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Breast Sagging classification Dr Barry Eppley IndianapolisBackground: It is well known in breast implant surgery that the final shape of the breasts afterwards is highly influenced by what they looked like before. Besides asymmetry, the most common adverse breast shape problem seen in breast augmentation patients is sagging or ptosis. Such breast mound sagging can occur in many degrees of which most will require some type of breast lift technique to adequately address at the time of implant placement.

The most challenging breast sagging problem in breast implant surgery, in my experience and opinion, is the woman with a more mild or first degree breast ptosis. The amount of sagging they have is not quite enough to justify a breast lift. But there is enough sagging that the implants will likely drive down the nipple on the breast mound in a more downward direction or force most of the breast mound on the bottom side of the implant. This is a particular risk when the patients desires larger breast implant sizes.

In mild cases of breast sagging there are several strategies to help the breast mound and nipple get centered over the implants. The most common approach is to lower the inframammary folds (IMF) to center the implants over the low hanging nipple. An accompanying technique is a superior crescent mastopexy or an upper nipple lift. This simple technique helps move the nipple up on the breast mound up to 1 cm superiorly

Case Study: This 34 year-old female wanted breast implant surgery but had some moderate breast sagging after multiple pregnancies. She did not appear to have enough sagging to warrant a breast lift and did want such scars anyway. She also wanted larger breast implants.

Breast Implant Surgery with IMF lowering results front view Dr Barry Eppley IndianapolisUnder general anesthesia, 650cc silicone breast implants were placed in a partial submuscular plane through inframammary incisions. The original inframammary fold (IMF) creases were still evident above the new fold levels. The original inframammary fold creases were released right under the skin and rigotomies were also done using an 18 gauge needle. Superior nipple lifts were also done.

Breast Implant Surgery with IMF lowering result oblique view Dr Barry Eppley IndianapolisBreast Implant Surgery with IMF lowering results side view Dr Barry Eppley IndianapolisHer postoperative results show a centric nipple position on the enlarged breast mounds. Her nipple lift scars are barely noticeable at this early healing period. The original inframammary fold (IMF) creases are still present. Whether they will ever completely go away and round out remains to be determined.

Management of the persistent fold crease in breast implant surgery when the inframammary folds (IMF) are lowered can be done through several strategies. One technique is further rigotomies of the crease line with underlying fat grafting. Another technique is to reposition the implants up higher and re-establish the original inframammary fold levels.


1) Breasts that have mild to moderate degrees of sagging poses challenges in breast implant surgery.

2) Lowering of the inframammary fold (IMF) is one maneuver in breast implant surgery that can help avoid the need for a more formal breast lift.

3) Persistence of the original inframammary fold crease is one of the trade-offs, as well as the risk of bottoming out, when the inframammary fold is lowered in breast implant surgery.

Dr. Barry Eppley

Indianapolis, Indiana

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