Inframammary Fold Reconstruction Research Articles

Autologous Lipo-Dermal Advancement Flap for Inframammary Fold Reconstruction: A Technical Note for Prevention and Management of Caudal Breast Implant Migration

Inferior breast implant displacement, also known as caudal migration, or bottoming-out, is a known complication of breast augmentation. This leads to a loss of upper pole fullness, a more superiorly located nipple-areolar complex, and an unnatural appearance. Avoiding these complaints has been a longstanding challenge in the field of aesthetics and this technical note suggests a novel solution. This technical note describes the process of preoperative assessment, careful markings, and the use of an autologous lipo-dermal advancement flap that has been designed, mobilized, and rotated to be internally fixated to costal margins and the relevant deep fascial structures at the proposed inframammary fold level. This technique creates a robust partitioning hammock-like structure that stabilizes the breast implant and prevents future caudal displacement. The described technique may be implemented as an independent solution, or as an adjunct to other modalities like biological meshes in revision breast surgery.

The fascial structure of the breast: New findings on the anatomy of the inframammary fold

The inframammary fold defines the shape and structure of the breast, especially in women. As the inframammary fold is placed between the fifth and sixth ribs, the ligaments or fascia are thought to attach from these ribs. However, the previous literature on what structures constitute the inframammary fold does not provide sufficient knowledge for reconstructing the natural form of the fold. This study aimed to clarify the structure that involves the inframammary fold. Ten sides of five formalin-fixed, adult Asian cadaveric breasts were studied. Upon dissection of the breast, including the ribs, the fat lobules were removed while preserving the septal structures under the microscope. The fascial structures were observed grossly and radiographically. A multilayered fascial structure was noted from the dermis near the inframammary fold, anchored to the deep fascia of the pectoralis major muscle mainly at the height of the fourth rib and partially of the fifth rib, from the outside of the nipple to the linea axillaris media, where the fold could be clearly observed. Additionally, the fat lobules around the inframammary fold were subdivided by thin septa closer to the dermis, and they fused posteriorly and upward to form this fascial structure. The inframammary fold was not formed by an adhesion directly under the sixth rib, but by the skin "hanging" from the height of the fourth and fifth ribs due to the multilayered fascial structure that repeatedly fused and dissociated and the changes in the size of the fat lobules. This new anatomical finding may help in inframammary fold reconstruction.

Inframammary fold reconstruction after mammoplasty

Inframammary fold reconstruction after mammoplasty

Inferior mammary fold reconstruction in reconstructed breast: a novel technique

Background: In breast reconstructive surgery, the infra-mammary fold (IMF) is an integral component of breast identity. The distortion of the IMF during breast surgery or reconstruction following mastectomy often requires restoration. We have developed a new IMF reconstruction technique using de-epithelialised dermis secured to the periosteum of the rib. This acts as a hammock to support the breast tissue in the new position. This paper presents our nine-year experience of performing this original technique following free tissue transfer or tissue expanders (TEs) to reconstruct the breast post-mastectomy. Methods: Pre-operatively, the new IMF line is marked out while the patient is in a standing position. Two centimeters of the lower border of the reconstructed breast is de-epithelialised. The pectoralis major fascia is accessed through the dermis and the lower third of the flap is raised and folded in upwards. The dermis is then stitched to the periosteum of the rib at the desired higher level using interrupted 2/0 polydioxanone (PDS) sutures; thus, creating the new IMF. Results: A total of 9 patients were included in this report. The average age was 49 years (range, 31–61 years). Two cases had bilateral subcutaneous mastectomy and deep inferior epigastric perforator (DIEP) flap reconstruction. One case had immediate DIEP on one side and delayed DIEP on the other. One case had bilateral delayed DIEP. Two cases had unilateral delayed DIEP reconstruction following oncological mastectomy. Three cases were following TEs in unilateral breast reconstruction one of which had a high IMF that needed lowering. IMF in all cases was recreated using the same technique; each achieving a satisfactory outcome with no complications recorded. Conclusions: This technique provides the reconstructed breast with a well-defined IMF and improves its projection. The results are long-lasting and provide a sharp breast-thoracic angle, which is fundamental in the creation of a natural-looking reconstructed breast.

Comparative evaluation of the quality of life of patients depending of different inframammary fold creation techniques during a two-stage breast reconstruction

Reconstruction of natural-looking breast involves the restoration of all the constituent elements that define the identity of a normal breast. The inframammary fold is one of the main anatomical elements that determine the shape of the breast. That is why the technical features of various methods of the inframammary fold reconstruction affect the final aesthetic result of the reconstructive surgery. This article considers a comparative evaluation of the quality of life and satisfaction with the reconstructed breast after the two-stage breast reconstruction with different inframammary fold creation techniques.

Novel 3-Dimensional Imaging Analysis of the Ryan Procedure for Inframammary Fold Elevation in the Reconstruction of the Revised Breast.

Summary:The inframammary fold (IMF) can be challenging to reconstruct after disruption during mastectomy or breast reconstruction. The Ryan procedure is a previously described technique with little long-term analysis. Our goal is to analyze the long-term results of the Ryan procedure using 3-dimensional (3D) technology, with the hypothesis that 3D measurements will provide quantitative outcomes that add to the qualitative assessment of the reconstruction. We retrospectively reviewed consecutive breast reconstruction patients by a single surgeon from January 1, 2012 to January 31, 2015 to identify patients who underwent the Ryan procedure. Previously obtained 3D photographs were then analyzed to compare breast base diameter, breast projection, and inter-IMF distance pre- and postoperatively. A survey was then given to 15 health professionals in our department to assess the IMF and symmetry pre- and postoperatively. Eight patients were eligible for inclusion. Four patients were unilateral reconstruction and 4 were bilateral. The Ryan procedure resulted in an inter-IMF discrepancy reduction of 39% and a breast projection increase of 18%. Average length of follow-up was 2.82 ± 0.75 years. One patient required a secondary IMF revision. The majority of survey respondents felt that the IMF and IMF symmetry were improved or stable postoperatively. The Ryan procedure seems to be a reliable and durable technique for IMF reconstruction with increased projection, decreased IMF discrepancy, and increased symmetry. Additionally, 3D imaging provides a useful approach in the assessment of breast reconstruction outcomes, adding quantitative outcomes measures to its evaluation.

Inframammary Fold Reconstruction in the Previously Reconstructed Breast: A Comprehensive Review.

The inframammary fold presents a reconstructive challenge once disrupted during total mastectomy or inadequately restored during breast reconstruction. Various methods of recreating the inframammary fold have been proposed, but reports are generally based on small sample sizes and lack long-term analyses and patient-reported outcomes. The authors herein review the literature on inframammary fold anatomy and reconstructive techniques, highlighting the need for more critical analysis of methodology to develop more predictable and durable outcomes.

A Simple Algorithm for the Inframammary Fold Reconstruction, Balcony-Like Technique

The inframammary fold (IMF) is one of the most important landmarks that defines the breast region. Most of the current IMF reconstructive techniques are based on the creation of fibrotic structures to maintain the breast. We present a surgical technique of IMF reconstruction by the creation of a fascial flap underpinned by an anatomical evaluation of this structure and a simple algorithm to define the localization of the new IMF. Fifteen patients underwent our procedure of IMF reconstruction from 2004 to 2016. The patients were followed during at least 6 months after IMF reconstruction. This technique is based on the creation of a pectoralis major fascial flap fixed to the dermis by inverted resorbable sutures. The fascial flap represents a new ligament of the IMF reconstituting a physiological support. Cosmetic outcomes and stability over time were assessed. The long-term aesthetic outcome is optimal on all the patients treated with a natural shape and a good definition of the new IMF. There were no noted complications or revision surgery during the follow-up. Our technique consists of an anatomical reconstitution of IMF recreating a natural support “balcony-like” formed by the pectoralis fascia fixed to the dermis. This technique is useful to correct reconstructive or aesthetic procedures of the breast, with great cosmetic outcome and high reliability underpinned by the use of our position algorithm which is easy to use and enables a symmetrical position of the IMF.

THE USE OF THE ORIGINAL METHOD OF RESTORING THE INFRAMAMMARY FOLD DURING TWO-STAGE BREAST RECONSTRUCTION

The Inframammary fold (IMF) is an important component of attractive and esthetically normal appearance of the breast and one of the most important elements of natural breast ptosis. It plays a significant role in the formation and maintenance of breast shape as well as it provides support for the implants placed subpectoral that prevent their malposition. It is necessary to restore the IMF during breast reconstruction and it allows achieving results similar to their natural breasts. The IMF reconstruction existing methods on a row with the advantages have some disadvantages: visible scars and contour irregularities in case of the external access, indentations at the site of IMF, little ptosis improvement or small projection, therefore it is impossible to choice a particular method of its reconstruction. Considering certain shortcomings of the existing methods of reconstruction Prof. A. Ismagilov et al. have developed a new IMF reconstruction technique using the posterior sheet of the expander capsule. This article presents our 4-year experience of performing this original technique during two-stage breast reconstruction.

Small refinements in breast reconstruction: a technique for inframammary fold creation.

In breast reconstructive surgery, the inframammary fold (IMF) is an essential component of breast identity. The lack of the IMF following previous mastectomy requires restoration. We have developed a new IMF reconstruction technique using the posterior sheet (PS) of the expander capsule. This article presents our 10-year experience of performing this original technique during two-stage breast reconstruction. Preoperatively, the midline, lateral, and medial borders (MBs) of the implant pocket and the new IMF line were marked. After extracting the expander, the anterior sheet of the expander capsule was removed with the exception of its lowest 2-cm portion. Two needles were placed at the intersection of the new IMF line with the lateral border (LB) of the implant pocket and its MB. Within the pocket, horizontal dissection of the PS of the capsule was performed from one needle to another, after which the sheet was mobilized downward. The mobilized free border of the PS was pulled upward until the inframammary crease was at the new marked location, and then fixed with non-absorbable interrupted sutures to the underlying tissues. An implant was placed over this layer. The covering tissues were then closed. A total of 321 patients were included. The median age was 38 years (range, 18-58 years). No serious wound complications were observed. Breast-thoracic angle decreased in 21 patients (6.5%), and the distance from the IMF to the lower border of breast segment III was greater than that of the contralateral breast in 14 patients (4.4%). This technique provides a well-defined IMF without indentations or retraction. The results are stable on long-term follow-up and provide a sharp breast-thoracic angle, which is crucial in creating natural-looking ptosis of the reconstructed breast.

Inframammary Fold Reconstruction: A Biomechanical Analysis.

Background:Inframammary fold reconstruction has scarcely been evaluated in literature. No biomechanical analyses have been performed comparing different reconstructive methods. This evaluation compares the gold-standard suture reconstruction with an intrarib anchor system (Micro BioComposite SutureTak, Arthrex).Methods:Three analysis groups were compared including 8 Sawbone blocks, 22 embalmed cadaver, and 27 regular cadaver specimens (N = 57). Transient mechanical analysis was performed at 5 N/s using an Instron 5565 test frame.Results:Ultimate load favored the anchor system (compared with the gold-standard suture) by a factor of 9.8 (P < 0.0001) for the regular cadaver group and a factor of 1.7 (P < 0.038) for the embalmed cadaver group. A similar statistically significant benefit was shown for stiffness and load at 2-mm displacement.Conclusions:This analysis showed an anchor system to be the biomechanically superior fixation method in terms of ultimate load, fixation stiffness, and displacement at failure when compared with the gold-standard suture method in inframammary fold reconstruction. Because of superior stability in every aspect, an anchor system may be considered for inframammary fold reconstruction.

Inframammary fold reconstruction – a biomechanical analysis

Inframammary fold reconstruction – a biomechanical analysis

A new method for inframammary fold recreation using a barbed suture.

There are inherent limitations with previously reported inframammary fold (IMF) recreation methods. The IMF is firmly fixed to the chest wall, but not physiologically, and it is difficult to determine the correct IMF position in the supine position and in the absence of an implant. With our new IMF reconstruction method (i.e., drawstring method), the IMF is recreated by drawing a barbed suture, penetrating the dermis, along the IMF. The barbed suture is fixed to the costal cartilage at the medial IMF, and the head is drawn and cut externally at the lateral IMF. The IMF level and depth can be finely adjusted by the tension, in a seated position after implant insertion. Furthermore, the approach can be from a small incision, and a smooth IMF curve is reconstructed. Our drawstring method was performed in 102 patients who underwent reconstruction using a breast implant (n = 95) or flap (n = 7). The mean patient age was 52.0 years (range 33-77 years) and the follow-up period was 12 months (range 3-18 months). Suture or implant infection or exposure did not occur. Suture slack occurred in ten patients with implant-based reconstruction; their IMF became shallow. Insufficient skin expansion (P < 0.005) and strong traction of the barbed suture from the caudal side (P < 0.05) were related to IMF slack. The total revision rate was 2.9 %. With sufficient skin expansion, the drawstring method using a barbed suture enables smooth and symmetrical IMF reconstruction. 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 .

Reconstruction of the Inframammary Fold Using Barbed Suture

Achieving accurate inframammary fold (IMF) position and definition during breast reconstruction is a critical step toward obtaining optimal aesthetic outcomes. This article presents a simple technique for IMF reconstruction after implant-based breast reconstruction with an internal running, barbed suture. The results of this technique are retrospectively reviewed in 45 patients, with only 2 patients requiring additional procedures to adjust IMF position for a total revision rate of 4.4%. There have been neither instances of permanent contour deformity due to suture placement nor any instances of suture extrusion through the skin. Thus, this technique appears to be safe and effective and should be considered when surgeons are faced with an IMF asymmetry.

The Capsular Hammock Flap for Correction of Breast Implant Ptosis

A well-defined inframammary fold (IMF) is essential in providing an aesthetically pleasing and stable result in breast procedures. The position of the IMF on the chest wall determines the "footprint" of the breast, and hence the breast and chest aesthetic as a whole. Implant malposition is reported in the literature to occur in 5-8% of primary breast augmentation patients. This occurs most commonly in a caudal direction, which is the most difficult problem to correct, as reported by Tebbett (Clin Plast Surg 28:425-434, 2001). Numerous surgical techniques to correct the malpositioned IMF have been described, including periosteal anchorage techniques as reported by Persichetti et al. (Ann Plast Surg 70:636-638, 2013), periareolar approaches that secure the IMF to the rib cage, and superiorly based capsular flaps. Here we describe a novel simple capsular flap technique using the lower anterior capsule, which is divided and formed into an inferiorly based flap and used as a "hammock" to re-establish the IMF and support the implant. As the capsule is made of a compact fibrous shell with a dense collagen network and excellent blood supply, using it as a flap to reposition and maintain the implant is ideal. Previous studies and tests have shown the reliability of capsule-based flap reconstruction due to the capsule's intrinsic strength and good vascularity, as shown by Rubino et al. (Ann Plast Surg 46:95-102, 2001). We describe our series of 12 primary breast augmentation patients with caudal implant malposition who underwent IMF reconstruction and implant repositioning with this technique. We explain our simple and repeatable technique that shows a stable and very durable result in repositioning the IMF and implant, with no recurrence of implant ptosis. 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.

Current Advances for Aesthetic Improvement in Breast Reconstruction: Mimicking the Augmented Breast

Background: Women seeking implant-based breast reconstruction increasingly request a round, projecting breast with an amplified upper pole that mimics the augmented breast. Two-stage reconstruction provides the opportunity to recreate a well-defined inframammary fold (IMF) with ptosis, to modify final implant characteristics (volume upsizing, high profile, gel implants) and correct contour irregularities with lipofilling at exchange to achieve this desired outcome. Methods/Technique: All patients completing two-stage breast reconstruction were added prospectively into a database. Patient demographics, oncologic phenotype and treatment, surgical details including IMF reconstruction, implant characteristics, and outcomes were reviewed. 2D and 3D photos and intraoperative videography were captured, further illustrating the technique. Results: 84 two-stage breast reconstructions were completed in 50 women between 5/2010– 11/2013. Mean age at the time of mastectomy was 42.8 years and mean BMI was 30. At the time of exchange, the majority of implants were typically upsized from the final expansion volume, with a volume increase ranging from 10-150cc (mean increase 46cc). Mean expander fill volume and final implant volume were 595cc and 618cc respectively. Fifty-nine reconstructions (70%) included inframammary fold reinforcement. Sixty-eight (81%) of reconstructions utilized high profile or extra-high profile implants. Selective use of fat grafting was implemented later in the series. Conclusion: Current advances in two-stage implant based breast reconstruction are outlined to achieve upper pole fullness, anterior projection of the breast, and definition of the inframammary fold. These strategies afford reconstructive outcomes that parallel the desired aesthetic features of the augmented breast.

Management of Upper Abdominal Laxity After Massive Weight Loss: Reverse Abdominoplasty and Inframammary Fold Reconstruction

Management of Upper Abdominal Laxity After Massive Weight Loss: Reverse Abdominoplasty and Inframammary Fold Reconstruction

Management of Upper Abdominal Laxity After Massive Weight Loss: Reverse Abdominoplasty and Inframammary Fold Reconstruction

Central to body contouring after weight loss surgery is treatment of the abdominal region, often through a circumferential abdominoplasty. This procedure, however, neglects the laxity of the lower thoracic/upper abdominal region. A reverse abdominoplasty with reconstruction of a new inframammary fold (IMF) corrects this deformity through removal of excess skin along the IMF. Since 2002, we have performed 88 reverse abdominoplasty procedures within the context of a single or staged total-body lift (TBL). A retrospective chart review of 129 TBL cases indicated that 88 patients had a combined or staged reverse abdominoplasty and circumferential abdominoplasty. Complication rates were noted as localized or generalized. Fifty-three of our patients had combined reverse abdominoplasty and circumferential abdominoplasty and 35 had the reverse abdominoplasty during a second stage. The complication rates for both groups were about 5% per patient per procedure with differences that were not statistically significant. Also, the revision rates for reverse abdominoplasty and circumferential abdominoplasty were similar for both groups, indicating patient satisfaction with the procedures. In selected patients, effective treatment of the abdominal region demands correction of both the upper and lower abdominal laxity and contour. This can be performed safely, effectively, and reliably by a reverse abdominoplasty with IMF reconstruction independently or simultaneously with circumferential abdominoplasty.

Immediate Single-Stage Breast Reconstruction Using Implants and Human Acellular Dermal Tissue Matrix With Adjustment of the Lower Pole of the Breast to Reduce Unwanted Lift

Breast reconstruction using implants remains an aesthetic challenge toward achieving symmetry and natural appearance. Closing the areolar defect results in a vertically elevated breast mound. The use of human acellular dermal tissue matrix has been reported to provide coverage and durability over breast implants while allowing for improved shape of the reconstructed breast. This study reports the operative technique used in a series of breast reconstructions using saline implants and human acellular dermal tissue matrix in an immediate one-stage procedure. Complications and appearance were evaluated for all reconstructions. Indications for inframammary fold reconstruction and lower pole breast enhancement using chest skin advancement were discussed. Twenty-three patients were included in the study; 11 had unilateral reconstruction and 12 had bilateral reconstruction for 35 total reconstructions. All patients had immediate reconstruction following skin-sparing mastectomy. Nine patients had inframammary fold reconstruction and 11 patients had a lower chest advancement flap with fold reconstruction. The mean follow-up was 9.5 months with a range of 1 to 24 months. Complications occurred in 3 patients. Human acellular dermal tissue matrix can successfully be used in conjunction with breast implants to achieve an aesthetically pleasing breast reconstruction in one stage at the time of skin-sparing mastectomy. The use of a tissue expander and its associated risks and costs are eliminated. The complication rate is low. In addition, either inframammary fold reconstruction or lower chest advancement and fold reconstruction to augment lower pole skin coverage can improve symmetry with the opposite breast.

Expansion tissulaire et seins tubéreux : à propos de dix cas

Introduction Tuberous breast is a deficiency of mammary development, principally in the lower lateral and medial quadrants. In types II and III of the Grolleau classification, we perform a two-stage correction by tissue expansion associated with an implant in order to avoid the double bubble deformity and the difficulty of medial infra-mammary fold reconstruction. Materiels and methods Between February 2003 and February 2006, ten patients have been treated by implantation of an anatomical expander associated with a vertical and horizontal Puckett plasty. The second operation consisted in the replacement of the expander by an anatomical prosthesis associated, if necessary, with a second Puckett plasty and lipofilling. Results There was no double bubble deformity. Three patients required a complementary lipofilling to improve the result of the lower medial fold. One prosthesis had to be repositioned and one expander infection was responsible of a three-month delay in the reconstruction procedure. Conclusion Tuberous breast correction is a therapeutic challenge in quite psychologically distressed patients. In types II and III, tissue expansion associated with a Puckett plasty increase the volume of the lower pole and reduces the risk of the double bubble deformity. The implantation of an anatomical prosthesis gives more natural effect to the contour of the glandular lower pole. This therapeutic attitude gives the chance of achieving a completely satisfactory result.