Chapter 78.

Esthetic Breast Surgery

EMBRYOLOGY

ANATOMY

PHYSIOLOGY

BLOOD SUPPLY

Arterial

Venous

LYMPHATIC SUPPLY

INNERVATION

BREAST REDUCTION SURGERY

BREAST PTOSIS

NIPPLE HYPERTROPHY

NIPPLE INVERSION

PROLIFERATIVE BREAST DISEASE

Subcutaneous Mastecotmy

Management of Moderately Hypertrophied and Ptotic Breasts

Massively Hypertrophied Breasts

Complications

AUGMENTATION MAMMOPLASTY

Preoperative Evaluation

Operative Technique

Postoperative Managment

Complications

Other Issues

□ reduction mammoplasty : surgical correction의 motivation

① functional because of intolerable size

② severe shoulder & back pain

③ excoriation of shoulder area

④ excoriation in inframammary area

EMBRYOLOGY

1. 6주 : axilla와 inguinal area를 연결하는 linear ectodermal ridge(mammary ridge)가 bilateral로 형성(fig 78-1)

① 2/3 of supernumerary area : ant. thorax & abdomen

② 20% : axilla

③ remaining few : groin, thigh, buttock, back, face, neck

2. 4개월

① mammary gland가 계속 발달하여 downward thickening

② growth of ectoderm into underlying mesoderm

--> forming lactiferous duct & branches & canalize

3. 7개월

① small duct acini formed

② all main ducts concentrate & open into skin

4. nipple : proliferation of surrounding mesoderm with formation of smooth m fb

--> arranged in circular & longitudinal fashion

5. areola

① created by ectoderm

② reconizable by 5th m

③ contains apocrine gl(seb gl)

: rudimentary mammary lobule(glands of Montgomery)

ANATAMY

1. breast position

① superior : 2, 3rd rib

② inferior : 7, 8th rib

③ medial : parasternal

④ lateral : ant. axillary line

2. nipple position

① 4th ICS, slightly lat. to midclaviclar line

② approximately 2-3 cm below midhumeral position

3. supported by surrounding CT with fibrous attachment(Cooper's lig)

① breast를 pectoralis major fascia와 상부 skin에 suspend & attach

② allows some movement of breast in skin envelope

③ support for breast

4. nipple contain 16-24 mammary ducts

PHYSIOLOGY

□ 3 developmental phase of breast

① initial phase of breast development

ⓐ birth ~ puberty : gradual increase in glandular tissue & stroma

ⓑ breast development에 관여하는 hormone

□ estrogen

□ progesteron : 주로 alv system

□ adrenal corticoids

□ prolactin : final differentiation of alv epi. cell into mature milk producing cell

□ insulin

□ thyroxine

□ GH

② mature breast during menstrual cycle

ⓐ resting phase

ⓑ proliferative phase(3-7 day)

: estrogen ↑ --> epithelial proliferation, dense stroma

ⓒ luteal phase(2nd week)

□ progesteron ↑ --> follicular differentiation

□ inflammatory cell↓

□ epi. cell의 3 types이 구분 : myoepithelial cell, B cell, A cell

ⓓ secretory phase(21-27 day)

□ influence of estrogen, progesteron, prolactin

□ breast volume increase 15-30ml with associated water retention in stroma

: histamine effect as a result of estrogen activity

□ prolactin : predominant factor in premenstrual tension

□ stroma : edematous & venous congestion

ⓔ final phase(28 day & beyond)

□ withdrawl of estrogen & progesteron

□ basal cell remain engorged with glycogen

③ during menopause

ⓐ diminution of estrogen & marked decrease of progesteron

ⓑ breast involution & gradual atrophy of glandular tissue

ⓒ some increase in the elastic fiber in the connective tissue stroma

BLOOD SUPPLY

Arterial

□ 3 main arterial routes

① ant perforating br of int thoracic a: med

ⓐ 60% of total breast blood flow

ⓑ mainly to medial portion

② lat thoracic a(from subclavian a): ant lat

ⓐ 30%

ⓑ upper outer & lat portion

③ br of 3, 4, 5th post intercostal a: low lat

Venous

□ 2 main veinous drainage

① supf & deep venous system

□ supf v system

ⓐ transvere network → int thoracic v → innominate v

ⓑ longitudinak network → lower neck v

② deep drainage system

: intercostal v → vertebral v → azygos v → SVC

□ largest venous systems consist of

: perforating br of int thoracic v→ innominate v

□ lat breast, chest wall, pectoral m area → axillary v

LYMPHATIC SUPPLY

□ 4 main lymphatic routes

① cutaneous

② internal thoracic

③ post intercostal

④ axillary area

1) skin : axillary LN로 drainage

① med. aspect --> int. mammary chain

② inf. portion --> lymphatics of rectus abdominis sheath

--> subdiaphragmatic & intraabdominal LN --> liver

2) areola --> subareolar plexus(Sappey) of lymphatics

-ant pectoral LN

□ retroareolar mammary lymphatics

--> ant. pectoral LN(Rotter's node)

--> deep axillary node(Grozzman's pathway)

3) stroma : axillary LN

□ 6 groups

ⓐ ext mammary LN

ⓑ interpectoral(Rotter's) LN

ⓒ scapular LN

ⓓ axillary v LN

ⓔ central axillary LN

ⓕ subclavian LN

INNERVATION

1. upper breast : supraclavicular n from 3, 4th br of cervical plexus

2. med & inf aspect : ant cuta division of intercostal n(2-7th AC)

3. nipple : lat cutaneous n. of T4

□ sympathetic □-adrenergic stimulation → nipple sm m contraction

4. areola, nipple dermis : Krause's end bulb & Ruffini's corpuscle

BREAST REDUCTION SURGERY

1. types of dermal pedicles(fig 78-8)

① classic bipedicle lat dermal pedicle(= Strombeck)

② lat. dermal areolar flap(= Skoog) : 유두함몰이 잘 발생

③ sup. based nipple-areola flap(= Pitanguy)

④ inf. oblique dermal flap

ⓐ small breast에 국한

ⓑ 200-300gm hypertrophy

2. 가장 흔히 사용하는 4 techniques

① superiorly based dermal pedicle(Pitanguy)

② vertical bipedicle dermal flap(McKissock)

③ free nipple graft

④ inf pyramidal dermal flap(Georgiade)

3. standard procedure for preop marking(fig 78-11)

□ superiorly based dermal pedicle(Pitanguy)(fig 78-12)

① reduction < 500 g

② marking in upright position

③ procedure

ⓐ sup. pedicle deepithelized with 1.5 cm deepi. circumareolar area

ⓑ incision extend 1-2 cm into keyhole

ⓒ resection of inf portion of breast

ⓓ med & lat flap approximation

ⓔ suction drain

④ AB & A'B' can be up to 7 cm

□ vertical bipedicle dermal flap(McKissock)(fig 78-16)

① vetical line of keyhole should be acute

AB & A'B': not exceeding 5 cm

② lat & med flap 을 horizontal lazy-S로 하는 이유

ⓐ better projection

ⓑ avoidance of boxy appearance

③ vertical pedicle의 두께: 1 cm → base area는 더 두껍게 남겨둠

④ flap을 keyhole쪽으로 1.5 cm extend

: allowing flap to be folded on itself at the time of closure

⑤ resection of breast tissue under med & lat flap

⑥ flap approximation & areolar position

□ free nipple graft(fig 78-18)

① massive hypertrophy시에 가장 많이 사용 : 특히 2000gm이상 절제시

--> partial breast amputation and free nipple graft

② A point를 2-3cm 위에 잡는 이유

: hypertrophied breast에 의해 skin이 traction 되기 때문

□ inf pyramidal dermal flap(Georgiade)(fig 78-20)

① 300 - 2,000gm resection 이 필요한 경우에 유용

② 장점

ⓐ uniformly satisfactory results

ⓑ nipple sensation 유지

ⓒ min. decrease in blood supply to skin flaps or nipple-areola complex

③ standing position에서 design

④ procedures

ⓐ incision : never extended to midline

ⓑ dermal pedicle deepithelization

: periareolar area에 2 cm의 dermal periphery를 남김

ⓒ excision시 skin flap을 1.5 cm의 uniform thickness로 남김

⑤ pyramidal flap에서  thickness

ⓐ base of flap : at least 10 cm

ⓑ nipple base : at least  5 cm

BREAST PTOSIS

1. 3 categoies(breast ptosis classification)(fig 78-25)

① minimal ptosis: just inf to inframammary crease

② moderate ptosis: 3 cm below inframammary crease

③ severe ptosis: greater than 3 cm below inframammary crease

2. 각 type 별 correction method

① class A type : simple elliptic deepithelization sup to areala, bringing nipple areloa into slight higher position

② class B type : sup. deepithelization & advancement technique with excision of redundant skin in V-type fashion inf & lat

③ class C type : class B method or inf or vertical dermal pedicle flap

□ angmentation과 같이 시행할 시

: upright position에서  design하여 augmentaion 먼저 시행 후 교정

<-- augmentation에 의해 nipple-areolar complex의 height가 변화

NIPPLE HYPERTROPHY(FIG 78-31, 32, 33)

1. Regnault : dermis까지 nipple 주위를 일부제거 distal portion을 새 위치로 collapse

2. Pitanguy : nipple의 일부를 vertical manner로 excision

3. V-type nipple excision : lactiferous duct blockage problem(ductal obstruction)

NIPPLE INVERSION(FIG 78-34, 35, 37)

1. Hauben & Mahler technique : does not divide lactiferous duct

2. Pitanguy technique : transnipple areolar incision

--> duct사이의 fibrous & m tissue에 incision를 가해 free하게 해줌

3. Broadbent & Woolf technique : connective tissue를 잘라 release

① duct가 short & hypoplastic

② nipple 아래의 fibrous & collagenous bulk의 defeciency

4. Schwager technique

PROLIFERATIVE BREAST DISEASE

□ cancer risk

① proliferative breast disease without atypical hyperplasia

: non-proliferative disease women의 2배

② with atypical hyperplasia: 5½ 배

③ atypical lobular or ductal hyperplasia with (+) family Hx : 11배

④ cysts & (+) family history: 3배

⑤ > 55세 + proliferative disease : 2.2 배

□ nonproliferative lesion

① cysts

② fibroadenomas

③ apocrine changes

④ mild H/P without tendency for cellular bridging or space istension

⑤ sclerosing adenosis

⑥ epithelium-related calcification

⑦ papillary apocrine disease

Subcutaneous Mastectomy

□ nipple biopsy상 atypical epitheilia hyperplasia 혹은 dysplastic change가 있으면 2o procedure로 5일째(술후) excision

--> indication : atypical hyperplasia with (+) family Hx

□ techinical aspect of sc mastectomy

① incision 영향요소

ⓐ breast 크기

ⓑ nipple-areolar complex의 위치

ⓒ ptosis 정도

② inframammary incision lying approximately 5.5cm inf to areola

③ 2 way dissection

ⓐ pectoralis fascia 위쪽으로 dissection → axillary area 까지

ⓑ breast tissue와 subdermal vascular plexus 사이의 fatty cushion로 dissection

④ base of nipple is identified with suture, as is axillary tail of specimen for orientation by pathologist

⑤ axilla쪽으로 direction하여 tail of Spence 와 axillary L.N 포함

⑥ submuscular pocket is created

incision : over 7th rib through SA m

⑦ important to maintain position of prosthesis inferiorly

: to minimize fullness in sup portion of chest area

⑧ SAm approximation

⑨ 24 hrs 후 hematoma 반드시 검사

⑩ 10 일후 breast exercise 시작

ⓐ rotary arm motion

ⓑ large sweeping circles in both direction

Management of Moderately Hypertrophied & Ptotic Breast

□ wide dermal pedicle flap : nipple-areola vascularity 보존하기 위해

Massive Hypertrophied Breast

1. resection of breast tissue > 700 gm

2. free nipple graft고려

Complications

1. hematama: 24시간이내 나타남

2. tissue ischemia: 특히 nipple - areola complex area에 잘 생김

3. skin redundancy or persistent ptosis

AUGMENTATION MAMMOPLASTY

□ 3 approaches for breast enlargement

① materials, injected within breast: paraffin, silicone

② alloplstic implants: polivinyl alcohol, polyurethane, silicone

③ autogenous tissue: lipoma, fat, dermal-fat grafts, omentum

Preoperative Evaluation

1. preop history

① previous breast problem

② pregnancy & their effects on the breasts

③ changes associated with menstruation(pain, swelling, nipple discharge)

④ personal or family Hx of abn bleeding

⑤ current medication

⑥ drug allergies

⑦ past surgical procedures with any associated Cx

⑧ any family Hx of breast Ca

2. physical examination

① size of breast & nipple-areola complex

② breast position on chest wall

③ asymmetry in breast position or shape

④ presence or absence of stretch mark or scars

⑤ ptosis 유무

⑥ type & degree of nodulaity

3. contraindications

① inappropriate motives & goals

② serious psychologic disorders

③ difficulty tolerating potential complicatins on limitations

4. menstruatin시기의 last two weeks동안은 op 안함

5. preoperative mammography indication

① > 40세

② family history of breast ca

③ significant nodularity(+)

Operative Technique

1. inframammary fold를 upright postition에서 marking

2. type of incision

① inframamary incision : simplicity but more conspicuous scar(보통 4cm 길이)

② periareolar incision

ⓐ least conspicuous scar

ⓑ 단점	a. deep dissection이 어렵다.

b. 수술시간이 길어짐

ⓒ breast tissue속으로 incision시 문제점

a. bacterial contamination of wound

b. cicatricial blockage of breast tissue

--> 임신 시 cyst formation

c. microcalcification within scar --> X-ray상 판독혼란

ⓓ contraindication

a. small nipple-areolar complex

b. areolae of light color

ⓔ 4th intercostal n. 보존 위해 med. shifting

③ transaxillary incision

ⓐ scar(-)

ⓑ 단점	a. exposure가 어렵다

b. symmetrical pockets를 만들기 어렵다

c. intercostal-brachial n. 손상

d. subclavian v.의 thrombosis

④ tunnel from abdominoplasty : abdominoplasty를 동시에 시행 시

□ location of implant

① subglandular placement

ⓐ 장점

□ easy dissection

□ more predictable sizing & contouring

□ satisfactory results

□ less capsular contracture

② submuscular placement

ⓐ 장점

□ capsular contracture↓

□ nipple sensory change↓

□ potential for communication with breast parenchyme↓

□ mammography 판독에 지장이 없다.

□ biopsy well not endanger the implant

□ relatively avascular easy dissection

□ Cx↓(hematoma, infection, extrusion of implant)

ⓑ 단점

□ severe ptosis, distinct inframammary fold의경우 어렵다

□ asymmetry in implant position

: implants may side upward or shift laterally over time

→ less distinct inframam fold or double fold deformity

□ closed capsulotomy가 어렵다.

□ m contraction over implant can be unattractive & cleavage is not as easily obtained

□ more postoperative pain

□ difficult hemostasis, esp. inf. & med m. attachment

□ dissection of pocket

① subgl. dissection : as large as possible

: lat. aspect 박리는 minimize → lat. cutanous n. 손상방지

② subm. dissection시 inframammary crease 1-2cm아래까지 박리

: inf. attachment of P major detach

③ lateral intercostal n를 반드시 보존

④ implant location: beneath the P major, bur above P minor

□ Implant

① gel filled silicone implant: leaching이 문제

② inflatable implants

ⓐ deflation이 문제(1.2-76%)

ⓑ advantages

□ small incision

□ different vol의 implant insertion → asymmetry correction

③ double-lumen implant

ⓐ outer shell perforation이 문제

ⓑ main rationale for double-lumen implant

□ prevent leaching of silicone gel into surrounding tissue

□ additional security provided if the inner shell breaks

④ polyurethane-covered silicone gel imglants

ⓐ capsular contracture↓

: ingrowth of scar tissue into polyurethan surface

→	□ breaks up the vector forces of scar contracture

□ periprosthetic space제거하여 contamination, adherence 감소

ⓑ 단점

□ longer incision

□ difficult to insert & position the implant

□ reop시 제거하기가 힘들다

□ allergic reaction: self limiting

□ blood collect between polyuethane shell & sillicon implant

□ others

a. polyurethane shell is degraded

b. high infection rate

c. lack bounciness

d. axillary lymphadenopathy

e. late hematomas

Postoperative Management

1. early activity with vigorous massage

2. forbid brassier may reduce the incidence of difficult capsular contracture

3. prophylactic compression capsulotomy should also be performed routinely rather than when needed

Complications

1. fluid accumulation & hematoma

2. sensory change

3. infection

4. scars

5. asymmetry (unequal pockets & capsular contracture)

6. implant extrusion

7. contour irregularities (TMC cause : capsular contracture)

8. capsular contracture

① the most frustrating complications

② regarded as exageration of abnormal wound healing

③ postoperative 4-8 month후 관찰가능

9. loss of clevage

10. lactation fistula

11. implant rupture

12. Mondor's dis

① thrombophlebitis of inframammary vein

② usually self-limiting & asymptomatic

③ arm elavation 시 tender cord palpable

--> no Tx

□ Baker classification of capsular contracture(table 78-1)

Grade I	: augmented breast feel as soft as unoperative breast

Grade II	: minimal-less soft; palpated but is not visible

Grade III	: moderate-firm; palpated easily & it(or distorsion from it) is visible

Grade IV	: severe-hard, tender, painful, cold; distorsion is present

□ capsular contracture

① 원인	ⓐ leaching of silicone gel

ⓑ improperly managed hematoma

ⓒ FB(dust, lint, globe powder, implant impurities)

ⓓ inadequate sized pocket

ⓔ subclinical infection(Staphylococcus epidermidis)

ⓕ both postop management & pt compliance

② 치료

ⓐ placing drains at time of surery

ⓑ steroid

□ 기전	a. inflammatory response 개선

b. fibroblast number & activity ↓

c. inhilit wound contracture

□ steroid-related problem

a. implant shift inferiorly

b. thinning of surgical scar

c. striae

d. bluish discoloration of skin

e. implant, exposed by erosion of overlying soft tissue

f. implant,removed because of impending erosion

ⓒ expansion exercise

ⓓ adequate design, size, shell thickness implant 사용

ⓔ percutaneous injection of steroids within the capsule

ⓕ antibiotics

ⓖ pulsed electromagnetic energy treatment in association with 2 stage augmentation mammoplasty

ⓗ Vit-E

□ 기전

□ stabilize lysosomal membrane

□ inhibit inflammation

□ reduce the number of fibroblast

□ retards collagen accumulation

□ massage

□ compression capsulotomies

□ Cx

□ contour distortion due to incomplete capsulare tear

□ implant displacement or rupture

□ hematoma

□ infection

□  various upper extremity injury of surgeon

□ surgical capsulotomy(recur : 30%)

□ circumferential & radial division of capsule & extension of the pocket

□ complications : hematoma, infection, exposure of implant

ⓛ capsulectomy

□ dissection of one side of capsule & replacement of implant in new pocket

□ exchanging implant for double-lumen type with steroid instilled in outer compartment & replacement of subglandular implant into submuscular pocket