Trans-axillary approach for breast implant exchange in high risk cases of irradiated or attenuated skin

SummaryBackgroundBreast reconstruction with implants after tissue expansion is one of the most common methods of reconstruction. Although this approach is generally reliable, exchange of breast tissue expander for implant through the standard anterior incision presents a challenge in cases with attenuated soft tissue envelope due to radiation, thin anatomy, prior surgery, or combination of the above. We propose that a trans-axillary approach is a safe and alternate approach for implant exchange in the high-risk patients.Technique and case examplesA case series of 16 patients with multiple risk factors for compromised soft tissue that underwent a trans-axillary approach for implant exchange is reported. The trans-axillary implant exchange technique involves use of a standard 4 cm axillary incision, removal of the expander, judicious capsulotomy, placement of permanent implant, and closure in three separate tissue layers.ResultsAll trans-axillary cases were successful and all incisions were well healed without dehiscence, infection, or seroma. The average patient age was 49.4 years, and 50% of patients had received or were scheduled to receive radiation therapy. Nine patients underwent unilateral trans-axillary expander exchange while 7 patients were bilateral. Median implant size was 360 cc (mean 369 cc, range 150–600 cc), and mean follow-up for all patients was over 24 months. There were no cases of implant extrusion, capsular contracture requiring re-operation, or lymphedema. Six patients underwent concurrent or subsequent nipple reconstruction.ConclusionsThis approach illustrates application of a technique commonly used in breast aesthetic augmentation to address a common reconstructive dilemma, which we believe to be a useful tool in prosthesis-based breast reconstruction, especially in patients with compromised soft tissue envelopes.