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Breast Augmentation using Shaped Implants: Endoscopic Transaxillary or Inframammary Approaches?

Patients who undergo augmentation mammoplasty may have naturally small breasts, loss of breast volume after breastfeeding, or other congenital reasons such as pectus excavatum, pectus carinatum, and Poland syndrome. Breast augmentation is the most common aesthetic procedure in the USA and the fastest growing surgery in Asia. Many factors should be considered before augmentation mammoplasty for maximal satisfaction. Ideally, surgeons should decide on the surgical procedure, implant type and size, incision line, plane of dissection, and level of dual plane (in case of a subpectoral dissection) according to the patients’ physical profile and demand, following a thorough consultation with the patient.


While the inframammary incision is the most popular implant incision site in the Western world, the transaxillary incision using an endoscope is commonly used in the Asian population, as they are prone to hypertrophic and prolonged hyperemic scarring of the inframammary scar. Although the inframammary approach provides for easier manipulation of implants because of wider visual fields, the incision scar is more noticeable than an axillary scar, especially in Asians with thicker skin. In a more conservative environment such as Asia, even a well-managed inframammary scar may be of great concern; thus, the transaxillary approach is relatively popular in this region.


Standard Surgical Procedure using Shaped Implants

The standard surgical procedure for augmentation mammoplasty using a shaped implant has been through the inframammary approach. This is in part due to the common myth that an anatomically shaped implant is difficult to insert through a transaxillary incision. Since anatomically shaped gel implants were first approved by the Korean Food and Drug Administration in 2012, there were early concerns regarding the use of shaped implants through the transaxillary approach, in terms of malposition or rotation of the implant having a larger pocket than in the inframammary approach. However, studies have reported satisfactory results in a large case study.


In a matched case-control study conducted by Dr. Dong Won Lee, Dr. Jung Kim, and Dr. Hanjo Kim, they have used anatomical implants inserted through either the endoscopic transaxillary approach or the inframammary fold approach, evaluated the outcomes following augmentation mammoplasty by a single plastic surgeon, and compared the results of the inframammary and axillary approaches in terms of complications.


Surgical Methodology

The implants used in this study were textured, anatomically shaped, form-stable gel from Allergan. The average implant size was 314 cc (range, 210–535 cc). Implant size was selected based on skin laxity, breast shape, and patients’ preferences. The inframammary fold incision was used in the majority of patients (n = 195), followed by endoscopic transaxillary incision (n = 169). All the breast implants of enrolled patients were placed in the subpectoral pocket.


Under general or sedative anesthesia using propofol infusion, augmentation mammoplasty was performed via the endoscopic transaxillary or inframammary fold approach by a single surgeon. Regardless of incision type, the incision line was designed with a marking pen, and local anesthetic with 1% lidocaine mixed with 1:100,000 epinephrine solution was injected along the incision line, as well as the location of the lateral thoracic nerves. The distal nerve block of the lateral thoracic nerves allows the anesthesiologist to use a lower dosage of inhalation anesthetics or intravenous anesthetics. Through the incision, dissection was performed and the pectoralis major muscle was exposed. A subpectoral pocket was made depending on each incision. Pocket irrigation with antibiotics mixed in saline solution was performed. Negative drains were not inserted in any of the cases. The incision was repaired with #4-0 vicryl and #5-0 polydioxanone (PDS) sutures for the axillary incision and #2-0 and #5-0 PDS sutures for the inframammary incision. The skin was approximated in a subcuticular manner with histoacryl glue. The 14-point plan (except criteria 2, that is ‘avoid periareolar/transaxillary incisions’ in the case of endoscopic transaxillary approach) was used to minimize postoperative capsular contracture.


Postoperatove Care and Evaluation

Postoperatively, patients were instructed to wear a specially designed surgical brassier to maintain the breast in the adequate pocket with appropriate axis and to prevent rotation of the implant and hematoma formation. All patients received a prescription for oral first-generation cephalosporin. Patients were advised to rest and avoid raising their arms.


For evaluation of the surgical outcome, preoperative and postoperative digital photographs of patients’ breasts were taken in the frontal, semiprofile, and bilateral profile views, with the distance between the patient and the photographer consistent. Complications were observed at the outpatient clinic by the operating surgeon during the follow-up period. The rotation axis of shaped implant was evaluated by ultrasonography based on dots in the lower anterior part at the 1-year postsurgery follow-up. Malrotation was defined as implant rotation of more than 10 degrees on ultrasonographic evaluation.


A total of 364 patients (728 implants) were included in this study, with a mean age of 34.2 (± 7.71) years. The mean follow-up period was 26.5 (± 7.32) months.


See below the study's Patient Demographics:

During the follow-up period, possible complications due to augmentation mammoplasty included capsular contracture, hematoma, wound problem that required a surgical revision, implant malrotation, infection, and chronic seroma. The overall complication rate was 2.2% (16 cases of 728 implants); the complication rate was 2.7% in the transaxillary group and 1.8% in the inframammary group. There was no significant difference in the comparison between the two groups in terms of surgical complications (p = 0.593). Capsular contracture rates were 1.8% and 1.0% in the transaxillary group and inframammary group, respectively, with no significant difference (p = 0.386). Other complications also exhibited no significant differences between the two groups. Implant malrotation occurred in just one case (0.3%) in the transaxillary group. The patient complained of unnatural appearance of the breast, and malrotation was confirmed upon ultrasonographic evaluation (rotated by an angle of 30 degrees). The malrotation was corrected by changing the shaped implant to a smooth round implant bilaterally.


See below the complications after endoscopic transaxillary and inframammary approaches for breast augmentation:





Endoscopic Transaxillary or Inframammary Approaches?


Common incision sites for breast augmentation, in the order of popularity, are the inframammary, periareolar, axillary, and periumbilical approach. In the authors’ view, the capsular contracture rate through a periareolar incision would increase in a fairly high-risk surgery, with a continued risk of subclinical infection that may lead to delayed formation of capsular contracture. The periareolar incision may cut through large ducts; this can lead to potential bacterial colonization due to the increase in chance of contracting large amounts of bacteria resident in the ducts. In a meta-analysis with a random effect model, a study reported a higher rate of capsular contracture in the periareolar group than in the non-periareolar group (7.2% vs. 3.1%, p = 0.03). It is technically very difficult to insert an anatomical implant through a periumbilical incision due to a high risk of implant gel fracture during insertion.


See below the common incision sites for breast augmentation:




Previous transaxillary approach methods included blind surgery, where an exact dual plane dissection was not possible with blunt instruments. However, with advances in medicine, endoscopes are now used with the axillary approach; therefore, it should be considered from a different perspective than the previously blind approach. A study reported a capsular contracture rate of 2.6% in a series of 116 patients which is far less than previous reports. It is true that the endoscopic transaxillary approach has a steeper learning curve than the inframammary approach in which surgery is performed under direct vision of the surgical field. However, with experience, the capsular contracture rate may be similar to that of the inframammary approach. As described, these techniques enable the surgeon to minimize tissue trauma. during the endoscopic transaxillary approach for a lower capsular contracture rate. If conducted correctly, capsular contracture is not a problem.


Furthermore, there are prominent cautions with the inframammary approach. The inframammary incision is made in a dependent position; therefore, precise design of the new inframammary fold and accurate wound repair are essential for satisfactory results. Otherwise, it may lead to inappropriate location of the new inframammary fold, hypertrophic scars, and problems with the wound, eventually producing aesthetically poor results. The axilla incision has relatively less postoperative wound problems, because the incisional wound is distant from the implant pocket and is independent of the gravity of an implant. In the current study, none of the patients in the axillary group sustained major wound problems. When other complications such as hematoma, seroma, bottoming out, double bubble deformity, and/or capsular contracture occur, the correction of each approach may be a little different. In practice, the inframammary approach allows a wider visual field than the axillary approach, thus allowing for easier correction of complications. In the setting of reoperation on a previously axillary-approached patient, many surgeons would recommend an additional incision on the inframammary fold to manage the complications. However, experienced surgeons could address the above complications without adding an inframammary fold incision. We believe that the endoscopic transaxillary approach is a good alternative to the inframammary incision. In addition, a patient’s scar location preference should be considered for maximum satisfaction.


Conclusion

When a patient decides to undergo breast surgery, the patient has to make several decisions. The three most important decisions are the selection of the implant shape (round or shaped), size, and the approach through which the implant is to be inserted. These may depend on multiple factors such as the patient’s age, cultural background, and the weather conditions of where she may reside. Although breast augmentation is one of the most popular procedures in the field of plastic surgery with the highest satisfaction rate, patient satisfaction may be affected by unexpected circumstances such as hypertrophic scar or keloid of the incision site. To maximize patient satisfaction, it is important to consider the lifestyle of the patient to determine the type and size of implant to use, as well as the most appropriate incision location.


This study demonstrates that the endoscopic transaxillary approach is not inferior to the inframammary approach when shaped implants are used in augmentation mammoplasty. It is known that the transaxillary incision is more likely to result in malrotation of the implant. However, in this study, the transaxillary approach was associated with fewer complications; in fact, the observed complication rate was low. We conclude that it is a good alternative when using anatomically shaped implants in augmentation mammoplasty, especially for women who wish to avoid a visible scar on their chest.


Reference

Endoscopic Transaxillary Versus Inframammary Approaches for Breast Augmentation Using Shaped Implants: A Matched Case–Control Study (2019)

Current trends in breast augmentation: an international analysis (2018)

Comparison of breast augmentation incisions and common complications (2012)

Asian breast augmentation: a systematic review (2015)

 

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