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.