The inframammary fold is an important functional and visual aspect of the female breast. It is interesting to notice in art how often the breast is represented simply by a line drawing of the fold and the nipple. The fold is formed by differential expansion of the subcutaneous tissue above and below it. Above, the developing breast gland tissue and stromal fat slowly expand the skin envelope, stretching the dermal retaining ligaments, while the skin on and below the fold remain attached to the underlying thoracic and abdominal structures by shorter, undistended dermal retaining ligaments. The fold is most frequently disrupted in the performance of a mastectomy when the ligaments are divided and the subcutaneous tissue components removed. Then, most frequently, the skin at the level of the fold is advanced superiorly on the chest wall in the mastectomy closure. Recreating the inframammary fold is thus most commonly a part of delayed implant breast reconstruction, and the context in which I have frequently performed it is as a part of the technique of lower thoracic advancement in delayed implant breast reconstruction (1). It is in this context that I discuss it, but the principles leading to stable dermis-to-chest wall fixation forming the fold can be applied to other contexts. I have seen the fold disrupted by tissue expansion, in the process of breast implant placement, and traumatically. I believe the key point in recreating a stable inframammary fold is dermis-to-chest wall fixation, substituting surgically created scar for the divided or absent dermal retaining ligaments.

In delayed implant breast reconstruction, recreating the fold is not undertaken until chest wall tissues have retained good mobility, usually 4 or more months after mastectomy. Here, as mentioned, it would be a part of the technique by which a modest amount of skin is added over the implant and the stable inframammary fold recreated. This also can be performed as part of postexpansion fold creation and stabilization, the technique being virtually the same as regards formation of the inframammary fold. I briefly describe the technique of lower thoracic advancement and focus particularly on the formation of the inframammary fold.

In the immediate preoperative planning, the patient is marked in the sitting position. I have the patients wear their external prostheses and brassiere because they will adjust this to a level of comfort that I refer to as the tactile inframammary fold level (Fig. 41.1). This marked, the bra and prostheses are removed, and I can compare this to the level of the opposite fold in a patient having had a unilateral mastectomy. This is almost inevitably on or just below the sixth rib in the breast meridian.

In the event that the surgeon is going to add skin cover over an implant, he or she would proceed below the tactile inframammary fold level in the meridian to at most 5 cm down the meridian, this being roughly 1 cm per 100 mL of planned implant volume (Fig. 41.2). A crescent approximately 1 cm in greatest width at the meridian level is then outlined, tapering to the anterior axillary line laterally and medial to a point complementing the end of the inframammary fold on the opposite breast. This is more apparent as the patient leans forward. One should then be able to easily lift the center of this crescent up to the level of the tactile inframammary fold, where it will be affixed to the chest wall. If this point cannot be raised free of tension, it will need to be adjusted. If the surgeon were performing the inframammary fold formation after expansion, the deepithelialized crescent would be planned just at or slightly below the inferior level of the expander, which has almost inevitably gone below the level of the tactile fold to some degree. This tissue would then be advanced and affixed to the chest wall, increasing the ptotic presentation of the breast and producing a natural acute angle between the inframammary skin and the chest wall below the fold (Fig. 41.3).

Intraoperatively, the crescent is then deepithelialized. At the superior and inferior aspect, a small back cut of approximately 1 mm is made at about a 45-degree angle, which will facilitate eversion with the final wound closure. In the center of the deepithelialized zone, a full-thickness incision is then made from medial to lateral and carried down through the subcutaneous tissue to the chest wall. Here dissection is turned superiorly, usually in the line of the anterior axillary fold, and the pocket is formed for implant placement most commonly in the subpectoral position. Of importance, some of the costal slips of origin as well as some of the parasternal fibers of the pectoral major muscle must be divided to a level of approximately 3 or 9 o’clock. After implant placement, the inferior deepithelialized edge will be brought to the level of the tactile inframammary fold in the meridian to be affixed to the chest wall tissues, usually fascia and scar tissue generated by the mastectomy. If advancement has been used, then one might need to undermine the inferior area approximately 1 cm for each centimeter of advancement desired. As the inferior edge is advanced in the meridian, it is important that there be no subcutaneous fat intervening. In a thin patient, this is rarely a problem, but in someone with an abundant subcutaneous fat mass, this inferior fat tissue may need to be either resected or suctioned. The inferior dermal edge is then affixed to the chest wall with horizontal mattress absorbable suture. The initial and key fixing suture is in the meridian. The next sutures are placed half the distance between the meridian and the medial and lateral ends, dividing the deepithelialized inferior edge into quarters. The dermis-to-chest wall fixation is tight in the central half between those fixing sutures and then loosens progressively medial and lateral as the natural fold does. The superior deepithelialized edge is then turned in against the inferior and closed in layered suturings, and in the depth of the slight back cut, a running absorbable suture is placed and the eversion completed with a fine running nonabsorbable suture. An important technical point when performing dermis-to-chest wall fixation is to grasp the chest wall structures

and apply light inferior traction to them as they are sutured, simulating the downward pull of the advanced tissue. The scar and fascia will occasionally descend 0.5 to 1 cm over several months, so it is important that the fixation be performed at the proper level with this light tension; otherwise, postoperatively the fold may be too low. A light compressive dressing is put inferior to the fold, holding the advanced tissue at the proper level, and a support bra is worn for at least 1 week.