I would like to avoid capsular contracture as much as possible. I plan on having the Keller Funnel used but am unsure of which incision method to opt for. My doctor seems to prefer the aerola incision, but the assistant mentioned that they have many re-visits for correctional capsular contracture surgery. I am concerned with breast feeding/loss is sensitivity in the future as well, but my fiancé is concerned about seeing scars. Which incision choice would be best?
Inframammary Vs. Periaerola Incision with the Keller Funnel?
Doctor Answers (14)
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Inframammary vs. Periareolar Incision
Capsular contracture is the second most common reason for a secondary surgery following breast augmentation. (The first is for change of size.) The current and what seems to be the best ongoing theory for capsular contracture is bacterial colonization of the implant capsule. Unfortunately, there has yet to be definitive proof of this.
Regardless, conscientious surgeons use this as "law" and do many things to prevent bacterial colonization-antibiotics, changing of gloves multiple times, only one person touching the implants, Keller funnel, subpectoral implant placement and the best incision.
Several studies have suggested that there is a higher rate of capsular contracture using the periareolar incision. For that reason alone I prefer the inframammary fold incision. I start the incision about 1cm below the fold. When the implants get placed skin is pulled up onto the breasts and the scar is well hidden within the fold. So I really don't feel like there is much reason to use the periareolar incision except if a periareolar breast lift is to be performed.
Which incision is best
If the doctor that you are seeing is having a higher incidence of capsular contracture, I would be concerned about other factors causing this in addition to the approach. Capsular contracture is rare in most practices. I agree that at present, there is some weak evidence linking a higher risk using the aerolar approach. How this relates to individual practices is not clear as each practice has procedures that may be different than those of the authors of the studies. I have not seen any difference in the approach and capsular contracture in carefully monitoring these patients over the past 15 years and it is uncommon in our practice. We use a very robust and expensive surgical prep, exchange gloves, the Keller Funnel, antibiotic irrigation, no touch technique etc. I have used the endoscopic axillary approach over close to the past two decades which hides the incision completely and have seen no increased risk for capsular contracture with this. Most surgeons like the infra mammary approach due to its simplicity and avoidance of the breast tissue but the trans-areolar approach has advantages in the scar and in helping to shape the breast in some circumstances. I use all three approaches and discuss their tradeoffs with my patients.I recommend scheduling another appointment with your surgeon and discussing you and your fiance's concerns with him or her.
There are several ways to place the incision so that it is well hidden in natural skin folds or breast transitions.
- a.Hidden at the natural transition from the areola and the breast skin. The incision can be hidden in this natural color transition
- 2.Inframmary Fold
- a.The incision is hidden in the fold below the breast.
- a.The incision for the implant can be hidden in one of the natural axilla folds. I do these with the aid of scope which allows precise placement of the implant.
- b.Also the use of the Keller funnel has allowed the placement of larger silicone implants through the axilla.
No one incision is best for every patient and the majority of patients can have the implant placed through any of the three incisions listed above. When do correctly all three of the incisions are well hidden.
The incision at the border of the areola typically does not affect the ducts as the nipple stay completely attached. Breast augmentation whether it is through the nipple or fold should not affect your ability to breast-feed.
One of the thoughts behind capsular contracture is that the implant has some small amount of bacteria on the implant that causes the body to have a reaction and form the capsular scar tissue.
I do believe that the funnel decreases the chance that the implant will have any contaminant on it. The funnel keeps the implant from ever touching the skin.
The other benefits of the Keller funnel is that you can place the implant through a much smaller incision than can be placed with the traditional method. The funnel also avoids unnecessary trauma to the implant or the skin. This is especially important when used for larger implants or through a trans-axillary augmentation.
It is important to see your board certified plastic surgeon to help guide you to an implant that will give you an aesthetically pleasing breast.
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The funnel has no effect on capsular contracture. The evidence supporting the inframammary incision as the best for placement is weak. What you should remember is the likelihood of capsular contracture is small and you are statistically unlikely to get it
Inframammary vs periareolar incision
great question. You will find a variety of opinions on this topic. I would agree with the majority here: the periareolar incision, in my experience, has a higher capsular contracture rate.
in fact, since 2006, when gels came back on the market, i returned to the inframmary incision and have not had ONE cc since then. When i review my personal experience, all of the patients who have had a cc have had the periareolar incision. Granted the numbers are small, but no one wants this problem and it can be difficult to treat.
i do not believe the keller funnel prevents this issue. the funnel just allows for a slightly smaller incision.
hope that is helpful. best to you.
Keller funnel and IM crease incisions
I always use the funnel and have largely gone back to the crease incision as there seems to be good evidence that there is less capsular contracture through this approach. Anecdotally, since I have gone away from using the areola over the last 3 years, I have had only one CC in about 250+ augmentations.
IMF or Periareolar for Breast Augmentation
Data is soft on all of these issues with regard to capsular contracture. I would pick the surgeon you like and the incision you like. I perform all 4 types of approaches, and I do not think there is a difference in capsular contracture among any of those approaches. Kenneth Hughes, MD Los Angeles, CA
Periareolar (PA) versus inframammary fold (IMF) incision for implant placement
I think that scar-for-scar, the PA approach leaves a better scar, but if your areola is not large enough than funnel or not a silicone implant is not going through that incision. CC (capsular contracture), in my opinion, is not likely related to incision choice. Funnel does not guarantee no CC. If I were you I would do what YOU want as long as your board certified plastic surgeon thinks it is the right operation for you. Best of luck to you.
Incision and keller funnel
I do not think that inframammary or periareola has a significant difference in capuslar contracture rates. I also do not think that the Keller Funnel adds any advantage to the procedure except perhaps additional cost.
Best incision site
The inframammary incision site is a very easy incision site from the doctor's perspective. I can stand across the room and throw an implant in through that incision. The areola incision leaves the least conspicuous scar in my opinion. The color and texture change between the areola tissue and the skin helps camouflage the scar very nicely. Of course, this assumes that you have a large enough areola for this approach. The Keller Funnel facilitates the insertion of the implant but, in my opinion, really has no effect on your risk of capsular contractures. Likewise, the choice of which incision site to use is more of a cosmetic issue (where do you want your scar) and has no effect on capsular contractures. What DOES affect the risk of capsular contractures is the choice of placing implants above or below the chest muscle. When implants are placed below the chest muscle, the movement of the muscle over the implants as you go about your daily activities massages the implants and decreases the risk of capsular contractures. In my practice, placing implants under the chest muscle has virtually eliminated capsular contractures altogether. I haven't seen one in a long long time and I do a LOT of implants. The downside is that muscle doesn't stretch as easily as breast tissue and skin so it may take a little longer for the breast to soften and shape up afterwards and it is also more uncomfortable than subglandular placement, but I think it is worth it in the long run. You should still be able to breast feed no matter which incision site you choose. Permanent loss of sensitivity is VERY rare no matter which incision site is used.