Considering breast augmentation surgery? There are many decisions to be made - silicone gel or saline implants, over or under the pec muscle, round or teardrop breast implants, what implant size? In this article, we’ll look at one of the most common questions we answer during a breast implant consultation - which one of the breast augmentation incisions is best? We’ll examine all four breast augmentation incision options - inframammary, periareolar, transaxillary, and transumbilical – so that your decision-making process can be informed and tailored to your body type and goals.
THE FOUR BREAST AUGMENTATION INCISIONS
Breast augmentation is a popular plastic surgery procedure used by many women to increase breast size or improve breast symmetry and shape. During the breast augmentation procedure, the surgeon creates a pocket under the breast and inserts saline or silicone implants. Breast implants can be placed through one of four approaches: the inframammary incision (breast fold), the periareolar incision (nipple), the transaxillary incision (underarm), or the transumbilical incision (bellybutton).
Inframammary Incision
The inframammary incision is made in the crease underneath the breast (where the bottom of the breast meets the chest wall.) In women who don’t have a defined crease, the incision location is where the breast fold would normally be. The inframammary incision is best positioned in the deepest part of the crease - this minimizes visible scarring.
Inframammary incision placement gives your plastic surgeon immediate access to the bottom of your pectoral muscle where the implant pocket begins.
The inframammary approach is the most common incision option for breast implant placement.
Periareolar Incision
The periareolar breast augmentation incision is placed at the outer border of the areola (the darker-pigmented skin that surrounds the nipple.) The incision doesn't fully circle the nipple. It typically runs from the 4 to the 8 o'clock position but may go a little more or a little less depending on the diameter of the areola and the implant size needed.
Because breast implants are placed beneath the breast, a plastic surgeon using the periareolar breast augmentation incision has to tunnel through the full thickness of your breast tissue before making the implant pocket. We will see that this has implications for nipple sensation, scarring, and future breastfeeding.
Transaxillary Incision
The transaxillary breast augmentation incision is made in your armpit. It runs front to back in one of the fine creases of the underarm skin. The surgeon uses the opening to dissect a tunnel to the outer edge of the pectoralis major muscle and from there, starts to make the implant pocket.
Since the lower half of the implant pocket is distant from the underarm, the bottom of the pocket dissection has to be done with an endoscopic camera though some plastic surgeons prefer to do it by feel alone.
Transumbilical Incision
Yes, some breast implants can be placed through an incision in your belly button. The procedure is called trans umbilical breast augmentation (TUBA). The small incision (TUBA incision) is created just inside the rim of the upper half of the umbilicus. The plastic surgeon then uses a blunt pole-like device to create a tunnel underneath your skin and fat upward to the bottom of your breast. He or she then pushes a balloon underneath the breast and inflates it to create the implant pocket.
A saline implant is passed through the tunnel, into the pocket, and is then filled. This implant placement technique only works for saline implants that are inserted empty. You cannot place silicone implants through a transumbilical incision. This is why this incision type, which enjoyed brief popularity in the early 2000s, is only rarely used now in breast augmentation.
HOW SHOULD WE CHOOSE THE BEST BREAST IMPLANT INCISION?
Each of the four breast augmentation incisions has pros and cons. The best breast augmentation incision will depend on your anatomy, goals, and desires. It should be based on a detailed breast augmentation consultation between you and an experienced plastic surgeon.
But there are six objective criteria that we can use to rank the four incisions - scarring, accuracy, recovery, complications, versatility, and reusability. Let’s look at them one by one. For each criterion, I will explain the technical details and then pick the winners and losers.
1. Scarring
Scarring is the issue that most patients first think about in choosing their breast augmentation incision. It seems logical to ask yourself “where do I want my surgical scar to be?” But interestingly, after the surgery is healed, the scar is almost never an issue, regardless of which location was chosen. Almost all breast augmentation incisions heal to be thin, relatively unnoticeable lines. Minimal scarring is the norm.
When the scar is barely noticeable, incision placement doesn’t matter much. So, for the remainder of this discussion, let’s assume we’ve been unlucky and have more visible scarring than expected. In this case, incisions in any of the four locations will show, but we need to think about the specific situations in which they will be visible.
The inframammary fold scar, when placed where the breast meets the chest wall, will be hidden by almost all bikini tops. It typically sits in a natural crease and a shadow which means, even when you’re topless, it can’t be seen in most positions. Darker or thicker inframammary incisions will show when you are topless and lying on your back.
Periareolar incision placement, being adjacent to the nipple, will be covered by even the skimpiest bikinis. But, when you’re topless, a visible incision here will be the most obvious of all. This is because it’s located at the dead center of the breast. In that location, it’s not going to be overlooked.
A second issue with the periareolar incision has to do with the way scars heal. Scars shrink as they mature. They get thinner. Which is good. And they get shorter. Which is usually good, but not in this case. As this semi-circular scar shortens, it can bend and distort the lower border of the areola into an unnatural shape. This is always noticeable and can be very difficult to fix.
As we mentioned, with the periareolar approach, the surgeon creates a tunnel through the breast tissue for pocket creation and implant insertion. Any healing issues or excess scarring deeper in the breast tissue can pull the periareolar scar downward, causing it to dimple. This deformity, too, is impossible to miss.
The obvious advantage of the transaxillary incision is that it’s not on or anywhere near the breasts. For some women, this is a big plus. But the transaxillary scar, when it heals thicker or darker, will be obvious in social situations where the other incision types wouldn’t show. Where the inframammary or periareolar implant placement scars are only visible when you’re topless, the axillary incision can be seen in bathing suits, tank tops, and sleeveless dresses. The social visibility of the transaxillary scar should be considered before choosing it.
The transumbilical incision scar would seem like an obvious winner for the least visible scarring given its distance from the breasts and hidden location inside the rim of the belly button. But this neglects the long tunnels that the surgeon needs to dissect from the umbilicus to each breast. Scar tissue in either tunnel can dent or dimple the upper abdominal skin very visibly. And poor healing of the TUBA incision itself can distort the belly button. That too is easily apparent in a bikini and can not always be fixed with additional plastic surgery.
Of course, the benefits of placing the breast augmentation scar away from the breast (transaxillary or transumbilical) vanish if the woman needs a breast lift or, as we will soon see, an implant replacement.
WINNERS
Inframammary or Transaxillary Incision depending on your personal preference for scar location
LOSER
Periareolar Incision
2. Accuracy
For you to get the best possible breast augmentation result, your surgeon needs to precisely shape the implant pocket. He or she must carefully control the position of the upper, inner, and outer borders of the pocket. At the lower edge of the pocket, they must precisely release the pectoralis muscle to properly round the lower, inner curve of the breast. The choice of incision affects the accuracy of pocket creation.
Most plastic surgeons prefer inframammary incisions because they provide direct access to all parts of the pocket. The incision is immediately next to the lower half of the pectoral muscle. This is the most critical area in the entire dissection. An inframammary incision lets your surgeon see and feel the muscle to carefully control its contouring and release. The rest of the pocket is also easily seen for precise dissection.
In most women, the periareolar incision option is a close second for access and reliable pocket dissection. It’s centrally located on the breast and is close enough to the bottom of the pocket to allow your surgeon to feel the lower part of the pectoralis major muscle when releasing it. The periareolar incision is less advisable in women starting with C-cup or larger breasts. Remember that to get to the pocket with this incision type, the surgeon has to create a tunnel through all of the breast tissue. Larger breasts require a longer tunnel, and this does make it harder to see the entire pocket and feel the pectoral muscle.
The transaxillary incision is far from the lower pocket and makes it harder for your surgeon to accurately shape the breast, create a smooth inner curve, and carefully control the release of the pectoralis major muscle. This can lead to distorted pockets, implants that heal too high or wide apart, and imprecise control of the implant position. Studies show that implants placed via the transaxillary incision are at higher risk for incorrect positioning when they heal (malposition).
In a trans umbilical breast augmentation, the implant pocket is created by inflating a balloon behind the breast. The pocket cannot be seen and cannot be adjusted or refined. You inflate the balloon and you get what you get. The TUBA breast augmentation procedure is the one most likely to be complicated by incorrect implant placement since the surgeon has less control over pocket shape.
WINNERS (Tie)
Inframammary and Periareolar Incisions
LOSER
Transumbilical Incision
3. Recovery
Recovery comes down to how soon you look good and how soon you feel good. Our basic rule of thumb is that you will see 75% of your final result in a month and about 90% of your final result in two months. Add these stats aren’t affected by which incision your surgeon chooses.
Well-performed breast augmentation usually hurts significantly less than patients think. Most compare the pain to the tightness and soreness that you feel the day after a much too aggressive chest workout. Doesn’t feel great but not really problematic. Unless your surgeon uses a transaxillary approach. The armpit incision forces the surgeon to start the pocket near where the pectoral muscle narrows to insert on the humerus bone of your arm. That area is sensitive and it makes the recovery a lot more painful and quite a bit longer.
Pain from a transumbilical breast augmentation is about the same as from the inframammary or periareolar incision types. But, in addition to breast pain, you will have some degree of discomfort in your upper abdomen.
WINNERS (Tie)
Inframammary and Periareolar Incisions
LOSER
Transaxillary Incision
4. Complications
All surgeries have potential complications and, in this section, we are not going to look at all the potential complications of breast augmentation. Instead, let’s examine the specific complications whose risks are increased by particular breast augmentation incision options.
The inframammary approach does not raise the risk of any particular complication.
As we’ve discussed, your surgeon needs to tunnel through your breast tissue when he or she chooses periareolar incision placement. Making this tunnel will cut through some of the milk ducts. Though a rare complication, some women will not be able to breastfeed after a breast augmentation with this incision placement.
Dividing milk ducts also causes some less obvious problems. The ducts themselves are not sterile. So instruments, fingers, and implants that pass through the tunnel can become contaminated with bacteria from the milk ducts. Significant contamination can infect the implants and will usually force their removal to allow healing. Micro contamination may not produce an obvious infection but is implicated in the buildup of scar tissue and capsular contracture. Several studies have shown higher rates of infection and capsular contracture with periareolar implant placement.
Temporary changes in nipple sensation are common after breast augmentation regardless of incision placement. This is caused by some inevitable stretching of the nerve where it emerges from the rib cage on the side of the chest. This can lead to either an increase or decrease in nipple sensation but almost always resolves in a few weeks to months.
Cutting the nerve will cause a permanent loss of nipple sensation. This injury can occur where the nerve exits the rib cage regardless of incision type. But the periareolar incision’s location adds the risk of injury where the nerve enters the back side of the nipple. Not surprisingly, periareolar incision placement is most likely to cause a loss of nipple sensation.
As we’ve seen, the transaxillary incision increases your risk of malposition of the breast implant. Specifically, implants placed through an armpit incision are at higher risk of healing, too high and too far to the outside. The underarm contains many large and important nerves, arteries, and lymphatics. Though a transaxillary breast augmentation should not come near these structures, injuries have been reported especially when the approach is used to replace or revise implants.
Transumbilical incision placement is the riskiest of all. We’ve already discussed the high risk of breast implant malposition. Because your surgeon can’t see the implant pocket, ongoing bleeding may be present after the implants are inserted. This can lead to a blood clot (hematoma) that requires additional surgery and can promote capsular contracture.
While bluntly dissecting the abdominal tunnel to the breasts, surgeons using TUBA incisions have gone off course injuring abdominal organs, the heart, and the lungs. These injuries have caused deaths.
WINNER
Inframammary Incision
LOSER
Transumbilical Incision
5. Versatility
A versatile breast augmentation incision allows your surgeon to place the full variety of breast implant types and sizes in all possible pocket locations. It should work well for women with all types of starting breast anatomy. We’ll see how well each incision meets these criteria.
The inframammary fold incision is the gold standard for versatility. It allows your surgeon to use either saline or silicone implants. It can accommodate any implant size. From an inframammary incision location, a plastic surgeon can dissect any type of implant pocket (subglandular, subpectoral, full submuscular, and all dual plane pocket combinations.)
With one minor exception, inframammary incision placement works well with breasts of all sizes and shapes. The incision can be trickier to position correctly in women who do not have defined inframammary folds. But this is rare even in women who start with A-cup breasts and, even here, incisions can usually be located accurately.
The periareolar incision will work with silicone or saline implants and with most implant sizes. Very large silicone implants (over 550cc) can sometimes be difficult to insert through this incision placement in women with small areolas. This is because periareolar incisions are meant to run from 4 o’clock to 8 o’clock on the areolar border. Longer incisions risk distorting the areolar shape and can become too visible. Larger silicone implants require an incision at least 2 inches long or the implants can be damaged during insertion. For a two-inch incision to be limited to the part of the areola between four and eight o'clock, the areola has to be at least 1.9 inches in diameter. That’s already bigger than the average areolar diameter of 1.7 inches. For women with smaller-than-average areolas, a two-inch incision would have to go more than halfway around the areola. This can be done but may produce a very visible scar.
Large breasts are another potential problem for the periareolar incision because, with this approach, the surgeon creates a tunnel through the breast tissue to get to the implant location. A large breast means a long tunnel with more trauma to the breast tissue, more milk ducts cut, more chance of implant contamination, and ultimately more internal scarring of the breast. That doesn’t mean it can’t be done, but it’s not optimal.
The transaxillary incision works well regardless of the woman’s breast size and shape. It can be used for placing implants above or below the muscle and works for saline or silicone implants. The anatomy of the armpit does limit the potential length of the transaxillary incision. This can make it difficult to insert a silicone implant larger than 600cc.
Transumbilical incision placement can only be used with saline implants - an empty saline implant (of any size) can be folded up, passed through the tunnel, and then filled once it’s behind the breast. Silicone breast implants are prefilled and sealed and cannot be inserted through this small incision.
Transumbilically placed saline implants are almost always placed in front of the pec muscle. Subpectoral implant insertion can be done through this incision but raising the pec muscle off the rib cage blindly is both technically challenging and dangerous.
WINNER
Inframammary Incision
LOSER
Transumbilical Incision
6. Reusability
Modern breast implants are incredibly durable and most silicone gel or saline implants will last 16 years or more. But they do eventually wear out and need to be replaced.
That revision surgery can be as simple as removing the old, ruptured breast implants and replacing them with new ones. But you may also want smaller or larger implants. You might want to change implant type (silicone to saline or vice versa.) Your surgeon may need to expand or tighten the implant pocket and may need to remove scar tissue.
Ideally, you’d like future surgeries to use the same incision type and not produce new scars.
The inframammary incision can be used repeatedly for breast augmentation revision surgeries. The pathway to the implant is short and repeated dissections don’t typically lead to distortion of the anatomy. The approach from the breast fold allows access to all parts of the pocket for either capsulectomy (removal of the scar capsule) or capsulorrhaphy (suturing the scar capsule to reduce pocket size).
The inframammary scar can usually be completely removed and redone at revision surgery to improve its appearance.
As we’ve seen, the periareolar incision requires your surgeon to make a tunnel through all of your breast tissue from the skin to the chest wall. That tunnel has to be opened up and extended at each revision surgery. The internal scarring of the breast tissue increases with each surgery and can potentially distort the anatomy. Most often this shows up as a depression or pucker in the areolar scar. Unfortunately, even a small irregularity here can be clearly noticeable. Also, repeated use of periareolar incisions invites nerve injury and loss of nipple sensation.
Because of its central location over the breast, the periareolar incision usually allows access to all areas of the breast implant pocket for capsulectomy or capsulorrhaphy.
The transaxillary incision is usually avoided for breast implant revision surgery. It will work if the implant can be exchanged without any modification of the pocket. (This can rarely be reliably known in advance.) Capsulectomies and capsulorrhaphies are difficult, if not impossible, via this incision location. Complete clean-up of ruptured breast implants would also be challenging.
The transaxillary incision itself cannot be extended to improve access or insert larger, more cohesive (thicker gel) implants. The larger incision would be visible beyond the armpit. And repeated dissection in an already scarred underarm risks injury to the major nerves, arteries, and lymphatics of the arm. Most plastic surgeons choose a lower risk incision for revisions.
The transumbilical incision cannot be used for breast implant revision surgeries.
WINNER
Inframammary Incision
LOSER
Transumbilical Incision
THE BEST BREAST AUGMENTATION INCISION
By now, it should be clear that the inframammary incision is the best of the breast augmentation incision options. This incision placement has won or tied in every single category. It offers the greatest accuracy in breast implant pocket dissection and is least likely to produce surgery complications. It offers the fastest and least painful recovery and can be used for all sizes and shapes of breasts, all types of pockets, and with any implants. In fact, the inframammary approach is the only good incision location for placing the largest silicone breast implants.
Most importantly, only the inframammary incision can be used for the initial breast augmentation AND for all subsequent revision surgeries. Don’t underestimate the importance of this! You will need to have your implants replaced at some point - meaning you will likely end up with an inframammary scar. It makes little sense to have unnecessary scars from other incisions as well.
WHICH BREAST AUGMENTATION INCISION OPTIONS DO WE OFFER?
This article is based on the exact information we provide patients at their breast augmentation consultation. We strongly recommend the inframammary incision and it’s the option almost all of our patients choose.
We do occasionally see patients who prefer a different scar location. For these patients, we will offer the periareolar and transaxillary incisions. We do not perform the transumbilical breast augmentation because of its many limitations and high risk.
Please call or text our office at 972-498-4385 if you would like more information about breast augmentation, breast implant revision, breast lift, or breast implant removal procedures.
