eMedicine Specialties > Plastic Surgery > Breast

Breast Augmentation, Endoscopic-Assisted

Author: Michael R Davis, MD, Major, Medical Corps, Staff Physician, Plastic and Reconstructive Surgeon, United States Air Force
Coauthor(s): Laurence Z Rosenberg, MD, Southeastern Plastic Surgery; James Neal Long, MD, Assistant Professor of Plastic and Reconstructive Surgery, Division of Plastic Surgery, University of Alabama at Birmingham and Kirklin Clinics
Contributor Information and Disclosures

Updated: May 7, 2009

Introduction

A dominant trend seen in all branches of surgery is the idea of minimal incisional access to achieve the desired surgical outcome while limiting surgical consequences and facilitating faster patient recoveries. Plastic surgeons have concerned themselves with this issue over a longer time period than have other surgical disciplines. The intent has been to maximize cosmetic benefits for patients through limiting and camouflaging scars. 

In breast augmentation, one method of achieving this goal is through the remote placement of access incisions, as exemplified by the transaxillary endoscopic augmentation mammaplasty and transumbilical endoscopic augmentation (TUBA) mammaplasty procedures. With these procedures, the incisions are hidden in the first axillary crease and the navel, respectively, making the resulting scars very difficult to see. For this reason, these approaches are favored by many patients and surgeons alike.

Instruments using fiberoptics and endoscopic remote manipulation, combined with advances in technique, have resulted in consistently good results in the hands of appropriately trained surgeons. Reticulating endoscopes and high-definition cameras offer new visualization capabilities. These advances continue to bolster enthusiasm for these endoscopic approaches.

History of the Procedure

Transaxillary endoscopic augmentation mammaplasty

The transaxillary approach to breast augmentation was described by Troques in 1972 and Hoehler in 1973.^1,2 Besides the obvious advantage of the hidden incision, this approach facilitated direct access to the subpectoral plane. With this technique, the inframammary crease was altered and the origin of the pectoralis muscle was dissected blindly, accounting for a significantly higher incidence of implant malposition. The limited exposure of the blind technique did not allow complete division of the prepectoral fascia, resulting in the tendency of high-riding implants or the double-bubble appearance of the inframammary crease.

The advent of endoscopic plastic surgery in the 1990s allowed the application of the endoscope to breast surgery. The Emory group reported their experience with endoscopic breast augmentation through an axillary incision in 1993 using a specialized retractor and an air-filled optical cavity.3 Ho reported a technique that used glycine irrigation to create a liquid-filled optical cavity, although he now also uses a specialized retractor and an air-filled optical cavity.4 The increased control resulting from direct visualization of the dissection obviated many of the previous downfalls of the blind axillary approach. Howard demonstrated the benefits of the endoscope with the axillary approach by decreasing the incidence of implant malposition from 8.6% to 2% when the endoscope was used.5

Endoscopic transaxillary augmentation mammaplasty is now a widely used technique and has withstood the test of time. However, the learning curve is significant, and more straightforward cases should be considered during the initial experience. The axillary approach has limited application in secondary cases.

Transumbilical endoscopic augmentation mammaplasty (TUBA)

The transumbilical approach was first implemented in 1991 by Johnson and Christ and described in detail in 1993.6 The technique is unique as it does not employ a local or regional incision but rather uses a remote incision in the umbilicus. The TUBA endured significant early criticism but has gained popularity as it has been shown to be safe and reliable. Though TUBA is technically more challenging, a growing number of plastic surgeons are gaining expertise with this procedure. A primary criticism has been a lack of control of the operative site, especially with regard to bleeding and plane of dissection. With improved instrumentation and a general improvement in endoscopic skills, these criticisms have been proven invalid. The original study by Johnson reported a lower complication rate with less bleeding than other methods.⁶

Presentation

The importance of the initial consultation cannot be overemphasized. Discuss the four possible access incisions with the patient. Present the periareolar, inframammary crease, axillary, and umbilical incisions in a nonbiased manner, and assess the patient's enthusiasm for the axillary or umbilical incision. Discuss the potential complications of breast augmentation, emphasizing those complications unique to the endoscopic approaches. Discuss implant malposition, axillary hematoma, and lymphadenopathy. Finally, discuss the possible need for an additional inframammary crease incision to treat some complications with both approaches. All of the potential complications of breast augmentation must be discussed, including loss of nipple sensation, bleeding, infection, capsular contracture, asymmetry, unsatisfactory result, need for revisionary surgery, and so on.

Perform a physical examination. Describe the location of the proposed incision, and draw the position and size of the incision with a surgical marker. Pay particular attention to the distance from the areola to the inframammary crease and the transverse diameter of the breast. Assess the transverse diameter of the breast, and select implant size and direct fold adjustment. The need to lower the inframammary fold 1-2 cm is common; however, more than 3 cm should alert the physician to the presence of a constricted lower pole and the need for parenchyma alteration, which can be more straightforward with another approach. The ideal patient has a distance of 5-6 cm from the areola to the inframammary crease and, therefore, requires less inferior dissection.

Indications

Indications for endoscopic breast augmentation include the patient's desire for a remote incision and the absence of a well-developed inframammary crease to hide a crease incision below the horizontal visual axis.

Contraindications

Constricted lower pole

A constricted lower pole with a short distance from the inframammary crease to the areola is significantly more difficult and can require radial scoring of the breast parenchyma. The potential exists for inferior implant displacement from overdissection (lowering) of the inframammary crease and superior implant displacement from underdissection of the inframammary crease. In experienced hands, the transaxillary and umbilical approaches can be used for this type of anatomy.

Tubular breast

The need for correction of the herniated areola and the scoring of the constricted lower-pole parenchyma makes the periareolar access incision ideal for tubular breast deformity.

Ptosis

Endoscopic breast augmentation is possible to perform in pseudoptosis and grade 1 ptosis, but this anatomy requires the lowering of the inframammary crease to the base of the vertical descent of the breast. Ptosis is not considered ideal for the inexperienced surgeon and is subject to concerns of overdissection and underdissection of the inframammary crease.

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