For the uninitiated, breast augmentation may seem like a simple procedure with few nuances. But ask a room full of plastic surgeons and you’ll quickly hear different opinions about the best way to get the job done. Ultimately, the best approach is one that fits your anatomy and goals, which is why consulting with multiple surgeons can help you find the right match for you. While there are many established approaches, one more polarizing option—endoscopic biaxial breast augmentation—has gained attention.
Patients are often interested in biaxial breast augmentation because the incision is placed in the armpit and, when done well, “looks like nothing more than a crease,” notes Laguna Beach, CA plastic surgeon Daniel Mills, MD. This technique “preserves the natural anatomy of the breast without unnecessary dissection or disruption,” adds Newport Beach, CA plastic surgeon Goretti Ho Taghva, MD.
That said, some surgeons say the technique is far from their first choice. “Most plastic surgeons will choose an incision in the inframammary fold because it’s easier to see and control what’s going on with the implant and your body,” says Denver plastic surgeon Philippe A. Capraro, MD. “If you choose to proceed with an endoscopic biaxial breast augmentation, choose a surgeon who is comfortable and confident with the procedure.”
Dr. Mills, who has performed thousands of biaxial breast augmentations, says one of the biggest limitations is that many surgeons have never been trained in the technique and therefore avoid it. “This is a highly operator-dependent procedure,” says Dr Ho Tagva. “It requires experience, repetition and a thoughtful approach.”
“If this is a technique that interests a patient seeking breast augmentation, they should do their research to find the best board-certified plastic surgeon who has significant experience and can show the results of the surgeries they’ve had,” adds Las Vegas plastic surgeon Mike Edwards, MD.
Ahead, we break down what endoscopic biaxial breast augmentation involves, who it’s best for, and what to consider before choosing this approach.
What is endoscopic biaxial breast augmentation?
“An endoscopic biaxial breast augmentation is a breast implant procedure performed through a small incision hidden in the natural crease of the axilla/armpit,” says Dr. Ho Taghva. In her office, she uses “a high-definition endoscopic camera to create the implant pocket under direct visualization, rather than working blind. This allows me to precisely control the dissection, identify and protect blood vessels, and precisely place the implant—all without making incisions in the breast itself.”
While Dr. Ho Taghva notes that some surgeons perform this procedure without an endoscopic camera, she and Dr. Capraro believe it is vital to use one. “The placement of the incision in the armpit drastically affects the surgeon’s ability to see exactly what he is doing and where the implant is being placed,” says Dr. Capraro, which makes the endoscope essential. “When performed under true endoscopic visualization, it allows for accurate pocket creation, careful hemostasis, and consistent, reproducible results,” adds Dr. Ho Taghva.
What are the benefits?
“For many patients, the biggest appeal is that there is no scar on the breast or around the nipple,” says Dr. Ho Taghva. “The axillary incision tends to heal very well and is discreetly hidden when the arms are down. As a female, board-certified plastic surgeon, many of the patients who seek me for this approach appreciate the discretion, proportion, and long-term aesthetics.”
Another advantage is that the farther you are from the nerve in the nipple, the less likely you are to injure the nerve, notes Dr. Mills. He also prefers this incision over others because it avoids going through the breast tissue, thus reducing the chance of bacteria invading the ducts.
Who is a good candidate?
“This technique works best for patients who already have relatively symmetrical breasts and do not have significant glandular ptosis (breast droop)—in other words, patients who do not need a breast lift,” says Dr. Ho Tagva. “These are often first-time augmentation patients with good skin quality and well-defined anatomy. Many of the women who choose this approach are very aesthetic-conscious. They want a natural, balanced enhancement and are particularly concerned about avoiding any scarring of the breast itself.”
While Dr. Mills uses this technique almost exclusively, agreeing that it’s best for someone who doesn’t have a really defined submammary fold or a lot of droop. “It doesn’t stop the breast from falling off the chest, so these people will need another incision someday to get a lift anyway,” she explains.
Dr. Mills and Eugene, Oregon plastic surgeon Mark Jewell, MD note that the treatment is especially popular with Asian women. It’s the most preferred incision in Asia because they tend to get more hypertrophic scars, so to avoid clearly visible scars, they often opt for biaxial implants, explains Dr. Mills.
Additionally, many patients with athletic or slim body types seeking the refined aesthetic of Pilates or yoga seek this approach, says Dr. Ho Tagva. “This approach is also particularly beneficial for patients who do not have a well-defined inframammary fold—often because they have very little native breast tissue—where an inframammary incision is more likely to heal poorly or result in a visible, unnatural-looking scar.
Dr. Edwards says there are good plastic surgeons who can do this successfully in more complex patients with asymmetry and some degree of glandular laxity, but notes that it should be reserved for specialists who perform the technique regularly.
Dr. Ho Taghva also says that those who have previously had breast augmentation through other incisions might be better served with approaches that allow direct access for lift and revision work. However, if you want to revise a biaxial breast augmentation, Dr. Mills notes that you can successfully go back through the armpit incision.
What are the disadvantages?
Dr. Jewell names “animation distortion, implant rejection due to non-enhancement of the IMF, the need to wear an upper chest compression strap to push the implants down for four to six weeks, and a published higher risk of capsular contracture/infection” as some of the potential disadvantages of this technique.
Dr. Ho Taghva identifies the main drawback as the technical requirements of the process. “When done without adequate experience or visualization, the risks of asymmetry, malposition, or bleeding are increased,” he says. “It requires specialized training, comfort with endoscopic imaging, and a strong understanding of anatomy from a distant field of view. Because of this, it is not widely offered and is not suitable for every patient, particularly complex revision cases or patients who require elevation,” he says.
Dr. Capraro points to surgeons’ limited visibility as another issue, adding that complications will be more difficult to approach if they arise. The surgeon will also have to be more diligent in creating the perfect implant pocket to prevent movement later, he adds. In addition, Dr. Mills notes that with an inexperienced surgeon using this technique, you are more likely to end up with unevenness in the inframammary fold.
New York plastic surgeon Mokhtar Asaadi, MD, does not advocate this approach because “breast surgery creation should be very precise with minimal trauma to the muscles and soft tissues.” In addition, he says that “the implant should not touch the breast tissues and skin at the time of insertion.” Dr. Edwards notes that lateral or inferior implant malposition and failure of the implant to descend properly can also be concerns.
