BACKGROUND: Capsular contracture (CC) is the most common complication following primary breast augmentation and one of the most common causes of reoperation. Various studies have suggested certain risk factors, including incision choice. OBJECTIVES: The authors investigate a possible association between the three most common breast augmentation incisions (inframammary, periareolar, and transaxillary) and CC. METHODS: The authors conducted a retrospective chart review of 197 primary breast augmentation patients treated between 2003 and 2009. Significant CC was determined to have occurred if the patient required reoperation for her CC. Patients were excluded if they underwent an augmentation/mastopexy, had previously undergone breast surgery, or received shaped silicone gel implants. CC rates were analyzed on a per-patient basis with Fisher's exact test and on a per-breast basis with the Rao-Scott chi-squared test. RESULTS: One hundred eighty-three patients (336 augmented breasts) were included. Average patient age was 36.5 years. Mean follow-up was 392.6 days. Surgical complications included six breasts with CC (1.8%), three with hematoma (0.9%), and one with an infection (0.3%). Transaxillary incisions produced the highest incidence of contracture (6.4%), followed by periareolar (2.4%) and inframammary (0.5%). There was a statistically-significant difference in the incidence of CC among the three incision sites (P=.03). The increased rate seen with transaxillary incisions versus inframammary incisions was also statistically-significant. No significant association between implant fill material and contracture was found (P=.27). CONCLUSIONS: The risk of CC is significantly higher with transaxillary incisions than with periareolar or inframammary incisions. LEVEL OF EVIDENCE: 4.