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Periareolar Incision

Breast Augmentation with a Periareolar Incision

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John Q. Cook, M.D.

Chicago 312-751-2112
Winnetka 847-446-7562

Breast Augmentation with a Periareolar Incision

periaerolar incision | breast augmentation | John Q. Cook, M.D.

The areola is the colored zone that surrounds the nipple.

In general, the areola, the colored zone that surrounds the nipple, is a privileged area for surgical incisions. It is extremely rare, but not impossible, for an incision placed carefully along the border of the areola to heal with a thick scar.

For this reason, you may want to consider the periareolar approach if you have an ancestry that makes it more likely you will form thicker scars (e.g., African, Asian, Southern Mediterranean). This is especially true if you or someone in your family has ever developed a thick scar or a very dark scar.

Should Every Patient Get A Periareolar Incision?

Why not use this incision for everyone? As with everything else in breast surgery, there is no “one-size-fits-all” solution.

If you are planning to breastfeed there is some evidence that a periareolar incision may be more likely to interfere with lactation than an inframammary incision.
Even though the evidence about this is not definitive, it might make sense to avoid a periareolar incision if the ability to breastfeed is a priority for you.

Also, some areolae are not large enough to allow for the placement of an implant, at least through the standard incision, which runs along the lower edge of the areola, from the 3 o’clock to the 9 o’clock position. One possibility is to extend the scar onto the adjacent skin of the breast, but this may make the scar more noticeable. The other possibility is to encircle the entire areola with the incision and release the skin that surrounds the area, but this can have its disadvantages as well.

There are also differences in the character of the areolar border from one patient to another.
From the standpoint of periareolar incisions, it is best to have a well-defined areolar border, since this hides the scar nicely. If the areolar border is less distinct, which is the case in 20 to 25 percent of patients, the scar will be more conspicuous.

Some surgeons feel that when implants are placed through periareolar incisions there is a higher risk of capsular contracture — the formation of excess scar tissue around the implant — which can make the implant feel firm and distort the breast shape. There are some scientific studies that suggest this may be the case. It is generally accepted that subclinical infection may be part of what causes capsular contracture. The thought is that bacteria that live in the breast ducts might leak out through the nipple as the implant is inserted.

Also, with some techniques, the surgeon cuts directly through the breast tissue to reach the plane of implant insertion, which would certainly cut across some of the breast ducts and release bacteria. I will discuss below the particular technique that I use for periareolar augmentation and how it is potentially less disruptive of the breast structure.

WITH PERIAREOLAR AUGMENTATION, WHAT GOES ON UNDER THE SKIN IS IMPORTANT

There is a significant variation from one surgeon to the next as to what goes on under the skin with periareolar breast augmentation surgery.
This is potentially quite important for you to consider, since there may be effects on the development of capsular contracture and the quality of mammograms.

By far the simplest approach is for the surgeon to cut straight down through the breast tissue once he or she has made the surgical incision.
This can potentially speed the operation, but there may be disadvantages. First of all, if the surgeon cuts through breast structure, the implant will be exposed to bacteria that live in the breast ducts. We know that there is a greater risk of capsular contracture when implants are exposed to such bacteria. A second disadvantage is that when breast structure is cut, there may be confusing changes on mammograms.

When I perform periareolar breast augmentation I take a different approach, which is a little more complex but which is also better for my patients.
Rather than cutting breast structure, I open up the natural plane that is under the skin and above the breast structure. I follow this curve down to the lower edge of the breast, then pass under the breast at that point. From that point in the operation, I proceed just like I would with an augmentation done via the inframammary approach. Can I prove that this extra work is worth it? Absolutely not, but it seems common sense to keep the breast structure intact and leave the ducts alone.

PROS: For someone who is concerned about how the incision will heal, especially if she or someone in her family has ever formed a thick scar, the periareolar approach is worth consideration. The periareolar incision is less likely to form a noticeable scar then the other two possibilities. The areolar border is also a more private zone than the bottom edge of the breast or the armpit.

CONS: Not all areolae are optimal for this approach. There are some concerns about possible interference with lactation and increased risk of capsular contracture. For many patients undergoing breast augmentation, a number of advanced techniques may need to be applied, and this may require an inframammary incision.

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