The decision about where to place the incision for breast augmentation is usually made prior to surgery after discussion with your plastic surgeon. There are advantages and disadvantages for each approach, and each surgeon has his own preference for what he feels is best and what he feels comfortable with. The most popular type of implants these days is the silicone gel implants. Also many studies and statistics tell us that once you have breast implants, there is a very good chance that you will require at least one revision surgery within your life- time (or more if you choose silicone gels for preventive maintenance routine replacement). Keeping these two things in mind, most plastic surgeons (myself included and according to statistics from our professional societies) prefer the IMF approach over both the peri- areolar and transaxillary approach for several reasons. First is that the peri- areolar incision has a higher incidence of capsular contracture. Given that one of the more common reasons why you would need to have another surgery in the future is capsular contracture, it makes sense to do everything possible to avoid it. I think if you were going to go with saline filled implants and if you were more dark skinned (with a dark areola) then going through the areola might still be an acceptable approach to hide the scar better because there is less tissue manipulation of the breast tissue near the nipple (when placing saline- filled implants as opposed to silicone gel implants) that can express the bacteria that normally resides in the ducts that can seed the implant and cause capsular contracture. It's also easier and less traumatic to insert a silicone gel implant through an IMF scar than a peri- areolar and transaxillary approach. If you have to work hard to force a silicone gel implant into the pocket, you run into more of the risk of rupturing or damaging the implant during the process. Unlike a saline- filled implant, if you accidentally tear a silicone gel implant during the implantation process it won't deflate right away and may not be detectable until months or years later on. The tunnel that a silicone gel implant has to go through via the transaxillary approach is much longer and visualization and control is much more limited so I think there is much more trauma of the implant for this approach and thus greater chance for rupture of the implant. Also, it's not only the implant pocket that has to be dissected perfectly (and with the least amount of trauma and bleeding to avoid complications), the implant itself also has to be seated perfectly once it's delivered into the pocket. Trying to manipulate to position the implant perfectly in the pocket through the axilla by using one's fingers from an opening far away or by instruments (which will risk rupturing the implant more) is just needlessly making it harder for the surgeon (and increasing the risk for asymmetry and malpositioning)- all to just avoid a scar on your breast which only you and your significant other will see. You and everyone else, though, will see the shape, positioning and symmetry of the breasts (which is more important for most women than a small scar which few women worry more about). Placing the scar in the armpit is not going to fool anyone into thinking there there is no breast implant in place as one can almost always feel it. But, having malpositioned implants, asymmetry or capsular contracture is always a dead give- away- sometimes from across the room. In my practice requests for scar revisions after breast augmentation are very, very rare, and it's much simpler and less risky to do than a major revision for capsular contracture or implant rupture or malpositioning. You also have to remember the fact that you will most likely need to have another revision breast procedure within your lifetime. Most surgeons do not attempt a revision through the armpit incision if that was your original scar. It's even more difficult to do that then to place implants through that scar so you are looking at needing another scar on your breast (either peri- areolar or IMF). You would then have 2 different scars as opposed to just one if you started off with the IMF.In the end though, surgeons do what truly works for them and what they feel comfortable with. I would also not classify the transaxillary approach as a new or "more advanced" approach though as it's been around since the 1990's, and most Plastic Surgeons who have been trained in the modern era of plastic surgery have been trained how to do this technique. Most of us, however, choose not to use that approach because it offers few advantages and many more disadvantages. There is a good reason why most of us do not offer the transaxillary approach. Few of us would even venture to claim that it's a "safer technique" since there is absolutely no scientific data to back up that claim. What would make sense to most people is that if you are able to visualize what you are doing better and if you have more direct access and control of your dissection and implant pocket, you will be more precise with your implant placement. It's just physics and common sense. You have to look at the big picture and all the risks and benefits (present and future), and not just focus on a few small scars to guide your decision. Try to look beyond the marketing and frills where the risks are not talked about along with the benefits, and focus on long- term outcomes and sound decision making by getting as much information and opinions as possible.Best wishes.
