Inframammary Research Articles

Mastopexy on Reconstructed Breast Following Massive Weight Loss: An Innovative Technique Using Dermo-Capsular Flaps.

We have developed a dermo-capsular flap mastopexy technique for patients who have experienced massive weight loss after breast reconstruction. The aim of this technique is to lift the inframammary fold, adequately cover the implant, and remove excess skin, elevating the breast and obtaining symmetry with the contralateral breast. Between January 2014 and February 2017, we performed this technique on 20 women who were candidates for second-stage breast reconstruction following nipple-sparing mastectomy. All patients had experienced substantial weight loss (>15kg) and presented with ptosis after first-stage reconstruction. There were 8 patients with bilateral reconstruction following bilateral mastectomy (4 with bilateral nipple-sparing mastectomy). There were 12 patients with unilateral mastectomy, all with contralateral breast ptosis treated by augmentation via inverted-T mastopexy (n=7) or crescent mastopexy (n=5). The average lift of the nipple-areola complex was 5cm (range 2-8cm). The average follow-up was 12months (range 4-36months). Two patients had complications, including partial wound dehiscence (in a heavy smoker) and recurrence of breast asymmetry. Implant breast reconstruction after massive weight loss is still possible even in the setting of thin, ptotic, and anelastic breast tissue. Our inverted-T dermo-capsular flap mastopexy technique for reconstructed breast is safe and effective with good outcomes and high patient satisfaction. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Augmentation Mastopexy with a Dermal Encapsulated Round or Anatomic Autoprosthesis.

Several factors, such as aging, pregnancy, and weight loss, reduce the elasticity of the breast tissue, and ptosis occurs. Due to aging and gravity, it is not possible to completely prevent breast ptosis. The goal is to delay the recurrence of ptosis as much as possible. This study included 20 female patients aged 25-55years. The patients who underwent surgery had different levels of ptosis. Although the patients wanted their breasts to be lifted and an increase in projection, they did not want implants to be used. For this reason, autologous flaps were prepared from the patients, and these flaps were called autoprosthesis flaps. The flap donor area (FA) boundaries consisted of the inframammary fold at the bottom, the medial and lateral pillar legs at the two sides and the lower margin of the areola at the top. The skin on the FA was de-epithelialized. A hand dermatome was used to ensure that the extracted skin was not too thick because the rest of the dermal skin would form the cover of the planned autoprosthesis flap. Before surgery, the autoprosthesis flap baseline width, projection, and shape (round or anatomic) were planned for each patient. The autoprosthesis flap was prepared as a central pedicle, and the dermal layer, which was 1cm wider than the flap, was then attached over the autoprosthesis flap to the pectoral muscle fascia with at least 10 sutures in the recipient area. For a round autoprosthesis flap, the flap base diameter was 10-12cm on average, whereas for an anatomic autoprosthesis flap, the width of the flap was 10-12cm and the height was 12-14cm. Autoprosthesis flap projections varied from 4 to 6cm. Because of the autoprosthesis flap, breast projection was more prominent, even in the lying position. All the patients were very satisfied with their size, shape, projection, and natural appearance. In particular, the image in the lying position was very similar to a mastopexy performed with an actual breast implant; thus, sagging was not observed. In augmentation mastopexy patients who do not want implants, upper pole filling and adequate breast projection can be easily achieved with this method. The potential risks of capsule formation, implant rejection, and implant rupture were not observed with this technique. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Feasibility and Pilot Study Evaluating the Impact of Clinician-Measured Breast Length on Radiodermatitis and the Value of Multiple Longitudinal Skin Assessments in the Treatment Field

We explored the role of clinician-measured breast length and bra cup size in the development of radiodermatitis over time on treatment and the efficacy of using multiple measurements of skin toxicity during radiotherapy as an outcome in a pilot study. The feasibility of measures to be used in a larger future study was assessed then described quantitatively and narratively. We studied women receiving normofractionated or accelerated external radiotherapy provided in the supine position using 3-dimensional conformal techniques at a community cancer center in northwestern Illinois in this descriptive study. Acute skin toxicity was assessed using the RTOG scale in 7 areas within the treatment field across 6 time-points. The total score for the 7 areas was calculated each week. Breast length was measured by the PI, used as a variable to describe its role in the development of acute radiodermatitis in the 7 areas within the treatment field, and compared against patient-reported bra cup size. Repeated-measure ANOVAs examined radiodermatitis using maximum skin toxicity and 7 sites in the radiation treatment field over 6 time-points. Kendall’s tau correlation was implemented to explore the relationship between study variables. Forty women (39 non-Hispanic White, 1 Asian) consented to this study. Increase in breast length significantly correlated with increase in maximum RTOG score (p = .04); increased RTOG score in the upper medial breast quadrant (p = .04), upper lateral quadrant (p = .02), lower lateral quadrant (p = .02), inframammary fold (p = .001); with increasing BMI (p = .002) and bra cup size (p = .0003). The measured breast lengths and reported bra cup sizes were discordant. A woman with a breast length of 5 cm reported wearing a C cup. Another with a 6.5 cm length wore an AA-sized bra cup. Women with 10.5 cm breast lengths reported wearing a D, DD, or DDD-sized bra cup. No data were missing. Our results suggest that measuring breast length and multiple areas in the treatment field is feasible and may increase the sensitivity of skin toxicity assessment. Additional larger studies among diverse populations are needed to determine both the clinical significance of the sum of RTOG scores for 7 areas in the radiation treatment field and the utility of multiple individual scores in the treatment field and clinician-measured breast length.

Breast Reduction: Decreasing Complications and Improving Long-Term Aesthetic Results with Parenchymal Sutures.

The inverted T/keyhole pattern is commonly used for large breast reductions. This technique relies on the breast skin to retain the shape. With the passage of time "fallout" (pseudoptosis) occurs impairing the cosmetic result. A technique is described that uses parenchymal sutures and inframammary fold (IMF) reinforcement sutures to maintain the intraoperative shape. A retrospective study of 25 consecutive patients (50 breasts) where the IMF was reinforced and parenchymal sutures were inserted. The patients were followed up and the nipple to notch and nipple to IMF distance was measured and compared with that marked preoperatively and set intraoperatively. Complications, especially T junction breakdown, were also recorded. The mean age was 38 years (range, 16-62 years) with a mean follow-up of 12 months. The mean body mass index was 31 (range, 22-41). The mean mass of tissue excised was 925 g (range, 340-1,800 g) per side. The distance from the suprasternal notch to the nipple remained unchanged. The distance from the nipple to the IMF remained the same as that marked preoperatively except in 3 patients who developed pseudoptosis. Only 3 patients had wound dehiscence. Parenchymal and superficial fascial system sutures combined with IMF reinforcement contributes to maintaining the aesthetic result and decreasing complications, in weight stable patients.

Abstract: Acellular Dermal Matrix (ADM) Assisted Implant-Based Immediate Breast Reconstruction with Latissimus Dorsi Flap

INTRODUCTION: Capsular contracture is the most frequently reported complication after implant-based breast reconstruction that affects 2.8 to 15.9 percent of patients. This study was first undertaken to present authors’ experience with acellular dermal matrix for prevention of capsular contracture in implant-based immediate breast reconstruction with latissimus dorsi muscle flap, and to assess the final aesthetic outcome. METHODS: We performed a retrospective review of all patients who underwent immediate latissimus dorsi muscle flap breast reconstruction in combination with implant and acellular dermal matrix from January 2014 to December 2015. Demographic and clinical characteristics and postoperative complications, especially focused on capsular contracture, were assessed. They were also analyzed as the potential risk factors for the development of capsular contracture. In addition, the aesthetic outcome of the overall reconstruction and the final outcome of the inframammary fold were evaluated. RESULTS: During the study period, a total of 30 patients (30 breasts) were reviewed. The mean Baker grades for all 29 breasts (one breast was dropped out due to implant loss), evaluated one year after reconstruction, was 1.21 ± 0.49 capsular contracture. None of risk factors except seroma/hematoma (p < 0.033) were significantly associated with the development of capsular contracture. Overall aesthetic outcome was 8.2 ± 1.2 and aesthetic outcome of the inframammary fold was 3.5 ± 0.6 for physician and 3.4 ± 0.6 for patients. CONCLUSION: In this study, we have shown the ability of acellular dermal matrix to prevent capsular contracture observed in implant-based immediate breast reconstruction with lattisimus dorsi muscle flap and its use was proven to create superior aesthetic results.

Abstract: Mechanical Analysis of Reduction Mammoplasty Effects on Spinal Musculature

INTRODUCTION: Breast weight places a considerable burden on the spine, and can lead to back pain and postural changes. Reduction mammoplasty improves these physical symptoms, but the mechanical effect of the change in breast mass is unknown. The purpose of the study is to examine the mechanical effects of reduction mammoplasty on the forces across erector spinae muscles. It is hypothesized that the patientÕs body habitus, breast size and level of ptosis will affect forces across the erector spinae muscles. METHODS: Using a cantilever model, the sum of the forces and moments were solved in using static modeling parameters. Mechanical models composed thick and thin body width with high mass and low mass grade III ptotic breasts were created. The variables included were body thickness, mass of the breast, and center of gravity of the breast. It was assumed breasts were homogenous and symmetric. The forces were uniformly distributed across the spine and absorbed by the muscles attached to the spinous process. The mass of the breasts and their center of gravity were altered. The reaction forces across the spine was calculated for each combination of body width, change in breast mass, and change in breast center of gravity. RESULTS: Independent of body habitus, the percentage of breast tissue mass resected was directly proportional to the decrease in forces on the spinae erectae muscles. Decreasing the amount of breast tissue below the inframammary fold raised the center of the gravity of the breast. The thinner a patientÕs trunk the greater the effect raising the center of gravity had on the forces on the spinal muscles. CONCLUSION: Reduction mammoplasty reduces the force across the spinal muscles. In thin patients reducing the ptotic grade had a greater effect than in overweight patients. Further studies are needed to correlate the results of this mechanical model with clinical findings.

Mastopexie nach massivem Gewichtsverlust – Erweiterte Ribeiro-Technik und Einsatz der lateralen Interkostalarterien-Perforatorlappenplastik (LICAP-Flap) zur Autoaugmentation

Mastopexy in massive weight loss patients is challenging. The breast mound is often unstable and deflated, with a loose inelastic skin envelope. It has become apparent that mammaplasty techniques in these cases should rely more on glandular recontouring rather than on the skin envelope for shaping. Published methods include plication, suspension and autoaugmentation. The residual local tissue (glandular breast tissue, fat tissue, dermoglandular fat flap) is utilised to its full extent in order to reshape a form-stable breast with full upper pole projection. The evolution of a technique is presented. In this study we retrospectively analysed 68 massive weight loss patients who underwent an extended Ribeiro technique with a superomedial pedicle mastopexy and suspension by an inferior dermoglandular flap. The current procedure involves incorporating the lateral intercostal artery perforator flap (LICAP flap) and medial breast pillar additionally to the inferior dermoglandular Ribeiro flap. This essentially autoaugments the upper pole by creating an "autoprosthesis", narrows the widened breast, and redefines the inframammary fold. The outcome parameters complication rate, patient satisfaction with the aesthetic result, nipple sensibility and surgical revision rate were obtained. From 01/2011 to 12/2016, we performed 136 autoaugmentation mastopexies. The average age was 41.2 years, average body mass index (BMI) was 27,1 kg/m2, average weight loss was 54.3 kg, average sternal notch-NAC distance was 32.3 cm, average operation time was 109 minutes. In 12 breasts, a free-nipple graft was necessary. The complication rate was 5.1 %, surgical revision rate was 17.6 %. 95 % of the patients were "very satisfied" or "satisfied" with the aesthetic result. Nipple sensibility was rated as "very good" or "good" by 85 % of patients. Modification of the Ribeiro technique by using the medial and lateral breast pillar (LICAP flap) allows autoaugmentation of the upper pole. Parenchymal shaping through plication and suspension of the breast mound should improve breast shape over time, with the aim of reducing the incidence of recurrent ptosis. The presented technique is a reproducible and reliable method with a low complication rate.

The Supra-Inframammary Fold Approach to Breast Augmentation: Avoiding a Double Bubble.

This retrospective study evaluated 160 consecutive women undergoing primary subpectoral breast augmentation. An incision was made 0.5-1.0 cm above the IMF. Dissection proceeded directly to the pectoralis margin, preserving IMF fascial attachments. The pectoralis origin was released from the lower sternum. Surveys were administered to obtain patient-reported outcome data. Ninety-eight patients (61%) participated. Implants often appear high on the chest at early follow-up appointments but gradually settle. One patient (0.6%) developed a double bubble. No reoperations were needed for implant malposition. One patient had a mild animation deformity. There were no cases of symmastia. The mean result rating was 9.1/10. Four percent of surveyed patients found their implants too high; 8% found them too low. Ninety-two patients (94%) reported that their scars were well-hidden. Ninety-six women (98%) said that they would redo the surgery. A supra-IMF approach anticipates the normal descent of implants after augmentation. Scars remain hidden both in standing and supine positions. This method reduces the short-term risk of reoperation for implant malposition or a double bubble.

Reverse Mastopexy: A Novel Contouring Technique in Previously Reconstructed Breasts

Reverse mastopexy is a novel secondary surgical technique applied to patients who have previously undergone skin-sparing mastectomies with reconstruction. Benefits of this procedure include a natural contour to the reconstructed breast with greater breast mound projection, enhanced superior medial fullness, and reduced contour irregularities. Aesthetic improvement to the breast is appreciated with scar relocation to the inframammary fold. Nipple areolar reconstruction can then be performed in surgically undisturbed tissue. Eleven patients from January 2015 through January 2016 who underwent reverse mastopexy were included in our retrospective cohort review. A total of 22 reverse mastopexies were performed at a single institution by a single surgeon. Demographics included age (25-65 years), body mass index (25.5-41.4), and previous breast radiation (3 of 11). All the reverse mastopexies were performed secondarily to mastectomy with reconstruction to improve cosmesis. One patient had undergone unilateral autologous breast reconstruction with a latissimus dorsi flap; the remainder of the women had implant-based reconstruction. Initial short-term follow-up occurred at 1 week, 2 weeks, 1 month, and 2 months after the reverse mastopexy was performed. Follow-up phone survey revealed that all women were satisfied with their aesthetic outcomes (average preoperative vs postoperative satisfaction score: 3.9 vs 9.2; range: 0-10). Complications include localized suture abscess (n = 2), dermatologic reaction to the Dermabond skin closure tape (n = 1), and mild cellulitis 4 weeks after the procedure that resolved with oral antibiotics (n = 1). “Red-breast” syndrome was appreciated in 1 patient. No patient required reoperation. Reverse mastopexy improved cosmetic appearance and patient satisfaction in our population. Few options exist for secondary breast contouring after mastectomy with reconstruction. In comparison with fat grafting, reverse mastopexy is a single operation with predictable results without the potential to cause harvest site irregularities. In addition, reverse mastopexy offers improved scar location to the inframammary fold, which improves tissue bed quality for future nipple areolar reconstruction. Further study for long-term durability and satisfaction is indicated.

An evaluation tool for myofascial adhesions in patients after breast cancer (MAP-BC evaluation tool): Development and interrater reliability.

PurposeTo develop a tool to evaluate myofascial adhesions objectively in patients with breast cancer and to investigate its interrater reliability.Methods1) Development of the evaluation tool. Literature was searched, experts in the field of myofascial therapy were consulted and pilot testing was performed. 2) Thirty patients (63% had a mastectomy, 37% breast-conserving surgery and 97% radiotherapy) with myofascial adhesions were evaluated using the developed tool by 2 independent raters. The Weighted Kappa (WK) and the intra-class correlation coefficient (ICC) were calculated.Results1) The evaluation tool for Myofascial Adhesions in Patients with Breast Cancer (MAP-BC evaluation tool) consisted of the assessment of myofascial adhesions at 7 locations: axillary and breast region scars, musculi pectorales region, axilla, frontal chest wall, lateral chest wall and the inframammary fold. At each location the degree of the myofascial adhesion was scored at three levels (skin, superficial and deep) on a 4-points scale (between no adhesions and very stiff adhesions). Additionally, a total score (0–9) was calculated, i.e. the sum of the different levels of each location. 2) Interrater agreement of the different levels separately was moderate for the axillary and mastectomy scar (WK 0.62–0.73) and good for the scar on the breast (WK >0.75). Moderate agreement was reached for almost all levels of the non-scar locations. Interrater reliability of the total scores was the highest for the scars (ICC 0.82–0.99). At non-scar locations good interrater reliability was reached, except for the inframammary fold (ICC = 0.71).ConclusionsThe total scores of all locations of the MAP-BC evaluation tool had good to excellent interrater reliability, except for the inframammary fold which only reached moderate reliability.

A Formula for Planning and Predicting Postoperative Mammoplasty Results.

For women with macromastia, reduction mammoplasty is a safe and effective solution to increasing quality of life through alleviating pain and improving aesthetics. This study developed a way to combine a surgeon's view of breast measurement (volume) with a patient's view of breast measurement (distance between nipple and notch, inframammary fold, or midline) to provide patients with a better understanding of expected surgical outcomes after breast reduction with a medial superior pedicle. An institutional review board approved retrospective chart review was performed on all medial superior pedicle reduction mammoplasties performed by a single surgeon at a university medical center from 2008 to 2016, and a total of 133 patients were identified. Measurements of interest for this study were nipple to sternal notch (N-S), nipple to inframammary fold (N-I), nipple to midline (N-M), and breast diameter (BD). The average bilateral change per measurement was calculated for each patient in centimeters. Change was averaged for left and right breasts for N-S, N-I, N-M, and BD per patient. Grams removed for left and right breasts were also averaged. Each measurement of average change was divided by the gram average and multiplied by 100 to obtain centimeter change per 100 grams. Individual patient measurements per type of measurement were averaged to achieve a final improvement reported in centimeters per 100 g tissue removed per breast. The average change in the N-S distance was calculated to be a decrease of 1.5 ± 0.8 cm/100 g of breast tissue removed. The average change in N-I was calculated to be an overall decrease of 0.7 ± 0.5 cm/100 g. The average change in N-M was calculated to be a decrease of 0.1 ± 0.3 cm/100 g. Finally, the average change in BD was calculated to be 0.0 ± 0.4 cm/100 g. A surgeon's expression of breast measurements in terms of volume can be difficult for a patient to understand and visualize. This study determined the impact volume has on length of typical breast measurements to increase patients' understanding of expected outcomes. In summary, patients can be told to expect to see a nipple elevation of 1.5 cm per 100 grams of breast tissue removed using this medial superior pedicle technique.

Principles of Breast Re-Reduction: A Reappraisal.

This article examines outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction. A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. Patient demographics, surgical technique, and outcomes were analyzed. Ninety patients underwent breast re-reduction surgery. The average interval between primary and secondary surgery was 14 years (range, 0 to 42 years). The majority of patients had previously undergone primary breast reduction using an inferior pedicle [n = 37 (41 percent)]. Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 percent)]. The nipple-areola complex was repositioned in 60 percent of patients (n = 54). The mean volume of tissue resected was 250 g (range, 22 to 758 g) from the right breast and 244 g (range, 15 to 705 g) from the left breast. Liposuction was also used adjunctively in all cases (average, 455 cc; range, 50 to 1750 cc). Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 percent). Breast re-reduction can be performed safely and predictably, even when the previous technique is not known. Four key principles were developed: (1) the nipple-areola complex can be elevated by deepithelialization rather than recreating or developing a new pedicle; (2) breast tissue is removed where it is in excess, usually inferiorly and laterally; (3) the resection is complemented with liposuction to elevate the bottomed-out inframammary fold; and (4) skin should not be excised horizontally below the inframammary fold. Therapeutic, IV.

Preoperative implant selection for unilateral breast reconstruction using 3D imaging with the Microsoft Kinect sensor

This study aimed to investigate whether breast volume measured preoperatively using a Kinect 3D sensor could be used to determine the most appropriate implant size for reconstruction. Ten patients underwent 3D imaging before and after unilateral implant-based reconstruction. Imaging used seven configurations, varying patient pose and Kinect location, which were compared regarding suitability for volume measurement. Four methods of defining the breast boundary for automated volume calculation were compared, and repeatability assessed over five repetitions. The most repeatable breast boundary annotation used an ellipse to track the inframammary fold and a plane describing the chest wall (coefficient of repeatability: 70ml). The most reproducible imaging position comparing pre- and postoperative volume measurement of the healthy breast was achieved for the sitting patient with elevated arms and Kinect centrally positioned (coefficient of repeatability: 141ml). Optimal implant volume was calculated by correcting used implant volume by the observed postoperative asymmetry. It was possible to predict implant size using a linear model derived from preoperative volume measurement of the healthy breast (coefficient of determination R2=0.78, standard error of prediction 120ml). Mastectomy specimen weight and experienced surgeons' choice showed similar predictive ability (both: R2=0.74, standard error: 141/142ml). A leave one-out validation showed that in 61% of cases, 3D imaging could predict implant volume to within 10%; however for 17% of cases it was >30%. This technology has the potential to facilitate reconstruction surgery planning and implant procurement to maximise symmetry after unilateral reconstruction.

Central pedicle reduction mammaplasty with a vertical scar: a technical modification

Background: This study introduces a central pedicle reduction mammaplasty with a vertical scar technique.Objectives: This study is aimed to create a more conical breast shape and long-lasting better projection by modifying reduction mammaplasty by central pedicle flap.Method: Preoperative markings were made including the meridian line of breast and the new location of the nipple-areola complex (NAC). The new location of the inframammary fold was marked ∼2 ∼ 4 cm above the original inframammary fold. An incision was made around the areola, the area between the resection margins and NAC was excised en bloc. The breast parenchyma was excised circumferentially, so that a cone shaped central mound was formed. An inferior and inferolateral glandular resection was performed to reduce the area of the breast base by elevating the position of the inframammary fold. After completion of dissection, the central pedicle surmounted by the NAC was transposed to its new location.Result: Fifty-six patients were operated with our modified central pedicle technique. The mean amount of resection was 475 g (range = 130–1080 g). The mean length of follow-up was 18 months (range = 12–53 months). The mean postoperative satisfaction score was 4.23 (SD = 0.81). The breast parenchymal ratio significantly increased from 1.2 preoperatively to 3.9 postoperatively.Conclusion: The modified central pedicle reduction mammaplasty with a vertical scar technique is a versatile breast reduction technique for all shapes and tissue conditions, by providing an attractive conical shape of the breast with minimum scar burden and maximum preservation of breast function.

The Inframammary Fold (IMF): A Poorly Appreciated Landmark in Prosthetic/Alloplastic Breast Aesthetic and Reconstructive Surgery—Personal Experience

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Small refinements in breast reconstruction: a technique for inframammary fold creation.

In breast reconstructive surgery, the inframammary fold (IMF) is an essential component of breast identity. The lack of the IMF following previous mastectomy requires restoration. We have developed a new IMF reconstruction technique using the posterior sheet (PS) of the expander capsule. This article presents our 10-year experience of performing this original technique during two-stage breast reconstruction. Preoperatively, the midline, lateral, and medial borders (MBs) of the implant pocket and the new IMF line were marked. After extracting the expander, the anterior sheet of the expander capsule was removed with the exception of its lowest 2-cm portion. Two needles were placed at the intersection of the new IMF line with the lateral border (LB) of the implant pocket and its MB. Within the pocket, horizontal dissection of the PS of the capsule was performed from one needle to another, after which the sheet was mobilized downward. The mobilized free border of the PS was pulled upward until the inframammary crease was at the new marked location, and then fixed with non-absorbable interrupted sutures to the underlying tissues. An implant was placed over this layer. The covering tissues were then closed. A total of 321 patients were included. The median age was 38 years (range, 18-58 years). No serious wound complications were observed. Breast-thoracic angle decreased in 21 patients (6.5%), and the distance from the IMF to the lower border of breast segment III was greater than that of the contralateral breast in 14 patients (4.4%). This technique provides a well-defined IMF without indentations or retraction. The results are stable on long-term follow-up and provide a sharp breast-thoracic angle, which is crucial in creating natural-looking ptosis of the reconstructed breast.

THE USE OF THE ORIGINAL METHOD OF RESTORING THE INFRAMAMMARY FOLD DURING TWO-STAGE BREAST RECONSTRUCTION

The Inframammary fold (IMF) is an important component of attractive and esthetically normal appearance of the breast and one of the most important elements of natural breast ptosis. It plays a significant role in the formation and maintenance of breast shape as well as it provides support for the implants placed subpectoral that prevent their malposition. It is necessary to restore the IMF during breast reconstruction and it allows achieving results similar to their natural breasts. The IMF reconstruction existing methods on a row with the advantages have some disadvantages: visible scars and contour irregularities in case of the external access, indentations at the site of IMF, little ptosis improvement or small projection, therefore it is impossible to choice a particular method of its reconstruction. Considering certain shortcomings of the existing methods of reconstruction Prof. A. Ismagilov et al. have developed a new IMF reconstruction technique using the posterior sheet of the expander capsule. This article presents our 4-year experience of performing this original technique during two-stage breast reconstruction.

Variance of the pectoralis major in relation to the inframammary fold and the pectoralis minor and its application to breast surgery

Understanding the anatomy of the muscles and other structures of the chest is of great importance in breast surgery. We have conducted the first analysis of the overall variations and relationships among the pectoralis major (PM), inframammary fold (IMF), and pectoralis minor (Pm). We studied 30 patients and 10 cadavers, leading to a total of 50 breasts. Preoperatively, the breast width was measured, and the costal origin of the lowest IMF point was marked. Intraoperatively, we recorded the costal origins of the PM and IMF, PM width, the distance between the PM and IMF, and the relationship and distance between the PM and Pm. Among the patients, PMs originated from the sixth rib in 80% and above the IMF in 66.67%. The mean distances between the PM and IMF were 10.5 mm in the patients and 16 mm in the cadavers. The mean PM/breast width ratio was 0.82 in the patients and 0.85 in the cadavers. The PM and Pm mostly crossed on the fourth or fifth rib, and the average angles between the two muscles were 23.5° and 21.4° in the patients and cadavers, respectively. This study is the first to analyze the anatomical variations of the PM, IMF, and Pm simultaneously. We also examined the differences between Western and Asian populations. Understanding the anatomy is undoubtedly crucial for breast surgery, and here we provide a firm guide to the variations to be expected during operations, which can lead to successful outcomes. Clin. Anat. 30:357-361, 2017. © 2017 Wiley Periodicals, Inc.

A New Septum in the Female Breast.

BackgroundUnderstanding the female breast fascial system is of paramount importance in breast surgery. Little was written about breast ligaments. Most articles refer to Cooper's work without further anatomical studies. Lately, a horizontal septum has been described conveying nerves and vessels to the nipple areola complex.MethodsDuring the surgical dissection of the lower part of the breast, in supero-medial technique for breast reduction operations, a fascial septum between the lower two quadrants was detected. This fibrous septum was studied through anatomic dissection of breast tissues during routine breast reshaping procedures that was done on 30 female patients. Magnetic resonance imaging (MRI) was performed preoperatively in all cases and correlated with the intraoperative findings. In the other five cases, outside the clinical study, the imaging was done during routine investigation for breast swellings.ResultsA vertical septum was identified in the lower part of the breast, lying at the breast meridian between the two lower quadrants. It is a tough bi-laminated structure that extends from the middle of the infra-mammary crease caudally to nipple-areola complex cranially and from the pectoral fascia posteriorly to the overlying skin anteriorly. This was proved by MRI findings.ConclusionsThis study describes a new inferior vertical septum which separates the lower half of the breast into two definite anatomical compartments: medial and lateral.

Contralateral sensitive cross flap for reconstruction of a burned breast

Several different approaches for reconstruction have been already described taking into account size and shape of the native breast, location and type of cancer, whether adjuvant radiation and/or chemotherapy is needed, patient’s demographic information, and surgeon’s preferences and experience. We report a case of reconstruction in burn patient using a breast sensitive perforator flap from the contralateral side. Thanks to the volume excess, the left side was large enough to reconstruct the affected side. A supero-medial pedicled reduction mammaplasty was performed on the left breast, and the excess inferior-part was elevated laterally and caudally off the pectoralis major. The flap was supplied by two perforators from the internal mammary vessels, and it was transposed to the right side after resection of the burned breast tissue. The right nipple-areola complex was left buried under the flap. After 2 months, the flap pedicle was deepithelialized, debulked, and passed through inframammary fold. The nipple-areola complex was released as a pedicled flap and sutured to the flap tissue approximately at the same level of the contralateral from the sternal notch. Preoperative sensitivity assessment demonstrated worst sensation of the right breast compared to the uninjured side. At 6 months, postoperatively, the patient could localize pressure and sensibility tested by the use of cotton wool and a pinprick test was quite normal. A clear improvement was observed in cutaneous pressure sensation thresholds over the time. At 12 months, she could recognize cotton wool and a pinprick. No changes were observed in the nipple-areola complex sensibility. Level of Evidence: Level V, therapeutic study.