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U.S. Perspective on Transaxillary Breast Aug Reop


U.S. Surgeons weigh in on the Subfascial Ergonomics Axillary Hybrid approach to secondary breast augmentation using an axillary incision.

This is part 2 in a 2-part series.

Part 1: Transaxillary Technique for Secondary Breast Augmentation

Dr. Munhoz demonstrates that with patience, dedication, and proper surgical planning it is possible to perform secondary breast augmentation and revision surgery through the transaxillary approach, according to Jacob Haiavy, MD, past president of American Board of Cosmetic Surgery.

But there are notable differences in how Dr. Munhoz and many U.S. surgeons approach secondary breast augmentation and revision surgery through the transaxillary approach.

“The majority of the implants were placed in the premuscular plane, which I think is different than what North American surgeons do,” says Dr. Haiavy, who practices in Rancho Cucamonga, Calif. “There is no question that this requires comfort with use of endoscopic instruments, use of specialized instruments and a steep learning curve. It is also interesting to note that he employed autologous fat grating to improve contours when tissue thickness over the implant was inadequate in the premuscular pocket.”

In general, Dr. Haiavy says he agrees with Dr. Munhoz’s treatment algorithm.

“There are limitations to this technique, as I think that for patients that have severe capsular contracture and need full capsulectomy, it would be difficult to perform especially in the submuscular plane,” Dr. Haiavy says.

Still, the article demonstrates that with proper planning and technique revision surgery is possible with low complications rates.

“Unfortunately, surgeons that do not perform this technique tend to criticize it,” Dr. Haiavy says. “In my practice I perform both transaxillary and trans-umbilical methods of breast augmentation for patients that do not desire to have any scars on their breasts. Again, with proper planning and technique the results are excellent with a high satisfaction rate and low incidence of complications.”

Michael S. Kluska, D.O., past president of the American Academy of Cosmetic Surgery, says he has been performing transaxillary augmentation since 1997.

“There is a long learning curve but once you get it and understand what is going on, it is really versatile and easy to use,” says Dr. Kluska, who practices in Chattanooga, Tenn.

Many surgeons are hesitant to do this in secondary breast augmentation because they have limited visualization and access. And if they run into potential problems, such a ruptured blood vessel, it can be difficult to stop the bleeding for those not familiar with the anatomy or use of an endoscope. Another potential roadblock is that it can be difficult to remove a silicone implant.

“The whole idea behind the transaxillary approach is to have an invisible or shortened scar in the axillary hair line. To remove an implant, for example, really you need an incision of at least 4 cm to get hold of the implant and pull it out. A ruptured silicone implant become extremely difficult from that position,” he says. “On the contrary, a ruptured saline implant is no big deal. It’s ruptured, you go in, grab it, and pull it out. If you want to remove an intact saline implant, all you do is rupture it and pull it out.”

Dr. Kluska recommends, whenever possible, placing implants during the transaxillary approach in a total submuscular pocket. That includes pectoralis major, anterior rectus, serratus anterior and external oblique muscles.

“Most surgeons are taught to put their implants in a subpectoral pocket, which is not always complete submuscular but partially submuscular,” Dr. Kluska says. “In doing that, what happens is implants tend to move down and out in the transaxillary approach because surgeons do not release enough appropriate muscle fragments to prevent lateral migration.”

Any surgeon performing the transaxillary approach needs to know the anatomy and gain experience by starting to use it in primary augmentation with saline implants.

“Once the surgeon gets comfortable with that, then that surgeon can move onto placement of silicone implants,” Dr. Kluska says. “I would suggest always using, with any implants, a Keller Funnel (Allergan) because the Keller Funnel gives you a touchless technique. One of the higher potential risks and complications with the transaxillary breast augmentation is that you can theoretically drag bacteria in from the armpit when you’re pushing the implant in through a very small incision.”


Munhoz AM. Reoperative Transaxillary Approach Algorithm: Extending the Surgical Alternatives for Secondary Breast Augmentation in the Era of Scarless Surgery. Aesthetic Surgery Journal. 2020;40(11): 1179–1192.

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