Endoscopic, Trans-Axillary Breast Augmentation Under the Muscle
Dr. Schneider has become renowned for his development and perfection of the endoscopic breast augmentation surgery using a hidden underarm incision (trans-axillary). He first presented this revolutionary technique to Plastic Surgeons from all over the world at the National Meeting of the American Society of Plastic Surgery, in 1995. Since then, he has performed thousands of breast enlargements, breast implant exchanges, and breast implant revisions, using this highly advanced technique.
In Dr. Schneider’s opinion, this has three major advantages for the patient:
- No scar on the breast
- Less discomfort from the surgery (in our experience)
- A much faster return to your normal activities including returning to work and to the gym in the first week following the procedure.
No Scar on the Breast
The underarm incision is located high in the armpit in a natural skin crease, and over time, virtually disappears. Unlike incisions that do not sit in natural skin creases (under the breast or around the areola), these incisions virtually fade away, and once faded, can barely be seen.
In Dr. Schneider’s experience, the under-the-breast scar can become very wide and thick and may take years to fade. However, in the thousands of endoscopic breast augmentations that he has performed, less than 0.02% of patients had a significantly visible scar.
An incision on the breast (under the breast or around the areola) creates a weak point in the tissues right after surgery. Plastic Surgeons who use these incisions usually recommend that patients refrain from physical activity for several weeks to protect these incisions so they do not open and expose the implant. The great advantage of the underarm incision is that it is far away from where the pressure from the implant is, and because of this, the risk of the incision opening is dramatically reduced.
Because of this, Dr. Schneider allows his patients to return to their normal physical activity a day or two after surgery. This increased physical activity allows for quicker rehabilitation from the surgery, and patients are allowed in the gym and return to work as soon as they feel comfortable.
Not everyone will feel like going back to the gym in the first week and we recommend that you allow your discomfort to be your guide. However, we have had patients who were lifting weights overhead and on the treadmill towards the end of their first week after surgery.
Can the Underarm Incision Be Used for All Implant Types?
The underarm incision, endoscopic breast augmentation can be used with either saline implants, silicone implants, or gummy bear implants. Dr. Schneider has been using the technique with gummy bear implants for over 5 years.
Under the Muscle
The technique is typically used for placing the implants under the muscle (pectoralis major), though some patients can request that the implants are placed on top of the muscle.
Dr. Schneider will also use the underarm incision in patients choosing an implant exchange who have either a previous incision under the breast or around the areola. This is because he feels that this offers the patient a much faster recovery with no physical limitations.
Around the Nipple
A periareolar incision is an incision that is placed following the outline of the areola. Typically this runs from 3 o’clock to 9 o’clock but it can be placed anywhere on the areola. Usually, this incision leaves a minimally visible scar on the breast.
Typically patients must wait 2-3 weeks following this type of incision before they can return to their normal physical activities.
If a patient is looking for a revision of their breast augmentation or an exchange of their implants, and they already have a periareolar incision, the patient may choose to utilize this approach. However, in Dr. Schneider’s experience, the underarm incision may allow them a quicker recovery.
Under the Breast
This is the standard incision that most Plastic Surgeons use to perform breast augmentation. In fact, when most Plastic Surgeons are learning this operation during their residencies, this is the technique they are usually trained on.
If the surgeon is unskilled in the endoscopic breast augmentation procedure, this incision may offer them an advantage.
The disadvantage of this incision is that it leaves a scar on the breast. In Dr. Schneider’s experience, he has seen a fair number of patients whose scars using this approach are wider and thicker than ideal.
Also, this incision creates a weak point in the tissues that must heal. As such, patients with this incision usually are advised to not perform significant physical activity for several weeks following this type of surgery.
What is Your Desired Breast Shape?
Your shape after breast augmentation is determined by your underlying breast shape, breast size, and how the surgeon performs the surgery. The breast has 4 quadrants related to augmentation:
- The upper pole – from 10:00 to 2:00
- The cleavage or medial pole – from 2:00 to 5:00
- The bottom boob or lower pole – from 5:00 to 8:00
- The side boob or lateral pole – from 8:00 to 10:00
How full each of these areas is after surgery is determined by how the surgeon creates the pocket, the diameter of the implant, how the implant sits in the pocket, the projection (profile) of the implant, and your underlying anatomy.
Natural, Round, or In-Between
Shaping the Upper Pole
The breast naturally has a slope that extends from the upper chest down to the fullness of the breast. In a naturally appearing breast, that slope line is either straight or slightly concave when viewed from the side.
In a breast augmentation where a “natural appearance” is created, this slope angle is increased, but it is still either straight or slightly concave.
In the “round look”, a convex or round slope is created. Patients describe this as having a lot of fullness in the top of the breast.
Of course, there are many patients that want something in-between. How we vary the natural vs round look is determined by several factors: a wider diameter implant will have more projection at the top of the breast than a smaller diameter implant. Also, if the implant is higher projecting, the implant will have more fill in the upper pole than a lower projecting implant if both have the same diameter. Understanding your desired outcome is therefore the most important factor in providing you beautiful results.
Breast Size, Fullness and Cup Size
Breast size is often measured in “cup size”, or what size bra is required to fit the breast. Cup size in breasts, however, is not an exact measure like a cup size is in cooking. In cooking, one cup is exactly 250cc’s.
Bras are measured by taking the circumference in inches around your chest, just below your breasts, and the circumferential measurement over the middle of your breasts. This does give you an accurate circumferential measure for your bra: IE 34 or 36 etc. However, it does not give you an exact measure of cup size after augmentation because the shape of your breast and how it fits in a bra will vary.
Adding exactly 250cc’s to the size of one’s breast does not necessarily increase the breast one cup…. from a B-cup to a C-cup. And, as we all know, there is a range of sizes within a cup size… Big C, Small C, etc. Therefore, Dr. Schneider uses a different technique for determining the size that leads to much greater satisfaction than the standard way of putting implants or bags of rice in your bra.
Choosing The Size You Want: The Schneider Technique
When we discuss breast augmentation and the size of the breast you want, we are discussing a range as well as the look the patient desires. We find that the best way to achieve the desired size is not for the patient to actually pick a “cup” size or a breast implant size.
What we prefer, is that the patient shows us a variety of photos of breasts they like. For this, we prefer typical before and after type photos. They can also show us breast shapes and sizes they do not like. Dr. Schneider then uses the photos in the operating room as a guide for his breast augmentation surgical plan. Once the pocket is created based on how much fullness you desire in the different regions of your breasts and your underlying anatomy, inflatable “sizer” implants are inserted that vary in diameter, projection and volume. The “sizers” are then inflated and the volume of air measured until the resultant breast size and shape is a good match to your photos. Then the appropriately sized implants are chosen and inserted.
Types of Breast Implants
Breast implants were invented in the early 1960’s, and since that time a variety of different generation implants have been invented. Silicone implants have gone through 5 generations of development when we consider the silicone fill in the implant. The Gummy Bear implant is considered to be a generation 5 implant.
Gummy Bear Smooth Implants
What is the difference?
As implant fill has undergone development, the fill has become more and more cohesive. Initially, they were a silicone oil that leached through the shell of the implant. In addition, if the implant shell broke, the oil would leak out throughout the pocket and could even migrate to other tissues and lymph nodes.
The implants that were removed from the market in 1992 were generation 3 silicone implants. Even in these implants, the rupture rate was almost 80% at 12 years after implantation.
The generation 5 implant is highly cohesive meaning that if the silicone gel inside maintains the basic shape of the implant even if the shell is removed. In fact, if you take a gummy bear implant and slice it in half, it is like slicing a piece of jello in half. It maintains its shape.
The advantage of this in Dr. Schneider’s opinion is that they have less tendency to rupture, and a longer average lifespan than generation 4 implants.
Is there a disadvantage to the gummy bear implant?
The implants are more expensive than the generation 4 implants. They are also a little firmer because the gel inside is more cohesive. However, in Dr. Schneider’s experience, this alone has never been an issue for a patient.
Gummy Bear Shaped Implants
Gummy bear implants also come in a more natural, tear dropped shape. The goal of this design was to try and create something that produced some fullness in the upper pole of the breast while maintaining a natural appearance.
Interestingly enough, it has been presented at several Plastic Surgery conferences, that Plastic Surgeons themselves cannot tell the difference in the results between round and shaped implants.
The shaped implants are textured in order to try and maintain the vertical orientation of the implant. The idea behind this is that the texturing will anchor the implant in place. However, this does not always work and the implants can rotate which can create asymmetry, meaning the right breast does not look like the left.
One other problem with the shaped implants is that they are implicated in a very rare breast cancer called ALCL (anaplastic large cell lymphoma). ALCL seems to be specifically implicated in one company’s textured, shaped implant. In fact, the FDA recalled this implant by the Allergan corporation from the market.
Silicone Gel Implants
In 2006, generation 4 silicone implants were allowed back on the market. The filling in these Silicone generation 4 breast implants is much more cohesive than the generation 3 implants that were removed from the market in 1992.
They appear to have a much longer average lifespan than the generation 3 implants, and they do not have the gel bleed problem (silicone does not leach through the shell wall), as did the older implants. The large advantage of the silicone gel generation 4 implant is that they are less expensive than the generation 5 implant, and they are slightly softer. The disadvantage may be that they do not last as long on average compared to the gummy bear, generation 5 implants.
Saline Breast Implants
The saline implant was first invented and brought to market in 1968. It is a tried and true technology and works for many patients. In fact, Dr. Schneider uses saline implants in about 40% of his patients.
Implants are simply tools designed to enhance the breast. In some patients, saline implants may offer advantages. In other patients, gummy bear implants may be more advantageous. Just like a hammer and a screwdriver are both good tools, you would not want to use a screwdriver to pound in a nail.
The reason saline implants have gotten a bad reputation is that in very thin patients with very little breast tissue, the saline implant may show more visible rippling along the edges of the breast. Rippling is present in ALL implants, though the silicone and gummy implants tend to have less.
The amount of breast tissue that covers the implant is the key as to whether the patient will have visible rippling. If the patient has adequate tissue to cover the implant, there may be no visible rippling at all with saline.
Saline implants offer an advantage in that they allow the surgeon to adjust the fill volume of the implant and thus its fullness and roundness. If the implant is filled to its stated volume (a 300cc implant filled to 300cc’s), the implant tends to look and feel more natural. If the implant is overfilled (meaning filled to more than the stated volume), the implant will tend to look rounder in the upper pole.
Thus in patients who are seeking a rounder shape in the upper pole, an overfilled saline implant may be more advantageous than a very high profile gummy bear implant.
Saline implant lifespan varies by manufacturer type. Dr. Schneider chooses to use Mentor saline implants in most circumstances because in his opinion they seem to have a longer average lifespan. In fact, in Dr. Schneider’s own wife, her Mentor implants lasted over 25 years before they needed to be replaced for deflation.
Saline implants are inserted through a slightly shorter incision because the air in the implant is first removed, the implant is rolled, and then it is inserted and then filled via a fill tube. Once filled, the fill tube is removed from the self-sealing valve and then the incision is closed.
The breast augmentation performed by Dr. Schneider typically takes 45-60 minutes to perform. It is done in our AAAHC certified surgery center with the patient undergoing a twilight anesthesia. The combination of a very long-acting local anesthetic, as well as a muscle-relaxing medication, significantly improves the recovery and decreases your discomfort after surgery. In fact, Dr. Schneider’s use of a muscle relaxant in breast augmentation is published in the prestigious medical publication, “Aesthetic Surgery Journal”.
At the conclusion of the surgery, a clear dressing is applied to the incision and no bra or special straps are applied. The patient then wakes up in our recovery room, and most patients are able to be driven home within an hour.
The next day, patients are instructed to remove their dressing. They may shower 24 hours after the procedure, and they are asked to use their arms as much as possible. Dr. Schneider believes that movement speeds the recovery much like how a physical therapist would stretch and strengthen a muscle strain. Initially, after the surgery, the implants will look too high. This is due to swelling and spasm from the chest muscle. The implants will drop into position though, and the breast shape will improve over several weeks. Dr. Schneider likes the patients to not wear a bra, except for going to the gym, until the implants have dropped.