Breast augmentation: approaches and their impact on healing

Historically, breast augmentation surgery can be performed using three main approaches: the submammary sulcus approach, the areolar approach or the axillary approach. At FEMM, all three approaches are used, as each has its own advantages and particularities. The surgeon must be versatile and adapt to each case. The decision to place the scar in one place or another will depend on different factors, so there is no single type of incision.

However, the most common option is the submammary fold approach. The main reason is that the scar, about four centimeters, is hidden in the fold of the junction between breast and chest, becoming imperceptible. The areola approach is indicated when there is a case in which it is also necessary to work on the areola itself, either because there is a breast asymmetry in height and it is necessary to elevate them, or if we are faced with prominent areolas whose diameter or shape must be reduced. The axillary approach has the advantage that the main advantage is that the scar is hidden in the fold of the armpit.

The appearance of the scar resulting from breast augmentation surgery improves over time, up to a year and a half after the operation. It is important to follow individualized indications, the most common being moisturizing care with oils, such as rosehip or healing patches. There are other treatments, such as the early application of CO2 laser, Erbium, Pulsed Dye or the application of carboxytherapy six months after the operation.

Breast augmentation: the submammary fold approach

The submammary fold approach is the option mostly chosen by FEMM, unless there are breast asymmetries or alterations in the areola. From the point of view of visibility, this is hidden under the fold at the junction between the breast and the thorax. Thus, through the submammary fold, the pectoralis muscle can be comfortably and non-traumatically lifted to create the hollow under it. In addition, the depth of the mammary gland is isolated from the implant, since the gland is not opened, thus eliminating the risk of contamination of the prosthesis with the mammary gland and decreasing the possibility of developing a future capsular contracture.

Another advantage is that from a gynecological and oncological point of view there is no scarring that could confuse or alter the results of mammograms or other future tests.

The incision, about four centimeters long, is made to coincide with the new submammary fold, and is fixed at depth so that it remains right in that fold. If it is not fixed, it will become visible instead of remaining in the fold, hence the importance of deep fixation if we want the scar to go unnoticed. The fixation is done through internal resorbable stitches, which also help the final scar to be thinner, avoiding tension and traction to it.

When the patient has some breast before the operation and this is well formed, the incision can be made, and therefore the scar in the original submammary fold that the patient already has. However, on other occasions when the patient has very little breast or the submammary fold is high, the patient should be measured and a lower fold than the original one should be created, making the scar coincide with the fold. In addition to the fixation, from the scar to the depth of the tissue, a plane closure is performed to avoid tension that could widen it. Finally, a resorbable intradermal suture is used to hold the edges of the wound together during the first months without the need for stitches.

Breast augmentation: the areolar approach

Its main advantage lies in the change of color between the areola and the skin of the breast, lighter, conceals the presence of the scar, making the transition areola-skin. When the patient presents asymmetries at the height of the nipple, FEMM opts for this route, since making the incision through the areola can raise or lower it to symmetrize the height of the nipple.

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This approach is also ideal for placing implants in patients with asymmetries of the lower mammary poles or the height of the submammary folds. Thus, from this incision it is possible to access the subpectoral plane and work on the grooves. In other cases, it is necessary to carve the mammary gland to eliminate its conical aspect, or when the areolas project outward in the form of a pyramid, something common in patients with tuberous breasts. Also by the aerolar route it is possible to reduce its diameter or to elevate the breast in cases of mastopexy or breast lift.

However, the areolar approach may entail a slight increase in the possibility of suffering an encapsulation or capsular contracture, since the implant is in contact with the mammary gland. To reduce this possibility, antibiotic washes are performed in the hole where the implant will be placed, in addition to introducing the prosthesis through an insulating film that prevents contact between the prosthesis and the contaminated area of the areola.

Breast augmentation: the axillary route

It is usual to introduce the implants. The incision is placed hidden in the crease of the armpit and through it, both the subglandular planes, that is to say, above the muscle, and the subpectoral are accessed. Sometimes, in addition to the small incision of four centimeters in the axilla, a small counter incision is made in the submammary fold, with which the inferior insertion of the pectoralis major is detached with greater control.

The axillary approach has been criticized because it increases the possibility of capsular contracture as the areolar access. The patient must be chosen with caution, because if the selection process is not adequate, the implants will be high and the prostheses will not fill the lower poles of the breast.

The scar in breast augmentation

Regardless of the access route, the skin scar must be cared for. From the point of view of tissue analysis, the scar is considered to be mature six months after surgery. From the point of view of visibility, the scar remains reddened for a longer period of time due to the new capillary vessels.

Once the operation is performed, the first care is by the specialists, who will apply a dressing that protects the scar during the first three weeks. Subsequently, the patient is given a kit of moisturizing oils with rosehip oil to apply directly to the scar, as well as a moisturizing and firming cream that the patient should apply to the rest of the breast to prevent the appearance of stretch marks.

Rosehip oil should not be applied too soon, as it may cause cysts to appear in the area. In some patients in which the scar begins to thicken or is suspected of difficult healing, patches are placed to protect and press, improving the appearance after two or three months. It is important to be consistent with the application of these patches if they are to be successful. Sometimes rosehip is altered with patches.

The scar should be protected with a high sun protection factor (50) for at least one year. For certain patients with excessive pigmentation, carboxytherapy is applied after six months, and sometimes CO2 laser, Erbium or pulsed dye are used early, although these treatments will be indicated by the specialist in Plastic Surgery according to the evolution of each case.