Breast Augmentation Incisions: Where the Scar Goes, and Why It Matters Less Than You Think

One of the first questions almost every breast augmentation patient asks is: where will the scar be? It is a completely reasonable question, and the marketing around it is loud — especially the promise of an armpit incision that leaves the breast “scarless.” Patients raise versions of this constantly in Dr. Farhad Rafizadeh’s Morristown office, and it appears regularly on his RealSelf Q&A page.

Here is the reframe that makes this decision easy, and almost no one selling the “scarless” option leads with it: the location of the incision matters far less than the control it gives the surgeon over the pocket. Once you understand that, the question stops being “which scar can I hide?” and becomes “which approach gives me the best-positioned, lowest-complication result?” — which is a very different question with a much clearer answer.

The Three Incisions, Briefly

Almost every modern breast augmentation is done through one of three incisions. A fourth exists but is rarely used. Here is where each one goes and what it trades.

The Inframammary Fold — the Workhorse for a Reason

For most primary augmentations, the inframammary incision is the default that Dr. Rafizadeh reaches for, and it is the default for a large share of experienced surgeons. It is placed in the crease beneath the breast, and the reasons it is favored are practical rather than cosmetic.

The single biggest advantage is visualization and control. The incision opens directly onto the pocket, so the surgeon can see the entire space, control any bleeding precisely, set the position of the lower breast fold, and place the implant exactly where it belongs under direct vision. That precision is the foundation of a symmetric, natural result, and it is the hardest thing to reproduce through a remote incision. A natural-looking augmentation depends heavily on the fold being set correctly, and this is the approach that controls it best.

The second advantage is one patients rarely think about at the outset: the fold incision can be reused. Breast implants are not lifetime devices, and at some point most patients will need an exchange, a revision, or a removal. When that day comes, the same crease incision gives full access to the capsule and pocket, which means many patients get one discreet scar for the entire life of their implants rather than a fresh one down the line.

The trade-off is honest and small: there is a scar in the fold. Standing, it is hidden by the breast. Lying down or raising the arm can reveal a fine line, and a well-placed fold incision heals to a thin, pale mark that most patients find easy to live with. It does not show in clothing or a bikini.

The Periareolar Incision — and the Contracture Question

The periareolar incision runs along the lower border of the areola, where the darker skin meets the lighter skin. Its appeal is that the scar hides at a natural color boundary, and it is genuinely useful when a breast lift is being combined with implants, since the lift often uses that border anyway.

But it carries a specific consideration that deserves a straight explanation, because it is where the “incision doesn’t matter” camp and the “incision matters a lot” camp actually disagree in the literature.

The leading theory behind capsular contracture — the hardening of scar tissue around an implant — is that a low-grade film of bacteria on the implant surface drives it. The breast ducts naturally contain bacteria, and a periareolar incision passes directly through breast tissue and those ducts on the way to the pocket. That is the mechanistic reason several studies have found higher contracture rates with this approach.

The evidence is real but not unanimous, and it is worth being accurate about. A single-surgeon study by Bresnick, published in Plastic and Reconstructive Surgery in 2022, followed 322 augmentation-mastopexy patients with smooth silicone implants and found capsular contracture rates of 1.64 percent through the inframammary fold, rising to 5.36 percent through the periareolar incision — with the rate tracking inversely to the distance from the nipple. A 2018 meta-analysis by Li and colleagues similarly reported higher contracture rates with periareolar incisions than with inframammary or transaxillary approaches.

The honest position is that incision choice is one modifiable factor among several — not the whole story, but not nothing either. When a fold incision achieves the same goal with a measurably lower reported complication rate, that is a reason to prefer it.

In fairness, not everyone agrees the effect is meaningful. A 2023 review by Swanson argued that the access incision is unlikely to affect capsular contracture risk once other variables are accounted for. That disagreement is exactly why a careful surgeon weighs incision choice alongside implant type, pocket, and technique rather than treating any one of them as decisive. What is not in dispute is the direction of the periareolar findings, and there is no penalty for choosing the incision with the more favorable data behind it.

The Armpit (Transaxillary) — Scarless on the Breast, but Not Free

This is the option the patient in the question above was drawn to, and its appeal is easy to understand: the incision is tucked into a natural fold of the armpit, so there is no scar on the breast at all. For a patient whose single biggest fear is a visible breast scar, that is a real benefit, and in the right hands it can produce a beautiful result.

The trade-offs, though, are substantive and worth stating plainly.

• Less direct control. The surgeon is working at a distance from the pocket, which is why the modern version of this operation is done with an endoscope — a camera — to restore some of the visualization the fold incision has by default. It is more technically demanding to place the implant and set the fold precisely from the armpit.
• Harder with silicone. Saline implants are filled after insertion, so they pass through a small armpit incision easily. Silicone gel implants arrive pre-filled and are less compressible, so a transaxillary silicone augmentation requires more skill and a longer incision. Since Dr. Rafizadeh works almost exclusively with cohesive silicone gel implants, this matters.
• Usually not reusable. If a revision, exchange, or capsule procedure is ever needed — and over a lifetime it often is — the armpit incision generally cannot be used again. Revision typically means a new incision on the breast after all, so the “scarless” benefit can be temporary.
• The armpit scar is not invisible. It is off the breast, but it can be conspicuous in sleeveless tops, and armpit skin does not always heal as quietly as the breast fold.

None of this makes the transaxillary approach wrong. It makes it a specific choice for a specific patient — typically someone prioritizing no breast scar above all else, with an implant and anatomy that suit the route, treated by a surgeon who performs it regularly.

The Belly-Button Route, Briefly

You may see the transumbilical, or TUBA, approach advertised as truly scarless because the only incision is in the navel. It deserves a short, honest mention: it works with saline implants only, the implant is tunneled a long distance with very little direct control of the pocket, and if anything needs to be corrected later it cannot be addressed through the belly button. Dr. Rafizadeh does not consider it a sound trade for most patients, because a small cosmetic gain comes at a real cost in precision and future flexibility.

What Actually Decides Your Incision

Set aside the marketing and the decision comes down to a handful of real variables:

• Your implant. Cohesive silicone gel favors the inframammary fold; saline widens the options.
• Your anatomy. Areola size and shape, existing fold position, and whether a lift is also needed all steer the choice.
• Your priorities. If preserving nipple sensation and breastfeeding potential is paramount, the approaches that stay away from the areola have an edge. If no breast scar is your single non-negotiable, that pushes toward the armpit — with eyes open to the trade.
• The long game. Because implants are eventually revised, an incision that can be reused is a quiet but real advantage.

For the large majority of patients, those variables point to the inframammary fold. That is not dogma; it is where the control, the data, and the long-term practicality converge. Dr. Rafizadeh uses smooth, round cohesive implants from Motiva, Allergan, or Mentor in a dual-plane position and never uses textured implants — and the fold incision is the approach that lets him place them with the most control.

Questions Worth Asking Any Surgeon in North Jersey

If you are consulting for breast augmentation anywhere in Morristown, Summit, Chatham, Madison, Short Hills, Bernardsville, or across Northern New Jersey, these questions separate a thoughtful plan from a sales pitch:

• Which incision are you recommending for me specifically, and why — based on my implant and my anatomy?
• What is your own capsular contracture rate, and does it differ by incision in your hands?
• If I want the armpit approach, do you use an endoscope, and how often do you perform it with silicone implants?
• How will this incision affect a future revision or implant exchange?
• What can I realistically expect this scar to look like at one year?
• If preserving nipple sensation or breastfeeding matters to me, does that change your recommendation?

A surgeon who answers the revision question without prompting is a surgeon thinking about your next twenty years, not just your operating-room day.

People Also Ask

Common Questions Patients Search About Breast Augmentation Incisions

What are the three main breast augmentation incision options?

There are three in common use: the inframammary incision, hidden in the crease under the breast; the periareolar incision, placed along the lower border of the areola where colored and non-colored skin meet; and the transaxillary incision, made in a natural fold of the armpit so there is no scar on the breast at all. A fourth route through the belly button, called TUBA, exists but is rarely used and works only with saline implants. Each puts the scar in a different place and, more importantly, gives the surgeon a different amount of control over the pocket.

Which incision does Dr. Rafizadeh use most often?

For most primary breast augmentations Dr. Rafizadeh favors the inframammary fold incision. It gives the most direct view of the pocket, the most precise control over implant position and the lower breast fold, and in the published literature it is consistently associated with the lowest capsular contracture rates. He uses smooth, round cohesive gel implants from Motiva, Allergan, or Mentor in a dual-plane position, and never textured implants. The periareolar and transaxillary routes remain options for specific patients, but the fold incision is the workhorse for good reasons.

Does the incision location affect breastfeeding or nipple sensation?

It can, and it is a fair thing to weigh. The periareolar incision passes closest to the ducts and nerves that supply the nipple, so in theory it carries the greatest chance of affecting sensation or milk supply, though many women breastfeed successfully after it. The inframammary and transaxillary approaches stay away from the areola entirely and are generally considered the safest for preserving nipple function. No incision guarantees either outcome, but if future breastfeeding or nipple sensation is a priority, that is worth saying out loud at the consultation.

Can silicone implants be placed through the armpit?

Yes, but it takes more skill and usually an endoscope. Saline implants are filled after they are inside, so they slip through a small armpit incision easily. Silicone gel implants come pre-filled and are less compressible, so placing them through a remote armpit incision without direct vision is technically demanding and requires a longer incision. It can be done well by surgeons who do it regularly; it is not a shortcut, and it is not the right choice for every implant or every patient.

Will the inframammary scar be visible in a bikini or lying down?

The scar sits in the crease under the breast, so when you are standing it is hidden by the breast itself. Lying down or lifting the arm can expose a fine line, and that is the honest trade-off of this approach. In practice a well-placed fold incision heals to a thin, pale line that most patients find easy to live with, and it is not visible in clothing or a bikini. Scar quality depends far more on healing, tension, and aftercare than on which of these incisions was used.

Does the incision affect how the implant is positioned?

It can. The inframammary incision gives the surgeon a direct, well-lit view of the entire pocket, which makes it easier to set the implant symmetrically and to control the position of the lower breast fold precisely. Remote incisions like the armpit put more distance between the surgeon’s hands and the pocket, which is why they demand endoscopic assistance and greater experience to achieve the same precision. Control of the pocket is one of the strongest arguments for the fold incision.

If I need my implants replaced later, does my original incision matter?

It does. Breast implants are not lifetime devices, and at some point most patients need an exchange or removal. An inframammary incision can be reused for that surgery and gives the surgeon full access to the capsule and pocket, which matters if a capsulectomy or repositioning is needed. An armpit incision, by contrast, is difficult or impossible to work through a second time, so revision usually means a new incision on the breast anyway. Choosing the fold incision often means one scar for the life of the implants rather than two.

Is the “scarless” belly-button (TUBA) breast augmentation a good option?

It is marketed as scarless because the only incision is in the navel, but it comes with real limits. It works with saline implants only, the implant is tunneled a long distance blindly, and the surgeon has very little direct control over the pocket. If a problem develops or a revision is needed, it cannot be addressed through the belly button. Dr. Rafizadeh does not consider it a sound trade for most patients, because the small cosmetic gain of no breast-area scar comes at the cost of precision and future flexibility.

What is the best incision for breast implants?

There is no single best incision for everyone, but for most primary augmentations the inframammary fold incision is the strongest default. It gives the surgeon the most direct control over the pocket and is associated with the lowest capsular contracture rates in the published data. The periareolar and transaxillary approaches are reasonable in the right hands and for the right patient. The best incision is the one that fits your anatomy, your implant, and your priorities — decided at an examination, not from a list online.

What breast augmentation has the least scarring?

The transaxillary approach leaves no scar on the breast at all — the incision is hidden in the armpit — so by that narrow measure it produces the least visible breast scar. The belly-button route also avoids a breast scar but has significant drawbacks. It is worth remembering that least scarring on the breast is not the same as best result: the armpit scar can be conspicuous in sleeveless clothing, and the trade in surgical control matters. The inframammary scar is hidden in the crease and, in most patients, is barely noticeable.

What is the incision in the armpit for breast implants?

That is the transaxillary incision. The surgeon makes a small incision in a natural crease of the armpit and, usually with an endoscope for visualization, creates the pocket and places the implant from there, leaving no scar on the breast itself. Its appeal is entirely about scar location. Its drawbacks are less direct control over the pocket, greater technical difficulty with silicone implants, and the fact that it generally cannot be reused for future surgery.

What is the newest breast augmentation technique?

The most recent advances are less about a new incision and more about precision: endoscopic transaxillary technique, and at some centers robotic assistance, aim to give remote incisions more of the control that the fold incision has always offered. Nano-textured and smooth cohesive implants and the no-touch insertion funnel are other modern refinements. Newer is not automatically better, though. A meticulous inframammary augmentation with a smooth cohesive implant remains one of the most reliable operations in plastic surgery, and much of what is marketed as new is a refinement of technique rather than a genuine leap.

How to avoid capsular contracture after breast augmentation?

You cannot eliminate the risk, but several things lower it: minimizing bacterial contamination of the pocket during surgery, which is where incision choice comes in, along with careful technique, pocket irrigation, and a no-touch funnel insertion. Smooth implants in a dual-plane position, treating any bleeding meticulously, and following aftercare instructions all help. Because the periareolar route passes near the breast ducts and their resident bacteria, several studies link it to higher contracture rates, which is one reason the inframammary incision is often preferred.

What puts you at risk for capsular contracture?

The leading theory is a low-grade bacterial film on the implant surface, so anything that raises contamination or inflammation raises risk: bacterial exposure during surgery, hematoma or bleeding around the implant, and certain implant and pocket choices. Incision location plays a part — periareolar incisions have been associated with higher rates in several studies because they cross the breast ducts. Smoking, prior contracture, and radiation also increase risk. Careful surgical technique is the single biggest modifiable factor.

How common is capsular contracture after breast augmentation?

It is the most common reason patients need a second operation, but it is not frequent in absolute terms. Reported rates vary widely depending on implant, technique, and follow-up, and in modern series with smooth cohesive implants they are often in the low single digits. In one single-surgeon study of augmentation with smooth silicone implants, the rate ranged from about 1.6 percent with an inframammary incision to about 5.4 percent with a periareolar incision. The takeaway is not the exact number but that technique and incision measurably move it.

Sources & References

1. Bresnick SD. “Correlation between Capsular Contracture Rates and Access Incision Location in Vertical Augmentation Mastopexy.” Plastic and Reconstructive Surgery. 2022;150(5):1029–1033. PubMed
2. Li S, Chen L, Liu W, Mu D, Luan J. “Capsular Contracture Rate After Breast Augmentation with Periareolar Versus Other Two (Inframammary and Transaxillary) Incisions: A Meta-Analysis.” Aesthetic Plastic Surgery. 2018;42(1):32–37. PubMed
3. Swanson E. “Incision and Capsular Contracture Risk: Is There a Relationship in Breast Augmentation and Augmentation/Mastopexy?” Annals of Plastic Surgery. 2023;90(4):389–391. PubMed
4. Namnoum JD, Largent J, Kaplan HM, Oefelein MG, Brown MH. “Primary breast augmentation clinical trial outcomes stratified by surgical incision, anatomical placement and implant device type.” Journal of Plastic, Reconstructive & Aesthetic Surgery. 2013;66(9):1165–1172. PubMed
5. American Society of Plastic Surgeons. “The five factors of breast augmentation.” plasticsurgery.org
6. Dr. Farhad Rafizadeh, Morristown NJ — RealSelf Q&A. realself.com

Related Reading From Dr. Rafizadeh’s Blog

Patients researching breast augmentation in Northern New Jersey may find these articles useful:

• Natural-Looking Breast Augmentation in Morristown
• Capsular Contracture: Signs, Prevention, and Treatment
• Gummy Bear Breast Implants: Cohesive Gel vs. Textured
• Smooth vs. Textured Breast Implants
• Choosing Breast Implant Size
• Silicone vs. Saline Breast Implants

Bottom Line

Which breast augmentation incision is best? For most patients, the inframammary fold — not because of where it hides, but because of what it controls. It gives the surgeon the most direct command of the pocket, it is associated with the lowest reported capsular contracture rates, and it can be reused if the implants are ever revised. The periareolar incision hides the scar at the areolar border but passes near the breast ducts and carries higher contracture rates in several studies. The transaxillary armpit incision leaves the breast scarless, which is a genuine benefit for the right patient, but trades away direct control, is harder with silicone implants, and usually cannot be reused.

The mistake is choosing an incision from a website based on which scar sounds most hidden, rather than from an examination based on which approach gives you the best result. If you are weighing your options for breast augmentation in Morristown, Summit, Chatham, Madison, Short Hills, or anywhere across Northern New Jersey, Dr. Rafizadeh is glad to examine you and explain candidly which incision fits your implant, your anatomy, and your priorities — including the reasoning behind the recommendation.