Posted on 17 May 2016
There 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.
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.
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.
- 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.
- Around the belly button (aka: TUBA or trans-umbilical breast augmentation)
- The arm pit (trans-axillary)
- Around the areola (peri-areolar)
- 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.
Next is the trans-axillary approach which we 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 that we 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.
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, we are 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 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.
Bottom line for me is that the best incisions are the peri-areolar and inframammary incisions. 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. Contact Neaman Plastic Surgery today to learn if you’re a candidate and talk with Dr. Neaman about your incision options.
Dr. Keith Neaman
Dr. Neaman is a board-certified plastic surgeon that specializes in surgical body contouring. He prides himself on being on the cutting edge of plastic surgery. He takes an informative approach to each consultation, and through open dialogue and communication, he helps his patients decide on a treatment plan that meets their needs.