The Inframammary Crease Ligament                  Brooke R. Seckel, M.D.                    Shawkat Sati, M.D.            ...
The Inframammary CreaseIntroductionThe inframammary crease or fold is an essential landmark for an optimal result in aesth...
The anatomy of the inframammary crease has been the subject of significant debate in theplastic surgical literature. In 18...
The presence of a true ligament at the fold is still the subject of many debates.(Figure 3) According to Bayati and Seckel...
Maillard and Garey3 had described a crescent-shaped ligament between the skin andthe anterior surface of the pectoralis ma...
The disadvantages of this technique were again having a bulky inframammary region, andthe IMF appeared too deep. Pinella16...
the deep dermis of the skin flap at a point 2-3 cm below the superior edge of the flap to allowfor the advancement of suff...
References:   1- Cooper, A. P. On the Anatomy of the Breast. London: Longmans, 1845. P.10   2- Bayati S., and Seckel, B. R...
The Inframammary Crease
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The Inframammary Crease

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This is a paper that Dr. W. Thomas McClellan co-authored on the anatomy and reconstruction of the inframammary fold. This critical structure is often injured during breast augmentation and understanding of the anatomy is crucial to a good outcome in breast augmentation.

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The Inframammary Crease

  1. 1. The Inframammary Crease Ligament Brooke R. Seckel, M.D. Shawkat Sati, M.D. W. Thomas McClellan, M.D. Boston Plastic Surgery Associates, Emerson Hospital, Concord, MALahey Clinic. Department Of Plastic & Reconstructive Surgery, Burlington, MA Morgantown Plastic Surgery Associates, Morgantown WV
  2. 2. The Inframammary CreaseIntroductionThe inframammary crease or fold is an essential landmark for an optimal result in aestheticand reconstructive breast surgery. A well defined inframammary crease and an appropriateareola to inframammary crease distance is arguably the most important component of apleasing aesthetically correct breast appearance following breast augmentation, reductionmammaplasty and post mastectomy breast reconstruction.Failure to preserve the inframammary crease during breast augmentation surgery creates anunacceptably abnormal breast profile often referred to as a “double bubble” appearance or“Snoopy Deformity” which patients find most disturbing. (Fig 1)Failure to create a well defined inframammary crease symmetrical with the opposite breast isone of the most common problems following post mastectomy breast reconstruction,especially following the use of soft tissue expanders.Figure 1: Double bubble deformity: During the course of dissection of the subpectoral musculofascial pocketfor insertion of the prosthesis, the ligament can be disrupted if the dissection is carried out tooinferiorly. This will lead to inferior migration of the prosthesis and the “double bubble deformity”.(Reproduced with permission from Bayati S., and Seckel, B. R. Inframammary crease ligament.Plastic And Reconstructive Surgery 95: 501-508, 1995)
  3. 3. The anatomy of the inframammary crease has been the subject of significant debate in theplastic surgical literature. In 1845, Sir Astely Cooper1 stated that “at the abdominal margin,the gland is turned upon itself at its edge, and forms a kind of hem”. Since that time manyauthors have attempted to define the structure and anatomy of this area, in an effort tosimplify its reconstruction. In this chapter we will present the findings of our own cadaverdissections² and relate our clinical approach to the reconstruction of the inframammarycrease.Anatomy The inframammary fold is undetectable in the prepubescent breast; however with theonset of puberty it comes to define the inferior aspect of the female breast. The crease is sitedat the 5th rib medially and its lowest potion reaches the 6th intercostal space. The averagedistance from the inferior margin of the areola ranges from 5-9 cm. (Figure 2)Figure 2: (a) The horizontal position of the inframammary ligament originating from the fifth rib periosteummedially and extending to the fifth sixth intercostal space laterally. (b) The inframammary ligament originates from the fifth rib and inserts into the deep dermis of theskin(Reproduced with permission from Bayati S., and Seckel, B. R. Inframammary crease ligament.Plastic And Reconstructive Surgery 95: 501-508, 1995)
  4. 4. The presence of a true ligament at the fold is still the subject of many debates.(Figure 3) According to Bayati and Seckel2, there is a ligament that originates from the 5thrib’s periosteum medially, from the fascia between the 5th and 6th rib laterally, and insertsinto the deep dermis of the submammary fold. Their thinking was that it was a condensationof the rectus abdominis fascia medially and the fascia of the serratus anterior and externaloblique laterally.Their study revealed a difference between Cooper’s suspensory ligaments and theinframammary ligament. These authors emphasized that the presence of the double-bubblephenomenon is produced by the disruption of this ligament. (Figure 4) Figure 3: The inframammary ligament extends to insert deep into the deep dermis of the inframammary skin fold. Figure 4: Surgical technique: Internal Thoracic Advancement Flap
  5. 5. Maillard and Garey3 had described a crescent-shaped ligament between the skin andthe anterior surface of the pectoralis major, which is slightly lower than the anatomydescribed by Seckel et al. Van Straalen and Hage4 described a similar ligament found in thebreasts of female to male transsexuals. Nava5 disagreed, stating that the crease is devoid of a true ligament, rather having ausual two subcutaneous layers and one superficial fascia. This fascia deepens and the anteriorbreast envelope detaches creating this fold. Garnier6 concluded that a subcutaneousinframammary ligament does not exist. Lockwood7 described this superficial fascial systemas a subdermal structure, consisting of interwoven collagen fibers that support the skin byadhering to the underlying fascial layers. Shenaq8 suggested that it is a dermal structureconsisting of a collagen network arranged in arrays that run parallel to the skin surface alongthe long axis of the inframammary fold; that is held in place by the condensation of thesuperficial fascial system. Sundine9 did not demonstrate the presence of a ligament; they stated that thesuperficial fascia was connected to the dermis in the fold region in a variety of configurations.Lack of definition in this crease could be from breast hypoplasia, mastopathy, or iatrogenic. The male breast has neither a superficial layer of the fascia superficialis nor aninframammary ligamentous structure.Reconstruction of the Inframammary FoldHistory In breast reconstruction, the inframammary fold is one of the most difficult anatomicstructures to recreate. Nonetheless, it is a crucial element in achieving the optimal aestheticoutcome. During mastectomy the inframammary crease should be preserved and not disturbedwhen possible. Several studies have been done on the contents of the inframammary crease.Lakhani et al.10 found that 28% of their IMF specimens contained breast tissue and lymphnodes. However, Carlson et al.11 confirmed that IMF preservation is safe as it leaves less than0.02% of the total breast tissue and hence does not appreciably affect the completeness of amastectomy, as long as the patients are closely followed. However the IMF frequently needsto be violated during TRAM procedures to avoid compressing the pedicle. In 1977, Pennisi12 described a reliable external procedure whose main features weremarking the lower thoracic skin, creation of a dermal-fatty-superficial fascial flap, andturning up the flap and anchorage to the muscular fascia. Ryan13 added on that concept byfixing the flap to the periosteum. Bostwick14described an inframammary fold elevationtechnique through a short horizontal external approach. He sutured the lower thoracic flaphypodermis to the posterior capsule and deeper tissues. He avoided an external scar, and gavea better definition than the previous repairs, but had little projection and ptosis improvement. Versaci15 described a technique using an internal approach at the time of expanderremoval. Incision was made in the posterior capsule at the presumed position of the new fold.The lower third of the posterior capsule was detached. The undermined abdominal flapbecame the under-surface of the new breast. The skin flap was secured to the periosteum.
  6. 6. The disadvantages of this technique were again having a bulky inframammary region, andthe IMF appeared too deep. Pinella16 described liposuctioning the lower thoracic bulkiness. Nava et al.5 described an internal approach, where the implant is removed through theprevious mastectomy incision. The desired inframammary fold line is transposed bytransfixing needles into the pocket. The superficial fascia is located and cut along the wholeinframammary line, and a running stitch is used to secure the new fold. More recentlyPribaz17 described a technique using a Steinman pin in order to match the symmetry of thecontra lateral normal breast. The pin is introduced from lateral to medial underneath the skin,so that it remains in the cavity. Permanent sutures are placed throughout the entire length ofthe pin. An external bolster is applied and the pin is removed.We have developed an “Internal Thoracic Advancement Flap” method, which enables us toavoid the external scar of the original external procedure described by Pennisi and Ryan.Our Approach:The Internal Thoracic Advancement FlapThe most common and distressing disadvantages of previous techniques for reconstruction ofthe inframammary crease are: 1. Inferior migration of the reconstructed fold with flattening and loss of the fold and loss of the inferior pole of the reconstructed breast 2. A visible external scar which is particularly unsatisfactory when de-epithelialization has been performed as in the Ryan and Pennisi techniques and the de-epithelialized skin migrates down beneath the fold into a visible location. We use a technique similar to that of Versaci which utilizes an internal approach.However, we undermine and advance an inferior thoraco-abdominal flap superiorly.Attaching it to and suspending it to the periosteum of the ribs and intercostal fascia along thepre determined inframammary crease insertion point on the 5th rib and the 5th-6th intercostalspace. This technique may be applied during primary reconstruction, following the removalof a soft tissue expander, and in cases of breast augmentation in which “bottoming out” haveoccurred. First, the anatomical location of the proposed inframammary crease is marked on theinternal chest wall by using the bovie to coagulate a line along the appropriate landmarksoutlined above (Figure 2). An estimate of the amount of skin which must be recruited toprovide an adequate inferior pole of the breast is made. Dissection is carried out inferiorlybelow the 5th and 6th rib, through the inferior capsule (in the case of a soft tissue expander orbreast implant), or beneath the inferior mastectomy flap (in the case of a primary postmastectomy reconstruction). A crescent shaped inferior thoraco-abdominal flap is elevated8-10 cm at the center of the crescent below the IMC line at the mid clavicular line (Fig 3). With the OR table flexed as in an abdominoplasty, the inferior thoraco-abdominalskin flap is advanced superiorly. 0 Prolene buried sutures are placed into the undersurface of
  7. 7. the deep dermis of the skin flap at a point 2-3 cm below the superior edge of the flap to allowfor the advancement of sufficient skin superiorly to create an inferior pole of the new breast.The new Inframammary crease is then sutured to the periosteum of the 5th and 6th rib and theintervening intercostal fascia. Usually 8 to 10 sutures are required. (Figure 4). This maneuver typically provides a significant amount of tissue to provide anadequate “inferior pole” to the reconstructed breast profile. In cases of a breast augmentationwhich has “bottomed out”, the thoraco-abdominal flap is not created or advanced. Rather theinferior pocket capsule is opened, a 3 cm strip of capsule resected, and the excess inferiorpole breast skin is advanced internally with a running 0 Prolene suture to the periosteum andintercostal fascia along the landmarks of the inframammary crease.Complications: Complications of this procedure are the same as those with any breast implant procedure.These include extrusion, capsular contraction, asymmetry, failure to achieve an adequateinferior pole of the breast, bleeding, infection and scarring. The additional potentialcomplication is a failure of the suspension sutures or long term inferior migration of the flapand resultant loss of the fold. Inferior migration of the implant is another potential risk;however I have not seen the later event. When utilizing our technique we have experiencedless flattening and loss of fold compared with other methods of repair.Discussion: The inframammary crease, an adequate inferior pole of the breast, an appropriatenipple position and an appropriate areola to inframammary crease distance is the essentialcomponents of an aesthetically appropriate breast appearance. Failure to preserve or to reconstruct the inframammary crease following breastreconstruction or in cosmetic breast augmentation causes one of the most unsatisfactory anddistressing complications in aesthetic and reconstructive breast surgery. In this chapter we have presented a detailed anatomic description of the landmarks forthe inframammary crease. Our opinion is that a crease ligament or other condensation ofScarpa’s fascia and the posterior capsule of the breast constitutes a well defined anatomicallandmark which can be reconstructed. Reconstruction of this anatomic structure in the properlocation can restore an appropriate and aesthetically acceptable inframammary crease both inpost mastectomy breast reconstruction and in cosmetic breast augmentation when “bottomingout” or the “double bubble” has occurred following breast augmentation.
  8. 8. References: 1- Cooper, A. P. On the Anatomy of the Breast. London: Longmans, 1845. P.10 2- Bayati S., and Seckel, B. R. Inframammary crease ligament. Plast. Reconstr. Surg. 95: 501-508, 1995. 3- Maillard and Garey, L. J. An Improved technique for immediate retropectoral reconstruction after subcutaneous mastectomy. Plast. Reconstr. Surg. 80: 396, 1987 4- van Straalen, W. R., Hage, J. J., and Bloemena, E. The inframmamary ligament: Myth or reality? Ann. Plast. Surg. 35:237, 1995 5- Nava, M., Quattrone, P., and Riggio, E. Focus on the breast fascial system: A new approach for the inframammary fold reconstruction. Plast. Reconstr. Surg. 102: 1034, 1998. 6- Garnier, D., Angonin, R., Foulon, R., Chavoin, J. P., Ricbourg, B., and Costagliola, M. Le sillon sous-mammaire: Mythe ou realite? Ann. Chir. Plast. Esthet. 36:313, 1991 7- Lockwood, T. E. Superficial fascial system (SFS) of the trunk and extremities: A new concept. Plast. Reconstr. Surg. 87: 1009, 1991. 8- Boutros, S., Kattash, M., Weinfeld, A., Yuksel, E., Baer, S., and Shenaq, S. The intradermal anatomy of the inframammary fold. Plast. Reconstr. Surg. 102:1030, 1998 9- Muntan, C. D., Sundine, M. J., Rink, R. D., Acland, R. D., Inframammary fold: a histologic reappraisal. Plast. Reconstr. Surg. 105 (2): 549-56 2000 Feb. 10- Gui, G. P. H., K. A. Behranwala, K. A., Abdullah, N., Seet J., Osin, P., Nerurkar, A., and Lakhani, S. R. The inframammary fold: contents, clinical significance and implications for immediate breast reconstruction. Brit. Journ. Of Plast. Surg. 57 (2): 146-149 2004 11- Carlson, G. W., Grossi, N., Lewis, M. M., Temple, J. R., and Styblo, T. M. Preservation of the inframammary fold: What are we leaving behind? Plast. Reconstr. Surg. 98: 447, 1996. 12- Pennisi, V. R. Making a definite inframammary fold under a reconstructed breast. Plast. Reconstr. Surg. 60: 523, 1977. 13- Ryan, J. J. A lower thoracic advancement flap in breast reconstruction after mastectomy. Plast Reconstr. Surg. 70: 153, 1982. 14- Bostwick, J. III. Finishing Touches. Plastic and Reconstructive Breast Surgery. St. Louis: QMP, 1990. P.1126 15- Versaci, A. D. A method of reconstructing a pendulous breast utilizing the soft tissue expander. Plast. Reconstr. Surg. 80:387, 1987. 16- Pinella, J. W. Creating an inframammary crease with a liposuction cannula (Letter). Plast. Reconstr. Surg. 83: 925, 1989. 17- Chun, Y. S., Pribaz, J. J. A simple guide to inframammary-fold reconstruction. Ann. Plast. Surg. 55:8-11, 2005.

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