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Some of the differences in the shape of the breast with respect to the IMFs are shown in Fig. 4.

Fig. 4

These are the same as in Fig #3, but the implants are above the muscle. The effect of a high IMF and of not lowering it enough is about the same above or below the muscle. The persistence of the IMF causing a double fold, as in #2 above, is not related to or dependent on the implant being above or below the muscle. It is mostly due to the fold being very high and at a very acute angle. Not all IMF folds can be lowered and not all double folds can be eliminated at surgery. Time and slow pressure can do more than surgery alone.

The angle of the fold can be described as the angle of the lower breast with the chest wall. This is very inexact and greatly affected by posture, just as whether or not a pencil can be held under the breast. The angle is more acute in #1 and more obtuse in #3 of Fig. 4.

It is not the angle, but the appearance that is important. But in Fig 4, the down pointing of the nipple and the ability to hold a pencil under the breast in #1 are eliminated by filling up the IMF area with the larger implant as shown in #3. The middle #2 drawing depicts the incompletely filled out IMF, leaving a double bubble. This is corrected by pushing out the previous IMF with blunt dissection and filling up that area with the larger implant, shown in #3.

A double fold or double bubble after surgery will not be a problem if the nipple is at or above the level of the IMF as shown here. When the nipple is below the IMF and pointing down, the IMF must be lowered to prevent further down pointing.

Ordinarily in most cases, the IMF can be lowered 2cm routinely and up to 3cm without much trouble, but not always. Though theoretically it can be lowered to the level of the umbilicus and beyond, it is still the case that a very deep fold high above the nipple may leave a double fold appearance that will not stretch out at the time of surgery. With a smooth implant and with steroids, gravity, and pressure, a double bubble can sometimes be corrected or correct itself over time. If the implant is under the muscle, this adds pressure to the IMF area.

Even here if an implant is placed in #1 above without making any effort to stretch out the inframammary fold (IMF), the result will be a high riding implant and down pointing nipple above or below the muscle and with any of the four incision sites or any of the available implants.

Any time the inframammary fold is as high or higher than the nipple, the above upper fullness and down pointing will result if the fold is not lowered. A ball in a sock appearance can result if the IMF is higher than the nipple and is not lowered by surgery.

This can be prevented or corrected at surgery simply by lowering the IMF. This is best done with a blunt dissector that lifts the subcutaneous tissue of the chest wall up off of the muscles below. This splits or separates the fascia that is the superficial pectoral fascia, which is continuous with the superficial cervical fascia in the neck above and Scarpa’s fascia of the abdomen below.

Lowering the IMF is a subcutaneous dissection. It is simple in theory and in practice. But the very high IMF with the nipple 3 centimeters or more below it cannot always be lowered enough. If the new IMF cannot be made to be lower than the nipple, then the result may not be a good appearance.

Generally the IMF can be lowered 3 cm. But it is when we try to lower it more than 4, 5, or 6 cm then the result may not be so good even if the fold is successfully lowered and it does no show as a double fold. Sometimes the low lying down pointing nipple is too low in appearance on the chest. And if the implant is centered behind a very low lying nipple the whole breast appears too low. In this case, a lift is the only surgical solution.

Because the nipple that is very low lying is going to look very low on the chest and the implant will need to be quite large aesthetically, it can be a losing battle. Theoretically though, the IMF can be lowered to the umbilicus and beyond.

The IMF in most of our straightforward cases without any drooping lowers automatically or spontaneously without any effort or special attention on the part of the surgeon when the implant is placed and centered behind the nipple.

With the axillary approach for the beginner, it is especially easy to have the fold too high or too low, causing the implant not to be centered behind the nipple.

On the table with the patient supine it is easy to think it is in the correct position, only to see it too high when the patient is brought up to the sitting position. It is usually easy to lower it, even with the implant in place, with further blunt dissection.

If the implant is too low, there are several things we can do that can lift and repair the inframammary fold without requiring an incision. This repair will be described later.


The Persistent IMF or Double Fold or Double-Bubble

A double-bubble or double fold is the original inframammary fold that has not been pressed out. It is a fold in the dermis primarily, but also in the subcutaneous tissues attached. It is not due to any mysterious ligament or fascia.

Whenever the dissection is below the muscle along the chest wall with no specific attempt to press out or stretch out the IMF, the implant can follow the chest wall and leave the previous IMF intact, causing the double fold. The freeing of the original IMF is a subcutaneous dissection, not a submuscular dissection. The proper plane is to dissect the subcutaneous fat free from the underlying muscle and fascia, leaving the fat attached to the skin.

By double fold, it is meant the new IMF plus the old IMF (inframammary fold). So that now with the old one showing, there is a double-bubble appearance.

It is the old subcutaneous and dermal fold persisting that causes the problem, nothing more. No imaginary fascial bands or ligaments are necessary. The deep and persistent IMF cannot always be corrected, because the dermis can only stretch so far. If a surgeon were called upon to create a Ubangi lip in one operation at one time, it would not be possible.

But if after surgery a double fold is prominent and McGhan textured implants were used, it will not move. The implant that is fixed like Velcro like these implants are will not act as an obturator or dilator to stretch things out. They will remain fixed in position and whatever double fold there is after surgery will probably remain.

On the other hand, if you get it dissected out and want it to stay in place, the McGhan textured will hold it in place and prevent a late occurring capsule or double fold from developing. A smooth non-textured implant can allow this to happen.

The usual mild double-bubble is not a big problem fortunately. All that is required is pressing out or stretching out the previous persistent subcutaneous and dermal inframammary fold as described above.

Even though we know that inferior to the 5th rib the dissection is more difficult and the tissue is more fibrous, as well as we could search in the cadaver or in the live patient we could not discern a structure. All we see is just dense fibrous tissue that we have always known was there.

The author of an article in the 1995 PRS Journal on the Inframmary crease ligament is in error saying, “...separation of this ligament from the fifth rib periosteum will result in the “double-bubble” phenomenon.” The problem of the double-bubble in his patient was not that some imaginary ligament was transected, but that the subcutaneous and dermal inframammary fold were not released - pushed out or stretched out, as they must be.

The author remained submuscular and subfascial until he was inferior to the IMF. Therefore he just pushed it out on top of the muscle. Maybe he has not seen the double fold with the above muscle implant, but it is just as common as below.

One needs to penetrate the pectoralis muscle and fascia attachments the 5th rib, and then the implant and dissection are subcutaneous and the IMF is corrected. He did not do this. So with his dissection plane he did not release the skin fold from the underlying muscle and fascia. He was below the muscle in this area.


In our dissection of ten breasts with our cadavers over the past five years under the guidance of our anatomist Earle Davis Ph.D., I have not found anything to suggest that there is an “inframammary crease ligament.” We find that the dermis of the fold and below it is firmly attached to the underlying fascia of the rectus abdominus, serratus anterior and pectoralis major. This is obvious in palpation of your own chest wall as well as in surgery or dissection of cadavers.


In the “Intradermal Anatomy of the Inframmary Fold” by Boutros, Sean (prs1998), with both dissection and histological study “No evidence of any ligamentous structure in the area of the inframammary fold.”


So in summary, it is not failure of transection of the imaginary ligament in below the muscle dissection that caused the problem, but failure to release the dermis from the fascia in that plane and failure to correct the original IMF by simply pressing it out with blunt dissection.

The double-bubble is simply the persistent IMF made of skin, primarily dermis. The patient’s inframammary fold that has not been stretched out to a round shape to fit the contour of the new breast. It is made only of skin. The dermis retains its shape, and will not easily stretch out to the rounded contour we want. But like the Ubangi lip, with pressure and time many persistent inframammary folds that are causing a double-bubble appearance will stretch into the rounded shape covering the augmented breast.

Sharp dissection can be used to release the tissues so they can be pressed out, but more is needed. Blunt dissection is needed. The previous IMF must be bluntly be pressed out. And sharp dissection alone has no pressure to accomplish this.

Transecting sharply or with cutting cautery or laser is often not enough to expand the previous IMF. And by forming more scar tissue, cautery and laser cutting can add to the fibrosis that will make the double bubble even more persistent. Much more can be gained by actually stretching out the skin that makes up the previous IMF with blunt dissection. The most gentle blunt dissection or simple pressure from the implant itself can over time have a great effect on the persistent IMF (double-bubble) as well as the constricted lower breast that does not easily round out, as is common with a tuberous breast.

The pushing out and stretching of the skin of the IMF is the solution to avoiding or correcting the double bubble. Like the Ubangi lip or the stretching of the abdomen in pregnancy or with use of an expander, sharp dissection not only will not accomplish the desired result, but is potentially destructive. Cautery and sharp dissection induce scar tissue that will inhibit stretching that could occur from the pressure of the implant over a period of time.


In summary, as shown above, the persistent IMF is not only in the transaxillary subpectoral or submuscular case. It is shown to be just as much of a problem above the muscle and with any incision site.  It is unrelated to any imaginary ligaments described in the literature. And thinking there is a ligament or a structure that should be searched for or dealt with is not helpful and is a distraction to the surgeon and therefore counterproductive. The treatment of the high or persistent IMF is simple and direct. It must be dissected free and pushed out.

19. What’s new at this time


Our big change is the internet. We can now communicate instantly without cost if we have internet access.


We have a web site at breast-implant.org. Just about everything, including the program of the next meeting, is there.


We will probably have most of this handbook there.


We also have a communication web site with a message board to keep everyone informed.  Send in your email address and you will receive an invitation to join that site. Send it to acscbsweb@yahoo.com

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  1984-2015 American Society of Cosmetic Breast Surgery  Last modified: March 18th, 2015