Endoscopic Transaxillary Breast Augmentation

Abstract

The author contends that an important reason to choose the endoscopic transaxillary technique for breast augmentation is the avoidance of scars on the aesthetic unit of the breast. Other advantages include increased precision in creating the pocket, providing a well-shaped inframammary fold; reduced bleeding; less postoperative pain; and a shorter convalescence.

My patients in Sweden always request that I create as little scarring as possible on the aesthetic unit of the breast when I perform breast surgery. In fact, they appear to be more concerned about their scars than any other aspect of the surgery. With increased media exposure, general public sophistication about breast augmentation has become widespread. Today most people know that when a woman has 2 symmetrical scars, either around the areola or in the inframammary fold, she has undergone breast augmentation. I have seen patients with such scars who were as distressed about these obvious signs of surgery as they were about the preoperative appearance of their breasts.

I have heard colleagues say that the inframammary scar is placed in the fold and, as a result, is inconspicuous. However, in my hands, few scars placed on the body, except for those above the neck, become inconspicuous; most can be seen with the naked eye from 10 feet. I also find it difficult to place the scar in the future inframammary fold with precision because most augmentations will lower the inframammary fold. It is hard to know exactly where the future inframammary fold will be, and therefore placement of the incision is difficult.

Desire on the part of the patient for a short convalescence, allowing her to return to work sooner, is a current trend in aesthetic surgery. One of the major disadvantages of submuscular breast augmentation is the postoperative pain that patients frequently experience because of evulsions of the muscle fiber origins from the sternal and costal ribs. The blunt dissection of the pocket frequently causes microbleeding in the periosteum of the involved muscle origins.1, 2 However, if these muscle fiber attachments are released with electrocautery instead of blunt dissection, postoperative pain is reduced to almost none.

Submuscular breast augmentation with electrocautery dissection was first performed through the inframammary approach with a lighted retractor. When performing this procedure from a transaxillary approach, you have to use an endoscope. My experience with the transaxillary approach, using an endoscope, has shown that most patients experience little pain and can return to office work within a couple of days. Patients who do heavier work, including lifting, are usually advised to stay out of work for 2 weeks. Other advantages with this technique, compared with conventional blunt dissection: Intraoperative bleeding is reduced to an absolute minimum, and the pocket can be created with greater precision. Because bleeding is thought to be one of the causes of capsular contraction, electrocautery dissection should prove an advantage in this respect. But long-term follow-up is necessary to learn whether this holds true.

Increased precision, provided by this technique, in the creation of the pocket will also provide a better inframammary fold shape. In some patients, when performing a blunt submuscular dissection from the axilla, I have encountered a ligament in the inframammary fold (earlier described by Barnett³), which can be quite difficult to break. If this ligament is not broken, it usually results in a very obtuse and ill-defined inframammary fold, or ‘double bubble’ deformity. This can be avoided with electrocautery dissection and the use of an endoscope.

When one is dealing with a capsule through the axillary incision, the endoscope is the ideal instrument to use with regard to access and visibility, compared with earlier techniques involving lighted retractors and specially designed knives.⁴

Surgical technique

Place the patient in a sitting position while you mark the lateral and medial extents of the pocket, as well as the current and future inframammary folds. In most patients, I find that I lower the inframammary fold at least 2 to 4 cm. Mark the axilla incision with the patient's arms raised. I prefer to place the incision along the natural folds, 3 cm under the middle of the axilla (Figure 1). Inject the axilla incision with local anesthesia with epinephrine. I also usually inject this solution into the areas of anticipated dissection between the old and the new inframammary folds because this is the only area in which I plan to cut through the muscle. In all other areas I use the cleavage plane between the pectoralis major and minor muscles.

Start the procedure by identifying the lateral border of the pectoralis major muscle through the axillary incision. Then separate the pectoralis major from the pectoralis minor muscle. Create a small pocket with your finger, being careful to remain between the 2 muscles in the cleavage plane to avoid any bleeding. When introducing the endoscope, I stand above the patient's arm to get direct access to the pocket and to maneuver easily (Figure 2). Use the electrocautery in coagulation mode with a high-power setting; this will cut and coagulate at the same time without too much burning. In the event of a bleeder, it is practical to be able to switch from coagulation mode to spray mode.

It is important to dissect from the medial to the lateral side in wide, sweeping motions to avoid ending up with a small hole (Figures 3 and 4). In the event of bleeding, vision in a small hole is quickly obscured. While you are dissecting, it is important that your assistant follow your progress by observing the patient's skin surface to guide you as you approach your markings. When 2 cm remains to be dissected above the future inframammary fold, I usually cut through the muscle to better define the new inframammary fold. I cut through the muscle fibers, but only until I see the subcutaneous fat shining through, not more (Figure 5).

On the medial aspect of the pocket, it is possible to cut through the perforating vessels close to the sternum. It is therefore wise to slow dissection at this point to give the coagulation mode on the dissector more time to work. I enter the lateral part of the pocket under the serratus anterior and part of the fascia of the oblique external abdominal muscle. After completing the dissection in accordance with preoperative markings, I do not irrigate the pocket because it should be dry and clean. Nor do I use drains. However, I do use sizers because I find it difficult to predict the exact size of the implant that will provide the desired breast contour. Our standard implant has been silicone gel–filled, but we are now shifting to round cohesive gel implants because recent models are softer and very natural.

The following technical details are helpful:

• I have found it most convenient to have the suction connected to the electrocautery dissector to evacuate the smoke.

• To avoid a collapsed pocket resulting from suction, I insert a short plastic tube in the access incision in the axilla.

• To clear the endoscope lens without unnecessary extraction, I use a channel for irrigation with saline solution on the retractor.

I usually discharge patients after a couple of hours. As a dressing, I use a well-fitted bra and an elastic band that presses against the breasts' upper poles to keep the implants in the lower part of the pocket (Figure 6). Patients wear this band for the first week and are instructed to wear the bra, day and night, for 2 weeks. I remove the axilla stitches after 10 days (Figures 7 and 8).

Complications

When performing a submuscular dissection from the transaxillary incision, using a blunt technique, the inexperienced surgeon may find it difficult to position the pocket and the implant correctly with regard to the inframammary fold. This is because it is difficult to know whether the muscle fibers at the bottom of the pocket are truly avulsed from the ribs or merely stretched. If stretched, they may reassume tonicity later, causing the implant to sit too high. This will not be a problem when you create the pocket with electrocautery. The external mark on the patient's skin indicating the new inframammary fold is where the implant will stay; the problem of malposition no longer is an issue. The incidence of implant rippling or knuckling is the same as with all other techniques. I have seen 1 patient with pneumothorax, which I believe was caused by cauterization of a bleeding vessel with electrocautery using a pointed Bovie tip. Since then I have used only blunt tips for cutting and coagulation and have had no further problems, but one should always be aware of this risk.

Advantages of endoscopic transaxillary breast augmentation are as follows:

• After 15 years of performing transaxillary subpec-toral breast augmentation using a blunt technique for pocket dissection, it is easy for me to see the advantages of using the endoscope, through the same incision, to dissect the pocket under direct vision with electrocautery.

• It provides the ability to correct certain conditions, such as a very narrow breast base (Figure 9).

• When performing the dissection on top of the muscle and immediately behind the gland, I can cut a star-shaped incison through the gland to make it expand on top of the implant.

• In most of these patients, I can avoid inflicting any scars on the aesthetic unit of the breast.

• Patients experience less postoperative pain and return to work sooner.

• The technique facilitates a more precise designing of the pocket, making it possibile to create a better and more distinct inframammary fold.

• Bleeding during the procedure is reduced to almost none. Whether this is reflected in a lower rate of capsular contracture remains to be seen.

The disadvantages of this technique are a longer learning curve, a longer procedure (it takes me about 55 minutes instead of 30 minutes), and an investment in equipment.

References