Which is Better and Less Painful, Armpit or Aerola Incision?

Great question!  The armpit or trans-axillary incision's main advantage is that it is hidden in the armpit, far from the breast and not visible even without clothing.  The distance from the pocket is an issue so only saline implants rather than pre-filled silicone implants are typically used.  The peri-areolar incision heals fairly well and can be used for either saline or silicone implants.  It is usually not a very painful incision but it can be associated with a higher risk of loss of nipple sensation or hypersensitivity.  The inframmmary incision is well hidden in the fold of the breast, allows either a saline or silicone implant to be used and the risk of nerve injury is fairly low.   The umbilical incision has the same advantages and disadvantages as the trans-axillary approach.  Additionally, special instrumentation and experience is required.  If there is bleeding with any of the remote incisions, an inframmmary approach could be required to address it.  Please take an extra moment to discuss your concerns with your surgeon as well as the pros and cons of each technique.  If you are going to use silicone implants, a peri-areolar or inframammary incision seems most prudent.  Good luck!

There was a time about 20 years ago when the armpit approach was quite popular.  But its popularity has waned for several reasons.  First of all, while you don't have a scar on your breast, you do in your armpit and this can sometimes be visible (hairdressers, volleyball players...).  Most women eventually have subsequent surgery to replace implants or treat problems and these are usually done using an inframammary incision, so now you have four scars rather than two.  Plus, the armpit approach is more difficult for the surgeon: asymmetry is more likely and it can be a challenge to get the cleavage just right (and it is equally invasive).  I'm not sure one approach is more or less painful than the other.  I think all submuscular procedures are probably about the same in terms of pain.  A periareolar scar is also a good option, as recommended by your surgeon.  You don't want to insist that your surgeon use an approach that he or she is not comfortable with or uses infrequently.  Recovery to full activity is about a month regardless of the approach used.  Breasts can be touched right away.  Steristrips on incision usually come off in a week.  There are some examples of inframammary approaches on my website and periareolar (J.S.); the scar is nicely hidden in the crease.  A link is attached.

   In general, the risk for infection and capsular contracture may be greater for armpit and areolar incisions for different theoretical reasons.  I prefer the transumbilical, MF, or periareolar for saline and the IMF or periareolar for silicone.  The pain is due to placing the implant under the pectoralis major muscle, and I do not think any of these incisions is necessarily less painful.  Kenneth Hughes, MD Hughes Breast Augmentation Los Angeles, CA

Hello,

Thank you for your inquiry.

The 400cc silicone implants inserted from the armpit will result in a fairly visible a scar in the axilla with a higher chances of CC due to possible bacterial contamination. 

As for the insertion from around the areola, another visible scar will be placed at the point of entry. However, this method may be beneficial if you have decided to have a circumareolar (doughnut) lift.

Finally, the inframammary insertion may be the best bet in terms of aesthetics and low infection risks.

I encourage you to communicate your concerns and thoughts with your surgeon before your surgery so both of you would be on the same page.

I hope this helps and the best of luck to you.

Dr. Sajjadian

HI,

 

There is not a great deal of difference in post operative pain from different incision sites following  breast augmentation surgery. 400 cc silicone implants are fairly large implants and will be more difficult to place through a trans-axillary approach. There is recent evidence that implants placed through either the armpit or peri-areolar approach have a slightly increased risk of post- operative capsular contracture due to small amounts of bacteria located in the glands of the skin of those regions, and thus I recommend an infra-mammary approach for you. The new breast crease is also very effective at hiding the incision.

All my best,

Daniel  A. Medalie, MD

With all due respect, you want the best result from your augmentation, so pain (while important) should take a significantly lesser place than which incision is BEST! Scars are permanent, but reducing the risk of capsular contracture from bacterial contamination (armpit and periareolar incisions much more bacteria-filled than inframammary), damage to the nipple sensory nerve (higher risk of numbness with axillary or periareolar approaches), better hemostasis--control of bleeding vessels in surgery--(more accessibility via inframammary incision) might just tip the balance in favor of one choice over another. Here are the facts:

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 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.


So, perhaps your concern about a visible scar "trumps" all the rest of the data above, but now at least you have the information to make an informed choice with your surgeon and his/her preferences/habits! Best wishes! Dr. Tholen

There are pros and cons to all incision locations for breast augmentation.  All can leave a faint, barely visible scar in most patients, but some people scar poorly no matter where the scar is located.  I don't think that you will notice a significant difference in recovery time with any incision.

The correct incision is the one that is best for your anatomy. There is some degree of discomfort regardless of the site used.You will have arm and breast pain with the axillary incision.

Cupcake, 

There is no evidence that one incision hurts more than another in breast augmentation or that one heals faster than another.  Each approach has advantages and disadvantages.  I would suggest that you discuss this with your surgeon and think carefully about what he feels would work best in your situation.  

Keep in mind that in a sleeveless top, your axillary incisions will be noticeable.

In two to three weeks, you will be back pretty much to a normal lifestyle.

Best of luck to you,

Douglas Hargrave 

Thank you for your question. I use any of the three surgical approaches for implant placement (transaxillary, periareolar, or inframammary) depending on the needs and desires of the patient. For moderate sized silicone implants you might want to consider the inframammary approach as the longer incision required for these implants (compared to saline implants) may be less likely to lead to nipple numbness (periareolar) or a visible scar in the axilla. There is not a significant difference in recovery with any of the approaches as the limited incisional tenderness is not really noticed compared to the feeling of tightness most women experience. Generally all of the scars heal well, its more a matter of the possible consequences of the location of the incisions. All the best!