Why Isn't Endoscopic Breast Augmentation More Common?

I'm exploring potentially getting a breast augmentation but I am worried about having large scars. Out of the possible incisions used for a breast augmentation, it seems like endoscopic-assisted breast augmentation through the arm pit is the best way to hide a scar. Why aren't all breast augmentations performed this way? I assume there is a downside to this procedure but I don't know what it is. 


F, 23, New York

Great question. There are many technical differences between the endoscopic technique ("transaxillary breast augmentation") and inframammary breast augmentation.


Transaxillary breast augmentation -- where the breast implants are inserted through a small incision in the armpit -- has a number of increased risks associated with it. The risk of capsular contracture is slightly higher, and there's a slightly higher risk that the implant will migrate out of the pocket post-operatively.

Because the armpit naturally contains more bacteria, the risk of infection is slightly higher. And because there are so many nerves and blood vessels which transit through axilla, there's a higher potential for nerve damage or bleeding during endoscopic breast augmentation.

For a skilled plastic surgeon however, none of these risks amount to a significant reason to avoid the transaxillary approach.

Many plastic surgeons feel they have more control of the pocket when using the inframammary approach. Working with the hands allows plastic surgeons to feel the size and shape of the breast pocket more intuitively, and ensures correct placement and more perfect symmetry.

Conversely, it can be harder to gauge the dimensions of the pocket when working endoscopically, which can raise the risk of asymmetric implant placement.

The final decision, of course, lies with the patient. Today many patients prefer silicone gel implants, which cannot be implanted using the endoscopic approach. Also, if you wear tank tops or summer dresses, the small scars from armpit incisions may be more visible in some situations than the scars from crease incisions.

I suggest you talk to your plastic surgeon about the risks and benefits of each approach and see which approach he or she prefers.

Dr. Christine Blaine has 1 Breast augmentation before & after:

» View Dr. Christine Blaine's full profile

Every plastic surgeon will have their own opinion regarding the best approach for breast augmentation surgery. Transaxillary endoscopic breast augmentation can be more difficult and does carry some additional risks.

The endoscopic approach can be difficult to master, but today, with the advent of the Keller funnel, the approach has become easier and much more accurate than it used to be.

Keep in mind that if you want silicone implants, the two main options are the inframammary approach and the periareolar approach. Many plastic surgeons prefer these over the transaxillary approach because they have better precision when working with their hands.

You should consult with your plastic surgeon and see which breast enhancement technique he or she recommends in your specific case.

Dr. Robert Brueck has 1 Breast augmentation before & after:

» View Dr. Robert Brueck's full profile

While the arm pit or axillary procedure can have a very good result, my opinion of this approach lead me away from it. Often the incision ends up having to be enlarged to fit the implant in anyway. You are pretty much confined to saline implants if you're going to use a small incision. There is a slightly higher risk of capsule contracture and infection due to bacteria that live in the armpit. It is more difficult to achieve symmetry as much is done visually rather than by feel. I personally like to be able to feel the pocket with my fingers and evaluate symmetry and contours before I place the implant. Also this incision is not on the breast but it is in a location that may be visible in a tank top or bathing suit if it doesn't scar well.

Dr. Christopher Park has 3 Breast augmentation before & afters:

» View Dr. Christopher Park's full profile

The scarring for breast augmentation is generally excellent, and the reason that endoscopic breast augmentation has fallen out of favor is because its major benefit of being able to control for an extremely small incision was with use of saline implants which since the re-release of silicone breast implants back into the cosmetic market in 2006 are selected much more infrequently. The incisions for breast augmentation, most commonly in the breast fold, heal extremely well and well hidden. Good Luck

Great question!

Transaxillary breast augmentation has its proponents but it is not at all clear that it is the best approach. 

Pros and cons:

Axillary/endoscopic approach: pros: scar is off the breast, maybe less risk of change in nipple sensation or traversing breast gland tissue; cons: not all surgeons are comfortable with this approach, may have some increased risk of exposure to bacteria from the axillary area, more controlled pocket may be harder to develop, insertion of large silicone implants requires a larger incision which may counteract the benefits of an axillary incision, there may be an increased risk of implants migrating out to the upper outer breast depending on how the pocket is formed, and there are nerves and blood vessels in the axilla that are at risk which are typically not encountered from other approaches.

Inframammary (under breast) approach: lower risk of biofilm (bacterial film that can get on implants and increase risk of capsular contracture), faster surgery, easy to control pocket and easy to get large implants in if you have to extend the incision; cons: scars may be a bit more visble (though my patients have been very happy)

Periareolar (nipple): very hard to see scar, flexible for all types of implants, very popular with patients; cons: may have slightly increased risk of biofilm exposure to the implant (see above)

For more information visit plasticsurgery.org or surgery.org. Happy to help you in your decision-making process!

Dr. Tim Sayed has 5 Breast augmentation (Saline breast implants), Breast lift, Extended abdominoplasty before & afters:

» View Dr. Tim Sayed's full profile

The most popular technique for performing breast augmentations in the inframammary incision. This allows the surgeon the most accurate access to the breast pocket.

The only implant that can be used for an under arm incision is a saline implant. Those implants are being placed less frequently now as the gel implants continue to increase market share due to the more natural look and feel of gel implants. Some implant companies in the US are discontinuing warranty support on saline implants as they become less popular.

Dr. Jack Peterson has 1 Breast augmentation before & after:

» View Dr. Jack Peterson's full profile

Two reasons #1 recent studoes show that the inframammary incisions have the lowest capsular contracture rates and #2 you should not have "Large scars" anyway you have them if you use a skilled breast surgeon.

Dr. Manuel Pena has 3 Breast augmentation before & afters:

» View Dr. Manuel Pena's full profile

In good hands the axillary incision that you have in mind works very well. Most incisions from breast augmentation are well hidden no matter which is chosen. That's why the arm pit incision is not as common in the USA. The fold incision is most common since it's the most reliable for symmetry in the hands of most surgeons. It also allows switches and revisions to happen easily down the road. 

Hi Snap37, 

Endoscopy, surgery via small incisions using a lighted device called an endoscope, is the proverbial hammer in search of a nail. While it has revolutionized many areas of surgery, it has had limited application for plastic surgery. Much of what plastic surgeons do involves the need for larger incisions and this effectively negates the advantages of endoscopic surgery. 

Endoscopic breast augmentation has not caught on for several reasons. One of these is that it is limited to inserting saline implants. Saline implants are can be placed in the breast empty and filled once inside the implant pocket. This allows us to roll the implant into a thin tube and insert it through a tiny incision. I can put an implant into a breast, without an endoscope through a 1 inch incision under the breast. Using an endoscope, it is true that you can insert a saline implant through a site away from the breast, such as the armpit or the belly button thus avoiding a scar on the breast. There are a number of problems with this technique, however. 

To obtain good results, it is critical for the implant pocket to be created just so. The limited access provided by the endoscope compromises the ability to do this. Breast implant insertion through the armpit, with or without the use of an endoscope, has been around for nearly thirty years. The technique has never caught on widely because malposition of the implant is more common with this approach. This looks much worse than any scar.  In addition, if any bleeding occurs, it may be impossible to deal with through this incision. Finally, if there is any need for a revision of the surgery later, for any reason, a not uncommon occurrence, it cannot be done through the armpit. Even the surgeon who pioneered breast augmentation through the armpit no longer promotes this approach. 

I cannot emphasize enough how ridiculous it is to try to put in a breast implant through the belly button, the so-called TUBA (trans-umbilical breast augmentation). As I said above, it is a case of a hammer in search of a nail. What it does is make an easy operation very difficult. You can do the operation this way but you are limited to saline implants. I have to ask why go to all this trouble to avoid a 1 inch scar hidden under the breast? Although it has been around for years, the TUBA has never gained traction and less than 1 percent of breast augmentations are done this way. I feel that surgeons who advertise this use it primarily as a marketing gimmick to draw patients to their practice who don't want a scar anywhere on their breast, then convince them to have the operation done more conventionally. 

The popularity of silicone gel implants, since they came back on the market for cosmetic breast surgery has soared. These implants are pre-filled and must be inserted using a larger incision, typically 2-3 inches long, depending on the size of the implant. For the newest, form stable ("gummy bear") implants, the incision may have to be 5 inches long. The only practical location for this incision is in the crease under the breast. Although the scar is longer, it is well hidden and problems with this scar (widening, thickening, etc.) are uncommon. Trying to put a gel implant in through a small incision is like trying to put tooth paste back into the tube! Try that sometime. 

There is one final location for an incision to insert breast implants. This is along the edge of the areola. The length of this incision is limited and it may not be an option at all for women with small areolae, or those needing a large implant. I intensely dislike this location. The nipple/areola is the aesthetic focal point of the female breast. This is what draws our eyes. Any scar there, no matter how fine, will be visible and detract aesthetically, not to mention clearly showing that you have had surgery. It is  more difficult than the more straightforward incision in the crease under the breast, has a greater chance of reducing sensitivity of the nipple, and may affect breast feeding later. Why would you want to do this?

I advocate strongly in my patients for an incision under the breasts, for all the above reasons, regardless of what implant type or size they choose. 

Hope this helps!


R. T. Bosshardt, MD, FACS

Because the added costs and increased risks if bleeding happens than you will have 1 or 2 incisions to control any issues. If it ant broke why fixit? The majority of implants use circumareolar or infra mammary access incisions....