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.

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, MA
Lahey Clinic. Department Of Plastic & Reconstructive Surgery, Burlington, MA
Morgantown Plastic Surgery Associates, Morgantown WV

2. The Inframammary Crease
Introduction
The inframammary crease or fold is an essential landmark for an optimal result in aesthetic
and reconstructive breast surgery. A well defined inframammary crease and an appropriate
areola to inframammary crease distance is arguably the most important component of a
pleasing aesthetically correct breast appearance following breast augmentation, reduction
mammaplasty and post mastectomy breast reconstruction.
Failure to preserve the inframammary crease during breast augmentation surgery creates an
unacceptably 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 is
one 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 pocket
for insertion of the prosthesis, the ligament can be disrupted if the dissection is carried out too
inferiorly. 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. The anatomy of the inframammary crease has been the subject of significant debate in the
plastic 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 many
authors have attempted to define the structure and anatomy of this area, in an effort to
simplify its reconstruction. In this chapter we will present the findings of our own cadaver
dissections² and relate our clinical approach to the reconstruction of the inframammary
crease.
Anatomy
The inframammary fold is undetectable in the prepubescent breast; however with the
onset of puberty it comes to define the inferior aspect of the female breast. The crease is sited
at the 5th rib medially and its lowest potion reaches the 6th intercostal space. The average
distance 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 periosteum
medially 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 the
skin
(Reproduced with permission from Bayati S., and Seckel, B. R. Inframammary crease ligament.
Plastic And Reconstructive Surgery 95: 501-508, 1995)

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 5th
rib’s periosteum medially, from the fascia between the 5th and 6th rib laterally, and inserts
into the deep dermis of the submammary fold. Their thinking was that it was a condensation
of the rectus abdominis fascia medially and the fascia of the serratus anterior and external
oblique laterally.
Their study revealed a difference between Cooper’s suspensory ligaments and the
inframammary ligament. These authors emphasized that the presence of the double-bubble
phenomenon 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. Maillard and Garey3 had described a crescent-shaped ligament between the skin and
the anterior surface of the pectoralis major, which is slightly lower than the anatomy
described by Seckel et al. Van Straalen and Hage4 described a similar ligament found in the
breasts of female to male transsexuals.
Nava5 disagreed, stating that the crease is devoid of a true ligament, rather having a
usual two subcutaneous layers and one superficial fascia. This fascia deepens and the anterior
breast envelope detaches creating this fold. Garnier6 concluded that a subcutaneous
inframammary ligament does not exist. Lockwood7 described this superficial fascial system
as a subdermal structure, consisting of interwoven collagen fibers that support the skin by
adhering to the underlying fascial layers. Shenaq8 suggested that it is a dermal structure
consisting of a collagen network arranged in arrays that run parallel to the skin surface along
the long axis of the inframammary fold; that is held in place by the condensation of the
superficial fascial system.
Sundine9 did not demonstrate the presence of a ligament; they stated that the
superficial 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 an
inframammary ligamentous structure.
Reconstruction of the Inframammary Fold
History
In breast reconstruction, the inframammary fold is one of the most difficult anatomic
structures to recreate. Nonetheless, it is a crucial element in achieving the optimal aesthetic
outcome.
During mastectomy the inframammary crease should be preserved and not disturbed
when 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 lymph
nodes. However, Carlson et al.11 confirmed that IMF preservation is safe as it leaves less than
0.02% of the total breast tissue and hence does not appreciably affect the completeness of a
mastectomy, as long as the patients are closely followed. However the IMF frequently needs
to be violated during TRAM procedures to avoid compressing the pedicle.
In 1977, Pennisi12 described a reliable external procedure whose main features were
marking the lower thoracic skin, creation of a dermal-fatty-superficial fascial flap, and
turning up the flap and anchorage to the muscular fascia. Ryan13 added on that concept by
fixing the flap to the periosteum. Bostwick14described an inframammary fold elevation
technique through a short horizontal external approach. He sutured the lower thoracic flap
hypodermis to the posterior capsule and deeper tissues. He avoided an external scar, and gave
a 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 expander
removal. 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 flap
became the under-surface of the new breast. The skin flap was secured to the periosteum.

6. The disadvantages of this technique were again having a bulky inframammary region, and
the 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 the
previous mastectomy incision. The desired inframammary fold line is transposed by
transfixing needles into the pocket. The superficial fascia is located and cut along the whole
inframammary line, and a running stitch is used to secure the new fold. More recently
Pribaz17 described a technique using a Steinman pin in order to match the symmetry of the
contra 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 of
the pin. An external bolster is applied and the pin is removed.
We have developed an “Internal Thoracic Advancement Flap” method, which enables us to
avoid the external scar of the original external procedure described by Pennisi and Ryan.
Our Approach:
The Internal Thoracic Advancement Flap
The most common and distressing disadvantages of previous techniques for reconstruction of
the 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 the
pre determined inframammary crease insertion point on the 5th rib and the 5th-6th intercostal
space.
This technique may be applied during primary reconstruction, following the removal
of a soft tissue expander, and in cases of breast augmentation in which “bottoming out” have
occurred.
First, the anatomical location of the proposed inframammary crease is marked on the
internal chest wall by using the bovie to coagulate a line along the appropriate landmarks
outlined above (Figure 2). An estimate of the amount of skin which must be recruited to
provide an adequate inferior pole of the breast is made. Dissection is carried out inferiorly
below the 5th and 6th rib, through the inferior capsule (in the case of a soft tissue expander or
breast implant), or beneath the inferior mastectomy flap (in the case of a primary post
mastectomy reconstruction). A crescent shaped inferior thoraco-abdominal flap is elevated
8-10 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-abdominal
skin flap is advanced superiorly. 0 Prolene buried sutures are placed into the undersurface of

7. the deep dermis of the skin flap at a point 2-3 cm below the superior edge of the flap to allow
for 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 the
intervening intercostal fascia. Usually 8 to 10 sutures are required. (Figure 4).
This maneuver typically provides a significant amount of tissue to provide an
adequate “inferior pole” to the reconstructed breast profile. In cases of a breast augmentation
which has “bottomed out”, the thoraco-abdominal flap is not created or advanced. Rather the
inferior pocket capsule is opened, a 3 cm strip of capsule resected, and the excess inferior
pole breast skin is advanced internally with a running 0 Prolene suture to the periosteum and
intercostal 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 adequate
inferior pole of the breast, bleeding, infection and scarring. The additional potential
complication is a failure of the suspension sutures or long term inferior migration of the flap
and 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 experienced
less flattening and loss of fold compared with other methods of repair.
Discussion:
The inframammary crease, an adequate inferior pole of the breast, an appropriate
nipple position and an appropriate areola to inframammary crease distance is the essential
components of an aesthetically appropriate breast appearance.
Failure to preserve or to reconstruct the inframammary crease following breast
reconstruction or in cosmetic breast augmentation causes one of the most unsatisfactory and
distressing complications in aesthetic and reconstructive breast surgery.
In this chapter we have presented a detailed anatomic description of the landmarks for
the inframammary crease. Our opinion is that a crease ligament or other condensation of
Scarpa’s fascia and the posterior capsule of the breast constitutes a well defined anatomical
landmark which can be reconstructed. Reconstruction of this anatomic structure in the proper
location can restore an appropriate and aesthetically acceptable inframammary crease both in
post mastectomy breast reconstruction and in cosmetic breast augmentation when “bottoming
out” or the “double bubble” has occurred following breast augmentation.

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.