I have been asked by many patients about the length of the incision for a breast augmentation. Recently, one plastic surgeon has been advertising on the radio about his new “Stealth” incision technique. What is the story??
The bottom line is that all patients want as inconspicuous a scar as possible. This makes sense. What determines this? Certainly, incision length is a factor, but not as much a factor as you might think. The importance of these factors varies between individuals, so I can’t rank them specifically. However, I would list the factors that go into the visibility of a scar as follows:
1. Quality of the scar (flat, raised, or keloid) – this is determined by the biologic makeup of the individual patient and cannot be altered.
2. Location of the scar – different places on the body show dramatic variation in the tendency for the scar to be visible.
3. Orientation of the scar – If the scar follows the natural lines of tension, the scars tend to be better. Scars located in creases (such as the lower breast crease) tend to heal very well and be much more inconspicuous.
4. Tension of the scar as it heals – If there are mechanical forces acting on the scar as it is healing, the scar tends to widen, thicken and become more conspicuous.
5. How the tissue was handled during surgery – lay people and believe it or not, most surgeons do not appreciate this factor. If the wound edges are traumatized during surgery by excessive force (such as when trying to do a procedure through an incision that significantly reduces the surgeons ability to visualize what he is doing, the tissue may not heal as well as desired.
6. Length of the scar – A longer scar is more visible than a shorter scar, but a longer scar of better quality will be less conspicuous than a shorter scar of poorer quality.
7. Method of closure – how many layers of closure, what sutures are used, type of suturing, how delicately the tissue is handled.
All of this said, how do I plan my incisions for breast augmentation? I will restrict this discussion to silicone implants as they require a larger incision than saline implants as they are pre-filled by the factory and saline implants are inserted deflated, rolled up like a cigar and inflated once inside the breast.
Allergan, one of two manufacturers of mammary (breast) implants states in their product literature that the incision should be of sufficient length to place the implant inside the breast without risking damage to the implant. When inserting a silicone gel filled implant into the breast, the implant is deformed to enter the breast through an incision smaller than the base diameter of the implant. But how much smaller? The answer to that depends on the size of the implant. A larger implant requires a larger incision. If you force a silicone gel implant through an incision too small, the implant will either burst on the spot (I once witnessed a colleague do this) or more likely it will weaken the shell (the bag) of the implant and potentially shorten its lifespan. In my practice, I make my selection for implant size prior to the day of surgery, so I know based upon experience how long an incision to make so as to comfortably insert the implant and not have to worry about shell damage. For implants 200 – 300 cc, I usually use an incision size around 4.6 – 5 cm, for implants 300 – 400 cc I use an incision size approximately 5 – 5.5 cm, and in the rare case that I need to place an implant larger than 400 cc, a larger incision may be required.
That said, there is more to planning an augmentation to achieve a minimally visible scar than the length of the incision. I already stated that if the scar is in the lower breast crease it will be less conspicuous. So all the surgeon has to do is place the incision in the lower breast crease and he is guaranteed a less conspicuous scar, right? WRONG!!! Remember, we are enlarging the breast which means the diameter of the breast will increase. Depending upon the tissue characteristics of the breast (that’s a whole other discussion); I may elect to actually make the incision lower than the lower breast crease. Why? If you make the incision in the lower breast crease, and then place an implant such that the lower breast crease must now be lowered so as to position the implant properly behind the breast, then the initial breast crease incision will now be riding up on the lower portion of the breast, well above the crease, in plain sight and with more tension on the wound edges during healing. All this is a setup for a visible scar. So what do I do that is different? Taking into account the tissue dynamics of the breast, precise measurements of the breast are made. Knowing the size of the implant to be used prior to the start of surgery I can now plan where the desired, new lower breast crease will need to be and place the incision in that position so that the scar will lie within the new breast crease after surgery. This is a much more significant step in reducing scar visibility that merely trying to struggle through an incision too small to work through and insert an implant comfortably.
As far as closure is concerned, I use a three layer technique with all dissolvable sutures. The outer layer is a very fine suture and no removal of suture material is necessary.
The conclusion is that planning an incision to lie within the new lower breast crease using an incision that is just long enough to permit adequate visibility to the surgeon and prevent implant shell damage makes much more sense that struggling through an inadequate, shorter incision and risking damage to the implant.