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  • EssentialAnatomyforoncoplasticsurgery

    OmarZ.YoussefM.D

    Professorofsurgicaloncology

    NCI-CairoUniversity

  • Introduction RationaleforanatomicalbasisforOPS

    Anatomicalconsiderations:

    1. Surfaceanatomy

    2. Surgicalanatomy

    3. AppliedAnatomy

  • ONCOPLASTICBREASTANATOMY

    BCS

    OPS:LevelI-IIoncoplasticsurgery(GR/TM)

    Contralateralbreastsymmetrization

    Skin(NAC)sparingmastectomy

    Immediatereconstruction

    Implantbased

    Autologoustissuebased

  • IntroductionReconstructivePointofView

    Anatomicalfeaturescriticalforoptimalresults:

    Qualityandtensionofskinflaps

    Preservationoftheinframammaryfoldframe

    Viabilityofnippleareolacomplex(NAC)

    Integrityofthepectoralismuscle

    Qualityofabdominalandlatissimusflaps

  • IfwelookatbreastsurgerycomplicationslikeNAC

    necrosis,skinsloughing,woundcomplicationsand

    fatnecrosis,wewillrealizethatitlargely

    correspondstoanatomicalreasons

    Thatswhyathoroughanatomicalunderstandingis

    amust.

  • Surfaceanatomy

  • a) Langerslines:

    predominant

    orientationof

    collagenfibersin

    theskin.Skin

    creaselines

    aroundthebreast

    areessentially

    circular

    b)Kraissllines:

    linesofmaximum

    skinresting

    tensionrunina

    moretransverse

    orientation

    acrossthebreast

  • ONCOPLASTICBREASTANATOMY

    ModifiedSweatGlands

  • NAC Theepidermisofthenippleandareolaishighlypig-

    mentedandsomewhatwrinkled.

    Theskinofthenipplecontainsnumeroussebaceousandapocrinesweatglandsandrelativelylittlehair.

    The15to25milkductsenterthebaseofthenipple,wheretheydilatetoformthemilksinuses.

    Thesesinusesterminateincone-shapedampullae.

  • Thecircularareolasurroundsthenippleandvaries

    between15and60mmindiameter.Itsskin

    containslanugohair,sweatglands,sebaceous

    glands,andMontgomerysglands,whicharelarge,

    modifiedsebaceousglandswithminiaturemilk

    ductsthatopenintoMorgagnistuberclesinthe

    epidermisoftheareola

  • ONCOPLASTICBREASTANATOMY

    SegmentalTDLUdistribution

    Oncologicalaspect

  • ONCOPLASTICBREASTANATOMY

    SuperficialFascia

    Existenceasadistinctlayer

    56%

    Inthosecontainingthislayer;

    Complete 58%

    Irregular/containsislandsofbreasttissue 42%

    RobertsonSA,etal.BrJSurg2014.

  • Mainanatomicalfeaturesofthebreast

    Thefootprint

    Breastconus

    Skinenvelope

  • BreastFootprint

  • Startingfromthepectoralistendon3to6cm

    belowthesuperiormostpointoftheanterior

    axillaryfold,extendingdownthelateralchest

    wall

    Medially,theinframammaryfoldofthe

    breastfootprintextendstowithin1to2cmof

    thesternalmidline

    Curvinglaterallyatapoint7cmbelowthe

    sternalnotch

    Superiorly,Thiscurvetapersintothelateral

    partofthechestwallatapproximatelytwo

    finger-breadthsbelowtheclaviclejustbefore

    endingatitslateralborderbackattheaxillary

    fold.

  • Skinenvelope

    1. Quantityandquality

    2. Redundantskinwillleadto

    awkwardbreastshapesand

    to(early)ptosis.

    3. Skinshortageorover-

    tighteningwillleadto

    flatteningofthebreastand

    woundhealingproblems

  • Conusofthebreast

    SA=r2+rl

  • Anatomyofthebreast

  • ONCOPLASTICBREASTANATOMY

  • ONCOPLASTICBREASTANATOMY

  • ONCOPLASTICBREASTANATOMY

    7-17mm

    Dermis

    Breast

    Subcutaneousadiposetissue

    RobertsonSA,etal.BrJSurg2014.

  • ONCOPLASTICBREASTANATOMY

  • Skinflaps

  • Ligamentsofthebreast

  • ONCOPLASTICBREASTANATOMY

    Wueringers

    fibrousseptum

    Thinhorizontalseptumofdenseconnectivetissue

    WueringerE,etal.PlastReconstrSurg101;1486,1998.

  • HorizontalSeptum

  • Originofhorizontalseptum

    fromthoracicwallatthelevel

    of5thribconnectswitha

    ligamentoriginatingfrom

    pectoralisfasciaatthesame

    level,whichextendedintothe

    IMF

  • ONCOPLASTICBREASTANATOMY

    TowardsNipple-Areola

    Coveredcraniallyandcaudally bytwodenselayersofarteries

    Intraglandular:

    Cranially;thoracoacromialarterybranches Caudally;4th&5thintercotalarteries-cutaneousperforators

  • HorizontalSeptum

    Atitsmedialandlateraledges,septumbecomesmoredenseandcurvesupwards; ligamentsattachingbreasttothoracicwall

  • ONCOPLASTICBREASTANATOMY

    TowardsNipple-Areola

    Subcutaneous:

    Medially;containsperforatingbranchesinternalthoracicarterytraversing2nd4thintercotalspaces

    Laterally;containsbranchesofthelateralthoracicartery

  • TheinframmaryfoldIMF

  • IMF

    NomacrostructurefeaturingIMF

    Noanatomytextbookdescribedanyligament

    Highlydebated,relatedtotheories

  • Atrueinframammaryligament? THEORY

    Prepectoralligament:itisnotatrueligamentbutratherthe

    capsuleofaglandofectodermalorigin.Crescentshaped

    ligamentbetweenskinandanteriorsurfaceofpectoralismajor

    muscle

    MaillardGF&GareyLJ.PlastReconstrSurg80;396,1987.

    Subcutaneous,densefibrousstrandfollowingmarginofIMFand

    extendsfromsternumtolateralmarginofpectoralismajorat

    preaxillaryfold.

    VanStraalenWR,etal.AnnPlastSurg35;237,1995.

  • Inframammarycreaseligament:condensationofrectus

    abdominisfasciamediallyandfasciaoftheexternaloblique

    andSerratusanteriorlaterally.Originatesmediallyfrom5th

    ribperiosteumandlaterallyfromfasciabetween5thand6th

    ribswhichinsertsintodeepdermisofIMF.

    BayatiS&SeckelBR.PlastReconstrSurg95;501,1995.

  • Theinframammaryfold

    skin

    FasciaMammae

    DeepfasciaScarpa

    Cooper

    CondensationoftissuewithinthesuperficialfasciasystemFusionbetweenthesuperficialandmammaryfasciayieldstheinframammaryfold

    INFRAMAMMARYFOLD

  • IMF Nodemonstrableligamentousstructureof

    denseregularconnectivetissue

    Nomammarytissue

    Onlyepidermis,dermis,superficialfascia,

    adiposetissue

    Superficialanddeepfasciallayers

    connectedtothedermis.

    MuntanCD,etal.PlastReconstrSurg105;549,2000.

  • IMF

    MALES

    NosuchorganizedconnectivetissuestructureintheregionofIMF.

    MuntanCD,etal.PlastReconstrSurg105;549,2000.

  • BloodSupply

  • BloodSupplyofthebreast

  • Bloodsupply

    NACBloodSupply

    Mostconsistentisfrommedial(viainternalthoracicartery).

    Alsosuppliedfromanteriorintercostalarteriesandlateralthoracicartery.

    Veryrarelyfromdirectbranchesoftheaxillaryarteryorposteriorintercostal

    arteries.

  • NACbloodsupply

  • Venousdrainage

    Thevenousdrainageofthebreastisdividedintoa

    superficialsystemandadeepsystem.

    1.Thesuperficialsystem:

    transverse(91%)andlongitudinal(9%)

    2.Deepsystem:followsthearterialsupply

  • Venousdrainage

    Thesevenouspathwaysleadtothepulmonary

    capillarynetworkandprovidearouteformetastasisto

    thelungs.

    Thevertebralsystemofveinsprovidesanentirely

    differentmetastaticroute.Theseveinsformavertebral

    venousplexusandprovideadirectvenouspathwayfor

    metastasestobonesofthespine,pelvis,femur,

    shouldergirdle,humerus,andskull.

  • NerveSupply

  • NervesupplyINTERCOSTOBRACHIALNERVE

    Lat.cutaneousbranchofT2intercostalnerve

    Emergesfrom2thintercostalspace

    Anastomoseswithcutaneousbrachiimedialis

    nerve(branchofplexusbrachialis)

    Suppliesskinonmed.&post.arm

    90%fromT2alone

    3% fromT3alone

    7% fromacombinationofT2andT3

    VARIATIONS

  • 51

  • ONCOPLASTICBREASTANATOMY

  • Conclusion

  • Thoroughanatomicalknowledgeisamustto

    performsafebreastsurgicalprocedures

    Respectinganatomicalguidelineswould

    preventcomplicationsandimproveoutcome

    57

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