Hi all :) Would you please let me know in your opinion, what is the risk of capsular contracture and bacterial infection for the periaerolar incision, compared to the inframammary fold one? How much higher is it theoretically and practically? Do you experience more revisions with this incision than the inframammary fold one? Your feedback is greatly appreciated, thank you!
Periaerolar Incision Risks?
Doctor Answers 29
Periareolar vs inframammary fold incision for breast augmentation
From a practical standpoint there is no increased risk of capsular contracture when performing a periareolar incision when compared to an inframammary fold incision. Fortunately, with the use of cohesive gel silicone implants, or ones that are saline, the incidence of capsular contracture has dropped to such a low percentage that surgeons who have been operating for a decade (or two!) are now much less concerned about this complication than we were years ago.
Infections with augmentation mammoplasty is very rare and the incision site would not have any bearing. In my own practice, I have yet to experience a single significant infection in 26 years of performing augmentations.
As for periareolar incisions, they definitely heal quite well from a cosmetic standpoint but since a portion of the breast ducts will be divided, there may be potential issues with breast feeding (which could certainly be addressed at that time). In terms of scarring, I would like to echo Dr. Dadvand's remark that "if done properly both incisions are inconspicuous".
Breast implant incisions
I use the peri-areolar incision almost exclusively. In my experience the incidence of capsular contracture or infection is very low and no different than any other incision. The inframammary incision is good but it will reult in a bad scar in about 10-15% of patients and then it will be noticeable if the bra or the swimming suit rides up. I literally most times cannot find the peri-areolar scar after several years on my patients.
If your plastic surgeon is not using that incision, then it is because most likely he is not familiar with the technique and will say that it causes more infections, contracture or loss of sensation or inability to breast feed which in my experience is just not the case!
Also, I do not recommend the axillary incision for again if it is a bad scar(10-15% of patients), the patient will have to be aware when she raises her arms. Also, unless endoscopy is utilized, it is a blind procedure(the surgeon cannot visualize the pocket he is creating or has created)which will result in a number of patients experiencing asymmetry in placement of the implants. It is quicker and that is why it is used primarily.
The belly button incision is fine but you cannot place silicone implants through it and the chances of asymmetry and misplacement of implants is higher because again it is blind, unless endoscopy is used.
Also, with all these incisions, loss of sensation of the nipple can and does occur but in about the same percentage or about 1%.
An informed patient about these incisions is the best patient! Watch my videos and see the all inclusive special pricing that I am featuring for breat enlargement.
Periareolar vs inframammary incision for breast augmentation
I do let the patient decide what incision to use, but I prefer the periareolar. There is no increased risk of infection nor loss of sensation. If the patient need a lift in the future, then the incision can be extended all of the way around to accomplish this. I have seen some inframammary scars that have ugly widening and prolonged erythema.
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Periareolar Incision for Breast Augmentation: Risks
The periareolar incision (under the nipple) for breast augmentation and placement of breast implants is not as common as an incision choice as the lower breast fold or infra-mammary fold incision. The incision is curved under the border of the nipple pigment and actually heals very well. There may be a theoretic increased risk of capsular contracture secondary to bacterial contamination of the breast implant because of the close proximity to the nipple ducts, both internal and external. This can be lessened by protecting the implant from the nipple on insertion and a careful dissection plane down to the implant pocket. This incision, in my hands is utilized if the patient needs a breast lift or mastopexy, if I need to lower the breast fold, or if the patient requests it. I do not use it routinely, and have difficulties in the patient with small areola. I have found there may be more incisional discomfort with this, though it is the second line incision for breast augmentation and if performed correctly, I have seen no increased risk of capsualr contracture.
Periareolar Incision Risks
I typically allow my patients to choose their incision of choice. Although it seems theoretically possible to have a higher incidence of infection and sensation change with the peri-areolar incision, it has never been shown to be true in the literature. Therefore, I let the patient choose, although I point out that the peri-areolar incision may be easier to hide in patients with small breasts and wide areola or a lack of an inframammary fold.
Incision Options for Breast Augmentation
Your second question is very astute. Although there is a theoretically increased risk of capsular contracture and bacterial infection with a periareolar incision, this does not bare out clinically. Ultimately the ideal study would be to perform one incision on one breast and another incision on the other and compare the results. However, most patients would not sign up for this type of study for obvious reasons. Also rthere are many factores that contribute to capsular contracture and it would be difficult to say that the incision location was reponsible.
I perform the majority of my augmentations through the periareolar incision because it gives the extra advantage of making any adjustments to the areolas when there are small asymmetries. Periareolar incisions also heal very well because they are paced right at the edge of the darker areolar skin and the native breast skin. There is a correlation between nipple sensation changes and periareolar incisions but the influencing factor was implant size, with larger implants leading to greater chance of nipple sensation changes.
Overall, if done properly both incisions are inconspicuous and are not related to a higher or lower chance of complications.
Hope that helps and good luck!
Dr. Babak Dadvand
Perioareolar (nipple) incision with breast implant augmentation
I use the periareolar incision in approximately 50% of cases as it allows some versatility in adjusting the height of uneven areolas. However, the limitations are thes size of the areola (small ones do not allow placement of larger silicone implants) as well as the concerns for bacterial contamination with biofilm and subsequent capsular contracture (CC). Having said that, it is my overall impression that the rate of CC is roughly equivalent in my practice and the in range of 5% over a 3 year period (overall 8% in national studies for Baker III/IV).
Periareolar vs Inframmary or Transaxillary Incision
Thanks for asking a good question. I have never experienced a breast augmentation infection whether using periareolar or transaxillary incisions (my two preferred approaches). The only negative of a periareolar incision is the likelihood that breast feeding will be more difficult to start and/or maintain due to some of the breast ducts being severed. The approach however leaves a consistently small and barely visible incision and the risk of loss of nipple sensation is no higher than with the other approaches. The risk of capsular contracture seems no higher with any particular incision.
My feeling about the inframammary scar is that it should usually be avoided. I have seen a small proportion of patients with that incision show minimally visible and acceptable scars, however I have seen a lot of patients with light/dark/raised or depressed scars that they regret having. Others will disagree, however I have been performing breast enlargement surgeries for over 25 years.
Jon A Perlman, MD
No increase of complications with areolar incision
I have been using both inframammary and peri-areolar incisions for breast enlargement for over 10 years, and have seen no significant difference in incidence of capsular contracture or infections between both approaches.
The areolar approach delivers a superior scar to my opinion, and also allows the surgeon better 360 degrees access to the pocket. It is my preferred approach.
Incision choice in breast augmentation
Infection in breast augmentation is very rare when performed to todays standard of care. Of the two approached, I prefer periareolar as the inframammary if low can show under a bikini and if high is plainly visible in the nude when standing. It is my preference to never place a scar on the breast when elevating the nipple is noot necessary which is why I prefer to perform transaxillary cold-subfascial augmentation. The patient is lifet with a very thin scar in the armpit that usually disappears into a fold in the armpit.
All the best,
Rian A. Maercks M.D.