Incision Indecision. Periareolar Incision in Breast Augmentation

The periareolar incision; This incision is placed around the edge (or just within) the areola, the pigmented skin surrounding the nipple. In most instances, the skin around the areola is thinner than the skin in the fold beneath the breast. There is some evidence that, all other things equal, thinner skin forms better scars than thicker skin. Some surgeons tout a periareolar (around the nipple-areola) scar as less visible than a scar beneath the breast. Is that true? Not necessarily. It depends on the quality of the scars in the two places, and that’s not totally predictable.

The greatest advantage of an incision around the areola is that it’s located in thinner skin that usually heals well.

The greatest trade-offs of a periareolar incision are increased trauma to breast tissue, increased exposure of the implant to bacteria normally found in the breast, and if you develop a bad scar, the scar is located in the most visible location on the breast.

A periareolar scar is located on the most visible area of the breast. As long as the scar is good—great. But if it’s not so good, and we don’t know who may form a bad scar, it’s not so great. It’s true that the skin of the areola area usually heals well, but if it does not, the less than optimal scar is noticeable every time you look at the nipple or areola.

Another stated advantage of the periareolar incision is that it’s easier for the surgeon to reach all parts of the breast from a central incision.

Truth is, a skilled surgeon can reach all parts of the breast under direct vision by all incisions (with the exception of the belly button incision where a portion of the dissection is usually "blind"). Trade-offs of the periareolar approach? If you have a very small areola, incision length can be inadequate without extending the incision onto breast skin which forms less optimal scars. When you cut skin, you cut nerves. When you cut nerves, most grow back, but not all, and not predictably. You might think that an incision around the areola would always make patients lose more sensation compared to other incisions, but it doesn’t! Why not? We don’t know! Probably because sensory loss is very unpredictable and may be more related to how the surgery is done (more about that later) or the size of the implant (the larger, the more stretch on nerves and potential sensory loss).

Every woman’s breast tissue contains bacteria. These bacteria live on the skin of healthy women and enter the breast through the nipple.

They don’t usually cause infection because the body is accustomed to their presence in the breast. But put large foreign objects, your breast implants, in the area, and the bacteria can sometimes produce problems. When an implant is inserted through a periareolar incision, the breast implant is more directly exposed to breast tissue compared to other approaches. With more exposure to bacteria, you might think that infection rates would definitely be higher with this approach, but increased infection risk has not been scientifically documented. Even if an implant doesn’t get infected, bacteria around the implant are probably a major factor contributing to capsular contracture, so you might expect a higher risk of capsular contracture with a periareolar incision.

Again, not scientifically confirmed, but in our practice, we’ve seen a slightly higher incidence of capsular contracture in patients who select the periareolar approach.

If you happen to form bad scars (and this can happen, regardless of your history of scars), the areola would not be an ideal place to have a bad scar. Bad scars are very rare in any location, but to date, we have no way of reliably predicting which patients will develop bad scars.