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The Inframammary Fold

 

The dissection of the inframammary fold (IMF) is the key to breast implant surgery.  It is the most difficult and the most important area of dissection.

1. The Dissection Procedure

 

 

Fig. 1

Through any of the four incision sites the dissection of the pocket is rapid and easy except for the IMF. The easy dissection can be done gently with the finger, whether above or below the muscle. The finger dissection is gentle, and avoids undue trauma to tissues.

Above the muscle and beneath the breast there is a plane of loose areolar tissue with a small amount of fat that easily allows separation of the breast from the underlying pectoral muscle. With blunt or finger dissection superior to the fifth rib and superficial to the pectoral fascia the dissection is easy and bloodless.

Below the muscle it is equally easy to lift the muscle off the ribs down to the 5th and 6th where the pectoral muscle is firmly attached. This subpectoral plane superior to the 5th rib is also free of bleeding and easy to dissect with blunt gentle finger dissection. 

Either above or below the muscle the firm attachment and resistance to dissection begin over the 5th rib. The IMF is usually located at the 5th or 6th rib. Here the subcutaneous fat from the fifth through the 6th to the 7th ribs is less thick or less in amount than above the 5th rib, where the breast tissue begins or below the 6th and 7th ribs where the abdominal subcutaneous fat begins. You can feel this on your own body whether male or female. And also notice as you feel yourself how much more firmly attached the tissue is over the 5th - 7th ribs, and how much more mobile the breast and subcutaneous tissues of the abdomen are above and below this area.

The breast implant surgeon finds how easy the pocket is to dissect above the 5th rib and may insert the implant before giving special attention to the inframammary fold. The implant will then be too high. The implant can be gradually lowered with dissection of the inframammary fold even with the implant in place until it is properly positioned and centered behind the nipple.

The implant that is too high with the patient lying on the table may look like it is in the proper position, and the fact that it is too high may not become obvious until the patient is brought up to a sitting position.

The dissection of the pocket except for the IMF is so easy it can be done with the implant or a sizer, as has been shown with the umbilical approach, where the implant or sizer is inserted and inflated and used to create the pocket.

This gentle blunt dissection of the pocket is ideal. All dissection should be so gentle and easy, but it is not. It is very difficult to dissect the IMF with the finger. It is too tough. The attachment is the superficial pectoral, external oblique, serratus anterior and rectus abdominus fascia extending into the subcutaneous tissue and attaching to the deep dermis. In slender patients, there can be little or no subcutaneous fat present.

Preserving as much subcutaneous fat attached to the skin in the IMF dissection is desirable. The tissues are thin in this area, and if the fat is not preserved there may be little else but deep dermis in contact with the implant, causing the implant to be more palpable and visible. Also, the fat attached to the skin may partly protect from early capsule formation.

 

In all of the drawings above only the fullness of the breast and the position of the inframammary fold (IMF) has changed. The higher fold in 4 as compared to 1 gives the appearance of ptosis. And if the fold is lowered and the breast is filled with an implant, the ptosis appearance and the ability to hold a pencil disappears. If #8 has an implant compared to #5 or 6, the IMF is routinely lowered to center the implant behind the nipple. Otherwise, the implant would be too high.

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