The question comes up in nearly every consultation, usually somewhere in the last ten minutes. Where is the scar going to be?
It’s a fair thing to ask, and patients often ask it apologetically, as if worrying about a scar is vain when they should be asking about safety. It isn’t vain. You’re going to live with this for the rest of your life, and you’ll see it every day.
What most patients don’t realize is that incision choice isn’t only cosmetic. Where I go in affects how precisely I can build the implant pocket, how much breast tissue gets divided along the way, and in at least one case, the odds of a complication years down the road.
The three that matter
There are three incisions in real use for breast augmentation today.
Inframammary sits in the crease under the breast, where the breast meets the chest wall.
Periareolar runs along the lower border of the areola, at the line where the darker skin meets the lighter skin.
Transaxillary is placed in a fold of the armpit, leaving no scar on the breast itself.
You’ll sometimes see a fourth listed, the transumbilical or belly button approach. I don’t offer it and very few surgeons still do. It only works with saline implants, the surgeon is working at a considerable distance from the pocket, and if anything needs correcting later you’re opening a different incision anyway. It was a clever idea that the field has largely moved past.
The inframammary fold, and why it’s usually my answer
If a patient has no strong preference, this is where I go.
Working through the fold puts me directly at the bottom edge of the pectoralis muscle, which is exactly where the pocket begins. I can see what I’m doing. Pocket dissection is more precise, bleeding is easier to control, and if I need to adjust the fold position to match the implant I’ve selected, I’m already there.
It also divides the least breast tissue of any approach, which matters for reasons I’ll get to below.
The trade-off is honest: there is a scar on the breast, roughly an inch and a half to two inches, sitting in the crease. In most women it’s hidden by the breast itself once the implant settles. Standing in front of a mirror you generally have to lift the breast to find it. In a woman with very little natural tissue and a poorly defined fold, it can sit slightly lower and be more visible, and that’s a conversation we have before surgery, not after.
There’s also decent evidence behind the preference. A 2024 cohort study of 194 augmentation patients compared the inframammary approach against endoscopic transaxillary and found shorter operating times and significantly lower postoperative pain scores in the inframammary group.
Periareolar, and the contracture question
This was the standard approach for a long time. Its use has dropped considerably over the past decade or so, and the reason is worth understanding.
The breast ducts carry bacteria. Not an infection, just normal flora that lives there. Cutting through the areola to reach the pocket takes the implant past those ducts on its way in, and the current thinking is that this seeds the implant surface with a thin bacterial film. That film doesn’t cause an infection you’d notice. What it appears to do is keep the immune system mildly agitated around the implant for years, which is one of the leading explanations for capsular contracture.
Multiple series have reported higher contracture rates with periareolar compared with inframammary. It isn’t a dramatic gap, and plenty of women have periareolar augmentations that never give them a moment’s trouble. But when I’m choosing between two approaches and one carries a somewhat higher long-term risk for no offsetting advantage, that decides it for me.
There’s a second issue patients rarely consider. The periareolar scar sits at the center of the breast. Whatever it looks like, it’s in the place your eye goes first.
I still use this incision. Usually when a patient is having a small lift at the same time, since the periareolar incision does double duty.
Transaxillary, and why it isn’t on my list
The appeal is obvious. Nothing on the breast at all, with the scar tucked into a fold of the armpit.
Some surgeons do this well and I don’t want to talk anyone out of a result they’re happy with. But it isn’t an approach we use here, and the reasons are worth spelling out.
Working from the armpit puts the surgeon a long way from the pocket, usually with an endoscope. Controlling the lower pole and the fold position from that distance is genuinely harder. If a revision is needed later, it typically can’t be done through the armpit at all, so you end up with a breast scar anyway on top of the one you already have. The cohort study above also found longer operating times and more postoperative pain with this route.
And the scar isn’t as invisible as it sounds. An armpit scar shows in a sleeveless top and any time you raise your arms. A well-placed inframammary scar generally doesn’t show in anything, including swimwear.
So at our practice the conversation is between the fold and the areola.
One thing I never do to the fold
Some surgeons lower the inframammary fold to make room for a larger implant. I don’t, and it’s worth knowing why before you agree to it anywhere.
Lowering the fold means dividing the ligaments that support the breast from below. It buys room, but it weakens the structure holding everything in place and raises the risk of bottoming out, where the implant slides too low over time and the nipple ends up pointing upward. Fixing that is a revision operation, and it’s one of the more common repairs I’m asked to do on other surgeons’ patients.
Keeping your fold intact also means you won’t need a compression bra around the clock afterward. There’s more on that technique and what it means for recovery on our breast implants page.
What the scar actually looks like over the first year
Patients underestimate how long this takes, and then panic at month two.
For the first six weeks or so it’s a thin line, often flat and pink. Between roughly six weeks and four months it commonly gets worse before it gets better. It can thicken slightly, turn red or purple, and feel firm. This is normal remodeling and it alarms people who expected steady improvement.
From four months onward it softens and fades. By twelve months you’re looking at close to the final result, and by eighteen it’s essentially done. A mature inframammary scar in most patients is a pale flat line you have to look for.
Skin type matters here more than technique. If you scar thickly elsewhere on your body, tell me at the consultation. There are things we can do about it, and they work far better started early than started once a scar has already thickened.
How anesthesia narrows the choice
This is specific to how we work and it surprises people.
Because we perform awake breast augmentation under local anesthesia rather than general, the approach has to be one that can be fully and comfortably anesthetized locally, and completed efficiently. The inframammary fold suits that well. The transaxillary approach, which typically involves endoscopic work and takes longer, is harder to do that way.
So if awake augmentation is what brings you to us, that narrows the incision conversation before we start. Most patients are glad to make that trade once they understand what they’re getting in return.
What this means for your consultation
Bring the question up early rather than saving it for the end.
The answer depends on your tissue, your fold, the implant you and I settle on, whether you want a lift at the same time, and how you scar. Implant size plays a part too, since a larger silicone implant simply needs a longer opening to get through, which can rule out the smaller approaches. Our guide to breast implant profiles covers how those measurements get made.
If you’re just starting to research, the breast augmentation in Bergen County page walks through implant types, placement, and recovery.
Common questions
Which breast augmentation incision leaves the least visible scar?
The transaxillary incision leaves no scar on the breast at all, though the armpit scar is visible in sleeveless clothing and with raised arms. A well-placed inframammary scar sits hidden in the breast crease and is usually not visible in any clothing, including swimwear.
Does the periareolar incision increase the risk of capsular contracture?
Several published series have reported higher capsular contracture rates with the periareolar approach than with the inframammary approach. The leading explanation is that passing the implant through breast ducts exposes it to normal bacteria that live there, which can form a film on the implant surface.
How long is a breast augmentation scar?
An inframammary incision is generally about one and a half to two inches long. Silicone implants require a slightly longer incision than saline, because saline implants are filled after they are placed.
When will my breast augmentation scar stop being noticeable?
Most scars look worse between about six weeks and four months as the tissue remodels, then steadily improve. By twelve months the scar is close to its final appearance, and by eighteen months it is usually a pale, flat line.
Talk through your options in Paramus
Incision choice is one of several decisions we make together at the consultation, and it’s rarely the first one. Our office is on Winslow Place in Paramus, convenient to all of Bergen County. Call (201) 546-1890 or request a consultation.
Medically reviewed by Dr. Michael Gartner, DO, FACS — double board-certified plastic surgeon and Fellow of the American College of Surgeons, practicing in Paramus, New Jersey for over 20 years.
