Hi Terri. Thank you for your question!Choosing the right incision site is important to get the best results. When deciding the incision you have to consider the following things: Your surgeon’s skill and comfort level in a specific incision approachThe degree of visual and surgical control your surgeon will haveThe ability of the incision to provide access to create and dissect a surgical pocket without much damage to the surrounding tissues (e.g., nerves and blood vessels), and appropriate insertion of the implant.Degree of exposure of the implant to your own body’s bacteriaYour preference regarding the final location of the scarSize of the implantThe Main Goal should be to choose an incision site that will minimize scarring, allow safe creation of the breast pocket, and safe insertion of the implant.There is no incision site that is best for all patients and the decision must be tailored to your breast characteristics in collaboration with your surgeon – So what are your options?The majority of surgeons offer 3 options and each has its pros and cons:Inframammary (under the breast)ProsSurgeon has direct vision of the breast pocket and more surgical control reducing chances of breast tissue damage, implant damage, bleeding, and complications like asymmetrical breastsThe implant can be placed “under the muscle” or “over the muscle”Any type of implant can be inserted using this incision siteCritical nerves and blood vessels are unlikely to be damaged reducing the chances of changes in nipple sensationThe scar could be well-hidden within the crease of the breastsThis technique allows the ’bloodless’ techniqueConsAlthough the scar would be hidden under the breast, it may sometimes move onto the breast, worsening the aesthetic looksThis approach is not suitable if there is areolar asymmetry or areolar herniationIt is less desirable in patients who have glandular tissue asymmetry which requires reshaping of the breast tissueWho is it for?The inframammary incision site is best suited for patients who have a small areola (dark pigmented skin around the nipple), and those who require large implants or form-stable implantsTransaxillary (within the armpit)ProsThe Incision will be hidden within the armpitThere is less damage to the breast tissues while dissecting an implant pocket compared to the periareolar approachWith proper technique the rate of capsular contracture is low relative to other sitesNo muscle is cut, the implants simply slides into a natural sub-muscular spaceRelatively quick surgery, shortest time under anesthesiaConsThis procedure requires that your surgeon is well experienced in this technique as it is a “blind procedure” meaning your surgeon will be unable to see the site of dissection to create the breast pocket and if your surgeon is not skilled, it will require revision surgery for complications like breast asymmetry and implant malpositionIf a revision surgery is ever required, it is more difficult to do it through the axillary incision and a new incision may be requiredThe surgeon will be limited to place the implant behind the muscleWho is it for?The axillary incision approach is most suitable for patients who have great concerns about having a scar on the breast and those who have a small areola, and require a small silicone or saline implantPeri-areolar (through the dark pigment around the nipple)ProsUseful to avoid a scar in the fold of the breast. This is especially true if there is distinct border and color difference between the areolar skin and the surrounding breast skin. – it is a great way to hide the scar on patients with dark areolasProvides your surgeon direct vision during pocket dissection and good surgical controlAllows easier correction of areolar/nipple asymmetriesConsThe implant type and size that can be inserted is dependent on the diameter of your areola as we do not want to damage the implant – This limits your implant optionsIf your areola is not large, it will limit your surgeon’s visual and surgical control.This incision requires dissection directly through the breast tissue which may cause changes in nipple sensation and may prevent you from milking normally unless your surgeon takes great care to not damage the milk ducts and blood supplyDuring insertion, the implant has a higher risk to be exposed to bacteria inside your breast tissue holding higher rates of infection and capsular contracture – This can be avoided if your surgeon uses the “No touch technique” using a Keller Funnel.Risk of capsular contracture and nipple insensitivity is increased compared to the other techniquesWho is it for?If you are someone with a large and dark areola, and are not planning on breastfeeding or having children in the future, then this option is valuableNow regarding your concern of loss of sensation or hyper-sensitivity, it is important to realize that all incisions have some risk of in reducing sensation in the breasts/nipples. I do agree that the risk may be higher with peri-areolar incision as there are many nerves in the vicinity of the site.The risk is also higher with larger implants that can press against sensory nerves near the breast tissue resulting in numbness.Occasionally, breast sensation actually increases making it uncomfortable upon touch.Fortunately, the changes in sensation are usually temporary, and everything returns to normal within a year or sooner.In the end, for comprehensive information, you must consult with a board-certified plastic surgeon about your goals, concerns, and expectations.
