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Breast Augmentation: The Incisions

Women will occasionally ask about incision choices in placing the breast implants. The most popular at present amongst plastic surgeons is the Peri-areolar. In many cases, the wound heals so well that it is barely perceptible 3-6 months later.  Close-up Images of four post-operative breasts (of my patients) are provided below for your perusal. All four had augmentation via the peri-areolar approach. A brief discussion of the "Pros" and "Cons" of the different approaches also follows:

periareolar breast augmentation patient 1periareolar breast augmentation patient 2
periareolar breast augmentation patient 3periareolar breast augmentation patient 4

Periareolar Breast Augmentation: Commonly Referred to as "Through the Nipple"

This is the most popular approach and the one I use the most often (>90%). The incision is at the border of the areola (the pigmented area around the nipple) and the normal breast skin. It offers a cosmetically-appealing healing characteristic when used sparingly. This means that women who have had three operations through this incision do not look as good as women who have been operated once via the incision. Secondary healing is rarely as nice as primary healing. Another nice aspect of this approach is the accessibility to the whole wound should bleeding or other problems arise. It also allows the most control possible for developing the breast mound. It can be re-used of the patient requires re-operation for bleeding or capsular contracture. A negative aspect is the potential decrease in the ability to breast feed as lower breast ducts are cut during the approach. The implant can be placed pre-pectoral "over the muscle" or retro-pectoral "behind the muscle" via this approach.

Submammary Breast Augmentation: Commonly Referred to as "Under the Breast"

This incision is placed at or near the lower breast fold. It offers the accessibility for control like the peri-areolar and can be used for re-operation if required. This might be the incision of choice in the case in which the woman would like to preserve potential breast-feeding as much as possible. The approach avoids most of the breast ducts preserving breast anatomy the best. A negative aspect is the scar which heals variably with occasional hypertrophic scarring. This is thought to be partially due to rubbing of the scar against the lower bra band. The implant can be placed pre-pectoral "over the muscle" or retro-pectoral "behind the muscle" via this approach.

Trans-Axillary Breast Augmentation: Commonly Referred to as "Through the Armpit"

This incision was designed in an attempt to move the incision off the breast into a fold in the armpit. There are occasional reports of painful sensory changes in the arm from damage to a nerve near the incision. Accessibility suffers a bit from this approach as the surgeon is operating through a small incision quite a distance away from the area to be operated. Implant malposition in placement is more common. The use of an endoscope partially corrects for this shortcoming. If the patient requires re-operation, it is rare for it to be possible via the "armpit" incision, so usually another incision is made. The implant can be placed pre-pectoral "over the muscle" or retro-pectoral "behind the muscle" via this approach. In rare instances after an explanation of its shortcomings I will agree to operate via the armpit.

Trans-Umbilical Breast Augmentation: Commonly Referred to as "Through the Belly Button"

This recently-devised approach was again an attempt to get the incision off the breast. While it seem attractive it has some major shortcomings some of which are partially alleviated by the use of an endoscope. The most objectionable aspect of the approach is the relative lack of control. A balloon dissector makes the pocket for the implant. Most often the placement is pre-pectoral. Re-operation is almost never possible through the incision. Of the approaches presented, this is the only one I will not offer. I am simply not comfortable with the downsides.

"What about Nipple Sensation?"

The change in nipple sensation during breast augmentation using any of the approaches available involves a slight risk of altering nipple sensation. The choice of incision doesn't seem to alter this risk. This is probably due to the fact that the placement of an implant can disrupt the nerves mediating sensation to the nipple. The risk is greatly reduced by placing implants of moderate size. Larger augmentation patients seem to have a higher risk of sensory change which only makes sense: larger pocket, more potential for interrupting nerves.

Note: The above of course is a matter of professional opinion. This piece is written for the general information of those seeking Cosmetic Surgery. It is presented freely in this format for this purpose. No other rights are granted. It may not be duplicated, cited or otherwise copied in any form without the written consent of the author.



©John Di Saia, MD... an Orange County California Plastic Surgeon       Dr John Di Saia, an orange county california plastic surgeon