Breast enlargement through nipple or under the muscle, which do doctors prefer and why?

I recommend an incision through the fold to minimize your complication rate.   I recommend an in-office examination as well as a detailed discussion with a surgeon who you are comfortable with.   Finally, make sure your surgeon is a Double-Board Certified Plastic Surgeon certified by the American Board of Plastic Surgery (ABPS), a member of the American Society of Plastic Surgery (ASPS) and the American Society of Aesthetic Plastic Surgery (ASAPS).Best,Dr. DesaiBeverly Hills Institute for Aesthetic Plastic SurgeryHarvard Educated, Beverly Hills & Miami Beach TrainedDouble Board-Certified Beverly Hills Plastic Surgeon

First of all, the incision location has nothing to do with whether the implant is above or below the pectoralis muscle.  Incision location, in part is surgeon preference.  The most common location is under the breast.  Personally, I try not to use an incision near the nipple, periareolar, due to concerns about contamination from bacteria.  Placement of the implant above or below the muscle is also in part surgeon preference.  The most commonly used position is under the muscle.

Hello,The data is conclusive that inframammary scars have the lowest capsular contracture rate, the number one complication of breast surgery.  Periareolar scars do not deserve their reputation as being inconspicuous. After nearly two decades of specializing in revision surgery, I can assure that the average periareolar incision is more conspicuous than the average inframammary incision. Subpectoral placement leads to lower complications, especially long term, than over the muscle. Best of luck!

You have posed a number of very commonly asked questions...When undergoing breast augmentation there are a number of choices which need to be made: saline or silicone? Volume: Larger or smaller? Incision? However, one of the most commonly debated choices is that of implants placement: subglandular/ submammary vs. subpectoral/ submuscular? While many surgeons recommend submuscular placement there are distinct differences to each approach.
 Subglandular Augmentation (“overs”): 
Subglandular augmentation means place of the implant underneath the breast tissue but above the pectoralis muscle. Subglandular placement spares the pectoralis muscle which leads to reduced post operative pain/discomfort and no impact on muscle function post augmentation. Recovery is also faster.Subglandular augmentation can impact mammographic evaluation of the breast. However, as dedicated breast radiography has become more prevalent this has become less of an issue. Fellowship trained radiologists have become familiar with evaluating breasts post augmentation. It is also important to note that implant position does not interfere with visualization of breast tissue via contrast enhanced MRI (the most sensitive and specific study available for breast cancer detection).Studies suggest there is an increased risk of capsular contracture when implants are placed in a subglandular space.Aesthetically, implants placed superficial to the pectoralis major create a rounded, convex appearing breast profile. This effect is camouflaged, at least initially in larger breasted patients. However, as a woman ages fat atrophies and breast tissue descends. The result is a more noticeable implant specifically in the upper pole. Similarly, patients who have thin coverage superiorly are more likely to be able to perceive the implants and at higher risk of visible rippling when compared to subpectoral augmentation.  Subpectoral Augmentation (“unders”): 
Subpectoral augmentation is technically a bit of a misnomer. Traditionally, subpectoral augmentation involves the release of the pecotralis major muscle from its lower attachments. This allows the muscle to “window-shade.” The upper hemisphere of the implant sits underneath the muscle (dual plane). This release contributes much of the discomfort encountered postoperatively by patients.Subpectoral implants have a lower rate of capsular contracture.Aesthetically, in contrast to submammary implants (which are prominent in the upper pole- especially in thinner patients), the pectoralis muscle both conceals the underlying implant and flattens the upper pole. This flattening effect creates a natural sloping as one proceeds from the upper portion of the implant to the lower portion.The most commonly cited drawback to sub-muscular augmentation is the animation deformity associated with contraction of the overlying muscle.In my practice, all things considered, sub-muscular is the plane of choice.The choice of incision in the setting of breast augmentation is one which is made jointly by both the patient and the surgeon. Surgeons typically have their preference as do patients. 
Your options include-
The direct approaches:
-IMF (fold)- (+) popular, direct access with good visualization, if placed appropriately it is well tolerated and well camouflaged; (-) the scar can migrate as the fold descends with augmentation, the incision can be misplaced
-Infrareolar- (+) commonly used alternative to the IMF incision, the location is more consistent and predictable than the IMF, especially useful in those patients with a poorly defined fold; (-) there is a limitation based on the size of the areola (smaller areolas will limit incision size and thus impact visualization), this technique is also associated with slightly higher rates of contracture
The indirect approaches:
-Transaxillary (armpit)- (+) avoids a scar on the breast mound but must be performed endoscopically as there is no direct visualization of the pocket during dissection otherwise; (-) can be limiting with regards to implant size and type (although the Keller funnel has helped)  
-Transumbilical (belly button)- (+) avoids a scar on the breast mound; (-) no direct visulization of the pocket, saline implants only.
Ultimately, no approach is perfect. They are different as is each surgeon. The incision decision is best made in concert with your board certified plastic surgeon (ABPS).

Dear lisatran32084,I recommend a comprehensive scar management program after your breast augmentation procedure. We specialize in minimal scars. Its starts with a peri-areolar incision that hides the scar at the border of the areola. Next, I close my incisions in 5 layers and take stitches out week one and week two.  I don't recommend absorbable sutures because they cause inflammation that worsens scars. Then we tape your incisions once a week for 6 weeks. Lastly we start you on a 3 month topical scar management protocol with a scar gel thats FDA approved. Mederma, FYI, has no proven clinical efficacy so I would not waste your money on that product.Daniel Barrett, MD, MHA, MS 
Certified, American Board of Plastic Surgery  
Member, Am. Society of Plastic Surgery

Lisa, thanks for posting. Incision placement can be a difficult decision based on skin pigment and type, areolar diameter, etc (I assume when you say "under the muscle" that you mean the incision under the fold.  Either approach can be used to put the implant above or below the muscle).  There is some evidence to suggest that incision through the areola ("nipple") may lead to bacterial contamination and increased risk of capsular contracture.  The pros and cons should be discussed by your local BCPS to your satisfaction.  Be cautious of any doctor who only does things one way as there are some indications that will often make one option better than the other.  Please see attached web reference.  Good luck!

If there is more than one way to do a procedure, there usually are reasons why one way is better than another in certain, but not all, situations.  With respect to the nipple (actually areolar) incision, the advantage is that the areolar scar may be difficult to find when fully healed.  On the other hand, the areolar scar may become unsightly (I have seen both), and therefore obvious when exposed.  The areolar scar also requires cutting the breast gland to get to the space behind the breast.  Bacteria can dwell within the breast ducts, and this, as well as the bacteria resident in the nipple, has led some plastic surgeons to recommend avoiding the areolar incision.  Personally I think that cutting through the breast gland is best avoided when possible.  In any case, the areolar incision can be used as an access to either the retro-glandular space (the space behind the breast tissue) or the retro-muscular space (the space behind the muscle).   In other words, placement of an implant under the muscle can be performed through a nipple incision.  Whether the implant is placed behind the breast tissue (above the muscle) or behind the muscle is also a point of discussion.  There are pros and cons here also and you should talk to your board certified plastic surgeon for advice.  Generally behind the muscle can be more painful and may cause the implant to move with muscle contraction but it covers part of the implant with muscle which may decrease the rate of capsular contracture (making the breast feel hard) and the ability to feel the deep seated implant.  The latter is especially important in thin women.  Placing the incision near the fold beneath the breast or through the armpit avoids any cutting of the breast gland and the bacteria in the breast or nipple.   

Hello, thanks for your question and provided information as well... The best position is through the inframammary fold. But every surgeon has it's own manners, besides that depending on your actual case, your surgeon will recommend you the best technique. 

In my opinion the best position for an breast implant scar is though the inframammary fold (IMF or fold).  This is different to the position of the implant which is under or over the muscle.  I believe this incision is best, as it is hidden in the fold, gives excellent access to exactly where I want to place the implants and rarely results in nipple issues (numbness etc).  A scar around the nipple has a risk of nipple numbness (sometimes permanently), it also means that the implant is placed through the breast tissue which has an increased rate of capsular contracture & infection.  Many surgeons will have their preferred method & approach, and this is my personal opinion.  Regards Kim 

There are many opinions about the prefered location of breast implant incisions and the implant pocket location. I prefer to guide my patients to receive the technique which would provide the least potential side effects such as capsular contracture, implant malposition, infection, etc. The scientific data conclusively shows that the approach with the fewest complications and side effects is: 1) incision at the inframammary fold, 2) placement of implants in the "dual plane" sub-muscular pocket and 3) utilize the "no touch technique" of breast implant placement with the use of a Keller funnel. Best of Luck to you!