Plastic and reconstructive surgery of the breast PDF
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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 PlastischeundRekonstruktiveChirurgie derBrust. www.thieme.comon theproductdescriptionpage. Translator:StephanieKramer,BA,DiplTrans,IoL,Berlin Illustrator:Hedwig Hentschel Some of the product names, patents, and registered designs ©2009GeorgThiemeVerlag, referred to in this book are in fact registered trademarks or Rüdigerstrasse14,70469Stuttgart,Germany proprietary names even though specific reference to this fact is http://www.thieme.de notalwaysmadeinthetext.Therefore,theappearanceofaname ThiemeNewYork,333Seventh Avenue, without designation as proprietary is not to be construed as a NewYork,NY10001,USA representationbythepublisherthatitisinthepublicdomain. http://www.thieme.com This book, including all parts thereof, is legally protected by Coverdesign:ThiemePublishing Group copyright. Any use, exploitation, or commercialization outside Typesetting byPrimustypeHurler,Notzingen,Germany the narrow limits set by copyright legislation, without the pub- Printed inGermanybyDruckereiGrammlich,Pliezhausen lisher’sconsent,isillegalandliabletoprosecution.Thisappliesin particular to photostat reproduction, copying, mimeographing, ISBN 978-3-13-103572-1 preparation of microfilms, and electronic data processing and 123456 storage. 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
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