Many wastewater treatment plants in the USA, which were originally designed as secondary treatment systems with no or partial nitrification requirements, are facing increased flows, loads, and more stringent ammonia discharge limits. Plant expansion is often not cost-effective due to either high construction costs or lack of land. Under these circumstances, integrated fixed-film activated sludge (IFAS) systems using both suspended growth and biofilms that grow attached to a fixed plastic structured sheet media are found to be a viable solution for solving the challenges. Multiple plants have been retrofitted with such IFAS systems in the past few years. The system has proven to be efficient and reliable in achieving not only consistent nitrification, but also enhanced bio-chemical oxygen demand removal and sludge settling characteristics. This paper presents long-term practical experiences with the IFAS system design, operation and maintenance, and performance for three full-scale plants with distinct processes; that is, a trickling filter/solids contact process, a conventional plug flow activated sludge process and an extended aeration process.