Choosing an Incision for Breast Augmentation

Breast implants can be placed through 5 possible incisions.  It can be confusing for the patient picking the best approach for their situation.  I offer 4 of the 5 but prefer the inframammary ( in the crease below the breast) for reasons to be discussed.

The 5 potential incisions:

  1. Axillary (through the armpit). In this approach (which is sometimes assisted by an endoscope) a tunnel has to be created to permit development of the pocket.  It would be considered a “remote” approach.  Obtaining symmetrical pockets is a bit harder and occasionally the implants can fall into the tunnel when the patient is recumbent if it persists after healing.
  2. Periareolar (through the nipple). An incision along the border of the areola (usually about 180 degrees on the bottom side) is used for access.  In this technique, the implants is dragged through breast tissue for placement in the pocket.  I will discuss the importance of this in a minute.
  3. Inframmary (through the breast crease). The most direct approach and allows development without disturbing breast tissue.
  4. Periumbilical (through the umbilicus). This is another remote technique and is limited to saline implants.  It is seldom used anymore and shares the difficulty of making the pockets symmetrical with the axillary approach.
  5. Transabdominoplasty.  In the occasional patient undergoing an abdominoplasty concurrent with breast augmentation the implant can be placed under the breast without an incision using access available by the dissection of the abdominoplasty.

Although I am willing to place implants by any of the incisions save for the transumbilical, I prefer the inframmary.  Here is my reasoning:

The major significant aesthetic problem after breast augmentation is capsular contracture (hardening of the implant).  The problem dwarfs any other cosmetic side effect including the post-op scar.  A year after an augmentation almost no patient even considers the scar as all yield consistently near invisible results.  The development of a capsular contracture, however is a real aesthetic issue if it occurs.  Anything to reduce the incidence is worthy of consideration.

Plastic surgeons don’t really know what causes capsular contracture.  One emerging theory which looks more plausible by the day is the formation of a “biofilm”.  A biofilm known to all of us is plaque on the teeth.  Certain types of bacteria can generate a substance that is used as a structure in which to hide out-the biofilm.  It’s presence can cause local problems, gingivitis in the case of plaque.  That’s why the hygienist scrapes it off at the time of dental cleaning.

Biofilms may play a role in capsular contracture.  Two of the approaches expose the implants to contamination, the axillary and the periareolar.  There is one published study (not enough yet to consider the case closed) showing that the inframmary approach has a lower incidence of capsular contracture than the inframmary . This suggests, but certainly does not prove, that contamination of the implant might be reason for the difference.

In my opinion, the aesthetics of the scars is of very minor importance.  I think capsular contractures are a big deal.  If it’s possible that a given approach has a lower incidence of capsular contracture, it makes sense to me to prefer that choice. As I mentioned above, this is why I prefer the inframmary approach.

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