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When considering breast augmentation, there are several options for incision placement. The most common site is the natural fold underneath the breast, termed the "inframammary fold". The incision generally is hidden except in women who had small breasts before surgery, or when lying down (such as on the beach wearing a bikini top). This is the most common choice of access incision. Alternative methods include the "periareolar" margin which is the border of the areola. This is a reasonable option when the areola has enough pigment, and therefore is darker compared to the surrounding skin, as scars are hidden very well when placed along the border between two different skin tones.
Women with small or faint areolae are not good candidates. Other less common places for the incision to be made are the axilla (armpit) or the belly button. These incisions can only be used when patients have relatively small breasts and saline implants are selected. As a general rule for breast augmentation, placement of silicone implants requires that incisions are longer compared to the incisions used for placement of saline implants. This is because silicone implants are pre-filled whereas saline implants are initially deflated, and then filled once placed inside the breast.
With regard to breast reconstruction after mastectomy, implants are inserted through the mastectomy incision and placed beneath the chest muscle. The incision placement is determined by the oncologic surgeon performing the mastectomy (depending on whether it is deemed necessary to remove the nipple or not). In nipple-sparing mastectomy, the most common sites for incision placement are the lower/outer "inframammary fold" area, or the "9 o'clock" position on the breast itself.
The process involves making an incision in the crease under the breast (inframammary fold), in the areola (nipple), or in the armpit (transaxillary) and inserting the breast implant. The implant may be placed under the muscle (submuscular), or above the muscle (sub-glandular). Saline implants are filled to the desired size once they are inserted. Silicone implants come prefilled, according to size, so a slightly larger incision must be made in order to insert a gel implant. The incision is then closed with sutures.
The possibilities for access to insert breast implants depend upon the type and size of implant to be inserted, and any concomitant procedures performed. Saline-filled breast implants are often filled after insertion, can be easily inserted, and often require very small access incisions. Silicone implants are inserted in a fully inflated state, and may require slightly larger incisions. Form stable devices generally require larger incisions. That being said, usually a 3-4 cm incision is adequate for most implants, and can be well camouflaged if planned correctly.
One possibility to consider with your surgeon is the insertion of the implant through your axilla. A small tunnel is dissected from a well-hidden incision in the axilla to allow insertion of the implant beneath the pectoralis muscle. Sometimes this requires the use of an endoscope, or surgical telescope inserted through the same incision.There are limits as to the size of implant that can be inserted through this incision, and saline implants are particularly amenable to this approach.
Another possibility is to place the access incision along the border of the nipple-areolar complex and the skin of the breast. The coloration and texture of this area helps to camouflage the surgical scar. Usually a small, curvilinear scar beneath each areola is sufficient access.
Alternatively, implants can be inserted through an incision in the junction of the breast's inferior pole and the chest wall. In most women, this scar is hidden below the breast, and covered by a bra or bikini. However, it is more visible when the patient lies down, or when viewed from below, as there is no natural pigmentation to hide the scar.
A newer, and less-commonly applied technique for breast implant insertion is performed at the same time as the tummy-tuck. The implants are inserted through the incision used to slim the abdomen. The only scar is hidden in the suprapubic region, which is usually covered by underwear or bikini bottoms. This approach is only employed if the patient is having an abdominoplasty along with the breast augmentation. This technique is referred to as TABA or transabdominoplasty breast augmentation.
The best access incision for breast augmentation varies between patients, breast and implant types, presence or absence of other breast procedures such as mastopexy presence of other scars on the breast or abdomen, and the size of the implant to be inserted.
Breast implants can be inserted through several approaches. In 95% of my breast augmentations and breast revisions it is inserted through the periareolar approach. A small incision underneath the nipple-areolar complex which camouflages beautifully with the darker pigment of the areola. Other approaches include a transaxillary through the armpit, inframammary approach underneath the crease or through the bellybutton or transumbilical approach. I believe the transumbilical approach may be dangerous and more unpredictable and may not yield consistent results as we find with the periareolar approach. The inframammary approach was the gold standard in the 70s and 80s and it still is a safe and effective approach. However, you cannot camouflage the scar as you can through the periareolar. Transaxillary approach I believe is also somewhat unpredictable in terms of positioning of the implants. Malposition is more common through the transaxillary approach as I believe the muscle attachments along the sternal area are not as easily released. As a result in the majority of the thousands of breast implants that I have performed and will continue to perform I will go through the periareolar approach as my preferred technique.
Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.