Breast Implant Incision Options

What are the incision options for breast augmentation? What are the scars like?

Breast augmentation incisions are placed strategically so as to be minimally noticeable once the incisions have healed. There are three incisional approaches that are commonly used: at the border of the areola (peri-areolar), in the underarm area (axillary) and in the crease at the bottom of the breast (inframammary fold). Each has advantages and disadvantages, and each is ideal for a particular kind of preoperative scenario.

Peri-areolar incision

This is made at the border of the areola, from about the 4 o'clock to 8 o'clock position. It works nicely for patients with larger areolar diameters (4.0 cm or larger), as if often the case after pregnancy and lactation. The color difference between areolar skin and breast skin nicely conceals the scar in most cases, and in many patients the scar is almost undetectable within just a few weeks or months of surgery. This incision truly has the possibility of producing a scar that is ultimately invisible or almost invisible.

A theoretical downside with this incision is that it by definition requires the division of milk ducts when the breast tissue is dissected down to the pectoralis major muscle, and this may interfere with future attempts at breast feeding. There are some who believe that this incision carries a higher risk for capsular contracture as bacteria may be present in the milk ducts which could possibly adhere to the implant surface during breast augmentation surgery, which may over time lead to contracture. The latter is a theoretical concern, and it has not been conclusively shown that the peri-areolar approach has a higher rate of capsular contracture than the axillary and inframammary fold approaches. The peri-areolar incision is therefore still frequently used, as the aesthetic outcomes are usually excellent.

Trans-axillary incision

This is the ideal approach for patients with very youthful-appearing breasts, who do not require correction of significant breast asymmetry or major alteration of breast shape (such as tubular breasts). When the breasts are small and perky, the inframammary fold is clearly visible and it therefore does not conceal a scar very well - and sometimes not at all. If the areolar diameter is small, then a peri-areolar incision is not practical. So patients with small, perky breasts and small areolar diameters are best served by an incision in the underarm area, also known as the transaxillary approach.

Placing an implant through this approach is technically more challenging and requires the use of an endoscopic camera and endoscopic surgical instruments. Make sure the surgeon who offers you an augmentation through this approach has a great deal of experience with it. The axillary incision must heal in a warm, moist environment, and it therefore takes longer to fade to the point that is difficult to see. Patients tend to be a bit self-conscious about raising their arms above their head while wearing a swimsuit for the first six to nine months after surgery, but by one year postop most have a scar that is difficult to discern even on close-up examination of the underarm area.

Inframammary fold incision

This is the most commonly used incision for breast augmentation in some practices, primarily because it is the quickest and easiest approach. It is a reasonable approach to use for patients that have fuller, more pendulous breasts, where the lower pole of each breast hangs over the inframammary folds somewhat and will tend to conceal a scar placed in this area. It is not a great choice for a patient with very perky, youthful-appearing breasts where the inframammary folds are clearly visible, and will remain clearly visible postoperatively.

Another problem with this incision is that even when breasts are full in the lower pole and somewhat pendulous, there is nothing to conceal the scar when a patient lies down and the breasts fall off to the side somewhat. If a scar in the inframammary fold heals with some widening and/or hyperpigmentation, it can be rather obvious. This incision should therefore be reserved for patients who have small areolas and who would benefit from a breast-area incision in order to correct significant asymmetry or other problems with breast shape (or who simply prefer to not have the surgery performed through the axillary approach).

Can breast implants be inserted through the belly button?

Yes, but that does not make it a good idea. This approach is primarily in use by physicians who place unnaturally large saline implants in a sub-mammary (on top of the pectoralis major) position. As the incision location is so far from the ultimate implant location, it does not allow much precision in the creation of the implant pocket. It is therefore more likely to result in asymmetry, tends to result in more bleeding and scarring because of poor visualization, and it often disrupts the infra-mammary fold. It has a higher rate of revisional procedures and a higher rate of capsular contracture than other approaches.