How do I know what incision is best under the boob or in the nipple? (Photos)

I prefer the incision under the breast. It heals nearly invisibly and is a more direct approach.  There are other good reasons to use the inframmary approach.  If, in twenty years from now, say you want the breasts lifted.  the peri areola incision could make the lift more risky because some of the circulation may be compromised.  Statistically the split between inframmary and periareola is probably 50/50.  Ultimately I let the patient decide.

The inframammary and the periareolar are the two most frequently used access incisions for augmentation. Excellant results can be obtained using either one. Most surgeons have a preference for one or the other. In my practice, I allow the patient to choose in most cases. In my opinion, most implants should be placed under the muscle. This provides better coverage, avoids interrupting signicant blood supply, and lowers the risks of complications from future procedures such as breast lifts, etc. 

Hello,Periareolar incisions put you at the highest risk for the most common complication of breast augmentation: capsular contracture. It also cause injury and scaring to the underlying breast tissue which has a direct implant on mound shape and implant palpability. Finally, although touted as a more aesthetically pleasing incision, I can tell you that on average they are more conspicuous and thickened than ideal. Inframammary incisions offer the lowest risk of complications and reoperation and are more pleasing than periareolar incisions on average. Subpectoral implants have a lower risk of capsular contracture, rippling, and unpredictable tissue stretch than subglandular implants. Go visit a few ABPS certified/ASAPS member surgeons who specialize in breast surgery. Best of luck!

The nipple incision is referred to as a "periareolar" incision, since it's located right on the junction of the darker areola skin and the lighter breast skin. The other incision is called an "inframammary fold" incision. Both are very useful, and both tend to be very cosmetically acceptable as time passes. In recent years, the inframammary incision has become more common, due to the opinion of many breast augmentation experts (including myself) that the rate of capsular contracture is lower than with a periareolar incision,. Capsular contracture is a problem in which the tissue around the implant thickens and tightens, making the implant hard, and sometimes displacing the implant. I typically use an inframammary fold incision, but will also use the periareolar incision if the patient really prefers that approach. I almost always place the implants beneath the pectoralis major muscle. The muscle provides a thicker layer of padding or cushioning over the implant, making it less likely that an implant edge or wrinkle will be visible. 

Dear bere17,I tend to prefer the periareolar incision because its the most well hidden. There is a natural border between the areola and the rest of the breast skin the hides the incision extremely well. You have to be completely naked to see it vs other incisions like transaxillary and inframammary are visible in clothing such as sleeveless shirts and bikini tops when extending your arms up. I've also noticed increased rates of bottoming out with inframmary incisions that is not reported. Transaxillary implants are always wide in appearance because the surgeon is not able to dissect medially enough to provide better cleavage. Ultimately, I can perform any of the incisions but I recommend the periareolar. There is no difference in sensation because the nerves that control nipple sensation come in laterally from the back and injury to them occurs when surgeons dissect to far laterally which is why transaxillary incisions have the highest nipple sensation disruption. There is no difference in breast feeding ability. One study did show a slight increase in capsular contracture with use of periareolar but that study was small and did not incorporate modern techniques such as below muscle placement, keller funnel usage and triple antibiotic irrigation. Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Essentially, the approaches and implant position that will be best for you are the ones YOU prefer, after learning about advantages and disadvantages of each choice.  Your surgeon should explain the possibilities in some detail, and there are many answers on our site.

Hi Bere,Be sure to find a surgeon who is comfortable with both approaches and who does several hundred BA each year.  Either incision is fine, it depends where you want the scar the rest of your life!  We almost always go under the muscle no matter the incisions.  Most of our patients elect to have the armpit approach to avoid a cut on the breast all-together.  The Aesthetic Surgery Journal published an
article several years ago proving that the armpit
incision has less bacteria than the breast fold incision or the nipple incision.  This paper, published on April 26, 2011 by Dr.
Sophie Bartsich, is from the prestigious New York Presbyterian Hospital and
Columbia University Medical Center and is titled “The Breast: A Clean-Contaminated
Surgical Site”.  The investigators proved
scientifically that the nipple region demonstrated a bacteria concentration
which was five times higher than the breast fold site which demonstrated a
concentration four times higher than the
armpit (axillary) area!  Much has
been published in our plastic surgery journals on the armpit breast
augmentation in recent years. Another study which is in the link below from the
Aesthetic Surgery Journal showed a lower infection rate than normal in 2,000
patients undergoing an armpit (axillary) breast augmentation.  These Plastic Surgery Journals are
“peer-reviewed” and edited, they are the gold-standard in our field as being
valid science.  You may review the web
reference below from the Aesthetic Surgery Journal and you will see the
axillary BA method outlined.  The website below also has videos showing
patients with axillary incisions demonstrating the quick recovery routine
postoperatively. All the best!!Dr. Joe
 
 

It is somewhat difficult to tell absolutely from a photo rather than an examination, But it appears that you have no ptosis or droop to year breasts and therefore would be an appropriate candidate for any approach. My preference in the lack of ptosis is using the axilla or armpit. This allows me to do a breast augmentation without putting the scar on the breast.

Hello and thank you for your question!  Congratulations on deciding to pursue breast augmentation. From what you have provided with your pictures, it looks like you will have a great result with this operation. Getting a breast augmentation is an important decision. The procedure itself is half of the process, but the more important half is your recovery and long-term results. Lowering your risk for potential problems is key. In a straight-forward breast augmentation, I prefer to use the inframammary crease incision because:1) it is more well-hidden as you have nice lower pole cleavage and have a natural shadow/crease there that will hide your scar; a scar around the the nipple-areola complex is more visible because it sits on the center of the breast and the scar can be quite obvious in some people.
2) it gives a straight-shot access to develop a submuscular pocket and really control the boundaries of your breast pocket made to place the implant: it does not violate your inferior breast border (like an umbilical approach) or your lateral border (as in cases where people use the armpit and then end up with implants in the armpit). " Pocket control" is key for long-term results.
3)the inframammary crease is the cleanest of all sites compared to the nipple (where many glands and ducts exist), the armpit (where there are many sweat glands and hair), the umbilicus which harbors bacteria. Studies have shown that this decreased bacterial burden also decreases long-term potential for capsular contracture; furthermore, the crease is the least sensitive of all the areas and as patients heal, their scars may get sensitive and the crease decreases scar hypersensitivity issues. Speaking of sensitivity, cutting further away from the nipple-areola complex should theoretically further protect preserving nipple sensation.
I think you will have an excellent result with breast augmentation if you go to a board certified plastic surgeon with expertise in aesthetic breast surgery. Make sure to check reviews on yelp/realself/google+/Facebook/etc, before and after photos, following on instagram for the surgeons you are considering to gain a better understanding of the results they deliver for their patients and then go with someone who fits your needs best. I recommend going to a board certified plastic surgeon with expertise in aesthetic breast surgery.
Take care,
Dr. Sean Kelishadi

Good results may be
obtained with both types of incisions depending on individual anatomy, a
patient's concerns and desired outcome. There are pros and cons of each.Periareolar: The incision which goes around the
edge of the dark areola that surrounds the nipple (usually the lower half) is
used to insert the implant.Pros:The scar usually blends wells well with the
surrounding tissue. • The same incision can be used again if later
surgeries are needed.• The space for the implant can be seen clearly
with direct vision.Cons:• The incidence of infection after surgery may
be minimally greater.• Breastfeeding in the future may be interfered
with in some but not in most patients.• Nipple sensation may be decreased, but it is
usually temporary.• While the scar usually blends in at the edge
of the areola, there is also a chance it could be lighter or darker than the adjacent
tissue.• If the areola is too small, the incision may
not be a good option for larger silicone gel
implants.• Potential slightly higher risk of capsular
contraction.Inframammary: The incision is placed at the
bottom of the breast near the crease called the inframammary fold.. This is the
most commonly-used incision today.Pros:• The same incision can be used again if later
surgeries are needed.• The space for the implant can be seen clearly
with direct vision.• Slightly lower risk of infection.• While it is a visible scar, the position
underneath the breast in the fold means it is usually not visible while standing without clothes.• Potential slightly lower risk of capsular
contraction.Cons: • The scar can be visible on the breast when
lying down.• Placement higher or lower on the breast will
make the incision visible. • If there is a secondary procedure to place a
larger implant, the scar may be located higher
on the breast. If a smaller implant is placed, the crease may be raised, exposing the scar in a lower position,
possibly in view under a bra or swimsuit. • Longer appearing incision than around the
areola.• May not blend in as well as a periareolar
scar.
There
are two choices for breast implant placement: sub-glandular (under the breast
tissue and in front of the chest muscle – the pectoralis muscle) or
sub-muscular (under or partially under the chest muscle). The best location
depends on many factors including: tissue thickness, weight, desired outcome,
and individual anatomy. Each position has advantages and disadvantages:
Subglandular implant benefits:
A shorter
recovery time.
Less
discomfort initially.
No
distortion of the breast when the pectoralis muscle flexes.
Mild
preoperative sagging can be improved, especially if no breast lifting
procedure is performed.
Easier
surgical procedure.
Larger
implants can be placed.
 Subglandular
implant disadvantages:
The implant
may be more visible.
More
visible rippling, especially in patients with a small amount of natural
breast tissue.
Generally,
saline implants do not produce a good result in front of the muscle.
Higher
incidence of capsular contraction.
“Bottoming
out” in some patients.
Some
radiologists have more problems reading a mammogram with an implant in
front of the muscle.
 Submuscular implant benefits:
Usually
results in a better appearance for naturally small breasted women
Less
tendency for seeing ripples of the implant.
A more
natural feel to the breast especially in slender women who don’t have much
of their own breast tissue.
Less
interference with mammograms, although most radiologists take additional
views no matter where the implants are placed.
Lower rate
of capsular contraction.
Less of a
chance of “bottoming out” where the implant bulges at the lower aspect of
the breast and the nipple and areolas tend to appear excessively elevated.

Submuscular implant disadvantages:
Recovery
usually takes a little longer and is more uncomfortable initially.
There may
be an “animation deformity”, which is a temporary distortion of the
breasts when the pectoralis muscle is flexed. Body builders and weight
lifters generally prefer implants in front of the muscle.
It is
harder to achieve cleavage in women who have widely spaced breasts.
The
implants often ride higher on the chest.
Actually,
most patients who have breast augmentations today have breast implants placed
in a combination or “dual plane” position. This approach has the same benefits
and disadvantages of a total “submuscular implant”, but with a lesser tendency
to ride high on the chest wall. The disadvantage as compared to a total
“submuscular implant” is a higher tendency for bottoming out.
The
ideal placement in any particular patient depends on their particular anatomy
and understanding of the pros and cons of each approach and desired outcome..
Keep in mind that following the advice of any
surgeon on this or any other web site who proposes to tell you what to do
without: examining you, physically feeling the tissue, assessing your desired
outcome, and taking a full medical history, as well as discussing the pros and
cons of each operative option would not be in your best interest. I would
suggest that your Board Certified Plastic Surgeon be certified by The American
Board of Plastic Surgery who is ideally a member of the
American Society for Aesthetic Plastic Surgery (ASAPS) that you trust and are
comfortable with. You should discuss your concerns with that surgeon in person.
That way, you can have a better idea what is safe and makes the most sense for
you.Robert Singer, MD FACSLa Jolla, California