The periareolar incision for augmentation mammaplasty allows for excellent, direct access with an inconspicuous scar, making this a particularly versatile approach. First described in the 1970s (1,2,3,4), this method provides central access to the implant pocket and is compatible with all planes of dissection and most types of implants (5). It is equivalent to or better than an inframammary approach at preserving nipple sensation (6,7). The nipple-areola junction appears to be a privileged area for scars; the resultant scar is often inconspicuous. In fact, in our experience, very few patients have expressed dissatisfaction with their scars. This is in contrast to our earlier experience with inframammary incisions, where dissatisfaction with scars was more common (8). The location of the periareolar incision is independent of the inframammary fold. Furthermore, it is an excellent choice when lowering of the inframammary fold is desired either at the first operation or subsequent operations (5). This incision does not interfere with breast biopsies or mastectomy incisions performed through or around the areola and is compatible with future mastopexy incisions by simply extending the periareolar incision around the entire areola (3,4,5,8,9,10,11,12,13,14). Finally, should the patient require revisionary surgery, the periareolar approach can be used again for most procedures (15).

This approach does violate some breast parenchyma and may create scarring within the breast, but in practice this is rarely a problem clinically or radiographically (9,10,12,14). A periareolar scar may be more visible than an inframammary scar in the upright patient but tends to be less visible when the patient is supine. The scar is only visible when the entire breast is exposed; otherwise the scar is hidden by even the most minimal amount of clothing. The periareolar approach can be used in virtually all women, in breasts with or without ptosis, and with most small or large areolas. As the amount of breast parenchyma increases, the periareolar incision becomes less desirable because of the increasing amount of breast tissue that must be traversed to reach the retromammary space. One concern of going through the breast near the nipple is the increased likelihood of contamination of the implant with breast bacterial flora. Such contamination has been speculated to be a risk factor for infection or capsular contracture (16).

In breast augmentation, the choice of incision must be considered along with several other decisions, including subpectoral versus subglandular pocket placement, smooth versus textured and round versus anatomic implant choice, and accompanying mastopexy or not. A periareolar incision facilitates a future mastopexy, whereas a previous inframammary incision does not help and may in fact interfere. If the patient’s areola is large or the inframammary fold is high, the periareolar approach is similarly appealing. Even if the areola is small or the fold is diminutive or absent, it may be desirable to use the existing areola edge rather than estimate the location of the incision at the site of the new fold to be created by the breast implant. In patients with minimal or no ptosis and an existing inframammary fold 4 to 6 cm below the caudal edge of the areola, the periareolar approach has no major cosmetic advantages over the inframammary incision. Although remote incision placement, such as transaxillary and transumbilical, may carry certain cosmetic advantages, in many situations it is more difficult and potentially less accurate than the periareolar approach, even with the help of an endoscope. The periareolar approach is direct, easy, and user friendly and does not require special equipment (18).