Dr. Brooke R. Seckel
A major concern of my patients in Boston seeking breast augmentation with implants is the location and visibility of the breast implant scars. It is important to understand that a great deal of attention is placed on hiding your breast augmentation incision to give you the best breast implant scar possible. However if you decide to have breast implants you will have to decide, with the help of your plastic surgeon, where you want your incision to be placed.
• Beneath the breast-the Inframammary Crease (IMC) breast augmentation incision.
• Through the Areola of the breast-the Trans areolar (TA) breast augmentation incision.
• In the Axilla or armpit – the Trans axillary breast augmentation incision
• Through the Umbilicus or belly button-the Trans umbilical breast augmentation (TUBA) incision.
• Inframammary crease breast implant scars are hidden in the fold underneath your breast, the Inframammary Crease. After breast augmentation the enlarged breast falls over the crease and hides the incision scar. Length of scar depends on size of silicone gel breast implant, larger implants require a longer scar.
• Trans areolar breast implant scars are placed in the pink area of the areola. The color of the final scar is closer to the color of the areola and is less noticeable. In addition since the areola is usually covered, even with a bikini, the scar is rarely seen.
• Trans axillary breast implant scars are hidden in the hair bearing tissue of the arm pit and can only be noticed when you raise your arms.
• Trans umbilical breast implant scars are hidden inside the belly button far away from the breast and are unlikely to be recognized as a breast augmentation scar
It is very important to understand that many factors go into the decision as to where to place your breast implant scar. This important decision requires a consultation with a board certified plastic surgeon and a thorough discussion of your options. Of course your preference for the location of your incision is very important. However, your first choice may not always be recommended because of individual variations of your anatomy and the type of implant that you choose. Several important factors that determine this decision are:
• The type of breast implant that you choose. Saline breast implants can be placed and later filled through very small incisions in almost any of the above locations. Silicone gel breast implants require longer incisions and big sized silicone gel implants cannot always be placed through the arm pit or areola. Textured implants can be more difficult to place than smooth walled silicone gel or saline implants.
• Your age and whether you plan on breast-feeding in the future. Generally speaking younger patients who plan to breast-feed in the future should not have breast implants placed through the areola. There is risk of injury to the ductules of the mammary gland which could interfere with breast-feeding later on.
• The shape and size of your breast and areola. If the areola is very small it can be difficult to place silicone gel breast implants through a Trans areolar incision. If the breast is sagging, a condition called mammary ptosis, a breast lift may be needed. If a breast lift is needed there will be additional scarring around the areola and possibly a vertical line on the bottom half of the breast. Most often breast implants are placed through the breast lift incision that is being used. Patients with tuberous breasts often require a complex augmentation procedure which may involve an inframammary crease incision and or a breast lift incision.
• Surgeon preference. Most plastic surgeons are able to perform several variations of the breast augmentation incision. However your board certified plastic surgeon will likely have a preference for the incision that works best for that particular surgeon. It is important to ask why and understand the reasons that your surgeon prefers a particular incision. Many plastic surgeons will attempt to accommodate your choice if possible.
The best breast implant scar location is the one that you and your board certified plastic surgeon choose after your breast augmentation consultation and a thorough discussion of the options that are best suited for you. There is usually more than one option and you will have to choose one. Some generalizations which may help you to decide between the different options are:
• The Inframammary Crease Incision-This incision is the most frequently and commonly used incision for breast augmentation. In most cases it is very well hidden beneath the fold of the breast and can usually be seen only if you lift your breast up to show the scar. The benefits are that during surgery the visibility of the important breast and chest muscle anatomy is excellent so that a very accurate symmetrical placement of your breast implant is possible. In addition this incision allows for easier placement of larger silicone gel and textured breast implants. Another benefit, which I feel is important, is that the breast gland is never cut using this incision. This is a definite advantage, in my opinion, for patients who plan to breast-feed in the future.
• The Trans Areolar Incision-The advantage of the trans-areola incision is that is well hidden by the color of the areola. However this incision must be carried through the breast gland tissue to reach the plane beneath the breast and to access the space underneath the chest muscle for placement of the implant. In my opinion the Trans areolar breast incision should not be used in women who plan to breast-feed in the future because the breast gland and ducts can be violated during this procedure. Another disadvantage is that visibility and exposure of the breast implant pocket beneath the breast or beneath the muscle is more limited with this approach than with the inframammary crease incision. In addition larger silicone gel implants are difficult if not impossible to place through this small incision.
• The Trans Axillary Incision-The benefit of Trans axillary breast augmentation incision is that it is well concealed in the arm pit away from the breast. In my opinion the disadvantage of this technique is that the surgeon has no visibility of the breast implant pocket unless an endoscope is used. In addition the action of the chest muscle or Pectoralis Muscle under which the implant is placed, tends to push the implant up higher on the chest toward the arm pit. In some cases this can prevent adequate dropping of the breast implant into the proper position underneath the nipple areola and lower portion of the breast. This can result in the implants appearing too high on the chest. In my experience this tendency for the implants to be too high after Trans axillary breast augmentation can result in the need for breast implant revision to drop the implant lower into a more natural position. This revision will require a new inframammary crease incision.
• The Trans Umbilical Incision-The trans-umbilical breast augmentation is a relatively new technique and in some areas is highly marketed. The benefit is that the incision and thus the scar is hidden far away from the breast. The disadvantage is that an endoscope must be used to tunnel under the skin from the belly button region up to the breast to create the pocket for the breast implant. This limited visibility can interfere with the creation of an adequate accurate pocket in which to place the implant. In addition only saline breast implants can be placed using this technique. Because the saline breast implant must be passed through an endoscope and possibly be traumatized, use of the Trans umbilical breast augmentation approach invalidates the manufacturer’s warranty of the implant. For this reason I do not use this approach.
Healing of your incisions occurs in stages. It takes two weeks for the initial healing phase to finish and your scar to become less pink and able to be gently massaged. However the scar does not begin to develop significant strength until about six weeks. This is why heavy lifting and vigorous exercise and physical activity is usually not recommended for at least six weeks after breast augmentation.
The strength of your scar continues to increase significantly from six to twelve weeks. Healing continues for months, and research studies have shown that most skin incision scars are pink for on average seven months. The color can continue to lighten and improve for two years.
It is important that you follow the specific instructions of the plastic surgeon who performs your breast augmentation surgery. However in my practice I have the patient start massaging the scar at about two weeks after surgery. I recommend the use of a moisturizing cream to prevent friction and have the patient gradually increase the pressure by massaging the scar morning and night with the finger. In addition I have my patients use a topical scar cream called ScarGuard® which is a form of silicone that can be applied to the surface of the scar. Both pressure and topical silicone can reduce redness and lumpiness of most incisional scars.
Occasionally some breast augmentation scars can become red, raised, itchy and lumpy or bumpy. These are called hypertrophic scars and some individuals are prone to forming this type of scar after any surgery or injury to the skin.
In my practice I treat hypertrophic or red scars with the 1540 non-ablative fractional Erbium laser. This laser treatment is the most successful I have ever seen in my 32 years of practice and can turn a red raised scar into a flat white or skin colored scar. The treatments require no down time are very tolerable without anesthesia and take only a few minutes. At least 4 treatments scheduled a month apart are required.
Your choice of your plastic surgeon is the most important decision you will make when considering breast augmentation surgery with implants. Delicate surgical technique, including use of the Keller Funnel for inserting the implant, can improve your result. Be sure to consult at least two Board Certified Plastic Surgeons. Choose a surgeon who is very experienced in breast augmentation and aesthetic plastic surgery. The Smart Beauty Guide is a good place to start as surgeons must be board certified, members of the American Society of Plastic Surgeons, and the American Society for Aesthetic Plastic Surgery to be included in this guide.