1. Division of Plastic Surgery Federal University of São Paulo – EPM. São Paulo - Brazil UNIFESP Breast Augmentation with Transaxillary Approach: The Advantages of a Z Incision. A 344 Case Experience Authors: Élvio Bueno Garcia, MD, PhD* Antonio C. Graziozi, MD, PhD* Marcel V. A. de Menezes, MD Natasha Sallum, MD Lydia M. Ferreira, MD, PhD* Breast Augmentation with Transaxillary Approach: The Advantages of a Z Incision. A 344 Case Experience Authors: Élvio Bueno Garcia, MD, PhD* Antonio C. Graziozi, MD, PhD* Marcel V. A. de Menezes, MD Natasha Sallum, MD Lydia M. Ferreira, MD, PhD*

2. This study describes the axillary incision in a Z form in order to facilitate its approach with a direct access to the pectoralis muscle margin and better aesthetic results in a scar with tension line breaking. OBJECTIVE Nothing to disclose

3. 344 patients were operated aging from 18 to 50 years old between 2004 and 2009. Inclusion critteria: patients desiring breast augmentation and breasts free of scars. Exclusion critteria: previous breast surgery, ptosis, asymmetry, tubular breast. MATERIAL AND METHODS

4. Non endoscopic axillary approach Submuscular plane Textured silicone gel implants ranging from 175 cc and 350 cc MATERIAL AND METHODS

5. The Z incision: located inside the axilla’s hair 2cm each leg of the Z Skin is moved by traction superiorly towards the pectoralis muscle margin. MATERIAL AND METHODS

6. Dissection: made with a rhombus dissector from the upper pole until 2 cm under the inframammary crease Implant placed through the axilla Closure leaving suction drains MATERIAL AND METHODS

7. The Z scar permitted a wide access which facilitated the pectoralis muscle approach. It also abbreviated surgical time since no subcutaneous tunnel is needed. The scar's aesthetic result was well disguised. Follow up: 1 to 6 years RESULTS

8. Z scar in the same patient a 6 months and 4 year follow up RESULTS

9. Aesthetic result in a 1 year follow up RESULTS

10. RESULTS

11. RESULTS Complication rate: Seroma …………………………………..….6,17% Unfavorable aesthetic result ………………5,2% Inframammary fold asymmetry …..……1,7% Implant lateralization ………………..….0,85% Double inframammary crease ……..….0,58% Implant cranially malpositioned ……….1,7%

12. The Z scar hasn't been prolonged beyond the limits planned. It could possibly happen with a linear or curved incision when moved laterally by tracion. DISCUSSION

13. Provides the same result on the breast Smaller and broken lined scar Less noticeable scar Comparative studies about aesthetic results between different types of scars could be published. DISCUSSION

14. A standout aesthetic result along An amplified, facilitated and shortened procedure. Inclusion of even bigger implants Simplified the procedure, revealling to be a favorable choice for patients undergoing breast augmentation. CONCLUSION