Aesth. Plast. Surg.

26:219222, 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. Nordstrm
Beijing, China
Helsinki, Finland

Abstract. Tissue expansion has become the most important

method for postmastectomy breast reconstruction. However,
well-defined inframammary fold and ptosis are difficult to
achieve with this technique. This study was performed to evaluate the inframammary fold and ptosis achieved in breast reconstruction using a textured tissue expander, later replaced by a
textured implant. In ten postmastectomy patients, a textured
tissue expander was inserted into a submuscular pocket. Every
two to three weeks the volume of the expander was increased
by about 30%. About three months after the last filling, the
expander was removed and replaced with a permanent textured,
gel-filled implant. The profile of the reconstructed breast was
recorded before and after the tissue expansion, as well as before
and after the change of the implant. The results showed that the
inframammary fold did not move significantly upwards or
downwards during the expansion period when a textured tissue
expander was used. Waiting three months after the last inflation
of the expander before replacing it with the permanent implant
resulted in a more ptotic breast mound. Usually, however, no
real ptosis was achieved, meaning that the angle between the
lower part of the breast and the lower chest wall was more than
90 degrees. These findings indicate that a textured expander
could help create a pronounced inframammary fold, but without ptosis. A three-month waiting period before inserting the
permanent implant may improve the development of an inframammary fold.

This paper was presented at the 11th Congress of The International Confederation for Plastic, Reconstructive and Aesthetic
Surgery, Yokohama, Japan, on April 1621, 1995.
Correspondence to: J. Fan, MD, PhD, Mid-2 Division of Plastic
Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Ba-Da-Chu Road, Beijing 100041, China; email:
fanjincaidoctor@sina.com

Key words: Tissue expanderBreast reconstruction

Mastectomy

The inframammary fold is an important landmark in the

female breast. Creation of a well-defined inframammary
fold in breast reconstruction is a fundamental element in
obtaining a good aesthetic result. Moreover, matching
the contralateral side is very important, especially regarding the shape of the inferior part of the breast. Tissue
expansion has become the most important method for
postmastectomy breast reconstruction, creating a softtissue envelope to receive a permanent mammary implant [1,4,6,9,11,15]. However, problems related to this
reconstructive procedure, for example, how to create a
well-defined inframammary fold and ptosis, still exist
[4]. Using a textured tissue expander has been suggested
as a solution to this problem [8]. The purpose of this
study was to assess the effectiveness of an anatomical,
textured tissue expander to develop a well-defined inframammary fold and ptosis.
Material and Methods
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 expanders. Prior to the operation, the level of the inframammary
fold of the breast to be reconstructed was marked according to the contralateral breast in a standing position.
A textured, center-valve tissue expander (Style 133, McGhan Medical Corporation, USA), 400 ml in six patients
and 500 ml in four was inserted in a submuscular pocket.
The pocket was created by opening the old postmastectomy scar and elevating the inferior part from the chest

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Breast Reconstruction with Textured Tissue Expanders

Fig. 1. Development of the inframammary fold of

the reconstructed breast, corresponding to the
angle between the lower chest wall and the
inferior breast mound, shows that a three-month
maturing period before the replacement of a
permanent implant significantly increases
drop-shape of the expanded breast.

wall by detaching the pectoralis major muscle. A vacuum

drain was placed in the pocket for blood draining. The
incision was closed in three layers. At the end of the
operation, the expander was inflated with normal saline
until the dead space was filled, while avoiding blanching
the skin over the expander. Inflation was started two
weeks after the operation, with two to three week intervals, resulting in expander volume about 30% over the
nominal volume of the expander. Three months after the
last filling, the expander was replaced with a textured
anatomical gel-filled implant (BioDimensional RTV,
McGhan Medical Corporation, USA) 330390 ml in volume. During the same operation, if necessary, the contralateral breast alteration was done to match the reconstructed breast.
Before and after the tissue expansion, as well as before
and after the replacement of the permanent implant, the
profile of the reconstructed breast was recorded in the
midclavicular line by means of a specially designed plaster strip. The data achieved in this way were then copied
onto paper, scanned (ScanJet IIc, Hewlett Packard,
USA), and transferred to a desktop computer. These profiles allowed us to measure, with accuracy, the correlation between the filling volume and the changes observed in the projection of the reconstructed breast, the
inframammary fold position, as well as the angle between the lower chest wall and the inferior breast mound.
The Student t-test was used for statistical analysis of the
obtained data.

before replacement of the expander with the implant

changed it to an average of 99 degrees (p < 0.01) (Fig. 1).
The correlation between the projection of the expanded
breast mound and the filling volume is shown in Fig. 2.
An average of 0.5 cm more projection was achieved
during the three-month maturation period (n 8; p <
0.05). This technique showed that it is able to help to
develop a well-defined inframammary fold, but usually
without ptosis (Figs. 3, 4).
Discussion
Tissue expansion, due to its simplicity and effectiveness,
has become a very important method for breast reconstruction (immediate and delayed) after mastectomy
[14,6,8,9,11,15]. Modified radical mastectomy is suitable for this technique. However, except for common
complications [14,9,11,15], tissue expansion does not
usually create a well-defined inframammary fold and

Results
In the ten patients who had undergone the serial tissue
expansion, a desired 30% expansion was usually
achieved in three to five months. During the inflation of
the tissue expander, the inframammary fold moved up or
down 1.0 0.5 cm in the midclavicular line. The angle
between the lower chest wall and the inferior breast
mound developed to an average of 112 degrees during
the tissue expansion, and a three-month waiting period

Fig. 2. The projection of the expanded breast mound, correlated

to the filled expander volume, is shown a slight increase (0.5
cm in mean) three months after latest filling. Correlation between projection of breast and final filling volume in eight
patients. Immediate after the final filling. After three
months maturing period.

J. Fan et al.

Fig. 3. A 55-year-old woman undergoing breast reconstruction

with a 400 ml textured tissue expander two years after modified
radical mastectomy. The expander was filled with 550 ml normal saline over the three months following insertion in the
submuscular pocket. Three months after the last filling, the

221

expander was replaced with a 360-ml textured anatomical gelfilled implant. (A) Preoperative view. (B) View of the fullfilled expander before change of implant. (C) View after the
change of implant in one week, a specially designed plaster
strip used for the study measurement.

Fig. 4. A 49-year-old woman undergoing

breast reconstruction with a 400 ml
textured tissue expander one year after
modified radical mastectomy. The
expander was filled with 520 ml normal
saline over the three months following
insertion in the submuscular pocket. Three
months after the last filling, the expander
was replaced with a 360-ml textured
anatomical gel-filled implant. (A)
Preoperative view on the operation table.
(B) View after the change of implant six
months later.

ptosis breast. Although tissue expansion above the pectoralis major muscle or large overexpansion has been
suggested [2], the results are usually not satisfactory but
instead, usually increasing complications, especially in
immediate breast reconstruction [7,8]. Extra operations
to reconstruct the inframammary fold are presented, such
as the Pennisi technique (internal approach) and the
Ryan technique (external approach) for this purpose
[5,10,1214]. However, both operations do not have
stable results but the inframammary fold becomes obtuse

again, even though the external approach combined with

expanding the lower part of chest below the inframammary fold seems to get more stable results [13,14]. But
this external approach often produces an unsightly scar.
A solution for creating a well-defined inframammary
fold and some degree of ptosis breast has been suggested
by using a textured tissue expander [8]. In this study we
have evaluated the effectiveness of the textured tissue
expander to create a well-defined inframammary fold or
ptotic breast by carefully following up the profiles of the

222

reconstructed breast mound. Our experience is that a textured tissue expander is well fixed to its surrounding by
its rough surface and will stay in place whereas a smooth
tissue expander often does not. This can, to a certain
degree, help to develop a well-defined inframammary
fold but usually without ptosis. A three-month waiting
period before replacement with a permanent implant further develops the inframammary fold, makes the expanded breast mound more drop-shaped and slightly increases the projection of the inferior part of reconstructed
breast mound.
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