Incision sites for breast augmentation: armpit, areola, and breast fold

Why does the incision site matter?

In breast augmentation, the incision is both the passage through which the implant is inserted and the place where a scar will remain. The commonly used incision sites are the crease under the breast (inframammary fold), around the areola (periareolar), and the armpit (transaxillary).

A 2021 review organized breast augmentation planning in the United States into five steps ^[1]. The order is to assess whether a breast lift is needed at the same time, choose the implant, decide on the layer for the implant and the position of the breast fold, and then select the incision site ^[1]. In other words, the incision is not chosen in isolation but is decided in coordination with the other choices.

Breast fold incision

With a breast fold incision, the implant is inserted through an incision placed in the crease under the breast. Because the space for the implant can be created under direct view, it has been considered a method that makes technical control easier. A 2015 publication on the armpit incision also mentioned a perception that the armpit approach offers less control than the breast fold approach ^[3].

A 2013 study analyzed data from two long-term clinical trials that used round silicone implants and anatomically shaped cohesive silicone implants. Incisions around the areola and in the armpit carried a significantly higher risk of moderate or worse malposition and of revision surgery than a breast fold incision ^[2]. The risk of capsular contracture was higher with the armpit incision, and for the areola incision it was higher only in the unadjusted analysis ^[2].

This study analyzed participants in long-term clinical trials of specific implants, so its findings cannot be applied directly to other implants or to Korean patients.

Areola incision

An areola incision is made along the border between the areola and the surrounding skin, so the scar lies at the edge where the color changes. In the 2013 study above, the areola incision carried a higher risk of malposition and revision surgery than the breast fold incision ^[2].

Breastfeeding is also a common question. A 2018 meta-analysis analyzed 4 cohort studies and 1 cross-sectional study, and the relative risk comparing the areola incision with the breast fold incision was 0.84 (95% confidence interval 0.45 to 1.58), so there was no evidence that the areola incision lowers the rate of exclusive breastfeeding (feeding the baby only breast milk) ^[5]. However, in the same analysis, the rate of exclusive breastfeeding was lower in women with implants than in women without implants, with a pooled relative risk of 0.63 ^[5].

In a 2021 systematic review of the rare complications of milk discharge (galactorrhea) and milk cysts (galactocele), 48% of the 38 patients had an areola incision and 24% had an armpit incision ^[6]. The authors stated that there were too few cases to be certain, but proposed the areola incision as a possible weak risk factor ^[6].

Armpit incision

An armpit incision has the advantage that the implant can be inserted without leaving an incision line on the breast ^[3]. A 2015 publication explained that using an endoscope makes it possible to create the space for the implant precisely with a clear view, and that the care process after surgery helps stabilize the position of the implant ^[3].

A 2023 publication stated that breast augmentation with implants is becoming increasingly accepted in Asia and that Asian women still prefer the armpit incision ^[4]. The publication considered that using an endoscope improves control during surgery and reduces complications, but this is the view of a publication introducing a technique ^[4].

On the other hand, in the 2013 analysis of clinical trials above, the armpit incision carried a higher risk of capsular contracture, malposition, and revision surgery than the breast fold incision ^[2]. The research summary does not state whether this analysis looked separately at whether an endoscope was used.

Scars and individual differences

Every incision leaves a scar. Where the scar sits, how noticeable it is, and how it heals vary from person to person depending on skin type, constitution, and wound care.

When choosing the incision site, not only the location of the scar but also the type of implant, the layer in which it is placed, and whether the breast fold needs to be adjusted are considered together ^[1]. It can be seen as a process of finding a balance between where you would like the scar to be, how much control the surgery allows, and the risk of complications.

What to check during your consultation

The incision site is decided when your feelings about scarring, your body type, and the implant plan all fit together. It is a good idea to check the following during your examination and consultation.

• The incision site that suits your body type and implant, and why
• The location and length of the scar for each incision site
• An explanation of the risks of malposition, capsular contracture, and revision surgery
• For an armpit incision, whether an endoscope will be used
• Consideration of any plans to breastfeed in the future