Technique and incisions ease challenge of breast augmentation with lar

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When gel implants returned, one of the big concerns was keeping the implant intact.
Though silicone implants tend to be lighter than saline, they do not settle into the pocket as quickly as saline.

Dr. Kluska

GREENSBURG, PA. & BIRMINGHAM, ALA. The return of silicone gel breast implants to the market presented a tough new challenge for surgeons who were fans of the transaxillary breast augmentation approach — specifically, now how to get the larger implant through a small axillary incision? While there are caveats — and concerns — surrounding the technique, there are strong supporters who say obstacles can be overcome and the payoff is the ability to provide patients with a highly satisfying breast augmentation and well-hidden scars.

(Far left) 38-year-old female patient before and after (near left) transaxillary placement of 460cc moderate profile silicone gel implants in the total submuscular plane. (Near right) 32-year-old female patient before and after (far right) placement of 550cc smooth round moderate profile saline implants in the total submuscular plane via the transaxillary approach. (All photos credit: Michael Kluska, D.O.)

"You're able to create this nice breast mound, and to put a scar on the breast itself, either on the nipple or in the inframammary fold, is simply not what the plastic surgeon should be doing," states Michael Kluska, D.O., a board-certified plastic surgeon in private practice based in Greensburg, Pa. "The surgeon should be trying to hide the scars as much as possible, and the most convenient place is the armpit."

Dr. Core

PLACEMENT POINTERS When it comes to the challenge of placing large silicone gel implants through axillary incisions, concerns range from the potential for too much dissection laterally, which could cause the implant to slide under the arm upon reclining, to potential problems with sentinel node mapping. Dr. Kluska believes that avoiding such problems begins with selecting the appropriate candidates, including patients who have no sagging and relatively reasonable expectations for size following augmentation. For a silicone gel implant, the incision should be at least 5.5 cm in length, but Dr. Kluska says there are creative incision techniques that allow for more flexibility in fitting the implant in, including a curvilinear-shaped incision. "You can create what we call a hockey-stick type of incision — a curvilinear incision — that allows the skin to expand to be larger than the length of the incision once it's cut." Once the incision is made, surgeons often make the dissection into the subcutaneous space in a conical fashion, with the dissection into the pocket becoming narrower, but Dr. Kluska says that approach can cause problems. "I try to reverse this shape and dissect in a reverse cone shape, creating more diameter to the dissection once beyond the skin edges," he says. "This, ultimately, creates more space for the implant to slide through the subcutaneous space 'tunnel' into the submuscular pocket." Dr. Kluska says the advantage of a completely submuscular pocket, as opposed to subpectoral pocket, is that it allows the implant to sit beneath the pectoralis major muscle and serratus anterior muscles, as well as under the upper part of the abdominal musculature. "It's a completely submuscular implant that has more longevity, maintains a better look, has less capsular contracture and withstands the test of time." Grady Core, M.D., a Birmingham, Ala.-based board-certified plastic surgeon, says he's preferred the transaxillary augmentation approach with endoscopic assistance for 16 years with saline implants, and when gel implants returned, one of the big concerns was keeping the implant intact. "We were doing 98 percent of our saline augmentations endoscopically, and when the new generation gel implants came back, we were concerned about the cohesiveness, and if there would be any problem with gel fracture or deformity," says Dr. Core, who teaches the transaxillary technique yearly at the American Society of Aesthetic Plastic Surgery annual meeting. "We didn't want to deform the implant in putting it through the incision, and the issue was, how could we get the implant through the [axillary] incision without damaging the implant?" he relates. "But we found that, with a smaller implant and a low profile, it's actually pretty easy."

TECHNIQUE NUANCES Like Dr. Kluska, Dr. Core devised creatively-shaped incisions to fit the implant into the pocket. "Instead of a 2.5-cm incision, I've used a Z-type or T-type incision to open the axillary so we can pass the implant though a larger passageway," Dr. Core says. He says the techniques work for silicone gel implants up to 300cc, and while some may try larger implants with transaxillary incisions, 300cc is as high as he will go.

"When you get to implants over 300cc, it becomes more difficult and you can potentially encounter damage to the implant," he says. "You could go up to 400cc, but I wouldn't recommend implants any larger than that in a transaxillary route."

Dr. Kluska, on the other hand, has used implants via the transaxillary approach as large as 700cc, noting, however, that most patients do not go that large and that the average is in the 330cc to 600cc range. Dr. Core recommends using a small retractor, instead of the standard size, in working with the incision to place the implant: "You would think it would help to put the retractors in and pull firmly to open the incision as wide as possible in all directions, but actually that works against you with a larger implant," he explains. "If you use a standard retractor and pull to try to get the incision apart, it actually closes the incision almost in a valve-like fashion and makes it more difficult to put the implant in. So, with a large implant, you want instead to use a very small retractor and lift up and retract outward to get the implant started in the passageway," Dr. Core continues. "Then you use sort of a gentle circumferential compression to extrude the implant through the incision and into the submuscular pocket."

RELATED RISKS Dr. Core notes that since the silicone implants tend to be lighter than saline, they do not settle into the pocket as quickly. Unless good superior pole compression is used post-operatively, the implant can remain higher up while the lower part of the pocket closes, causing an asymmetry and requiring reoperation. Regarding concerns about transaxillary breast implantation causing trauma to the armpit or problems with sentinel node mapping, he says he has not seen convincing evidence of a risk with the smaller incisions. "As far as trauma to the armpit, we know from our saline implant experience that that is not an issue because the passageway is so small, you literally can pass the instruments and scope through what amounts to a very small tunnel that spreads the local tissue and does not disturb the lymphatics," he says. "No one has done a definitive study on whether you can do sentinel node mapping routinely on people who have had endoscopic breast augmentation, but I have had patients who had sentinel node mapping who had endoscopic saline breast augmentation and there were no problems." One issue that does concern him is seromas. Dr. Core says that in more than 1,000 cases of saline implants, he never had a single case of an axillary seroma, but with far fewer transaxillary silicone gel implantations, he has had three cases. "We've had three seromas and one dehiscience with exposure of the pocket requiring explantation in a relatively small number of transaxillary gel implant cases of about 50, compared to no extrusions and no seromas in more than a thousand cases over 16 years with saline," he reports.

"I think this could be because there is more dissection and destruction of the local lymphatic tissue to make room for the passage of the gel implant, so it is a completely different situation than with saline endoscopic augmentation," Dr. Core says. To prevent such problems, he suggests making the incision lower in the axilla in order to avoid as much lymphatic tissue as possible. He also notes that there appears to be a decrease in the seroma rate after increasing the length of time he has the patient wear a compression strap across the upper chest and under the arms, which is used to accelerate closure of the passageway through which the implants were placed. However, he is still watching the issue closely. "If I continue to see a higher rate of seroma or other problems, I will reconsider the use of this approach for placement of gel implants."

VIVE LA DIFFéRENCE For his part, Dr. Kluska says, "I have not experienced any seroma or hematoma and I attribute this to the specific technique that I use via the transaxillary approach. Using the balloon expander allows for auto-dissection and minimal to no trauma to the tissues. This translates into less injury which equals less inflammation and swelling and therefore less seroma. Just because you go through the armpit does not mean that everything is the same. There're so many nuances that separate one surgeon from the next."

DISCLOSURES
Drs. Kluska and Core have no relevant financial disclosures.

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Technique and incisions ease challenge of breast augmentation with large gel implants

Article-Technique and incisions ease challenge of breast augmentation with large gel implants

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