Introduction

Breast augmentation via the inframammary fold (IMF) incision is the most widely used approach in Western countries [1, 2]; however, the axillary approach is the dominant incision used in China [3, 4]. Several theories have been described with regard to the differences between these two approaches. Cheng believed that Asian patients have a tendency towards the formation of hypertrophic scars. Therefore, an incision hidden within the axilla is favored [3]. Alpert considered that an inframammary scar might be more prominent on a thin Asian woman who lacks significant breast tissue and defined IMFs [5]. In contrast, Tebbetts believed that an adequate incision length, with care to avoid trauma to the edges of the skin and with the use of precise closure techniques, produced scars of equivalent quality at all of the current incision locations in a wide range of skin types [6]. Furthermore, he believed that patients who were provided sufficient information about the potential benefits and concessions of all types of incisions would overwhelmingly choose the inframammary approach [7].

The preference of the incision location for breast augmentation is a personal one that is influenced by many factors including the patient’s understanding of the various options, body habitus, and personal requirements. The experience and preference of the surgeon also play a role. Thus far, systematic preoperative education material with regard to the different incision locations for breast augmentation is still scarce in China, and most Chinese women obtain their knowledge from Internet sources, advertisements, and the experiences of friends. Therefore, they often struggle to make a truly informed decision, in part because of their limited knowledge of the incision approaches.

Few studies have described the decision-making process with respect to incision locations for breast augmentation, and few have investigated the personal views of the patients. In this study, we surveyed Chinese patients to ascertain their preferences and concerns regarding incision locations based on a comprehensive understanding of the different incision approaches.

Patients and Methods

Ethics Committee Approval and Informed Consent

This study was approved by the institute’s ethics committee. Informed consent was obtained prior to the start of the questionnaire.

Inclusion and Exclusion Criteria

Consecutive patients who were seen in our department and who asked for esthetic breast augmentation surgeries with implants due to breast hypoplasia during 2012.5 and 2014.1 were included. After a physical examination and a preliminary decision as to the pocket, implant volume and type, and IMF location, the patients with anatomic variables and constraints that made one incision superior or inferior were excluded. The exclusion criteria are listed in Table 1 [6]. All of the remaining patients were informed as to the purpose of the survey and their answers and personal information were guaranteed to remain private. They were free to decide whether they wished to participate in the study.

Table 1 Exclusion standard [6]
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Preoperative Education Material

We examined the existing published literature to compile a comparison of axillary, periareolar, and IMF incisions, which were then outlined in a table and served as the preoperative education material. The transumbilical approach was not included because of its infrequent application. The comparison table included scar location, tissue trauma, recovery period, alteration in nipple–areola complex (NAC) sensation, capsular contracture rate, and the possibility of a change in the incision location for a secondary procedure [6–19] (Table 2). The higher risk of alterations in nipple–areola sensation and capsular contracture has remained controversial [15, 20–27], and therefore, we searched the relevant literature and listed the range of alteration rates in nipple–areola sensation and capsular contracture rates of the 3 incision types as reported in various studies. Few randomized controlled trials were found in the related fields. The studies provided evidence levels of grades 3–4. Expert panels at the Plastic Surgery Hospital (Institute), Chinese Academy of Medical Sciences (CAMS), Peking Union Medical College (PUMC) reviewed the draft of the preoperative education material.

Table 2 The preoperative education material of the incision locations [6–19]
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Questionnaire of Incisions

We conducted semi-structured interviews with 20 patients to determine their concerns about incisions for breast augmentation surgery. The recorded data were then used to generate the items on the questionnaire.

Plastic surgeons, nurses, and psychologists employed at the Plastic Surgery Hospital (Institute), CAMS, PUMC, School of Psychology, Beijing Normal University, and at the Chinese People's Armed Police General Hospital reviewed the initial draft of the questionnaire. The questionnaire then underwent examinations for test–retest reliability and content validity.

The final version of the questionnaire contained the following 3 parts (Fig. 1):

Fig. 1
figure 1

The preoperative education material and questionnaire regarding incision locations for breast augmentation

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  • Part I investigated the patients’ initial choices and the main reasons for those choices, which were based on their preliminary knowledge.

  • Part II included the preoperative education material with regard to the incisions. The patients read the comparison table by themselves and were free to ask the surgeon any questions. The surgeon provided explanations when necessary but never provided any advice or suggestions that may have persuaded the patients in any way. All patients consulted the same surgeon. Some patients asked for pictures of scars, which prompted us to provide a series of pictures of incision scars at each location that were obtained approximately 1 year after the surgery. The pictures illustrated different degrees of pigmentation, vascularity, width, and height; the pictures presented scars that ranged from almost invisible to very obvious so as not to influence the patients’ decisions. The patients were informed that the scar was a necessary concession of augmentation surgery and that the possible appearance of the scar was related to personal physical differences and variable factors that might result in almost invisible scars or more obvious ones at each incision location.

  • Part III ascertained the patient’s final decision as to the incision location and the primary concerns that influenced that decision.

Statistical analysis

The software program EpiData (version 3.0, www.epidata.dk/) was used for data management. Statistical analyses were performed using the SPSS software (version 21.0, SPSS). A Chi square test and kappa value were used to examine the test–retest reliability of the questionnaire. Frequencies and percentages were used to describe the distributions of the categorical data and the ranked data. The McNemar–Bowker test was used to test the paired nominal-scale data. The demographic data of the patients were analyzed with a multinomial logistic regression model to test the effects of the variables on the choice of incision. Significance was assigned at P < 0.05.

Results

A total of 216 patients participated voluntarily in this research study and signed the informed consent from between 2012.5 and 2014.1. The voluntary participation rate was 98.18 % (216/220); the average age of the patients was 31.5 years old (range 18–55 years) and the average BMI was 18.85. All of the patients received silicone gel implants with a textured surface. Two hundred and thirteen patients (98.61 %) received anatomic breast implants, while only 3 patients (1.39 %) received round implants. The average volume of the breast implants was 249.94 ml. It took approximately 15–20 min for the patients to complete the questionnaire.

Test–Retest Reliability and Content Validity Examinations

According to the design of the questionnaire, 24 patients filled in Part III of the questionnaire again 2–4 weeks later. The kappa values are listed in Table 3. The questionnaire showed acceptable test–retest reliability (P < 0.05). The opinions of the experts and a literature review confirmed that the items were representative of important domains that were relevant to the incisions for breast augmentation surgery.

Table 3 Test-retest reliability of the questionnaire
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The Initial Choices of the Patients and Their Primary Reasons

Each respondent chose one incision for augmentation mammoplasty based on her initial knowledge and indicated the main reason for this choice. A total of 176 (81.48 %) patients chose the axillary approach, 27 (12.50 %) chose the periareolar approach, and 13 (6.02 %) chose the IMF approach. The main reasons for these choices are listed in Table 4. Most of the Chinese patients initially preferred an axillary incision because they believed that a scar located in the armpit would be easy to conceal.

Table 4 The initial choices of the patients and their primary reasons
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The Final Decision of the Patients and Their Primary Concerns

After they read the preoperative education material on the incision locations, the respondents were given the chance to choose one incision location again. Eighty-six (39.81 %) patients changed their initial decisions. The numbers of patients who choose the axillary and the periareolar approaches decreased to 117 (54.17 %) and 13 (6.02 %), respectively, while the number of patients who opted for an IMF incision increased to 86 (39.81 %). The changes in the incision location were analyzed by a McNemar–Bowker test. The results suggested statistically significant differences in the patients’ decisions before and after they received the preoperative education with regard to the different incision locations (P < 0.05) (Table 5).

Table 5 The patients’ decisions of incision location before and after they received the preoperative education
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Eighty-six patients changed their initial decisions. Among these, 73 who originally chose the axillary or periareolar approach selected the IMF approach, 8 who originally chose the periareolar approach selected the axillary approach, and 5 who originally chose the axillary approach selected the periareolar approach (Table 5). The primary concerns of the patients who changed their decisions of the incision location are listed in Table 6. Patients who originally chose the axillary or periareolar approach who eventually selected the IMF approach were primarily concerned about the superiority of the IMF incision in terms of the lower capsular contracture rate (32.88 %), the lower possibility of injury to the breast parenchyma (23.29 %), and lower likelihood of tissue trauma (23.29 %). The patients who switched from the periareolar or axillary incision to the other were mostly concerned about the easily concealed scar.

Table 6 The primary concerns of the patients who changed their decisions of incision location
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The primary concerns in the election or rejection of one incision are listed in Table 7. The majority of patients who chose the axillary incision and periareolar incision cited easily hidden scars as their primary selection criterion (60.68 % and 92.31 %, respectively, for the axillary and periareolar approaches). However, the patients who opted for the IMF approach were primarily concerned about the lower capsular contracture rate (29.07 %), lower likelihood of tissue trauma (24.42 %) and lower possibility of injury to the breast parenchyma (20.93 %). In contrast, patients who rejected the axillary approach mainly cited the higher possibility of tissue trauma (38.38 %), the need to wear a strap during the recovery period (36.36 %), and the possibility of scar exposure (17.17 %) as their primary concerns. The patients who opted against the periareolar approach did so mostly because of the possibility of injury to the breast parenchyma (31.53 %), higher capsular contracture rate (24.63 %), and higher alteration rate of NAC sensation (15.76 %). All of the patients indicated that the possibility of scar exposure was the deciding factor in their rejection of the IMF incision approach.

Table 7 The primary concerns in the election or rejection of one incision
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The overall primary concerns of the patients in their choice of the incision are listed in Table 8. An easily hidden scar (43.98 %), lower capsular contracture rate (23.15 %), and lower possibility of injury to the breast parenchyma (17.13 %) were the top 3 of the patients’ overall primary concerns in their decision-making process for the incision location.

Table 8 The overall primary concerns of the patients in their choice of a particular incision
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The Demographic Data of the Patients and How the Data Might Have Affected the Decision of the Incision Location

The demographic data of the patients are listed in Tables 9 and 10. Each patient’s age, marital status, income per-month, educational background, pregnancy history, breast feeding history, body mass index (BMI), implant volume, and preoperative breast cup size were analyzed by a multinomial logistic regression to test how the decision on the incision location was affected (Tables 11, 12, and 13). The preoperative breast cup size and BMI had significant impacts on the patient’s choice of incision location. The patients with a preoperative cup size of AA were 12.316 times more likely to choose the axillary approach relative to the IMF approach compared with those with a B cup (P = 0.044; 95 % confidence interval [CI] 1.069–141.923). For each one-unit increase in BMI, the odds that a patient would choose the axillary versus the periareolar approach decreased by 32.4 % (1–0.676) (P = 0.049; 95 % CI 0.457–0.999). In other words, for each one-unit decrease in BMI, the odds that a patient would choose the axillary approach versus the periareolar approach increased by 47.9 % (1/0.676–1). This implied that the patients with a lower BMI were more likely to choose the axillary approach rather than the periareolar approach than those with a larger BMI. No other variables were found to have a significant impact on the patient’s final decision with regard to the incision location.

Table 9 Patient demographics-1
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Table 10 Patient demographics-2
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Table 11 The outcomes of multinomial logistic regression model (a comparison of the axillary approach and IMF approach)
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Table 12 The outcomes of multinomial logistic regression model (a comparison of the IMF incision and periareola incision)
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Table 13 The outcomes of multinomial logistic regression model (a comparison of axillary approach and periareola approach)
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Discussion

The choice of the incision location is one of the core steps in breast augmentation surgery. The current incision locations for augmentation mammoplasty include the IMF, periareola, axilla, and umbilicus. Generally speaking, the IMF incision is the most direct and simplest approach because it incurs minimal tissue damage, less pain, and has a shorter recovery period [6, 8, 9]. The periareolar incision is appropriate when mastopexy is needed or in cases of tuberous breast deformity. However, some studies have suggested an increased risk of capsular contracture, alterations in nipple–areola sensation, and injury to the breast parenchyma [6, 13, 15–17]. The axillary incision avoids a breast scar. However, compared with other approaches, the transaxillary approach causes more tissue trauma and a painful and prolonged recovery period [8, 28]. The umbilical approach is the least used because of the additional morbidity and complications related to the creation of the abdominal tunnels and the decreased accuracy of the surgical vision and control.

Spencer [29], Fishman [30], Gladfelter [31], and Spector [32] discussed patient education materials for augmentation mammoplasty but did not include enough specific information about the incision locations. Dowden described that the patients complained that they felt forced to accept the surgeon’s preference for the incision location [33]. Tebbetts described an approach that integrated patient education and informed consent in cases of breast augmentation to contribute to a valid decision-making process and to ensure an optimal decision [6, 34]. In China, systematic preoperative education material regarding incisions for breast augmentation surgery is still scarce, and few studies have described the decision-making process of the incision location. The preoperative education and questionnaire on incision locations that we compiled have provided patients with sufficient knowledge, and more importantly, an opportunity to realize and express their personal requirements; this has contributed to an improvement in physician-patient communication and to an improvement in patient satisfaction. Moreover, a well-informed patient who actively participates in the decision-making process is an essential ingredient for a successful outcome of augmentation mammoplasty.

According to the survey of members of the American Society for Aesthetic Plastic Surgery (ASAPS), 64 % surgeons preferred the inframammary incision, while 25 % preferred the periareolar incision, and 8.7 % preferred the transaxillary approach. Thirty-eight percent of surgeons who were surveyed reported that they used their indicated approach 100 % of the time regardless of the patient’s physical characteristics and preference, while 32 % surgeons reported that the incision location was determined mainly according to the patient’s preference [1]. Naidu and Codner reported a similar proportion of incision locations used in the USA [35, 36]. However, in China, the axilla is the dominant incision location used in breast augmentation surgery. Our survey found that the axillary incision was the favorable approach by the majority of Chinese patients both before and after they received preoperative education (81.48 % and 54.2 %, respectively) because easily hidden scars were the primary concern of most Chinese patients in the decision-making processes with regard to the incision location. For these Chinese women, a scar in the axilla was thought to be easier to hide than a scar in the periareolar area or the IMF, because they were worried that a scar in the periareolar area or the IMF might be more visible by their sexual partners on an intimate occasion. This seemed to suggest that some Chinese women might, to a certain extent, worry that their sexual partners might become aware of their breast augmentation history. This noteworthy concept might be related to conservative and traditional Chinese principles. Thus, it would be quite meaningful that the Chinese plastic surgeons pursue refinements in surgical techniques and instrumentations with respect to the axillary incision. This may help to achieve comparable accuracy and control with the IMF approach and minimize tissue trauma and bleeding in order to satisfy the requirements of these Chinese patients.

However, some patients held different viewpoints on which scar location is easier to conceal. Among the 95 patients who selected “easily hidden scar” as their primary concern that prompted a particular incision location, 12 chose a periareolar incision and 12 chose an IMF incision. Some patients mentioned that they were not worried if their sexual partners knew their history of augmentation mammoplasty, but were worried about axillary scar exposure if they wore sleeveless blouses or swimming suits. It seemed that the ideal incision location in terms of how well the scar could be concealed differed among the patients. A patient’s individual requirement for an easily hidden scar should be recognized and fully communicated before the surgery.

It was worth noting that nearly 40 % of Chinese women would choose the IMF incision and valued the superiority in the lower capsular contracture rate, less tissue trauma, and a lower possibility of injury to the breast parenchyma over an easily hidden scar. It seemed that the acceptance of the IMF incision by Chinese women had been underestimated. The current low usage of the IMF incision in China is partly due to the limited knowledge of the patients with regard to the superiority of the IMF incision. Preoperative education and the questionnaire provided to the Chinese patients detailed information of incision locations along with the opportunities to express their requirements, and helped reduce unnecessary surgical risks and trauma.

The patients’ demographic data were analyzed by a multinomial logistic regression to test the impact of this data on the choice of incision. All the patients in the study received silicone gel implants with a textured surface. Most of them (98.61 %) used anatomic breast implants, and therefore, the implant type was not included in the regression model. We found that preoperative breast cup size and BMI had significant impacts on the patient’s decision as to the incision location. Patients with an AA cup were 12.316 times more likely to choose the axillary approach instead of the IMF approach compared with those with a B cup. For each one-unit decrease in BMI, the odds that a patient would choose the axillary versus the periareolar approach increased by 47.9 %. The results suggested that patients with a low BMI and small preoperative breast cup size were more likely to choose an axillary incision. The slim patients with significant hypoplasia and ill-defined IMFs were more worried that the incision scar might be visible in the periareolar area or the IMF and tended to choose an axillary incision. The discovery of correlations between BMI and preoperative breast cup size with incision choices was in agreement with some expert opinions on the issue [5, 8]. Asian women are usually short and slim with a low BMI and small breasts compared with Westerners and African Americans [3]. An axillary incision is particularly advantageous in some Chinese patients with small breasts and ill-defined IMFs.

One limitation of this study was that the data were collected from a single center. However, the patients were included in the study consecutively, and the sample size suggested appropriate representation. Moreover, it was difficult to examine the test–retest reliability of Part I of the questionnaire when the setting of this study was considered. The important items in Part III that related to the statistical analysis were included in a test–retest reliability examination. The results demonstrated good reliability. In addition, the capsular contracture rate of the different incisions remained controversial [24, 26, 27]. The core study of Natrelle round silicone breast implants at 10 years post-surgery reported a lower capsular contracture rate for the IMF approach (17.4 %) and the periareolar approach (18.6 %) as opposed to the axillary approach (23.6 %), but the difference was not significant [37]. Some other core studies and evidence-based medicine studies did not provide the specific capsular contracture rate of the different incision locations [25, 38–40]. However, some experts believed that the periareolar incision is associated with a higher risk of capsular contracture because of possible implant contamination (due to the transection of parenchymal ducts that are often colonized by bacteria) [6, 15, 17, 19, 20, 41–43]. Few randomized controlled trials and systematic reviews were conducted in related fields, so in the comparison table, we listed the range of the capsular contracture rates of the 3 incision types that were reported in different studies; this was then given as the preoperative education material, and expert panels reviewed the draft of the preoperative education material to avoid possible errors and bias. So as not to mislead the patients, we also explained to the patients during the survey that the capsular contracture rates of the different incision locations remained controversial, and that the range of capsular contracture rates listed were obtained from different studies.

Further studies have been designed to follow up the participants to evaluate their outcomes, including complications, scar conditions, and postoperative satisfactions, to assess the effectiveness of the preoperative education and questionnaire regarding incision locations. In the long term, the preoperative education and questionnaire of the incisions will help more Chinese women understand the surgery in great detail, help them make informed decisions, and achieve satisfactory effects with fewer risks and less trauma. More importantly, preoperative education on incision locations may make a difference now and may even change the future of Chinese plastic surgery.

Conclusion

The systematic and objective preoperative education material and questionnaire regarding different incision locations helped the Chinese patients fully understand the characteristics of the different incisions, helped them make truly informed decisions, and helped them express their personal requirements. More than half of the Chinese patients opted for the axillary approach mainly because an easily hidden scar was considered the primary concern during the decision-making process. The patients with a low BMI and a small preoperative breast cup size were more likely to choose an axillary incision. However, a considerable number of Chinese women would choose the IMF incision and value its superiority in terms of a lower capsular contracture rate, less tissue trauma, and lower possibility of injury to the breast parenchyma. Patients should be provided with detailed preoperative education on each incision location and be encouraged to choose incisions based on a comprehensive understanding and their personal requirements.