Skip to main content

Advertisement

SpringerLink
Log in

The Inframammary Fold (IMF): A Poorly Appreciated Landmark in Prosthetic/Alloplastic Breast Aesthetic and Reconstructive Surgery—Personal Experience

  • Case Report
  • Breast Surgery
  • Published:
Aesthetic Plastic Surgery Aims and scope Submit manuscript

Abstract

The inframammary fold (IMF) is the most critical visual landmark that affects final aesthetic outcome of augmentation mammoplasty and even post-mastectomy alloplastic breast reconstruction. Unfortunately, structural integrity of this landmark is greatly overlooked and very often neglected. Excessive undermining of the lower breast pole with aggressive disruption/lowering and subsequent poor reconstitution of the IMF scaffold combined with imbalanced implant-tissue dynamics may result in downward implant displacement with creep bottoming and upward tilt of the nipples. The current report reviews the experience of the senior author (BA) over 30 years in breast aesthetic and reconstructive surgery with IMF reconstruction and fixation to the chest wall at the inferior border of the implant. Illustrative cases are presented.

Level of Evidence V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8

Similar content being viewed by others

References

  1. Govrin-Yehudain J, Dvir H, Preise D, Govrin-Yehudain O, Govreen-Segal D (2015) Lightweight breast implants: a novel solution for breast augmentation and reconstruction mammaplasty. Aesthet Surg J 35(8):965–971

    Article  PubMed  PubMed Central  Google Scholar 

  2. Cordeiro PG, Jazayeri L (2016) Two-stage implant-based breast reconstruction: an evolution of the conceptual and technical approach over a two-decade period. Plast Reconstr Surg 138(1):1–11

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Bogetti P, Cravero L, Spagnoli G, Devalle L, Boriani F, Bocchiotti MA, Renditore S, Baglioni E (2007) Aesthetic role of the surgically rebuilt inframammary fold for implant-based breast reconstruction after mastectomy. J Plast Reconstr Aesthet Surg 60(11):1225–1232

    Article  PubMed  Google Scholar 

  4. Mallouris A, Kakgia D, Yiacomettis A, Vasilakaki T, Drougou A, Lambropoulou M, Simopoulos C, Tsaroucha AK (2016) Histological comparison of the human trunk skin creases: the role of the elastic fiber component. Eplasty 16:e15

    PubMed  PubMed Central  Google Scholar 

  5. Patel JC, Fletcher JW, Singer D, Sullivan P, Weinzweig J (2004) An anatomic and histologic analysis of the alar-facial crease and the lateral crus. Ann Plast Surg 52(4):371–374

    Article  PubMed  Google Scholar 

  6. Boutros S, Kattash M, Wienfeld A, Yuksel E, Baer S, Shenaq S (1998) The intradermal anatomy of the inframammary fold. Plast Reconstr Surg 102(4):1030–1033

    Article  CAS  PubMed  Google Scholar 

  7. Bayati S, Seckel BR (1995) Inframammary crease ligament. Plast Reconstr Surg 95(3):501–508

    Article  CAS  PubMed  Google Scholar 

  8. Van Straalen WR, Hage JJ, Bloemena E (1995) The inframammary ligament: myth or reality? Ann Plast Surg 35(3):237–241

    Article  PubMed  Google Scholar 

  9. Lockwood TE (1991) Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg 87(6):1009–1018

    Article  CAS  PubMed  Google Scholar 

  10. Vegas MR, Martin del Yerro JL (2013) Stiffness, compliance, resilience, and creep deformation: understanding implant-soft tissue dynamics in the augmented breast: fundamentals based on materials science. Aesthet Plast Surg 37(5):922–930

    Article  Google Scholar 

  11. Atiyeh B, Dibo S, Nader M, Papazian N (2014) Preoperative assessment tool for the planning of inframammary incision and implant profile in breast augmentation. Aesth Plast Surg 38:878–886

    Article  Google Scholar 

  12. Montemurro P, Quattrini Li A, Hedén P, Avvedimento S (2016) A four-layer wound closure technique with barbed sutures for stable reset of the inframammary fold in breast augmentation. Aesthet Surg J 36(8):966–971

    Article  PubMed  Google Scholar 

  13. Mallucci P, Branford OA (2016) Design for natural breast augmentation: the ICE principle. Plast Reconstr Surg 137:1728–1737

    Article  CAS  PubMed  Google Scholar 

  14. Swanson E (2010) Photometric evaluation of inframammary crease level after cosmetic breast surgery. Aesthet Surg J 30(6):832–837

    Article  PubMed  Google Scholar 

  15. Ibrahim AE, Atiyeh BS, Dibo SA, Sarhane KA, Abbas JS (2012) De-epithelialized dermal barrier for a safe immediate prosthetic breast reconstruction post circumvertical skin sparing/reducing mastectomy (SSM/SRM). Eur J Plast Surg 11:787–793

    Article  Google Scholar 

  16. Atiyeh B, Dibo S, Abbas J, Papazian N (2016) Tensioned reverse abdominoplasty for reconstruction of large post-mastectomy defects. Rev Bras Cir Plást 31(2):252–256

    Google Scholar 

  17. Yacoub C, Baroudi R (2016) Extended reverse abdominalplasty: a technique for reconstructive and cosmetic application on the anterolateral area of the chest. In: Atiyeh B, Abbas J, Ibrahim A (eds) Breast cancer surgery and the principles of oncoplastic surgery for partial and total breast reconstruction. LAP LAMBERT Academic Publishing, Saarbrücken, pp 314–336

    Google Scholar 

  18. Campbell CF, Small KH, Adams WP Jr (2016) Response to “Can We Really Control the Inframammary Fold (IMF) in Breast Augmentation?”. Aesthet Surg J 36(10):317–320

    Article  Google Scholar 

  19. Atiyeh B, Rubeiz M, Hayek S (2005) Refinements of vertical scar mammaplasty: circumvertical skin excision design with limited inferior pole subdermal undermining and liposculpture of inframammary crease. Aesthet Plast Surg 29(6):519–531

    Article  Google Scholar 

  20. Kim YJ, Kim YW, Cheon YW (2014) Prevention of implant malposition in inframammary augmentation mammaplasty. Arch Plast Surg 41(4):407–413

    Article  PubMed  PubMed Central  Google Scholar 

  21. Calobrace MB (2015) Teaching breast augmentation: a focus on critical intraoperative techniques and decision making to maximize results and minimize revisions. Clin Plast Surg 42(4):493–504

    Article  PubMed  Google Scholar 

  22. Hidalgo DA (2000) Breast augmentation: choosing the optimal incision, implant, and pocket plane. Plast Reconstr Surg 105:2202–2216

    Article  CAS  PubMed  Google Scholar 

  23. Atiyeh B, Al-Amm C, El-Musa KA (2002) The transverse intra-areolar infra-nipple incision for augmentation mammoplasty. Aesthet Plast Surg 26(2):151–155

    Article  Google Scholar 

  24. Kolker AR, Austen WG Jr, Slavin SA (2010) Endoscopic-assisted transaxillary breast augmentation: minimizing complications and maximizing results with improvements in patient selection and technique. Ann Plast Surg 64(5):667–673

    CAS  PubMed  Google Scholar 

  25. Cardenas-Camarena L, Ramirez-Macias R (2006) Augmentation/mastopexy: how to select and perform the proper technique. Aesthet Plast Surg 30:21–33

    Article  Google Scholar 

  26. Montemurro P (2016) Response to “Can We Really Control the Inframammary Fold (IMF) in Breast Augmentation?”. Aesthet Surg J 36(10):315–316

    Article  Google Scholar 

  27. Youn ES (2006) Importance of the new position of the nipple-areola complex in breast augmentation surgery. Plast Reconstr Surg 118:18S–31S

    Article  CAS  PubMed  Google Scholar 

  28. Spear SL, Albino FP, Al-Attar A (2013) Classification and management of the postoperative, high-riding nipple. Plast Reconstr Surg 131(6):1413–1421

    Article  CAS  PubMed  Google Scholar 

  29. Spear SL, Pittman T (2013) Discussion: the double-bubble deformity: cause, prevention, and treatment. Plast Reconstr Surg 132(6):1444–1445

    Article  CAS  PubMed  Google Scholar 

  30. Campbell CF, Small KH, Adams WP Jr (2016) The inframammary fold (IMF) fixation suture: proactive control of the IMF in primary breast augmentation. Aesthet Surg J 36(5):619–623

    Article  PubMed  Google Scholar 

  31. del Yerro JL, Vegas M, Fernandez V, Moreno E, Sanz I, Puga S, Vecino MG, Biggs TM (2013) Selecting the implant height in breast augmentation with anatomical prosthesis: the ‘‘Number Y’’. Plast Reconstr Surg 131:1404–1412

    Article  PubMed  Google Scholar 

  32. Mallucci P, Branford OA (2015) Shapes, proportions, and variations in breast aesthetic ideals: the definition of breast beauty, analysis, and surgical practice. Clin Plast Surg 42(4):451–464

    Article  PubMed  Google Scholar 

  33. Tomita K, Yano K, Nishibayashi A, Seike S, Hosokawa K (2016) Aesthetic outcomes of inframammary fold recreation in two-stage, implant-based, breast reconstruction. Springerplus 5(1):1656

    Article  PubMed  PubMed Central  Google Scholar 

  34. Becker H (2013) A prospective randomized study comparing two different expander approaches in implant-based breast reconstruction: one stage versus two stages. Plast Reconstr Surg 131:643e–644e

    Article  CAS  PubMed  Google Scholar 

  35. Eriksen C, Lindgren EN, Frisell J, Stark B (2012) A prospective randomized study comparing two different expander approaches in implant-based breast reconstruction: one stage versus two stages. Plast Reconstr Surg 130:254e–264e

    Article  CAS  PubMed  Google Scholar 

  36. Farace F, Faenza M, Bulla A, Rubino C, Campus GV (2013) Is mammary reconstruction with the anatomical Becker expander a simple procedure? Complications and hidden problems leading to secondary surgical procedures: a follow-up study. J Plast Reconstr Aesthet Surg 66:741–746

    Article  PubMed  Google Scholar 

  37. Kalus R, Dixon Swartz J, Metzger SC (2016) Optimizing safety, predictability, and aesthetics in direct to implant immediate breast reconstruction: evolution of surgical technique. Ann Plast Surg 76(Suppl 4):S320–S327

    Article  CAS  PubMed  Google Scholar 

  38. Atiyeh BS, Abbas J, Costagliola M (2012) Dermal barrier for immediate prosthetic breast reconstruction. Rev Bras Cir Plást 27:630–635

    Article  Google Scholar 

  39. Eichler C, Schell J, Uener J, Prescher A, Scaal M, Puppe J, Warm M (2016) Inframammary fold reconstruction: a biomechanical analysis. Plast Reconstr Surg Glob Open 4(3):e634

    Article  PubMed  PubMed Central  Google Scholar 

  40. Swanson E (2016) Can we really control the inframammary fold (IMF) in breast augmentation? Aesthet Surg J 36(10):313–314

    Article  Google Scholar 

  41. Ryan JJ (1982) A lower thoracic advancement flap in breast reconstruction after mastectomy. Plast Reconstr Surg 70:153–160

    Article  CAS  PubMed  Google Scholar 

  42. Nava M, Quattrone P, Riggio E (1998) Focus on the breast fascial system: a new approach for inframammary fold reconstruction. Plast Reconstr Surg 102:1034–1045

    Article  CAS  PubMed  Google Scholar 

  43. Handel N, Jensen JA (1992) An improved technique for creation of the inframammary fold in silicone implant breast reconstruction. Plast Reconstr Surg 89:558–562

    Article  CAS  PubMed  Google Scholar 

  44. Halls MJ (2012) Superiorly based single mastectomy flap with inferiorly based dermal flap and anchorage of the inframammary crease procedure for immediate breast reconstruction in patients with ptosis. Plast Reconstr Surg 130(4):632e–633e

    Article  CAS  PubMed  Google Scholar 

  45. Atiyeh B, Chahine F (2016) Comments on “A four-layer wound closure technique with barbed sutures for stable reset of the infra-mammary fold in breast augmentation”. Aesthet Surg J 36(9):291–292

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Plastic and Reconstructive Surgery, American University of Beirut Medical Center, Beirut, Lebanon

    Bishara Atiyeh, Amir Ibrahim, Salim Saba, Fadl Chahine & Nazareth Papazian

  2. Plastic and Reconstructive Surgery, Kare Plastic Surgery and Skin Health Center, Los Angeles, CA, USA

    Raffy Karamanoukian

Authors
  1. Bishara Atiyeh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Amir Ibrahim
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Salim Saba
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Raffy Karamanoukian
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Fadl Chahine
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Nazareth Papazian
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Nazareth Papazian.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest to disclose and received no financial or material support.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Atiyeh, B., Ibrahim, A., Saba, S. et al. The Inframammary Fold (IMF): A Poorly Appreciated Landmark in Prosthetic/Alloplastic Breast Aesthetic and Reconstructive Surgery—Personal Experience. Aesth Plast Surg 41, 806–814 (2017). https://doi.org/10.1007/s00266-017-0854-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00266-017-0854-7

Keywords

Search

Navigation