What are the risks of a periaerolar incision?

The periareolar incision (under the nipple) for breast augmentation and placement of breast implants is not as common as an incision choice as the lower breast fold or infra-mammary fold incision. The incision is curved under the border of the nipple pigment and actually heals very well. There may be a theoretic increased risk of capsular contracture secondary to bacterial contamination of the breast implant because of the close proximity to the nipple ducts, both internal and external. This can be lessened by protecting the implant from the nipple on insertion and a careful dissection plane down to the implant pocket. This incision, in my hands is utilized if the patient needs a breast lift or mastopexy, if I need to lower the breast fold, or if the patient requests it. I do not use it routinely, and have difficulties in the patient with small areola. I have found there may be more incisional discomfort with this, though it is the second line incision for breast augmentation and if performed correctly, I have seen no increased risk of capsualr contracture. 

The risk of capsular contracture and infection is higher with the periareolar incision generally speaking. However, I have used the periareolar placement frequently with no resulting infection or CC. Complication rates vary by surgeon, therefore it's probably better to ask the surgeon you're interested in having perform your surgery for their stats.

Infection in breast augmentation is very rare when performed to todays standard of care.  Of the two approached, I prefer periareolar as the inframammary if low can show under a bikini and if high is plainly visible in the nude when standing.  It is my preference to never place a scar on the breast when elevating the nipple is noot necessary which is why I prefer to perform transaxillary cold-subfascial augmentation.  The patient is lifet with a very thin scar in the armpit that usually disappears into a fold in the armpit.

 

All the best,

 

Rian A. Maercks M.D.

Bacterial infection of a breast implant can occur with any incision site whenever there is a break in sterile technique. Although there is thought to be a correlation between bacterial colonization of a breast implant (not overt infection) and development of capsular contracture, there are no studies demonstrating this effect. However, there are studies that show higher rates of capsular contracture for implants placed in the subglandular position (above the muscle) than for implants in the submuscular position (over the muscle).

There are 3 primary  incision options for breast  augmentation. All are acceptable and depend on the patient's choice and the surgeon's experience and expertise-

1. The most common approach is in the Inframammary Fold - simple, easy access , heals well , and gives the best opportunity for correction of any subtle  breast asymmetries. It is the most common incision I use for both saline and silicone implants.  In my experience, it has a very small nipple sensory loss incidence.

2. the Periarealar approach - must be made precisely in the areolar -breast skin interface to prevent the scar from being visible .  There is no good data to support that it causes more infection or implant contracture. Therefore, it really comes down to surgeon and patient preference.  I use it in patients with almost no breast tissue or no apparent inframammary fold . It is not my preferred approach

3.  The Transaxillary approach- the armpit incision is also a good approach and was popular in the 90's and is use more in certain regions of the USA than others due to surgeon and patient preference.   Again, it has no distinct disadvantages except perhaps it is more difficult to correct primary breast asymmetries using this approach

I use the periareolar incision in approximately 50% of cases as it allows some versatility in adjusting the height of uneven areolas. However, the limitations are thes size of the areola (small ones do not allow placement of larger silicone implants) as well as the concerns for bacterial contamination with biofilm and subsequent capsular contracture (CC). Having said that, it is my overall impression that the rate of CC is roughly equivalent in my practice and the in range of 5% over a 3 year period (overall 8% in national studies for Baker III/IV).

In my mind, the literature does suggest a slightly higher incidence of capsular contracture when implants are placed through the PA approach.  In addition, there is potentially a higher risk for change in nipple sensation.  And, the scar is on the most projecting portion of the breast and so it potentially has a higher risk for being more noticeable.

That being said, many surgeons achieve great results through all three approaches and so it really comes down to a decision of which incision and which surgeon you feel most comfortable with.  The one incision I would be wary of is the TUBA (belly button approach) which is most commonly promoted by non-plastic surgeons and which has a much higher risk for complications.

I hope that helps!

It sounds like you are aware of the theoretical risk of the periareolar incision, which is in closer proximity to breast tissue leading to possible bacterial contamination and capsular contracture. There isn't much evidence to support that in my view. Another misconception is that it increases the chance of sensory loss to the nipple, also unproven. The inframammary incision works well but if the implant size is ever changed it may no longer be in the fold at the right level. There are plusses and minuses to each option, depending upon implant size and type and other considerations.

No one really knows what causes capsular contracture but there is likely a combination of causes with some being more dominant is some patients. Factors believed to cause capsular contracture include low grade infections, repeat breast surgeries, genetic factors, blood in the implant pocket, rough handling during surgery causing muscle spasm etc., implant rupture, trauma to the chest, radiation etc. Those are mostly independent of the skin incision used.

Revision rates are something else and can be necessary because of capsular contracture (usually sometime after surgery) or a suboptimal result (usually apparent early after surgery). The revision rate is likely higher the further away from the breast the skin incision is especially in the hands of a less experienced surgeon. Some patients need surgical adjustments to the breast itself at the time of augmentation in order to achieve the best result. And this can be hard or impossible to do if the skin incision is in the belly button or the armpit. The choice of skin incision for implant introduction should be dependent on what the patient needs/wants and the surgeon's experience. I personally prefer areolar skin incision over inframammary fold incisions in first time patients because of the tendency of incisions in the fold to migrate. However people scar differently and a bad scar in the areola is more visible than one in the fold.

Periareolar incision incision has the same safety profile in my experience.  Incision size is limited by the areolar size which can be an issue, especially with silicone implants.  Which position will produce less noticable scarring depends how visible the inframammary fold region is and what kind of scarring results