The Inframammary Crease
A well-defined inframammary crease and an appropriate areola to inframammary crease distance is arguably the most important component of a pleasing and aesthetically correct breast appearance. Failure to preserve the inframammary crease during breast augm
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The Inframammary Crease Brooke R. Seckel, Shawkat A. Sati, W. Thomas McClellan
5.1 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 and aesthetically correct breast appearance following breast augmentation, reduction mammaplasty, and postmastectomy breast reconstruction. Failure to preserve the inframammary crease during breast augmentation surgery creates an unacceptably abnormal breast profile often referred to as a “doublebubble” appearance or “Snoopy deformity,” which patients find very disturbing (Fig. 5.1). Failure to create a well-defined inframammary crease symmetrical with the opposite breast is one of the most common problems following postmastectomy breast reconstruction, especially following the use of soft tissue expanders. The anatomy of the inframammary crease has been the subject of significant debate in the plastic surgery literature. In 1845, Cooper [1] 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. This chapter will present the findings of cadaver dissections [2] and relate the authors’ clinical approach to reconstruction of the inframammary crease.
5.2 Anatomy
Fig. 5.1 “Double-bubble” deformity. During the course of dissection of the subpectoral musculofascial pocket for prosthesis insertion, 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 and Seckel [2])
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 (Fig. 5.2). The According to Bayati and Seckel [2], there is a ligaaverage distance from the inferior margin of the areola ment that originates from the 5th rib’s periosteum ranges from 5 cm to 9 cm. The presence of a true liga- medially, from the fascia between the 5th and 6th ribs ment at the fold is still the subject of many debates. laterally, and inserts into the deep dermis of the sub-
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5 The Inframammary Crease
mammary fold (Fig. 5.3). They believed 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. Maillard and Garey [3] had described a crescentshaped ligament between th
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