Brazilian plastic surgeon shares algorithm for transaxillary approach in secondary breast augmentation.
The transaxillary approach has an important role and acceptable complication rate in secondary breast augmentation. But achieving optimal outcomes for secondary breast augmentation patients requires that surgeons grasp what can be a steep learning curve.
Plastic surgeon Alexandre Mendonça Munhoz, MD, PhD, authored a paper published November 2020 in the Aesthetic Surgery Journal assessing 62 of his patients who had secondary transaxillary approach breast augmentation in which he shares his algorithm. Dr. Munhoz, assistant professor of plastic surgery at Hospital Sírio-Libanês and chief of the Plastic Surgery Department, Hospital Moriah, São Paulo, Brazil, tells Aesthetic Authority that he has performed the axillary technique for breast augmentation since 1999.
The transaxillary approach offers secondary breast augmentation patients important aesthetic benefits in an era of scarless surgery, yet many breast surgeons are hesitant or are not skilled in its use. In those cases, surgeons do not exchange implants using the same incision, which leaves patients with a new breast scar, he says.
“This is a bad situation, losing all the benefits of the complete absence of the breast scar offered in the first breast augmentation by the axillary technique…,” Dr. Munhoz says. “At a time of great technological development with endoscopic surgery, the use of robots and less and less invasive procedures and smaller scars, the need for new scars seems even more absurd, especially in the breast region.”
More than half of the patients Dr. Munhoz described had their implants removed because of capsular contracture.
Forty-three of the patients, nearly 70%, had a previous premuscular pocket and, in 35 of those patients, the new pocket remained in the same position. Nineteen patients had a previous submuscular pocket, and 15 patients had the new pocket transferred to the premuscular plane, according to the paper.
Dr. Munhoz begins dissecting in the previous axillary incision up to the subcutaneous plane.
“At this stage, it is crucial that the dissection be more superficial and closer to the skin flap in order to avoid invading the posterior triangle of the axilla and injuring important anatomic structures within the fibrous tissue…,” he writes.
He continues the dissection to the lateral border of the pectoralis muscle.
If the patient’s implant is in the submuscular pocket, Dr. Munhoz dissects under direct view until he sees the implant’s fibrous capsule.
For patients whose implants are in the premuscular pocket, Dr. Munhoz incises the pectoralis fascia and dissects the upper-medial pole using retractors and electrocautery. He moves laterally toward the intermediate pole, to the lateral-inferior quadrants.
Dr. Munhoz lifts the existing implant and gland away from the pectoralis muscle, and sections residual fibrous attachments connecting the capsule and muscle at the inframammary fold.
“… it is important not to expand this dissection beyond the limits of the previous implant in order [to] avoid creating a large and loose [subfascial] pocket for the new implant,” he writes.
He performs a capsulotomy under direct endoscopic view in patients with Baker grade II/III capsular contracture. But if patients have Baker grade III/IV capsular contracture, Dr. Munhoz performs partial capsulectomy for submuscular pockets or possibly total capsulectomy for implants in the premuscular plane.
He expands the new pocket to house the new implant in tight compression. To avoid lateral implant displacement, Dr. Munhoz limits the lateral dissection to the anterior axillary line. In addition, it is important to create a new pocket according to the dimensions of the new implant to be inserted in order to avoid instability and displacements.
Dr. Munhoz irrigates the pocket with an antibiotic solution, then places the new implant in the new location and assesses implant position as the patient is seated at a 90-degree angle.
For patients whose premuscular pockets have inadequate soft-tissue coverage, Dr. Munhoz might use autogenous fat grafting by marking the medial/superior edge of the breast and pushing the implants medial and upward to simulate cleavage limits. He injects the fat using a 15 cm cannula, 1.9 mm to 2.1 mm in diameter, which results in the superficial spreading of the fat in the subcutaneous tissue from the upper pole toward the lateral and medial poles.
Dr. Munhoz’s technique, called Subfascial Ergonomics Axillary Hybrid, or SEAH, is indicated for primary and secondary breast augmentation by the axillary incision.
He performs a layered wound closure without suction drains but places an elastic band over the superior breast poles, which remains for four weeks.
Dr. Munhoz reported 10 minor complications in an average 72-month follow up, including capsular contracture in a patient with previous Baker III contracture, subcutaneous banding in the axilla, seroma, minor wound dehiscence and hypertrophic scar at the axilla incision, malposition, and hematoma.
Fifty-nine patients, which was more than 95% of patients studied, were very satisfied or satisfied with their aesthetic results, according to the paper.
The best candidates for transaxillary secondary breast augmentation are patients with previous transaxillary breast augmentation, no ptosis, or ptosis grade I or II, according to Dr. Munhoz.
“Patients with breast ptosis, grade III to IV, and with severe areola asymmetry are not good candidates and maybe the new incision (areola, or even mastopexy) may be more advantageous than the axillary,” he says.