The Axillary Approach

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There is no such thing as the perfect breast-augmentation technique, so opinions differ (and debates are heated) among plastic surgeons about the best way to perform this procedure. We believe that transaxillary submuscular breast augmentation, performed using saline implants and a blind dissection technique without endoscopy, is a simple procedure associated with a high level of satisfaction and a low rate of complications.

The literature compares various techniques for breast-implant placement in the submuscular or subglandular planes; the use of silicone or saline implants; and transaxillary, transumbilical, inframammary, or periareolar incisions. Within each technique, there are myriad nuances and variations among surgeons, who must choose an operation that works well in their hands, makes the patient happy, and has a relatively low complication rate.

Initial Consultation

It is important for the patient to understand what breast augmentation will accomplish for her. Limitations, risks, benefits, and postoperative expectations should be discussed in detail. Since the patient will have a long-term prosthesis, it is of paramount importance to discuss long-term consequences.

The main indications for breast augmentation are hypomastia and breast asymmetry. The decision to have breast augmentation should be explored in the initial consultation. The patient’s answer to, “Why do you want to have breast augmentation?” can be very telling. Reasons stated by women seeking breast augmentation have varied tremendously.

Typically, a woman who is having the procedure to enhance her own self-image (without concern for external forces) will have the highest likelihood of success and happiness with the operation. Furthermore, she will be in the best position to handle a complication appropriately, should there be one.

During the initial consultation, the patient is asked to place silicone breast implants of a known size in her bra and to wear a shirt that reveals her silhouette clearly. The patient tries on implants of different sizes until she finds the size that she likes.

We offer our patients the option of trying on various sizes again on the second consultation. Usually, they choose either the same size or a size similar to the one chosen at the initial consultation. We encourage patients to choose implant sizes within the range of 150 to 400 mL, with exceptions for certain situations.

Preoperative Workup

The patient should obtain routine medical clearance, along with psychiatric clearance (if needed). Medications that can interfere with a good outcome, such as those that increase the likelihood of bleeding, should be discontinued before surgery. A pregnancy test should be ordered preoperatively for a woman in her childbearing years.

A complete blood count and international normalized ratio will provide a general idea of the patient’s hematological state. Urinalysis is also important, since ongoing infection may warrant treatment before prosthesis insertion.

A mammogram should be obtained by a woman whose level of risk of breast cancer is considered high, based on the recommendations of the American Cancer Society. To improve the surgical outcome, the patient should stop smoking for at least 2 weeks before and after the operation.

Two specific circumstances call for additional steps. If a woman seeking breast augmentation is planning to become pregnant shortly after the procedure, she should understand that pregnancy can create changes in breast shape and size. There is a small chance that a breast-augmentation operation will have complications that could render a woman unable to breast-feed.