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Usual surgical approaches to breast augmentation surgery

The three most common surgical incision approaches to breast surgery are inframammary, periareola and axillary. Another two, the transumbilical or the abdominoplasty incision are rather old procedures, and lack both popularity and superiority over the major three. Finally, fat grafts are sometimes considered to give a natural lift to breast augmentations.

Francois Le Berre

PhD Bio-Science, Plastic Surgery Coordinator, Metro Beauty Centers

All three most common procedures allow for subglandular (under the breast parenchyma), subpectoral (under the major pectoral muscle) and dual-plane implant placement (sandwiched in between the major and minor pectoral muscles). The decision of which incisional approach is best for a given woman, depends on the patient’s breasts characteristics and patient’s expectations. Do not forget the surgeon is working for you, and that there must be a logic behind the reasoning of your surgeon to offer you a particular surgery. Here is what you might want to know:

The endoscopic Transaxillary approach

A woman who does not want any scars on her breasts or is highly concerned about nipple sensation may be an excellent candidate for a transaxillary incision. The transaxillary approach is a tried-and-true method, and the success of the operation is based on the surgeon’s competence. Endoscopically maxillary incision being a minimally invasive approach, it requires the use of an endoscope and detailed anatomical knowledge from a competent surgeon, familiar with the technique. A good knowledge of anatomy is essential for patient safety, not only to preserve function and sensation, but to also prevent complications from reoperative breast surgery. When done by a skilled surgeon, this operation starts with a 4 to 5 cm incision in an existing crease in the armpit to open up the soft tissues. The openings are gently held by prongs to allow instruments to be moved forward and a subcutaneous tunnel bored. The technique uses direct endoscopic camera visualization to ensure proper orientation. Sharp dissection of the soft tissues is performed with a cauterizing pen, to minimize bleeding and injury to arteries, nerves and other organs, and to maximize the control over the implant pocket. This pocket is made to accommodate the implant by cutting through the tough tissue protecting the Pectoralis major: the fascia. When performed in the state of the art, the surgeon has a direct and clear view of the muscles and fascia layers that cannot be matched with an inframammary approach.

It is a much more demanding operation than the other approaches for the surgeon, but when done by a skilled surgeon, presents no more complications than the inframammary approach. The benefits are the preservation of nervous sensations, extremely natural results with a scar hidden away in the axillary armpit, invisible at best. Patients who undergo this particular technique report higher satisfaction than in the other groups.

The Periareolar incision

If periareolar incisions tend to offer excellent camouflage (their main “selling” point), and are a useful tool in mastopexy (breast lift), they come with some serious challenges and potential complications.

For a start, because of the underlying tension after implant insertion, stretching of the areolar diameter is prevalent in such surgery. The visibility and quality of scars will of course depend on the technique of closure and method of postoperative support. But too much skin tension at the time of closure or inappropriate suturing, will produce unaesthetic widened scars, and might contribute to their hypertrophy and even dermis necrosis. Because of the skin tension, aesthetic renditions are rather unfavorable on dark-skinned areolas too.

Other difficulties emerge when the nipple areola complex is small. Contrary to a saline implant, a silicone implant will be difficult to introduce through this site, in which case, another incision approach is preferable. A flattening of the front of the breasts is likely, and not much of projection (1 to 2 cm) is to be expected if the implant is inserted through subpectoral dissection (under the pectoral muscle). For this reason, this surgery is not recommended for patients wishing to greatly increase their cup size, or with breasts with significant ptosis, the aesthetic rendition would not be satisfactory.

Periareolar incision is best indicated if a mastopexy (breastlift) is required after a breast augmentation. Great care must then be taken if implants are to being inserted this way, to very carefully manipulate the breast parenchyma without injuring it. Biofilm contamination will occur if implants get contaminated with oozing milk ducts, infections appearing soon after, and capsular contracture bringing complications on the long term. Another important thing to keep in mind is that the Pectoralis major is one of the most critical purveyors of blood supply to the overlying breast gland and skin envelope. For this reason, a subpectoral implant in such an approach would be preferable to a subglandular (over the muscle, under the mammary gland), to avoid a couple of serious risks: 1. Subglandular implant would directly expose the implant to the friction of the breast parenchyma with the associated risks and discomfort. 2. The risk of skin and fat necrosis from poor blood irrigation significantly rises with the elevation of the breast gland off the pectoral muscle.

The Inframammary (IMF) approach

It is a rather quick and straight forward approach, starting with a 4 to 6 cm incision located in the lower third of the breast and running along the inframammary fold, which defines the lower edge of the implant. Historically, this incision has been the most commonly used incision for breast augmentation surgery, because it allows for a large implant to be placed with good visibility, without compromising any underlying tissue. The main draw-back this approach has, is that sometimes even a well-planned incision becomes too high as an implant descends. How much an implant descends depends on its weight, placement, adherence to surrounding tissues, and patient’s soft tissues characteristics. Some surgeons might address this issue by using textured implants. However, the risk of severe capsular contracture is higher with a textured implant than with a smooth implant.

Women who have a well-defined inframammary fold and slight glandular breast ptosis are best candidates for this approach. The inframammary incision is commonly used in revision surgery or secondary breast surgery on the patient with inadequate revisions and poor scarring from the previous surgery.  

The Transumbilical (TUBA) approach

It describes the procedure by which, an unfilled saline breast implant is inserted through a tunnel from the umbilicus to the breast. If this procedure is rather forward, it is only feasible with unfilled saline implants, it lacks of precision and offers poor accuracy.

Fat Transfer - liposuction

Fat injections for breast augmentation

Recent interest in the use of fat injection for breast augmentation has increased, with many surgeons believing that this procedure is safe. Fat tissue, adding to the volume of breast tissue, may affect young-woman end-organ responsiveness to hormonal influence. These concerns raise the question of whether such procedures could possibly contribute to the development of breast cancer in later life. Furthermore, fat injection in sizable volumes has been demonstrated to cause the formation of oil cysts and calcifications, including rim calcification around the oil cysts that may result in unnecessary biopsies being performed to exclude the possibility of neoplasia. 

In conclusion

Incision choice should be predicated on the type of breast surgery the patient wishes to be performed, the patient’s anatomy, the type and size of the breast implant, the patient’s preference and surgeon’s preference and skill set. The gold standard with the highest number of satisfied patients remains the endoscopic transaxillary approach. The inframammary approach is a simpler, more upfront surgery that still requires a scar on the breast tissue. The periaerolar approach better serves the need for a breast lift, once the implant has been put into place, it is, usually, it is a procedure that needs to be carried with great care. The transumbilical or the abdominoplasty incision fail to offer any advantage against other procedures, and they have the drawback of lacking precision. Fat injections for the breast are still somewhat new and better made use of with some parcimony.

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