Transaxillary Incision Research Articles

Trans-axillary single port insufflation technique-assisted endoscopic surgery for breast diseases: Clinic experience, cosmetic outcome and oncologic result.

With an increasing demand for postoperative cosmetic effects in breast diseases, the single port by trans-axillary incision and air-inflation system, which provided better space and spared the assistant the effort of retraction, is widely used in clinic surgical treatment for multiple breast diseases. According to inclusion and exclusion criteria, patients who underwent trans-axillary single-incision surgery at Tianjin Medical University Cancer Hospital between December 2020 and July 2022 were included in the study. We collected and analyzed data on age, fertility history, ultrasound grade, clinical stage, pathological results, oncological prognosis, patient-centered cosmetic outcome, etc. A total of 115 cases were included, of which 33 patients with benign disease underwent mass resection, 68 patients with malignant tumors underwent mastectomy. 10 patients had a special type of breast lesion. A mastectomy was performed in 4 patients with male mammary gland development. Of the 115 cases, the maximum mass diameter was 3.00 ± 1.644 (0.6-8.5) cm. Blood loss during surgery was 85.77 ± 50.342 (10-200) ml. The surgery took 131.84 ± 59.332 (30-280) minutes to complete. The patient spent a total of 5.05 ± 2.305 (2-18) days in the hospital. And the length of surgical incision in all patients was 3.83 ± 0.884 (3-8) cm. All patients were very satisfied with the appearance of their breasts after dressing. 94.78% of patients were satisfied with the position of the incision. Through this study, we believe that in benign breast diseases and malignant breast tumors, trans-axillary single port insufflation technique-assisted endoscopic surgery has oncological safety and an aesthetic effect for most people with breast diseases.

Comparison Of Endoscopic Transaxillary And Peri-areolar Approaches In Breast Augmentation With Smooth Implants.

The most common surgical approaches for breast augmentation in Asia have traditionally been peri-areolar and transaxillary. In recent years, transaxillary approach has become increasingly popular with the use of endoscopic methods, which result in safer and better outcomes. In the literature, there are no comparison studies of endoscopic transaxillary and peri-areolar approaches. This prospective study compared the outcomes of 275 women undergoing primary breast augmentation (endoscopic transaxillary n=205, peri-areolar n=70). All procedures were performed by a single surgeon using smooth round silicone implants and dual-plane pockets from April 2013 to March 2016. Every patient was monitored for a minimum of 4 years for minor and major complications. Types and percentage of patients experiencing minor complications among transaxillary and peri-areolar patients were localized fluid collection in the wound (1% transaxillary, 7.1% peri-areolar), hypertrophic scarring or keloids (1% transaxillary, 8.6% peri-areolar), and areolar and nipple deformity (0% transaxillary, 8.6% peri-areolar). Major complications were postoperative bleeding (0% transaxillary, 2.9% peri-areolar) and capsular contracture, Baker Group III or IV (1% transaxillary, 5.7% peri-areolar). Endoscopic transaxillary breast augmentation had better outcomes, with lower rates of complications than the peri-areolar approach. Reviewing the literature, our study is the first direct comparison of peri-areolar and endoscopic transaxillary incisions using smooth implants. With the risk of anaplastic large cell lymphoma associated with certain macrotexture implants, endoscopic transaxillary approach using smooth implants is the safer technique and very good alternative choice for Asian women who do not want any scarring on their breasts. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Chest Wall Reconstruction in Male Poland Syndrome Patients with Endoscopic-Assisted Latissimus Dorsi Muscle Flap Transfer

Pectoralis major absence generates chest wall deformity and always requires surgical intervention. This study aimed to introduce a technique to reconstruct the chest wall for male Poland Syndrome patients with endoscopic latissimus dorsi muscle (ELDM) flap via a single transverse axillary incision and evaluate its safety and effectiveness. A prospective study was designed to recruit male Poland Syndrome candidates for ELDM chest reconstruction. By performing a short and hidden transaxillary incision, we created anterior chest wall pocket and transferred the latissimus dorsi muscle (LDM) flap to recontour the chest wall. Data for patient demographics, LDM flap dimension, operative time, and complications were collected. Upper extremity functional disabilities were evaluated by the disabilities of the arm, shoulder and hand (DASH) outcome questionnaire. Satisfaction with the outcome was measured by satisfaction with outcome subscale of the BREAST-Q questionnaire. This study recruited 11 eligible patients to receive ELDM chest wall reconstruction. ELDM flap harvesting averagely consumed 79.9 minutes. Without significant complications, all patients recovered uneventfully. Chest wall anomalies of different severity were corrected safely and effectively. The score of DASH was 3.7±3.3 preoperatively and 4.0±3.7 postoperatively with no statistically significant difference. The score of satisfaction with the outcome was 84.8±14.3. For chest wall anomalies of different severity in male Poland Syndrome patients, the ELDM technique provides a safe and efficient way to reconstruct the chest wall with a better aesthetic outcome, high satisfaction rate, and satisfactory upper limb function.

Muscle-Splitting Transaxillary Revision Breast Augmentation-A Single Surgeon's Experience.

Well discussed in a previous article published by the senior author, primary transaxillary breast augmentation drawbacks include the need to correct complications arising from reuse of the axillary incision which the literature is sparse on. We here discuss a technique in patients who underwent a secondary transaxillary breast augmentation procedure. This study aims to present a technique for transaxillary revision breast augmentation with conversion to a muscle-splitting plane which has the advantage of good upper and medial pole coverage and adequate lower pole expansion. We performed a retrospective chart review of 41 women with previous silicone gel implants placed through a transaxillary incision who presented with rippling or a desire for larger implants (January 2016-July 2020). Inclusion criteria were age 18 years or older and having undergone breast augmentation surgery. Exclusion criteria were active smoking and body mass index (BMI) greater than 30 kg/m2. At one year postoperatively patients were asked a "yes or no" question regarding satisfaction with the overall result and with the scar quality. A total of 41 patients were included in this study; no patients were excluded. The patients' age ranged from 32 to 47 years, the average being 38 years old. All participants were female. Mean BMI was 21.9 kg/m2 and all patients had a pinch test <2cm. Indications for surgery included rippling (all patients) and a desire for larger implant size (n = 5). Size of new implants ranged from 325cc to 430cc; all were of a larger size than those used in the primary surgery. Operative time was on average 53 min. [4483 min.]. Mean follow-up was 13 months, ranging from 12 to 15 months. There was no additional cost related to operative time. Regarding patient satisfaction, 100% replied they were pleased with the overall results and scar quality. There were no major complications. The transaxillary approach for muscle splitting breast augmentation revision surgery offers a safe and reproducible technique. Despite having a mean follow-up of only 13 months, we demonstrate a low rate of complication as well as high degree of patient satisfaction with no extra cost when compared to other techniques. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Experience on Subfascial Mammary Augmentation and Influence of Incisions on Technique

Introduction: Mammary augmentation is among the most popular types of cosmetic procedures and mammary prosthesis the most commonly accepted technique. A mammary prosthesis can be placed on transaxillary, periareolar, submammary incisions in subglandular, subpectoral, subfascial planes or in a combination of planes. Given the potential interaction between the prosthesis and the surrounding tissues, the plane in which the prosthesis is implanted has an important role among the factors affecting this interaction. The plastic surgeon decides on the incision and plane to be used by assessing the advantages and disadvantages. Materials and Methods: Prostheses were implanted in the subfascial plane in 47 patients who underwent augmentation mammaplasty. Round Moderate Plus or High Profile Cohesive II™ Gel implants were used. Device volumes ranged from 275 to 600 cc. Of the 47 procedures, 23 were performed over an axillary incision, 20 over an inframammary incision, and 4 over a periareolar incision. Endoscopic-assisted dissection was performed in all of the 23 cases in which transaxillary incision was used. Results: All 47 patients who underwent subfascial prosthesis implantation were followed up for a mean of 5 years (range: 2–7 years). Long-term results were satisfactory with few complications. The overall patient satisfaction rate was 89.3%, and none of the patients required an implant removal or change. None of the patients complained of severe pain, regardless of the type of incision, and resumed their daily activities on postoperative day 2. Conclusion: The subfascial augmentation technique provides good and long-term results. It requires longer operating times and is a more difficult technique compared to other planes. As the choice of incision does not largely affect the overall result, the position of the scar depends on the patient's preference, the properties of the implant, and the experience of the surgeon. The endoscopic assistance should be preferred when using the transaxillary approach.

A Simple and Low-cost Method of Sleeve to Insert Silicone Gel Breast Implants.

Summary:Contact between silicone implants and skin/breast parenchyma has been described as an agent of implant contamination and biofilm formation, resulting in implant complications. The no-touch technique was introduced to avoid implant contact and reduce skin/breast contamination. The authors propose an easily available sleeve option using a saline sterile plastic container that provides elastic and transparent protection for inserting silicone implants. These sterile containers can be easily converted into a sleeve by cutting off the narrow end of the container, which then easily fits into the small inframammary, periareolar, and transaxillary incisions. The authors have performed this technique in 10 patients (20 implants) undergoing primary breast augmentation or revision breast surgery, with microtexturized implants ranging in size from 255 to 500 ml (mean, 325 ml) and obtained satisfactory results with no cases of complications. Our clinical outcome shows that this new sleeve does not interact with the implant or the patient’s skin and soft tissues and has the added advantage of low cost compared with similar available devices, but further randomized and controlled studies are required to corroborate this effect.

Breast Reconstruction in Poland Syndrome Patients with Latissimus Dorsi Myo Flap and Implant: An Efficient Endoscopic Approach Using Single Transverse Axillary Incision.

Breast hypoplasia or amastia with pectoralis major muscle defect in female Poland syndrome patients always necessitates surgical intervention. This study aims to introduce an efficient endoscopic technique to perform breast reconstruction in Poland syndrome patients with a latissimus dorsi myo flap and an implant using a single transverse axillary incision (ELDM + IMPLANT) and to evaluate its safety and effectiveness. A prospective study was designed to recruit Poland syndrome candidates for ELDM + IMPLANT breast reconstruction. Only one transaxillary incision was made to harvest the LDM flap and create the anterior chest wall pocket. The LDM flap was transposed to the front to reconstruct the breast with a silicone implant. Patient demographics, LDM area, implant size, contralateral symmetry surgery, operative time and post-operative complications were collected. The BREAST-Q reconstruction module was used to evaluate patient quality of life. The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire was used to evaluate patient upper extremity disabilities. Sixteen eligible patients were recruited and received ELDM + IMPLANT-BR. Mean endoscopic time for LDM flap harvesting was 61.6min. All of the 16 patients recovered uneventfully without any significant complications. The post-operative scores of satisfaction with breast and psychosocial well-being were significantly higher than the pre-operative ones. The score of DASH was 7.1 pre-operatively and 8.3 post-operatively with no significant difference either. The score of satisfaction with outcome was 80.0. Our proposed ELDM + IMPLANT technique provides a safe and efficient way to reconstruct breasts in Poland syndrome patients with a high satisfaction rate, optimized aesthetic outcome and minimized donor site morbidity. This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Gynecomastia: glandular-liposculpture through a single transaxillary one hole incision

Gynecomastia is characterized by the benign proliferation of breast tissue in men. Herein, we present a new method for the treatment of gynecomastia, using ultrasound-assisted liposuction with both conventional and reverse-cutting edge tip cannulas in combination with a pull-through lipectomy technique with pituitary forceps through a single transaxillary incision. Thirty patients were treated with this technique at the author’s institution from January 2010 to January 2015. Ten patients were treated with conventional surgical excision of the glandular/fibrous breast tissue combined with liposuction through a periareolar incision before January 2010. Medical records, clinical photographs and linear analog scale scores were analyzed to compare the surgical results and complications. The patients were required to rate their cosmetic outcomes based on the linear analog scale with which they rated their own surgical results; the mean overall average score indicated a good or high level of satisfaction. There were no incidences of skin necrosis, hematoma, infection and scar contracture; however, one case each of seroma and nipple inversion did occur. Operative time was reduced overall using the new technique since it is relatively simple and straightforward. According to the evaluation by the four independent researchers, the patients treated with this new technique showed statistically significant improvements in scar and nipple-areolar complex (NAC) deformity compared to those who were treated using the conventional method. Glandular liposculpture through a single transaxillary incision is an efficient and safe technique that can provide aesthetically satisfying and consistent results.

Video-assisted thoracoscopic surgery for intrathoracic first rib resection in thoracic outlet syndrome.

First rib resection is a surgical treatment for decompressing the neurovascular structures in thoracic outlet syndrome (TOS). Historically, extrathoracic approaches have used a posterior, supraclavicular, or transaxillary incision to remove the first rib. In this report, we demonstrate video-assisted thoracoscopic surgery for intrathoracic first rib resection (VATS-IFRR). Between 2009 and 2014, eight patients underwent VATS-IFRR for TOS. Surgery was performed through two 5-mm ports and one 10-mm port. Endoscopic graspers, a hook-type electrocautery probe, a long peapod intervertebral disc rongeur, and Kerrison punches were used. The types of disease, operative times, chest tube indwelling days, lengths of hospital stay after operation, perioperative complications, postoperative pain scale ratings, and postoperative symptom recurrence rates at provocation tests were reviewed. The surgical outcomes were compared to published outcomes of extrathoracic approaches and other VATS approaches. The eight patients (3 right ribs, 5 left ribs) exhibited neurogenic (1 patient), combined type (2 patients), arterial (4 patients), and venous type (1 patient) TOS. The mean operative time was 190 (range 155-310) minutes. No mortalities or major complications occurred. The mean chest tube indwelling duration was 6 (range 3-10) days, and the mean postoperative hospital stay was 9 (range 4-21) days. The mean immediate postoperative pain numeric rating scale (NRS) score was 2.7/10 (range 2-4). No recurrence was observed during follow-up (median 25.5 months, range 10-64 months) in any patient. VATS-IFRR was safe and had several advantages. Thus, VATS-IFRR is a minimally invasive surgical option suitable for treating selective cases of TOS.

Nipple Shields in Transaxillary Breast Augmentation.

Infection after breast augmentation occurs in 1.1% to 2.5% of patients. Bacterial contamination of the implants could explain some complications of breast implant surgery, including infection, capsular contracture and even anaplastic large cell lymphoma. Because of the evidence of bacterial spread from the nipple, nipple shields have been proposed as a routine maneuver to avoid contamination of the implants. To determine if nipple shields are useful in transaxillary breast augmentation. A culture was obtained from the dressing (nipple shield) in 26 patients with transaxillary incision, and follow-up lasted for 18 months. A retrospective study of patients undergoing breast augmentation between 2008 and 2012 was conducted as well to know our rate of infections. A total of 753 patients between the ages of 18 and 62 years, with a mean age of 34 years, were identified. Of these 753 patients, most underwent surgery using a transaxillary incision (72.5%). The most common placement plane was subfascial (59.2%), and in most cases, an anatomical prosthesis (78%) was used. No cases of infection or capsular contracture were observed in the study group. However, 13.5% of the breasts had positive cultures of swabs taken under the nipple shields. Staphylococcus epidermidis and Enterococcus faecalis were isolated from the nipple culture. Within the retrospective study, we detected 2 cases of acute infection (0.26%) and 5 cases of late infection (0.66%). The acute infections were caused by Staphylococcus aureus. In the late infections, Pseudomonas aeruginosa was isolated in 3 cases, and S. aureus was isolated in 1 case. Nipple shields did not make any difference for outcomes when using the transaxillary method. Acute infections seem to occur more frequently via the areola route. Late infections seem to have a hematogenous component because an infectious background was present in all cases.

Application of the formulas of optimal location in splitting pectoralis major in modified dual-plane breast augmentation

Objective To evaluate the design formulas of the optimal location for splitting pectoralis major in terms of making type Ⅰ or Ⅱ dual-plane implant pocket. Methods Sixty-five patients with micromastia were collected. Breasts were divided into two types according to the soft-tissue pinch thickness of the lower pole: type Ⅰ (thickness>2 cm; 34 cases) and type Ⅱ (thickness ≤2 cm; 31 cases). The optimal levels at which the pectoralis major (PM) was severed were 3/4 or 2/4 of the distance of new inframammary fold for type Ⅰ or Ⅱ dual-plane pockets, respectively. All patients completed the pre- and post-operative BREAST-Q augmentation modules before and 6 months after surgery. The scores were changed into hundred-mark system by QScore software. Results The recovery processes were well-off. The breasts contour was good. Patients reported higher scores of satisfaction with breasts, psychosocial well-being and sexual well-being after surgery than before surgery (62.0±8.9 vs 27.9±4.3, 65.0±17.2 vs 17.4±8.3, 60.5±14.2 vs 30.3±5.5, P<0.05). The mean satisfaction score for the overall outcome was 90.6±5.4. However, there was no significant difference in physical well-being between before operation and aftre operation (85.3±9.5 vs 84.7±10.6). No complications such as severe capsular contracture, or displacement occurred. Conclusions The design formulas make the determining procedure of the optimal location for pectoralis major splitting for two types dual-plane implant pockets easier and more exactly. Our modified design method can provide the implant with the optimal soft tissue coverage, and bring desired and stable breast aesthetic outcomes. The higher satisfaction and quality of life reported by patients indicate that the formulas are feasible and worth to recommend. Key words: Endoscopy; Breast augmentation; Dual-plane; BREAST-Q questionnaire; Transaxillary incision

Post Stab Injury Subclavin Artery Pseudoaneurysm Excision

Figure 1: Stab wound in supraclavicular region already sewn at local hospital. Figure 2: CT angiography showing subclavin artery pseudoaneurysm with two openings in subclavin artery anterior and posterior. Figure 3: A) Supraclavicular inscision to expose proximal subclavin artery B) Exposed subclavin artery. Figure 4: A) Excised pseudoaneurysm B) Opening in subclavin artery closed with vein patch. Figure 5: Closed tranaxillary and supraclavicular surgical incision with negative suction drain in situ. Abstract A pseudoaneurysm, also known as a false aneurysm, is a hematoma that forms as a result of a leaking hole in artery. Hematoma was contained by the surrounding tissues. Also it must continue to communicate with the artery to be considered a pseudoaneurysm. Post stab injury subclavin artery pseudoaneurysm is rare entity with great significance because of risk of complications like thrombosis, rupture, gangrene, limb loss and should be operated early whenever diagnosed. Our case report has 24 year male patient with history of stab injury to left supraclavicular region followed by pulsatile swelling after two days due to subclavin artery pseudoaneurysm. We excised pseudoaneurysm with vein patch closure of opening in subclavin artery. Introduction According to the literature data, post traumatic pseudoaneurysm is rare entity [1]. Most common site is common femoral artery, followed by radial and brachial artery but subclavin artery is very rare because trauma to it is rare. Incidence of complications associated with such pseudoaneurysm is estimated around 2-6% [2]. We present a case of the patient in whom pseudoaneurysm of left subclavin artery developed after two days of stab injury by pointed object and was successfully treated by surgical excision and vein patch closure of opening in subclavin artery. Case Report A 24 -years-old male patient was admitted at our Institute with history of stab injury to left supraclavicular region lateral side that was closed at local hospital (Figure 1). After two days the patient noticed gradually increasing pulsatile swelling at closed stab injury site. Clinical examination revealed presence of pulsating mass at stab injury site of 10 by 10 cm in diameter. Left brachial, radial and ulnar artery pulsations are palpable. Ultrasonography and CT angiography verified presence of pseudoaneurysm connected by two opening in third part of left subclavin artery (10 cm in diameter) (Figure 2). After short preoperative preparation, the patient underwent surgical intervention under general anaesthesia. Left supraclavicular incision taken to access and loop the proximal subclavin artery (Figure 3A and 3B). Left side transaxillary incision taken to access and loop the axillary artery. Intravenous heparin (5000 IU) was administered. Proximal subclavin artery and axillary artery both clamped. Dissection and separation of pseudoaneurysm followed by excision was done with cautery along with its content the clotted blood (Figure 4A and 4B). The opening of pseudoaneurysm in left subclavin artery was closed with vein patch with prolene 6-0. The vein patch was prepared from small axillary vein tributary. After putting 14 number negative suction romovac drain n supraclavicular and axillary region, wound closed in layer (Figure 5). Skin closed with stappler. Radial and ulnar artery pulsation checked. Drain removed after 48 hours. On the tenth postoperative day the patient was discharged. Discussion Post traumatic pseudoaneurysm is rare. The most common cause for such pseudoaneurysm is itragenic like post av fistula dialysis needle puncture or invasive procedures like percutaneous coronary interventions. Most common site for such pseudoaneurysm is radial, brachial and common femoral artery. Post stab injury pseudoaneurysm is rare in that subclavin artery pseudoaneurysm was rarest. If such pseudoaneurysm became infected, the surgical treatment can be extremely difficult. Although recently published, meta-analyses showed no superiority of subclavin artery stenting in such pseudoaneurysm because even after closing the opening which connect subclavin artery with pseudoaneurysm, the already formed pseudoaneurysm is high risk of infection [3,4]. So excision of that pseudoaneurysm is must. If the subclavin artery is normal with clearly visible opening that connect with pseudoaneurysm then pseudoaneurysm can be excised without sacrificing the part of subclavin artery by just vein patch closure of that opening with prolene suture. Sometimes rarely excision of part of subclavin artery with interposition grafting may be required. Conclusion The pseudo aneurysm excision was simple and safe even in inexperienced hands by proper anatomical knowledge. Proximal and distal control of artery is must for safe excision of pseudoaneurysm. By proper anatomical dissection pseudo aneurysm can be excised without damaging the surrounding vital structure like brachial plexus and axillary vein. Timely management was important to prevent complications like infection, rupture and gangrene. If the subclavin artery is normal with clearly visible opening feeding pseudoaneurysm then pseudoaneurysm can be excised without sacrificing the part of subclavin artery by just vein patch closure of opening in subclavin artery with prolene. Sometimes rarely excision of part of subclavin artery with interposition grafting may be required.

Commentary on: transaxillary endoscopic breast augmentation with shaped gel implants.

There has been longstanding resistance to the transaxillary approach to breast augmentation because of a perceived lack of technical control. There is a growing body of literature, however, that suggests many of these views may be outdated and inaccurate. In their recent review article entitled “Evidence Based Medicine: Augmentation Mammaplasty,” Lista and Ahmad suggested that either inframammary or transaxillary incisions were preferred for breast implant placement.1 Their article did not distinguish between the endoscopic and nonendoscopic transaxillary approaches. Two single-surgeon, large patient series supporting the nonendoscopic approach have recently been reported by Mills et al and Gryskiewicz and LeDuc and showed low complication and reoperation rates.2,3 Additionally, Gryskiewicz and LeDuc reported higher patient satisfaction scores reported by transaxillary patients compared with inframammary patients.3 To address the need for added technical control in transaxillary breast augmentation, the addition of endoscopic assistance was initially reported by Price et al in a series of patients undergoing saline implant placement in a partial subpectoral pocket.4 Long-term experience has since shown that endoscopic assistance has allowed for tissue visualization and control of creation of the device pocket in a way that matches the inframammary approach in how the partial subpectoral tissue pocket is created in preparation for implant placement.5 Mills et al compared available data on transaxillary breast augmentation outcomes in …

Comparison of the postoperative incidence rate of capsular contracture among different breast implants: a cumulative meta-analysis.

BackgroundA large number of clinical studies have reported that the different materials used in breast implants were a possible cause of the different incidence rates of capsular contracture observed in patients after implantation. However, this theory lacks comprehensive support from evidence-based medicine, and considerable controversy remains.ObjectivesIn this study, a cumulative systematic review examined breast augmentation that used implants with textured or smooth surfaces to analyze the effects of these two types of implants on the occurrence of postoperative capsular contracture.MethodsWe conducted a comprehensive search of literature databases, including PubMed and EMBASE, for clinical reports on the incidence of capsular contracture after the implantation of breast prostheses. We performed a cumulative meta-analysis on the incidence of capsular contracture in order from small to large sample sizes and conducted subgroup analyses according to the prosthetic material used, the implant pocket placement, the incision type and the duration of follow-up. Relative risks (RR) and 95% confidence intervals (CI) were used as the final pooled statistics.ResultsThis meta-analysis included 16 randomized controlled trials (RCTs) and two retrospective studies. The cumulative comparison of textured and smooth breast implants showed statistical significance at 2.13 (95% CI, 1.18-3.86) when the fourth study was entered into the analysis. With the inclusion of more reports, the final results indicated that smooth breast implants were more likely to be associated with capsular contracture, with statistical significance at 3.10 (95% CI, 2.23-4.33). In the subgroup analyses, the subgroups based on implant materials included the silicone implant group and the saline implant group, with significant pooled statistical levels of 4.05 (95% CI, 1.97-8.31) and 3.12 (95% CI, 2.19-4.42), respectively. According to implant pocket placement, a subglandular group and a submuscular group were included in the analyses, and only the subglandular group had a statistically significant pooled result of 3.59 (95% CI, 2.43-5.30). Four subgroups were included in the analyses according to incision type: the inframammary incision group, the periareolar incision group, the transaxillary incision group and the mastectomy incision group. Among these groups, only the pooled results of the inframammary and mastectomy incision groups were statistically significant, at 2.82 (95% CI, 1.30-6.11) and 2.30 (95% CI, 1.17-4.50), respectively. Three follow-up duration subgroups were included in the analyses: the one-year group, the two- to three-year group and the ≥five-year group. These subgroups had statistically significant results of 4.67 (95% CI, 2.35-9.28), 3.42 (95% CI, 2.26-5.16) and 2.71 (95% CI, 1.64-4.49), respectively.ConclusionIn mammaplasty, the use of textured implants reduces the incidence of postoperative capsular contracture. Differences in implant pocket placement and incision type are also likely to affect the incidence of capsular contracture; however, this conclusion awaits further study.

Modification of two-incision trans-axillary robotic thyroidectomy

The objective of this study is to describe the modification of port placement for the four-arm technique of robotic thyroidectomy to avoid a chest incision and eliminate crowding of the working space provided by the trans-axillary incision. The study methodology involved description of port placement modification to avoid chest incision and report of two cases with appropriate literature review is presented. Trans-axillary robotic thyroidectomy (TART) is often performed with a second chest incision, but the move toward single incision operation and placement of four arms via a single incision require expertise. We describe two patients who underwent TART using a trans-axillary incision and a separate 1 cm incision in the anterior axilla 2.5-cm below the trans-axillary incision for placement of the fourth arm. This design allowed for a more ergonomic placement of the fourth arm while not compromising the working space provided by the trans-axillary incision. Additionally this port was used for surgical drain placement Robot-assisted trans-axillary thyroidectomy poses several challenges in the early surgical learning curve. One roadblock to exposure and efficiency is appropriate port and arm placement. Our modification offers an alternative where a four-arm technique is made possible without a chest port and not occupying the working space provided by the trans-axillary incision. Use of this inferior axillary port is cosmetically acceptable, surgically efficient, and allows avoidance of a visible chest incision for placement of the fourth arm.

Clinical applications of dual plane breast augmentation under endoscope through transaxillary incision

Objective To introduce the technical key points and clinical efficacy of dual plane breast augmentation under endoscope through a transaxillary incision.Methods By analyzing the 89 surgical cases,we have summarized the key points of the pre-operative design,surgical skills and postoperative management.Results All patients had no uncontrolled bleeding during operation and loss of nipple and areola sensation.71 patients got 6-12 months follow-up,showing that only one case presented with unilateral capsular contraction,and the others had satisfied results.Conclusions Blunt dissection can reduce the risks of uncontrolled bleeding on the inner side of the pocket and the damage of the nerves on the lateral side of the dissecting pocket.The lower inner part,lower part and lower lateral part are the areas that could be sharply dissected by electrocautery under endoscope to achieve the dual plane Ⅰ.The drainage and bandage are necessary after the operation. Key words: Endoscope; Breast augmentation; Dual plane technique

Axillary Endoscopic Subglandular Tunneling Approach for Types 2 and 3 Dual-Plane Breast Augmentation

Dual-plane techniques offer excellent pocket locations for breast augmentation. Traditional techniques require incisions in the inframammary or periareolar crease, which are rarely accepted in the authors' department because of visible scars on the breast. Therefore, the authors developed a transaxillary approach for dual-plane procedures using an endoscope. During a period of 36 months between April 2009 and March 2012, 89 consecutive patients with small breasts were treated surgically. They underwent transaxillary types 2 or 3 dual-plane breast augmentation as outpatients. For the axillary endoscopic subglandular tunneling approach (AESTA), a long subglandular tunnel was created along the lateral portion of the pectoralis major muscle to reach the nipple-areolar complex. The type 2 dual-plane technique was applied in 67 patients, and the type 3 technique was used in 22 patients. The mean age of the patients was 37.5 years (range 31-48 years), and the mean postoperative follow-up period was 11 months (range 7-42 months). Good surgical outcomes were obtained, and the procedure was reproducible. The use of AESTA allowed the authors to achieve types 2 and 3 dual-plane breast augmentation through a transaxillary incision. They believe that AESTA can yield constant and satisfactory outcomes similar to the inframammary and periareolar approaches. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Trans‐axillary Robotic Thyroidectomy: Avoiding the Chest Port

Objectives: Describe modification of port placement for the four-arm technique for robotic thyroidectomy to avoid a chest incision and eliminate crowding of the working space provided by the trans-axillary incision. Methods: Description of port placement modification to avoid chest incision as well as report of two cases and appropriate literature review. Results: Placement of four arms via a trans-axillary incision requires expertise. Transitioning from a chest port for placement of the fourth arm to a single-incision surgery, avoiding a visible chest incision, can be challenging. We describe this technique and two cases of trans-axillary robotic hemithyroidectomy (TART) using a trans-axillary incision and a separate 1 cm incision in the anterior axilla, 2.5 centimeters below the trans-axillary incision, for placement of the fourth arm. This design allowed for a more ergonomic placement of the fourth arm while not compromising the working space provided by the trans-axillary incision. Additionally this port is used for surgical drain placement. Conclusions: Robot-assisted trans-axillary thyroidectomy poses several challenges in the early surgical learning curve. One roadblock to exposure and efficiency is appropriate port and arm placement. Our modification offers an alternative where a four-arm technique is made possible without a chest port and without occupying the restricted working space provided by the trans-axillary incision. Use of this inferior axillary port is cosmetically acceptable, surgically efficient, and allows avoidance of a visible chest incision for placement of the fourth arm.

Comparison of Breast Augmentation Incisions and Common Complications

The recent article by Stutman et al, regarding the comparison of breast augmentation incisions and complications was reviewed with emphasis on capsular contracture. In contrast to other articles in the literature, the authors did not find a difference in contracture rates between the inframammary, periareolar, and transaxillary incisions. The patient data used, however, did not include a key issue regarding contracture-the use of breast pocket irrigation, which has been shown to significantly reduce the incidence of contracture. The authors' conclusion that surgeons may proceed without worry that there is a difference in complication rates between incisions is contrary to mounting evidence. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Effect of Incision Choice on Outcomes in Primary Breast Augmentation

Capsular contracture (CC) is the most common complication following primary breast augmentation and one of the most common causes of reoperation. Various studies have suggested certain risk factors, including incision choice. The authors investigate a possible association between the three most common breast augmentation incisions (inframammary, periareolar, and transaxillary) and CC. The authors conducted a retrospective chart review of 197 primary breast augmentation patients treated between 2003 and 2009. Significant CC was determined to have occurred if the patient required reoperation for her CC. Patients were excluded if they underwent an augmentation/mastopexy, had previously undergone breast surgery, or received shaped silicone gel implants. CC rates were analyzed on a per-patient basis with Fisher's exact test and on a per-breast basis with the Rao-Scott chi-squared test. One hundred eighty-three patients (336 augmented breasts) were included. Average patient age was 36.5 years. Mean follow-up was 392.6 days. Surgical complications included six breasts with CC (1.8%), three with hematoma (0.9%), and one with an infection (0.3%). Transaxillary incisions produced the highest incidence of contracture (6.4%), followed by periareolar (2.4%) and inframammary (0.5%). There was a statistically-significant difference in the incidence of CC among the three incision sites (P=.03). The increased rate seen with transaxillary incisions versus inframammary incisions was also statistically-significant. No significant association between implant fill material and contracture was found (P=.27). The risk of CC is significantly higher with transaxillary incisions than with periareolar or inframammary incisions. 4.