Breast embryology:

• Mammary ridge:
  • 5-6^th week of development when ingrowths/outgrowths from ectodermal skin layer penetrate mesoderm
  • Amazia: absence of mammary gland
  • Amastia: total absence of breast
  • Athelia: absence of nipple
  • Anterior thoracic hypoplasia: pectoralis m. present, superiorly displace NAC

Anatomy

• Pectoralis muscle:
  • Blood supply with submuscular augmentation = thoracoacromial a. à thoracoacromial a. collaterals are disrupted with subglandular implant placement
  • Attachments
    • Sternal half of clavicle
    • Ventral surface of sternum and costal cartilages II-VI
    • Slip of the aponeurosis of the external oblique muscle
    • Flexes, adducts and rotates the arms medially

• Breast innervation:
  • Thoracic nerves III-VI
  • Nipple: lateral cutaneous nerve of 3^rd and 4^th intercostal nerve (has a lateral branching pattern)
  • Preserve by blunt dissecting lateral to lateral edge of pec minor

Pre-op

• Mammogram: patients who have genetic predisposition to breast ca and older patients
• Pinch test: divide by 2 (tissue is folded over): if pinch <2-3 cm, tissue cover 1-1.5cm= submuscular placement
• Max prosthetic size determined by breast base width
• Ideal postop position of the nipple can be simulated with the arms elevated above the horizontal plane
• Ideal distance btwn nipple and new IMF should be calculated based on the lower ventral curvature (LVC) of implant

Choosing an Implant:

• Saline: higher rupture risk, esp if these are NOT overfilled
• Form stable: (high-cohesive): very low incidence of rupture
• Form stable implants:
  • Lower rates of rippling and rupture
  • Increased rotation complications
  • Decreased rates of contracture
  • Increased rates of seroma (textured)

Approach:

• Periareolar:
  • Must be at least 3 cm in diameter
• Submammary:
• Transaxillary

Technique:

• Submuscular dual plane positioning:
  • Dual planes Ià IV
  • Important not to divide the muscle higher than the nipple-sternal line
  • Muscle divisions not possible from the axillary approach

• Misc Breast Topics:
  • Tuberous breast deformity:
    • • Tx: parenchymal scoring: double bubble when IMF is not sufficiently obliterated
        • Radial release of lower pole breast fascia
        • Decrease NAC size
      • IMF is elevated, herniation of breast tissue into NAC

• Complications:
  • Possible damage to long thoracic nerve and intercostobrachial nerve/MABC (transaxillary approach) à minimize dissection in axillary fat
  • PIP gel implants: increased risk of rupture (2-6x), can be explanted but needs yearly follow up
  • Increased rippling in textured silicone vs. smooth silicone
  • Implants are more contaminated through the sweat glands
  • Contracture
    • submuscular minimizes, as do textured surfaces (esp in subglandular plane)
    • frequency = 5-10%
    • inframammary incision minimizes

• • Late seroma:
    • a/w double capsule phenomenon (1%) à more likely than ALCL
  • ALCL:
    • CD30, cytokeratin negativity
    • Textured shell, a/w T cell (chronic inflammation)
    • More indolent course, favorable prognosis

• • double bubble deformity: high profile and form stable leads to decreased risk
  • visible rippling more likely in saline and older silicone implants (less likely in textured implants)
  • rate of 10 year revision with saline implants =25%

• Implant Monitoring
  • Saline implant breast ca. monitoring: mammogram with Eklund view
  • Implant size interferes with mammogram
  • Monitoring of silicone implants:
    • 3 years post op then biannually (MRIs)
    • For silent ruptureà linguine sign = intracapsular rupture on MRI

Mastopexy

• 2/2 :
  • involution, aging, weight loss and multiple pregnancies
  • attenuation of coopers ligaments
• Blood supply:
  • Superior pedicle: deep branches of the IMA from the second interspace
  • Inferior/central pedicle: IMA branches from the fourth interspace
  • Medial pedicle: 3^rd superficial branch of the IMA
  • Lateral pedicle: superficial branches of the lateral thoracic a.
• Regnault classification: Nipple relative to IMF
  • Nipple at IMF or 1 cm below (1)
  • Nipple below IMF, above lower contour of the gland, 1-3 cm below IMF (2)
  • Nipple below IMF and at the lower contour of the gland (3)
  • Pseudoptosis: normal nipple position with glandular tissue below IMF
• Nipple position: 20 +-3 cm from the suprasternal notch

• Augmentation is completed before mastopexy component (but can be safely performed together)
  • Selection of implant with enhanced projection may alleviate need for mastopexy of many ‘downgrade’ type of mastopexy needed
  • Aug/mastopexy: increases upper pole fullness
  • Presence of breast ptosis in aug/mastopexy: increased rate of re-operation

• Donut mastopexy:
  • Most common complication = widened areola
  • Limit skin resection to 2:1 ratio outside diameter to areolar diameter

• Vertical mastopexies: A/w increased distance from nipple to IMF

• Late complications:
  • Recurrent ptosis
  • Scar widening or hypertrophy
  • Problems with areolar spreading have been largely addressed with use of permanent suture and the ‘pin wheel’ technique

Breast Reduction:

• Anatomy
  • Superficial arteries:
    • From 2-3 intercostal spaces from the IMA à superior pedicle
    • Medial branches of the IMA
    • Superficial thoracic a. (branch of lateral thoracic)à lateral pedicle
  • Dominant blood supply to NAC = IMAà runs just above the pectoralis fascia
  • Inferior pedicle:
    • 4^th intercostal space perforator from the IM system
  • Central pedicle:
    • Severs superficial veins
    • Relies on same arterial and venous blood supply as inferior pedicle
  • Superior pedicle:
    • Arterial supply from the IM system @ 2^nd or 3^rd intercostal space (descending br in the S-M pedicle)
    • Highest risk of altered nipple sensation post-op (resects both medial and lateral innervations to the nipple)
  • Lateral pedicle:
    • Reliable blood supply but often this is the tissue you are trying to remove
  • Medial pedicle:
    • Good sensation, especially when deep branch of 4^th intercostal nerve is preserved by leaving tissue over pectoralis fascia
    • 3^rd and 4^th intercostal space perforators from IMA
  • Veins do not accompany arteries and are located just beneath the dermis
• Innervation:
  • Main sensation to nipple and areola = lateral 4^th intercostal n.
  • Skin of superior quadrants: most sensitive
• Benign gynecomastia: ductal epithelia hyperplasia w/ proliferation of stroma and fibroblasts

• Skin resection pattern:
  • Inverted T pattern:
    • 21 percent wound healing complications (most common complication)
    • Vertical component of the wise pattern skin resection is kept short to accommodate for expected stretching, but shortening tends to flatten the breast and prevent projection
  • Vertical:
    • Best used for small and medium sized breast reductions
    • No more than 9 cm of transposition
  • Periareolar: small reductions only with minimal excess skin
• Liposuction only breast reduction:
  • Breasts that contain more fatty tissue than glandular tissue (older patients) w/ high nipples and good upper pole fullness
  • Liposuction only reduction mammaplasty:
    • Doesn’t typically impair breast feeding potential
• Reduction mammaplasty indicated in teenagers if significant, even if risk of continued breast growth post-op

• Complications and Side effects:
  • Recovery of nipple sensation is unpredictable ~85 percent recover to normal or to near-normal
  • Chances are breast feeding are 50/50 (also cited at 30%)
  • Periop abx help prevent wound healing problems (more common in obese and smokers
    • Breast ducts are contaminated with staph epi and proprionibacteria
  • If nipple and areola look congested, removal of sutures od release of compression are indicated
  • Bottoming out and pseudoptosis: result of under resection inferiorly
  • Resection size is not a/w relief of symptoms
  • Self filling osmotic tissue expanders: increases rate of infection