Subcutaneous fibrous banding after transaxillary subpectoral endoscopic breast augmentation

Primary Breast Augmentation Using Axillary Skin Incision, Submuscular Implants, and Intraoperative Tissue Expansion

BACKGROUND

Primary breast augmentation in small, pointed, or tubular breasts using axillary skin incision, submuscular cohesive gel implants, and intraoperative tissue expansion dramatically reduces complications.

METHODS

A 2.5- to 3.5-cm-long incision is made in the hair-bearing part of the axillae beside a natural fold. Incisions are opened using dissection away from the axillae, and an opening is made underneath the muscle on top of the thoracic cage. Blunt finger dissection is performed, and temporary breast expanders and special dissectors are inserted. The expanders create volume and desired breast shape. Sterility is ensured by entering implant pockets only with expanders and elevators and changing gloves before placing implants. No irrigation or antibiotic solution is used on implants or in the pockets. One thousand three hundred ten breast augmentations were performed between 2004 and 2019 (including a 2-year follow-up) using textured, cohesive round implants. Patients were followed up 3-4 months postoperatively. The parameters analyzed were size, shape, firmness, scars, and sensation in the nipple areola complexes. Patients contacted the clinic if problems occurred.

RESULTS

Of the 1,310 patients, only 2 had a Baker grade 3-4 capsular contraction. We also found 2 cases of implant rupture at the end of the 10-year guarantee period. Implants were replaced with identical ones. No infections were seen. Six cases of implant malposition were corrected by surgery. The total number of reoperations was 10 (0.8%).

CONCLUSIONS

The axillary skin incision is an extremely efficient technique with few complications. The lymphatic drainage system is preserved, and implant pockets are left in a virgin state.

Mondor's subcutaneous banding after transaxillary breast augmentation: case report and the review of literature

Mondor's disease is a rare benign condition characterized by the formation of subcutaneous bands or strings in various locations, generally assumed to be symptoms of thrombophlebitis or phlebitis of the subcutaneous veins. Some findings, however, point toward a lymphatic origin of the bands. More biopsies of the cord and histologic studies are necessary to resolve this dispute. The chest, abdominal wall, penis, upper inner arm, and other regions of the body can be affected. The pathophysiology is unclear, but trauma of some kind, such as transsection during surgery or external compression, probably triggers its development. Mondor's thrombophlebitis occurs in 12 % of breast cancer patients. Typically, there is an abrupt onset of tenderness and pain in the affected area a few weeks or months after breast surgery. The disease course is self-limiting, lasting weeks or, on rare occasions, months before spontaneously resolving. Usually, no treatment is necessary, but sometimes a topical nonsteroid antiinflammatory ointment is given. The majority of reports describe thrombophlebitis on the thoracoabdominal wall as a sequela of breast surgery. Mondor's bowstring cord on the upper inner arm after previous transaxillary breast augmentation is rarely reported in the literature and less known. This report is intended to update our knowledge on this possible complication, which may cause unnecessary distress to the patient and the treating physician.

LEVEL OF EVIDENCE V

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Reoperative transaxillary breast surgery: using the axillary incision to treat augmentation-related complications

BACKGROUND

The axillary incision for breast augmentation has been an option for patients and surgeons for more than 30 years now. Controlled clinical trials have demonstrated that reoperations continue to be significant (15-24% at 3 years) independent of incision choice. The misbelief that the transaxillary approach is not adequate for reoperations inhibits patients' and surgeons' decisions on what incision is best in each case.

METHODS

A retrospective analyses was performed seeking reoperation cases performed from January 2008 to January 2011 that used the same axillary incision as the previous transaxillary augmentation. Data on the cause for the reoperation, time between surgeries, patient age, implant volume, locality of the primary operation, and details regarding the implant type and pocket plane were gathered and analyzed.

RESULTS

A total of 15 patients and 26 breasts needing reoperation were found in this period. The average time between the first surgery and reoperation was 12 months, average patient age was 36 years, and implant volume ranged from 195 to 360 cc, with an average of 283 cc. Six of these patients were previously operated on by the authors and nine were operated on by other surgeons and came to our service seeking revision. Details regarding the implant type and pocket plane are also given. The main causes for reoperation were capsular contracture (26.9%), size change (15.4%), seroma/hematoma (11.5%), infection (11.5%), axillary banding/scarring (11.5%), lower-pole deformity/high-riding (11.5%), asymmetry (7.7%), and rippling/waviness (3.8%).

CONCLUSION

Transaxillary breast augmentation reoperation is feasible if certain principles are followed.

Simultaneous Endoscope-Assisted Contralateral Breast Augmentation with Implants in Patients Undergoing Postmastectomy Breast Reconstruction with Abdominal Flaps

BACKGROUND

Unilateral breast reconstruction after mastectomy provides the challenge of achieving symmetry with the opposite side. Reduction mastopexy is a common balancing procedure for the contralateral breast used to achieve pleasing and symmetrical breasts. Although symmetry is the ultimate goal, some women have a hypoplastic and/or ptotic contralateral breast, and the recreation of this shape would therefore not be desirable.

METHODS

From April of 2000 to April of 2005, a total of 158 patients underwent postmastectomy breast reconstruction using either free deep inferior epigastric perforator flaps (n = 142) or superficial inferior epigastric artery flaps (n = 16) at Chang Gung Memorial Hospital. Of the 158 patients, 19 (12.0 percent) underwent endoscope-assisted placement of implants into the contralateral breast at the same surgical stage to form a more pleasing breast mound. Mean patient age was 46.1 +/- 7.6 years. All patients had a slender body habitus, with small to medium-sized breasts. Saline-filled implants were placed in a submuscular position with the assistance of endoscopy. Five different incisions for access were used: transaxillary (n = 6), Port-A-Cath catheter scar (n = 4), inframammary (n = 1), biopsy scar (n = 1), and transmidline (n = 7).

RESULTS

The success rate was 100 percent, with complete survival of the 19 flaps. In three patients, revision procedures were carried out at 12 to 44 months' follow-up because of implant leakage, capsular contracture, and nipple ptosis (one patient each). The remaining patients were highly satisfied with the cosmetic result, and symmetry was achieved, with soft, natural appearing breasts during the follow-up period of 29.2 +/- 16.9 months. The transmidline approach was superior to the other routes, because no additional scar was produced and access was easier.

CONCLUSIONS

Contralateral breast augmentation at the same stage with deep inferior epigastric perforator or superficial inferior epigastric artery flap surgery can be performed with high success rates and poses no surgical risks or morbidity to patients. The combined procedure does not significantly extend the time of operation, and aesthetically pleasing results and symmetry can be achieved and sustained over the long term.

Subfascial transaxillary breast augmentation without endoscopic assistance: technical aspects and outcome

BACKGROUND

Although transaxillary breast augmentation (TBA) is a well-studied procedure, few previous reports exist concerning the subfascial technique, especially without endoscopic assistance. This study aimed to analyze the feasibility of the technique after breast augmentation in terms of its indication, surgical technique, limitations, and clinical outcome.

METHODS

For this study, 42 patients underwent TBA without endoscopic assistance. The technique was indicated for patients with breasts of small or moderate volume without ptosis, patients who wanted no breast scars, and patients who had a poorly defined inframammary fold. The mean follow-up period was 16 months. Implant and incision approach complications were evaluated. Information on patient satisfaction was collected.

RESULTS

A total of 14 complications occurred in 42 patients, all of them minor. Axillary incision-related complications occurred in 26% of the patients, as represented by a late axillary subcutaneous band (119%), sensory loss in the inner aspect of the arm (71%), and a hypertrophic scar and small wound dehiscence (71%). No patient presented with capsular contracture, visible rippling, or infection. Most of the patients (93%) were either very satisfied or satisfied with their result, and none regretted the surgery.

CONCLUSION

The TBA procedure without endoscopic assistance is a simple and reliable technique for breast augmentation. Most of the complications in this study were minor and predictable. They did not interfere with the aesthetic outcome nor the normal postoperative recovery. With TBA, success depends on patient selection as well as careful intra- and postoperative management.