Which incision site is best for breast augmentation with silicone?

There are four types of incisions used for augmentation mammoplasty:
axillary (armpit), periareolar (around the areola – the dark skin
surrounding the nipple), umbilical (belly button), and inframammary (in
the skin crease under the breasts). Each of these choices has pros and
cons; some surgeons use some or all of these options, whereas others
have a preference based on training, experience, or habit.

The armpit (axillary) incision is often thought to
create a "hidden" scar because the scar is not visible on the breast
itself. However, the armpit scar can be visible when the arm is raised
while the patient is wearing a swimsuit, sleeveless top, or strap-type
blouse, and this scar may be wider or more visible than other areas
because of its presence in a warm, wet, bacteria-rich environment which
is constantly being stretched with every arm movement.

In addition, dissection from the armpit incision requires that the arm
be elevated during surgery, raising the position of the breast and
potentially causing malposition of the implant with relation to the
crease. A higher proportion of high nipple, "bottoming-out"
augmentations are caused by improper pocket creation that results from
this incision raising the breast during surgery.

One final consideration with the axillary incision is that dissection
from this vantage point is somewhat more likely to cause nipple
sensation loss, since the (lateral fourth intercostal) nerve to the
nipple runs along this dissection route on the side of the chest wall.

The periareolar incision is generally made from the
three o'clock to nine o'clock position at the junction between the
normal breast skin and the darker adjacent areolar skin. Usually, this
scar can be minimally visible when healed; however, this scar is visible
when unclothed and can occasionally be unsightly, wide, thick, or
irregular and it can produce a sharply visible line in an area where the
areola color normally undergoes a gradual transition from dark to
light. In addition, this incision requires cutting through ducts that
end at the nipple, as well as the breast tissue itself, in order to
create the implant pocket. This can cause internal breast scarring
and/or calcification, which can make mammograms more difficult to read.
Since the nerve branches to the nipple area are partially cut by this
incision, a somewhat higher likelihood of nipple-areola numbness is
present. Ductal bacteria may also increase the possibility of capsular
contracture, so cutting through breast ducts is inadvisable, in my
opinion.

Some surgeons may advocate the use of a periareolar incision along the top edge of the areola,
excising a small crescent of skin above the nipple/areola complex in
order to achieve a “crescent lift” for small degrees of breast droop or
lower- positioned nipples. The amount of “lift” with this procedure is
minimal to none, and because of this, I believe this should be
considered a “scam” (in some cases) designed to charge higher “mini-lift” prices for what is
a standard augmentation incision choice if a surgeon utilizes this
approach anyway. If the cost is identical to augmentation alone, then in
rare cases, this may be a reasonable recommendation.

The umbilical incision (TUBA--trans-umbilical breast augmentation) involves use of an endoscope
(a lighted tube commonly used to perform tubal ligations,
appendectomies, gallbladder removals, and visual evaluations of the
stomach or colon) to create a pocket beneath the breast or chest muscle
for the implant. Only saline implants can be placed with this
incision. The implant pocket is created by blunt dissection with a
temporary tissue expander or the implant itself. Bleeding or
inframammary crease malposition can require an additional incision on
the breast, which negates the main advantage of using the umbilical
approach (no visible breast scar). Very few plastic surgeons utilize
this incision for breast augmentation, and the learning curve is
difficult, but acceptable results have been produced by reputable,
board-certified plastic surgeons, so consideration of all options is
reasonable. Silicone gel breast implants cannot be placed via this
incision.

The inframammary incision (beneath the breast in the
crease) is the most common incision used for breast enlargement with
implants. I believe this incision provides the best exposure for
creating an implant pocket with the least amount of bleeding (and the
highest likelihood of controlling this bleeding should it occur), avoids
the course of the nerve to the nipple in most cases, does not cut
through breast tissue and/or ducts (avoiding the mammographic concerns),
and leaves a short scar that is not visible clothed or unclothed unless
one lifts the breast or looks from beneath. When the patient is
reclining, the breast falls to the side and up, and the crease
(inframammary) scar can be visible; in most cases it is nearly
imperceptible. I use dissolving stitches beneath the skin surface—no
cross-hatch or railroad-type marks, no sutures to be removed, and just a
thin-line scar hidden in the natural inframammary crease.Though use of the Keller Funnel can reduce the bacterial contamination of implants placed via any of the 3 non-umbilical incisions, the inframammary incision has been most reliable for reduction of capsular contracture, and is the most common incision used when any type of revisionary surgery is necessary. I hope this helps. Best wishes! Dr. Tholen

Transaxillary approach is through the arm-pit. It is the most sophisticated technique. Armpit incision is a wonderful scar-free option for breast augmentation. Silicone or saline implants can absolutely be inserted through the arm-pit, don't let anyone tell you that is not an option. There is really no reason for an incision under the breast or through the nipple. The scarring under the armpit is minimal, there is minimal bleeding or bruising. Review the attached video. Don't let doctors not comfortable with the approach talk you out of it. It does not make sense to put scar tissue on a breast. Transaxillary is the standard in Asia and the UK and the results are completely natural. Patients are so happy not having to deal with any types of incision or scarring on the breast with little to no pain after surgery.

The two sites I frequently use for breast
augmentation with silicone implants are circumareola and inframammary. I use a circumareola approach when the
patient needs a simultaneous lift because of asymmetry or ptosis. I prefer the inframammary approach when the
patient does not.Best Wishes,Gary Horndeski, M.D.