There are multiple options when it comes to the incision for breast augmentation. Every surgeon will have their preferred approach, and sometimes patients will also have a strong preference. Each incision has advantages and disadvantages, and fortunately, we have published clinical studies to help us compare specific complication rates between various incisions.
The most common incisions are the inframammary fold incision, the periareolar incision, and the transaxillary incision. Patients who are having a simultaneous breast lift (mastopexy) will usually have the augmentation performed within the scars placed to lift the breast so there is no separate scar.
A very unusual approach is trans-umbilical breast augmentation (aka TUBA), which was more of a marketing gimmick than a safe, effective way to place a breast implant (as you might imagine).
Inframammary Fold (IMF) Incision for Breast Augmentation
The IMF incision is the most common approach and my personal preference. Some surgeons place it in the center of the IMF, but I like to place it just lateral to the center.
This tends to be a bit more hidden and affords the surgeon more ergonomic access during surgery, as we are positioned on the patient’s side. The reasons why the IMF approach is most popular are that:
1) It lies along a natural anatomic crease and is therefore not very noticeable.
2) It gives the surgeon the most direct access to the subglandular or submuscular plane where the implant will be placed.
3) It is the incision most commonly used for revision surgery (so why not start with it instead of having two scars?)
And most importantly, 4) it has the lowest rate of capsular contracture.
What is capsular contracture?
Capsular contracture occurs when the scar tissue your body makes around a breast implant (which we call a capsule) thickens and contracts, causing the implant to get tight, misshapen, and painful. The risk of this happening has been found to be lower when using the IMF incision compared to the periareolar incision, which brings us to that incision.
Periareolar Incision for Breast Augmentation
There are many surgeons who prefer this incision for routine breast augmentation. When the scar heals nicely, and it usually does, it is barely visible because your eyes expect to see a border at the edge of the areola, and the scar blends in (just like the IMF scar).
However, if the scar doesn’t heal well, as in a hypertrophic scar (what many mistakenly call a “keloid”), then you’re stuck with an ugly scar at the most visible part of the breast.
Studies have shown a higher risk of capsular contracture using a periareolar approach, although the risk is still low.
Lastly, the length of the incision is determined by the size of the areola, so in a patient with a small areola, you are limited in terms of how long of an incision you can make, which will limit surgical exposure and the size of the implant you can place. This is why revision surgeries, which often require a larger incision, are usually performed using the IMF approach, even when a patient had a previous periareolar approach.
I mentioned above that some surgeons prefer this incision for routine breast augmentation. There are times when, despite the higher risk of capsular contracture, this incision is the best approach. For patients with a tuberous breast deformity or constricted lower pole with no defined IMF, the periareolar incision is often used, as it allows the surgeon to “score” and release the breast tissue of the lower pole, and it avoids guessing where the new inframammary fold will be after placement of the implant.
Transaxillary Incision for Breast Augmentation
I will be honest with you — I have never understood the attraction of the transaxillary incision. Why would anyone want a scar on their armpit that could be visible when wearing clothing, more than a scar at the fold of their breast, which is largely hidden?
Just like the periareolar and IMF approaches, when it heals well, the scar is barely visible. However, if it doesn’t, then you have an ugly scar in your armpit. If I were prone to hypertrophic scars, I would much prefer to have one along the IMF than around the nipple or in the armpit.
The transaxillary approach is generally limited to saline implants, which come out of the box unfilled and can be placed through a small incision and then filled internally. My patients tend to choose silicone implants, so I avoid the transaxillary approach. Saline implants have a higher rupture rate than silicone implants, and replacing a ruptured implant generally requires an IMF incision. So to to me, it makes sense to just start with that incision.
Some surgeons find a way to squeeze a silicone implant (pre-filled) through the axilla, but the main reason I avoid this approach is that it gives the surgeon the worst visibility and ergonomics for doing this operation. This translates to having less control over the implant pocket, which determines implant position. The incision is as far as it could be from the most critical part of the procedure, which is controlling the position of the implant as it relates to the IMF. The transaxillary approach has a higher rate of inferior implant malposition (aka “bottoming out”), and to correct this typically requires — you guessed it — an IMF incision.
Performing the transaxillary breast augmentation requires specialized equipment called an endoscope, which adds expense and complexity to what should be a simple operation. Some surgeons do it without an endoscope, but this is essentially blind surgery using a large blunt instrument to disrupt the tissues to create the implant pocket. Some superb surgeons use this approach and get great results, but when one of the masters of this approach (Dr. David Hidalgo of NYC) was asked what he thinks is happening internally when he uses this approach, his response was, “I don’t want to see what it looks like in there.”
So it works, but it doesn’t sit well with those of us who prefer a precise, controlled procedure. Surgeons who use this approach are typically doing it because certain patients demand it, but I am fairly certain it isn’t their preferred approach.
Choosing the Right Incision With Halvorson Plastic Surgery in Asheville, NC
By now, you will guess that my bias is to use the IMF approach. However, I like to discuss all of these approaches and see where my patients are regarding their preferences. It is your body, after all. If you strongly prefer one incision over the others and understand the pros/cons of each approach, then I’m happy to accommodate such preferences.
This is typically limited to IMF and periareolar approaches, as I really prefer to avoid the transaxillary approach. The vast majority of my patients go along with the IMF approach, and it is, without a doubt, what I recommend.