Post on 04-May-2018
EssentialAnatomyforoncoplasticsurgery
OmarZ.YoussefM.D
Professorofsurgicaloncology
NCI-CairoUniversity
Introduction• RationaleforanatomicalbasisforOPS
• Anatomicalconsiderations:
1. Surfaceanatomy
2. Surgicalanatomy
3. AppliedAnatomy
ONCOPLASTICBREASTANATOMY
• BCS
• OPS:LevelI-IIoncoplasticsurgery(GR/TM)
• Contralateralbreastsymmetrization
• Skin(±NAC)sparingmastectomy
• Immediatereconstruction
– Implantbased
– Autologoustissuebased
IntroductionReconstructivePointofView
Anatomicalfeaturescriticalforoptimalresults:
• Qualityandtensionofskinflaps
• Preservationoftheinframammaryfoldframe
• Viabilityofnipple–areolacomplex(NAC)
• Integrityofthepectoralismuscle
• Qualityofabdominalandlatissimusflaps
• IfwelookatbreastsurgerycomplicationslikeNAC
necrosis,skinsloughing,woundcomplicationsand
fatnecrosis,wewillrealizethatitlargely
correspondstoanatomicalreasons
• That’swhyathoroughanatomicalunderstandingis
amust.
a) Langer’slines:
predominant
orientationof
collagenfibersin
theskin.Skin
creaselines
aroundthebreast
areessentially
circular
b)Kraissllines:
linesofmaximum
skinresting
tensionrunina
moretransverse
orientation
acrossthebreast
NAC• Theepidermisofthenippleandareolaishighlypig-
mentedandsomewhatwrinkled.
• Theskinofthenipplecontainsnumeroussebaceousand
apocrinesweatglandsandrelativelylittlehair.
• The15to25milkductsenterthebaseofthenipple,
wheretheydilatetoformthemilksinuses.
• Thesesinusesterminateincone-shapedampullae.
• Thecircularareolasurroundsthenippleandvaries
between15and60mmindiameter.Itsskin
containslanugohair,sweatglands,sebaceous
glands,andMontgomery’sglands,whicharelarge,
modifiedsebaceousglandswithminiaturemilk
ductsthatopenintoMorgagni’stuberclesinthe
epidermisoftheareola
ONCOPLASTICBREASTANATOMY
“SuperficialFascia”
Existenceasadistinctlayer
56%
Inthosecontainingthislayer;
Complete 58%
Irregular/containsislandsofbreasttissue 42%
RobertsonSA,etal.BrJSurg2014.
• Startingfromthepectoralistendon3to6cm
belowthesuperiormostpointoftheanterior
axillaryfold,extendingdownthelateralchest
wall
• Medially,theinframammaryfoldofthe
breastfootprintextendstowithin1to2cmof
thesternalmidline
• Curvinglaterallyatapoint7cmbelowthe
sternalnotch
• Superiorly,Thiscurvetapersintothelateral
partofthechestwallatapproximatelytwo
finger-breadthsbelowtheclaviclejustbefore
endingatitslateralborderbackattheaxillary
fold.
Skinenvelope
1. Quantityandquality
2. Redundantskinwillleadto
awkwardbreastshapesand
to(early)ptosis.
3. Skinshortageorover-
tighteningwillleadto
flatteningofthebreastand
woundhealingproblems
ONCOPLASTICBREASTANATOMY
7-17mm
Dermis
Breast
Subcutaneousadiposetissue
RobertsonSA,etal.BrJSurg2014.
ONCOPLASTICBREASTANATOMY
“Wueringer’s
fibrousseptum”
Thinhorizontalseptumofdenseconnectivetissue
WueringerE,etal.PlastReconstrSurg101;1486,1998.
Originofhorizontalseptum
fromthoracicwallatthelevel
of5thribconnectswitha
ligamentoriginatingfrom
pectoralisfasciaatthesame
level,whichextendedintothe
IMF
ONCOPLASTICBREASTANATOMY
TowardsNipple-Areola
Coveredcraniallyandcaudally bytwodenselayersofarteries
Intraglandular:
•Cranially;thoracoacromialarterybranches
•Caudally;4th&5thintercotalarteries-cutaneousperforators
HorizontalSeptum
Atitsmedialandlateraledges,septumbecomesmoredenseandcurvesupwards; ligamentsattachingbreasttothoracicwall
ONCOPLASTICBREASTANATOMY
TowardsNipple-Areola
Subcutaneous:
•Medially;containsperforatingbranchesinternalthoracicarterytraversing2nd–4thintercotalspaces
•Laterally;containsbranchesofthelateralthoracicartery
IMF
• NomacrostructurefeaturingIMF
• Noanatomytextbookdescribedanyligament
• Highlydebated,relatedtotheories✰
Atrueinframammaryligament? THEORY
“Prepectoralligament”:itisnotatrueligamentbutratherthe
capsuleofaglandofectodermalorigin.Crescentshaped
ligamentbetweenskinandanteriorsurfaceofpectoralismajor
muscle
MaillardGF&GareyLJ.PlastReconstrSurg80;396,1987.
Subcutaneous,densefibrousstrandfollowingmarginofIMFand
extendsfromsternumtolateralmarginofpectoralismajorat
preaxillaryfold.
VanStraalenWR,etal.AnnPlastSurg35;237,1995.
“Inframammarycreaseligament”:condensationofrectus
abdominisfasciamediallyandfasciaoftheexternaloblique
andSerratusanteriorlaterally.Originatesmediallyfrom5th
ribperiosteumandlaterallyfromfasciabetween5thand6th
ribswhichinsertsintodeepdermisofIMF.
BayatiS&SeckelBR.PlastReconstrSurg95;501,1995.
Theinframammaryfold
skin
FasciaMammae
DeepfasciaScarpa
Cooper
“Condensationoftissuewithinthesuperficialfasciasystem”Fusionbetweenthesuperficialandmammaryfasciayieldstheinframammaryfold
INFRAMAMMARYFOLD
IMF• Nodemonstrableligamentousstructureof
denseregularconnectivetissue
• Nomammarytissue
• Onlyepidermis,dermis,superficialfascia,
adiposetissue
• Superficialanddeepfasciallayers
connectedtothedermis.
• MuntanCD,etal.PlastReconstrSurg105;549,2000.
IMF
MALES
NosuchorganizedconnectivetissuestructureintheregionofIMF.
MuntanCD,etal.PlastReconstrSurg105;549,2000.
Bloodsupply
NACBloodSupply
Mostconsistentisfrommedial(viainternalthoracicartery).
Alsosuppliedfromanteriorintercostalarteriesandlateralthoracicartery.
Veryrarelyfromdirectbranchesoftheaxillaryarteryorposteriorintercostal
arteries.
Venousdrainage
• Thevenousdrainageofthebreastisdividedintoa
superficialsystemandadeepsystem.
1.Thesuperficialsystem:
• transverse(91%)andlongitudinal(9%)
2.Deepsystem:followsthearterialsupply
Venousdrainage
• Thesevenouspathwaysleadtothepulmonary
capillarynetworkandprovidearouteformetastasisto
thelungs.
• Thevertebralsystemofveinsprovidesanentirely
differentmetastaticroute.Theseveinsformavertebral
venousplexusandprovideadirectvenouspathwayfor
metastasestobonesofthespine,pelvis,femur,
shouldergirdle,humerus,andskull.
NervesupplyINTERCOSTOBRACHIALNERVE
Lat.cutaneousbranchofT2intercostalnerve
Emergesfrom2thintercostalspace
Anastomoseswithcutaneousbrachiimedialis
nerve(branchofplexusbrachialis)
Suppliesskinonmed.&post.arm
90%fromT2alone
3% fromT3alone
7% fromacombinationofT2andT3
VARIATIONS