David B. Reath, MD
Knoxville, TN (865) 450-9253
HKB Knoxville Staff

Breast Augmentation: The Incision Decision

breast augmentation incision sitesThere are many important questions to answer and decisions to be made when considering breast augmentation. Such as saline or silicone? Over or under the muscle? What size implant? And, where to place the incision. This last question is one that I have been asked a lot, but as of yet I haven’t explained my thoughts on this in a blog. So, here goes……

Without getting too elemental, the purpose for the incision is to allow the safe placement, and accurate positioning of the breast implant. As such, the incision must allow complete and direct vision of the entire pocket that is being dissected for the implant. The size and shape of the pocket is very important to the final outcome. And the better you can see what you are doing, the more accurately you can do this. If shaped implants are being used (and I do not do a lot of these) pocket shape and dimensions are even more critical than with round implants.

Also, we have learned that there are a number of things that can increase the thickness of the capsule that the body makes around the implant. Small amounts of blood can increase capsule thickness and make the breasts feel firmer than desired. So, you need to see the entirely of the pocket to make sure there are no small areas of bleeding.

A couple of other things before I talk about the different incisions. Everybody heals a bit differently. Some people will naturally make scars that look better than others. It’s a genetic thing. And, the length of the incision will depend upon the type of implant being used. Saline implants have the shortest incision because they are filled after they have been placed in the pocket. The length of incision for silicone implants will depend upon the size of the implants: the larger the implants, the longer the incision.  Shaped silicone implants will have the longest incisions.

There are four different incisions that have been used for breast enlargement:

  1. Around the belly button (aka: TUBA or trans-umbilical breast augmentation)
  2. The arm pit (trans-axillary)
  3. Around the areola (peri-areolar)
  4. In the fold beneath the breast (inframammary)

Let’s just get rid of the TUBA right away. Bad idea, in my humble opinion. I’ve seen some of these scars and they don’t always look great and they’re never covered by a two-piece bathing suit. But more importantly the operation is done blindly. You cannot see the surgical field or see what you are doing. Does this make sense to you? Not to me! Pocket dimensions cannot be controlled as well, and there is nothing you can do about bleeding. It makes no more sense to me to put implants in through the belly button, than it would to take your appendix out through your knee.

If you are thinking about breast augmentation, don’t contemplate your navel. (I know, I really shouldn’t have  but……………..)

Under The Arms:
Next is the trans-axillary approach which I do not use. My main concern here is, again, you cannot see the entirety of the pocket. So the same concerns about precision of pocket dissection and control of bleeding persist. There are a few surgeons who use this approach with an endoscope and this can alleviate some of these concerns. However, it is not recommended by any of the implant manufacturers because of a greater likelihood of damage to the implant. Plus if you ever had an issue with the surgery and had to re-operate latter on, you would probably need to use a different incision. And the trans-axillary can be seen in normal clothing.

The Two Incisions I DO Recommend
The two incisions that I will use are the peri-areolar incision and the inframammary incision – more frequently the latter. These two incisions allow complete visualization of the surgical field, so the surgeon can do what needs to be done.

The Peri-Areolar:
Not all women are a candidate for the peri-areolar incision. If the diameter of the areola is too small, or if a much larger incision is needed for a larger implant, this won’t work. Also, this approach will probably not work for shaped silicone implants.

There have been some concerns about the peri-areolar incisions with regard to the potential for sub-clinical infections from bacteria in the milk ducts. Very small amounts of bacteria can get in around the implant. While these are not enough to create an infection, they can increase the thickness of the capsule and lead to a firmer feeling breast. So, some surgeons shy away from this incision because they are concerned about the possibility of bacteria in the milk ducts which are right next to the incision. Personally I am not sure whether this is more of a theoretical or real concern. Probably it is an issue for some women but not all.

The Inframammary Incision:
The inframammary incision is the most versatile incision, and allows the best access to the surgical site. We try to keep this right in the grove beneath the breast so that it will not be seen when the breast falls naturally against the chest wall. In many women, this heals so well that it is hard to see unless you look for it very closely. Also, if your body makes good looking scars, then either an inframammary scar or a peri-areolar scar will look good. However, if you are prone to making more obvious looking scars, it’s probably best not to have this at the edge of the areola.

The Bottom Line
Bottom line for me is that the best incisions are the peri-areolar and inframammary incisions. Incidentally, the major breast implant manufacturers, Allergan and Mentor, agree with this. These incisions allow for the most effective creation of the pocket for the implant. Definitely stay away from the trans-umbilical approach, and be careful with the trans-axillary approach. Without a doubt, the inframammary approach is the most common approach used today.

(By the way, there are women who can be seen in certain publications without wearing a top or much else for that matter. You may or may not have seen such magazines. And it’s apparent that some of these lovely ladies have been very good patrons of plastic surgery. But where, you might ask yourself, are their scars? Well, consider the art of air-brushing. Again, just saying…)

On another note, if you or one of your friends are wanting to learn more about breast augmentation, our staff has written an informative and entertaining 37-page eBook called A Girlfriend’s Guide to Breast Augmentation. It’s a free download so you might want to check it out.

All the best,

Dr. David B. Reath




David B. Reath, MD

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