Issues and Selection Criteria for Incision Approach

Patient selection of incision approach largely depends on the patient’s knowledge of incision options and the relative advantages, tradeoffs and limitations of each approach. Most patients, prior to in-depth education from a surgeon, form opinions about incision locations based on the experience of friends who have had breast augmentation, from internet sources, or from surgeon marketing materials. Few patients have adequate information on which to make informed choices when they first contact a surgeon’s office. Patients can form opinions based on information from internet sources or from other materials they have seen, but until they receive complete information about incision alternatives, they rarely have an in-depth perspective of the true positives or potential limitations of available incision alternatives.

Patients who have an optimal result from breast augmentation rarely express any concern whatever about the location of their scar, positively or negatively. Absent gross scar hypertrophy or scar malposition, educated patients understand that a scar is a necessary tradeoff of augmentation, that the location of the scar is not as important as the quality of the result, and that few normal observers of a beautiful breast pay much attention to any scar (just as few observers would pay much attention to a stretch mark). Incision location is much more a preoperative concern than a postoperative concern, provided the surgeon educates the patient and applies basic principles to optimize scar quality. The most important of principles to optimize scar quality in every case, regardless of skin type or other considerations, include: (1) adequate incision length to minimize trauma to skin edges for access and implant insertion, (2) avoiding trauma to skin edges during the procedure, (3) optimal incision location to minimize tension and stretch on the incision, and (4) optimal incision closure techniques that minimize tension on the skin while also minimizing the amount of suture left in the wound to stimulate inflammation.

Surgeons usually have a personal preference for incision location based on their individual training, personal experiences, or marketing beliefs. Few surgeons had extensive experience with multiple incision locations during their training, and understandably, surgeons tend to prefer the incision location that they learned during residency training or the incision with which they have the most clinical experience. Unfortunately, once surgeons gain a preference for a specific incision location, they sometimes tend to form and verbalize negative opinions about alternative incision locations that are not based on truth, scientific data, or logic.

Some surgeons base choice of incision on marketing concerns, promoting a specific incision location as superior because few competing surgeons in the same geographic area are using that incision location. Many surgeons market “short scar” in lieu of educating patients that an excessively short scar almost assures additional trauma to skin edges that compromises scar quality and makes the scar more apparent. Certain cultures or nationalities of surgeons and patients have strongly ingrained preferences for incision location that are based almost completely on perceptions instead of facts or logic.

Logically, patients and surgeons should choose an incision alternative that is most likely to facilitate an optimal result for the patient, recognizing that an optimal breast augmentation outcome depends on many factors that are more important compared to the location of the scar. In order of priority, surgeons should include the following considerations when choosing incision location:

Incision Location Choice in the Decision Process

Incision location is the fifth priority decision of the High Five™ decision process algorithm for primary breast augmentation.² Decisions to choose pocket location, implant volume (weight), implant type, and location of the inframammary fold decisions precede selection of incision location. Prioritizing incision location choice above any of the other considerations potentially compromises the outcome, especially the long-term outcome, because the incision location decision does not directly impact the quality of the patient’s tissues long-term or the position of the breast on the chest.

Inappropriately prioritizing the choice of incision location can limit other options and compromise other decisions. For example, prioritizing a periareolar incision in a patient with a very small diameter areola limits implant options to inflatable or small non-inflatable implants, and prioritizing an umbilical incision location precludes the patient having options of prefilled, especially form stable, silicone gel implants and the accuracy and control of dissection under direct vision. Patients frequently prioritize incision location above more important decisions, and patient education is vitally important to help patients understand which decisions are most important to optimize results, minimize reoperations, and prevent uncorrectable deformities. A superb scar in the patient’s desired location can never compensate for a suboptimal operation and outcome.

In the United States, informed consent law requires that patients make choices regarding their medical care. Surgeons can provide information and assist in the decision process, but patients ultimately must choose the options for their care that they determine are best. Surgeons can easily influence a patient’s choice of incision location through the content of information they provide the patient, but surgeons are legally responsible for providing the patient valid information about all options during the informed consent process and documenting that the patient understands the options. Informed consent law requires that the patient make the final decision of incision location.

Popular Myths Regarding Incision Location

Many myths have evolved regarding incision location in breast augmentation. The following are untrue statements regarding incision locations:

Objectivity in Evaluating Incision Approaches

Scientifically valid comparisons of incision locations are virtually impossible because the number of variables that affect scar width and quality preclude preoperatively establishing scientifically valid cohorts of patients with similar wound healing mechanisms. Any surgeon can select photographs to prove or disprove any opinion regarding scar quality outcomes in breast augmentation, but selected photographs do not provide objective, scientifically valid comparisons.

Other factors that complicate or obviate objective comparisons of incision locations are surgeons’ willingness to verbalize opinions about incision location that are not based on significant clinical experience, or variations in surgeons’ decision processes and technical skills that can affect scar location and quality.

The author’s opinions and statements in this chapter derive from 30 years of clinical experience using inframammary, axillary, periareolar, and a limited number (six) of umbilical incision approaches. Comments regarding the umbilical incision approach are based on this limited experience and on logic derived from experience with the other incision approaches.

The Inframammary Incision Location—Advantages and Tradeoffs

The inframammary incision approach is the most widely used incision approach in breast augmentation. Based on published data and logic, the inframammary approach is the incision approach to which surgeons should objectively compare all other incision approaches. The inframammary incision approach provides a level of direct vision and surgical control that is unmatched by other incision locations, and enables surgeons to achieve greater control over a greater number of surgical variables that affect outcomes. The most important of these variables are the degree of tissue trauma and bleeding that occur during the operation, the degree of precision during pocket dissection, and the ease with which the surgeon can introduce the implant without damaging the device. No incision approach surpasses the inframammary approach with respect to these three important considerations.

Compared to all other incision approaches, the inframammary approach causes the least trauma to adjacent tissues for pocket access and implant insertion. All areas of the implant pocket are directly visible and accessible through this approach, and surgeons can precisely complete pocket dissection in all pocket locations and place all types of breast implant via this approach. The inframammary approach requires no special instrumentation, and is the most efficient of all approaches with respect to minimizing operative times, thereby minimizing drug dosages and optimizing patient recovery.¹ In the author’s published study detailing techniques that deliver predictable 24 hour recovery, comparable recovery was achieved via inframammary, periareolar, and axillary approaches, but operative times were longer for periareolar and axillary approaches compared to the inframammary approach.¹