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Breast Implants: Placement and Incision Sites

The breast consists of milk ducts and glands, surrounded by fatty tissue that provides its shape and soft feel. Skin elasticity also contributes to breast shape. Factors such as pregnancy (when milk glands are temporarily enlarged) and the inevitable effects of gravity as you age combine to stretch the skin, causing the breast to droop or sag.

The breast implant can be placed either partially under the pectoralis major muscle (submuscular) or on top of the muscle and under the breast glands (subglandular) depending on the thickness of your breast tissue and its ability to adequately cover the breast implant. You should discuss with your surgeon the pros and cons of the breast implant placement selected for you.

The submuscular placement may make surgery last longer, may make recovery longer, may be more painful, and may make it more difficult to have some reoperation procedures than the subglandular placement. The possible benefits of this placement are that it may result in less palpable implants, less capsular contracture, and easier imaging of the breast with mammography. The subglandular placement may make surgery and recovery shorter, may be less painful, and may be easier to access for reoperation than the submuscular placement. However, this placement may result in more palpable implants, more capsular contracture, and more difficult imaging of the breast with mammography.

Incision Sites

To permit the smallest possible incision, the breast implant is typically inserted empty, and then filled with saline. You should discuss with your plastic surgeon, the pros and cons for the incision site specifically recommended for you. There are three common incision sites: under the arm (axillary), around the nipple (periareolar), or within the breast fold (inframammary).

If the incision is made under the arm, the surgeon may use a probe fitted with a miniature camera, along with minimally invasive (very small) instruments, to create a “pocket” for the breast implant.

Periareolar - Areola - Nipple Incision

This incision is most concealed, but is associated with a higher likelihood of inability to successfully breast feed, as compared to the other incision sites. This incision is a half-circle at the outer edge of the areola, the colored area around the nipple. The scar is extremely favorable and blends well with the areola. It grants the plastic surgeon with the best access for precise placement of the implant, resulting in a strong cleavage and better symmetry. There is also better control of any bleeding during surgery, which ultimately affects the chance of scar formation or capsular contraction.

Inframammary - Breast Fold Incision

This incision is less concealed than periareolar and associated with less difficulty than the periareolar incision site when breast feeding. This is a one to two incision made by your cosmetic surgeon near the under-breast fold. Like the peri-areolar incision, this approach affords the plastic surgeon the greatest control over the position of the implant, giving the patient more attractive cleavage. The final scar is very favorable.

TransAxillary - Under Arm Incision

This incision is less concealed than periareolar and associated with less difficulty than the periareolar incision site when breast feeding. An incision placed in the arm pit is also known as a Trans-Axillary incision. Despite the myth that this scar is usually unnoticeable, it can be more prominent than other scars, especially when a woman is wearing sleeveless cloths. This access point is very far from the central location of the implant making it very difficult to precisely position the implants, thus causing the implants to sit away from each other, creating a wide cleavage. It is associated with a higher risk of bleeding and less control, often forcing the surgeons to use drains which can increase the risk of infection.

Trans-Umbilical (TUBA) Endoscopic - Belly Button Incision

The Trans-Umbilical Breast Augmentation (TUBA) involves making a one to two inch incision at the edge of the "belly button," through which a long metallic tube is forced towards the breasts. Then the breast implant is folded and pushed through this tube to its final position under the breasts. There have been some reports of complication with the insertion of this tube, when the tube accidentally speared the liver or lung.

This approach has specific disadvantages as compared to the peri-areolar approach. First, because the implants cannot be placed precisely, there is a higher chance of breast asymmetry and of overly-wide cleavage. Second, if a patient also needs a Breast Lift, another incision has to be made around the areola.

This procedure is often marketed as a “Scarless Breast Augmentation,” but, to the contrary, the scar around the umbilicus could be very noticeable, and at times unsightly, especially if a woman is wearing a shirt that exposes the midriff.

Because this approach can be challenging, and due to its potential complication rate, it should be performed only by a board certified plastic surgeon who has extensive experience with it

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