Incision Indecision - Axillary Incision

The axillary incision

Placed in the deepest area of the armpit, the axillary incision is probably the least conspicuous of all augmentation incisions. Proper incision placement is critical. If placed in the highest portion of the armpit hollow, the scar is unnoticeable in virtually any body position. Even with arms fully raised, and even before the scar fades, losing its pink color, the incision looks like a normal crease. Once the scar is mature, it is almost impossible to detect in most patients, even with the arms raised. Another stated advantage of the axillary approach is better preservation of sensation in the breast. Actually, sensory preservation is quite variable and is more likely related to the type of dissection

performed and the size of the implant.

The greatest advantage of an incision in the armpit is that its location makes it the least visible of all scars for breast augmentation.

The greatest trade-offs of axillary incisions are that a surgeon must be experienced, the operation time is usually slightly longer if the surgeon uses state-of-theart techniques, and the patient must tolerate more potential nuisances in the armpit and upper arm areas postoperatively.

With older axillary techniques, after making the incision in the armpit, the surgeon used various types of blunt instruments to "blindly" create a pocket for the implant. The development of an instrument called an endoscope (Figure 6-14) allows surgeons to see inside the body on a television screen to more precisely control the operation.

With the advent of modern endoscopic instrumentation, surgeons can see to precisely create the pocket for the implant instead of bluntly, blindly tearing tissues. This minimizes bleeding, maximizes accuracy, and shortens recovery. The longer operation time required for endoscopically assisted axillary augmentation is more than compensated by increased accuracy and control. A slightly longer operating time can mean more costs but should not increase any risks associated with the operation. Ask your surgeon.

The axillary approach using endoscopic instrumentation is technically more demanding of the surgeon compared to periareolar and inframammary approaches and is difficult for some surgeons to learn. If you are considering an axillary approach, be sure that your surgeon is experienced in endoscopic techniques and that the surgeon minimizes blunt, blind dissection.

The axillary approach traverses more normal tissue enroute to the pocket compared to the inframammary approach, and there are more critical structures (nerves and blood vessels) located in the armpit area compared to any other incision approach. Risk of injury to these critical structures is exceedingly small in the hands of an experienced surgeon, but nevertheless deserves consideration. Finally, minor nuisances around the incision (swelling, numbness, tiny bands of tissue beneath the skin, etc.) that can occur with any incision are usually somewhat more noticeable and bothersome to patients who have axillary incisions compared to other incision locations.

Regardless of a surgeon’s expertise, making an incision and tunnel through the armpit area requires that patients accept the fact that postoperatively, they may be dealing with one or more of the following:

• Enlarged lymph nodes in the armpit area,

• Fluid collections beneath the skin in the armpit area,

• Areas of numbness or tingling in the armpit and upper innerarm areas,

• Potential permanent numbness in areas of the armpit or upper inner arm,

• A ridge where the incision is located for several weeks that requires care when shaving,

• Possible formation of small bands in the armpit area that may limit arm lifting movements. (These usually resolve spontaneously in a few weeks.)

All of these potential nuisances are manageable, and many patients experience few of these nuisances, but if you are considering an axillary incision approach, you should know that these nuisances are possible.

The axillary approach is not ideal for reoperations to correct postoperative complications or problems because it limits a surgeon’s direct vision and control. A second incision, usually inframammary, may be required to address postoperative problems or complications. Although it is technically possible to treat an excessively tight capsule (capsular contracture) via the axillary approach, the inframammary approach affords the surgeon much more control, more complete removal of capsule, and better control of bleeding, and it avoids traversing breast tissue (required with the periareolar approach).