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November 27, 2009

Breast Implants: Consideration #5: Location of Incision

There are four commonly used incisions for breast augmentations.

  1. Inframammary fold - a gently curved incision in the fold beneath the breast
  2. Periareolar - a semicircular incision around the lower half of the areola
  3. Transaxillary - a straight incision in an armpit crease
  4. Transumbilical - a curved incision in the upper half of the umblicus

Incision options

According to a recent study published in the Aesthetic Surgery Journal, Board Certified Plastic Surgeons in the USA prefer the inframammary fold and periareolar approaches.  The actual percentages of Board Certified Plastic Surgeons who prefer a particular approach...

  1. Inframammary fold - 64%
  2. Periareolar - 25%
  3. Transaxillary - 8.7%
  4. Transumbilical - 0.4%

Why is the inframammary approach most popular?

  • Most versatile:  Any type of implant (saline or silicone, round or tear drop, smooth or textured, small or large) can be placed through this incision.  The inframammary approach allows access into either of the available pockets (under the breast or under the breast + muscle).
  • Useful for secondary surgery:  Hopefully, you will not need a second (or third) surgery.  However, most implants will not last the lifetime of a women undergoing primary breast augmentations in her 30s.  She should plan on additional procedures.  The inframammary incision can be reused again and again for replacements of implants, corrections of problems, etc.
  • Excellent precision:  Because the incision is directly beneath the breast, the surgeon can see what he is doing.  Any bleeding can be immediately stopped.  The pocket domain can be precisely controlled.  There is no need for guesswork.
  • Distant from nerves and milk ducts:  Because the inframammary incision is away from nerves and milk ducts, there should (theoretically) be a decreased incidence of nipple numbness and fewer difficulties with subsequent breast feeding.  Moreover, since milk ducts may contain bacteria, remaining distant to bacteria may reduce a patient's risk of infection.
  • Good aesthetics:  Inframammary scars tend to heal well; scars rarely hypertrophy (become thick and raised).  Moreover, since an attractive breast has a subtle "hang," the mound should itself obscure the resultant scar.  At the minimum, the inframammary scar should fall within the shadow of the breast.
  • Limitations:  Very, very few.
    • Rare patients may have so little natural breast tissue that they don't really have folds; these patients may benefit from another approach.
    • Constricted breasts may be better treated with periareolar incisions.  (Constricted breasts are tight breasts with little tissue other than immediately behind the areolae.)
    • Others may object to the scar, but they must remember that the other scars (periareolar, transaxillary, and transumbilical) may be more advantageous only in the short term.  If those patients need secondary surgery, they are probably going to end up with inframammary incisions anyway.  Then, they have two sets of scars. 

Why is the periareolar incision also frequently used?

  • Somewhat versatile:  Many types of implants can be placed through this incision; however, large silicone implants cannot always be placed through small areolae.  Tear-drop-shaped implants may be difficult to maneuver through small areolae too.  Both the subglandular and subpectoral pockets can be created through this incision.
  • Particularly useful for constricted/tubular breasts:  The areola can be reduced in size at the same time.
  • Can be useful for some secondary surgeries:  Some secondary surgeries can be performed through this approach.  However, on other occasions, the surgeon must convert to an inframammary technique.
  • Excellent precision:  Like the inframammary incision, the periareolar approach allows for great control and precision.
  • Good aesthetics:  Periareolar scars may be somewhat invisible.  For maximum camouflage, some plastic surgeons advocate tattooing any visible scars with ink similar in color to the patient's natural areolae.
  • Limitations:  Some.  But this is still a useful technique.
    • If the patient has small areolae, then the periareolar incisions may not allow for placements of large silicone implants or tear-drop-shaped implants.
    • Some secondary surgeries may still require an inframammary approach.
    • Periareolar incisions may be more likely to damage the nerves that supply nipple sensation.  If erogenous nipple sensitivity is important to the patient, this may not be the best approach.
    • Periareolar incision may be more likely to damage milk ducts.  If the patient might breast feed in the future, then this may not be the best choice.

What are the problems with the transaxillary approach?

  • Only somewhat versatile:  Saline implants can be easily placed through the armpit.  However, it is difficult to place even moderate-sized silicone implants through the transaxillary incision.  It would be very difficult (if not impossible) to place tear-drop-shaped implants through this approach.  Both the subglandular and subpectoral pockets can be created through this incision.
  • Not useful for most secondary surgeries:  Most of these patients will end up requiring a second set of incisions (probably at the inframammary folds.  Then, they are stuck with four incisions, rather than just two.)
  • Reduced precision:  Unless complex endoscopic equipment is used to improve visualization, precision is markedly reduced.
  • Usually, good aesthetics:  If the scar heals nicely, then the breast itself has no scars (until the secondary procedures).  However, some of these incisions heal thick.  Then, the patient is stuck with scars that other people will see when she wears routine clothes, such as tank tops.
  • Limitations:  Many.  I don't use this technique anymore.
    • While some surgeons claim that they can place small silicone implants through transaxillary incisions, they certainly cannot get medium or large silicone implants through this approach.
    • It would be very difficult to orient tear-drop-shaped implants via the armpits.
    • Secondary surgeries can only very infrequently be performed through the under arms.  Usually, these patients will require inframammary incisions.
    • Without complex endoscopic equipment, visualization is impaired.  Could there be a greater likelihood for bleeding complications and for malpositioned implants?

Why is the transumbilical breast augmentation (TUBA) condemned?

  • This is a novelty technique.  Most Board Certified Plastic Surgeons think that it is foolish.
  • No versatility regarding implant type:  Only round, saline implants are possible with the TUBA.  It would be impossible to place a silicone implant or a tear-drop-shaped implant with this technique.
  • No subpectoral placement:  Only subglandular placement is possible.
  • Not at all useful for secondary surgeries, under any circumstances.
  • Poor precision:  Most of the patients complain that at least one of the two breasts is "off to the side" or "too close to the middle."
  • The scar may be invisible.  However, a secondary procedure would necessitate inframammary or periareolar scars.
  • This technique is officially condemned by implant manufacturers.  Use of the TUBA approach invalidates device warranties.

Bottom lines: 

  • Like my colleagues around the country, I advocate incisions at the inframammary folds and around the areolae.
  • For most patients, the fold will be best, especially since silicone is becoming so much more popular than saline.
  • In the unusual patient who either has constricted breasts or poorly defined folds, periareolar incisions may be better.



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A Facebook User

I had implants replaced this last year. I'm 57, left handed, good health or abnormalities. After the surgery my right breast started to heal differently than the right. The implanted appears to be higher & points downward on the right. It's firmer & feels like it's pinched or twisted. When I use my right hand or flex my neck muscles my right breast jumps. What is going on with my right implant? Why is it so different?

Michael C. Pickart, M.D., F.A.C.S.

I wonder whether...
* this is part of the normal healing response, or
* your right breast is suffering an early capsular contracture

Please see your plastic surgeon. Or, visit a Board Certified Plastic Surgeon in your locale. You deserve a proper diagnosis and treatment regimen.

For early capsular contractures, I usually recommend vitamin E, ibuprofen, and breast implant massage. It's likely that non-operative measures will help.

Good luck!

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