When planning a breast augmentation, there are generally three preoperative decisions that must be made. These include choosing the size and style of the breast implant, choosing the pocket plane into which the implant will be placed, and selecting an incision location to gain access to the breast. With respect to the choice of incision, any incisional strategy for breast augmentation must balance the sometimes competing goals of providing comfortable access to the breast, while placing the incision in the most inconspicuous location possible. To this end, several different approaches have been described, including incisions located around the areola, through the nipple, in the axilla, and in the umbilicus. However, for many surgeons, it is the inframammary fold approach that provides the best balance between these two aspects of incision location. Perhaps the most important advantage of the inframammary fold approach is that direct access to the breast is provided, which facilitates accurate creation of the dimensions of the pocket and precise control of bleeding. The resultant scar then falls strategically within the inframammary fold crease where it remains unseen unless the breast is lifted or the patient lies supine. The other incisions tend to variably compromise operative exposure for dissection of the breast pocket either due to incision length, as can be the case with periareolar or transnipple incisions, or due to their remote location, as with the transaxillary and periumbilical techniques. In addition, with these other incisions, pocket dissection is often performed in a blunt fashion, which can compromise precise pocket development and hemostasis. Also, if any patient develops complications such as hematoma, capsular contracture, or shape distortion, the inframammary approach may then be necessitated anyway to provide adequate exposure to correct the problem. Therefore, despite the relatively inconspicuous appearance of the other resulting scars, many surgeons find the inframammary fold approach to be the most attractive option when comparing operative exposure with scar quality and location.

Placing the incision so it will eventually fall directly in the resultant inframammary crease requires that many factors be taken into account. Perhaps the easiest situation to deal with is the patient who preoperatively has enough breast volume to form a defined crease and enough skin to accommodate the breast implant without recruiting upper abdominal skin to assist in forming the lower pole of the breast. This also assumes the inframammary fold location will not change. In these cases, the incision is diagrammed directly in the fold, and it is made long enough to allow adequate exposure for accurate pocket dissection and placement of the breast implant. Incision length for saline implants ranges from 3 to 4 cm in most cases, and for silicone gel implants, 4 to 5 cm. When the more cohesive anatomically shaped silicone gel implants are used, incisions of up to 7 cm in length may be required for larger implants. In these types of patients, the scar will consistently and reliably fall directly in the fold postoperatively, and in most cases, will be almost imperceptible (Fig. 110.1). When the existing skin envelope of the breast is not adequate to easily accommodate the proposed breast implant, skin from the periphery of the breast will be recruited, and a new inframammary fold location will generally be created. This must be taken into account when planning incision location. Direct measurement of the base diameter of the proposed breast implant can assist in placing the new fold. By using the radius measurement of the implant, a measurement from the nipple to the proposed fold can be made to approximate the location of the new fold. The elasticity of the skin must also be taken into account. Assuming the lower pole breast skin will stretch to accommodate the breast implant, this measurement is optimally made with the lower pole skin under stretch to attempt to predict this proposed effect. Alternatively, a maneuver I have found to be helpful in these types of patients is to gently lift the breast skin envelope away from the chest wall, with mild tension directed from above and with the patient supine, and observe where the new fold tends to form. Placing the incision at the lower margin of this fold ensures the resulting scar will fall in the new fold formed after the breast implant is inserted (Fig. 110.2). In cases of severe restriction of the skin envelope of the breast preoperatively, placement of the inframammary fold incision can be difficult to gauge accurately. The location of the fold is almost always lowered in these patients, and the lower pole breast skin tends to be relatively inelastic so the stretch effect will be limited. As a result, direct measurement of the distance from the nipple to the proposed fold is the best method to predict the ultimate location of the new inframammary fold. This measurement is again guided by the radius measurement of the width of the proposed breast implant. There is still a tendency for the incision to ride up on the lower pole of the breast in these types of patients, and an additional 0.5 to 1 cm lowering of the planned incision is generally used to increase the likelihood that the scar will fall directly in the subsequent fold (Fig. 110.3).

After the location of the desired fold is determined, the actual incision can be located anywhere along this line. A common strategy to position the incision is to drop perpendicular from the medial aspect of the areola or the nipple to the proposed fold and then measure the desired distance laterally along this line. I have found that an even more lateral location can be desirable in some patients. By measuring from the lateral margin of the areola and then extending laterally, the scar

is even more difficult to see as the breast falls over the fold (Fig. 110.4). This approach also has the added benefit of allowing more of the inframammary fold to be addressed surgically from above and to the side rather than when the incision is located directly in the midportion of the fold. Accurately dissecting the fold to a desired level is easier to do from this more remote location than when the incision is directly in the center of the fold (Fig. 110.5).