Most plastic surgeons favour the infra-mammary incision location for most breast implants. The peri-areolar incision is made as a semicircle at the lower border of the pigmented areola. It does heal beautifully in most cases and uses the interface of the darker and lighter pigmented skin to camouflage the incision. For patients with small areolae, it may be preferable to use the infra-mammary incision, located underneath the breast. This incision also heals very well, and is especially useful for women with well defined creases under their breasts.
The axillary incision (in the armpit) is another option, but it’s better suited for saline implants than silicone gel. Because this access incision is a greater distance from the implant pocket, it’s less precise than the peri-areolar and infra-mammary approaches. Studies have confirmed that there is a higher implant revision rate using the axillary approach. Usually the axillary scars heal well, but they may still be visible when the patient wears sleeveless outfits. There is also a higher rate of breast implant infections with the peri-areolar and axillary approaches.
Patients frequently ask what effect the incision location has on maintaining nipple sensation after surgery. The answer is that the access incision usually has little effect on nipple sensation. Rather, it’s the size of the implant pocket that has the largest impact on nipple sensation. Large implants may require a pocket that stretches the nerves to the point that they do not function well, increasing the odds of impaired nipple sensation. Even so, the vast majority of my patients maintain normal nipple sensation.
Breast implants may be placed over or under the pectoralis major muscle. In the early days of breast augmentation, all implants were placed on top of the muscle. However, in recent decades, it has become more common to place implants underneath the pectoralis major muscle. The muscle covers the top half of the implant, providing additional thickness of coverage over the implant in the critical cleavage area. This makes it less likely that the implant edges or ripples will be visible when wearing a bra or swimsuit. Studies have also shown that the rate of capsular contracture is lower when the implants are placed under the muscle. Breast imaging to screen for breast cancer is more accurate when the implants are placed behind the muscle. For these reasons, I prefer to place implants underneath the muscle for most of my breast implant patients.
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