What Would Determine Nipple Incision Vs. Under Breast Vs. Armpit Preference for a Person?

Still in discovery and info stage of decision of doing this.doing this? Is it better for anyone one way or another? Dependig on size, chance of losing sensation in nipples or having hyper nipple sensation?, placement?, previous implants? What do I consider in making that choice?

Doctor Answers (11)

Transaxillary or Armpit Breast Augmentation is my preference for all primary cases without ptosis

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The transaxillary approach is very misunderstood.  It is much more difficult and technically demanding then directly accessing the breast through an infra-mammary approach or through the nipple.  This is the main reason that most surgeons think it is too difficult or frankly impossible.  In my opinion it just does not make sense to place a scar on the breast in an aesthetic elective procedure unless a lift is needed.  For primary augmentations with class I-II ptosis I exclusively use the transaxillary Cold-Subfascial Breast Augmentation TM.  What this means is that I access the interface of the pectoral fascia and pectoralis major muscle through the axilla (arm pit) and carefully dissect the fascia from the muscle.  The implant goes under the strong supportive fascia and above the muscle.  This is VERY different from "above the muscle" or subglandular techniques which typically do not fare well.  The fascia not only shapes the breast beautifully but the muscle is out of the picture allowing the breast implant to sit naturally more medially than dual plane techniques and it also offers the implant lasting support to prevent bottoming out and undesirable changes.  Live surgical videos have been published on the technical aspects of the Cold-Subfascial Breast AugmentationTM where the delicate dissection can be observed. 

Even the product representatives may believe that transaxillary placement is too difficult or impossible but these beliefs are remnants from early experience decades ago with saline transaxillary augmentation with a 2-3 cm incision.  The reality is that an endoscope it not necessary and the axillary incision heals and nearly disappears in most women and a larger incision in the axilla can be shortened and hidden with suture technique. 

I hope this helps,

All the best,

Rian A. Maercks M.D.


Miami Plastic Surgeon
5.0 out of 5 stars 31 reviews

Breast Implant Incision Site

+2
Breast augmentation incisions are placed strategically so as to be minimally noticeable once the incisions have healed. There are three incisional approaches that are commonly used: at the border of the areola (peri-areolar), in the underarm area (axillary) and in the crease at the bottom of the breast (inframammary fold). Each has advantages and disadvantages, and each is ideal for a particular kind of preoperative scenario.
Peri-areolar incision
This is made at the border of the areola, from about the 4 o'clock to 8 o'clock position. It works nicely for patients with larger areolar diameters (4.0 cm or larger), as if often the case after pregnancy and lactation. The color difference between areolar skin and breast skin nicely conceals the scar in most cases, and in many patients the scar is almost undetectable within just a few weeks or months of surgery. This incision truly has the possibility of producing a scar that is ultimately invisible or almost invisible.
A theoretical downside with this incision is that it by definition requires the division of milk ducts when the breast tissue is dissected down to the pectoralis major muscle, and this may interfere with future attempts at breast feeding. There are some who believe that this incision carries a higher risk for capsular contracture as bacteria may be present in the milk ducts which could possibly adhere to the implant surface during breast augmentation surgery, which may over time lead to contracture. The latter is a theoretical concern, and it has not been conclusively shown that the peri-areolar approach has a higher rate of capsular contracture than the axillary and inframammary fold approaches. The peri-areolar incision is therefore still frequently used, as the aesthetic outcomes are usually excellent.
Trans-axillary incision
This is the ideal approach for patients with very youthful-appearing breasts, who do not require correction of significant breast asymmetry or major alteration of breast shape (such as tubular breasts). When the breasts are small and perky, the inframammary fold is clearly visible and it therefore does not conceal a scar very well - and sometimes not at all. If the areolar diameter is small, then a peri-areolar incision is not practical. So patients with small, perky breasts and small areolar diameters are best served by an incision in the underarm area, also known as the transaxillary approach.
Placing an implant through this approach is technically more challenging and requires the use of an endoscopic camera and endoscopic surgical instruments. Make sure the surgeon who offers you an augmentation through this approach has a great deal of experience with it. The axillary incision must heal in a warm, moist environment, and it therefore takes longer to fade to the point that is difficult to see. Patients tend to be a bit self-conscious about raising their arms above their head while wearing a swimsuit for the first six to nine months after surgery, but by one year postop most have a scar that is difficult to discern even on close-up examination of the underarm area.
Inframammary fold incision
This is the most commonly used incision for breast augmentation in some practices, primarily because it is the quickest and easiest approach. It is a reasonable approach to use for patients that have fuller, more pendulous breasts, where the lower pole of each breast hangs over the inframammary folds somewhat and will tend to conceal a scar placed in this area. It is not a great choice for a patient with very perky, youthful-appearing breasts where the inframammary folds are clearly visible, and will remain clearly visible postoperatively.
Another problem with this incision is that even when breasts are full in the lower pole and somewhat pendulous, there is nothing to conceal the scar when a patient lies down and the breasts fall off to the side somewhat. If a scar in the inframammary fold heals with some widening and/or hyperpigmentation, it can be rather obvious. This incision should therefore be reserved for patients who have small areolas and who would benefit from a breast-area incision in order to correct significant asymmetry or other problems with breast shape (or who simply prefer to not have the surgery performed through the axillary approach).

Michael Law, MD
Raleigh-Durham Plastic Surgeon
4.5 out of 5 stars 38 reviews

What Would Determine Nipple Incision Vs. Under Breast Vs. Armpit Preference for a Person?

+2

As you can see there are multiple ways and opinions on how to approach this. All have good points but for the record, I use underarm almost exclusively and I use the endoscope for most accurate control of the fold, AND you can use silicone implants, even up to over 500cc by using the Keller Funnel. I can change implants and do a capsulotomy and even add saline through the underarm. More important to find a good surgeon!

John J. Corey, MD
Phoenix Plastic Surgeon
4.5 out of 5 stars 16 reviews

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Breast Augmentation Incision

+2

While all three are acceptable, I find that:

1) all scars typically heal well, but...

2) Under the breast (in the fold) is one the patient almost never sees, whereas the other two they may

3) Under the breast is more versatile (you can't put silicone in through the other two always)

4) Under the breast is often needed in any future surgeries

So obviously my bias is under the breast.  Also, the only person who ever sees that scar is someone with whom you are topless, and that is usally a very small number of people.  (Whereas the under armpit may be visible in a bikini or sundress).

Michael Decherd, MD
San Antonio Plastic Surgeon
5.0 out of 5 stars 17 reviews

What would determine nipple incision vs. under breast vs. armpit preference for a person?

+1
Hello! Thank you for the question! The typical incision used for breast augmentation are: inframammary (in the fold beneath your breast), periareolar (at the border of the areola), axillary (within the armpit crease), and TUBA (through the umbilicus). Incision placement will do a lot with your preference, surgeon comfort level with that approach, and the type of implant - silicone implants will be difficult to place within certain access incisions. Breast augmentation scars are well concealed and are very discrete. They should not be visible within clothing, and likely hidden without clothing. If your concern is the visibility without garments, you should consider remote access incisions such as in the armpit. However, these other incisions heal very well on the breast and often times inconspicuous.

It is common for scars to fully mature for up to a year. In the meantime, there are a few things that may help to ameliorate your incision/scar. The most proven (as well as cheapest) modality is simple scar massage. Applying pressure and massaging the well-healed scar has been shown to improve the appearance as it breaks up the scar tissue, hopefully producing the finest scar as possible. Other things that have been shown to add some benefit, albeit controversial, are silicone sheets, hydration, and topical steroids. In addition, avoidance of direct sunlight to the incision will significantly help the appearance as they tend to discolor with UV light during the healing process.

If unsightly scars are still present after approximately a year's time, other things that your surgeon may consider are intralesional steroid injections, laser, or just surgical revision of the scar itself.

Consult with a plastic surgeon your goals, concerns, and expectations. Certainly incisions should be considered, but should not limit your overall result by hindering visualization and access to your surgeon, and what produces the best results in his/her hands.

Hope that this helps! Best wishes!

Lewis Albert Andres, MD
Scottsdale Plastic Surgeon
5.0 out of 5 stars 11 reviews

Breast augmentation incisions

+1

I spend alot of time with patients in the office reviewing the different incisions, pockets, implant shapes and sizes, etc..  There are positives and negatives to each for many different reasons.

Steven Wallach, MD
Manhattan Plastic Surgeon
4.5 out of 5 stars 16 reviews

Incision choice for breast augmentation

+1

The most common preference for plastic surgeons is inframammary or "crease" incisions for a variety of reasons.  This is my general preference as well.

  • Most accurate pocket with lowest rate of implant malposition (creation of symmetric pockets is easiest through this direct approach)
  • Hides well
  • No breast tissue is divided (less likely to effect sensation or breast feeding than some of the others)
  • Easiest to control the shape of the lower pole of the breast in cases such as breast base constriction
  • Revisions can be done through the same incision, if necessary
  • Theoretical lower risk of capsular contracture from a more "sterile" incision site without axillary or breast duct bacteria
  • In the event the scar is not perfect it is in a hidden location

York Yates MD, Utah.

York Jay Yates, MD
Salt Lake City Plastic Surgeon
5.0 out of 5 stars 40 reviews

Every approach yields good results and tradeoffs

+1

The choice of incisions  for breast implant placement is important to discuss with your surgeon as their experiences with each are valuable.  The choice is tied closely to the type of implant being placed, anatomy and patient preference, as is the choice of implants dimensions & volume.  Approaches through the nipple & arm pit are harder to do when placing gel implants (can't be compressed) and can give numbness in the nipple and inner arm respectively.  Under the breast and arm pit incisions are easily concealed.  Added advantages of under the breast and arm pit approaches is less dissection through breast tissue when using a below muscle placement, which may effect interpretation of future breast imaging.  Saline vs. silicone recommendations frequently are based on soft tissue/breast tissue coverage and yes, patient preference.  These are all topics that will be addressed during your in office consultation, where a physical examination will help focus the surgeon's recommendations.  Good luck!

Vaishali Doolabh, MD
Jacksonville Plastic Surgeon
4.5 out of 5 stars 2 reviews

It's your choice, but a lot depends on the surgeon too

+1

It's your choice, but a lot depends on the surgeon too, my choice is circumareolar. Your nipple needs to be at least 3cm across but at that size I can get almost any implant in. I think that these are the best least conspicuous scars. The tiniest bathing suit will cover a nipple incision, while an inframammary incision will be visible if the suit rides up or is small.

William B. Rosenblatt, MD
New York Plastic Surgeon
4.0 out of 5 stars 9 reviews

Incision location

+1

There are three common sites for incision placement for a breast augmentation.  Most plastic surgeons across the country use the incision in the fold under the breast, which leaves a very inconspicuous scar which is covered anytime you are dressed or in a bathing suit.  It has the lowest chance of complications and any additional surgery in the future can be performed through this approach. This is the most straightforward approach for the plastic surgeon.

The periareolar approach is second in popularity and in my opinion this leaves the most inconspicuous scar.  Again, it is always covered when you are dressed even with a very small bikini top. The scar is hidden by the color change between the skin and the darker color of the areola. Like the incision in the crease under the breast any additional surgery in the future can be performed through this scar. This is a very straightforward approach for the surgeon, unless the breast is larger, in which case more breast tissue has to be divided.

The last approach is the armpit or axillary approach. It has as its advantage there is no scar on the breast, which does appeal to some patients.  However, the surgeon is at a greater distance from the area where the most important part of the surgery is performed. If the scar does heal perfectly, it has as another disadvantage that it may be visible when you are completely dressed, wearing a sleeveless shirt or in a bathing suit. I have noticed this scar in women at the gym who are wearing a sport bar during their workout.  I practice in Florida and I find most patients choose the incision either under the breast or around the areola.

As far as sensibility of the nipple goes, the possibility of interfering with sensation is a result primarily of the size of the implant relative to the size of the breast.  A larger implant requires a larger pocket and the nerve to the nipple is located at the outside of the breast where it can be injured as the pocket is made larger to accommodate a larger implant. This can occur with any of the incision locations.  It is a common misconception that the periareolar approach carries a higher rate of loss of feeling.

Ultimately I let the patient decide where she would like the scar to be.  There has to be a scar in order to do the operation. In my practice I have only had one patient complain about the scar after the procedure. The scar does need to be a bit longer for silicone implants compared to saline.

Thank you for your question and best of luck. 

Ralph R. Garramone, MD
Fort Myers Plastic Surgeon
4.5 out of 5 stars 23 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.