BREAST COSMETIC SURGERY

PRESENTER-DR AMRIT PAL SINGH CHAWLA

SCHEME OF PRESENTATION

ANATOMY FOR PLASTIC SURGERY OF THE BREAST BREAST AUGMENTATIONENDOSCOPIC APPROACHES TO THE BREAST MASTOPEXYREDUCTION MAMMAPLASTY BREAST RECONSTRUCTION

ANATOMY OF THE BREAST

IDEAL BREAST ARCHITECTURE

• The appearance of the ideal breast is somewhat subjective

• Each patient has their own opinion as to the aesthetics of their breasts, which should be given consideration with any operative alteration of the breast.

• Reconstruction or cosmetic enhancement of the breast encompasses not only the way the breast looks, but also how it feels to the touch

• Size, symmetry, proportionality and the location of the breast and its landmarks on the chest wall all play a role in the attractiveness of the breast

• The distance from the sternal notch to the nipple and the distance from the midclavicular line are each 19-21 cm. The distance from nipple to the inframammary fold is 5-7 cm .The distance from the nipple to the midline is 9-11 cm

• These measurements offer guidelines for altering the breast, which must be individualized, based on proportionality, variances in chest wall anatomy, posture and patient preference

• The breast mound is situated over the pectoralis major muscle between the second and sixth ribs in the non ptotic state

• Important landmarks include the upper pole, location of the nipple areolar complex, inframammary fold and lateral breast fold. The upper pole of the breast extends from just below the clavicle to the level of the nipple

DEVELOPMENT OF THE BREAST

• The breast originates from the ectoderm, the germinal layer which forms the initial breast bud. The connective tissue is derived from the mesoderm. A group of glands, derived from the epidermis, develops within the dermis and underlying fascia

• Breast development occurs along the milk line, which extends from the axilla to the groin. The normal breast develops at the level of the fourth intercostal space on the anterolateral chest wall

• Onset of puberty occurs at approx. 9 yrs of age

• Typically, by age 14, parenchymal growth has extended to its mature borders.

• These include the clavicle at the superior border, the sternum at the medial border, the inframammary fold for the inferior border and the anterior border of the latissimus dorsi for the lateral border

• Breast tissue can extend beyond the borders particularly medially and inferiorly. The breast tissue that extends laterally through the axillary fascia into the axillary fat pad is referred to as the “tail of Spence”

PARENCHYMA

• The glandular tissue of the breast is dispersed through a significant amount of adipose tissue

• The glands themselves consist of millions of lobules clustered together into 20-25 lobes. Interlobular ducts join to form approximately 20 primary lactiferous ducts that open onto the nipple areolar complex

• The lactiferous ducts converge into a specialized ductile network, which stores the milk prior to lactation. The glandular parenchymal ducts are lined with cuboidal cells which transition to stratified squamous epithelium

• The Coopers ligaments provide numerous interconnections between the deep and superficial fascial layers

• With attenuation of these support structures, breast ptosis will develop

- Regnault delineated a classification system for mammary ptosis

• Mild (first-degree) ptosis is described when the nipple lies at the level of the inframammary fold.

- Moderate (second-degree) ptosis

• Descent of the nipple lies below the level of the inframammary fold but it remains above the most projected portion of the breast.

- Severe(third-degree) ptosis

• Is present when the nipple lies below the inframammary fold at the lower contour of the breast

- A separate variant, pseudoptosis

• Is present when the inferior pole of the breast descend, but the nipple lies above the level of the inframammary fold

NIPPLE AREOLA COMPLEX

• The nipple areola complex is the primary landmark of the breast

• It is located at the prominence of the breast mound

• 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

ARTERIAL SUPPLY

VENOUS DRAINAGE & LYMPHATICS

NERVE SUPPLY

• Breast is supply by the anterior and lateral cutaneous branches of 4th to 6th intercoastal nerves.

• The nerves convey sensory fibres to the skin and autonomic fibres to smooth muscles and to blood vessels.

• It does not control the secretion of Milk

MUSCULATURE

BREAST AUGMENTATION

INTRODUCTION

• Augmentation mammoplasty is a cosmetic procedure done to resolve the dissatisfaction that some women feel with small breasts, either because their breasts never developed to a desired size or because their breasts lost volume after pregnancy or weight or ageing

• When compared to the normal, inadequate breast volume may lead to a negative body image, feelings of inadequacy and to low self-esteem

• These disturbances may adversely affect a patients interpersonal relationships, sexual fulfillment, and quality of life

• There has been a steady increase in breast augmentation surgery with the emerging importance of body image, changes in societal expectations, and the increasing acceptance of aesthetic surgery

• Augmentation mammaplasty was performed 289000 times in 2009, as the most frequently performed cosmetic surgical procedure in women in the United States

EVOLUTION OF IMPLANTS

SALINE IMPLANTS

• The use of inflatable saline-filled breast implants was first reported in 1965 in France

• The saline-filled implant was developed in order to allow the non inflated implant to be introduced through a relatively small incision, and then inflating the implant in situ

• The original saline filled implants manufactured by Simiplast in France had a deflation rate of 75% at 3 years, and was subsequently withdrawn from the market

• In 1968, the Heyer Schulte Company introduced its version of the inflatable saline filled breast implant in United States

SILICONE IMPLANTS

• These silicone gel breast implants were designed under more stringent ASTM (American Society for Testing Methodology) and FDA-influenced criteria for shell thickness and gel cohesiveness

• Silicone is a mixture of semi inorganic polymeric molecules composed of varying length chains of polydimethyl siloxane [(CH3)2-SiO]

• Liquid silicones are polymers with a relatively short average length and very little cross-linking. They have the consistency of an oily fluid and are frequently used as lubricants in pharmaceuticals and medical devices

• Interestingly, silicone containing compounds are ubiquitous in everyday life. The general public has been exposed to them for over 50 years in consumer products such as hairsprays, suntan lotions, and moisturizing creams

• Silicones are extremely resistant to the action of enzymes when implanted into living tissue largely due to their hydrophobic nature

OPERATIVE PLANNING

INCISION LENGTH & PLACEMENT

• Breast augmentation requires an incision in the skin and subcutaneous tissue, with creation of a pocket in which a breast implant is placed and positioned

• There are a number of technical variations. One of three incisions can be used, each with advantages and drawbacks

• The Inframammary incision provides excellent access and does not require dissection within the breast parenchyma

• Disadvantage is a scar that may be noticeable in the smaller breast

• Periareolar incision is cam outflaged in the areola and heals with little visible scarring but has

• Disadvantage of possible changes in sensation in the nipple areolar area

• An Axillary incision leaves no scars on the breast but it is more difficult to create the pocket with this approach.

• The pocket into which the implant will be placed can be in one of two positions relative to the breast tissue and pectoralis major muscle

• Subglandular placement superficial to the pectoralis muscle fascia provides more ability to control the shape of the breast and is associated with a more rapid postoperative recovery

• In submuscular placement of the implant, the contour of the breast may be smoother because the edges of the implant are blunted by the muscle, there is less chance of developing capsular contracture & nipple sensation is protected,

• Disadvantages include more postoperative discomfort and longer recovery, movement of the implant when the muscle is flexed, and less ability to lift the parenchyma in a breast

• When considering potential problems that can develop after augmentation mammoplasty, it is useful to distinguish between operative complications and implant concerns

• Perioperative complications are relatively low, with bleeding or hematoma in 1% to 3%, wound infections in 1% to 2%, and some degree of diminished sensibility of the nipple areolar complex in approximately 15% of patients,

• More numerous and more serious are the sequelae presenting weeks or years after the surgery. These include capsular contracture, implant deflation, implant rupture, and implant displacement

DELAYED COMPLICATIONS OFAUGMENTATION MAMMAPLASTY

• Periprosthetic capsular contracture

• All surgical implants undergo some degree of encapsulation due to the natural foreign body reaction by the surrounding tissues

• Clinically significant periprosthetic capsular contracture is characterized by excessive scar formation that leads to firmness, distortion & displacement of the breast implant

• Seromas, hematomas, and even blood staining of the periprosthetic tissues may incite capsular contracture.

IN 1975, BAKER PROPOSED A CLINICAL CLASSIFICATION SYSTEM OF CAPSULAR CONTRACTURE AFTER AUGMENTATION

• Implant rupture and deflation

• Any defect in the silicone elastomer shell of a saline filled breast implant will ultimately result in deflation of the implant

• The saline filling material leaks out of the implant and is harmlessly absorbed by the surrounding tissues

• Clinical recognition of deflation is usually made by the patient and virtually always requires surgical explantation and replacement of the implant

ENDOSCOPIC APPROACHES TO THE BREAST

INTRODUCTION

• Endoscopic appproach to conventional surgical problems have significantly enhanced treatment options, since their introduction in the later half of the 20th century (Berger1996/Paige1997)

• Less traumatic tissue dissection in conjunction with smaller surgical incisions have enabled many patients to benefit from reduced postoperative pain, expedited recovery and improved cosmesis

• Widespread availability of endoscopic equipment and refinements in technique have improved the relevance and utilization of endoscopic approaches in a wide variety of plastic surgical applications in recent years

• In plastic surgical approaches to the breast, either cosmetic or reconstructive, the optical cavity is a mechanically maintained, dissected space with room air providing the optical transmission medium

• Therefore, the only option for creation and maintenance of the optical cavity is mechanical retraction

• Internal mechanical retractors apply a centrifugally directed force on the roof of the optical cavity. This provides the lift necessary to deepen the space for optimal visualization and manipulation of the surgical field

ENDOSCOPIC AUGMENTATIONMAMMAPLASTY

• INDICATIONS

• It include the patients desire for a remote incision and the absence of a well developed inframammary crease to hide a crease incision from view in the horizontal visual axis

• Patients without significant ptosis are ideal candidates

• This minimizes the need for excessive manipulation or dissection during creation of the implant pocket from a remote site

• Due to the need for control and accuracy in this dissection and concerns over the risk of under or over-dissection, aggressive management of ptosis via this approach is not recommended for the inexperienced surgeon

• While it is possible to place an implant into the subglandular plane from the axillary approach to improve moderate ptosis

• Both silicone and saline devices may be introduced through the transaxillary approach, although due to the physical constraints of the transaxillary tunnel, introduction of silicone gel implants >300 cc may be challenging and require special care to avoid damage to the device or surrounding anatomic structures during insertion

• This limitation is due to a desire to have a hidden transaxillary scar

• For the scar to blend into a high transverse axillary crease it can rarely be longer than 5 cm

• As the scar becomes longer in runs the risk of being more visible if a womens arm is raised

• A saline implant of any size can be placed through an incision of 3 cm

• Therefore, women who desire a hidden scar and an implant >300 ccs will need to consider the tradeoff of a longer, more visible scar with a silicone implant vs a short, hidden scar with a saline device.

• COMPLICATIONS

• Most implant malpositions are related to superior displacement, however, inferior displacement with bottoming out is more difficult to treat. This occasionally cannot be corrected remotely and requires an inframammary incision.

• Axillary banding across the axillary incision may be related to hypertrophic scarring, lymphatic channels or thrombophlebitis

• Minor complications such as implant deflation, mild capsular contracture, or small hematomas may often be dealt with through the existing transaxillary approach with video endoscopic assistance

MASTOPEXY

• Though written in Middle English and dating back to l387-1400, this excerpt from the Reeves Tale clearly conveys that Chaucers youthful character Malyne, with her rounde and hye breasts, is particularly attractive to her suitors

• In their pursuit of the aesthetic breast, plastic surgeons have relied heavily on the mastopexy, an operation often referred to by the lay public as the breast lift. In performing mastopexies, plastic surgeons address breast ptosis, a word whose etymologic root is Greek for falling

• It is not surprising to note the confusion among patients between what is a breast reduction and what is truly a mastopexy

• The vast majority of patients undergoing surgical intervention to treat ptosis of the breast are treated with skin resection and redraping over a repositioned breast mound the operation that is the mastopexy

• The pathophysiology of breast ptosis is multifaceted but can be conceptualized as being the result of the combination of expansion and aging, or separately as a result of a congenital deformity

• In its classic description, breast ptosis is the result of inadequate parenchyma or parenchymal maldistribution in the face of excess, lax skin and connective tissues

• Parenchymal changes with, weight changes in the obese, and pregnancy, are also accompanied by specific alterations in the integrity of Coopers ligaments, the breasts fascial components, and the overlying skin

• INDICATIONS

- Those who need an augmentation with mastopexy

- And who need a formal reduction mammoplasty

TREATMENT/SURGICAL TECHNIQUE

• There are four basic scar pattern for mastopexy techniques: Periareolar, Vertical, J or L & inverted-T

• Periareolar technique

• The periareolar technique is best-suited for patients with mild to moderate breast ptosis and in whom the parenchyma is adequate from a volume standpoint

• The obvious advantage of the periareolar technique, be it for mastopexy, augmentation, is that the incision is camouflaged in the aesthetic transition from breast skin to the skin of the nipple areola

• Disadvantages of periareolar techniques relate to precise skin excision and ultimately a limited degree of cephalic nipple-areolar complex movement.

• Other disadvantages include possible scar wide and decreased breast projection.

• Periareolar Benelli mastopexy

• The Benelli mastopexy technique is an extension of the donut mastopexy that was borne from dissatisfaction with the limitations of the simpler periareolar methods of mastopexy

• The Benelli modifications allow the periareolar technique to be used to treat larger breasts with increasing degrees of ptosis

• TECHNIQUE

• GOES periareolar technique with mesh support

• Further expanding, the indications for the periareolar technique is Joao Carlos Sampaio Goes of Brazil

• He introduced the double skin technique, in which the basic principle involves formation of a resistant lining of the breast by the use of a layer of prosthetic mesh

• This mesh provides increased support of the new breast shape during the healing and skin contraction processes

• This method forms an internal brassiere, making use of the anteriorpectoral fascia, the intramammary connective ligaments, a periareolar dermal flap, an absorbable mixed mesh, and the external skin lining

VERTICAL/SHORT SCAR TECHNIQUES

• As the degree of the breast ptosis increases, so does the total length of the incision necessary to correct it

• The logical extension of the periareolar scar is the addition of a vertical component

• The current preferred method has the latitude to allow resection of glandular tissue, if desired, and also the insertion of an implant in either the subglandular or the subpectoral plane if more volume is required

GROTTING SCULPTED VERTICAL PILLAR MASTOPEXY

• Technique

• The markings are performed with the patient in the standing position with the arms hanging at the sides. The inframammary fold is marked on both sides

• Next, the future nipple position is determined using a combination of reference points

• The inframammary fold in transposed onto the anterior surface of the breast.

COMPLICATIONS

• NIPPLE LOSS

• SCARS

• FLAP NECROSIS

• NIPPLE MALPOSITION

• COSMETIC DISSAPOINTMENTS

• OTHERS COMPLICATIONS - INFECTION & HEMATOMA

REDUCTION MAMMAPLASTY

INTRODUCTION

• Hypertrophy or overgrowth of the breast is excessive, development without any pathologic process

• It can be familial, with a typical onset during puberty and pregnancy when hormonal changes exert an abnormal influence on growth in some individual

• Reduction mammoplasty is the resection of excess fat, breast tissue, and skin to achieve a breast size proportional to the body

Indications

• Decrease the volume of the breast

• Reshape the beast to correct ptosis

• Elevate the breast tissue to an anatomically correct position on the chestwall,

• Reposition the nipple and areola on the reduced & reshaped the breast

• Preserve the nerve supply to the skin and nipple areolar complex

• Maintain blood supply to the breasttissue,

• Minimize scar

• The pedicle is the portion of the breast tissue preserved with its blood and nerve supply while the surrounding breast tissue is removed

• An inferior pedicle technique is used most often but there are central, superior, medial, lateral, and doubtly attached vertical and horizontal pedicles

• Suction assisted lipectomy is used with excision techniques to remove excess fat laterally and there area small number of patients with mild to moderate hypertrophy, fatty breasts, good skin tone, no ptosis, and good breast shape for whom liposuction alone will reduce volume, with small scar

• In the very large pendulous breast, in which the pedicle would be exceptionally long, the nipple areolar complex is removed and transplanted as a graft. This technique is useful also for patients with vascular disorders or impaired wound healing

• The 1920s saw the advent of more reliable operations in the work of Thorek, Aubert, and Passot

• Thorek published his breast amputation technique in 1922,which consisted of a lower pole amputation and free nipple graft. His technique is still used with some modificationseven today for extremely large breasts

• The next year, Aubert put forth his technique for reduction mammoplasty, which emphasized the import of minimizing dissection of the skin overlying the breast parenchyma to minimize vascular complications

• In 1925, Passot described transposition of the nipple-areolar complex into a buttonhole incision more cephalically onthe breast mound, which results in no vertical scar on the reduced breast

• Modifications and additions were still being made to the cadre of pedicle optionsfor the Wise pattern skin resection technique of breast reduction in the 1980s

• But the year of experience & followup after these reduction procedures demonstrated that the reduced breasts tended to bottom out and lose upper pole fullness

• Orlando and Guthrie, originators of the superomedial pedicle, had devised their approach in an effort to augment the upper pole and thereby reduce bottoming out

• Sequelae of reduction mammoplasty include changes in the sensibility of the nipple and areola in 20% to 25% of cases, usually a decrease but occasionally increased sensation

• Lactation and breast feeding are not always possible after breast reduction

• Complications with reduction mammoplasty include

• Wound dehiscence , in slough, loss of tissue, hematoma, infection, and fat necrosis with palpable nodules of poorly vascularized fat

BREAST RECONSTRUCTION

INTRODUCTION

• The main objective of breast reconstruction is to restore symmetry by recreating:

• Volume

• Shape

• Position

• Compare to the opposite breast

• Breast reconstruction after mastectomy has evolved over the last century to be an integral component in the therapy for patients with breast cancer.

• The goals for patients undergoing reconstruction are to correct the anatomic defect and to restore form and breast symmetry

• Within the last 30 years, the technical emphasis has focused on the use of tissue expanders with implants, latissimus dorsi myocutaneous transfer, and the transverse rectus abdominis myocutaneous (TRAM) flap to achieve adequate breast restoration

INCIDENCE

• 28.9 women per 100,000 population with breast cancer in India 1993-97 (Surveillance and Risk Assessment Division, CCDP, Health Canada).

More likely if:

• Younger

• Not of indigenous descent

• Living in the metropolitan area

• Holders of private health insurance

• Treated in a private hospital at the time of their initial breast cancer surgery.

Advantages

• Don’t need to wear an external prosthesis

• Better self esteem

• ‘Feel whole again’

• Less grief

Disadvantages

• More surgery

• Delays for planning/organisation

• Longer recovery

• Unsatisfying outcome (if expectations are too high)

• Other scars if tissue is taken from elsewhere, with associated risks

• Specific surgical side effects

FACTORS AFFECTING CHOICE OF RECONSTRUCTING PROCEDURES

Age,

Medical conditions

Previous abdomional or thoracic surgery .

Coronary artery disease.

Chronic obstructive pulmonary disease .

Chr steriod use

Obesity.

• Breast reconstruction is a proces that involves more than just a creation of a mound on a womans chest.

• Reconstructive plan must accommodate not only the size shape of the opposite breast but also the position on the chest wall , the location of the inframammary crease ,the height ,size ,color of the nipple-areolar complex the amount of breast ptosis

• Breat reconstruction can be divided in to two main types:

- AUTOGENOUS TISSUE

- ALLOPLASTIC MATERIAL

• Autogenous tissue provide better symmetry than an implant

• The choice of procedure depends on the age , health , contralateral breast size and shape personal preference and exp of reconstructive surgeon

Complications with reconstructive surgery include partial or complete flap loss wound break down and infection.

• Blood loss is another main concern.300ml -575 ml.

LATISSIMUS DORSI MYOCUTANEOUS FLAP

PREOPERATIVE MARKING

• The skin island should measure approximately 8 cm wide by 20 cm long

• Wider islands tend to be difficult to close primarily. The shape is an ellipse with a slightly wider portion at the inferomedial pole

• The superolateral end of the ellipse should begin at the posterior axillary line below the tip of the scapula

INTRAOPERATIVE DETAILS

• The procedure then begins by incising the skin island and dissecting through the subcutaneous tissue to the muscle. Bevel this tissue away to maximize the number of vascular perforators from the muscle to the skin island.

• Once into the subcutaneous tissue, continue this plane of dissection inferiorly to elevate the skin from the remainder of the muscle

• Using electrocautery, skin elevation proceeds until visualization of the muscle's inferior and medial origins at the spinous processes and posterior iliac spine.

• In the lateral direction, identify the full vertical edge of the muscle and free it from the skin in this plane of dissection. Continue this action superiorly from the skin island at the tip of the scapula to the axilla to identify the superior origins of the muscle.

FLAP ELEVAION

• The next step is to release and elevate the muscle flap completely from its origin. This is accomplished by identifying the plane of dissection beneath the muscle that is superficial to the deep posterior muscles of the thorax

• Starting laterally, the approximate location of the origin of fibers from the lower ribs is at a position that is one-third the distance of the muscle's insertion

• In this area, the serratus anterior and external oblique lie deep to the muscle

• An avascular plane can be created with careful dissection medially

• This plane continues to the inferior points of origin overlying the serratus posterior inferior muscle

• Once this point has been reached, transect the inferior origin of the muscle medial to lateral through the thoracodorsal fascia

• At this point in the procedure, the medial and lateral rows of the segmental arteries that feed the muscle come into view. Clip and coagulate these perforators that arise from the lumbar and intercostal arteries to ensure hemostasis and to prevent postoperative hematoma

• Once the muscle is reflected completely, detach the superior border of the muscle from the tip of the scapula

• In this area, the teres major, serratus anterior, and rhomboids meet with the connective tissue of the superior origin of the latissimus dorsi

• Completely detach all points of origin and tether the muscle to the axilla by its insertion and neurovascular pedicle

• With the muscle reflected, using scissor dissection, isolate the pedicle and separate the thoracodorsal nerve. Further assess the integrity of the vascular anatomy and excise the nerve

FLAP TRANSFER

• The anterior chest incision now is made to prepare flap inset

• Position this incision using either the old mastectomy scar or creating a fresh curvilinear incision at the inframammary fold

• With the anterior skin flap elevated in the subcutaneous plane, create an axillary tunnel to connect the anterior and posterior wounds

COMPLICATIONS

• Implant contracture22

• Implant rupture

• Hematoma

• Seroma

• Flap necrosis

• Hypertrophic scarring of donor site

• Infection

TRAM (TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS) FLAP

• There are two main types of TRAM flap procedures:

• The pedicle flap procedure and free flap procedure

• In each case, a portion of skin, fat and muscle is removed from the lower abdomen and transferred to the mastectomy site

THIS SCHEMATIC DEMONSTRATES HOW THE TRAM FLAP IS MOVED FROM THE ABDOMINAL AREA TO THE MASTECTOMY SITE

THIS SCHEMATIC DEMONSTRATES A LEFT TRAM FLAP USED IN THE RECONSTRUCTION OF A RIGHT MASTECTOMY DEFECT

• BLOOD SUPPLY

• Epigastric system of blood vessels. The superior epigastric vessels enter the flap from its superior aspect, while the deep inferior epigastric vessels enter from its inferior aspect.

• The pedicled TRAM flap gets its blood supply from the superior epigastric vessels, whereas the free TRAM flap gets its blood supply from the deep inferior epigatric vessels

ADVANTAGES

The reconstructed breast is made of natural tissue

• There is no exposure to synthetic materials (i.e. breast implants)

• The patient gets a "tummy tuck" in the process

• DISADVANTAGES

• It is a large surgical procedure

• There is a potential for decreased abdominal strength afterward

• The procedure leaves additional abdominal scars

THANK YOU