A Novel Classification of the Inframammary Fold for Use in Primary Breast Augmentation

We congratulate Phillips et al. on a fine study regarding the inframammary fold in women presenting for breast augmentation.1 The authors also note the lack of conformity regarding inframammary fold histology among investigators. We also wish to highlight some issues. Caveat 1: The inframammary fold is a variable structure that may be poorly formed in severe hypoplasia (type F0 and F1 breasts, 26 percent in their study). When the inframammary fold is better developed, it is essentially a subcutaneous structure occurring between the superficial fascia and the skin, but it also has a deeper component, emanating from deeper structures (i.e., deep fascia or periosteum), that is more tenuous. Raising the arm stretches the poorly formed subcutaneous structure and effaces it in F0 and F1 breasts. In contrast, in patients presenting with macromastia,2 the fold was always present (F3). Caveat 2: The inframammary fold is mainly a subcutaneous structure, similar to the nasolabial fold or buttock crease. If a new fold is created, the whole length of the original inframammary fold must be destroyed from medial to lateral or it will persist, especially in the F3 breast. If a new fold is formed, it should ideally be recreated from the medial aspect of the breast to its lateral aspect, not just along the suture line. Caveat 3: A double-bubble deformity3 occurs when a prosthesis is placed below the original inframammary fold, unless the original fold is totally destroyed, which becomes more difficult as the inframammary fold definition increases. The deformity occurs irrespective of the plane in which the prosthesis is inserted. It will be more obvious clinically in F3 breasts if the neo-inframammary fold is designed lower than the original fold, as shown in their study. It is the subcutaneous part of the inframammary fold that persists. If the prosthesis is bigger than the vertical breast foot plate, this will create a double bubble, except when there is a poorly defined fold (type F0 and F1). Caveat 4: There is a ratio of suprasternal notch to nipple::nipple–inframammary fold of usually 21:7 in the “ideal” breast.4 Nipple position is slightly changed by augmentation; it is usually elevated by approximately 1 cm. In contrast, the nipple-to-inframammary fold distance lengthens with augmentation, even if the original inframammary fold is retained. Hence, by insertion of a “large” prosthesis combined with lowering the inframammary fold (2 cm or more), that “golden ratio” is distorted, which may lead to the “headlight” breast, where the nipple sits in the middle of the breast and the suprasternal notch-to-nipple distance is similar to the nipple-to-inframammary fold. Caveat 5: The inframammary fold will descend with time due to the weight of the prosthesis5 and aging. Fixation of the incision/fold is critical to minimize this outcome. The inframammary incision is usually about 5 cm long, but the inframammary fold runs from the medial aspect of the breast to the anterior axillary line. These inframammary fold sutures, acting together with the integrity and strength of the rest of the inframammary fold, provides support to the prosthesis. The inframammary fold is more tenuous between the deep fascia/muscle and the superficial fascia. It is in this plane that the prosthesis descends and accounts for a late presentation of a double-bubble deformity. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Don A. Hudson, F.R.C.S., F.C.S.(S.A.), M.Med., F.A.C.S.N. Bruce Lelala, F.C.Plast., M.Med.Department of Plastic and Reconstructive SurgeryGroote Schuur Hospital andUniversity of Cape TownCape Town, South Africa