Aesth. Plast. Surg.

26:219–222, 2002
DOI: 10.1007/s00266-002-1477-0

© 2002 Springer-Verlag New York Inc.

Development of the Inframammary Fold and Ptosis in Breast Reconstruction
with Textured Tissue Expanders

Jincai Fan, Edoardo Raposio, Jiping Wang, and Rolf E.A. Nordström
Beijing, China
Helsinki, Finland

Abstract. Tissue expansion has become the most important Key words: Tissue expander—Breast reconstruction—
method for postmastectomy breast reconstruction. However, Mastectomy
well-defined inframammary fold and ptosis are difficult to
achieve with this technique. This study was performed to evalu-
ate the inframammary fold and ptosis achieved in breast recon-
struction using a textured tissue expander, later replaced by a The inframammary fold is an important landmark in the
textured implant. In ten postmastectomy patients, a textured female breast. Creation of a well-defined inframammary
tissue expander was inserted into a submuscular pocket. Every fold in breast reconstruction is a fundamental element in
two to three weeks the volume of the expander was increased obtaining a good aesthetic result. Moreover, matching
by about 30%. About three months after the last filling, the the contralateral side is very important, especially re-
expander was removed and replaced with a permanent textured, garding the shape of the inferior part of the breast. Tissue
gel-filled implant. The profile of the reconstructed breast was expansion has become the most important method for
recorded before and after the tissue expansion, as well as before postmastectomy breast reconstruction, creating a soft-
and after the change of the implant. The results showed that the tissue envelope to receive a permanent mammary im-
inframammary fold did not move significantly upwards or plant [1,4,6,9,11,15]. However, problems related to this
downwards during the expansion period when a textured tissue reconstructive procedure, for example, how to create a
expander was used. Waiting three months after the last inflation well-defined inframammary fold and ptosis, still exist
of the expander before replacing it with the permanent implant [4]. Using a textured tissue expander has been suggested
resulted in a more ptotic breast mound. Usually, however, no as a solution to this problem [8]. The purpose of this
real ptosis was achieved, meaning that the angle between the study was to assess the effectiveness of an anatomical,
lower part of the breast and the lower chest wall was more than textured tissue expander to develop a well-defined infra-
90 degrees. These findings indicate that a textured expander mammary fold and ptosis.
could help create a pronounced inframammary fold, but with-
out ptosis. A three-month waiting period before inserting the Material and Methods
permanent implant may improve the development of an infra-
mammary fold. Ten patients (50 ± 2 years old), who had undergone
unilateral modified radical mastectomy for the breast
carcinoma more than one year before, were candidates
for the breast reconstruction with textured tissue expand-
ers. Prior to the operation, the level of the inframammary
This paper was presented at the 11th Congress of The Interna- fold of the breast to be reconstructed was marked ac-
tional Confederation for Plastic, Reconstructive and Aesthetic cording to the contralateral breast in a standing position.
Surgery, Yokohama, Japan, on April 16–21, 1995. A textured, center-valve tissue expander (Style 133, Mc-
Correspondence to: J. Fan, MD, PhD, Mid-2 Division of Plastic Ghan Medical Corporation, USA), 400 ml in six patients
Surgery, Plastic Surgery Hospital, Chinese Academy of Medi- and 500 ml in four was inserted in a submuscular pocket.
cal Sciences, Ba-Da-Chu Road, Beijing 100041, China; email: The pocket was created by opening the old postmastec-
fanjincaidoctor@sina.com tomy scar and elevating the inferior part from the chest

USA) 330–390 ml in vol. At the end of the The correlation between the projection of the expanded operation.15]. McGhan Medical Corporation. except for common midclavicular line by means of a specially designed plas. correlated the tissue expander. as well as the angle be- tween the lower chest wall and the inferior breast mound.5 cm in the midclavicular line. Modified radical mastectomy is suit- profile of the reconstructed breast was recorded in the able for this technique. The projection of the expanded breast mound. The changed it to an average of 99 degrees (p < 0. Three months after the without ptosis (Figs. 1. Inflation was started two during the three-month maturation period (n ⳱ 8. the inframammary fold moved up or to the filled expander volume.9. with two to three week inter. a desired 30% expansion was usually achieved in three to five months. as well as before struction (immediate and delayed) after mastectomy and after the replacement of the permanent implant. complications [1–4. the expander was replaced with a textured anatomical gel-filled implant (BioDimensional RTV. incision was closed in three layers. the correla- tion between the filling volume and the changes ob- served in the projection of the reconstructed breast. Hewlett Packard. resulting in expander volume about 30% over the develop a well-defined inframammary fold. until the dead space was filled. .01) (Fig.6. corresponding to the angle between the lower chest wall and the inferior breast mound. Correlation be- between the lower chest wall and the inferior breast tween projection of breast and final filling volume in eight mound developed to an average of 112 degrees during patients. Results In the ten patients who had undergone the serial tissue expansion. tissue expansion does not ter strip. However.5 down 1. The Student t-test was used for statistical analysis of the obtained data. scanned (ScanJet IIc. These pro- files allowed us to measure. if necessary. USA). 䊐 After three the tissue expansion.220 Breast Reconstruction with Textured Tissue Expanders Fig. 2. shows that a three-month maturing period before the replacement of a permanent implant significantly increases drop-shape of the expanded breast.8. and transferred to a desktop computer. has become a very important method for breast recon- Before and after the tissue expansion. During the same operation. is shown a slight increase (0. 3.05).11. due to its simplicity and effectiveness. 䊏 Immediate after the final filling. wall by detaching the pectoralis major muscle. structed breast.5 cm more projection was achieved the skin over the expander. A vacuum before replacement of the expander with the implant drain was placed in the pocket for blood draining. the inframammary fold position. but usually nominal volume of the expander. This technique showed that it is able to help to vals. The angle cm in mean) three months after latest filling. Tissue expansion. last filling. 1). the [1–4. Discussion ume.0 ± 0. The data achieved in this way were then copied usually create a well-defined inframammary fold and onto paper.15].9. with accuracy. During the inflation of Fig. 2. p < weeks after the operation. Development of the inframammary fold of the reconstructed breast.11. and a three-month waiting period months maturing period. 4). while avoiding blanching An average of 0. the con- tralateral breast alteration was done to match the recon. 0. the expander was inflated with normal saline breast mound and the filling volume is shown in Fig.

3. (A) Preoperative view. (B) View after the change of implant six months later. Three months after the last filling.8]. A 49-year-old woman undergoing breast reconstruction with a 400 ml textured tissue expander one year after modified radical mastectomy. 221 Fig. filled expander before change of implant.12–14]. (B) View of the full- radical mastectomy. The expander was filled with 550 ml nor. Extra operations A solution for creating a well-defined inframammary to reconstruct the inframammary fold are presented. ptosis breast. 4. immediate breast reconstruction [7. especially in this external approach often produces an unsightly scar. even though the external approach combined with toralis major muscle or large overexpansion has been expanding the lower part of chest below the inframam- suggested [2]. such fold and some degree of ptosis breast has been suggested as the Pennisi technique (internal approach) and the by using a textured tissue expander [8]. The expander was filled with 520 ml normal saline over the three months following insertion in the submuscular pocket. the results are usually not satisfactory but mary fold seems to get more stable results [13. Although tissue expansion above the pec. Fig. a specially designed plaster submuscular pocket. In this study we Ryan technique (external approach) for this purpose have evaluated the effectiveness of the textured tissue [5. However. But instead. A 55-year-old woman undergoing breast reconstruction expander was replaced with a 360-ml textured anatomical gel- with a 400 ml textured tissue expander two years after modified filled implant. again. (C) View after the mal saline over the three months following insertion in the change of implant in one week.14]. the strip used for the study measurement. the expander was replaced with a 360-ml textured anatomical gel-filled implant. usually increasing complications. Fan et al. both operations do not have expander to create a well-defined inframammary fold or stable results but the inframammary fold becomes obtuse ptotic breast by carefully following up the profiles of the . Three months after the last filling.10. (A) Preoperative view on the operation table.J.

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