Surgical Considerations

Incision Placement

Around the Areola (peri-areolar):

These incisions are very popular with most surgeons. Your areola is the brown skin around your nipple (the part that sticks out). Typically these incision are made along the lower edge of the areola from the three to nine o'clock positions. I prefer to make them between the twelve and six o'clock positions to stay as far away from the sensory nerves that come around the side of the breast as I can. They only need to be slightly less than two inches long so that can be anywhere from a third to half the circumference of the areola.

These incisions need to be carried down through the breast tissue to reach the plane where the pocket for the implant will be made. A few, but by no means all of the breast ducts will be cut. This could theoretically impair your ability to breast feed. I hasten to add that I know of many women that have successfully breast fed after having had these incisions. If the surgery is done within a year of breast feeding milk production may occur again and the milk may leak through the incision. In this circumstance you may want to either wait, pick another incision location or take the pills that your obstetrician can provide to dry up your milk. Milk ducts also contain small amounts of bacteria that will be released in cutting through them. There are those that feel that this bacteria may increase the rate of capsular contracture. There is, as yet, no proof that this is the case, but no one will argue that this is a more invasive approach that alters, in a small way, the architecture of the breast.

These incisions usually heal very nicely into a white line along the areolar margin. I had these incisions and they healed as well as any I have seen. I have had doctors examine me and not notice them, but I know they are there and see them whenever I look in the mirror. Given the choice today, I would choose to have the incisions hidden beneath my breasts where I would not see them. I mention this only as a personal observation.

Beneath the Breast (inframammary):
These incisions are made in the fold beneath the breast. Often the fold will drop slightly after surgery from the weight of the implant and stretch of the skin so that the scar ends up just above the fold. The length is usually about two inches long. I place these incisions a little to the side of the middle of each breast where they will be the least conspicuous. This approach is the least invasive of all the possible incisions. There is only a small amount of skin and fat to go through before you are in the right place to make the pocket for the implant. The breast tissue is not affected at all. They usually heal quite nicely and are relatively inconspicuous. Given a choice today this is the incision I would choose for myself.

Under the Arm (transaxillary):
This is a popular approach for many patients because the incision is placed under the arm and not on the breast. They are my least favorite incisions for several reasons. Because the incision is away from the breast it is more difficult to see what you are doing within the pocket. One of two approaches can be used. The more common is to do much of the operation "blindly". The initial incision and dissection is done under direct vision until the edge of the pectoralis muscle is located. Then a large blunt instrument is used to push through the tissues and create the pocket. The lower edge of the muscle is forcibly torn from its attachment to the ribs. Because this can result in bleeding the pocket is often filled with cold water to constrict the blood vessels. It is more difficult to get the lower inner aspect of the pocket shaped exactly the same on both sides.

The alternative approach to this method starts the same way, but when the edge of the muscle is reached an endoscope is used with a cautery to dissect the pocket and cut through the muscle attachment to the ribs. The cautery is the instrument we use to seal off the ends of bleeding blood vessels. Most women have some sort of asymmetries or tissue characteristics that need to be dealt with that can be more difficult of even impossible to correct through a transaxillary approach. With the addition of the endoscope the incisions must be made a little longer, about two and a half inches.

These incisions often heal well, but for some time they are a nuisance to shave around and should not be covered with deodorants or anti-perspirants. In my experience it takes longer for women to feel comfortable raising their arms up over their head. Not infrequently secondary surgery must be done through a different incision resulting in more scars.

Implant Placement: Over or Under the Muscle

Take a moment to look at the following diagram to understand the size and location of the muscles that make up your chest wall.

(diagram coming soon)

Notice that the pectoralis major muscle is a large fan shaped muscle. You will see that it does not cover the lower outer aspect of the chest wall. Most surgeons detach the muscle from its lower origin along the ribs when placing the implant under it. This means that only about half the implant will be covered by the muscle. The bigger the implant, the less it will be covered. The pectoralis minor muscle is much smaller and lies under the outer edge of the pectoralis major. The serratus muscle lies along the sides of your chest wall. The main sensory nerves to your breast come up between the slips of this muscle to enter the back of your breast tissue and from there the rest of your breast. Most surgeons place the implants on top of the pectoralis minor and serratus muscles, but below the pectoralis major muscles.

Over the Muscle (subglandular):

Pros:

When textured implants are used the capsular contracture rate is only 5-10%. In women with a moderate amount of breast tissue (B cup or larger) this can be an excellent choice and produce very natural looking breasts that age well. The recovery is usually easier than when the implants are placed in a submuscular position. End results are usually achieved in a matter of weeks.

Cons:

The use of smooth implants in a subglandular position very frequently (up to 70%) results in capsular contracture. When textured implants are used in thinner women with small breasts rippling may be visible in the upper and inner aspects of the breasts. It is also easier to see the upper edges of the implants when they are placed over the muscle.

Under the Muscle (subpectoral):

Pros:

Using smooth implants under the pectoralis muscles reduces the capsular contracture rate to less than 10%. In thinner woman the added bulk of the muscle over the upper and inner aspects of the implants makes the edges less visible and the curve of the breast more natural. When textured implants are used the rippling in the areas under the muscle is usually invisible.

Cons:

The recovery is more uncomfortable for several days. The swelling takes longer to come down and for the breasts to settle. It may take several months to see the end result. When the pectoralis muscle is contracted during exercise or in some daily movements the muscle flattens the implants and pushes them outward changing the shape of the breast. Occasionally an indentation over the implant is seen along the edge of the muscle. When there is a moderate amount of breast tissue that is lax or becomes lax in time it may sag below the position of the implant which is held in place by the muscle resulting in a double bubble deformity.

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Implant Characteristics | Anatomical Considerations | Surgical Considerations
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