Periareolar Vs. Inframammary Incisions

Two incision options that are frequently used in breast implant procedures are periareolar and inframammary incisions. The periareolar incision is done around the pigmented part of the nipple. The areola is the pigmented skin that surrounds the nipple itself and the incision is placed within that pigmented skin. The inframammary incision refers to the incision that is placed below the breast in the crease that is present at the bottom of the breasts. It is usually hidden by the portion of the breast that overhangs the incision.

IMPLANT PLACEMENT

Both periareolar and inframammary incisions are effective techniques in terms of allowing access to the breast tissue in breast enhancement procedures. The two types of implants that may be placed using either of these incisions are silicone and saline implants. In terms of where the implant is placed, it can be placed underneath the muscle which is called submuscular placement or it can also be placed underneath the breast tissue and above the muscle and that is called subglandular placement. Both types of incisions allow for the implants to be placed at either level.

There are a couple of differences in terms of the length of the incision that is possible. The periareolar incision is guided by the diameter of the areola, so women who have very small areolas have a much shorter possible incision. The reason that comes into play is because when using a saline implant, the incision that is necessary to accommodate the implant is generally shorter than when using a silicone implant.  Saline implants come empty and are rolled up in a very tight fashion when inserted during surgery so they can be placed through a 2-cm incision.

Silicone implants come prefilled with silicone gel.  There are different types of silicone gels.  Some of them are much more rigid so a longer incision is needed in order to accommodate the placement of silicone implants.  That is one of the differences between the inframammary and the periareolar incisions. With the inframammary incision, the incision can be made as long as necessary to accommodate a larger implant. The periareolar incision is limited by the size of the patient’s areola. 

TEAR-DROP IMPLANTS

When deciding between periareolar and inframammary incisions, it is important to remember that a tear-drop shaped implant needs to be well aligned with the axis of the breast, which requires visibility and access to the pocket. When placing the implant, the surgeon has to dissect out the pocket. The pocket needs to be dissected precisely, especially for a tear-drop shaped implant, since it has to be oriented along the correct axis so that it fits correctly. Round implants can be placed without any orientation since they are round and there is no axis for them.  

When creating the pocket for a shaped implant, the right dissection has to be done to permit the implant to fit along the correct axis.  The inframammary incision generally provides an easier way for surgeons to create the exact size, width, and dimensions of the pocket for that particular implant.  When a surgeon is looking to put a very large implant in a patient they are going to be limited by the diameter of the areola. If the doctor needs to create a very large pocket, visibility may be affected by a smaller incision, so that is another factor to consider when choosing the incision.

PATIENT CANDIDACY FACTORS

Before proceeding with a periareolar or inframammary incision, a surgeon needs to take into account the patient’s characteristics such as their preexisting breast tissue and the size of the breast. The surgeon also needs to determine if there is any ptosis, which is any overhang of the breast tissue that might camouflage the inframammary incision. The size of the areola is a consideration as well. Skin color is a factor because patients who have very dark pigmented skin can potentially present a problem in terms of healing the scar that’s placed in the inframammary position. Patients with darker skin may benefit from using the periareolar approach.  

PERIAREOLAR LIMITATIONS

There are potential side effects to using the periareolar approach because a: surgeon will actually transect tissue in order to get below the breast into the area where he/she needs to place the implant deep to the breast tissue. Transecting or cutting through the breast tissue brings a potentially higher risk of losing sensation to the nipple.  There is also a potentially risk of losing the ability to breast feed.  These side effects need to be considered in young patients or patients who have not had children.  The periareolar incision can affect their potential recovery and their ability to breast feed.  This is specific to the periareolar incision because cutting through the breast tissue means potentially going through the nerve endings that are much closer to the nipple proper. The incision is within a few millimeters of the nipple. There is a slightly lesser risk of losing sensation or the ability to breastfeed with the inframammary incision because of the remote distance of the incision from the nipple.

INFRAMAMMARY LIMITATIONS

Sometimes the scar can be a little bit more obvious in patients who do not have any overhang or if the breast tissue is not mature. In younger patients, where the breast itself rests higher on the chest, there is no shadowing effect of the lower aspect of the breast.  If patients are wearing a bikini or crop top and lift their arms up, which raises their bra, the incisions may become noticeable underneath the bottom of the breasts. A surgeon has to be meticulous in terms of closure and making sure that a scar heals very well.  That is the main consideration for the inframammary incision.  

RECOVERY TIME

Both periareolar and inframammary incisions take several weeks to heal.  In the inframammary area, just like a scar on other parts of the body, the incisions tend to be a little pink at first, but they fade with time.  The fading process can take up to a year and sometimes even longer.  Within the pigmented portion of the areola, the skin is different and there are some little foldings within that area.  The periareolar incision is a little less noticeable than the incision on the skin underneath the breast.  This perioarolar area also goes through the normal healing process but it is not quite as obvious because it is in a less conspicuous spot.

RESULTS

Neither a periareolar or inframammary incision is more effective in giving longer lasting results for breast augmentation. Once they are healed, there should not be any issues in terms of problems with scar breakdown. A patient with an inframammary incision has to be very careful in terms of clothing rubbing on the incision because the implant will be pushing down on the incision. The patient wants to avoid a situation where the wound breaks open. Gravity is going to be putting the most pressure on the inferior portion of the breast which is where that incision is made. Also, the patient needs to be healthy and doing everything in terms of proper nutrition and avoiding infections to prevent the wound breaking down and opening up.

ADDITIONAL INCISIONS

Besides periareolar and inframammary incisions, there are two additional types of incisions.  There is the axillary incision, which is made within the armpit and can be used for saline implants. The other one is done through the belly button, which is when the implant is placed remotely and then tunneled up through the abdomen to the breast. These incisions are limited to saline and the dissection is much more limited. 

The inframammary incision allows revisions to be done and there certainly are some patients who will need a revision for some reason.  If there is a lot of work that needs to be done or major complications that need to be addressed, most physicians will probably use the inframammary approach so as to be able to access the breast pocket quickly and fix the problem.  

FINAL THOUGHTS

With any kind of breast plastic surgery, patients need to be well educated in terms of the risks and benefits.  There are a lot of different types of implants available and it is important for patients to have a comprehensive discussion with a board-certified plastic surgeon in order to choose the right implant and incision for them before proceeding with the surgery.  Breast augmentation surgery has great results in a lot of patients. It is very effective in terms of improving both self-esteem and quality of life for women. 

Written By Cosmetic Town Editorial Team- MA

Based on an exclusive interview with Dr. Olivia Hutchinson in New York, NY