Endoscopic Trans-Axillary Breast Augmentation: 28 Years’ Experience.
Breast augmentation is one of the most commonly performed aesthetic procedures in women in the United States and globally. Previously, many surgeons have preferred the inframammary over the transaxillary approach to this procedure secondary to the advantage of direct visualization and improved pocket control intraoperatively. In addition, the blind technique, which characterized early transaxillary breast augmentation was thought to be associated with higher complication rates, less satisfactory outcomes, and higher risk to the patient. However, the use of the endoscope with electrocautery has allowed for excellent visualization, a bloodless pocket dissection, and superb technical control by the performing surgeon, allowing for precise implant placement and predictable postoperative results. Furthermore, transaxillary endoscopic breast augmentation (TEBA) allows for the avoidance of a visible postoperative scar, an important consideration as the demand for minimally invasive interventions continues to increase. In this study, the authors review the lead surgeon’s technique with TEBA, routine postoperative protocol, results, and complication management from this extensive experience.
Methods/Technique:
A retrospective chart review was performed to evaluate the long-term outcomes of transaxillary endoscopic breast augmentation of a single surgeon over a 28-year period. The lead author performs TEBA under endoscopic visualization using a 4mm, 30-degree endoscope. Implants are placed in a sub-pectoral plane following release of the inferomedial and inferior pectoralis major insertions. All patients are given implant displacement exercises as well as upper extremity range of motion instructions, beginning postoperative day one. A methylprednisolone 5-day taper is prescribed for all patients at three weeks postoperatively. Patients are monitored closely for development of axillary banding or early evidence of capsular contracture and are treated aggressively with capsule softening maneuvers or kenalog injection, when appropriate. Data from the last 10 years of the lead surgeon’s practice is presented in this study.
Results/Complications:
178 women underwent TEBA from 2010–2020. Average age at the time of primary breast augmentation was 34 years old (range 18–69). Average follow up time was 4.8 years (range 0.25–21 years). 97 (54.5%) patients received silicone implants, and 81 (45.5%) patients received saline implants with an average implant volume of 361cc (range 175–550cc). 41 patients (23%) required kenalog injection for postoperative axillary banding. 12 patients (6.7%) developed capsular contracture (Baker grades II-III). Of these patients, 2/12 had saline implants, 10/12 had silicone implants, and 58.3% had axillary banding requiring kenalog injection on the ipsilateral side of the capsular contracture. 7 (58.3%) patients with capsular contracture required operative intervention, whereas the remainder responded to conservative management. Of the 7 patients requiring operative intervention for capsular contracture, 5 were able to be managed with a repeat transaxillary endoscopic approach. 1 patient developed a hematoma on postoperative day 0, and one patient required explant with delayed implant replacement secondary to infection. 19 patients (10.7%) underwent reoperation for alternative indications with the most common being implant rupture, age-associated and postpartum development of ptosis, and desire for change in implant size.
Conclusion:
Experience gained from the lead author demonstrates that TEBA is both a safe and effective technique for achieving predictably excellent, long-term, postoperative results. While the initial use of the endoscope does involve a learning curve, the trained surgeon can safely perform both primary and revision breast augmentation procedures with low complication rates, all while avoiding a visible scar on the breast.