The Laminated Nature of the Pectoralis Major Muscle and the Redefinition of the Inframammary Fold: Clinical Implications in Aesthetic and Reconstructive Breast Surgery

Extended Superior Dermoglandular Pedicle Approach: A Versatile Technique for a Variety of Breast Deformities

Background

Although the selected pedicle is important in how it maintains nipple viability and is of equal importance, it can be utilized with the remaining breast tissue to reshape the breast mound. It is ideally used as an extended pedicle, as it allows us to use the tissue in the lower pole of the breast. The purpose of this article was to evaluate additional indications and outcomes using the extended superior pedicle approach along with conventional techniques.

Methods

This is a retrospective study over 5 years of using an extended superior dermoglandular pedicle approach for managing a variety of breast deformities. Postoperative complications, along with patient and surgeon satisfaction, were assessed.

Results

All 68 patients expressed that the results were either excellent (85.3%) or very good (14.7%) according to the evaluation parameters. Among the 68 patients, there were 62 very good outcomes (91.2%) and six good outcomes (8.8%) according to surgeon evaluation. Only one reduction experienced a superficial partial loss, which was improved with no intervention. There was minor asymmetry in three patients (4.4%), which was not experienced by the patients, and poor scar quality in one dark-skinned patent.

Conclusions

The author was able to expand the utility of extended superior pedicle for various breast deformities, such as reduction mammoplasty; mastopexy; augmentation mastopexy, either autoaugmentation or prosthetic; tuberous breast; after lumpectomy resection; and even in secondary breast deformities with reproducible and reliable outcomes across a wide patient population.

Anatomical Variations of the Pectoralis Muscle and Its Importance for Breast Implant Surgery

In breast augmentation, during submuscular or dual plane dissection, anatomical variations of the inferior and costal origin of the pectoralis major muscle (PMM) play a key role to ensure optimal implant coverage. Especially, a short and narrow muscle or surgical release along the sternum increases the risk of irregularities and animation deformities of the implant.

Methods

In 84 consecutive aesthetic breast augmentations intraoperatively, measurement of PMM dimensions was performed bilaterally. These PMM measurements were then correlated with the preoperative breast width, the inframammary fold, and the placement of the implant's lower pole.

Results

One hundred sixty-eight PMMs of 84 patients were dissected with a dual plane II or III technique for primary aesthetic breast augmentation. In 88% of breasts, the calculated implants' lower pole was below the inferiomedial origin of the pectoralis muscle. In 10% of patients, a separation (more than 1 cm wide and 2 cm wide) in the inferior-medial origin of the PMM was noted. An asymmetry more than 0.5 cm in length between the left and right pectoralis major was noted in 36% of patients.

Conclusions

In this series, the anatomy of the PMM demonstrates a substantial variability in width and length and a considerable asymmetry in its dimensions. These findings emphasize the importance of good access and visualization of the origin of the PMM fibers before its division.

Variations in the anterior thoracic wall with sternalis muscle and accessory pectoralis major muscle

PURPOSE

The new type of the sternalis muscle needs to be recognized, and the accessory pectoralis major muscle (AcPM) was found between the pectoralis major and minor muscle. It needs to be acknowledged those two different variations can exist in one case.

METHODS

The muscle was found on a 73-year-old male cadaver during the dissection class for the anterior thoracic wall. It was proceeded to identify the adjacent structures with precise dissection.

RESULTS

The cadaver had sternalis muscle bilaterally. Both side sternalis muscles had a medial and lateral belly and attached to pectoral fascia and rectus abdominis sheath. The pectoralis major muscle (PMaj) had a more profound slip attached to the costal cartilage of rib 4 and 5, which is AcPM. The pectoral nerve traveled through the clavipectoral fascia to the AcPM and through PMaj to the sternalis muscle.

CONCLUSIONS

This study presented a new type of sternalis muscle. Two different variations were developed along with the pectoral nerve. It needs to be recognized in the diagnostic images, the muscle rehab outcome, and the surgical complication.

Four-step Augmentation Mastopexy: Lift and Augmentation at Single Time (LAST)

Supplemental Digital Content is available in the text.

Augmentation mastopexy is one of the most difficult challenges plastic surgeons face, especially concerning sustainability of upper pole fullness and lower pole ptosis correction. We describe our technique for augmentation mastopexy that provides inferolateral muscular support for the implant and standardizes a sequence of surgical stages to resolve multiple situations and present the outcomes of patients who underwent such an approach.

Latest Trends in Subpectoral Breast Reconstruction

There has been a shift in recent years toward a growing popularity of implant-based breast reconstruction, especially in the setting of increased frequency of concurrent contralateral prophylactic mastectomy. Advancements in implant safety and technology have also allowed for an expanding implant reconstruction practice across the country. The traditional approach is immediate two-stage implant reconstruction with placement of a tissue expander within a subpectoral pocket. The introduction of acellular dermal matrix has revolutionized implant-based breast reconstruction, allowing surgeons the opportunity to minimize morbidity while maximizing aesthetic outcomes. There have also been advances in the management of postoperative pain control as well as secondary revision surgery.

Inframammary fold subcutaneous cushion assessment using MRI (magnetic resonance imaging)

Background

The inframammary fold (IMF) is one of the most important elements in the determination of the aesthetic of the female breast. During mastectomies, it is important to preserve the subcutaneous portion nearby the IMF, attempting that, this preservation will greatly facilitate reconstruction allowing more satisfying aesthetic results. The aim of the present study is to evaluate the thickness of the subcutaneous IMF cushion using magnetic resonance imaging (MRI) acquisition images.

Methods

We have gauged the right breast IMF subcutaneous cushion from patients (all the cases without previous surgery in this topography) who were submitted to MRI in a diagnosis radiology center, between January and February of 2017. MRI images were analyzed in T1 fat saturated sequences. The assessment of the fold cushion was realized in the projection of axial measurements in sagittal plane.

Results

Among the 50 evaluated patients, the median measure of breast base was 9.91 cm. The median measure of the subcutaneous IMF cushion assessment in the sagittal projection of the breast base meridian was 2.40 cm (varying from 1.34 to 4.05 cm, with percentile 5% of 1.51 cm and percentile 95% of 3.55 cm).

Conclusions

Other studies indicate the negligible amount of breast tissue and the low incidence of neoplasia in this topography, the preservation of the IMF seems feasible. The measurements of the IMF thickness, evaluated by MRI in this study, provide reference values for maintaining a desirable inframammary crease.

Anatomical Variations of the Pectoralis Major Muscle: Notes on Their Impact on Pectoral Nerve Innervation Patterns and Discussion on Their Clinical Relevance

BACKGROUND

The presented study attempts to classify individual anatomical variants of the pectoralis major muscle (PM), including rare and unusual findings. Rare cases of muscular anomalies involving the PM or its tendon have been presented. An attempt has also been made to determine whether anatomical variations of the PM may affect the innervation pattern of the lateral and medial pectoral nerves.

MATERIAL AND METHODS

The research was carried out on 40 cadavers of both sexes (22 males, 18 females), owing to which 80 PM specimens were examined.

RESULTS

Typical PM structure was observed in 63.75% of specimens. The most frequently observed variation was a separate clavicular portion of the PM. In one female cadaver (2.5% of specimens) the hypotrophy of the clavicular portion of the PM was noticed. In two male cadavers (5% of specimens) the fusion between the clavicular portion of the PM and the deltoid muscle was observed. In one of those cadavers, small sub-branches of the lateral pectoral nerve bilaterally joined the clavicular portion of the deltoid muscle. The detailed intramuscular distribution of certain nerve sub-branches was visualized by Sihler's stain. PM is mainly innervated by the lateral pectoral nerve. In all specimens stained by Sihler's technique, the contribution of the intercostal nerves in PM innervation was confirmed.

CONCLUSIONS

Surgeons should be aware of anatomic variations of the PM both in planning and in conducting surgeries of the pectoral region.

Reverse-Muscle Sling Reduces Complications in Revisional Mastopexy-Augmentation

BACKGROUND

Simultaneous augmentation-mastopexy is a particularly tricky operation with a considerable reoperation rate. The pectoralis muscle sling has proven to be a suitable alternative technique for long-term results in breast parenchyma suspension without silicone implants. This study aims to propose a promising approach to simultaneous augmentation-mastopexy revisional surgery using an inverted dual-plane technique acting as a muscular sling.

METHODS

A 10-year historic cohort was conducted to obtain the following variables from our preexisting database: age, preoperative measurements, operative technicalities, implant details, time from procedure to revision, complications, and outcomes.

RESULTS

Twenty-six patients assessed after the initial postoperative year were analyzed. Review of this series of patients revealed a revision rate of 3.8% and overall rate of morbidity of 11.5%.

CONCLUSION

Simultaneous augmentation-mastopexy using an inverted dual-plane technique acting as a muscular sling is a reliable and safe procedure. Review of this series of patients revealed low rates of morbidity and reoperation need.

LEVEL OF EVIDENCE IV

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A new percutaneous method for inframammary fold reconstruction in implant-based breast reconstruction: Vertical pendulum suture

Several operative techniques for inframammary fold (IMF) reconstruction have been described and have resolved the shortcomings of conventional methods. However, there are still difficulties with IMF reconstruction, that is, performance through small mastectomy scars, creation of a smooth IMF curve, transfer of external IMF markings to the interior chest wall, or determining correct IMF without an implant in place. We have used a type of anchor suture with a completely percutaneous approach, the vertical pendulum suture (VP suture), to reconstruct the IMF easily in implant-based breast reconstruction.The VP suture requires a pair of skin incisions a few millimeters in length (incisions A and B). The needle passes through the subcutaneous tissue from incision A, the chest wall, again through the subcutaneous tissue, and exits from incision B. Then, the needle passes through the edge of the dermis from incision B, the superficial layer of the subcutaneous tissue, again through the other edge of the dermis, and exits from incision A. The knot is tied and buried in the subcutaneous tissue. The whole technique can be performed percutaneously without visualizing the inside of the pocket. A retrospective case series study of photographs and chart review was conducted for all cases of unilateral implant-based breast reconstruction performed from December 2016 to December 2017 at Ina Central Hospital, Ina, Japan.Nine consecutive patients underwent unilateral implant-based breast reconstruction. Five patients treated using the VP suture were included in this study. All 5 patients showed good esthetic results over the follow-up period (average, 11 months). Scalloped appearance was observed in all patients, but flattened spontaneously and disappeared within 3 months postoperatively. There were no complications, such as hematoma, infection, skin necrosis, pneumothorax, seroma, scar contracture, or implant injury.The VP suture is completely percutaneous, parallel to the IMF, and is easy to perform at any time during surgery regardless of whether the implant is in place or not. IMF reconstruction is facilitated by freeing the surgeon from the need to visualize the inside of the pocket.

Positional relationship between the pectoralis major and external abdominal oblique muscles for consideration during dual-plane breast augmentation

During dual plane breast augmentation (DPBA), the costal origin of the pectoralis major (the PM) should be cut to ensure appropriate coverage and positioning of an implant. However, surgeons sometimes make inappropriate planar incisions and insufficient muscular incisions because the external abdominal oblique (the EAO) muscle partially overlaps the lateral portion of the PM. The goal of this study was to clarify the positional relationship between the PM and EAO with the aim of improving the accuracy of implant and muscular incisions during DPBA. Forty sides of 20 embalmed and fresh cadavers were dissected. The midline and midclavicular line (MCL) were used as reference lines for measurements. We clarified the overlapping patterns between the PM and EAO, and measured the distances from the MCL to the borders of those two muscles. The costal part of the PM originated from the 5th (25%), 6th (70%), or 7th rib (5%), respectively. The distances from the MCL to the lateral border of the PM at the 4th, 5th, and 6th ribs were 49.8 mm, 30.5 mm, and 6.3 mm, respectively. In 90% of the specimens, the PM and the EAO overlapped near the MCL. The width of the overlapping portion between the PM and EAO was about 25 mm. This study is one of the first to suggest an innovative approach for explaining the positional relationships between the PM and EAO. Our findings can be useful for surgeons attempting to produce optimal outcomes in DPBA, especially in procedures that involve patients of different races. Clin. Anat. 31:339-346, 2018. © 2018 Wiley Periodicals, Inc.

Aesthetic outcomes of inframammary fold recreation in two-stage, implant-based, breast reconstruction

Background

When the inframammary fold (IMF) is excised in mastectomy procedures for oncologic reasons, it must be recreated to restore a natural breast shape. Despite refinements in surgical techniques, postoperative loss of a well-defined IMF can occur. This study aimed to assess the outcomes of IMF recreation after two-stage, implant-based breast reconstruction.

Methods

We retrospectively reviewed 75 consecutive patients who underwent unilateral, two-stage, implant-based breast reconstruction between 2013 and 2015 at the authors’ institution. Among them, IMF recreation was performed in 37 patients through a modified Nava’s internal method. Aesthetic outcomes of the recreated IMFs were evaluated by observer assessment of two criteria, and critical factors affecting IMF outcomes were also analyzed.

Results

We found that contralateral breast ptosis (p < 0.05) and lack of postmastectomy radiotherapy (PMRT, p < 0.01) were significant predictors of better IMF outcomes. Nipple-sparing mastectomy and skin-sparing mastectomy resulted in better IMF outcomes, as compared with non-skin-sparing mastectomy (p < 0.05 for each), while no significant difference was observed between them in patients who did not undergo PMRT (p = 0.19). Similarly, larger implant volume, but not projection of implant, was a predictor of better IMF outcomes when limited to patients who did not undergo PMRT (p < 0.05). Age, body mass index, timing of reconstruction, and extent of overexpansion had no significant effect on IMF outcomes.

Conclusions

Based on these critical factors, the shape of the reconstructed breast and the need for reshaping the contralateral breast can be predicted. Special attention should be paid to patients with non-skin-sparing mastectomy and PMRT. When these patients desire a medium- to large-sized ptotic breast, conversion to autologous reconstruction can achieve symmetrical breast reconstruction.