Anatomical Breast Augmentation & Hybrid Fat Grafting

I generally prefer the inframammary incision, positioned slightly below the natural fold. This allows precise control and the lowest risk of bacterial contamination - a key factor in preventing capsular contracture and ensuring long-term results.

Placing the incision slightly lower also accounts for the natural descent of the implant over time; if placed exactly at the fold, the scar may end up on the underside of the breast and become more visible.

With regard to planes, this is often confusing to patients and surgeons even. My preference is the subfascial plane, in keeping with my preservation philosophy across my procedures. This is the interval between one's own breast tissue and just under the thin flimsy layer covering the pectoralis major muscle (therefore, the plane between the breast tissue and above the fascial layer is subglandular). In thinner patients (who are often Asian, but not always), the traditional default has been going under the muscle (i.e. submuscular) as the overlying skin is too thin (< 2 cm) which means the edges of the implant are more likely to be visible (i.e. rippling) and the implant itself may also "move" as the muscle is draped over it - this is known as an animation deformity. In recent times, there has been much fanfare about the dual plane approach. Essentially, this is an in-between, where part of the implant is covered by muscle, and the rest covered by breast tissue. This may be utilised depending on a patient's goals and the "footprint" of her breast on her chest.

As for the shape of the implant, the reality is, even experts cannot tell the difference. For me, the decision is straightforward - if one wants to achieve a fuller look with more cleavage show, then it is a round implant I am going for. Not only does this achieve the desired cosmetic outcome, the risks of malrotation of a tear-drop or gummy bear shaped implant such that it goes upside down for example, is completely negated.

In suitable patients, fat grafting may be used as an adjunct (i.e. hybrid breast augmentation) to refine contours or soften transitions, especially along the cleavage area, for a softer and more natural silhouette. In select patients where their body frames do not support the safe placement of larger implants to achieve their desired goals, a smaller implant may be placed, in combination with fat grafting, to achieve a larger total breast volume than that from implants alone.

On a final note, there are other incisions such as those in the armpit (axillary), around the nipple (peri-areolar) and even, through the belly button (umbilical). I am not a fan of the armpit and belly button approaches because these are sites that are generally not considered to be absolutely clean. This can then increase one's risk of infection and capsular contracture. Additionally, visualisation is generally also sub-optimal so special instruments are required, which adds on further costs with arguably marginal benefits if any, at all. The biggest risk in such approaches, in my opinion, is a bleeding point that may be missed, leading to a haematoma, which then needs to be evacuated through further surgery, known to increase the risk of future capsular contracture, or worse, require complete removal of the implant if the haematoma becomes infected. As for the periareolar approach, while attractive in theory, this can further risk altered sensation of the nipple and future breast feeding, as we are now getting ever closer to the milk ducts. This is also an area that I would not consider as absolutely clean either. Most importantly, stitching of the nipple-areolar complex is deceptively complex - the risks of poor scarring (especially in Asian skin that tends to be more pigmented in this region) or widening of the scars over time (remember we now have an implant below that stretches things out) is not to be underestimated.