Things to consider when conducting inframammary fold incision

In the first surgery, I tend to select axillary / inframammary / areola incision in ratio of 4:4:2. I tend to hear some weird informations when I talk to the patients. Some tell me that “inframammary fold incision is only for the beginning surgeons because it is a basic skill.”



I thought that this was some nonsense when hearing it from a perspective of a well experienced surgeon. This is why today, I would like to share about the things to consider when conducting inframammary incision.

Inframammary fold incision is not something good for beginners to perform.

All surgeries have some things that are easy and not, but we cannot say that appendectomy and cesarean or any other operations are easy. Nothing are as simple as you say.

The problem with the inframammary fold incision is the location of the incision.



Desquamation and putting in the implant are enough for areola or umbilical incisions. But for inframammary fold incision, first we need to estimate where the inframammary fold is and then conduct the incision.

So if the incision itself is done is the wrong place, there is no turning back. When we design the surgery, we need to exactly estimate the correct incision spot. This requires much experience.

This is not something that can be done lightly. There are many different variables for different patients such as the area of the implant and the other is how elastic the skin is.



The area of the implant can be found in the information provided by the manufacturers and we refer to that when drawing out the location where the implant would be put in. The problem here is that when the implant goes in into the breast, the skin gets pulled and becomes tight causing the areola/nipple to shift from the original location. So we need to foresee this change and know where the areola/nipple to shift to in order to draw out the implant housing position.

There is another variable. It is the distance between the nipple and the inframammary fold. The skin in this area extends in different degree from one person to another. So when we design the procedure, the assistant has to pull the breast skin towards the collar bone and measure the distance from the nipple to see where the new position of the inframammary fold would be.

In most of the time, the doctor uses formula of implant height and others in order to find out the distance between the areola and the new inframammary fold. The number would increase for aged patients who have loose skin and decrease for those young patients who have tight skin.

It also becomes difficult if the location of areola and the breast mound are different. If the right breast is rather higher than the left, then the implant pocket of the left breast would have to be made below the pectoralis muscle and there should be dual plane on the right breasts so that the right breast is pulled up more with the usage of the implant. We consider this point and design the procedure so that the left and right breasts are at the same height level after the breast augmentation.



It becomes a little easier if the left breast if lower than the right but it is larger than the right breast. If we put in larger sized implant on the left breast than the implant would pull down making the inframammary fold of both breasts at the same level.

Suture is also important in inframammary fold incision. It is different to that of axillary and umbilical incision. The incision is done on the bottom part of the breast and this has to hold the implant. If there is some inflammation caused or the stitch loosens then the whole surgery must be conducted again.

Not only is stitching necessary, but we need to maintain the capsule and others as much as possible along with precise desquamation. We need to suture all the structures in the body in perfect shape. The surgeon needs to be careful of all these factors in order to avoid any complications that might be caused.

Inframammary fold incision can be applied to any shape of breasts and any situations with many different techniques to come up with best possible result. But, one must be more careful about the things that you do not need to be careful of in other incision methods in order to avoid any complications and problems.

This is why inexperienced doctor cannot perform with good result.

I hope the contents have helped you today.
Thank you for reading and have a great day.

What do I need to do if my breasts sag after breast implant augmentation?

Some of you might be getting married or are planning to give birth before breast augmentation. Today, I would like to share about what to do in case your breasts sag after breast augmentation due to aging or giving birth / breastfeeding.

One thing that you should recognize is that not one same pattern applies to everyone. The things that can happen to you after breast augmentation varies from one person to another. Therefore, I would like to share some different types and what you can do with you face such problems.

1) Losing skin elasticity

This is when you breasts look like that they lost volume in the upper side, and sag a little. This is not complete sagging but the breast skin has lost some elasticity..
There are those who require a change to a larger implant in such case. The larger implant would pull on the skin making the skin tighter. This makes the breast skin more elastic.




If you have used small size implant more so than what should have been used considering your physical body, it could be better to increase the size of the changing implant. But in general, your skin is thin and weak therefore, larger implant used could only lead to more sagging of the breast.

If the size of the implant was appropriate in the first surgery, it is better to maintain that size in the surgeries after. If you do increase the size of the implant, then it is recommended that you use form stable implant.

The 5th generation silicone gel, i.e. form stable implant was introduced 5 years ago in our country. All of those patients who got breast augmentation before that time used unstable implants. Such implants are not helpful in avoiding the sagging therefore it is better to replace such implants for better shape and elasticity.
One thing that you should keep in mind when changing to larger implants is that there is more possibility of suffering capsular contracture.



I have experienced this many times and I think this is what happens in the re-surgeries. If the original implants did not cause any problems then it means that the implants have no effect on the surroundings., that the implant matched well with the breasts. But if the new set of implants come into the body, the body may react by attacking rather than adapting. Therefore, such activity could end up in capsular contracture in some cases.
Also, you would have to make the size of the pocket larger for the larger implant. We cannot take this lightly and just make the pocket larger. We must remove the capsule as much as possible. For such reasons, I recommend areola or inframammary fold incision rather than the axillary incision for re-surgeries.

2) Low degree of capsular contracture holding up the implant at the upper part and the skin losing some elasticity (fake sagging)

If you have a severe case of capsular contracture, then you would have visited the hospital before you came in for the problem of sagging breasts. If you have low degree of capsular contracture, you tend to stay as you are. (You might not even think that you have capsular contracture) The implant is caught up by the capsular contracture and when you give birth and sagging is caused, an elephant shape is caused because the upper breast only has implant and the lower breast is only composed of your breast tissue.



This is not real sagging but a fake sagging of the breasts. The nipples are facing downwards and the implants are captured at the upper part of your breasts.

Patients think that they have the upper bulge in the breast after giving birth or breastfeeding. Such problem can be solved by opening up the capsule. You would not need general anesthesia in some cases.


But if you have a severe case of capsular contracture then you might need re-surgery that requires shifting of the implant to lower spot or applying dual plane procedure. This would require general anesthesia.

3) Severe case of capsular contracture

If you have a severe case of breast sagging then this would require correction (breast lifting). But the problem is that there already are implants in your breasts. We need to decide on what to do with these implants.

At times, we just remove the implants and conduct the correction surgery. This would apply to those patients who had large original breasts or have had the implants for a very long time. Some might perceive the implants to be bad for them due to many pregnancies or even some might want to remove the implants due to the complications that they have suffered.



Such cases would result in rather simple correction surgeries. But if the implants have been in the body for a long time, these implants make the breast tissue cells contract and thin. Such outcome could limit what we can do during the correction surgery.

But most of the patients want to continue to use the original implants or even use larger ones for re-surgeries. This is a problem. The more severe the lifting surgery is, the blood circulation to your skin and areola/nipple gets cut off. Lifting requires desquamation of much tissue cells and replacement therefore there are a lot of bleeding. Such activity limits the blood supply into the nipple.

Therefore, if we have to replace the implants and correct the sagging breasts, we need to forego some greed on trying to do too much lifting. We should correct the breasts to only some degree, not perfect. But, if you want aggressive correction done, then we need to do the lifting first then place the implants back into the breasts after much time.

The new implants should be form stable implants and we need to remove the capsule as much as possible. Also, we need to use the suction drain.


It is better to do as little incision as possible when conducting the correction for sagging breasts. It is better to do the incision around the areola rather than conducting vertical incision of inverted T incision.

There is nothing dangerous about conducting correction surgery and using the implant in the very first breast augmentation. This is conducted with normal, usual state of blood circulation/supply. But the environment changes in the re-surgery. The implants have made the breast skin thinner and the blood circulation is already somewhat damaged.

Therefore conducting surgery could limit the blood circulation and leading to complications.

The correction should not be too aggressive and if the sagging is very much severe, then the whole process can be conducted in two procedures.