Injections of silicone into breast tissue to enhance the size and shape has been around for almost 100 years.  Soon after its inception the myriad of problems associated with silicone in the soft tissues revealed themselves and the injection of significant volumes of the substance was banned along with the other “revolutionary” injectable of the day- paraffin.  Early in the 1960’s silicone was resurrected in the form of silastic bags filled with the previously banned silicone gel creating the first “silicone” implants.  Injection ports were added to the silastic bags and other substances were tried as the filler material leading to the saline filled implant that is so popular today.  Parallel to the rapid advances in filler material manufacturers at the request of plastic surgeons began experimenting with more exotic fill materials, different thicknesses and texturing of the sack ultimately leading to the textures and shapes of today’s implants.  Into the 1970’s the inframammary incision remained the incision of choice until the axillary incision was introduced and popularized in the 1980’s.  That’s right, the mid-1980’s.  Personally my first transaxillary breast augmentation was done in 1985.  Normally I would not have command of events in the 1980’s, but I had the opportunity to see this patient recently in consultation for a facelift.  Her transaxillary breast augmentation with saline implants was looking good at 26 years!

On occasion when reading today’s latest advertisements certain assertions stand out.  Recently I was drawn to an ad about breast augmentation by a young surgeon claiming to perform all of the latest techniques including the “new” transaxillary augmentation.  I guess to his target marketing audience the axillary incision may be new and unique to the young surgeon, but with a little research the truth can be uncovered.  The latest or newest silicone implants are still silicone gel but improved with something called memory gel that seems to make the gel fill silicone less liquid and more discernibly shaped and coherent. This new silicone technology may or may not improve the long term results but certainly has been advertised as a breakthrough in breast implants and they absolutely charge a premium for it.

The purpose of marketing oneself as a premier breast surgeon is to separate what is offered as a Plastic Surgeon from the others doing breast enhancement. Without the marketing benefit of good credentials or a gallery of representative photos showing the quality of work performed, the only possible marketing angle available may be the assertion that one uses the newest technology not available to lesser surgeons or that one is accomplished in the newest techniques that lesser surgeons are not capable of performing. Usually these procedures are much like the previously mentioned transaxillary breast augmentation, the claim of credentials not received or expertise in operations that have been around for years may be successful marketing to a poorly informed clientele but not to prospective patients in this age and time.

Read more about top plastic surgeon Dr. Paul Howard.

Scars and Breasts

Plastic surgeons obsess about scars.  Many people who consult with a plastic surgeon do so because of their ability to deal with scarring on the skin as well as our ability to create the best or least noticeable scars.  To create the best scars requires more than vigilance in suturing wounds, it requires the ability to know how scars can be expected to heal on certain parts of the body as well as the ability to use wrinkles (or relaxed skin tension lines), shadows, and anatomic structures to camouflage or hide scars.  For instance, it is a well-known fact that scars located within hair-bearing skin are more forgiving than other scars and can be well hidden within the hair of the scalp, pubis, or armpit (axilla).  Another basic premise of wound healing is the fact that tension is generally bad for scar healing.  Let us also agree that any scar visible on the otherwise flawless female breast cannot in and of itself be desirable yet it can be tolerable.

Breast augmentation seems to be one of the only plastic surgical procedures where surgeons will ignore many of the basic tenets of wound healing in order to make the operation easier to perform.  Honestly evaluating the currently available incisions used to place implants in breast augmentation will lead us to choose the incision most likely to leave the best or least noticeable scar.

The most commonly performed incision for breast augmentation is called the Inframammary, or beneath the breast, incision.  It is frequently chosen for many reasons, but arriving at the best scar is not among them.  Suffice it to say that regardless of the incision chosen, the ability to place the implant in the proper position is achieved leaving only the quality of the scar as evidence that an operation had been performed.   If the scar is off the breast or imperceptible, the patient can maintain what I call plausible deniability with respect to their plastic surgical procedure.   Without a scar as evidence, nicer breasts can be attributed to genetics, hormones, or even good luck.

The approach to breast augmentation with an incision that fulfills most if not all of our criteria for a good scar is the transaxillary, or armpit approach.  This incision is placed within the hair-baring skin of the armpit, therefore is not on the breast and is not effected by the increased skin tension created with the placement of the implant.  The incision being located off the breast allows for early implant massage which is known to improve position and “softness.”  Finally, the incision in the armpit does not indicate what operation was performed even if slightly visible.  The axillary incision does not scream “breast augmentation” as the Inframammary incision does.

The periareolar incision is located around the dark part of the nipple at the junction between the areola and the lighter breast skin.  The incision placement makes good plastic surgical sense because the areas between light and dark skin are good for camouflaging scars.  The periareolar incision does suffer from its placement in an area of increased tension after placing implants and is not a useful incision if the nipple/areola complex is naturally small.  This incision suffers from a further problem: it is the most likely incision to cause permanent numbness on the breast skin.  Certainly a numb nipple is not desirable regardless of the benefits.

The transaxillary incision has been around 30 years yet one hears a litany of “possible” problems using this incision.  The perceived problems include “nerve damage” due to proximity to the brachial plexus, implant malposition, “high implants” as well as other non-specific problems that seem to be due to a generalized discomfort using the incision.

Suffice it to say that most surgeons who do not offer the transaxillary incision simply do not know how to do it, are amateurs who are not board certified plastic surgeons, or are operating at such high volumes they choose the easiest incision to meet their time constraints.  The published plastic surgery literature does not recognize rare problems such as nerve damage or malposition as complications related to the transaxillary incision.

Dr. Paul Howard pioneered the use of the endoscope for minimal incision breast augmentation surgery using the armpit incision.  Read more about Dr. Paul Howard’s breast augmentation.

Breast Implant Armpit Incision

Photo shows a healed armpit scar after having breast augmentation surgery.

View breast augmentation before and after photos.

Introduction to Breast Augmentation

Breast augmentation with saline or silicone implants has become an increasingly popular option for women either born with a small chest or for those who suffer from the effects of child birth or have gained and then lost a lot of weight.  Breast imperfections coupled with the societal preference for a larger bust have caused breast enhancement to become one of the most frequently performed surgeries done by plastic surgeons.  The operation can be a challenge to perform as there are a number of decisions the patient and surgeon must make to obtain the best results.

The first and most basic decision is the choice of breast size and the possible need for a breast lift, or mastopexy, in addition to augmentation.  Next, the type of implant should be explored.  Some people desire the “natural” feel of silicone implants and others prefer the improved projection and lifting obtained with saline implants.  The surgeon will usually recommend that the implants be placed in the submuscular position (beneath the pectoralis muscle) although on a rare occasion sub-mammary (beneath the breast tissue and on top of the pectoralis muscle) placement is indicated.

Finally, the incision location is discussed.  There are basically four different incisions available: Axillary (armpit), Periareolar (around the nipple/areola), Inframammary (under the breast), and umbilical (through the belly button).  Most surgeons will know 2 or 3 of these approaches with the “TUBA,” or transumbilical approach, being the least performed incision due to the limitations of implant placement.  In many instances, the transaxillary approach is recommended due to its location in the armpit away from the breast itself, the quality of the scar in the hair bearing skin, and the fact that early implant manipulation to keep the implants positioned perfectly in the submuscular pocket without putting pressure on a breast incision.

Price shopping breast augmentation is a calculated risk as one is by necessity shopping a general anesthetic also.  Non-plastic surgeons performing breast augmentation are generally a “one trick pony.” That is, they tend to offer implants and rarely breast lifts (which are harder to do), nor do they offer a selection of incisions as the inframammary scar seems to be the easiest for the amateur surgeon to perform.

The caveat is to always check the credentials of your surgeon as there are no “weekend” courses to teach breast augmentation as there are for other procedures such as liposuction.  Also, beware of the “less is more” argument.  That is, minimal training as a “cosmetic surgeon” is somehow better than completing an American Board of Medical Specialties Board Certification as a real plastic surgeon.  Breast augmentation gone wrong is very difficult to reconstruct and shopping for the cheapest surgeon does not guarantee board certification, clinical judgment, or experience.

Dr. Paul Howard pioneered the use of the endoscope for less invasive breast augmentation surgery with the transaxillary (armpit) incision. 

Read more about top breast augmentation surgeon Dr. Paul Howard and his no-scar-on-the-breast breast augmentation.

About Breast Augmentation by Paul S. Howard, MD, FACS

Breast augmentation has been the most popular plastic surgery procedure among women for decades. Breast enhancement surgery can improve a woman’s image in clothing, swimwear, and overall figure. Breast augmentation mammoplasty is the surgical procedure to enhance the appearance of the breast with implants. These implants are surgically placed by creating a submuscular pocket for the implant. Dr. Howard does not prefer implant placement in the sub-glandular (on top of the muscle) position due to the un-natural appearance and the increased risk of capsular contracture (hardening of the implants).

Read more about top breast augmentation surgeon Dr. Paul Howard in Birmingham, Alabama.