What is an Inframammary Fold or IMF?

Anatomy of The Inframammary Fold (IMF) and Its Importance in Breast Surgery Procedures

The female breast is one of the rare anatomical structures in your body that lacks any bony or cartilaginous support. It’s suspended from your chest by its soft tissues. Its final shape significantly influenced by surrounding structures such as your inframammary fold at the base of your breast.

The inframammary fold is a key visual landmark in cosmetic breast surgery, from breast augmentation, breast reduction, and breast lift surgeries, to breast revision and breast reconstruction procedures. As a result, cosmetic plastic surgeons worldwide agree that preservation of the inframammary fold is important in all types of cosmetic breast procedures. However, if damage to the inframammary fold is unavoidable, surgeons take great care to resuspend it properly.

Learn more about Breast Surgery.

At Coco Ruby Clinic you’ll find plastic surgeons with years of experience, they take care in the placement of your inframammary fold during your breast surgery procedure, to bring you the results.

Inframammary Fold – What Is the IMF?

The inframammary fold (IMF), also known as the inframammary crease or inframammary line is the border where your lower breast and chest meet. The location of the resulting groove is at the level of your fifth rib, extending downward to reach your sixth intercostal space (space between your sixth and seventh rib). The inframammary fold is undetectable during your childhood years and only comes to define the lower aspect of your breasts when you reach puberty.

Although the importance of the inframammary fold in cosmetic breast plastic surgery is well accepted, its anatomy remains a topic of controversy among plastic surgeons. Some consider the inframammary crease as a ligamentous structure that extends from your fifth rib and inserts into the inner layer of the overlying skin (dermis). Whilst, others disagree and prefer to classify it as a specialised interwoven network of collagen fibres. These fibres support your inframammary skin fold by adhering to a condensed superficial covering of connective tissue (fascia).

Regardless of its correct anatomical description, the inframammary fold is a defining feature in a woman’s breast shape and structure.

Credits to User: Mikael Häggström, Public domain, via Wikimedia Commons

Inframammary Incision for Breast Surgery

The inframammary incision is a surgical incision made either along or underneath your existing inframammary crease. It’s the most common type of incision in both breast augmentation and breast reconstruction procedures. In fact, survey studies show more than 83.9% of plastic surgeons prefer this approach.

The advantages of an inframammary incision include;

• Direct visualisation of the breast tissue and pocket
• Inframammary fold hides postoperative scarring
• Ability to reuse the same surgical incision location in revisional surgery
• And, more.

Your Inframammary Fold – Why Is It Important?

The inframammary fold serves as an important anatomical, functional, and surgical landmark for cosmetic plastic surgeons performing cosmetic breast surgery, be it breast augmentation, breast reduction, breast lift, breast revision or reconstruction procedure.

1. Breast Augmentation

A surgical incision within the inframammary fold offers a versatile wide access point for your plastic surgeon to place any type of breast implant, especially those larger in size, with precision. It allows for minimal breast tissue dissection, faster healing, and unnoticeable breast augmentation scarring concealed within the fold.

For aesthetic results and minimal risk of implant malposition, careful surgical closure and stabilisation of your inframammary fold are necessary during your breast augmentation procedure.

2. Breast Reduction

Breast reduction or reduction mammaplasty are common plastic surgeries for women suffering from chronic neck, shoulder, and back pain or women who find physical activity difficult due to large heavy breasts. The majority of breast reduction surgeries employ the inframammary crease incision for premium results.

• Vertical or lollipop breast reduction involves two incision sites, one around your areola (pigmented area around the nipple) and the second is a vertical line running from the lower edge of your areola to your inframammary line. It’s for those who want a moderate breast reduction.
• The inverted-T breast reduction or Anchor technique also heavily relies on your inframammary fold as a surgery marker. Two incisions are made both vertically from the areola to your inframammary crease, and along the inframammary fold as well. A third surgical incision is also placed around the areola.

The access provided by the inframammary fold allows for a maximal degree of tissue removal and reshaping, ideal for those seeking significant breast reduction.

3. Breast Lift

Plastic surgeons utilize the inframammary line as a tool to assess the varying degrees of breast ptosis, allowing them to determine the breast lift (mastopexy) option for you.

A breast has the nipple and tissue mound lying above the inframammary crease, while in ptotic breasts:

• Grade I (mild ptosis): Nipple lies at the level of the inframammary fold, above the lower contour of your breast
• Grade II (moderate ptosis): Nipple lies below the inframammary fold, but still above the lower contour of your breast
• And, Grade III (severe ptosis): Nipple lies below the inframammary fold, at the lower contour of your breast
• Pseudoptosis: Majority of your breast mound lies below the inframammary fold, but the nipple remains above it

4. Breast Revision

Breast implant revision surgery is a complex procedure that involves the removal or replacement of your current breast implants. Women undergo breast revision surgery to change the size or type of their implants, or to correct complications from primary breast augmentation procedures such as implant malposition.

Overenthusiastic dissection of the inframammary fold is one of the most common causes of implant malposition. The popcorn technique or capsulorrhaphy is a method used to reduce the size of your implant pocket capsule. The capsule is the scar tissue layer formed around your breast implant. It’s your body’s automatic response to foreign objects and a normal part of your healing process.

The popcorn technique involves scorching the implant capsule with scattered small burns causing the capsule to shrink. Tightening of your implant capsule pocket and the new scar formation fixes your breast implants in place and prevents any future implant malposition or displacement. The popcorn technique gets its name from the snap and pop sound produced by the cautery tool used.

How Inframammary Fold Reconstruction works

The inframammary fold is one of the most difficult anatomical breast structures to recreate. However, it’s an obligatory step in breast reconstruction surgery as it determines your final aesthetic results. An ideal restored or reconstructed IMF should be well-defined, symmetrical to the contralateral breast, and has a sharp breast-chest angle.

Preoperatively, your plastic surgeon will mark out your new inframammary crease line while you’re in a standing position. There, they will perform a surgical incision during your breast reconstruction procedure. Furthermore, after breast pocket dissection and implant placement are done, sutures will be placed to close off your breast pocket and reinforce your inframammary fold. The technique used in IMF reconstruction will depend on your;

• Breast anatomy
• Type and size of implants
• And, the method your plastic surgeon prefers.

Inframammary Fold Malposition – Mistakes Surgeon can make with the IMF

In cosmetic breast procedures, plastic surgeons frequently need to raise or lower your inframammary fold depending on the type of cosmetic breast surgery being done. For example, Breast augmentation usually requires your inframammary crease to be at a lower position to recruit more skin to accommodate your new breast implants. Whereas, Mastopexy and reduction mammaplasty on the other hand require the inframammary fold to be elevated.

Low Positioning – IMF too Low

Lowering the inframammary line is almost a routine step while performing breast enlargement surgery. However, if you have ptotic or tuberous breasts, improper lowering of your inframammary fold may result in low-lying breasts. It can also result in a double bubble deformity.

So, what causes a double-bubble?

It is a result of lowering your inframammary crease, without your plastic surgeon completely removing or obliterating your preexisting one. In such scenarios, your implants may descend, and leave your previous IMF intact, unstretched and visible. Low hanging breast tissue (due to ageing, pregnancy, or weight gain) can also cause a double bubble deformity over your original inframammary line, while your breast implants remain in their original position. This creates what appears to be a second bulge beneath your breast, hence the ‘double bubble’ description.

High Positioning – IMF too High

Positioning the inframammary crease higher is not uncommon during breast lift and breast reduction procedures. However, if your plastic surgeon lifts your inframammary fold too high from its location, you may end up with high riding breasts. And If the inframammary crease was positioned at the level of your nipple or higher, your breast may acquire “a ball in a sock” appearance. In other words, it has upper breast fullness with a down-pointing nipple.

Medical Sources about Inframammary Fold or IMF

• Oxford Academic Aesthetic Surgery Journal – Lowering the Inframammary Fold
• SpringerLink Case Report on The Inframammary Fold (IMF): A Poorly Appreciated Landmark in Prosthetic/Alloplastic Breast Aesthetic and Reconstructive Surgery—Personal Experience
• Annals of Plastic Surgery on A Simple Method for Proper Placement of the Inframammary Fold Incision in Primary Breast Augmentation
• Annals of Plastic Surgery on A Simple Guide to Inframammary-Fold Reconstruction
• Ovid.com Insights on The Intradermal Anatomy of the Inframammary Fold
• Oxford Academic Aesthetic Surgery Journal on Lowering the Inframammary Fold
• Ovid.com Insights on Inframammary fold: a histologic reappraisal
• US National Library of Medicine on A Simple and Scarless Method for Inframammary Fold Correction Using a Barbed Suture
• Springer Breast Augmentation on The Inframammary Crease
• US National Library of Medicine on The Supra-Inframammary Fold Approach to Breast Augmentation: Avoiding a Double Bubble
• Oxford Academic Aesthetic Surgery Journal on Inframammary Crease: Positional Relationship to the Pectoralis Major Muscle Origin
• Plastic and Reconstructive Surgery Article on The Supra-Inframammary Fold Approach to Breast Augmentation: Avoiding a Double Bubble
• SpringerLink on Inframammary Fold Dynamics: Problems and Solutions
• Oxford Academic Aesthetic Surgery Journal on A Classification and Algorithm for Treatment of Breast Ptosis
• Plastic and Aesthetic Research on A simple classification and a simplified treatment’s algorithm for ptotic breasts
  

  Further Reading Continued

• Breast Augmentation Article Classification of Breast Ptosis on Springer Link
• American Board of Cosmetic Surgery Procedure Learning Center on Breast Lift Guide
• American Board of Cosmetic Surgery Procedure Learning Center on Breast Reduction Guide
• Science Direct Nursing Health Topics on Breast Reduction
• Oxford Academic Aesthetic Surgery Journal on Popcorn Capsulorrhaphy in Revision Aesthetic Breast Surgery
• US National Library of Medicine on Small refinements in breast reconstruction: a technique for inframammary fold creation
• ABS Annals of Breast Surgery Article on Inferior mammary fold reconstruction in reconstructed breast: a novel technique
• Oxford Academic Aesthetic Surgery Journal on The Inframammary Fold (IMF) Fixation Suture: Proactive Control of the IMF in Primary Breast Augmentation
• Science Direct Article on Aesthetic role of the surgically rebuilt inframammary fold for implant-based breast reconstruction after mastectomy
• National Library of Medicine on Lowering the inframammary fold
• Plastic Surgery and Reconstructive Surgery Special Topic Discussion on The Double-Bubble Deformity Cause, Prevention, and Treatment.