The Best Breast

John B. Tebbetts, M.D.

by John B. Tebbetts, M.D.

In the world of breast augmentation, “rapid recovery” has become a marketing buzzword on surgeons’ websites and in surgeons’ marketing materials.  Large numbers of plastic surgeons worldwide advertise and promote “rapid recovery” to patients and the media.  But what exactly is “rapid recovery”; how many surgeons really deliver it, and where is the proof that they deliver it?

I’ve heard many surgeons comment that it doesn’t matter if a patient recovers in one day or three weeks.  I strongly disagree.  While patients may tolerate unnecessarily long recoveries, it’s only because most of them don’t know they could be out to dinner the same evening and back to full, normal activities the next day.  Most importantly, most patients don’t know that the length of time required to recover relates directly to how the surgery was performed, and to their risks of developing capsular contracture or having multiple reoperations in the future.  Currently published scientific studies directly relate a 24 hour recovery to the lowest published rates of capsular contracture and the lowest reoperation rates in the history of breast augmentation.

The key message for patients:  If you can be out to dinner the evening of augmentation and return to normal activities within 24 hours, you and your surgeon have significantly reduced your risks of having reoperations in the future!

What really determines how fast you recover?  In order of importance:

1)     Your level of patient education

2)     How your surgeon performed your surgery, specifically a) how much bleeding occurred, and b) how much trauma occurred to your tissues during surgery

3)     The drugs, drains, bandages, and other ancillary measures you received during and after surgery (the fewer the better for the fastest recovery)

4)     Your ability and commitment to follow your surgeon’s instructions immediately following surgery.

Since our scientific studies detailing the processes required to deliver out to dinner and 24 hour recovery were published,  surgeons worldwide are aware that rapid recovery is achievable for patients, and that patients are now looking at recovery as they choose a surgeon.  As a result, “rapid recovery” has become a common marketing buzzword for surgeons.  Regrettably for patients, surgeons can use any buzzword they like with very little accountability, unless patients are informed enough to ask the right questions that separate buzzwords and hype from a surgeon’s ability to really deliver 24 hour recovery.  The reality is that far more surgeons use the buzzword “rapid recovery” compared to surgeons who can really deliver it.  As a patient, what do you need to know to determine whether a surgeon really delivers an optimal, fast recovery?

The key issue for patients is determining prior to surgery whether the surgeon really delivers “rapid recovery”, just how rapid is it, and is there any independent confirmation (not isolated patient testimonials, but confirmation by an independent body of examiners) of the surgeon delivering predictable 24 hour recovery.  Here’s information that should help.

Early in your interaction with a surgeon’s office, ask the following questions:

• “What will my recovery be like, and when can I return to normal activities.”  If you can’t return to full, normal activities within 72 hours, for any reason, you won’t be experiencing optimal recovery.  Prolonged recovery means that your tissues have experience more trauma, and/or that more bleeding has occurred…than is optimal for the most rapid recovery.
• “What drugs will I receive following surgery?”  If the drug list includes ANY narcotic strength pain medication such as Vicodin, Darvocet, Percocet, any codeine containing medication, Demerol, or any other similar medication, you will not experience optimal recovery.  If you require that level of medication, your tissues have experienced more trauma and bleeding than is optimal.  The medications will make you drowsier, you won’t be able to mobilize as quickly, and if you don’t mobilize optimally in the first 8 hours, you will not experience optimal recovery.  In addition, most of these medications increase your risks of nausea, constipation, and other side effects that slow recovery every time.
• “What will my bandages or special bras be like after surgery?”  If the answer is, “You’ll have none of those”, great.  But if you are going to require any of those, they will be restrictive, cumbersome, and restrict your ability to feel comfortable doing the type of mobilization that is essential for 24 hour recovery.
• “Will I have drains after surgery?”  Again, if the answer is “Drains are unnecessary following a first time augmentation, great.”  If you’re going to have drains, or even if the surgeon or personnel hedge the answer about drains, they know that you’re likely to have enough tissue trauma and bleeding that they feel drains may be necessary.  No way are you going to experience 24 hour recovery with drains in place.  Ever.
• “Can I get a pain pump or strong pain medication and muscle relaxants after surgery?  I have a low pain threshold, and will need those.”  If a surgeon suggests or provides either a pain or narcotic pain medications, the surgeon knows better than anyone else how much trauma and bleeding he or she is going to cause during the surgery—and if those are necessary, there’s way more trauma and bleeding than is optimal.  If the surgeon is providing them just to satisfy you when they are unnecessary, it’s my opinion that you may not be getting anywhere close to the most optimal care that is available.   Rather than educating you and helping you get the most rapid recovery with the least risks of drug side effects and retarding your recovery, surgeons who provide you with these drugs are not doing all they can do to assure you the most rapid recovery.  As a colleague who really delivers 24 hour recovery told me, “It’s easier to give patients drugs after surgery than to educate them before surgery and learn to deliver 24 hour techniques.  I’m glad I don’t have to do that anymore.”
• And finally, when a surgeon claims to deliver 24 hour recovery or especially “rapid recovery” in advertising materials or discussions, ask the question:  “Aside from patient testimonials, can you give me any scientific data that you have published or any confirmation by an independent body that you predictably deliver 24 hour recovery?”  It’s highly unlikely that many patients would ever ask a surgeon this question directly, but you can certainly ask the surgeon’s office personnel on the phone.  Wait until they play the “rapid recovery” card in discussions with you (you won’t hear “24 Hour, but you will likely hear “rapid recovery”)…and then ask the question.  You’ll likely get your answer from the expression on their face.

The best surgeon, if the surgeon performs a significant number of breast augmentations, cannot guarantee that you won’t experience a surgical complication.  But the best surgeons’ complication rates are a matter of record in the medical scientific literature or the surgeon can share the rate of occurrence with you and provide verification of the facts.

Recovery is unquestionably the best measure of what a surgeon does that tells you how much trauma and bleeding occurred during your augmentation.  More importantly, trauma and bleeding increase risks of capsular contracture, and that relates to your risks of reoperations in the future.  No matter how you look at it, if you’re educated, recovery is your best measure of surgical performance in breast augmentation.

No surgeon’s photographic results in before or after books or on the Web come anywhere close to telling you as much about the surgeon compared to the surgeon’s record with respect to patient recovery and outcomes .

Surgeons can buy anything you see in a before and after book or on their websites.  Any photograph of a before and after result that you see on the Web is a selected result…and trust me, what you see is the best the surgeon has ever done in 99% of instances.  Any surgeon can assemble testimonials.  Forget pictures when it comes to making decisions or selecting a surgeon.  They are useless if you are educated.  Fun to look at…maybe…but not any true measure of a surgeon’s skills and certainly not any predictor of how you’ll recover and your likelihood of reoperations in the future.

Remember—in supervised FDA studies that surgeons can’t manipulate, between 15% and 25% of first time augmentation patients had a reoperation within just 3 years.  The only study ever published of patients within an FDA PMA study where all 24 hour recovery processes were applied had a zero percent reoperation rate at 3 years.

Recovery is one of the few things no surgeon can hedge on, claim to produce without producing, or manipulate to the benefit of the surgeon.  It either happens optimally (24 Hour) or it doesn’t.  When it doesn’t, there is always a reason, and the reason is always the same.  The surgeon is not following the best scientific information and confirmed best processes and techniques to the letter.  If he were, optimal recovery just happens and you’re out to dinner the evening of surgery.

The buzzwords “rapid recovery” mean virtually nothing.  “24 hour recovery” means exactly what it says.  It’s real, it’s verifiable, and it’s not a buzzword.

John Tebbetts, M.D.

I’d like to let our many friends and extended patient family know why Terrye and I may not be posting as much on our blog and  other information sites for a while.

On Friday, Terrye took our daughter Kas to the Texas State Fair in Dallas for school day at the fair.  They were standing on the midway watching a dart game where folks throw darts to break balloons, and Terrye was standing back behind several kid spectators in the spectator area.  Someone threw a dart that somehow bounced off a balloon and possibly a wall of the concession, arched up into the air, and unbelievably flew out of the game area into the spectator area.  Terrye had her sunglasses on, but somehow the dart arched downward between her sunglasses and her face, and pierced into her eyeball.  We’ve had the best team of ophthalmologists we could assemble taking care of her, but it’s too early to tell what the ultimate outcome will be.  On Friday, there was so much blood in the eyeball that they could not see inside the eye adequately to fully assess the injuries.  I was in Montana, and couldn’t get a plane out on Friday night, but made it back Saturday morning.  Saturday afternoon, enough of the blood had cleared to allow the ophthalmologists to determine that the dart had penetrated much deeper than they initially thought, and had pierced all the way through the back of the eyeball.  The surgeons were able to see leakage of fluid from inside the back chamber of the eye out of the hole in the front of the eyeball.  They took Terrye to surgery last night, and repaired the hole to stop leakage, but were unable to see to the back of the eyeball adequately to do a laser procedure on the retina, so she will need to have that done when the blood has cleared enough to allow them to visualize the retinal puncture at the back of the eyeball.

I’m happy to report that Terrye is doing amazingly well, given the challenges.  Her only comment has been, “Thank God it was me and not Kas or one of the other children.”   Pretty much says it all about how blessed I am to have this amazing lady in my life.  Kas is doing well also and has been an amazing mini nurse and source of support for her Mom.  We’re blessed in many ways and fortunate that T and K are doing well and that it’s not something worse.

Knowing Terrye, despite my and her other surgeons’ admonitions, I know without a shadow of a doubt that she’ll be back in action and back in touch with all her friends before we docs may think is ideal.  She’s just that kind of girl.

 By Terrye Tebbetts

The umbilical incision

Umbilicus is the medical term for your belly button. The incision for the umbilical approach is placed in and around the belly button. I use the terms “in” and “around” because, to some degree, the location of the incision depends on the size of the belly button. Most women’s belly buttons are small, and the incision required is one inch or more in length. The surgeon may not make the initial incision one inch, but the instruments required for the operation usually stretch the incision, and portions of the incision can sometimes extend outside the boundaries of the belly button.

The main advantage of the belly button incision is that it is located off the breast. The belly button incision sounds very acceptable to many women because they are familiar with other endoscopic procedures in the abdomen that use similar incisions, such as ligation of the fallopian tubes (tubal ligation). Actually, the incision required to insert a breast implant through the umbilicus is much larger than that required for many abdominal procedures.

The main advantage of an incision in and around the belly button is that the incision is located off the breast.

The main disadvantages of the umbilical incision compared to other incisions are:

• It offers the surgeon the least direct vision and control compared to other incisional locations and, therefore, the least predictable results.

• It is located farther from the breast, and more normal tissues must be traversed enroute to the implant pocket, increasing tissue trauma, potential pain and bleeding, and recovery time.

Access to the breast is created by bluntly pushing a one inch-diameter tube from the umbilicus to each breast through the tissues of the upper abdomen.

The pocket for the implant is developed by inserting an uninflated implant, blowing it up, then pushing it vigorously side to side to tear a pocket to receive the implant. The surgeon cannot see inside the pocket to create the most precise pocket with the least bleeding.

When the pocket is created by any method other than direct vision, the pocket is less accurate, bleeding is potentially increased, control is less, and tissue trauma is potentially greater.

Most surgeons who use the umbilical approach do not offer implant placement behind muscle. If you are thin, dual plane or traditional behind muscle is better long term.

Precise dual-plane pocket development and pectoralis muscle positioning is currently not an option if the umbilical approach is selected. No currently published studies indicate that patients having augmentation via the umbilical approach can routinely experience comparable recovery to the inframammary and axillary approaches we have published.

The umbilical approach is not ideal for reoperations to correct postoperative

complicatioins or problems because it limits a surgeon’s direct vision and control. A second incision, usually inframammary may be required to address postoperative problems or complications. Although it is technically possible to treat an excessively tight capsule (capsular contracture) via the umbilical approach, the inframammary approach affords the surgeon much more control of capsule removal, more complete removal of capsule, and better control of bleeding.

So why would anyone want to use this approach? It sounds good, until you really look at it objectively. Does this mean that you can’t get a good result through this incision? No. It just means you should be able to expect an even better result in the same patient through an axillary approach, with a faster recovery by avoiding additional tissue trauma when passing through the abdominal tissues and avoiding blunt, blind dissection. The armpit incision satisfies the advantage of moving the incision off the breast. The armpit incision is much closer to the breast, so much less normal tissue is traumatized getting to the breast, and the risk of depressions or troughs in the abdomen from bluntly pushing a large tube through the fat are avoided. From the armpit, the entire pocket can be created precisely and bloodlessly under direct vision for a more accurate, more controlled pocket with less bleeding. Your surgeon can also easily place the implant above or below muscle via the armpit, depending on your tissue needs.

Why would any surgeon want to use the umbilical approach? The umbilical approach allows some surgeons to differentiate themselves from other surgeons by advertising: “I can do it, and they don’t. Come to me.” The umbilical approach can be appealing from a marketing perspective, but I challenge any surgeon to debate me in a scientific forum on the logic of why it is really better. There is no scientific study that indicates that recovery (the best indicator of tissue trauma and bleeding) after umbilical augmentation can compare to the twenty-four hour return to normal activities we have confirmed for patients via inframammary, periareolar, and axillary approaches. We have many patients who are interested in umbilical augmentation—until they learn the facts and compare recovery to the other approaches. As long as surgeons are performing umbilical augmentations using blunt, blind dissection techniques, the umbilical approach offers no comparison to other approaches if precision, control, minimal tissue trauma and bleeding, and the most rapid recovery are objectives. In fairness, I hope that one day the umbilical approach will be able to offer the same level of control as other approaches and avoid unnecessarily traumatizing a normal area of the body (the abdomen) to get to the breast. When it can, and when a surgeon can create the pocket without using blunt, blind dissection, I’ll be happy to endorse the approach. We can always use more options—provided they make sense.

By Terrye Tebbetts

The axillary incision

Placed in the deepest area of the armpit, the axillary incision is probably the least conspicuous of all augmentation incisions. Proper incision placement is critical. If placed in the highest portion of the armpit hollow, the scar is unnoticeable in virtually any body position. Even with arms fully raised, and even before the scar fades, losing its pink color, the incision looks like a normal crease. Once the scar is mature, it is almost impossible to detect in most patients, even with the arms raised. Another stated advantage of the axillary approach is better preservation of sensation in the breast. Actually, sensory preservation is quite variable and is more likely related to the type of dissection

performed and the size of the implant.

The greatest advantage of an incision in the armpit is that its location makes it the least visible of all scars for augmentation.

The greatest trade-offs of axillary incisions are that a surgeon must be experienced, the operation time is usually slightly longer if the surgeon uses state-of-theart techniques, and the patient must tolerate more potential nuisances in the armpit and upper arm areas postoperatively.

With older axillary techniques, after making the incision in the armpit, the surgeon used various types of blunt instruments to “blindly” create a pocket for the implant. The development of an instrument called an endoscope (Figure 6-14) allows surgeons to see inside the body on a television screen to more precisely control the operation.

With the advent of modern endoscopic instrumentation, surgeons can see to precisely create the pocket for the implant instead of bluntly, blindly tearing tissues. This minimizes bleeding, maximizes accuracy, and shortens recovery. The longer operation time required for endoscopically assisted axillary augmentation is more than compensated by increased accuracy and control. A slightly longer operating time can mean more costs but should not increase any risks associated with the operation. Ask your surgeon.

The axillary approach using endoscopic instrumentation is technically more demanding of the surgeon compared to periareolar and inframammary approaches and is difficult for some surgeons to learn. If you are considering an axillary approach, be sure that your surgeon is experienced in endoscopic techniques and that the surgeon minimizes blunt, blind dissection.

The axillary approach traverses more normal tissue enroute to the pocket compared to the inframammary approach, and there are more critical structures (nerves and blood vessels) located in the armpit area compared to any other incision approach. Risk of injury to these critical structures is exceedingly small in the hands of an experienced surgeon, but nevertheless deserves consideration. Finally, minor nuisances around the incision (swelling, numbness, tiny bands of tissue beneath the skin, etc.) that can occur with any incision are usually somewhat more noticeable and bothersome to patients who have axillary incisions compared to other incision locations.

Regardless of a surgeon’s expertise, making an incision and tunnel through the armpit area requires that patients accept the fact that postoperatively, they may be dealing with one or more of the following:

• Enlarged lymph nodes in the armpit area,

• Fluid collections beneath the skin in the armpit area,

• Areas of numbness or tingling in the armpit and upper innerarm areas,

• Potential permanent numbness in areas of the armpit or upper inner arm,

• A ridge where the incision is located for several weeks that requires care when shaving,

• Possible formation of small bands in the armpit area that may limit arm lifting movements. (These usually resolve spontaneously in a few weeks.)

All of these potential nuisances are manageable, and many patients experience few of these nuisances, but if you are considering an axillary incision approach, you should know that these nuisances are possible.

The axillary approach is not ideal for reoperations to correct postoperative complications or problems because it limits a surgeon’s direct vision and control. A second incision, usually inframammary, may be required to address postoperative problems or complications. Although it is technically possible to treat an excessively tight capsule (capsular contracture) via the axillary approach, the inframammary approach affords the surgeon much more control, more complete removal of capsule, and better control of bleeding, and it avoids traversing breast tissue (required with the periareolar approach).

By Terrye Tebbetts

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 a large foreign object, your breast implant, 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.

by Terrye Tebbetts

Wednesday evening from 6- 8 pm Central time, I will be hosting a live question and answer session on www.implantinfo.com  – you will find the event under the Discussion section of their site.  This is a very imformative and helpful sight to women who are thinking about getting implants or who already have them – you will find great support and assistance there.  There is “wisdom” to be had and a great new family to join. 

We will discuss 24 Hour Recovery, High Five Measurement System, Form Stable – Gummy Bear implants – you name it – we will talk about it.  I don’t always say what the ladies want to hear, but you can always count on me to be honest with them!  Let the debate and the discussions begin!

So if you are near your computer Wednesday night – please log in and ask questions – anyone who asks a question will recieve a free copy of The Best Breast 2 book – see the instructions on the site for how to get your free book!  Don’t miss it!

By Terrye Tebbetts

The inframammary incision

Located in the fold beneath the breast, the inframammary incision is the most widely used incision in augmentation and is the standard against which all other incision locations must be judged. The reasons?

It gives the surgeon excellent access for augmentation in a wide range of breast types, offers better control of the operation in many instances, places the incision closest to the pocket compared to any other incision, requires the surgeon to go through less normal tissue compared to any other incision, has no critical adjacent structures (nerves or blood vessels), and is a “gold standard” that most surgeons learned during their residency training. More women have had (and continue to have) augmentation through an inframammary incision compared to all other incision locations combined.

The greatest advantage of an incision beneath the breast is the degree of control it allows the surgeon in a wide range of breast types and the fact that it minimizes damage to normal tissues and potential damage to adjacent critical structures.

More augmentation patients have had this incision location than all other incision locations combined.

The only trade-off of an inframammary incision is the presence of a scar in the fold beneath the breast.

The trade-off of the inframammary incision is the scar beneath the breast. Properly placed in a patient with normal healing, after the scar matures, the scar is less noticeable than the imprint of your bra on your skin when you remove your bra.  A very small percentage of patients form less than optimal scars (more about that later). If you have formed very heavy scars on your chest area in the past (that did not improve with time), you may want to consider another incision location. No test can predict the quality of scar you will form. But for the vast majority of patients (well over 90 percent) , the inframammary scar location is an excellent choice.

So why would patients consider other incisions? In our experience, two main reasons:

1. If a patient has a “head trip” or preconceived negative ideas or concepts about an inframammary scar without understanding the trade-offs of other scar locations, or

2. If a patient has a personal friend or acquaintance who has had another incision approach and is happy with it. It’s human nature to think that if your friend is happy with a certain incision approach, you should choose that approach. In fact, that’s not true at all once you’re really informed.

By  Terrye Tebbetts

  There is much debate and discussion about incision location preferences, but just like a lot of other issues in breast augmentation – most decisions are based on an opinion instead of truly understanding the pros and cons of each option.  Here is some insight about incision locations and tradeoffs from The Best Breast 2.  Each day this week we will go into more detail on each incision location:  Inframammary, Periareolar, Axillary and Transumbilical.

Based on twenty years of experience with all incision locations, I am convinced of the following:

 Most patients worry far more about incision location before the surgery than they care after the surgery (provided they have a good result).

If an incision is on you, you will notice it!

If you have a beautiful breast, neither you nor anyone else will care where the incision is located.

Every patient thinks that the incision location she has is best.

Incision location is a common way that surgeons use to market their augmentation practice. If a surgeon touts the ‘X incision’” as unquestionably the best, and states,

“I am the expert at the “X incision,” run the other way.

No incision is best, and the likely message is that the surgeon doesn’t know how to do it any other way.

If a surgeon is experienced with all incision locations, the surgeon will offer you all options.

If you hear negative comments about an incision location from another patient or surgeon, it’s usually because neither has much experience with that incision location.

No incision location is always best. Each location has advantages and trade-offs.

Every woman’s breasts, at some time in her life, are likely to acquire a blemish, a stretch mark or a biopsy scar. A well-executed incision scar is usually no more noticeable than these other blemishes, and if the breast is beautiful, who notices? Who cares?

Just because your friend had a certain incision doesn’t mean that incision location is best for you. In most cases, it doesn’t matter. A few, very rare breast deformities are best addressed through a certain incision, and when these deformities occur, we don’t hesitate to tell a patient, “With this specific breast deformity, a specific incision location gives us better control over your operation, and, hopefully, we’ll get a better result.” But in over 90 percent of patients that we see, we offer the patient a choice of incision locations. If a surgeon is experienced in all incisional approaches, the surgeon is less likely to recommend one location over another. Instead, the surgeon will give you a full range of options.

What’s really most important about incision location?

• How much control it gives your surgeon over your operation.

• How much it allows your surgeon to minimize trauma to your tissues.

• How far the incision location is from the implant pocket.

• How much normal tissue your surgeon must go through before getting to the implant pocket. The greater amount of normal tissue your surgeon has to go through, the more trauma, bleeding, pain, length of your recovery, and possible other complications you should expect.

• How many critical structures (mostly nerves and blood vessels) are located near the incision or on a path from the incision to the pocket.

Don’t form an opinion about incision location until you know about all the alternatives! Incision location is one of the LEAST important decisions you’ll make in augmentation. Each incision location has relative advantages and trade-offs.

What about Scars?

We’ve said it once, and we’ll say it again. No scar location is necessarily always better than another. Let’s examine some myths about scars:

Myth 1

For patients with minimal or no breast tissue, a scar under the breast isn’t a good choice.

Not necessarily. If the scar is properly positioned exactly in or very slightly above the crease beneath the breast, it will be minimally noticeable.

We’ve heard from more than one patient, “My boyfriend (a medical student on a medical fact finding mission, I’m sure ) said that he saw a scar on a topless dancer that was up on the breast, and it was terrible.

I don’t want that incision.” The facts? Topless dancers have more inframammary incisions than any other incision. The reason the scar was more noticeable was that it was improperly located. If the scar is placed too high above the fold, it’s in an area where it is maximally stretched by the pressure of the implant. If it were kept exactly in the fold or very slightly above the fold, there’s less stretch, and the scar would be narrower. A popular misconception I’ve heard from surgeons is that inframammary scars should be placed well above the fold “so that it won’t show when she raises her arms in a bikini.” Fact is, less than 1 percent of a woman’s life is spent in a bikini. Fact is, a good scar exactly in the fold is far better than a widened scar that occurred because it was placed too far above the fold. If a surgeon is experienced in all incision locations, you can just choose! If you don’t like one (incision or surgeon), choose another!

Myth 2

One incision location is less noticeable than another.

Not true. It depends on the patient’s body position, who is looking, how long after the surgery (whether the scar is mature and faded), and the quality of the scar (largely dependent on each patient’s healing tendencies). What is always less noticeable is a better quality scar, regardless of its location.

Myth 3

A shorter scar is always better than a longer scar.

Not true. The quality of a scar is much more important than its length.

A short, ugly scar is always more noticeable than a slightly longer, thin, faded scar. Experience has taught many surgeons that when you make an incision too short to minimize scar length, you often stretch that incision and “traumatize” the incision edges excessively during surgery. The scar does not heal as well, often stays redder longer and becomes wider. The result is a shorter scar, but also an uglier scar. A better quality scar, even if it is slightly longer, is far better than a short, ugly scar.

Myth 4

If you can put the incision off the breast in the armpit or the belly button, it’s always better.

Not true. We’ll cover specific advantages and trade-offs of each incision location later in this chapter, but there are definite trade-offs for both the axillary (armpit) and umbilical (belly button) approaches that may not appeal to some patients. Fact is, after surgery, scar location usually becomes a nonissue if the patient has an excellent result.

Myth 5

One scar location or another always preserves breast sensation better.

Not true. We formerly believed the axillary (armpit) incision preserved sensation better than other approaches, but after many more years’ experience, we don’t think that is necessarily true. The factors that most affect sensation are 1) surgical technique—the more the surgeon directly visualizes the anatomy and the less bleeding, the less risk of nerve compromise, and 2) the size of the implant—the larger the implant, the larger the pocket required, the more nerves are likely to be cut, and the more stretch the implant places on nerves; hence, the greater the chance you’ll lose more sensation.

Myth 6

Surgeons pick scar locations because they think one is best.

Not necessarily true. Surgeons usually pick scar locations based on their experience. If they have a lot of experience with different scar locations, they’ll offer you all options and discuss the trade-offs. If they’ve only done augmentations one way (or even the majority one way), that’s the scar location they will most likely suggest.