Posted on February 10, 2020
By: Dr. Asaf Yalif
When women come to us for breast augmentation consultations at our Atlanta and Alpharetta offices, we often have a lengthy discussion about the incision choices for augmentation and also, whether or not to place the implant above or below the pectoralis major muscle. Today’s blog is designed as an introduction to how we approach these questions and to help you as you approach your consultation.
In choosing an incision for augmentation we have to balance a few factors. Among them are cosmesis/visibility, ability to physically get the implant in, and risk to surrounding structures, namely the breast. If you plan to combine your augmentation with a breast lift, that will affect the incision location as well. Let’s look at each incision type individually.
This incision is fairly remote from the breast, and there are already creases present in the axilla that we can use to “hide” the incision. The negative is that the dissection is done bluntly and can increase the risk of bleeding and asymmetry between the 2 sides. In addition, this approach usually places the implant behind the pectoralis muscle, but as we don’t sharply divide some of the attachments of the muscle there is an increased risk of motion of the implant when you use your chest muscle.
The periareolar approach involves a smiley face incision at the border of the areola and the breast skin. This is usually fairly well hidden. The negative is that you have to divide breast tissue to get behind the breast and/or pectoralis muscle. This means a slightly higher risk of contamination of the implant from anything within the milk ducts at the time of the surgery. This can increase the risk of contracture/scarring around the implant. In addition, we are creating scars to some of the duct system, which may make breastfeeding more difficult. Lastly, the incision is not large, so if the desire is for a very large implant, it may not be able to be placed via this incision. You can see illustrations of the periareolar incision on the American Society of Plastic Surgeons’ breast augmentation procedure page.
The trans-umbilical breast augmentation (TUBA) approach makes an incision at your bellybutton, and then a camera is used to dissect your abdomen and to the breast. The advantage is there is no scar on the breast mound, like the trans-axillary approach. The negative is that we cannot place a pre-filled implant through this incision (no silicone). In addition, this is not a common technique as it requires additional training, and there is a steep learning curve. As a result, few physicians have trained on this or perform it well. However, it is a good option in the correct hands.
This incision is placed in/around the breast fold beneath the breast. It is our preferred method because it enables us to access the breast and pectoralis muscle without disruption of the breast tissue (no change in the ability to breastfeed and no contamination of the implant from the milk ducts). In addition, if there is any asymmetry between the right and left sides, we can attempt to correct this more directly through this incision. This incision may be visible though and can cause occasional increased scarring.
How do we choose which one to recommend? We ask what you would like and have a discussion on which approach is best for you. We look at your body habitus, the size implant we are leaning towards, your health, and so on before recommending one or another approach. But we always make sure you are comfortable with whichever approach we choose and why we choose it. You can see some of our real patients’ results in our breast augmentation before-and-after photos.
We can place the implant either in front of or behind the pectoralis major muscle. The decision to go in front or behind the muscle is a complex one. It depends on how muscular you are, how big the implant is, and how much breast tissue you have. There is a balance that can be struck between potential visibility of the implant and excess motion from the pectoralis muscle. This is the discussion you should have and one you should consider when approaching the topic with your plastic surgeon.
We usually don’t recommend large implants above the muscle as the weight of the implant, without at least some muscle support, may lead to premature ptosis/heaviness to the breast. That being said, we always make a recommendation based on the implant/soft tissue dynamic, the patient’s activity level, and what our patients want for their final result. It is notable that subglandular placement is more associated with contracture, at least early on. But again, this is a good basis for discussion.
If you’re interested in learning more about the different types and styles of breast implants available at our Alpharetta and Atlanta offices, please read our related blog post.
We are always happy to answer your questions online and in person. We know that there is a complex interplay between the implant, your body and activity level, and the incisions we use to get you to your result. You can also call of our offices at (404) 476-8774 to schedule an appointment.
As a triple board-certified plastic surgeon, I make sure to spend significant time with you to understand your breast implant choices while informing you of your options so that I can help you realize your breast augmentation goals. With my years of experience and technical expertise, I know that I am more than capable of providing you with a result that exceeds your expectations.
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