Inframammary Fold: A Histologic Reappraisal

Abstract

The inframammary fold is a defining element in the shape and structure of the female breast. It should be preserved whenever possible in ablative procedures and recreated accurately when the breast is reconstructed after mastectomy. To date, no accurate anatomic description of this essential structure exists. Previous studies have suggested that the fold is produced by a supporting ligament running from the dermis in the fold region to a variety of locations on the rib cage. This clinic's experience with mastectomy, augmentation mammaplasty, and breast reconstruction does not support the existence of a ligamentous structure. To define the structure of the inframammary fold, 10 female and 2 male cadavers were studied. The anterior chest wall was removed en bloc and frozen in orthostatic position. Parasagittal sections were made of the inframammary fold with the chest wall intact. After decalcification of the ribs and routine histologic preparation, thin sections were stained with Gomori's trichrome. On light microscopic examination, no demonstrable ligamentous structure of dense regular connective tissue could be identified in the fold region in any of the 12 specimens. Superficial and deep fascial layers were uniformly observed anterior to the pectoralis major and serratus anterior muscles. The superficial fascia was connected to the dermis in the fold region in a variety of configurations. In some cases, the deep fascia fused with the superficial fascia and dermis at the fold level. In other cases, bundles of collagen fibers arising from the superficial fascial layer were found to insert into the dermis at the inframammary fold, slightly inferior to it, or both. These bundles were observed consistently in sections from the sternum to the middle axillary line. They were distinct from Cooper's suspensory ligaments, which are seen more superiorly in the glandular tissue.

Incidence of the superficial fascia and its relevance in skin‐sparing mastectomy

“…10 However, the specific architecture of the superficial fascia in the breast region remains controversial: Anatomists have claimed that the SL divides into a superficial layer (SL, Camper) and a deep layer (Scarpa), with the mammary gland enclosed between the two. 11 This concept has been rejected by others, mainly surgeons. 12 In 1956, Haagensen, who was convinced of the existence of the SL, stated that it is seen only by surgeons who look for it closely but can provide them with a useful guide to dissect skin flaps in a relatively avascular plane without including any mammary tissue.…”

Understanding the Fascial Supporting Network of the Breast

“…Muntan et al 11 described the fascia of the fold as having different configurations; the deep fascia being fused with the superficial fascia at the fold level or alternatively, bundles of fibers arising from the superficial fascial layer and inserting into dermis. Boutros et al 12 in a later study said that there was no evidence of a ligamentous structure in the area of the inframammary fold and that it is an intrinsic dermal structure consisting of regular arrays of collagen held in place by a zone of adherence that is a specialized area of the superficial fascial system.…”

High Transverse Capsuloplasty for the Correction of Malpositioned Implants Following Augmentation Mammoplasty in Partial Submuscular Plane

“…Bottoming down is one of the most common clinical forms of malplacement. The anatomy of the inframammary crease has been discussed extensively [14,15], and lowering the inframammary crease is commonly performed in patients with lack of a breast envelope on the lower pole without any untoward affects on breast aesthetics [13,16]. Bottoming down is frequently reported following augmentation in both subglandular and submuscular pockets [3,5,11].…”