Breast ( anatomy, reduction,

tuberous breast deformity,

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


PATHOLOGY
• Three types of gynecomastia
have been described: florid,
fibrous, and intermediate. The
6
florid type is characterized by an
increase in ductal tissue and
vascularity.
• The fibrous type has more
stromal fibrosis with few ducts.
• The intermediate type is a
mixture of the two.
DIAGNOSIS
• A careful history and physical examination
is the most important part of any workup
for gynecomastia.
• The history notes the time of onset of the
gynecomastia, symptoms associated with
the gynecomastia, drug use.
• Physical examination includes assessment
of the breast gland and includes the nature
of the tissue, isolated masses, and
tenderness. The thyroid is evaluated for
enlargement. The testes are examined for
asymmetry, masses, enlargement, or
atrophy.
• 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