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Lifting the Inframammary Fold without an Incision . . . William Roy Morgan  M.D., F.A.C.S.

I have not written a clear description of this technique with drawings and case results as I should.

I have been doing it since the 1970s with success in most of  more than 30 cases of various types. If it is not feasible to try this for reasons explained below or if it fails, the fold can be lifted with more control and greater certainty with an open external incision procedure. 

It is best to do this closed technique early while the tissues are still in the healing phase, rather than later.

It is especially useful for the axillary approach, because there is no incision already on the breast, such as areolar or inframammary, to use.

If the implant is textured or if the implant is submuscular and the muscle is pushing it down with force, it may not work.

And sometimes the pocket is small and the implant will not easily move upward.

The 375cc you mentioned is not too large to have a lot of gravity pressing down on the repair.

I usually make two or three layers of suture using only permanent sutures for the primary layer, and then probably absorbable pds or vicryl or moncryl above that in two other rows to take the pressure off the primary layer. The permanent suture primary suture layer is placed exactly where the new raised imf is to be. The temporary supporting suture lines above it can be as small as 3-0  or 4-0 absorbable suture. This allows a little bit of over correction..

The permanent suture used is at least a 3-0 in size or larger. I prefer monofilament so that there less chance of bacterial wicking. But a multifilament permanent would do.

I have heard that 8, 10, 12, 15 and 20 lb fishing line that is polypropolene when you seriously want it to stay and be strong can be used. A 4-0 nylon suture is only 2lb test. And a 3-0 polypropolene may only be a little more than twice that.  Polypropolene can be autoclaved without losing much strength or gas claved for sure.

The needles are curved, cutting and long - such as 2 ½” or 3” needles. These can be curved from a straight Keith or intestinal flat sharp straight needle such as a Bunnell.

The implant may be perforated by this procedure and if so it will need to be replaced. It might just be easier to go through a new areolar incision to do all this but that just depends on the case. That is the areolar, the patient’s wishes, the confidence of the surgeon, the amount of lifting to be done, and the expected downward pressure that can defeat it.

With all these considerations the consent should still warn of hematoma, infection, further surgery to replace the implant etc. just as we would do for a primary case or for another operation such as through the areola.

The new imf is carefully marked with a dotted line  and the patient standing. Then two more dotted lines are marked above it for over correction with long lasting but dissolving sutures.

The over correction is explained to the patient. The patient is told that flesh colored 3m brand paper tape may be required over the sutured area to hold the implant up while the tissues heal together and become strong. This might be for two or three weeks.

A bra needs to be worn and maybe some padding under the breast in the bra to hold up the implant, such as one or two socks also for a couple of weeks.

There are special bras, such as designed by J.D. Metcalf and sold by KM products that can be used for support. They are adjustable with velcro to fit.

Also by having the patient press with her knuckle under the breast on either side against the rib, she can see that there is tenderness associated with this repair and this is true whether it is done internally or externally.

Of course if the implant is below the muscle and the muscle is pushing it down with some force, it may be best to put the implant in a subfascial or submammary suprapectoral plane. If this is needed then for symmetry it might also be required on the other side. Sometimes not.

Pictures are taken.

Then at surgery:

The skin is prepped thoroughly . Gown and gloves are worn. There is a scrub nurse assisting. There is an Iv for sedation and all this is then done under the usual large amount of local anesthesia. That is one gram of lidocaine and 1cc or 1/1000 epinephrine mixed up to 300 to 400cc with saline. I would probably use only a total mixture of 300cc total volume with saline for this one side.

Being careful to cause no pain or memory of the local injection I would numb all the periosteum thoroughly over the ribs where suturing is planned. . The needle does not need to actually go down to and touch the very tender periosteum to do this repair as long as with each needle insertion the strength is equal to about a five pound pull – as with lifting a 5 or more pound dumbbell - so that the repair will be strong.

Start in the center of the marked new imf and place the first needle insertion down through the deep fascia over the ribs where the suture is to be anchored slightly above the mark on the skin with the dotted line marking the precise location of the new imf (inframammary fold).

Then slide the needle out the other side and test the strength of the tissues.

Place the needle back into the exit hole following the suture in and being careful to not grasp dermis going in.

Then place the needle back toward the original entry hole, but this time go along the deep dermis rather than going deep down to the rib.

As the needle point seeks and finds the original entry hole, it is brought through it without catching any dermis there.

The suture is pulled along and pulled entirely through the exit hole until it disappears.

The two ends of the suture are then only at the entry hole and if the dermis at the exit hole appears to be caught a little the suture is pulled back and forth like a Gigli saw while holding the dermis up at the exit hole until it breaks loose and the exit hole is free of tension and indentation.

The sutures are then tied with 4-6 ties of square knots and then cut at the knot.

The dermis is then pulled up over this knot and it is buried.

The row of permanent sutures is then placed following the dotted line drawn and this pattern of placement.

All the while the breast implant is held way up out of the way of the suture.

If the breast implant cannot be held up moderately easily, then the pocket is not big enough for this type of repair perhaps and an areola incision may be necessary with removal of the implant and repair from both inside and externally, rather than risking rupture of the implant and the almost certain dense capsular contracture that accompanies a ruptured or perforated implant.

If the areolar incision is made then the pocket can be enlarged at that time so there is less chance of force from a tight pocket on the repair.

This external repair works best if the only force against it is the weight of the implant.

I would use the same prophylactic antibiotic regimen for this procedure as for an open breast surgery.

Best of luck with this patient.

It is always nice to hear from you.

Thank you,

William Roy Morgan, M.D., F.A.C.S.

1419 Superior Avenue #2

Newport Beach, CA 92663

phone 949-645-6665

ascbs web site is ascbs.us

web site is  wrmorganmd.org

 

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The American Society of Cosmetic Breast Surgery 2017    Last modified: June 23, 2017