Springer-Verlag France S.A.R.L Nathalie Bricout Forewords by John Bostwick and Jean-Pierre Lalardrie Breast surgery With 61 0 drawings and photographs in black and white and in color Illustrations: Yves Morel, Nathalie Bricout Springer-Verlag France S.A.R.L Nathalie Bricout, MD Plastic Surgeon 157, rue de l'Universite 75007 Paris France ISBN 978-2-8178-0928-1 ISBN 978-2-8178-0926-7 (eBook) DOI 10.1007/978-2-8178-0926-7 Based on: Nathalie Bricout: Chirurgie du Sein Translation by Dr David LeVay This work is subject to copyright. All rights reserved in all countries whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in other ways, and storage in data banks. Duplication of this publication or parts thereof is only permitted with written consent of publisher and author or trustee, under the French Law of n march 1957 in its current version. Violations fall under the prosecution of art. 425 and following of the French penal code. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. © Springer-Verlag France 1996 Originally published by Springer-Verlag France, Paris, 1996 Softcover reprint of the hardcover 1st edition 1996 29181543210-Printed on acid-free paper Contents Forewords ................................................................................................................ xv Acknowledgments .................................................................................................. XXI The normal breast ............ ........................ ........................... ........... ............... ......... 1 Embryology .................................. .......... ......... ............. ..... ......... ............... ......... 3 Normal development .................................................................................. 3 Anomalies of development ........................................................................ 4 Anatomy and morphology of the breast ......................................................... 7 Descriptive anatomy ................................................................................... 7 Structure ................................................................................................. 7 Glandular tissue ............................................................................... 7 Adipose tissue .................................................................................... 8 Connective tissue .............................................................................. 9 Superficial fascia .................................................................................... 10 Skin .......................................................................................................... 10 Nipple-areolar plaque ........................................................................... 11 Fixation of the breast ............................................................................. 12 Age changes ............................................................................................ 12 Vascular anatomy ........................................................................................ 12 Arterial vascularisation .............................. .............. ..... ....... ............. ... 12 Origin ofp lexuses ............................................................................. 13 The thoracoacromial artery...................................................... 13 The lateral thoracic artery......................................................... 14 The medial thoracic artery.......... ............................ ...... ....... ..... 14 The infracostal arteries .............................................................. 14 Formation of the three plexuses ...................................................... 16 Subdermal plexus ....................................................................... 16 Preglandular plexus ................................................................... 16 Retroglandular plexus ................................................................ 18 Nipple-areolar plaque ...................................................................... 18 Surgical applications ........................................................................ 19 Venous drainage .................................................................................... 20 Nipple-areolar plaque ...................................................................... 20 Superficial flow ................................................................................. 20 Deep flow ........................................................................................... 21 Anastomoses between the two systems .......................................... 21 Surgical implications ........................................................................ 21 Lymphatic drainage ............................................................................... 21 Plexuses ofo rigin .............................................................................. 21 VI Surgery of the breast Lymph currents ................................................................................. 22 Lymph nodes ..................................................................................... 22 Axillary nodes ............................................................................. 22 The medial thoracic (parasternal) nodes ................................ 23 Surgical applications ........................................................................ 23 Innervation ............................................................................................. 23 Cutaneous nerves .............................................................................. 24 Cutaneo-glandular nerves ............................................................... 24 Surgical implications ........................................................................ 24 Morphologic anatomy ................................................................................ 25 The base of the breast ............................................................................ 25 The inframammary crease ................................................................... 26 The supramammary crease .................................................................. 27 The height of the breast ........................................................................ 27 The quadrants of the breast .................................................................. 27 The segments of the breast ................................................................... 27 Anterior projection of the breast ......................................................... 29 Inframammary (or dihedral) angle .................................................... 29 Breast size ............................................................................................... 29 Residual breast volume ......................................................................... 31 Conclusion .............................................................................................. 31 Photography ...................................................................................................... 33 Equipment .................................................................................................... 33 Camera .................................................................................................... 33 Lighting ................................................................................................... 33 Lenses ...................................................................................................... 34 Films ........................................................................................................ 34 Choice of background ........................................................................... 34 Shooting ........................................................................................................ 36 Subject ..................................................................................................... 36 Framing ................................................................................................... 36 Views ....................................................................................................... 36 Frontal ............................................................................................... 36 Three-quarter .................................................................................... 38 Profiles ............................................................................................... 38 Other views ........................................................................................ 38 Timing of photography ............................................................................... 39 Conclusion ................................................................................................... 39 References ........................................................................................................... 40 Surgical approaches to the breast ........................................................................ 41 The different approaches to benign tumors ................................................... 45 Intra-areolar approaches ............................................................................ 45 Radial approaches ....................................................................................... 47 Axillary route ............................................................................................... 48 Inframammary route .................................................................................. 49 Summary ...................................................................................................... 50 Contents VII The problem ofm ammary discharge ............................................................. . 51 Isolated mammary discharge ................................................................... . 51 Discharge associated with a nodule ....................................................... ... 52 Tumorectomy .................................................................................................... . 53 Approach ..................................................................................................... . 53 Tumorectomy .............................................................................................. . 53 Quadrantectomy .............................................................................................. . 57 Mastectomy ....................................................................................................... . 59 Halsted's operation ..................................................................................... . 59 Modified radical mastectomy ................................................................... . 60 Operative technique ............................................................................. . 61 Mastectomy ...................................................................................... . 61 Axillary nodal clearance ................................................................. . 61 Closure of superficial layers ................................................................ . 63 Important points ................................................................................... . 64 References .................................................................................................... . 65 Surgical treatment ofg ynecomastia ............................................................. . 67 Usual technique .......................................................................................... . 68 Variants ........................................................................................................ . 69 References .................................................................................................... . 69 Hypertrophy and ptosis ........................................................................................ . 71 General considerations .................................................................................... . 73 Hypertrophy ................................................................................................ . 73 Definition ............................................................................................... . 73 Physiopathology ................................................................................... . 74 Clinical examination ............................................................................ . 74 History .............................................................................................. . 74 Examination of the breast .............................................................. . 75 Repercussions of hypertrophy ........................................................ . 78 Preoperative assessment ...................................................................... . 78 Ptosis ............................................................................................................ . 79 Definition ............................................................................................... . 79 Physiopathology ................................................................................... . 79 Analysis .................................................................................................. . 80 Glandular ptosis .............................................................................. . 81 Skin ptosis ......................................................................................... . 81 Dysmorphism due to excess ofs kin envelope ............................... . 83 Conclusion ............................................................................................. . 83 References .................................................................................................... . 84 Surgical treatment of hypertrophy and ptosis ............................................. . 85 Evolution of ideas ....................................................................................... . 86 Evolution of ideas and requirements ................................................. . 86 Biesenberger's technique (1928) .................................................... ... 86 The oblique method (1961) .............................................................. . 90 Strombeck's technique (1960) ........................................................ .. 94 Skoog's technique (1963) .................................................................. . 98 VIII Surgery of the breast Pitanguy's technique (1961) .............................................................. 101 The oblique lateral method ............................................................. 104 The lateral method ........................................................................... 106 McKissock's technique (1972) ........................................................... 108 The dermal vault technique (1972) ................................................. 110 Weiner's technique (1972) ................................................................. 118 The Saint-Louis technique ............................................................... 120 Preoperative design .................................................................... 120 Positioning .................................................................................. 122 Operation .................................................................................... 122 Validity and limitations ............................................................. 128 Personal experience .......................................................................... 130 Preoperative design .................................................................... 130 Positioning .................................................................................. 132 Procedure .................................................................................... 132 Recent developments ........................................................................ 145 Inferior pedicle technique ......................................................... 145 Posterior pedicle technique ....................................................... 147 Peixoto's technique ..................................................................... 148 Marchac's technique ................................................................... 149 The "round-block" ..................................................................... 150 Amputation of the breast with areolar graft (Thorek) ................. 151 Operative technique ................................................................... 151 The scar defect ............................................................................................. 154 The surgeon's responsibility ................................................................. 154 The technique used ........................................................................... 154 The glandular procedure ........................................................... 154 Cutaneous procedure ................................................................. 154 Scar sites ...................................................................................... 155 Suture techniques ............................................................................. 156 The breast factor .................................................................................... 156 Cutaneous factor ............................................................................... 156 Glandular factor ............................................................................... 156 The morphology of the breast ......................................................... 157 Patient factors ......................................................................................... 159 Age ..................................................................................................... 159 Life style ............................................................................................ 159 Stage of reproductive life ................................................................. 159 Obesity ............................................................................................... 159 Revision procedures .................................................................................... 160 The scar problem is an isolated one .................................................... 160 There is an associated morphologic problem .................................... 160 Conclusion ................................................................................................... 161 References ..................................................................................................... 162 Breast augmentation .............................................................................................. 163 Definitions ......................................................................................................... 167 Contents IX Amazia ......................................................................................................... . 167 Aplasia ......................................................................................................... . 167 Hypoplasia ................................................................................................... . 167 Atrophy ........................................................................................................ . 168 Physiopathology ............................................................................................... . 171 Clinical examination ....................................................................................... . 173 The breast .................................................................................................... . 173 Analysis of breast size .......................................................................... . 173 Analysis of content ............................................................................... . 175 Overall analysis ........................................................................................... . 180 Supplementary investigations .................................................................. . 181 Breast implants ................................................................................................. . 183 Smooth-walled implants prefi1led with silicone gel ............................... . 183 Smooth inflatable implants ....................................................................... . 183 Prefilled implants covered with polyurethane ........................................ . 186 Prefilled implants with textured walls ..................................................... . 187 Textured inflatable implants ..................................................................... . 188 Double-lumen implants ............................................................................. . 188 Advantages and disadvantages ofs ilicones ................................................. .. 189 Structure of the silicones ........................................................................... . 189 Reaction of the organism to silicones ...................................................... . 191 Local (foreign body) reactions ............................................................ . 191 Other local problems ............................................................................ . 195 Regional and remote phenomena ...................................................... . 197 Systemic problems associated with silicones .................................. ... 197 The different surgical approaches .................................................................. . 199 Areolar approaches .................................................................................... . 200 The nipple approach .................................................................................. . 202 The inframammary approach .................................................................. . 202 The axillary approach ................................................................................ . 204 Pre-or retropectoral placement of the implant ............................................ . 205 Prepectoral placement ............................................................................... . 205 Retropectoral placement ........................................................................... . 206 Summary ..................................................................................................... . 208 Operative technique ......................................................................................... . 211 Operative position ...................................................................................... . 211 Landmarks .................................................................................................. . 211 Dissection of the compartment and insertion of the implant .............. . 212 Closure ......................................................................................................... . 214 Immediate complications ................................................................................ . 215 Postoperative pain ...................................................................................... . 215 Postoperative effusion ............................................................................... . 215 Infection ............................................................•.......................................... 215 Implant rupture .......................................................................................... . 216 Other complications ................................................................................... . 216 Malposition of the implant ........................................................................ . 216 Secondary complications ................................................................................ . 219