The Inframammary Fold (IMF) Fixation Suture: Proactive Control of the IMF in Primary Breast Augmentation.

Previous reports have suggested that inferior implant malposition following primary breast augmentation is secondary to violation of the inframammary fold (IMF) and subsequent poor reconstitution of the scaffold during the initial surgical procedure. Additionally, inferior malposition may be related to occult weakness at the level of the IMF incision over time. Specifically, in an inframammary dual-plane/submuscular pocket, instability of the IMF can result in continued inferior descent of the breast implant due to the weight of the implant, the weight of the breast parenchyma, and the downward force of pectoralis animation. Certain preoperative breast topography requires surgeons to alter the IMF to create optimal aesthetic results. In women with a short nipple-to-IMF distance or tuberous breast deformity, the IMF is intentionally lowered to expand the lower pole. However, inadequate subcutaneous release of the native IMF can result in a tight band across the inferior aspect of the implant. Additionally, failure to reconstitute a new IMF in these patients can also result in continued implant descent without banding. Although the etiology of implant malposition is multifactorial and patient dependent, the literature has focused on reactive, secondary techniques rather than proactive maneuvers in primary augmentation to prevent the deformity. These have included radial scoring, conversion to a subglandular plane or neo-submuscular pocket, creation of a dual plane, postoperative upper-pole compression and support of the neo-IMF, capsulorrhaphy, use of acellular dermal matrix, and deep fixation to the chest wall perichondrium. Prevention remains the most powerful solution, and preoperatively recognizing patients who are at high risk for this complication allows for prevention of the deformity. Our practice has categorized the following as high-risk: