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William P. Adams, Commentary on: Effect of Incision Choice on Outcomes in Primary Breast Augmentation, Aesthetic Surgery Journal, Volume 32, Issue 4, May 2012, Pages 463–464, https://doi.org/10.1177/1090820X12442530
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“Effect of Incision Choice on Outcomes in Breast Augmentation,” by Jacobson et al,1 is an interesting article providing us with additional insight into capsular contracture (CC). For the past 50 years, plastic surgeons have been plagued by CC and its effects on aesthetic and reconstructive breast implant patients. It is important for the reader to keep in mind that we’ve learned a great deal in the past 20 years with regard to CC. A wealth of solid scientific data now points to the primary cause of CC being bacteria, biofilms, and subclinical infection.
The authors present some additional information that will help surgeons educate patients and assist in their preoperative decision-making. The five critical decisions that surgeons make during breast augmentation planning have been previously described, with the incision being the final (and least important) of the five.2 Nevertheless, due to the growing data in support of the subclinical infection theory for CC, many surgeons have discussed potential differences in CC rates as they correspond to incision location. In 2008, Wiener3 reported a significant 16-fold increase in CC with periareolar incisions for breast augmentation, as compared with the inframammary approach. He logically discussed this being primarily due to increased exposure of the implant and pocket to contaminants from dissection through the breast tissue with periareolar access. On the basis of Wiener’s study, many surgeons (including me) have counseled patients that the periareolar approach carries a higher rate of CC. Supporting data were reported by Bartsich et al,4 who found a significant number of bacteria in breast tissue compared with skin. For the same reasons, patients in my practice undergoing breast implant placement and periareolar mastopexy have their implants placed through an inframammary incision while the mastopexy is done through a second periareolar approach.
