When I first started my practice, I inserted most of my breast implants for my Scottsdale and Phoenix patients via periareolar (halfway around the areola) incisions. I liked the central access to the breast pockets via this incision pattern, and the scars usually blended nicely with the color junction at the edge of the areolas.
In recent years, papers were published in the plastic surgery journals comparing capsular contracture (scar hardening) rates between various incision types. What was demonstrated was that going through the areolas increased the risk of capsular contracture due to possible implant contamination by bacteria that can live in women’s milk ducts. The risk was even worse with transaxillary (armpit) incisions because of the bacteria that live in the armpit glands. The inframammary (breast crease) incision had the lowest rates because this technique bypasses the breast tissue to get under the muscle, and is therefore the cleanest approach.
Once I saw this data, I immediately changed my protocol, so now I perform almost all of my augmentations through an inframammary fold (IMF) approach. This incision also allows a precise angle to dissect the pocket and can be a good access point for revisions where I am dissecting a new space under the muscle (neosubpectoral pocket). The scar itself is fairly small (less than an inch and a half), it hides nicely in the breast crease, and tends to heal well. It also has minimal impact on breastfeeding.
With some patients, I feel that the periareolar approach is still the best option. For patients having tuberous breasts corrected, I have to score and possibly remove some of the natural breast tissue in order to expand the lower breast tissue. Since I will, by necessity, be cutting into the glandular tissue and milk ducts, in addition to needing a scar around the areola to reduce the areolar size, I don’t feel the areolar approach adds much extra risk and it allows me to avoid an extra scar. Patients having breast revision surgery who have a previous areolar scar, or patients with extremely tight lower breast skin can also sometimes benefit from a periareolar approach. Ultimately, the incision location for each patient is decided based on a thorough discussion and weighing out of the pros and cons of each option, and is customized on a case by case basis.