitting high.  However it's a great way to avoid a scar on the breast with your initial augmentation.

There are a number of breast augmentation access incisions. Each has advantages and disadvantages unique to them. The most common are infra-mammary fold (beneath the breast), infra-areolar (beneath the areola),trans- axillary (armpit), trans-umbilical (belly-button).
Generally, the infra-mammary and infra-areolar are the most commonly used as they provide a more direct approach with good visualization. Incisions will generally be 5-6 cm (smaller for saline as they are filled after placement). Limitations on these approaches are generally defined by anatomy. I small areola may not accommodate an adequate incision for access. A patient with a poorly defined fold may not be a good candidate for an IMF incision due to the uncertainty surrounding placement.
Distant approaches such as the trans-axillary or trans-umbilical approach are less direct and have higher complication and contracture rates (3x) as well as revisionary rates. There are also limitations on the devices used as silicone devices cannot be placed via the trans-umbilical approach. Larger silicone implants are also difficult to place via the trans-axillary approach due to the narrow window of placement through the axilla.
All are generally reasonable options (however, some are more safe and reliable). Your board certified plastic surgeon (ABPS) is uniquely qualified to guide you to a safe and reasonable surgical plan.
Donovan Rosas MD
Board Certified by the American Board of Plastic Surgery
Member: American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons
RealSelf Top 100
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The Trans Ax procedure addresses the muscle in a different way than IMF or periareolar incisions.  Specifically the breast crease is divided or lowered at the IMF.  Over time this can cause a longer nipple to IMF distance resulting in a nipple which appears too high and an implant that sits too low.  Most rapid recovery techniques use the IMF incision which when healed is not visible on front guaze if placed correctly.  The revision rates are higher with the TransAx technique.

As you can see from a majority of the previous responses, most Plastic Surgeons are no longer using the Transaxillary approach for breast augmentation for a variety of reasons:If you require revisionary surgery down the road (which almost all patients will), you cannot perform this surgery through the TA approachThere is a higher risk for asymmetry of the implants when placed through this approachThere is the risk for nerve damage when proceeding through this approachIt is much harder to place pre-filled silicone breast implants through this approachThat being said, I have to politely challenge some of the comments made by the previous surgeon.  1. There is more postoperative pain associated with this approach.-Not necessarily.  I have personally performed a good number of procedures through this approach and in my experience there is no appreciable difference in discomfort2.  There is a greater chance of asymmetry post op and loss of nipple sensation.-While there is definitely a greater change of asymmetry, I know of no studies supporting the increased risk for nipple sensation3. There is a 3 times greater chance of capsular contracture with this approach.-While going through the axilla theoretically places you at higher risk for CC since this is a less clean area than the IMF, I don't know of any studies supporting a 3-fold higher risk4. Yes, in order to do a revision or an implant exchange in the future, you will need an inframammary incision. -This is a great point and one that I would definitely consider!I hope this helps and wish you the very best!Warmest regards,-Gregory A Buford MD FACS PCEOBoard Certified Plastic Surgeon and Author

Dear Jam29,
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