My patients in Sweden always request that I create as little scarring as possible on the aesthetic unit of the breast when I perform breast surgery. In fact, they appear to be more concerned about their scars than any other aspect of the surgery. With increased media exposure, general public sophistication about breast augmentation has become widespread. Today most people know that when a woman has 2 symmetrical scars, either around the areola or in the inframammary fold, she has undergone breast augmentation. I have seen patients with such scars who were as distressed about these obvious signs of surgery as they were about the preoperative appearance of their breasts.

I have heard colleagues say that the inframammary scar is placed in the fold and, as a result, is inconspicuous. However, in my hands, few scars placed on the body, except for those above the neck, become inconspicuous; most can be seen with the naked eye from 10 feet. I also find it difficult to place the scar in the future inframammary fold with precision because most augmentations will lower the inframammary fold. It is hard to know exactly where the future inframammary fold will be, and therefore placement of the incision is difficult.

Desire on the part of the patient for a short convalescence, allowing her to return to work sooner, is a current trend in aesthetic surgery. One of the major disadvantages of submuscular breast augmentation is the postoperative pain that patients frequently experience because of evulsions of the muscle fiber origins from the sternal and costal ribs. The blunt dissection of the pocket frequently causes microbleeding in the periosteum of the involved muscle origins. However, if these muscle fiber attachments are released with electrocautery instead of blunt dissection, postoperative pain is reduced to almost none.

Submuscular breast augmentation with electrocautery dissection was first performed through the inframammary approach with a lighted retractor. When performing this procedure from a transaxillary approach, you have to use an endoscope. My experience with the transaxillary approach, using an endoscope, has shown that most patients experience little pain and can return to office work within a couple of days. Patients who do heavier work, including lifting, are usually advised to stay out of work for 2 weeks. Other advantages with this technique, compared with conventional blunt dissection: Intraoperative bleeding is reduced to an absolute minimum, and the pocket can be created with greater precision. Because bleeding is thought to be one of the causes of capsular contraction, electrocautery dissection should prove an advantage in this respect. But long-term follow-up is necessary to learn whether this holds true.

Increased precision, provided by this technique, in the creation of the pocket will also provide a better inframammary fold shape. In some patients, when performing a blunt submuscular dissection from the axilla, I have encountered a ligament in the inframammary fold (earlier described by Barnett), which can be quite difficult to break. If this ligament is not broken, it usually results in a very obtuse and ill-defined inframammary fold, or ‘double bubble’ deformity. This can be avoided with electrocautery dissection and the use of an endoscope.

When one is dealing with a capsule through the axillary incision, the endoscope is the ideal instrument to use with regard to access and visibility, compared with earlier techniques involving lighted retractors and specially designed knives.

Surgical technique

Place the patient in a sitting position while you mark the lateral and medial extents of the pocket, as well as the current and future inframammary folds. In most patients, I find that I lower the inframammary fold at least 2 to 4 cm. Mark the axilla incision with the patient’s arms raised. I prefer to place the incision along the natural folds, 3 cm under the middle of the axilla (Figure 1). Inject the axilla incision with local anesthesia with epinephrine. I also usually inject this solution into the areas of anticipated dissection between the old and the new inframammary folds because this is the only area in which I plan to cut through the muscle. In all other areas I use the cleavage plane between the pectoralis major and minor muscles.

Patient with an axillary incision is marked with the current and proposed inframammary folds.

Start the procedure by identifying the lateral border of the pectoralis major muscle through the axillary incision. Then separate the pectoralis major from the pectoralis minor muscle. Create a small pocket with your finger, being careful to remain between the 2 muscles in the cleavage plane to avoid any bleeding. When introducing the endoscope, I stand above the patient’s arm to get direct access to the pocket and to maneuver easily (Figure 2). Use the electrocautery in coagulation mode with a high-power setting; this will cut and coagulate at the same time without too much burning. In the event of a bleeder, it is practical to be able to switch from coagulation mode to spray mode.

The breast tissue is retracted with a curved blade retractor, and the endoscope is in place.

It is important to dissect from the medial to the lateral side in wide, sweeping motions to avoid ending up with a small hole (Figure 3 and Figure 4). In the event of bleeding, vision in a small hole is quickly obscured. While you are dissecting, it is important that your assistant follow your progress by observing the patient’s skin surface to guide you as you approach your markings. When 2 cm remains to be dissected above the future inframammary fold, I usually cut through the muscle to better define the new inframammary fold. I cut through the muscle fibers, but only until I see the subcutaneous fat shining through, not more ( Figure 5).