Nature
tends to want to go back the way it was. Therefore it is expected that the IMF
area will heal back more densely than the superior areas surrounding the
implants, thus pushing the implants up with capsule contracture. Capsule
contracture causes the implants to rise up on the chest.
Capsule
contraction begins in this lower area of the pocket. It is the healing down of
the previous IMF that has been dissected up and pressed out to accommodate the
implant. As the capsule forms, the implant is pushed up. It may be because of
exposure of the deep dermis with the stretching out of the previous IMF that
this tends to want to heal back.
|
Fig.
3 |
The
nipple pointing down in #1 is converted to a more desirable appearance in #3 by
lowering the IMF and perhaps using a larger implant to fill the new volume below
the nipple created. In #2,
the IMF has been lowered,
but a double fold remains. This is the original IMF that has not been pressed
out. These implants are below the muscle.
A
textured McGhan implant will not move down and press it out.
It remains with adherence,
like Velcro
,
where it is placed. Sometimes with a
smooth implant,
gravity and pressure, especially if under the muscle,
will correct a minor double fold. The presence of steroid also will help and
prevent rapid healing and worsening of the double fold appearance.
2.
The importance of the new IMF position
The
inframammary fold (IMF) also warrants discussion because the management of this
area is the key to an attractive shape in many cases.
A
larger implant requires more lowering of the IMF. If the IMF is not low enough,
the implant will appear too high. The implant should appear to be centered
behind the nipple while on the table and with the head of the table elevated to
a sitting position.
In
the breast with ptosis or pseudoptosis, the position of the IMF and implant size
are critical to the appearance. The "ball-in-a-sock" and down pointing
nipple result when the fold is not lowered, and can often be corrected by
lowering the fold.
The
"double-bubble", or double fold, is the persistence of the previous
IMF. This can occur with all incisions and either above or below the muscle.
Some
of the important effects of the inframammary position and IMF dissection are:
1. Too high or too low appearance
2. Direction of nipple pointing
3. Double fold or double-bubble
4. Synmastia or uni-breast
5. Ptosis and pendulous breast
6. Implant size
7. Capsule contraction
7. Palpability of the implant
8. Ball in the sock appearance
9. The breast shape
10. The curve of the CN and NC lines.
(clavicle-nipple=CN, nipple-chest=NC - profile lines)
11. Asymmetry
At surgery some common important considerations to observe and correct if possible are
1. Too high
2. Too low
3. Unequal - asymmetrical
4. Cleavage
5. Size
6, Persistent original IMF - double bubble
7. Pointing direction
8. Implant centering
9. Feel to palpation
10. Flow with movement and position change
11. Shape front and profile