Breast Augmentation: The Axillary Approach

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28.1 Introduction
Breast augmentation has become a very popular procedure with a variety of techniques with which it is performed. The literature describes the evolution of various techniques of breast implant placement in the submuscular versus the subglandular plane; silicone versus saline implants; and transaxillary versus transumbilical, inframammary, or periareolar placement of the inci­sion [1-3]. Within each technique itself is a myriad of nuances and variations among surgeons. As with everything in cosmetic surgery, a surgeon has to choose an operation that works well in his or her hands, makes the patient happy, and has a relatively low complication rate. There is no such thing as the perfect breast augmentation technique; thus, opinions differ, and debates are heated among plastic surgeons as to the best way to perform a breast augmentation. The author believes that the transaxillary breast augmentation with saline implants via a blind dissection technique—i.e., without an endoscope—is a simple procedure with a high level of satisfaction and a low rate of complications. This chapter will focus on this particular procedure and how the surgeon can avoid pitfalls.

Initial Consultation
An initial consultation is set up to discuss the breast augmentation procedure and to decide whether the prospective patient is a good candidate for the surgery. The medical history is reviewed, a physical exam is performed, and the patient is asked to get medical clearance from her own physician as well as basic labs to ensure that she will undergo the procedure safely. The patient has the opportunity to discuss the procedure with an experienced nurse and the plastic surgeon who will perform the procedure, and she is given the opportunity to talk to patients who have had the same procedure performed by the same surgeon.
It is important for a patient to understand what a breast augmentation will accomplish for her. Limitations, risks, benefits, and postoperative expectations should be discussed in detail. Because a patient will have a long-term prosthesis in her breast, it is even more important to discuss long-term consequences.
In the initial consult, the patient is asked to place known-size silicone breast implants in her bra and wear a shirt that will reveal her silhouette clearly. The patient tries on different sizes of implants until she finds the size she likes. Patients are offered the option to try sizes again on their second consultation. Usually they pick either the same size or a very close size to the one chosen at the initial consultation. Patients are encouraged to choose implants in the range of 150-400 ml, with exceptions in certain situations.

Silicone or Saline Breast Implants
The choice of implant type affects the type of surgery to be performed. It is difficult to perform a silicone breast augmentation through an axillary approach. The incision has to be 5 cm with a silicone implant [4] instead of 2 cm with a saline implant. The technique discussed in this chapter is limited to saline implants inserted through an axillary incision.

Silicone implants are advantageous in certain situa­tions. They feel more natural than saline implants when a woman has had many breast procedures and has very little breast tissue or muscle remaining in the breast. Silicone implants may also be preferable when a woman is very thin, in which case the silicone implants may feel more natural. In these two situations, the patients are offered silicone breast augmentations.

If a woman’s breasts are a small B-cup or bigger and the saline implants are submuscular, the feel ot the breast is very natural, so the argument that “silicone implants feel more natural” is not a valid reason to have silicone implants.