In short
- 🔑 The scar that looks worst at one month can be identical at twelve. In a prospective study of 163 patients using the Vancouver scale, the axillary approach scored 6 at one month and the inframammary fold 4 — and at twelve months both scored 2.
- Final satisfaction with the scar was 9 out of 10 in both groups.
- ⚠️ Judging a scar before the year is judging a phase, not a result.
- The worst moment to look at is between the second and the fourth month: it is when it is at its reddest and sometimes at its most raised. It is normal progress.
- What makes it worst and does depend on you: smoking, the sun on an immature scar and straining the area before time.
- What makes it worse and does not depend on you: a local complication —a haematoma or an infection— and your own tendency to scar.
- ⚠️ A hypertrophic scar and a keloid are not the same thing, and how often they occur changes with the approach: in a series of 275 women, they appeared in 1% of those operated on through the armpit and in 8.6% of those operated on through the areola.
- In an augmentation with an implant there is an added factor: the scar closes over a breast that has increased in volume, and that means tension.
Where the scar goes according to the approach chosen is already explained in the page on the scar and the approach. This one answers the other question, the one that comes after surgery: is it going to stay like this?
The short answer is no, and there is a study that measured it with a validated scale at 1, 6 and 12 months. Its figures are the best reassurance available on this subject, because they are not an opinion.
The curve of the first year, measured
This is what this page contributes.
A prospective study followed 163 patients undergoing augmentation with an implant and assessed their scars at one month, at six months and at a year with the Vancouver scale, a validated instrument that scores vascularity, pigmentation, pliability and height of the scar. The lower the score, the better.
| 1 month | 6 months | 12 months | |
|---|---|---|---|
| Axillary approach (94 patients) | 6 | 4 | 2 |
| Inframammary fold (69 patients) | 4 | 3 | 2 |
And the patients’ satisfaction with the appearance of their scar at a year: 9 out of 10 in both groups.
🔑 Read it slowly, because it has two lessons.
The first: the scar improves a great deal and goes on improving throughout the first year. Going from 6 to 2 is not a nicety.
The second, and it is the more reassuring one: at twelve months there was no significant difference between the two approaches. The one that scored worse at a month —with more vascularity and more height— ended up the same. The authors state it expressly: the scars of the two locations reach a comparable appearance in the long term.
⚠️ It is a cohort of Chinese patients and it was not randomised —each patient chose her approach—, so the figures are an order of magnitude. What carries over well is the shape of the curve, not the exact number.
What happens in each phase
Translated into what you will see:
The first few weeks. A fine pink line, with the stitches removed or dissolving. There may be some swelling around it.
From the second to the fourth month. 🔑 The worst moment to look at. The scar turns redder, sometimes thicker, and it may itch. It is the proliferative phase and it is what should happen. Many people take fright at exactly this point because they think it has got worse — and in a way it has, but it is a stage, not the result.
From the fourth month to the year. It pales gradually, flattens and softens. It is the phase in which the figures in the study go down from 4 to 2.
From a year on. This is when it makes sense to assess it, and when it is decided whether it needs anything more.
Hypertrophic scar and keloid: not the same thing
They get confused and they are worth separating.
A hypertrophic scar is a thickened, raised scar that does not go beyond the limit of the original incision. It usually appears in the first few months and often improves with time and with treatment.
A keloid grows beyond the edges of the wound, invading healthy skin. It is less common, harder to treat and has a clear individual and family predisposition.
How often they occur. In a prospective series of 275 women operated on by the same surgeon with smooth implants in the dual plane, and followed for a minimum of four years:
| Endoscopic axillary approach (205) | Periareolar approach (70) | |
|---|---|---|
| Hypertrophic scar or keloid | 1% | 8.6% |
| Deformity of the areola or nipple | 0% | 8.6% |
| Fluid collection in the wound | 1% | 7.1% |
⚠️ How to read this. It is a study by a single surgeon, in an Asian population, not randomised —the patients chose the approach— and with level of evidence IV. It does not show that the periareolar approach is worse for everyone: it shows a pattern consistent with the anatomy —the skin of the areola is different— in one particular series.
What is worth taking away: if you have a personal or family history of keloids, that is a fact to put on the table before surgery.
🔑 And it is worth saying what changes and what does not, because it is usually put wrongly: a predisposition to keloids does NOT determine the approach. What changes is the follow-up. In those cases the scar is watched more closely, intense pulsed light (IPL) is used to reduce its vascularity —and with it the risk of a keloid—, and if early hypertrophy appears it is treated early with cytostatics, 5-fluorouracil or steroids, without waiting to see whether it settles on its own.
What makes a scar worse
In order of how much they depend on you:
1. Tension on the scar. It is the main mechanical factor. A scar that closes under tension widens. And in an augmentation with an implant there is a particularity: the skin closes over a breast that has just increased in volume, so there is tension by definition. That is one of the reasons you are asked not to strain your arms or carry weight in the first few weeks.
2. Smoking. It compromises the circulation of the tissue that has to heal. The FDA names it expressly among the causes of necrosis of breast tissue, and delayed healing appears on its list of complications occurring in at least 1% of patients.
3. The sun on an immature scar, which can leave it persistently hyperpigmented.
4. A local complication. A haematoma or an infection alters the healing of that area. It is another reason not to let warning signs pass, which are on their own page.
5. Your personal tendency. It exists, it is in good part genetic and it is not chosen. It can, though, be anticipated if there is a history.
Treatment, separately
What is done with a scar —silicone, pressure, sun protection, laser, intense pulsed light, on what schedule and from when— is not specific to breast augmentation and has a page of its own, which owns the subject: the scar protocol after surgery.
And if what you have is an old scar that did not settle well, the route is scar revision.
What can be said here is what the clinic’s regimen consists of, without repeating the schedule that belongs to that other page: moisturising, sun protection and silicone sheets, and above that our laser scar optimisation protocol, which is the part that really changes the appearance of a scar that is not settling well.
Book an appointment
You can book your own appointment. Pick the day and time from the free slots in the diary, in a panel that opens right here, without leaving this page.
Frequently asked questions
Is my scar going to show?
At a year, not much. In the study using the Vancouver scale, the median score fell from 6 to 2 with the axillary approach and from 4 to 2 with the inframammary fold over twelve months, and the patients’ satisfaction with the appearance of their scar was 9 out of 10 in both groups.
My scar is redder than it was a month ago. Is something wrong?
Probably not. The worst moment to look at is between the second and the fourth month: it is the phase in which the scar turns redder and sometimes thicker. From then on it pales and flattens.
When can you really see how it is going to end up?
From a year on. Judging it before that is judging a phase.
Which approach leaves the better scar?
In the long term there was no significant difference between the axillary and the inframammary fold in the study that compared them at a year. What does change is the speed: the axillary scored worse at one month and at six months. Where each one goes and what other consequences the choice has is on the page about the approach.
I have a tendency to keloids. Can I have surgery?
Yes, and it is worth saying so beforehand. What does not change is the approach: a predisposition to keloids does not determine it. What changes is the follow-up — closer, with intense pulsed light to reduce the vascularity of the scar and early treatment with cytostatics, 5-fluorouracil or steroids, if early hypertrophy appears.
What is the difference between a hypertrophic scar and a keloid?
A hypertrophic scar is thickened but does not go beyond the limit of the incision, and it usually improves with time. A keloid grows beyond the edges of the wound, invading healthy skin, and is harder to treat.
Can I sunbathe?
Not on an immature scar without protection: it is one of the commonest causes of a scar being left persistently hyperpigmented. The specific schedule is on the scar protocol page.
Sources
- Sun J, et al. The Comparison of Scars in Breast Implantation Surgery with Inframammary Fold Incision Versus Axillary Incision: A Prospective Cohort Study in Chinese Patients. Aesthetic Plastic Surgery, 2019. PMID 30607574. — Prospective cohort study with 163 patients assessed at one month, at 6 months and at 12 months with the Vancouver scale and a satisfaction score: at one month, a median of 6 in the axillary group and 4 in the inframammary fold group (p < 0.05), with a higher proportion of high scores for vascularity and height in the axillary group; at 6 months, 4 against 3 (p < 0.05); at 12 months, a median of 2 in both groups and a median satisfaction of 9 in both, with no significant differences; the authors conclude that the scars of the two locations reach a comparable appearance in the long term. Level of evidence III.
- Nguyen HH, To LT. Comparison Of Endoscopic Transaxillary And Peri-areolar Approaches In Breast Augmentation With Smooth Implants. Aesthetic Plastic Surgery, 2021. PMID 34251473. — Prospective study of 275 women operated on by the same surgeon with smooth round implants and a dual plane pocket between 2013 and 2016, with a minimum follow-up of four years: hypertrophic scar or keloid in 1% of the endoscopic transaxillary group and in 8.6% of the periareolar group; areolar or nipple deformity in 0% and 8.6%; a localised fluid collection in 1% and 7.1%; Baker III-IV capsular contracture in 1% and 5.7%. Level of evidence IV; groups not randomised.
- Risks and Complications of Breast Implants. U.S. Food and Drug Administration, updated 14 December 2023. fda.gov. — Delayed healing appears among the local complications occurring in at least 1% of patients; smoking appears among the causes of necrosis of breast tissue.
Book your consultation
If the scar worries you, there are two things worth saying at the first consultation: whether you have a personal or family history of keloids, and how you usually heal. Not because they change the approach —they do not—, but because they change the follow-up and the treatment that will be proposed to you from the start.
Clinical confirmation by the surgeon
Registration no. 46/4624077
Registration no. 46/4624503
