Timing of Breast Augmentation, Incsion Types and Nipple Sensitivity

Timing of Breast Augmentation and Other Important Information

Many women wonder if they should wait until their family is complete before undergoing breast augmentation. Certainly, pregnancy and breast-feeding change the breast skin, shape, and size; these are common reasons many women choose to have breast augmentation surgery at our Minneapolis / St. Paul area clinic. As leading breast surgery experts in Minnesota and the upper Midwest, our staff works closely with patients during the breast implant surgery decision-making process.

Should a woman who has not yet had a child (but plans to in the future), or a woman who wishes to have more children later, undergo augmentation mammoplasty?

If your breast development is complete and you have had breast enlargement surgery, and then later become pregnant and breast-feed, your breasts will indeed change in appearance, just as they do in a woman who has larger breasts naturally, becomes pregnant, and nurses her baby.  Since breast implants are in most cases beneath the chest (pectoralis major) muscle, and in all cases beneath the breast itself, the presence of implants does not interfere with the function of the breasts. Whatever breast tissue a woman has prior to breast enlargement surgery will swell and respond to the normal hormonal changes of pregnancy and later breast-feeding. The degree of enlargement, skin stretch, and later droop or sagging is as individual as each woman. A patient who had breast augmentation prior to pregnancy may choose to undergo a breast lift when her family is complete, just as the woman without breast implants.  Others may simply choose a slightly larger implant to further fill the stretched skin brassiere.  Or, you can indeed wait until your family is complete, and then undergo breast augmentation surgery, or augmentation plus breast lift (mastopexy) if a lift is needed in addition to restoring volume.

What you need to know is that it is safe and appropriate to choose either way, whichever is best for you. The breast augmentation experts at Minneapolis Plastic Surgery, Ltd. offer decades of experience with thousands of patients considering breast enlargement, breast lift (mastopexy), breast lift  plus implants, or breast implant revision at our nationally-accredited (AAAASF) in-office surgical facility in Golden Valley, Minnesota.

Breast Feeding

Breast augmentation does not generally affect the ability to breast feed. One study shows that about 54 percent of women without implants reported problems nursing. 93 percent of breast augmentation patients had their children before undergoing the procedure, so nursing was not an issue. Of the 7 percent who had children and nursed them after augmentation, 50 percent reported problems, essentially the same number as those without implants.

Some surgeons have postulated that if a periareolar (around the dark part of the nipple) incision is chosen, a smaller percentage of women will preserve the ability to breast feed.  This is because as many as half of the ducts to the nipple (and some branches of the sensory nerve to the nipple area) are severed by this incision. If you have never breast-fed and undergo augmentation (regardless of incision chosen), you will, in the majority of cases, retain whatever breastfeeding capability you had prior to surgery. Most women who have breast-fed prior to undergoing breast augmentation have successfully been able to nurse again after augmentation mammoplasty. However, as noted in the study above, many women are not capable of breast-feeding (irrespective of breast size), and these patients will still be unable to nurse a baby after breast augmentation surgery, regardless of incision placement.

If you have fibrocystic mastitis (this is not a “disease” since about half of all women have fibrocystic changes in their breasts) you may note tenderness or swelling in your breasts prior to your menstrual cycle. Augmentation mammoplasty does not change this for the better or worse in most cases, but it is advantageous for all breast augmentation patients to consider a surgery date that is just after your period rather than just before, in order to reduce pain, swelling, or bleeding tendency with your surgery. This, in turn, can reduce the risks of developing capsular contracture in certain patients.

Choice of Breast Augmentation Incision

There are four types of incisions used for breast augmentation surgery: axillary (armpit), periareolar (around the areola — the dark skin surrounding the nipple), umbilical (belly button), and inframammary (in the skin crease under the breasts). Each of these choices has pros and cons; some surgeons use some or all of these options, whereas others have a preference based on training, experience, or habit.

Breast Augmentation Incisions
Armpit (Axillary) Incision

The armpit (axillary) incision is often thought to create a “hidden” scar because the scar is not visible on the breast itself. However, the armpit scar can be visible when the arm is raised while the patient is wearing a swimsuit, sleeveless top, or strap-type blouse, and this scar may be wider or more visible than other areas because of its presence in a warm, wet, bacteria-rich environment which is constantly being stretched with every arm movement.

 In addition, dissection from the armpit incision requires that the arm be elevated during surgery, raising the position of the breast and potentially causing malposition of the implant with relation to the crease. A higher proportion of high nipple, “bottoming-out” augmentations are caused by improper pocket creation that results from this incision raising the breast during surgery.

Since silicone gel implants are pre-filled at the factory, implants larger than about 400cc are not able to be inserted via this incision. Saline implants of a larger size can be inserted and filled once in place, but may still have rippling issues that gel implants do not.

Re-operation (for bleeding, malposition, capsular contracture, or other reason) will often require an inframammary incision, resulting in 4 scars, not 2, eliminating the “advantage” of the no-scar-on-the-breast axillary choice.

One final consideration with the axillary incision is that dissection from this vantage point is somewhat more likely to cause nipple sensation loss, since the (lateral fourth intercostal) nerve to the nipple runs along this route on the side of the chest wall.

Periareolar Incision

The periareolar incision is generally made from the three o’clock to nine o’clock position at the junction between the normal breast skin and the darker adjacent areolar skin. Usually, this scar can be minimally visible when healed; however, this scar is visible when unclothed and can occasionally be unsightly, wide, thick, or irregular and it can produce a sharply visible line in an area where the areola color normally undergoes a gradual transition from dark to light. Sometimes, these scars can be depressed (indented) or raised, and can therefore be visible through clothing or swimwear. In addition, this incision requires cutting through ducts that end at the nipple, as well as the breast tissue itself, in order to create the implant pocket. This can cause internal breast scarring and/or calcification, which can make mammograms more difficult to read. Since the nerve branches to the nipple area are partially cut by this incision, a somewhat higher likelihood of nipple-areola numbness is present. Ductal bacteria may also increase the possibility of capsular contracture, so cutting through breast ducts is inadvisable, in our opinion.

Some surgeons may advocate the use of a periareolar incision along the top edge of the areola, excising a small crescent of skin above the nipple/areola complex in order to achieve a “crescent lift” for small degrees of breast droop or lower-positioned nipples. The amount of “lift” with this procedure is minimal to none, and because of this, we believe this should be considered a “scam” (in most cases) designed to charge higher “mini-lift” prices for what is a standard augmentation incision choice if a surgeon utilizes this approach anyway. If the cost is identical to augmentation alone, then in rare cases, this may be a reasonable recommendation.

Umbilical Incision

The umbilical incision (TUBA or trans-umbilical breast augmentation) involves use of an endoscope (a lighted tube commonly used to perform tubal ligations, appendectomies, gallbladder removals, and visual evaluations of the stomach or colon). The endoscope is used to create a pocket beneath the breast or chest muscle for the implant. Only saline implants can be placed with this incision. The implant pocket is created by blunt dissection with a temporary tissue expander or the implant itself. Bleeding or inframammary crease malposition can require an additional incision on the breast, which negates the main advantage of using the umbilical approach (no visible breast scar). Very few plastic surgeons utilize this incision for breast augmentation, and the learning curve is difficult, but acceptable results have been produced by reputable, board-certified plastic surgeons, so consideration of all options is reasonable. Silicone gel breast implants cannot be placed via this incision.

Inframammary (Crease) Incision

The inframammary incision (beneath the breast in the crease) is the most common incision used for breast enlargement with implants. We believe this incision provides the best exposure for creating an implant pocket with the least amount of bleeding (and the highest likelihood of controlling this bleeding should it occur), avoids the course of the nerve to the nipple in most cases, does not cut through breast tissue and/or ducts (avoiding the mammographic concerns), and leaves a short scar that is not visible clothed or unclothed unless one lifts the breast or looks from beneath. When the patient is reclining, the breast falls to the side and up, and the crease (inframammary) scar can be visible; in most cases it is nearly imperceptible. Both Dr. Richard H. Tholen and Dr. Douglas L. Gervais use dissolving stitches beneath the skin surface, which means no cross-hatch or railroad-type marks, no sutures to be removed, and just a thin-line scar hidden in the natural inframammary crease.

Skin and Nipple Sensation after Surgery

Regardless of incision choice, creation of the surgical pocket for the implant will unavoidably cut some of the tiny sensory nerves to the breast skin, and skin sensation will be diminished or absent in the areas these nerves supply. Over time, sensation will generally recover as nerves heal, but may not return to 100 percent of preoperative sensation. Note that this has nothing to do with nipple erectility (response to cold or stimulation), as different nerves are responsible for this response.

In a few cases, depending on your own particular anatomy, the nerve or nerve branches to the nipple-areola region may also be cut during the surgical pocket creation, and you will permanently lose sensation to the nipple-areola complex on that side. About 5-10 percent of women will lose nipple-areola sensation with augmentation alone, and about 15 percent will lose nipple-areola sensation if a breast lift is necessary. Again, incision choice can affect these statistics: a higher number of women may lose nipple sensation with a periareolar or axillary (armpit) incision.

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