Breast augmentation via axillary

During the last decades, axillary breast augmentation has gained wide acceptance since it allows the size of the breasts to be increased without leaving any visible scar on them. The scar is hidden in a natural wrinkle in the armpit, which makes it practically invisible over time.

The use of the endoscope allows us, under direct vision:

• Control bleeding during the intervention, reducing the possibility of hematomas, seromas and capsular contracture.
• Completely release the insertions of the pectoralis major muscle on the ribs, allowing the prosthesis to be perfectly placed in its permanent position.
• Use round or anatomical prostheses.
• Use an atraumatic dissection technique, which reduces postoperative pain.

Common questions

Is there an increased risk of infection or capsular contracture?
On the contrary, the access route with the highest risk of infection and capsular contracture is the periareolar route, since the areola and nipple area has a higher concentration of bacteria. On the contrary, the armpit and undermammary fold have similar results, since the prosthesis does not come into contact with the nipple-areola.

Does the axillary route contraindicate breastfeeding?
Absolutely. Both placement through the inframammary fold and through the axillary route have the advantage that they do not alter the morphology of the mammary gland, which is why breastfeeding is allowed.

Is it more painful?
Postoperative pain depends mainly on the plane of placement of the prosthesis (submuscular plane is more painful) and how traumatic the dissection is (that is, how fine we are making the pocket where we will place the prosthesis). Until the appearance of the endoscope as a surgical tool, the dissection performed was traumatic, since the insertions of the pectoral muscle in the ribs were released blindly, by traction of the muscle (literally tearing off the muscle). The endoscope allows you to have a direct view of the area and detach the muscle using electrocautery (cutting the insertions using a scalpel that cauterizes and cuts at the same time), just as it is done from the areola or the sulcus.

I have read that the lymphatic drainage of the breast is altered. It’s true?
Absolutely. Not only is there no scientific evidence of this, but on the contrary, many studies over the last decade show that surgery does not affect the lymph nodes in the armpit or arm. Next, we will proceed to explain it in more detail.

What is the sentinel lymph node technique? When a person is diagnosed with breast cancer, during the tumor extension study, one of the questions that the surgeon must ask himself is whether the tumor has invaded the lymph nodes in the armpit, which is where 95% of the blood drains. breast tissue. If the tumor has spread to those nodes, a lymphadenectomy (removal of those nodes) and pathological analysis (biopsy) are performed. Traditionally, this lymphadenectomy was done routinely until the sentinel lymph node technique was discovered. The sentinel lymph node is the FIRST lymph node that captures radiological contrast in the axillary lymph node chain. Traditionally, a radiological contrast is infiltrated and using a device that detects the radiation, that lymph node is located in the operating room, removed and sent for analysis. If tumor cells are observed in the biopsy of said lymph node, this would indicate that the tumor has spread to the axilla and that axillary lymphadenectomy must be performed. Otherwise, we can avoid lymphadenectomy, and therefore, its consequences (lymphedema… ).

Does axillary breast augmentation surgery affect the location of the sentinel lymph node? Like any new technique in medicine, the location of the sentinel lymph node initially generated new doubts in the scientific community. It is normal that this is the case, since it is like that, raising doubts and looking for the solution, as medicine advances. Some surgeons wondered if having previously placed a prosthesis through the axillary route could have deformed the lymphatic drainage pattern of the armpit, making it difficult to locate the sentinel lymph node in the future (the first lymph node that captures contrast in the chain) in case the woman developed in the future a breast cancer, which would mean the obligation to perform lymphadenectomies directly on patients who, having undergone axillary breast augmentation surgery, later developed breast cancer throughout their lives. In response to this question, numerous scientific studies appeared denying this theory:

1. In 2003, Dr Huang described a case of a patient who underwent armpit augmentation surgery and who, four years later, was diagnosed with breast cancer. He describes that the sentinel lymph node was located without problems, 5 cm below the axillary incision.Huang G], et al. (2003) Sentinel lymph node biopsy in the augmented breast: Role of the transaxillary subpectoral approach. Aesth Surg J 23:184-187
2. In 2004, Dr Jakub followed three cases in which the sentinel lymph node was located without problems (100% success). Jacub JW, et al. (2004) Breast cancer in patients with prior augmentation: Presentation, stage, and lymphatic mapping. Plast Reconst Surg 114:1737-1742
3. In 2006, Dr. Munhof described an experimental study in which his patients were infiltrated with Technetium 99 a week after having undergone breast augmentation surgery and how the sentinel lymph node was located without problems. Munhoz AM, et al. (2006) Subfacial transaxillary breast augmentation without endoscopic assistance: Technical aspects and outcome. Aesth Plast Surg 30:503-512
4. In 2007, Dr Prado and Dr Leniz described an experimental study on a cadaver demonstrating that the location of the sentinel lymph node is always found in the lower region of the axilla, very far from the approach area for axillary augmentation. Prado A, Leniz P. Implications of transaxillary breast augmentation, lifetime probability of developing breast cancer, and sentinel node mapping interference. Aesthetic Plast Surg. 2007 Jul-Aug;31(4):317-9.
5. In 2007, Dr Graf described the surgical technique and explained in detail the reasons why the axillary lymph node region is not affected, especially the sentinel lymph node area. Graf R, et al. Implications of transaxillary breast augmentation, lifetime probability of developing breast cancer, and sentinel node mapping interference. Aesthetic Plast Surg. 2007 Jul-Aug;31(4):322-4.
6. In 2008, Dr Graf and Dr Shado studied 40 cases of axillary breast augmentation and infiltrated periareolar Te. They evaluated lymphatic drainage before, 30 days after and 6 months after, finding no alterations.
7. In 2011, Dr Graf and collaborators described a case of accidental appearance of melanoma in the nail in a patient undergoing axillary augmentation surgery, in which the sentinel lymph node was correctly located and analyzed. Sentinel lymph node detection in a patient with subungual melanoma after transaxillary breast augmentationPlast Reconstr Surg.
8. In 2011, Dr Weck analyzed 27 patients before undergoing axillary breast augmentation surgery, after 21 days and after 6 months. Nodal chain was not affected and the lymph node was perfectly visible in all cases. Evaluation of the effects of transaxillary breast augmentation on sentinel lymph node integrity. Aesthet Surg J. 2011 May;31(4):392-400

In summary, many studies for more than a decade explain that the sentinel lymph node is located in the lower region of the armpit, while to place an implant only the upper region of the armpit is accessed. With all this information, we can affirm that to date there is enough scientific information to deny that breast augmentation surgery through the armpits in any way alters the lymph nodes of the armpit in such a way that it could pose any difficulty in the event that the patient will be diagnosed with breast cancer in the future.

Advantages

1. We did not leave any visible scar on the chest. The scar is hidden in an original wrinkle that forms in the armpit.
2. One year after surgery, even looking closely at the armpit, the scar is difficult to find.
3. The endoscopic technique does not injure the inframammary fold, for this reason it is very rare for the implant to descend (bottoming out).
4. It is an ideal technique to use smooth implants, which are currently the safest due to their zero incidence of anaplastic large cell lymphoma.
5. It does not injure the armpit nodes. Multiple studies have shown that surgery does not affect the detection of the sentinel lymph node in breast cancer.
6. It has a similar recovery in terms of pain to the submammary or periareolar technique.