Plastic and reconstructive surgery of the breast

293 Pages·2009·42.217 MB·English

by  Christian J. Gabka, Heinz Bohmert

Plastic and Reconstructive
Surgery of the Breast
Christian J. Gabka, MD
Professor of Surgery
Plastic and Aesthetic Surgery
Ludwig-Maximilians-Universität
Munich, Germany
Heinz Bohmert, MD
Professor Emeritus
Division of Plastic Surgery
Ludwig-Maximilians-Universität
Munich, Germany
With contributions by
P. Blondeel, A. Gagnon, T. Schoeller, G. Wechselberger
2nd edition
694 illustrations
Thieme
Stuttgart · New York
IV
LibraryofCongressCataloging-in-PublicationData Important note: Medicine is an ever-changing science under-
Gabka,ChristianJ. going continual development. Research and clinical experience
[Plastischeund rekonstruktiveChirurgie derBrust.English] are continually expanding our knowledge, in particular our
Plasticandreconstructivesurgeryofthebreast/ knowledge of proper treatment and drug therapy. Insofar as
ChristianJ.Gabka,HeinzBohmert;withcontributions this book mentions any dosage or application, readers may rest
byP.Blondeel...[etal.].—2nded. assured that the authors, editors, and publishers have made
p.;cm. every effort to ensure that such references are in accordance
Rev.translationofthe2ndGermaned.publishedin2006. with the stateof knowledgeat the timeof production of the
Bohmert'snameappearsfirstontheprevioused. book.
Includesbibliographicalreferencesandindex. Nevertheless, this does not involve, imply, or express any
ISBN978-3-13-103572-1(alk.paper) guarantee or responsibility on the part of the publishers in re-
1. Breast—Surgery—Atlases. I. Bohmert, Heinz. II. Blondeel, specttoanydosageinstructionsandformsofapplicationsstated
PhillipN.III.Bohmert,Heinz.Plasticandreconstructivesurgery in the book. Every user is requested to examine carefully the
ofthebreast.IV.Title. manufacturers’leafletsaccompanyingeachdrugandtocheck,if
[DNLM:1. Mammaplasty—Atlases.2. Mammaplasty—Case necessaryinconsultationwithaphysicianorspecialist,whether
Reports.3. BreastNeoplasms—surgery—Atlases.4. Breast thedosageschedulesmentionedthereinorthecontraindications
Neoplasms—surgery—CaseReports. WP17G114p2008a] stated bythemanufacturersdifferfromthestatementsmadein
RD539.8.B64132008 the present book. Such examination is particularly important
618.1'9059—dc22 with drugs that are either rarely used or have been newly
2008027589 releasedon themarket.Everydosagescheduleoreveryformof
application used is entirely at the user’s own risk and responsi-
This book is an authorized and revised translation of the 2nd bility.Theauthorsandpublishersrequesteveryusertoreportto
German edition published and copyrighted 2006 by Georg thepublishersanydiscrepanciesorinaccuraciesnoticed.Iferrors
Thieme Verlag, Stuttgart, Germany. Title of the German edition: inthisworkarefoundafterpublication,erratawillbepostedat
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Translator:StephanieKramer,BA,DiplTrans,IoL,Berlin
Illustrator:Hedwig Hentschel
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V
Contributors List
PhilipBlondeel,MD ThomasSchoeller,MD
Professor Professor
DepartmentofPlasticSurgery DepartmentofPlasticand ReconstructiveSurgery
UniversityHospitalGent UniversityofInnsbruck
Gent,Belgium Innsbruck,Austria
Alain Gagnon,MD GottfriedWechselberger,MD
DepartmentofPlasticSurgery Professor
UniversityHospitalGent DepartmentofPlasticand ReconstructiveSurgery
Gent,Belgium UniversityofInnsbruck
Innsbruck,Austria
VI
Preface
Theideabehindthebreastsurgerytextbookpublishedmorethan Theaimofthebookistoprovideyoungplasticsurgeonswith
10 years ago by myacademic teacher, Professor Heinz Bohmert, a practical introduction to surgical techniques that are—in the
proved to be fully justified. No comparable presentation of the authors’opinionandintheirownexperience—promising,practi-
surgicaltechniquesinvolved,withdetaileddescriptionsandout- cable,andpatient-oriented.Wherenecessary,criticaldiscussions
standingly good illustrations (both drawings and photographs), ofstrategy,technologies,andindicationsarealsoprovided.
wasavailableatthetime. Weareparticularlygladtohavebeenabletoincludeasection
Due to the extremely rapid development of new techniques contributed by Phillip Blondeel—a recognized expert in the per-
and the growing need and demand for plastic surgery of the foratorflaptechniqueforbreastreconstruction.Thesectioncon-
breastduringoncologicalsurgery,thetimehadcometoprepare tributedbyourcolleaguesThomasSchoellerandGottfriedWech-
anewedition.Theresultisthiscompletelyrevisedandexpanded selberger may provide a stimulus for differentiated use of the
edition, which takes the same approach to the style of illustra- transversemyocutaneousgracilis(TMG)flap.
tion,focusingonprecisedepictions,cleardrawings,anddetailed Finally,wewouldliketoexpressourthankstothepublishers,
accompanyingtext. who have spared no expense in connection with the generous
More emphasis has been placed in this edition on aesthetic illustrative materials included and who provided the authors
surgery, particularly in the discussion of augmentation surgery. withvaluablesupport;weareparticularlygratefulinthisregard
In addition, considerable importance has also been given to toMs.AndreaHäberlein.
breast-conserving surgeryforpatientswithbreastcancer. ChristianJ.Gabka
VII
Abbreviations
ACA anteriorcerebralartery MI mechanicalindex
AChA anteriorchoroidalartery MIP maximalintensityprojection
ACoA anteriorcommunicatingartery MRA magneticresonanceangiography
ACV anteriorcerebralvein MRI magneticresonanceimaging
ADB angiomatosisDivry–VanBogaert MRV magneticresonancevenography
AICA anteriorinferiorcerebellarartery MSCT multisliceCT
ATA anteriortemporalartery MSCTA multisliceCTA
AVM arteriovenousmalformation MTT meantransittime
BA basilarartery NIHSS NationalInstitutesofHealthStrokeScale
BIF bifurcation OA ophthalmicartery
BVF blood flowvolume OccA occipitalartery
BVR basalveinofRosenthal OTA occipitotemporalartery
BZI borderzoneinfarction PC phase-contrast
CA calcarineartery PCA posteriorcerebralartery
CANCA cytoplasmicantineutrophiliccytoplasmicantibody PCoA posteriorcommunicatingartery
CBF cerebralbloodflow PET positronemissiontomography
CBV cerebralbloodvolume PI pulsatilityindex
cc cervico-cranial PICA posteriorinferiorcerebellarartery
CCA commoncarotidartery POA parietooccipitalartery
CCT cerebralcirculationtime;cranialcomputed PRF pulserepetitionfrequency
tomography PSV peak systolicvelocity
CoS confluenssinuum PTA percutaneoustransfemoralangioplasty
CS cavernoussinus PTT partialthromboplastin time
CSF cerebrospinalfluid PW pulsedwave
CT computed tomograph rt-PA recombinanttissueplasminogenactivator
CTA computed tomographicangiography SA subclavianartery
CVR cerebrovascularreactivity SAH subarachnoid hemorrhage
CVT cerebralvenousthrombosis SCA superiorcerebellarartery
CW circleofWillis SCOI smallcentrumovaleinfarction
CW continuouswave SiS sigmoidsinus
DMCV deepmiddlecerebralvein SPECT singlephoton emissioncomputed tomography
DSA digitalsubtractionangiography SphS sphenoparietalsinus
ECA externalcarotidartery SPS superiorpetrosalsinus
EC-IC extracranial-intracranial SSP subclavianstealphenomenon
EDV enddiastolicvelocity SSS superiorsagittalsinus
ESR erythrocytesedimentationrate STeA superficialtemporalartery
FLAIR fluidattenuatedinversionrecovery STeA-MCA superficialtemporalartery-middlecerebralartery
FMD fibromusculardysplasia StS straightsinus
FS fatsaturation SWS Sturge–Webersyndrome
FT fetaltype TAV time-averagedvelocity
FT-PCA fetal-typeposteriorcerebralartery TCCS transcranialcolor-codedsonography
GE gradientecho TCD transcranialDoppler
HSV herpessimplexvirus TEE transesophagealechocardiography
ICA internalcarotid artery TIA transientischemicattack
ICH intracranialhemorrhage TIBI ThrombosisInBrain Ischemia
ICP intracranialpressure TOF time-of-flight
ICV internalcerebralvein TR repetitiontime
IJV internaljugularvein TS transversesinus
IMT intima-media-thickness TTE transthoracicechocardiography
IPS inferiorpetrosalsinus VA vertebralartery
ISS inferiorsagittalsinus VG veinofGalen
LMC leptomeningealcollateral VV vertebralvein
LSA lenticulostriateartery WG Wegenergranulomatosis
MCA middlecerebralartery WMS Wyburn–Mason syndrome
MES microembolicsignal
VIII
Table of Contents
Basics
1 Anatomy of the Breast . . . . . . . . . . . . . . . . . . . . 3 2 Breast Implants. . . . . . . . . . . . . . . . . . . . . . . . . . 7
StructureoftheFemaleBreast . . . . . . . . . . . . . . . . 4 ImplantTypes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Blood Supply. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Risksand Complications. . . . . . . . . . . . . . . . . . . . . 7
NerveSupply. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 ImplantDefects . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
LymphaticSystem . . . . . . . . . . . . . . . . . . . . . . . . . 4 CapsularContracture . . . . . . . . . . . . . . . . . . . . . . . 8
MusculatureoftheThoracicWall . . . . . . . . . . . . . . 5 Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
BreastCancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
SafetyofSiliconeImplants . . . . . . . . . . . . . . . . . . . 9
Aesthetic and Plastic Surgery of the Breast
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 4 Mastopexy and Reduction Mammaplasty . . . . . 37
ReductionMammaplastywithaShort/VerticalScar
3 Augmentation Mammaplasty. . . . . . . . . . . . . . . 15 (Based ontheLejourTechnique). . . . . . . . . . . . . . . 38
ChoiceofImplant. . . . . . . . . . . . . . . . . . . . . . . . . . 16 SurgicalMarking . . . . . . . . . . . . . . . . . . . . . . . . . . 38
ChoiceofIncision. . . . . . . . . . . . . . . . . . . . . . . . . . 17 Infiltration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
PeriareolarApproach. . . . . . . . . . . . . . . . . . . . . . . . 17 De-epithelialization. . . . . . . . . . . . . . . . . . . . . . . . . 41
InframammaryApproach. . . . . . . . . . . . . . . . . . . . . 18 Liposuction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
AxillaryApproach. . . . . . . . . . . . . . . . . . . . . . . . . . 18 SurgicalProcedure . . . . . . . . . . . . . . . . . . . . . . . . . 41
ComparisonofDifferentApproaches. . . . . . . . . . . . . 18 ReductionMammaplastyUsingthe
ImplantPosition . . . . . . . . . . . . . . . . . . . . . . . . . . 18 T-ScarTechnique . . . . . . . . . . . . . . . . . . . . . . . . . . 55
SubpectoralImplantation. . . . . . . . . . . . . . . . . . . . . 19 PreventingLoweringof theInframammaryFold. . . . . 55
SubglandularImplantation . . . . . . . . . . . . . . . . . . . 19 MarkingT-ScarIncisions. . . . . . . . . . . . . . . . . . . . . 55
TemporaryImplant Sizers. . . . . . . . . . . . . . . . . . . . 19 ManagingVenousCongestionof theNipple–Areola
Wound Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Complex. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Drainage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
BreastPtosis(AugmentationMastopexy). . . . . . . . . 20
SurgicalApproachesinSecondaryProcedures . . . . . 20
Reconstructive Surgery of the Breast
5 Breast Deformities. . . . . . . . . . . . . . . . . . . . . . . . 69 6 Delayed Breast Reconstruction. . . . . . . . . . . . . . 85
ClassificationofCongenitalBreastDeformities. . . . . 69 TimingofBreastReconstruction . . . . . . . . . . . . . . . 85
BreastAsymmetry . . . . . . . . . . . . . . . . . . . . . . . . . 69 ChoiceofReconstructiveProcedure. . . . . . . . . . . . . 85
Tuberous(Tubular)BreastDeformity. . . . . . . . . . . . 72
PolandSyndrome. . . . . . . . . . . . . . . . . . . . . . . . . . 72
Deformitiesof theChestWall. . . . . . . . . . . . . . . . . 76
TableofContents IX
6.1 Implants/Expanders. . . . . . . . . . . . . . . . . . . . . . . 87 FreeTRAMFlaps . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Dissectionof theInternalThoracicArteryandVein. . . 141
SurgicalTechnique. . . . . . . . . . . . . . . . . . . . . . . . . 88 Dissectionof theThoracodorsalVessels . . . . . . . . . . . 141
PostoperativeExpanderInflation. . . . . . . . . . . . . . . 93 FlapHarvesting . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
ExpanderExchangeand ContourReconstruction . . . 93 Closureof theFascia. . . . . . . . . . . . . . . . . . . . . . . . 145
ReconnectingtheFlap. . . . . . . . . . . . . . . . . . . . . . . 145
6.2 Latissimus Dorsi Flap. . . . . . . . . . . . . . . . . . . . . . 100 InsettingtheFlap . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 PostoperativeCare . . . . . . . . . . . . . . . . . . . . . . . . . 157
AnatomyoftheLatissimusDorsiFlap . . . . . . . . . . . 101 DeepInferiorEpigastricPerforator(DIEP)Flap. . . . . 157
IndicationsforaLatissimusDorsiFlap. . . . . . . . . . . 102 SurgicalTechnique . . . . . . . . . . . . . . . . . . . . . . . . . 158
PreoperativePlanning . . . . . . . . . . . . . . . . . . . . . . 103 ManagementofFlapCongestion. . . . . . . . . . . . . . . . 160
Assessmentof theLatissimusDorsi. . . . . . . . . . . . . . 103
Assessmentof theMastectomyDefect . . . . . . . . . . . . 103 6.4 SGAP Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
StrategicPlacementof theSkinIsland. . . . . . . . . . . . 103 RegionalAnatomy . . . . . . . . . . . . . . . . . . . . . . . . . 167
SurgicalTechnique. . . . . . . . . . . . . . . . . . . . . . . . . 105 PreoperativePreparation . . . . . . . . . . . . . . . . . . . . 168
PreoperativeMarking . . . . . . . . . . . . . . . . . . . . . . . 105 PreoperativeMarking . . . . . . . . . . . . . . . . . . . . . . . 168
FlapElevation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 SurgicalTechnique. . . . . . . . . . . . . . . . . . . . . . . . . 170
FlapPlacement. . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 PositioningSequence. . . . . . . . . . . . . . . . . . . . . . . . 170
BreastReconstructionUsinganAutologous FlapHarvesting . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
LatissimusDorsiFlap . . . . . . . . . . . . . . . . . . . . . . . 110 Microanastomoses . . . . . . . . . . . . . . . . . . . . . . . . . 170
Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 FlapShaping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
SurgicalTechnique . . . . . . . . . . . . . . . . . . . . . . . . . 110 PostoperativeCare . . . . . . . . . . . . . . . . . . . . . . . . . 171
Perforator-SparingorMuscle-SparingLatissimus
FlapHarvesting . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 6.5 Free Transverse Myocutaneous Gracilis Flap. . . . 179
Patient Selection . . . . . . . . . . . . . . . . . . . . . . . . . . 179
6.3 TRAM/DIEP Flap. . . . . . . . . . . . . . . . . . . . . . . . . . 119 AnatomyoftheTMGFlap. . . . . . . . . . . . . . . . . . . . 179
AnatomyoftheLowerAbdominalFlap . . . . . . . . . . 120 PreoperativeMarking. . . . . . . . . . . . . . . . . . . . . . . 180
PrinciplesoftheTRAM/DIEPFlapTechniques. . . . . . 120 SurgicalTechnique. . . . . . . . . . . . . . . . . . . . . . . . . 180
HistoricalDevelopment . . . . . . . . . . . . . . . . . . . . . 121 Breast Shaping. . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Donor-SiteClosure . . . . . . . . . . . . . . . . . . . . . . . . . 180
Patient Suitability. . . . . . . . . . . . . . . . . . . . . . . . . . 121 Donor-SiteMorbidity. . . . . . . . . . . . . . . . . . . . . . . . 180
Contraindications. . . . . . . . . . . . . . . . . . . . . . . . . . 122
PreoperativePreparation . . . . . . . . . . . . . . . . . . . . 122 6.6 Bilateral Breast Reconstruction. . . . . . . . . . . . . . 187
PreoperativeMarking . . . . . . . . . . . . . . . . . . . . . . . 122
PreoperativeMeasures. . . . . . . . . . . . . . . . . . . . . . . 126 7 Reconstruction of the Nipple–Areola Complex . 189
SurgicalTechniqueforUnipedicled RectusFlaps. . . . 126 NippleGrafting fromtheContralateralBreast . . . . . 189
PreparingtheMastectomyDefect. . . . . . . . . . . . . . . 126 LocalFlaps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Dissectionof theUnipedicledRectusFlap. . . . . . . . . . 126 Full-ThicknessSkin GraftingfromtheLabiaMinora . 189
FascialClosure . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 AlternativeApproaches . . . . . . . . . . . . . . . . . . . . . 190
Creationof theBreastMound. . . . . . . . . . . . . . . . . . 131 Tattooing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
PostoperativeCare . . . . . . . . . . . . . . . . . . . . . . . . . 132 Full-ThicknessSkin Grafting . . . . . . . . . . . . . . . . . . 190
SurgicalTechniquefor(Microvascular)
Oncologic Surgery of the Breast
8 Prophylactic Subcutaneous Mastectomy . . . . . . 199 10 Breast-Conserving Therapy. . . . . . . . . . . . . . . . . 219
Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
SurgicalTechnique. . . . . . . . . . . . . . . . . . . . . . . . . 199 SurgicalTechnique. . . . . . . . . . . . . . . . . . . . . . . . . 220
ImplantReconstruction . . . . . . . . . . . . . . . . . . . . . 200 AxillaryLymph-NodeDissection . . . . . . . . . . . . . . . . 227
AutologousTissueReconstruction. . . . . . . . . . . . . . 200 SurgicalTechnique . . . . . . . . . . . . . . . . . . . . . . . . . 228
SentinelLymph-NodeDissection. . . . . . . . . . . . . . . . 230
9 Modified Radical Mastectomy. . . . . . . . . . . . . . . 211 PlasticSurgeryMeasuresinBreast-ConservingTherapy 230
Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211 GeneralGuidelines . . . . . . . . . . . . . . . . . . . . . . . . . 230
SurgicalTechnique. . . . . . . . . . . . . . . . . . . . . . . . . 211 ReductionMammaplastyinBreast-ConservingSurgery 231
BreastRecontouringusingaLatissimusDorsiFlap . . . 241