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Breast16 September 20258 min read

Techniques of breast augmentation – axillary, submammary or periareolar?

A breast augmentation with implants is one of the most frequently requested procedures in aesthetic surgery. Besides the choice of shape, size and position of the implant, the incision largely determines the course of the operation, the position of the scar, the healing process and later options for adjustment.

The key points in brief

  • SubmammaryOffers a very good overview and control and is revision-friendly. Suitable for all implant positions (subglandular, subfascial, submuscular, dual plane); the incision is usually 3–4 cm in the inframammary fold.

  • Scars & requirementsWith the axillary approach, the scar lies in the armpit instead of on the breast; the approach goes well with submuscular/dual plane; in the first 10–14 days, do not raise your arms above shoulder height; revisions are often performed submammarily. The periareolar approach conceals the scar at the edge of the areola, requires an areola of ≥ 3.5–4 cm and is more suitable for subglandular/dual plane with moderate implant sizes.

  • Decision shortcutScar preference + planned implant position + revision plans lead to the choice of approach. With a combined lift, the lift pattern determines the incision; the implant is often inserted submammarily.

Woman in a white bra looking at her breasts

Breast augmentation with implants is one of the most frequently requested procedures in aesthetic surgery. Alongside the choice of shape, size and position of the implant, the incision largely determines the surgical procedure, scar position, healing process and later adjustment options. Three approaches have become established: axillary (armpit), submammary (inframammary fold) and periareolar (edge of the areola). This article provides a precise overview, compares strengths and limitations and shows when which technique makes sense.

Brief overview: what do the three approaches mean?

  • Axillary (armpit, “transaxillary”)

    The incision lies in a natural fold of the armpit. The implant is guided to the breast through a tunnel-like access – often with endoscopic support.

  • Submammary (inframammary fold, “inframammary”)

    The incision runs in the existing or newly created inframammary fold. This technique offers the most direct view of the surgical field.

  • Periareolar (at the edge of the areola)

    The incision follows the pigment transition of the areola. The scar often blends in well visually with the colour edge, but requires certain anatomical conditions.

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Consultation and treatment at the Westfalenklinik Dortmund

Consultation room of the Westfalenklinik
Consultation room

At the Westfalenklinik Dortmund, the choice of incision is planned individually – based on anatomy, choice of implant and the desired result.

Dr. Uwe Herrboldt discusses the options transparently, explains which scar patterns to expect with breast augmentation and recommends the technique that combines precision, safety and aesthetics in your case.

Comparison at a glance

Scar position & visibility

  • Axillary

    Scar in the armpit; usually covered in a bikini, visible in sleeveless clothing depending on arm position.

  • Inframammary

    Scar in the inframammary fold; usually concealed by the fold when standing upright and with a suitable fold.

  • Periareolar

    Scar at the edge of the areola; concealed by the change in skin colour.

View & precision during surgery

  • Axillary

    Indirect access; very precise with an endoscope, less so without.

  • Inframammary

    Very good control over all layers and the implant position.

  • Periareolar

    Good control, but limited incision length with a small areola.

Suitability for implant positions

  • Axillary

    Often submuscular or dual plane.

  • Inframammary

    Suitable for subglandular, subfascial, submuscular and dual plane – very flexible.

  • Periareolar

    Rather subglandular or dual plane if the areola is large enough.

Revision-friendliness

  • Axillary

    Revision operations are later often carried out pragmatically via the submammary approach.

  • Inframammary

    Very good; direct access for corrections.

  • Periareolar

    Possible, but dependent on areola size and tissue quality.

Special aspects

  • Axillary

    No scar on the breast itself; initially restricted arm movement.

  • Inframammary

    Reproducible results; with very flat breasts, the scar may be more visible at first.

  • Periareolar

    Scar at the colour transition of the areola; requires a sufficiently large areola (> approx. 3.5–4 cm).

Woman in a black bra with raised arm

Axillary approach (armpit)

The surgical procedure

Access to the breast is created through a short incision in the armpit. An endoscope is often used to prepare the implant pocket precisely under direct vision. The implant is then placed in the chosen position (usually submuscular or dual plane).

Advantages of the axillary approach

  • No scar on the breast itself – an argument with skimpy swimwear.
  • The breast skin in the visible area is spared.
  • Combines well with a submuscular/dual-plane position (especially endoscopically).

Possible disadvantages

  • Indirect access: less overview without an endoscope; a high level of routine is required.
  • Revision operations: later corrections are often carried out via the inframammary fold.
  • Restricted movement: do not raise your arms above shoulder height in the first few days.

Suitable for whom?

  • Patients who do not want a scar on the breast and accept the armpit scar.
  • Slim breast shapes with a planned submuscular or dual-plane position.
  • Sporty, active patients who prefer an inconspicuous scar pattern on the breast.

Submammary approach (inframammary fold)

The surgical procedure with the incision in the inframammary fold

An incision of approx. 3–4 cm in the inframammary fold allows direct, clear preparation of the implant pocket. The implant position – subglandular, subfascial, submuscular or dual plane – can be determined under exact vision.

Advantages of the submammary approach

  • Very good control over the surgical field and the implant position.
  • High reproducibility – important for symmetry and implant stability.
  • Flexible for all implant positions, sizes and shapes.
  • Revision-friendly: later adjustments are readily possible.

Possible disadvantages of the operation

  • With very little breast volume, the scar may be more visible at first, but with the new volume it usually moves into the fold.
  • If there is a tendency towards hypertrophic scars, more intensive scar care is advisable.

Who is it suitable for?

  • Patients who prioritise predictability and precise control.
  • Suitable for a planned dual-plane technique, larger implants or mixed indications (e.g. minor shape correction).
  • Advisable if future revision options are to remain as straightforward as possible.

Smiling woman in a black bra

Periareolar approach (edge of the areola)

How breast augmentation via the areola is carried out

The incision runs in a half-moon shape at the junction between the areola and the surrounding skin. The implant pocket is prepared through this access. A sufficiently large areola is a prerequisite.

Advantages of the periareolar approach

  • Scar at the edge of the areola, often well concealed by the change in colour and texture.
  • Good view of the glandular tissue; quick access with suitable anatomy.
  • Option for accompanying corrections to the areola (e.g. in cases of asymmetry).

Possible disadvantages of the incision

  • Anatomical limits: small areolae restrict the length of the incision and therefore the room for manoeuvre.
  • Sensation & breastfeeding: temporary changes in sensitivity are possible; the proximity to the milk ducts requires a particularly careful approach.
  • Bacterial flora of the milk ducts: studies point to a potentially increased risk of capsular fibrosis/capsular contracture; consistent antisepsis is crucial.

Who is the approach via the areola suitable for?

  • Patients with a sufficiently large areola who want a scar on the breast that is as inconspicuous as possible.
  • Suitable for subglandular or dual-plane placement and moderate implant sizes.

Which incision suits which implant position?

The choice of approach is closely linked to the implant position:

  • Subglandular (beneath the gland)

    periareolar and inframammary offer short routes; axillary is possible, depending on the technique.

  • Subfascial (beneath the connective tissue layer)

    often inframammary, as the fascia can be visualised precisely.

  • Submuscular (beneath the large pectoral muscle)

    axillary (endoscopic) and inframammary are well established; the inframammary view makes exact dual-plane preparation easier.

  • Dual-plane

    inframammary in particular, because of the very good control; axillary with appropriate experience.

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Factors that influence the decision

  1. Anatomy and tissue quality: skin elasticity, breast base, areola size, inframammary fold, symmetry.
  2. Choice of implant: size, projection, shape (round/ergonomic), surface.
  3. Desired implant position: subglandular, subfascial, submuscular, dual-plane.
  4. Scar preference: visibility in swimwear vs. the armpit region; personal priorities.
  5. Tendency towards conspicuous scars: individual wound healing, family predisposition; more intensive scar care if necessary.
  6. Combined procedures: with a simultaneous breast lift (mastopexy), the incision patterns change (e.g. vertical or T-shaped). Here the lift pattern dominates; implants are often inserted via an inframammary approach.
  7. Future revision options: inframammary offers the greatest flexibility for exchanges or adjustments.

Personal consultation on breast augmentation in Dortmund

Are you interested in the different techniques and approaches for breast augmentation, or would you like to find out more about the incision and implant position that suit you? Our doctors advise you with experience, precision and empathy at an individual consultation appointment in our clinic in Dortmund.

Healing phase & scar care: differentiated by approach

General: a compression bra, physical rest, sleeping on your back and avoiding pressure on the implants support healing. Follow-up appointments and, where appropriate, imaging as part of aftercare serve to monitor the healing process.

Axillary

  • No arm movements above shoulder height for the first 10–14 days.
  • Keep the armpit area dry; avoid tight straps.
  • Scar care: after wound closure, silicone gel/patches; later, UV protection.

Inframammary

  • Keep the inframammary fold clean and dry; bra underwires should not irritate the scar directly.
  • Early, gentle scar massage once cleared by the doctor.
  • UV protection and silicone therapy to reduce conspicuous scars.

Periareolar

  • Careful hygiene, as the areola can be pigmented and sensitive.
  • If there is a tendency towards pigment changes, consistent sun protection.
  • Gentle care products, no harsh peels in the area.

Woman in a white bra, hands on her breasts

Risks: put into realistic perspective

Every operation carries general risks such as bruising, swelling, secondary bleeding, infection, wound healing disorders, accumulations of fluid (seromas) and intolerance to suture materials. Specific aspects of breast augmentation include:

  • Capsular fibrosis/capsular contracture

    hardening of the connective tissue capsule; rare, the risk depends on technique, germ control and individual tissue reaction.

  • Sensory changes in the nipple

    usually temporary. With the periareolar approach there is anatomical proximity to nerves and milk ducts.

  • Asymmetries or implant displacement

    careful surgical technique and adequate aftercare reduce the risk.

  • Scar abnormalities

    hypertrophic scars or keloids are rare but possible – consistent scar care helps.

A thorough preliminary examination, sterile surgical conditions, atraumatic preparation, implant irrigation, “no touch” transfer and structured aftercare can reduce these risks.

Decision aid: checklist for the consultation

  • Where is a scar likely to be less bothersome: armpit, inframammary fold or edge of the areola?
  • Are larger implants or a dual-plane position planned, for which particularly precise preparation makes sense?
  • Is there a tendency towards conspicuous scars?
  • Is the areola large enough for a comfortable periareolar approach?
  • Should revision options remain as straightforward as possible?
  • Is an additional tightening procedure likely – now or in the future?

With these points, a clear preference emerges in the consultation.

Conclusion on the different incision techniques in breast augmentation

Axillary, inframammary or periareolar – each incision has clear strengths.

  • Axillary

    its advantage is that no scar is created on the breast itself, and it is particularly suitable for submuscular/dual-plane positions, but it requires endoscopic experience.

  • Inframammary

    offers very good control, high reproducibility and good options for later adjustments – a versatile standard.

  • Periareolar

    offers a scar concealed at the edge of the areola, but requires suitable anatomy and a particularly careful approach near the milk ducts.

The right choice emerges from individually weighing up anatomy, implant, desired implant position, scar preference and revision security. A structured consultation provides clarity.

Frequently asked questions

Can the scar be seen in swimwear?

Axillary: usually not; with high-cut tops it may be visible depending on arm position. Inframammary: usually hidden in the fold; more visible at first with very flat breasts. Periareolar: often inconspicuous at the colour transition.

Is breastfeeding possible later?

As a rule, yes. The periareolar approach lies closer to the milk ducts; for this reason, the tissue is handled particularly gently here to reduce the risk.

Which technique causes the least pain?

The perception of pain is individual. Submuscular positions often lead to a greater feeling of muscular tension at first – regardless of the approach.

Is the axillary technique suitable for very large implants?

Possible, depending on the tissue and surgical routine. For large volumes, the inframammary approach often offers more control.

What applies if a lift is also needed?

With combined mastopexy, the lift pattern (e.g. vertical, L-shaped or T-shaped) determines the incision. The implant is often inserted via an inframammary approach.

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