Breast deformities: Anatomical and physiological cosiderations in plastic repair

Abstract

Fixation of the breast is provided by the skin through multiple fibrous prolongations (Cooper's Ligament) into the gland and by the retro-mammary fascia which provides a suspensory ligament attached to the clavicula. A marked increase in the weight of the breast, from any cause, overtaxes this apparatus and produces ptosis. In mammary reconstruction, the transposed gland should be firmly attached to the pectoral fascia to simulate normal fixation. This is done by means of a circular row of non-absorbable sutures, which must not be permitted to involve large amounts of gland or fat. In reducing the gland, the central portion should be left intact to preserve the blood supply to the nipple and to retain such function as exists in the main central ducts. In glandular hypertrophy of the breast, a rare condition bordering on malignancy, the entire breast gland should be removed. Circulation in the breast is derived from: (1) the thoracic lateral, which supplies the external half and skin; (2) the internal mammary, which is the principal source of supply of the internal half, including the central portion of the gland and the nipple; and (3) several perforant branches of the intercostal arteries which also supply the deep and central portions of the gland. There is little anastomosis between these, so the main blood supply must be carefully preserved in each part. Since the thoracic lateral does not supply the nipple, the large amounts of glandular structure may be removed from the external quadrant without impairing the “take” of the transposed nipple. Great care must be taken in the excision of excessive fat and glandular structures in the area of the nipple and areola. Although the circular incision in the areola does not endanger the blood supply it should be superficial so as not to injure the underlying circular muscle fibers or interfere with the surrounding vascular plexus. As the blood supply comes through the deep portion of the gland, there is always risk of interfering with the blood supply when large quantities of fat and glandular tissue must be removed. The author employs a two stage procedure to minimize this risk. The nipple is transposed with most of the blood supply preserved and secondary resection is postponed until after the “take” of the central portion of the gland is complete.