After going to my consultation my doctor recommended a transaxillary incision, he specializes in a transaxillary incision. I'm getting 350cc silicone implants. I am unsure about the transaxillary incision because I've heard it is more prone to capsule contraction and malposition. Also I am young and I know ill need future surgery's that might not be able to be performed through the transaxillary incision. Should I choose the transaxillary incision regardless or opt for a different incision cite?
Transaxillary incision or inframammary crease incision?
Doctor Answers 14
Transaxillary vs. Inframammary Incision - Which One Is Best For Me?
The transaxillary incision is not a blind incision if you do it endoscopically. It gives you excellent visualization of the entire pocket with the ability to stop the arterial and venous bleeders. It also allows the surgeon to be sure that the entire pectoralis major muscle is cut off the 5th rib. This is displayed on a TV monitor which magnifies the image and makes it easier to see small bleeders and small pieces of muscle.
You have also been given misinformation that the transaxillary incision increases the chance of capsular contracture. Actually, blood around a breast implant is the #1 way to get a hard breast, and since arteries and veins are easily identified with an endoscope, they can be electrically cauterized. Then, of course, if one does not use a drain, no matter which incision one makes, this increases the chance of capillary oozing (blood around an implant), therefore leading to a hard breast.
The Keller funnel has made placing breast implants through an axillary incision incredibly easy, and with a "no touch" technique, decreases the chance of skin bacteria being drawn into the breast implant pocket which then leads to a capsular contracture.
Therefore, if your surgeon is using the transaxillary approach, also using an endoscope, drain, and a Keller funnel, I am sure he or she has decreased your chance of capsular contracture way below other incisions not using these advanced techniques.
Malpositioning of implants through any incision is directly related to experience of the surgeon. The learning curve for transaxillary breast augmentations is much steeper than other incisions, however once one gets the "zen" of the transaxillary approach, this surgery has less complications, and better overall results.
Your consultants who feel the inframammary incision is an invisible incision obviously are not from Hawaii. The bikini tops rarely cover the inframammary crease especially when one raises her arms, and it is the feeling in Hawaii that any scar on the chest is a negative.
Why is the transaxillary such an excellent way to put breast implants under the muscle? This is because once you make your incision in the axillary crease, the minute you stick your finger in the armpit, you are already below the pectoralis muscle. You do not have to cut the muscle off the 5th rib directly, and therefore decrease the chance of getting into the lung and getting a pneumothorax.
Also, the scar itself is completely invisible the majority of the time as it is placed in a natural crease. Since the creases in the armpit have no tension on them (Langers Lines), and since tension leads to scarring, basically there is no scar most of the time. And finally, no one, not even your mother, has intentionally looked at your armpits.
Pros and cons of breast augmentation incisions!
Choice of Incision
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 possible. Ductal bacteria may also increase the possibility of capsular contracture, so cutting through breast ducts is inadvisable for several reasons, 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 and capsular contracture 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.
Since inframammary crease incisions do not cut through the bacteria-filled ducts like periareolar incisions do, or the bacteria-filled armpit sweat glands like axillary incisions, there is less bacterial contamination of the breast implants, and a resultant drop in the potential for capsular contracture.
Trust me, re-operation for capsular contracture is a way bigger deal (and worse scar) than choosing axillary incisions because the scars "hide" better. In many cases axillary scars are just fine, heal beautifully, and no contracture is seen. Likewise, not every IMC incision heals "invisibly."
BUT, if experienced breast surgeons performed 1000 breast augmentations in a row with axillary incisions and 1000 in a row with IMC incisions, I'd bet you a sizeable sum that the IMC group will have fewer capsular contractures or "poor" scars. And the IMC scars are all hidden, whereas the (bad) axillary scars can be seen in swimsuits, sleeveless tops, etc.!
And, you wisely understand that if ANY revisionary surgery is necessary or requested (size change, or after childbirth/breastfeeding), axillary incisions will not allow many of these procedures, whereas IMC incisions can always be re-opened and no "new" scars left. (Who wants 4 scars when 2 will do?)
Choice of surgeon is the most important criteria in final scar appearance, then incision placement choice. But neither trumps your own genetics of healing! Best wishes! Dr. Tholen
When done endoscopically by a board certified plastic surgeon, I feel that the axillary incision offers lower risk of contracture and the best scar possible. Endoscopic technique uses a camera to visualize the inside of the chest and special tools to perform the surgery through an incision in the armpit. The surgery is very precise when done in this manner and malposition is not any more common than other approaches. All bleeding is carefully controlled with this technique as well.
However, some surgeons will do this surgery without endoscopic instruments. The pocket is created bluntly which is very imprecise and could lead to implants not being in the right position. This also causes significant bleeding which could also increase the risk of contracture.
We prefer the endoscopic transaxillary approach for it's minimal scar that is hidden at the top of the armpit. This avoids a scar on the breast which could be visible, cause numbness or damage the breast's capacity to breast feed.
Shim Ching, MD
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Inframammary Crease Breast Augmentation Incision Allows More Accurate Placement
Thank you for your question. The decision as to where to place your breast augmentation incision should be up to you unless there is a good surgical reason to choose one incision over another.
The inframammary crease incision has several advantages over the transaxillary incision. The most important is that the transaxillary incision is a blind procedure whereas with the inframammary crease incision the surgeon is able to see exactly where he or she wants to place the implant, and the implant pocket can be developed and prepared more accurately under direct vision. In addition, many surgeons feel that silicone gel breast implants require a larger incision for ease of placement, and although silicone gel implants can certainly be placed through a transaxillary incision, most feel that it is easier, and less traumatic, to place the implants through an inframammary crease incision using a Keller funnel.
Express your concerns to your plastic surgeon. If the surgeon is unwilling to place the implants through an inframammary crease incision, and you have decided that that is what you want, then you should seek consultation with another plastic surgeon who is certified by the American Board of Plastic Surgery, experienced in cosmetic breast surgery and who has a good reputation in your community.
Axillary or IMF incision
The IMF incision is the better choice, in my opinion. Implant pocket development is more precise, risk of uncontrolled bleeding is less, capsular contracture rates are lower, lateral pocket wall disruption is lower, and I think that the scar is less conspicuous when done correctly. With that being said, if you trust your surgeon, and he is more comfortable with the axillary incision, you might be better off letting him do what he is most comfortable with.
Implant incision placement
Incision for breast implants
I prefer to place breast implants through a more direct approach so I can properly visualize the pocket and control for bleeding, and pocket size with more precision. I usually go with a periareola or inframammary approach.
Transaxillary vs IMF incision
Capsular contracture is the most common complication of breast augmentation with implants. The decision as to which incision to use is up to you. If you are more concerned about the scar being off the breast than you are the risk of capsular contracture, then transaxillary is good for you. If an incision at your IMF (inframammary fold) would not bother you as much as having an increased risk of capsular contracture, then the IMF incision may be right for you. I personally like to reduce the risk of capsular contracture as much as possible, so if a patient is fine with an IMF incision I will use that. Other ways to reduce capsular contracture further are submuscular placement and the use of textured implants.
With regards to malposition, it is more difficult to control the pocket through the transaxillary approach. But if it is commonly used by your surgeon, and he gets great results with it, he may not have as many malposition problems which may be encountered by less experienced surgeons with that approach. But in general, many do believe based on a few studies, although conclusive hard scientific data does not exist, that there is a higher risk for both malposition and capsular contracture with the transaxillary approach.
Incision Options for My Breast Augmentation?
There are several ways to place the incision so that it is well hidden in natural skin folds or breast transitions.
Hidden at the natural transition from the areola and the breast skin. The incision can be hidden in this natural color transition.
Secondary surgery can easily be performed through this incision.
The incision is hidden in the fold below the breast.
Secondary surgery can be performed through this incision.
The incision for the implant can be hidden in one of the natural axilla folds.
Using the Keller Funnel allows for placement of silicone implants in a variety of sizes
Placement is very precise with the use of the endoscope.
This technique has become less popular as only saline implants can be place using this method.
Also patients run the risk of destroying the fold, which can cause their implant to drop overtime.
It is important to see your board certified plastic surgeon to help guide you to an implant that will give you an aesthetically pleasing breast.