Breast Augmentation in Boston - Your Incision Choices
A few weeks ago, Dr. Moss and I presented to readers information on the two types of breast implants: saline filled breast implants and the newly FDA approved silicone gel filled breast implants. This week we will focus on another area that patients have a choice in: the location of the incisions for insertion of breast implants. It should be noted that one of the reasons for the popularity of breast augmentation is that the incisions for breast augmentation are relatively small and for the most part well hidden, especially when compared to the visibility of the incisions required in either a breast lift or breast reduction.
There are three commonly used incisions for the placement of breast implants. They are:
• Inframmary-within the breast fold, where the bottom of the
breast meets the chest wall (see diagram).
• Periareolar-around the nipple
• Transaxillary-within the armpit
The inframmary approach is the most popular incision used for breast augmentation and the one that Dr. Moss uses most frequently. Because it is concealed underneath the breast it is not evident in most patients, when they are viewed from a standing position. While some very flat-chested women, with no ptosis (sag) to their breast, may be able to view their inframmary crease before breast augmentation, it is usually not visible after the breasts have been augmented with implants. In fact, for most patients to view their own inframmary incisional scar after breast implantation, the patient needs to lift up her breast and twist her body so that the incision is visible in a mirror.
The inframmary approach is also popular with young women because it is felt to be less likely to interfere with breast feeding. The reason for this is that the incision is far away from the nipple/duct complex, thereby reducing the likelihood that these structures would be injured. The retention of nipple sensation is felt to be better with the inframmary approach for the same reason.
When performing breast augmentation with saline filled implants via the inframmary approach, Dr. Moss uses a 4 cm. incision. When performing breast augmentation using silicone gel filled breast implants, Dr. Moss uses a 5 cm. incision. The reason for the longer incision is that gel filled breast implant are inserted already filled, while saline filled implants are inserted empty, and the surgeon fills them with a syringe after they have already been placed in the breast cavity.
This picture shows the air being evacuated from what will be a saline filled breast implant. The implant is inserted into the breast cavity in an empty state and then filled with the desired amount of saline.
Dr. Moss will also accommodate patients who want their breast implants placed through a periareolar incision. This approach utilizes an incision that is made halfway around the areola. This incision runs from the 3 o’clock to the 6 o’clock to the 9 o’clock position around the areola (see diagram above). The length of this incision is obviously dictated by the patient’s individual anatomy. While this incision would be visible to the trained eye of a surgeon, it is usually not noticeable to most people, because it has been made at the junction of the areola and the normal dermis (skin) of the breast. Essentially the two different colors of the areola and the skin camouflage the presence of this scar.
Patients should be aware that the periareolar approach for breast augmentation is associated with a higher likelihood of inability to breastfeed. However, many physicians are comfortable with this approach and either offer it to patients or prefer it.
Both the inframmary and periareolar approaches are popular with surgeons, and the vast majority of plastic surgeons use either one of these techniques. One of the reasons for the popularity of the inframmary and periareolar approaches is because either approach provides excellent visibility of the breast cavity, during surgery. One of the most important surgical factors in breast augmentation is the control of any bleeding, in the cavity that has been made in the breast, for implant placement. Control of intra-operative bleeding is a surgical technique that all board certified plastic surgeons are very well trained in, and therefore something patients should understand is part of any surgery. However, the more visible the opened breast cavity is, the easier it is for the surgeon to perform the surgery.
The third and less commonly used approach is referred to as the transaxillary approach. The incision for this approach is made through the armpit (see diagram above). The patients who choose this approach are usually patients who do not want any scars whatsoever on their breasts. It is important however, that these patients understand that if their scars do not fade to an unnoticeable state, it could limit their wearing of sleeveless clothing, including bathing suits. Patients also need to understand that to a large measure, the quality of scarring is beyond the control of a surgeon. Some patient’s heal with better looking scars and some heal with very noticeable scars.
The other consideration that patients need to be aware of with the transaxillary approach is that if revisional surgery is required at a later date, another incision will need to be made at either the inframmary or periareolar location. The transaxillary approach does not provide sufficient access to the breast cavity to perform revisional surgery successfully. Therefore, these patients would then have scars on both their armpits and breasts. Dr. Moss has chosen not to perform breast augmentation surgery via the transaxillary approach.
Dr. Moss finds that the scars from breast augmentation surgery are rarely of any concern to his patients. However, he does carry a product called Scarguard, for the patients who want the very best possible scar. This is a clear liquid that is painted on the incision, twice a day, for three months. Dr. Moss allows patients to use this product at either 4 weeks or when the incision is completely healed, which ever comes first. This product contains Vitamin E, silicone oil, and a steroid, all of which can help improve the quality of the scar. This product is available for purchase, in his office, for a cost of $65. Dr. Moss usually finds that most breast augmentation patients only need one bottle.
Dr. Moss will always discuss with any prospective breast augmentation patient, the placement of incisions, and what she can expect. He will also answer any question concerning the surgical approaches of breast augmentation during the initial consultation. If any patient has a question concerning the surgical approach that they would like answered before scheduling an appointment with Dr. Moss, they should call the office and ask for Carla, Dr. Moss’ wife and office manager. Carla had her implants inserted via the inframmary approach and is very satisfied with her incisional scars.