One of the most frequently asked questions about cosmetic surgery concerns scarring. The ideal is to have a successful cosmetic procedure and have no scars at all. Unfortunately, we are surgeons, not magicians, and scars are a fact of life. Many techniques have been tried to reduce or eliminate scars. Some have come and gone. Others have stayed. One of these is endoscopic surgery. It has been applied to many procedures, including breast augmentation. On the surface endoscopic breast augmentation through the armpit sounds like a winner. You get breast implants, no scar on your breasts, and only a tiny scar in the armpit. What's not to like? Well, there is more to it than that. There always is.  

Endoscopy, surgery via small incisions using a lighted device called an endoscope, is the proverbial hammer in search of a nail. As with lasers, it has been over-hyped and some practitioners have tried to promote it for procedures where it provides no real advantage and actually creates problems. 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 one of the biggest 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 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, this is truly 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. 

Endoscopic breast augmentation peaked during the period when only saline implants were available for breast augmentation. Since silicone gel implants came back on the market for cosmetic breast surgery in 2006, their popularity 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.