Where is the best location for a breast augmentation incision? Some plastic surgeons have very definite preferences, but what are the facts in the matter?

There are basically 4 incisions that can be used:
• Around the undersurface of the areola – Periareolar incision
• Beneath the breast in the fold – Inframammary incision
• Through an incision in the armpit – Axillary incision
• At the top of the belly button – Umbilical incision

The umbilical incision is limited to saline filled implants since a silicone implant will not fit through the small tunnel that leads up to the breast. Although some surgeons report good results with the umbilical approach, it may be difficult to precisely create the pocket for the implant, producing a disappointing result. In addition, liver and lung injuries have been reported.

The axillary incision has the advantage of avoiding a scar on the breast. I, however, have found this incision to leave a scar that may be quite noticeable with sleeveless clothing such as bathing wear. In addition, it is difficult to position the breast implant in the popular “dual plane location” in which the upper part of the implant is covered by the upper portion of the pectoralis major muscle and the lower part of the implant lies in front of the lower part of the pectoralis major muscle. Many plastic surgeons, including myself, believe that the dual plane location is the optimal position for the implant in most patients, another reason for not using the axillary incision.

The periareolar approach is the most versatile in my hands. It tends to produce a scar that heals very well. The beauty of the periareolar approach is that an incision located at the precise junction of the dark areolar skin and the lighter colored surrounding skin is difficult to see. Of all the incisions, however, this one is associated with the greatest chance of inability to nurse a child after surgery. There may also be a slight increase in the risk of altered nipple sensation compared with the other incisions and perhaps a slightly greater chance of contracture of the scar tissue that surrounds the implant requiring corrective surgery.

The periareolar incision can only be used when the areola is of sufficient diameter to allow for insertion of an implant. A saline implant can be inserted in cases of a diameter as small as 1 inch on stretch of the skin, but this may traumatize the areolar skin and produce problematic scarring. A silicone implant requires a diameter of at least 1 ½ inch on stretch of the skin for a small implant. Larger implants require larger diameters to avoid skin injury as well as to avoid implant damage that can predispose to leakage.

The inframammary incision was the original incision used for breast augmentation. If the incision is made precisely in the fold beneath the newly augmented breast, it usually heals inconspicuously, although problematic scarring can occur. If the scar migrates upward from the fold after surgery is completed, it tends to stretch out and be more noticeable. More and more surgeons are using this incision because it avoids the milk ducts that are important for nursing and also avoids the bacteria found in these ducts that may contribute to painful and disfiguring scar contracture. If scar contracture does occur, however, treatment through the inframammary incision may be more difficult.

If a breast lift is going to be done at the same time as the breast augmentation, the implant is usually inserted through the uplift incision.

Ultimately the choice of an incision is one that a patient should make in consultation with her plastic surgeon, but the guidelines listed above may help guide the process.

Should you desire further information, please contact my Los Angeles plastic surgery office for an appointment.