Transaxillary vs. Periareolar Breast Augmentation

Me and my husband are arguing about haveing the transaxillary incision. I'd rather do the Periareolar one. Which is best?

Doctor Answers 35

My wife and I disagree on the incision!!??

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you are not having the surgery.  it is not on your body and you are crazy to do anything other than support her decision. if there is a sound medical reason to do one incision over the other then it is between your wife and her surgeon. so sit in the corner and nod. 

Boca Raton Plastic Surgeon

Compromise - use the Inframammary Incision!

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This is compromise at it's best: neither of you get your first choice, but your wife ends up with a great - arguably the greatest incision.

Most patients and plastic surgeons sophomorically focus on the location of the scar as the most important issue in deciding on the incision. In fact, the scar is the least important distinction between the incisions.

Why? Because any of three locations almost always gives a good scar. When it doesn't, it is usually related to patient biology, such that someone who gets a bad scar in one location would get it in another. If any incision always gave a perfect scar, we'd all use it. And if any always gave a bad scar, no one would use it.

The transaxillary incision fundamentally doesn't makes sense to me personally: it is the only incision that is visible when fully dressed; when a revision needs to be done, it almost invariably requires another incision; you can lose sensation in the armpit making shaving difficult; unless done endoscopically, it is less accurate and typically more painful and bruised than other approaches; if done endoscopically, it takes much longer in surgery.

The periareolar yields a scar that is visible when the breast is viewed head on; the size of the areola can limit the size of the implant; the size of the areola and the amount of breast tissue limits the visualization and thereby accuracy and bloodlessness of the pocket dissection; and most important of all, dragging an implant through the breast contaminates the implant with the bacteria in the breast, the very bacteria implicated in capsular contracture (hardening.) The best study of its kind shows a statistically significant higher rate of capsular contracture with the periareolar incision than the inframammary incision.

The inframammary incision is hidden in the crease under the breast; it has the least swelling of hte breast since the breast gland itself isn't cut; it is an incision that can be used for any type of revision necessary in the future; it allows for complete and total visualization of the surgery; it allows all implant types to be placed with a minimum of trauma. And once augmented, the scar is up and under the breast, right at the crease where the breast meets the chest wall, an area that frequently has a bra mark that is even more visible than the scar itself.

My suggestion: go inframammary. From your relationship's point of view neither of you lose the argument. And from a medical point of view your wife gets what is to me the most reasonable incision choice.

Transaxillary vs. periareolar breast augmentation

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In my opinion a periareolar incision is a better choice. This incision allows your surgeon to fully visualize the pocket and is being created which results in more precision and a more predictable aesthetic outcome. Normally the scar is very inconspicuous. The idea of a breast augmentation performed through the armpit is appealing because the scar is well hidden and usually inconspicuous. Unfortunately however there are significant trade-offs with this procedure. In performing a transaxillary (armpit) breast augmentation an incision is made in the armpit and then a pocket is created. Most commonly this pocket is created under the muscle, Less commonly the pocket is made under the breast tissue and over the muscle. Usually the submuscular pocket is made bluntly and blindly. This means a blunt instrument is placed through the incision and under the muscle. After inserting the instrument the pocket is created by bluntly tearing the muscle attachments of the pectoral muscle along the inframammary fold and to some degree along the breast bone. It is done blindly meaning the surgeon is not able to visualize the pocket. The pocket is then washed out with sterile saline until the surgeon is satisfied there is no bleeding. The implant is then placed through the incision. Saline implants are the easiest to insert in the pocket as the empty implant shell can be placed through the incision and inflated after it is put in the pocket. Round silicone implants are more difficult to insert. Textured and anatomically shaped implant are not normally used. The downside to this procedure is that the pocket is normally not visualized and less precision in the formation of the pocket can be achieved. This is important because precise pocket creation is an essential step in achieving an ideal aesthetic outcome. Because it is done bluntly and visualization of the pocket is not possible small amounts of blood can remain and possibly lead to a capsular contracture. When the procedure is performed utilizing an endoscope (a device that helps visualize the pocket) some of the problems associated with a blunt and blind dissection are lessened.

Transaxillary vs Periareolar Breast Augmentation

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Which do you think is better for you? Listen to the benefits and drawbacks of both incisions from your surgeon:

transaxillary incision
- no visible incision on breast 
- incision well hidden in armpit
- can be more difficult to position implants precisely
- some surgeons are only comfortable with placing saline implants through this incision

- incision well hidden by areola border
- great ability to position implants in desired place
-increases  the risk of decreased nipple sensation
- increases the risk of infection and loss of breastfeeding ability

Transaxillary vs periareolar vs crease breast augmentation incisions

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The transaxillary incision is much less commonly used than it was several years ago. I have treated several patients from my area with misplaced implants through the armpit and even two whose doctors burned through the skin in the lower inner corner of the breast getting lost in where they were in the pocket dissection. Some revisions cannot be done through the armpit so another incision is needed. Finally, the numbness in the upper inner arm that can occur has made this less popular.

The areolar incision is nice but is sometimes limited in that some areolae are not big enough to place a desired silicone gel implant in through without damaging the integrity of the implant. A periareolar (around the entire areola) incision allows for larger implant insertion plus a modest breast lift.

Finally, the crease is a workhorse incision in this as any size implant can be inserted and all revisions can be done through the crease.

What Incision is Best?

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This is a good question as the majority of patient that wish to have a breast augmentation desire a result that is going to feel and look natural without having obvious scars.

There are several ways to place the incision so that it is well hidden in natural skin folds or breast transitions.
  • 1.Periareolar
    • 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.
  • 3.Axilla
    • 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.
    • 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.

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.

Your choice, not his

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It really should be your choice, as you are having the surgery. It's your body. Talk to your surgeon and determine which is the best for YOU not for him. You're the one who has to live with it!

Transaxillary vs Periareolar Incision for Breast Augmentation

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All breast augmentation incisions have their pros and cons. If you do not have a small areola then a periareolar approach is reasonable and the scar is more camouflaged. However you should be aware that there is a higher risk of capsular contracture and not being able to breast feed with this approach. A transaxillary approach also has a higher risk of capsular contracture and has no breast scars. An inframammary approach would probably be the safest with least risk of complications with the scar tucked beneath the breast to hide it.

Transaxillary vs periareolar breast augmentation

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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.  The transaxillary incision is much less used today due to its blind approach and inability to shape the breast pocket as precisely as with the inframammary or even periareolar incision.  Especially if you are in need of a breast lift, the periareolar incision may be the better option in this case. 

Hope that this helps!  Best of luck on your decision and for a great result!

There is no reason to argue about the best incision...

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Breast augmentation can be performed utilizing either the inframammary, periareolar or transaxillary approach with either silicone or saline implants.  There are pros and cons to any of the incision choices depending on each patient's unique situations.  It is best to visit a plastic surgeon who is comfortable with all three approaches to help guide you in your choices for a great breast augmentation result.

Sanjay Grover, MD
Orange County Plastic Surgeon
5.0 out of 5 stars 232 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.