Subfascial Transaxillary Approach in Primary and Secondary Breast Augmentation: An Update and Critical Evaluation of a 25-Year Review of 1015 Consecutive Cases

Subfascial pocket (SF) breast augmentation (BA) has gained popularity, while the transaxillary approach (TAA) offers the benefit of an inconspicuous scar. Previous reports on both techniques involved limited follow-up/samples, and few clinical studies specifically address surgical technique and outcomes following primary and secondary BA. Objectives: Assess outcomes from the SF TAA technique in a large series of patients who underwent primary and secondary BA. Methods: A retrospective cohort of patients who underwent BA between 1999 and 2024 was identified. The primary outcome was occurrence of incision and implant/pocket complications. Regression logistic analysis evaluated risk factors including age, BMI, smoking, implant surface/volume, and fat grafting. Results: The cohort contained 1015 patients (mean age: 28.5±7.3 years) and average follow-up was 77.6±38.6 months. In primary BA, 212 patients (23.4%) experienced at least one complication, most frequently capsular contracture. More complications were seen in secondary BA (p=0.016). Multivariate regression identified BMI<18.5 kg/m 2 as a significant risk factor for incision complications, while textured surface (OR: 2.70; p <0.001) and implant volume >350 cc (OR:2.79; p <0.001) were risk factors for implant/pocket complications. Conclusions: Despite extensive research on BA procedures, studies on SF TAA procedures are limited and have not analyzed long-term outcomes following primary/reoperative surgeries. Our results demonstrate that SF TAA is a reliable technique, and our data are compatible with other studies using different BA approaches. Knowledge of the axillary and pectoralis fascia anatomy allows surgeons to safely implement the SF TAA technique while minimizing risk.