Three incisional approaches to breast augmentation have been widely used: inframammary fold (the crease at the bottom of the breast), trans-axillary (underarm area) and periareolar (along the inferior border of the areolas). Many board-certified plastic surgeons – myself included – have abandoned the periareolar incision, as we now know that it is associated with a higher risk of capsular contracture and scar contracture compared to the other two approaches.
The inframammary fold (the crease at the bottom of the breast) is by far the most commonly used incision for placement of breast implants. It always has been, and it always will be. An incision that is planned and executed so that it falls within the inframammary fold is, in most cases, functionally invisible once it has healed and the resulting scar has fully matured. In some cases the preoperative level of the inframammary fold needs to be lowered, and in those instances it is important to use careful preoperative planning to determine exactly where the incision should be made – as one is planning an incision that is below the existing (pre-operative) fold.
The inframammary fold incision has a number of distinct advantages;
- The incision is at the periphery of the breast, so one does not have to cut through breast tissue to create the implant pocket.
- Direct access to the implant pocket permits full access to the pectoralis major muscle and the greatest number of options for altering pec major muscle anatomy, such as release of inframammary fold and parasternal origin fibers, and varying the degree of muscle separation from the posterior surface of the breast (dual-plane I, II or III dissection).
- The greatest number of options for improving preoperative breast asymmetry are available via the inframammary fold incision.
- The definition of the inframammary fold can be enhanced via the inframammary fold incision.
- If the inframammary fold needs to be lowered, this incision allows the surgeon to redefine and protect the new inframammary fold.
- Sutures can be placed that reduce the likelihood of postoperative inferior implant malposition (‘bottoming out’).
The trans-axillary or underarm area incision is also a perfectly reasonable approach to breast augmentation, and it is one I use frequently; however this incision is best reserved for specific patients. The trans-axillary approach is ideal for patients with very youthful-appearing breasts that are close to symmetrical, especially younger women with no history of pregnancy. In patients with small, youthful-appearing breasts the inframammary fold (and thus a scar in that location) can be more easily seen compared to women in which the lower pole of the breast conceals the inframammary fold. This may be a particular concern for patients that are prone to more noticeable scarring.
There are important limitations to know about the transaxillary or underarm approach. There are significant limits to the breast shape and pec major modifications that can be made, there are limits to what can be done to improve asymmetry, and when lowering the inframammary fold there is really nothing you can do to help define, support and maintain the new level of the fold. Also, it is important to know that most breast implant revisional surgeries require an anterior (i.e. inframammary fold) incision.
The patients for whom I use a transaxillary incision are most commonly young women (20’s and early 30’s) with small, youthful-appearing breasts which are roughly symmetrical and which do not require lowering of the inframammary fold to create an aesthetically ideal appearance. Many of these patients have not yet met their life partner, and they are therefore interested in the ‘stealthiest’ approach to breast augmentation. And it is definitely a very stealthy approach, for when a soft, cohesive (not highly-cohesive or ‘gummy bear’) implant is placed through an underarm incision, the breasts feel completely natural and the scar is in most cases impossible to detect.
Breast implants can be inserted through an incision in the belly button area (’trans-umbilical’ breast augmentation), however there are a number of problems with this approach and it therefore is not widely used. Approaching the surgery from such a remote location does not lend itself to the creation of a precisely-defined implant pocket, or the creation of a natural-appearing result, and this approach has a higher rate of complications and reoperation compared to the standard breast augmentation incisions. Most board-certified plastic surgeons do not use this approach.