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This document provides an overview of breast anatomy relevant to plastic surgery. It describes the borders and components of the breast, including parenchyma, Cooper's ligaments, the nipple-areolar complex, vascular supply, lymphatics, innervation, and associated musculature. Gynecomastia, the enlargement of male breast tissue, is also briefly discussed.
This document provides an overview of breast anatomy relevant to plastic surgery. It describes the borders and components of the breast, including parenchyma, Cooper's ligaments, the nipple-areolar complex, vascular supply, lymphatics, innervation, and associated musculature. Gynecomastia, the enlargement of male breast tissue, is also briefly discussed.
This document provides an overview of breast anatomy relevant to plastic surgery. It describes the borders and components of the breast, including parenchyma, Cooper's ligaments, the nipple-areolar complex, vascular supply, lymphatics, innervation, and associated musculature. Gynecomastia, the enlargement of male breast tissue, is also briefly discussed.
gynecomastia) Anatomy for plastic surgery of the breast Parenchymal borders:
• Superior border: clavicle
• Medial border: sternum • Inferior border: inframammary fold • Lateral border: anterior border of the latissimus dorsi Parenchyma • The functioning parenchyma produces milk in the post-partum period. Adipose tissue comprises a significant amount of the breast volume, representing 50–70% of the breast volume. • With age and the hormonal changes of menopause, the glandular tissue of the breast involutes, increasing the adipose to parenchymal tissue ratio. • The Cooper’s ligaments provide numerous interconnections between the deep and superficial fascial layers. These ligaments pass through ad invest in the breast parenchyma securing to the pectoralis fascia. With attenuation of these support structures, breast ptosis will develop. Nipple areola complex • The nipple areola complex is the primary landmark of the breast. • The nipple itself may project as much as ≥1 cm, with a diameter of approximately 4–7 mm. • The areola consists of pigmented skin surrounding the nipple proper and is on average approximately 4.2–4.5 cm in diameter. • The areola consists of keratinized, stratified epithelium and contains not only the lactiferous sinus openings, but also sebaceous glands and the Montgomery glands. • Deep to the nipple and areolar there are smooth muscle fibers which are arranged circumferentially and radially. These fibers are attached to the thick connective tissue of the areola and are responsible for nipple erection. Vascularity • The breast has a rich vascular supply from multiple arterial sources. • The primary arterial supply includes three main sources: the internal mammary perforators, lateral thoracic artery and the anterolateral intercostal perforators. • Additional arterial supply includes the thoracoacromial artery and its perforators and the vessels of the serratus anterior. • The internal mammary perforators enter the superior medial portion of the breast via the second through sixth intercostal spaces. The second and third perforators are the predominant of these perforating vessels. Because of their larger caliber the second or third perforators are the preferred recipient vessels for free tissue reconstruction using the internal mammary perforators. • Supplying the superolateral aspect of the breast is the lateral thoracic or external mammary artery. This vessel is a primary branch of the axillary artery and enters the breast after passing around the lateral border of the pectoralis major muscle at the inferior aspect of the axilla. It distributes its branches in the upper outer quadrant of the breast. • The lateral intercostal vessels represent an additional important blood supply of the breast. The lateral breast receives anterior intercostal arteries from the third through sixth interspaces. These vessels perforate the serratus anterior just lateral to the pectoral border. Lateral intercostal vessels enter the breast at the anterior margin of the latissimus dorsi to supply the lateral breast and overlying skin. • Medial intercostal perforators are responsible for direct supply of the inferior central portion of the breast inferior to the nipple areolar complex. • Venous drainage of the breast is via two systems. The subdermal venous plexus above the superficial fascia is quite variable and represents the superficial system. The veins arise from the periareolar venous plexus within the parenchyma, the superficial systems anastomose with the deep system. The deep system parallels the arterial supply with the veins paired to their respective arteries. Venous perforators following the internal mammary perforators drain via the internal mammary vein to the innominate vein. The lateral thoracic veins drain via the azygos vein into the superior vena cava. • Vascular anatomy is also of importance with regard to the recipient site for microvascular anastomosis when free tissue transfer is used for breast reconstruction. • The thoracodorsal vessels have been used, particularly when the reconstruction is immediately postmastectomy. The thoracodorsal artery is often small (<2 mm) and may have insufficient flow. The axillary vessels can be technically difficult for the assistant, since they must operate across the chest. In addition, the axillary system may limit flap movement and shaping the breast. • The use of the internal mammary vessels as a recipient site facilitates shaping the medial portion of the breast. However, the technique requires partial rib resection and eliminates the opportunity for a potential coronary artery bypass graft. • The internal mammary vessel may be preferred in delayed cases, especially in patients who have had adjuvant radiation, as dissection of axillary vessels can be very difficult. Lymphatics • The predominance of lymph drainage of the breast is via the interlobular lymphatic vessels to the subareolar plexus. Lymph is directed toward the axillary lymph nodes. • This drainage is parallel to the venous drainage of the breast. Lateral lymphatics course around the edge of the pectoralis major toward the pectoral lymph nodes. Additional lymphatics course through the pectoral muscles to the apical lymph nodes. From the axillary lymph nodes, lymph drains into the subclavian and supraclavicular lymph nodes. Innervation • Sensory innervation has three major nerve distributions which include the anterior lateral intercostals, the medial intercostals, and the cervical plexus. • The anterior rami of the lateral cutaneous nerves of the intercostals provide sensation to the lateral portion of the breast extending to and including the nipple areolar complex. The breast demonstrates a dermatomal pattern derived from the anterolateral and anteromedial branches of the intercostal nerves (T3–T5). • Branches of the cervical plexus provide the superior medial sensory innervation. • Intercostal segmental nerves contribute the remainder of the breast sensation and can be considered the primary sensory nerves. The third through sixth anterolateral intercostal nerves pass through the interdigitations of the serratus muscles to enter the lateral aspect of the breast. • Along the medial border of the breast, the second through sixth anteromedial intercostal nerves enter the breast parenchyma alongside the internal mammary perforating vessels. These sensory nerves provide innervation to the medial breast and nipple areolar complex.1 Musculature
• The muscles directly
associated with the breast include the pectoralis major, serratus anterior, external oblique and the superior portion of the rectus abdominis Pectoralis major • Origin- medial clavicle and lateral sternum • Insertion- on the humerus • Blood suplly: toracoacromial artery; intercostal perforators from the internal mammary artery • Inervation: medial and lateral anterior thoracic nerves • Action: flex; adduct and rotate the arm medially. • The pectoralis major is extremely important in both aesthetic and reconstructive breast surgery, since it provides muscle coverage for the breast implant Serratus anterior • Origin is the outer surface of the upper borders of the first through eighth ribs • Insertion is on the deep surface of the scapula • Vascular supply is derived equally from the lateral thoracic artery and branches from the thoracodorsal artery • The long thoracic nerve serves to innervate the serratus anterior, which acts to rotate the scapula, raising the point of the shoulder and drawingthe scapula forward toward the body. • Because the serratus anterior underlies the lateral aspect of the breast, in aesthetic surgery, blunt elevation of the pectoralis major laterally inadvertently elevates a small portion of the serratus muscle. To completely cover the implant with muscle in reconstructive surgery, often the serratus anterior must be elevated sharply to obtain a sufficient muscle layer to provide coverage. Rectus abdominis • Origin at the crest of the pubis and interpubic ligament to its insertion at the xiphoid process and cartilages of the fifth through seventh ribs. • It acts to compress the abdomen and flex the spine • When placing an implant for breast reconstruction, in attempting to achieve complete coverage with muscle, the rectus fascia must often be elevated to place the implant sufficiently caudal. External oblique • Its origin is from the lower eight ribs, and its insertion is along the anterior half of the iliac crest and the aponeurosis of the linea alba from the xiphoid to the pubis • It acts to compress the abdomen, flex and laterally rotate the spine, and depress the ribs. • Elevated along with the rectusabdominis fascia to provide inferior coverage of the breast implant during reconstructive surgery • In aesthetic surgery, placement of the implant inferiorly is usually not below these fascial attachments. If the implant is placed behind the fascia, the implant often “rides too high” and may result in a “double bubble” effect, wherein the breast parenchyma slides over and off the implant Gynecomastia Gynecomastia • Gynecomastia is enlargement of the male breast and is caused by an increase in ductal tissue,. stroma, and/or fat. Most frequently, the changes occur at the time of hormonal change: infancy, adolescence, and old age. • The most common cause of gynecomastia is unknown (idiopathic).
• In all three age groups (neonatal, adolescent,
and older men), gynecomastia appears to be related to either an increase in estrogens, a decrease in androgens, or a deficit in androgen receptors. • The incidence of gynecomastia rises again in older men (age > 65 years).
COMMON CAUSES OF GYNECOMASTIA
DIAGNOSIS PATHOLOGY • A careful history and physical examination • Three types of gynecomastia is the most important part of any workup have been described: florid, for gynecomastia. fibrous, and intermediate. The 6 • The history notes the time of onset of the gynecomastia, symptoms associated with florid type is characterized by an the gynecomastia, drug use. increase in ductal tissue and • Physical examination includes assessment vascularity. of the breast gland and includes the nature of the tissue, isolated masses, and • The fibrous type has more tenderness. The thyroid is evaluated for stromal fibrosis with few ducts. enlargement. The testes are examined for asymmetry, masses, enlargement, or • The intermediate type is a atrophy. mixture of the two. • Laboratory evaluation is based on the findings of the history and physical examination CLASSIFICATION Simon, Hoffman, and Kahn divided gynecomastia into four grades: 1
grade 1: small enlargement, no skin excess
grade 2 a: moderate enlargement, no skin excess b: moderate enlargement with extra skin grade 3: marked enlargement with extra skm Letterman and Schuster' created a classification system based on the type of correction: 1: intra-areolar incision with no excess skin 2: intra-areolar incision with mild redundancy corrected with excision of skin through a superior periareolar scar 3: excision of chest skin with or without shifting the nipple. Rohrich et al.,in a paper discussing the utility of ultrasound-assisted liposuction in the treatment of gynecomastia, developed the following classification grade I: minimal hypertrophy (<250 g of breast tissue) without ptosis grade II: moderate hypertrophy (250 to 500 g of breast tissue) without ptosis grade III: severe hypertrophy (>500 g breast tissue) with grade I ptosis
grade IV: severe hypertrophy with grade II or III ptosis
TREATMENT OF GYNECOMASTIA • The goal of surgery is: - to remove the excess breast tissue and skin, - ensure adequate positioning of the nipple-areola complex, - ensure symmetry between the breasts and chest wall, - to avoid significant scarring • Most fibrous or solid Simon stage 1 or 2a lesions are treated with surgical excision or more recently, in selected cases, with ultrasonic liposuction:with sharp tip cannulas, power-assisted liposuction, or ultrasound-assisted liposuction. • If surgical excision is chosen, a periareolar incision is performed. • The skin incision is placed at the junction of the areola and skin. • After the incision is made, a cuf of tissue 1 to 1.5 an in thickness is preserved directly deep to the nipple/areola complex. This maneuver prevents postoperative nipple/areola depression or adherence of the nipple/areola to the chest wall. • When liposuction is unsuccessful at removing all of the tissue required to achieve a good result, the pull-through technique is added. • In this technique, either the lateral or periareolar incision is opened slightly (about 1.5 em) and the residual tissue is grasped. The tissue is pulled out through the wound and removed with scissors or electrocautery. The pull-through resection is performed until the desired contour is achieved. • All patients are treated with compression garments for at least 1 month COMPLICATIONS
• Complications include inadequate resection, overresection, excess
skin, complex scars, hematoma, seroma, partial nipple necrosis, suture line dehiscence, pain, loss of nipple sensation, and infection. • Potential risks of ultrasonic liposuction include thermal burns and skin necrosis, because one of the byproducts of ultrasonic energy is heat. • This is avoided by using cool towels over the skin and avoiding superficial planes near the skin surface. TUBEROUS BREAST DEFORMITY • Tuberous breast deformity describes a spectrum of aberrant breast morphology first reported by Rees and Aston • There are several features of the tuberous breast that are important to identify before management. These include a constricted base, contraction of the skin envelope, relative micromastia, enlarged diameter of the nipple-areola complex and herniation of breast parenchyma through the nipple-areola complex. • Although the exact etiology has not been elucidated, it is generally accepted that this disorder has an embryologic origin.Most reports have speculated that the superficial investing fascia of the breast is abnormal and constricted at the base of the breast. This constriction at the base and deficiency at the areola is responsible for the reduced base diameter and areolar herniation Classification Von Heimburg: Type 1: hypoplasia of the lower medial quadrant Type II: hypoplasia of the lower medial and lateral quadrants with sufficient skin in the subareolar area Type III: hypoplasia of the lower medial and lateral quadrants with a deficiency of the subareolar skin Type IV: severe breast constriction with minimal breast base Grolleau Classification Type 1: lower medial quadrant deficiency
• Type II: lower medial and lateral quadrant deficiency
Type Ill: deficiency of all four quadrants
Treatment • The goals of surgery are to restore volume to the hypoplastic breast(s), expand the lower pole by releasing the tethering fibrous attachments or bands between the breast parenchyma and deep fascial and pectoralis muscle and also between the breast parenchyma and skin, and where necessary reduce the areola size and recess the herniated breast tissue. • The Mandrekas technique is illustrated. (Above, left) A periareolar approach is advocated. (Above, center) The dissection proceeds in the subcutaneous plane to the pectoral fascia. (Above, right) The dissection continues to the desired inframammary fold. (Below, left) The inferior pole of the breast is exteriorized, and the constrictive band is divided vertically. (Below, right) Finally, the areola is reduced, and the breast is recontoured