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Endoscopic transaxillary breast enlargement

   Only a few of the plastic surgeons perform a breast augmentation through the axillary approach, and there are even less who keep the entire process of creating the implant pocket under eye control with the help of the endoscope.
From those who perform the operation so-called transaxillary, the majority creates the pocket of the implant “blindly”, therefore the precise control of bleeding, the exact tissue preparation on each millimeter, for a submuscular implant placement the release of a certain part of the pectoral muscle, the preservation of nerves which provide the nipple sensation, or the exact shaping of the implant pocket and its’ adaptation to anatomical variations of the patient is not possible. Even though they insert the endoscope at the end of the process for a final control, it is rather only an alibi to be able to tell that an “endoscopic” procedure was carried out. The number of complications is high after such operations only observed from the outside, dealing “blindly” with the exact inner conditions. The rate of the capsular contracture is therefore high in these cases, and that’s why it spreads around completely incorrectly that every transaxillary approach is generally “dangerous”. It is not the axillary approach which is dangerous, but the operation from any approach if performed “blindly”. The transaxillary operations of the New Contour Plastic Surgery are carried out under endoscopic control from the beginning to the end.

Endoscopic operation pictures showing the anatomical variants of the nerves responsible for nipple sensation

Why do only a very few plastic surgeons perform the transaxillary breast enlargement under complete endoscopic control? Because the learning curve takes long years and the relatively large investment compensates only after a large number of operations. Because the per-unit costs, and also the price for such an operation is higher due to the equipment, instruments, expendable materials, and it requires a special training, practice and knowledge not only for the plastic surgeon, but also for his colleagues (assistants, scrub nurse, anesthetist), and it is fundamentally different from the routine of the abdominal or orthopedic endoscopic procedures. Even with an extensive practice the operation requires somewhat more time.


The procedure of the endoscopic breast enlargement requires a lot more and complex preparation and technical conditions than the traditional breast enlargement. Dr. Balajthy performs an operation (left side). Additional endoscopic pictures of the variations of the nerves providing the nipple sensation (right side).

Dr. Balajthy (red-blue cap) and his colleagues perform an endoscopic breast augmentation through the axillary approach
It is easier to place the implant under the glandular tissue, than under the muscle from the axillary approach, that’s why some among the ones who perform this operation “blindly”, place every implant under the gland avoiding the longer and demanding preparation for a muscle release, but this is not favourable for every patient. Before the transaxillary endoscopic breast enlargements of the New Contour Plastic Surgery the decision for implant positioning is always made regarding the individual anatomic conditions and physical activity of the upper arm of the patient and not the easiest and fastest method is chosen automatically. In that case, where the submuscular placement is not advantageous, we do not create the implant pocket simply under the gland, but under the muscular fascia, above the muscle. By this, at least at the upper part of the pocket there is an additional thin layer between the gland and the implant, which keeps it better in position and covers the upper rim of it. This method requires further special training and instruments. 

Sketch of endoscopic submuscular breast augmentation

In the course of a transaxillary breast augmentation, after forming the implant pocket, the implants have to be inserted and positioned through a relatively long tunnel. This is not easy, and it is only possible with implants of best quality. Some choose the easier way and use only implants with smooth surface, or use lubricating agents which might cause tissue damage. In the United States, for breast augmentations carried out this way, in 95% of the cases implants are used which can be filled with saline solution after the insertion (primarily for legal issues and not for medical ones – with all of their frequent and well known disadvantages like the harder touch, leakage and wrinkling), these are easier to handle. In the New Contour Plastic Surgery we do not choose the easiest way: we always use textured and cohesive (not liquid filled) silicone implants without any lubricants or filling device which might harm the implant. We can do this, because our professional anesthetist background cares for proper muscle relaxation, the cooperation of the operating surgeon and assistants is excellent and they have an extensive routine, and the top quality (if not the best) MENTOR implants are used which endure all kind of stress.

There are places in Europe, where implants of maximum 250 cc. (ml) are used in endoscopic transaxillary breast augmentations, which means a smaller diameter (and volumen), than the aesthetically optimal size even for the average built patient with moderate demands. In our practice there is no technical limit for the implant size even through the axillary approach, in taller patients with a wide chest, implants of 500 cc. were already used. The recommended implant size is not determined by the method of insertion, but by the anatomical conditions (chest width, muscle and glandular tissue thickness and shape) of the patient, just as by the individual aesthetic expectations (desired inner and outer fullness-roundness, upper fullness) determined after thorough consultation in front of the mirror and inspection of numerous “before & after” pictures.

We often hear it from our patients wanting transaxillary breast enlargement that others tried to talk them out of this method, telling that this approach is “dangerous”, “the wound doesn’t heal well” and “the scar is disadvantageous”. Well, only those say it, who do not have enough or any sort of practice with the axillary approach, or have never seen it at all. With the proper knowledge and everyday preparation routine of the axillary vessels, nerves, and lymphatic glands, their injury can be avoided just the same way, as of the pericardium and heart lying only 1.5 cm deeper under the ribs at the submammary approach.

The wound in the armpit requires a special suture technique, and a special treatment before and after the operation. Already on the 3rd postoperative day our patients have to wash these wounds with antiseptic shampoo (which would be prohibited at submammary approach), and we only see healing problems if someone doesn’t do this properly. Otherwise, supposing the uncommon wound healing problem, in case of a submammary approach the implant is more in danger compared to the axillary approach, because only a few tissue layers separate it from the submammary incision, and it is much more distant from the axillary one.

If the incision is made high enough and corresponds to a fold in a transverse, gently curved line in the armpit, one of the most favourable scars of the human body can be expected, because the thickness of the skin and its’ layers is the finest compared to other areas of the chest – certainly top quality absorbable, running, multilayer sutures are needed. Just like in cases of blepharoplasty (eyelid surgery) with a well chosen incision the abnormal scaring is very rare, so we have never seen keloids after a well performed axillary incision. The reason why in the Far East the axillary approach is preferred for breast augmentations (unfortunately mostly not endoscopically) is that the tendency for abnormal scaring – keloid – is much higher there. It is true, that the strain of the armpit is unpleasant in the first days or in the first week after the operation, but in exchange the bra doesn’t press the fresh wound and later the scar.


Pictures of axillary scars 6 months after breast augmentation

Keloids of the chest after birthmark removal by another surgeon on a patient with abnormal scaring and a benign tumor in the outer part of the breast (left). Picture of the fresh wound (middle) after endoscopic transaxillary removal and the scar six months after the surgery (right).
The axillary scar is always better on patients with abnormal wound healing.

A frequent argument against the axillary approach is that if the implants had to be exchanged for any reason or a capsular contracture had to be corrected, it wouldn’t be possible using the axillary approach again. Well, this is not true! Just the operation itself is difficult (overstrains the surgeon but not the patient) and requires even more practice and skills. At the New Contour Plastic Surgery, since 1994, in cases where a secondary operation was needed after transaxillary endoscopic breast augmentations for any reason (implant exchange, capsular contracture or correction of implant position), not in one single case was another approach necessary, all of these procedures could be successfully carried out through the original axillary incisions, without any additional scars.


Pictures of secondary endoscopic corrections. The implants didn’t have to be exchanged for new ones. Though this kind of operation doesn’t overstrain the patient, is technically very demanding. The cause for the condition requiring correction was a car accident on the 3rd postoperative week in the first case (upper left picture), and intense competition training (basketball) soon after the primary operation in the 2nd case (lower left picture). The results remained constant even years after the corrections (upper and lower pictures right), justifying that the problem didn’t originate from the implants, method or from the patient herself.


Axillary endoscopic pictures of a correction of a capsular contracture, implants were removed for the time of the operation.

To our knowledge, from an incision on the highest, hidden part of the armpit (and not on the side of the chest), employing the safety of the endoscopic control right through the entire operation, using textured cohesive silicone gel filled implants with submuscular and subfascial placement alike, nobody besides the New Contour Plastic Surgery performs breast augmentations in Europe.

In North America a relatively large number of clinics perform transaxillary breast enlargements, but we only know of one place where gel filled and not saline solution filled implants were used.

In the Far East many surgeons perform transaxillary breast augmentations, but with one exception only, these are carried out “blindly” and only rarely under the muscle.

With this method of the New Contour Plastic Surgery, transaxillary with textured implants, either under the muscle or the gland (and in our case under the fascia of the muscle), under constant endoscopic control only one other plastic surgeon performs breast augmentations to our present knowledge, Dr. Kunihiko Nohira in East-Japan, on the island of Hokkaido. The personal encounter in 2007 and our connection brought mutual advantages and exchange of working methods.

Though we perform transaxillary breast enlargements since 1994 in the New Contour Plastic Surgery, we do not persuade our patients to this method. A lot of them come to us, because they have already chosen this method after that they had seen the result of one or more of our former patients personally, or after that they had red everything available on this topic. For those who haven’t made the decision yet for this method, we explain the advantages and disadvantages of each method (submammary, periareolar and transaxillary approach) considering also their individual anatomical conditions, since we have the necessary routine and equipment for each one, and then the patient can make the decision. Mostly for the axillary approach.

Dr. Tibor Balajthy, who elaborated this method, had the honor in 2007 after his former presentations in Hungary, Europe and the Far East to create an educational training material, films and DVD of his transaxillary breast augmentation techniques on behalf of the MENTOR Company.

It is a delusion, that the axillary scar is unfavourable, and that this approach would be dangerous, and a later correction or implant exchange couldn’t be performed by this, and only small implants can be inserted transaxillary – just the opposite of them is the truth!

Dr. Tibor Balajthy
Before & After Gallery