What are the pros and cons of getting the incision through the nipple vs. under the breast?

The fact that both the periareolar and inframammary incisions are commonly used for breast augmentation should tell you that there are pros and cons for each. These are not absolute and what may be a pro for one patient may be a con for another. Some of these are scientific facts and others are subjective opinions of surgeons. There are also aesthetic vs. medical concerns. The many variables make this a complex issue and your decision should not be made without a consultation with a board certified plastic surgeon. Issues addressed would include risk of capsular contracture, affects on breast feeding, anticipated appearance of the scar, the areolar diameter, type and size of implants, etc. 

The moderate plus profile tends to create a very natural breast augmentation result. The gentle curvature of the implant tends to create a "tear drop" shape to the breast when a woman is standing. This is considered a natural result. The high profile implant tends to create a very round shape to the breast. This is a good implant for someone who wants maximum size and roundness. This tends to be less natural looking than the moderate plus profile implant. The higher the profile of the implant, the more volume it can hold in the same width and the rounder it becomes. 
Implant size selection depends on your unique measurements. We have a device called the Vectra 3D imaging system that shows you what you will look like with any implant. Our patients are very happy with the choice of implant they make when using this system. To learn more about how to choose the right size implant, you can read "A Comprehensive Guide to Breast Augmentation."

Most PS will cover the nipple and areola with a plastic barrier to prevent bacterial contamination at the time of surgery when they use the crease incision.  The PA approach scar can be very difficult to see bur other times it is obvious.  The fold incision is not visible unless you are lying down. This scar fades and is not obvious just like the PA scar. Most surgeons prefer the fold incision for surgery.

If you want the least risks for contractures, the inframammary is by far the lowest risk approach with the axillary approach being the worst.  The scar heals well in 95+% and the scar is never seen when topless since the breast covers it.  The peri-areola approach is nice for its aesthetics but if used more than a few times, the scar starts retracting and is problematic then.  So if you want to wear teeny bikini tops, then the areola approach is for you... but if you want the approach with the least risk, going under the breast is better.  And this is based on my 25+ years of experience and knowing someone who exclusively liked the peri-areola approach.

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.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

Thank you for the question. There are several good approaches to breast augmentation surgery; different surgeons will have their own preferences. In my practice, I prefer the inframammary or infrareolar approach for most patients.    
 For patients with very little breast tissue and/or underdeveloped inframammary fold areas,  I tend to recommend the us of an infra areolar  approach. Despite what you may hear, I think most patients can have the infraareolar incision used regardless of the size of breast implants or size of areola. The Keller funnel has made the insertion of all sizes of breast implants much easier. I think that the us of the funnel has also made it easier to perform a true "no touch" technique ( potentially decreasing the incidence of breast implant encapsulation).
Also, personally, I think the advantages of the infraareolar incision far outweigh any theoretical disadvantages. These advantages include proximity to the planned dual plane submuscular pocket dissection, relatively hidden/forgiving location of scarring, coverage by clothing/swimming suit etc.
Patients undergoing breast augmentation surgery should understand, that regardless of the incision used, that scar revision surgery is sometimes necessary to improve their outcome.
  I hope this helps.

Each surgeon has a preference for incisions under individual circumstances.  Recently inframammary scars have gained popularity however like many I'm reluctant to recommend that incision.  The primary reason is that I have seen dozens of patients who had that incision and have been left with long and sometimes darkened, lighter, depressed or elevated incision lines.  I have seen a few where the incision was almost invisibile but many times more where the patients regretted the incision line and its permanence.  Based on 3+ decades' experience, I prefer either the "periareolar" incision or the transaxillary incision with partial subpectoral placement of smooth silicone cohesive gel implants using the Keller funnel.  Discuss your surgeon's preference and recommendations since it would not be advisable to push your surgeon to use an incision that he/she does not customarily or frequently use.Best wishes,Jon A. Perlman, M.D. FACSDiplomate, Am Bd of Plastic SurgeryMember, ASAPS, ASPS LASPSBeverly Hills, Ca.