2121
Chapter 58 Ethnic Rhinoplasty
Problems and Complications
Close postoperative follow-up is important after augmentation rhinoplasty to mon-
itor the dorsal graft. Mild graft warping or shifting can be treated with nasal com-
pression exercises for 1 minute 10 times daily until the graft position stabilizes. Se-
vere warping or migration necessitates operative revision.
Wide, underprojected tips are susceptible to postoperative loss of projection if not
properly stabilized. Correction requires operative revision to stabilize the nasal base.
Grafting material is needed to place a caudal septal extension or replacement graft
to which the lower lateral cartilages can be secured.
The thick skin of many ethnic patients can cause prolonged postoperative edema.
This can be especially problematic in the supratip area, where edema can lead to scar
formation and create a polly-beak deformity. Edema that has persisted 4 weeks af-
ter surgery can be treated with nightly nasal taping. Recalcitrant edema can be treated
with injections of 0.2 to 0.3 ml triamcinolone acetonide 10 mg/ml.
Pneumothorax can occur during rib graft harvest. Meticulous technique, especially
blunt dissection within the perichondrial sleeve, is the best defense against this mor-
bid complication. If a pleural tear is discovered intraoperatively, a red rubber catheter
can be inserted into the defect. The wound should then be closed with the catheter
in place. After closure, a Valsalva maneuver can be performed as the catheter is with-
drawn to remove as much air as possible. A postoperative chest radiograph can con-
firm the presence of any residual pneumothorax and help to determine whether chest
tube placement is necessary.
Dorsal irregularities are often camouflaged by thick skin
in ethnic patients. Small visible bumps can be treated
with a needle shave in the office. The area to be treated
is first marked and then injected with a local anesthetic.
A 16-gauge needle is inserted, and the bump is rasped
with the needle’s bevel. Depressions, unfortunately, can-
not be treated in this manner. Revision surgery is needed
to fill the depression with cartilage or soft tissue grafts.
2122
Part X Rhinoplasty
This 37-year-old woman requested correction of her nasal deformity and left nasal
obstruction. The frontal view revealed a narrow dorsum, wide tip, prominent infratip
lobule, and an underprojected chin. On lateral and oblique views, she had a dorsal
hump, a hanging tip lobule, and an underprojected and underrotated tip. On basal
view, she had columellar deviation to the left, a flared right footplate, and nostril
asymmetry. Intranasal examination revealed a left septal deviation.
Scarring of the columella, alar base, and chest is more common in thick-skinned eth-
nic patients. Asian patients in particular scar poorly on the chest. Three weeks after
surgery, patients are given Silastic sheeting to place on their incisions each night. The
compression from the Silastic is thought to enhance the scar’s appearance. Tri am -
cin o lone acetonide injections can also be used to treat hypertrophic scarring.
Results
2123
Chapter 58 Ethnic Rhinoplasty
Nasal
Lower lateral cartilage
Septum
Lateral
Lower lateral cartilage
Upper and lower lateral cartilages
Lateral crural
strut graft
Tip
grafts
Lateral crural
strut grafts
Caudal septal
extension graft
Lateral crural
strut grafts
Lateral
osteotomy
Soft crushed
cartilage
Alar batten
graft
Medial osteotomies
Alar batten
graft
Excised septum
Caudal septal
extension
graft
Spreader
graft
Soft crushed cartilage
Surgical Plan
The surgical plan for this patient was to perform an external rhinoplasty approach. She had a hang-
ing tip lobule and underprojected tip, so stabilizing her nasal base was very important. She had a
very small segment of septal cartilage; costal cartilage would provide material to graft her nose and
augment her tear trough. Auricular cartilage was an option but would have required using both
ears. A caudal septal extension graft was used to support the base, shorten the nose, and rotate the
tip. Extended spreader grafts were used to stabilize the extension graft. Placement of a small radix
graft and dorsal hump reduction helped improve her profile. Repositioning the lateral crura helped
to improve the alar-columellar relationship. Her rhinoplasty worksheet details the maneuvers per-
formed during the surgery.
Surgical Steps
Right inframammary fold incision and sixth rib harvest
Submental incision and placement of medium silicone prejowl chin implant
Inverted-V midcolumellar incision connected to bilateral marginal incisions
Open septoplasty and septal cartilage harvest
Dorsal hump reduction and rasping
Bilateral lateral osteotomies
Costal cartilage spreader grafts
Bilateral cephalic trimming of lateral crura
Costal cartilage caudal septal extension graft sutured to spreader grafts
2124
Part X Rhinoplasty
Bilateral septal cartilage lateral crural strut grafts, dome sutures, and lateral crura
caudal repositioning
Interdomal suture and crushed cartilage
over domes
Crushed cartilage radix graft
Bilateral costal cartilage alar batten grafts
Full-thickness alar base reductions
Bilateral transcutaneous lower lid bleph -
aroplasty with fat repositioning and costal
perichondrial grafts to the tear troughs
Nine months postoperatively, the patient has appropriate dorsal width and smooth
brow-tip aesthetic lines. She has a narrower tip and more aesthetic alar-columellar
relationship. On lateral view, she has a smooth dorsum and increased tip projection
and rotation. Her basal view reveals a straight midline columella and improved nos-
tril symmetry.
2125
Chapter 58 Ethnic Rhinoplasty
This 24-year-old man requested rhinoplasty; there was no nasal obstruction. On
frontal view, he had a hanging infratip lobule and high alar insertions. On lateral
view, he had a deep radix, a dorsal hump, and an underprojected tip. His basal view
demonstrated a very slight columellar deviation to the right. Intranasal examination
revealed a right posterior septal deviation.
2126
Part X Rhinoplasty
2127
Chapter 58 Ethnic Rhinoplasty
Nasal
Lower lateral cartilage
Septum
Lateral
Lower lateral cartilage
Upper and lower lateral cartilages
Lateral crural
strut graft
Tip
grafts
Costal cartilage lateral crural
strut grafts
Caudal septal
extension graft
Lateral crural
strut grafts
Alar batten
graft
Medial osteotomies
Alar batten
graft
Alar rim grafts
Excised septum
Caudal septal
extension graft
Spreader
graft
Surgical Plan
The surgical plan was to improve the patient’s profile by performing a dorsal hump reduction and
increasing his nasal tip projection. Costal cartilage harvest was necessary to obtain enough carti-
lage to lower his nostrils. Auricular cartilage was an option but is generally less effective because it
is weaker. A caudal septal extension graft was used to stabilize his nasal base and prevent postop-
erative loss of tip projection. Correction of his flared nostrils was achieved by placing lateral crural
strut grafts and repositioning the lateral crura more caudally. His rhinoplasty worksheet details the
steps taken during the surgery.
2128
Part X Rhinoplasty
Surgical Steps
Inverted-V midcolumellar incision connected to bilateral marginal incisions
Open septoplasty and septal cartilage harvest; two fractures within septal cartilage
Dorsal hump reduction and rasping
Bilateral lateral osteotomies to narrow upper third
Right chest incision and sixth rib harvest
Bilateral costal cartilage spreader grafts
Costal cartilage caudal septal extension graft overlapping left caudal septum
Bilateral cephalic trimming of lateral crura
Bilateral lateral crural strut grafts, dome sutures, and lateral crura caudal reposi-
tioning
Interdomal suture and crushed cartilage placed over domes
Crushed cartilage graft to infratip
Bilateral internal alar base reductions
Thirteen months postoperatively, the patient has an improved alar-columellar rela-
tionship as a result of moving his lateral crura to a more caudal position. On lateral
view, he has a higher radix, lower dorsum, and increased tip projection and rota-
tion. The patient has a very subtle residual dorsal convexity that looks appropriate
in many male ethnic patients.
2129
Chapter 58 Ethnic Rhinoplasty
This 36-year-old woman requested rhinoplasty. On frontal view, she had a wide mid-
dle vault, nasal base, and tip. On lateral view, she had a dorsal hump, low dorsum,
underprojected tip, acute nasolabial angle, and underprojected chin. Her basal view
revealed a wide, underprojected tip with large, round nostrils.
2130
Part X Rhinoplasty
2131
Chapter 58 Ethnic Rhinoplasty
Nasal
Lower lateral cartilage
Septum
Lateral
Lower lateral cartilage
Upper and lower lateral cartilages
Lateral crural grafts
Lateral
crural grafts
Medial osteotomies
Alar rim grafts
Shield tip graft
Shield tip graft
Excised septum
Caudal septal
extension graft
Spreader
graft
Perichondrium
Cephalic trim
radix graft
Perichondrium
Supratip
graft
Lateral
crural graft
Shield
tip graft
Caudal septal
extension graft
Supratip
graft
Perichondrium
Surgical Plan
The plan was to perform an open septorhinoplasty and stabilize the patient’s nasal base. She had
a very small segment of septal cartilage, and costal cartilage was harvested to provide adequate graft-
ing material. A large caudal septal extension graft was needed to stabilize the base. A shield tip graft
with lateral crural grafts was necessary to provide adequate tip projection. A radix graft helped align
her profile. Chin augmentation helped balance her profile with the increased tip projection. Her
rhinoplasty worksheet illustrates the steps performed during the surgery.
2132
Part X Rhinoplasty
Costal cartilage–extended columellar strut
Shield tip graft and bilateral lateral crural grafts covered with perichondrium
Costal cartilage supratip graft
Full-thickness alar base reductions
Surgical Steps
Submental incision and placement of a medium silicone extended chin implant
Right inframammary fold incision and sixth rib harvest
Inverted-V midcolumellar incision connected to bilateral marginal incisions
Open septoplasty and septal cartilage harvest
Dorsal hump reduction and rasping
Bilateral lateral osteotomies
Bilateral spreader graft placement
Bilateral cephalic trim of lateral crura
Twenty months postoperatively, the patient has a narrower middle vault, nasal base,
and tip. On lateral view, she has a higher, smooth dorsum, increased tip projection
and rotation, and increased chin projection. The basal view shows a narrower tip
and nasal base.
2133
Chapter 58 Ethnic Rhinoplasty
2134
Part X Rhinoplasty
This 23-year-old woman requested rhinoplasty. On frontal view, she had a very wide
nose, ill-defined tip, and hanging alae. On lateral view, she had a low radix, low dor-
sum, an underprojected tip, and a retracted columella. The basal view revealed a very
wide base and underprojected tip.
2135
Chapter 58 Ethnic Rhinoplasty
Surgical Steps
Right inframammary fold incision and sixth rib harvest
Inverted-V midcolumellar incision connected to bilateral marginal incisions
Open septoplasty and septal cartilage harvest
Bilateral costal cartilage spreader grafts
Nasal
Lower lateral cartilage
Septum
Lateral
Lower lateral cartilage
Upper and lower lateral cartilages
Lateral
crural graft
Shield
tip
graft
Lateral crural grafts
Caudal septal
extension graft
Lateral
crural grafts
Double layer
septal cartilage
dorsal graft
Alar rim grafts
Shield tip graft
Shield tip graft
Perichondrium
Excised septum
Double layer
septal cartilage
dorsal graft
Surgical Plan
The surgical plan was to narrow the patient’s nose by increasing the dorsal height with a dorsal on-
lay graft. The abnormal, inverse alar-columellar relationship caused by the retracted columella and
hanging ala required a large caudal septal extension graft to lengthen the columella. The lateral
crura were not repositioned to avoid bringing down the alae. The shape of the lateral crura did not
influence her nasal tip shape, so cephalic trimming was unnecessary. A shield tip graft was used to
increase nasal tip projection and refine the tip. Alar base reduction was used to improve the width
of the nasal base and nostrils. Her rhinoplasty worksheet illustrates the maneuvers performed dur-
ing the surgery.
2136
Part X Rhinoplasty
Costal cartilage caudal septal extension graft sutured to nasal spine and spreader
grafts
Splinting grafts to stabilize caudal septal extension graft to nasal spine
Bilateral dome sutures, tip graft, and lateral crural grafts covered in perichondrium
Bilateral alar rim grafts
Double-layer septal cartilage dorsal graft covered on margins with perichondrium
Full-thickness alar base reductions
Six months postoperatively, the patient has a narrower dorsum and tip and increased
tip definition. Her columella is lower and presents a more aesthetic alar-columellar
relationship. On lateral view, she has a higher radix and dorsum, increased tip pro-
jection, and increased columellar show. The basal view reveals a narrower and more
projecting tip.
2137
Chapter 58 Ethnic Rhinoplasty
2138
Part X Rhinoplasty
The 28-year-old woman requested rhinoplasty. On frontal view, she had an amor-
phous tip. On lateral view, she had a low dorsum and an underprojected tip. In-
tranasal examination revealed a right septal spur.
2139
Chapter 58 Ethnic Rhinoplasty
Nasal
Lower lateral cartilage
Septum
Lateral
Lower lateral cartilage
Upper and lower lateral cartilages
Lateral crural grafts
Lateral
crural grafts
Alar rim grafts
Shield tip graft
Shield tip
graft
Excised septum
Dorsal graft
Spreader
graft
Perichondrium
Caudal septal
extension graft
Lateral
crural graft
Shield
tip graft
Septal cartilage
caudal septal
extension graft
Costal cartilage
dorsal graft
Perichondrium
Peri-
chondrium
Surgical Plan
The plan for this patient was to perform an augmentation rhinoplasty. She had a low, wide dor-
sum that is typical in the Asian patient. Costal cartilage was harvested to obtain material for dor-
sal augmentation. An alloplastic implant could have been used to avoid harvesting costal cartilage,
but this patient did not want artificial material used in her nose. The dorsal graft was used to raise
her dorsum and produce a narrowing effect on frontal view. A caudal septal extension graft stabi-
lized the nasal base. A shield tip graft was used to project and narrow the tip. Her rhinoplasty work-
sheet illustrates the steps performed during the surgery.
Surgical Steps
Right inframammary fold incision and sixth rib harvest
Inverted-V midcolumellar incision connected to bilateral marginal incisions
Open septoplasty and septal cartilage harvest
Costal cartilage spreader grafts
2140
Part X Rhinoplasty
Caudal septal extension graft placed end-to-end and secured with extended spreader
grafts and bilateral splinting grafts
Costal cartilage tip graft and lateral crural grafts covered in perichondrium
Bilateral alar rim grafts
Costal cartilage dorsal graft covered with perichondrium and crushed cartilage
Supratip graft
Bilateral alar batten grafts
Bilateral alar base reductions
One year postoperatively, she has a narrower dorsum and a narrower and more re-
fined tip. The lateral view reveals increased dorsal height and tip projection. Her nasal
starting point is close to her midpupillary line. The basal view shows increased pro-
jection and a more refined tip.
2141
Chapter 58 Ethnic Rhinoplasty
2142
Part X Rhinoplasty
This 28-year-old woman requested correction of her nasal deformity. She had no
nasal obstruction. On frontal view, she had a wide dorsum, tip, and nasal base. On
lateral view, she had a low radix, a very low dorsum, and an underprojected tip. The
basal view revealed a wide, underprojected tip.
2143
Chapter 58 Ethnic Rhinoplasty
Surgical Steps
Two ribs were needed in this patient. A very large dorsal graft was used to augment
her flat dorsum. The other rib graft was used for the septal extension graft and tip
grafts.
Right inframammary incision and harvesting of the sixth and seventh ribs
Inverted-V midcolumellar incision connected to bilateral marginal incisions
Septoplasty and septal cartilage harvest
Nasal
Lower lateral cartilage
Septum
Lateral
Lower lateral cartilage
Upper and lower lateral cartilages
Lateral crural grafts
Lateral
crural grafts
Alar rim graft
Shield tip
graft
Caudal septal
extension
graft
Batten graft
Shield tip graft
Excised septum
Perichondrium
Caudal septal
extension graft
Lateral crural
graft
Batten graft
Shield
tip graft
Caudal septal
extension graft
Dorsal graft
Perichondrium
Perichondrium
Crushed
cartilage
Surgical Plan
The plan for this patient was to perform an augmentation rhinoplasty. She did not want an allo-
plastic implant, so costal cartilage was harvested. An extended columellar strut was used to stabi-
lize the nasal base. A notch carved in the strut’s base was integrated with the nasal spine to prevent
movement. The strut was further stabilized with thin splinting grafts overlapping the caudal sep-
tum. To keep the dorsal graft midline, it was notched and integrated with the columellar strut. This
maneuver is frequently unnecessary, because the dorsal graft can be sutured to the upper lateral
cartilages. A shield tip graft and lateral crural grafts were used to provide tip projection and contour.
Her rhinoplasty worksheet illustrates the surgical steps performed.
2144
Part X Rhinoplasty
Caudal septal extension graft sutured to nasal spine
Hole drilled in nasal spine with a 16-gauge needle
Caudal septal extension graft secured to caudal septum with bilateral splinting
grafts
Costal cartilage dorsal graft covered in perichondrium
Notch carved in caudal aspect of dorsal graft and in-
tegrated with caudal septal extension graft
Bilateral alar batten grafts
Shield tip graft and lateral crural grafts
Crushed cartilage and perichondrium placed over tip graft
Supratip graft placed
Six months postoperatively, she has a narrower dorsum and tip. On lateral view, she
has increased dorsal height and tip projection. The basal view reveals her increased
tip projection.
2145
Chapter 58 Ethnic Rhinoplasty
2146
Part X Rhinoplasty
Concluding Thoughts
Ethnic patients requesting rhinoplasty frequently require increasing nasal tip pro-
jection or augmenting the nasal dorsum. They tend to have weak lower lateral car-
tilages and lack nasal tip support. Reductive methods may further decrease nasal tip
support and leave the patient with inadequate refinement. Structural grafting can
improve tip support and tip definition. Increasing the dorsal height can improve nasal
dorsal definition and create a narrowing effect. Structural grafting may require har-
vesting ear cartilage or costal cartilage. Most ethnic patients have inadequate septal
cartilage for grafting purposes. Costal cartilage will provide more than enough ma-
terial for grafting but does require more advanced techniques. Management of the
ethnic patient requires clear communication to ensure the patient and physician agree
on the intended aesthetic changes.
Clinical Caveats
Requests for cosmetic procedures are increasing in ethnic patients; rhinoplasty is
the most commonly requested.
Clear operative goals are necessary for patient satisfaction.
Careful planning of the chest incision minimizes morbidity.
Early and sequential costal cartilage carving allows warping tendencies to mani-
fest intraoperatively.
Knowledge of cartilage curvatures is essential for proper graft selection and usage.
Stable dorsal graft placement prevents postoperative graft migration.
Base reduction is frequently necessary in ethnic patients.
Close postoperative follow-up is necessary for optimal results.
Annotated Bibliography
Daniel RK. Hispanic rhinoplasty in the United States, with emphasis on the Mexican Amer-
ican nose. Plast Reconstr Surg 112:244-256, 2003.
A review of the author’s extensive experience with Hispanic rhinoplasties, including a
thoughtful classification scheme.
DeRosa J, Toriumi DM. The Asian nose. In Gunter JP, Rohrich RJ, Adams WP, eds. Dallas
Rhinoplasty: Nasal Surgery by the Masters, 2nd ed. St Louis: Quality Medical Publish-
ing, 2007.
A comprehensive review of the senior author’s approach to Asian rhinoplasty.
Rohrich RJ, Muzaffar AR. Rhinoplasty in the African-American patient. Plast Reconstr Surg
111:1322-1339, 2003.
A review of the anatomy, planning, and execution of African American rhinoplasty with
multiple case examples.
Suggested Readings
American Academy of Facial Plastic and Reconstructive Surgery. 2008 AAFPRS membership
study. Alexandria, VA: The Academy, 2009.
American Society of Plastic Surgeons. 2009 report of the 2008 statistics. Arlington Heights,
IL: The Society, 2009.
Lopez MA, Shah AR, Westine JG, O’Grady K, Toriumi DM. Analysis of the physical prop-
erties of costal cartilage in a porcine model. Arch Facial Plast Surg 9:35-39, 2007.
Stucker FJ, Lian T, Sanders K. African American rhinoplasty. Facial Plast Surg Clin North
Am 13:65-72, 2005.
Toruimi DM, Pero CD. Asian rhinoplasty. Clin Plast Surg 37:335-352, 2010.
Toriumi DM, Swartout B. Asian rhinoplasty. Facial Plast Surg Clin North Am 15:293-307,
2007.
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Chapter 58 Ethnic Rhinoplasty
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Credits
C-1
Figures, p. 1140: Adapted from Hester TR Jr, Codner MA, McCord CD, Nahai F, Giannopoulos
A. Evolution of technique of the direct transblepharoplasty approach for the correction of lower
lid and midfacial aging: maximizing results and minimizing complications in a 5-year experience.
Plast Reconstr Surg 105:395, 2000.
Figures, pp. 1143 (bottom left), 1149 (top and center), 1150: Adapted from Hester TR Jr,
Douglas T, Szczerba S. Decreasing complications in lower lid and midface rejuvenation: the im-
portance of orbital morphology, horizontal lower lid laxity, history of previous surgery, and min-
imizing trauma to the orbital septum: a critical review of 269 consecutive cases. Plast Reconst
Surg 123:1037-1049, 2009.
Figures, p. 1156: From Hester TR Jr, Douglas T, Szczerba S. Decreasing complications in lower
lid and midface rejuvenation: the importance of orbital morphology, horizontal lower lid laxity,
history of previous surgery, and minimizing trauma to the orbital septum: a critical review of 269
consecutive cases. Plast Reconst Surg 123:1037-1049, 2009.
Figures, pp. 1169 (top), 1176 (right), 1178 (top right and bottom), 1179: Adapted from Saltz R. En-
doscopic temporal-incision only midface lift is enhanced by Endotine technique. Aesthet Surg J
25:80-83. Copyright © Elsevier, 2005.
Figures, pp. 1198 (center and right), 1204, 1217 (bottom): From Terino EO, Flowers RS. The Art
of Alloplastic Facial Contouring. St Louis: Elsevier, 2000.
Figures, pp. 1198 (left), 1202, 1210, 1212 (top), 1216, 1221, 1227 (top left), 1232 (left), 1234 (left),
1238, 1239 (top): Adapted from Terino EO, Flowers RS. The Art of Alloplastic Facial Contouring.
St Louis: Elsevier, 2000.
Figure, p. 1274: Adapted from Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy
and clinical implications for cosmetic surgery. Plast Reconstr Surg 119:2219-2227, 2007.
Figure, p. 1275: Adapted from Schaverien MV, Rohrich RJ, Pessa JE. Vascularized membranes
determine the anatomical boundaries of the subcutaneous fat compartments. Plast Reconstr Surg
123:695-700, 2009.
Figure, p. 1278: Adapted from Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy
and clinical implications for cosmetic surgery. Plast Reconstr Surg 119:2219-2227, 2007.
Table, p. 1301: Adapted from Whetzel TP, Mathes SJ. Arterial anatomy of the face: an analysis of
vascular territories and perforating cutaneous vessels. Plast Reconstr Surg 89:591-603, 1992.
Figures, pp. 1331, 1333: Adapted from Moss JC, Mendelson BC, Taylor GI. Surgical anatomy of
the ligamentous attachments in the temple and periorbital regions. Plast Reconstr Surg 105:1475-
1490, 2000.
Figures, pp. 1437, 1443, 1447, 1450, 1453, 1456, 1460, 1461: Adapted from Baker DC. Minimal
incision rhytidectomy (short-scar face lift) with lateral SMASectomy: evolution and application.
Aesthet Surg J 21:14-31, 2001. With permission from Sage.
Figures, pp. 1454, 1464, 1466, 1467: From Baker DC. Minimal incision rhytidectomy (short-scar
face lift) with lateral SMASectomy: evolution and application. Aesthetic Surg J 21:14-31, 2001. With
permission from Sage.
Figure, p. 1476: From Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and
deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg 89:441-449, 1992.
Figure, p. 1477: Adapted from Stuzin JM, Baker TJ, Baker TM. Refinements in face lifting:
enhanced facial contour using Vicryl mesh incorporated into SMAS fixation. Plast Reconstr Surg
105:290-301, 2000.
Figures, p. 1478: From Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and
deep facial fascias: relevance to rhytidectomy and aging, Plast Reconstr Surg 89:441-449, 1992.
Figure, p. 1479: From Stuzin JM, Baker TJ, Baker TM. Refinements in face lifting: enhanced
facial contour using Vicryl mesh incorporated into SMAS fixation. Plast Reconstr Surg 105:290-
301, 2000.
Figure, p. 1481: From Stuzin JM. Restoring facial shape in face lifting: the role of skeletal sup-
port in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg 119:362-376,
2007.
Figure, p. 1482: From Lambros V, Stuzin JM. The cross-cheek depression: surgical cause and
effect in the development of the “joker line” and its treatment. Plast Reconstr Surg 122:1543-
1552, 2008.
Figures, pp. 1483-1486: From Stuzin JM. Restoring facial shape in face lifting: the role of skeletal
support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg 119:362-376,
2007.
Figure, p. 1490 (left): From Stuzin JM, Baker TJ, Baker TM. Refinements in fact lifting: enhanced
facial contour using Vicryl mesh incorporated into SMAS fixation. Plast Reconstr Surg 105:290-
301, 2000.
Figures, pp. 1494-1497: From Stuzin JM. Restoring facial shape in face lifting: the role of skeletal
support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg 119:362-376,
2007.
Figures, pp. 1498 (left), 1502: From Stuzin JM, Baker TJ, Baker TM. Refinements in face lifting:
enhanced facial contour using Vicryl mesh incorporated into SMAS fixation. Plast Reconstr Surg
105:290-301, 2000.
Figure, p. 1931 (bottom): From Janis JE, Trussler A, Ghavami A, Marin V, Rohrich RJ, Gunter
JP. Lower lateral crural turnover flap in open rhinoplasty. Plast Reconstr Surg 123:1830-1841,
2009.
Figures, pp. 1954 (top left, bottom center and right), 1955, 1956 (top, bottom right: left-side
oblique views): From Rohrich, RJ, Adams WP Jr. The boxy nasal tip: classification and manage-
ment based on alar cartilage suturing techniques. Plast Reconstr Surg 107:1849-1863, 2001.
Figures, pp. 1957 (top left and right, bottom center and right), 1958, 1959 (top, center right: left-
side lateral views; bottom right: left-side oblique views): From Janis JE, Trussler A, Ghavami A,
Marin V, Rohrich RJ, Gunter JP. Lower lateral crural turnover flap in open rhinoplasty. Plast
Reconstr Surg 123:1830-1841, 2009.
Figures, pp. 1963 (top left and center bottom), 1964, 1965 (top, center left: right-side oblique
views; bottom): From Rohrich RJ, Ghavami A. Rhinoplasty for Middle Eastern noses. Plast
Reconstr Surg 123:1343-1354, 2009.
Figures, p. 1978: From Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg
8:156-185, 2006. Copyright © 2006 American Medical Association. All rights reserved.
C-2
Credits
BREAST SURGERY
PART XI
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Applied Anatomy of the Breast
KRISTIN A. BOEHM, FOAD NAHAI
CHAPTER 59
2152
Part XI Breast Surgery
A
s in every medical discipline, plastic surgery is continuously evolving. Over the
years we have seen the development of more-complex techniques by less-
invasive means with the goals of ever-improved results and longevity. But most of
these refinements, published in the literature and touted at national meetings, focus
on the surgical techniques themselves. Articles and texts are replete with procedural
descriptions of new microvascular flaps for breast reconstruction or an individual
author’s stepwise instructions for fat grafting that maximizes survivability. Although
most surgeons would agree that a fundamental knowledge of anatomy is a critical
foundation to understanding and performing these new surgeries, the likely consen-
sus is that the anatomic principles are more static than the procedures being devel-
oped from them.
Nevertheless, advances are being made in the field of breast anatomy as well. Im-
proved techniques for study have led to the discovery of previously unknown struc-
tures, enhanced microscopic details, and even better understanding of anatomic vari-
ants. These new concepts can have clinical applications that may ultimately offer
advantages to patients. In breast surgery, for example, the enhanced ability to local-
ize the vascular and nerve supply to the nipple-areola complex has led to techniques
that more reliably preserve these structures and minimize the risk of complications
in this area.
So while we often use the term basic anatomy, the human form is extremely intri-
cate, and our knowledge of it and its structures is ever evolving. Staying in the fore-
front of knowledge of anatomy is as important as embracing new surgical techniques
in an effort to enhance patient care and deliver superior results.
Embryology
Any discussion of breast anatomy naturally begins with the de-
velopment of the breast in utero. At the fifth or sixth week of
development, mammalian breasts develop along the ventral side
of the embryo in longitudinal bands of thickened ectoderm
called milk lines. These milk lines extend from the axilla to the
inguinal region. Most animals develop multiple pairs of breasts
along the thorax and abdomen. Humans are distinct in that they
develop only a single pair of glands on the thoracic portion of
the milk line. This becomes evident at around 9 weeks’ gesta-
tion, at which time the milk line regresses except for a small
span in the pectoral region, where breast development will ul-
timately occur. Failure of this regression gives rise to polymas-
tia, characterized by accessory mammary glands, and polythelia,
in which supernumerary nipples are present. The axilla is the most common loca-
tion of extraglandular breast tissue, whereas additional nipples are most often found
on the chest wall below the breast. Amastia, or the absence of a breast, is a rare con-
genital anomaly; it occurs as a result of an arrested mammary ridge at about the
sixth week of fetal development.
The mammary gland develops as an invagination of ectoderm. Squamous epithe-
lium essentially invaginates to form a primary bud, which in turn stimulates the de-
velopment of 15 to 20 secondary buds. These epithelial extensions continue to grow
and extend into the connective tissue of the chest wall. By 20 to 24 weeks’ gesta-
tion, these invaginated epithelial cords develop lumina and will eventually form the
lactiferous ducts. The surrounding mesenchyme will become the supporting struc-
tures of the breast.
At birth, the individual branched ducts drain into more major ducts, which then co-
alesce into shallow epithelial pits. These pits become elevated and transformed into
the nipple. Failure to do so results in a congenitally inverted nipple; this occurs in
2% to 4% of individuals. During infancy and childhood, the supporting tissues of
the breast and the ducts will grow along with the increase in body size. At puberty,
hormonal stimulation will cause proliferation of glandular tissue.
Surface Anatomy
There is tremendous variation in the size and configuration of the mature female
breast. The gland typically extends from the second or third rib down to the sixth
or seventh rib, where the inframammary fold is defined. It extends medially from
the sternocostal junction across to the anterior or midaxillary line. The superolat-
eral part of the mammary gland extends toward the axilla, forming the axillary tail
of Spence. Along its deep surface, the breast mound sits atop the fascia of the pec-
toralis major, serratus anterior, external oblique, and upper rectus muscles. The deep
layer of the superficial pectoral fascia lies on the posterior surface of the breast.
Between this and the deep pectoral fascia is a potential space called the retromam-
mary bursa. This space is identifiable during mastectomy and allows a bloodless
plane of dissection.
The breast assumes a conical form with a base usually measuring 10 to 12 cm and
a thickness of 5 to 7 cm. Fat lobules confer a rounded contour to the breast; the dep-
osition of fat and branching of the lactiferous ducts that occur at puberty lead to
breast enlargement. By contrast, the decrease in adipose and glandular tissue that
accompanies aging can give a flaccid, pendulous configuration to the breasts of el -
derly women.
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Chapter 59 Applied Anatomy of the Breast
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Part XI Breast Surgery
The nipple-areola complex consists of pigmented, stratified squamous epithelium.
The complex typically measures 2 to 3 cm in diameter, and although its position is
variable, ideally it is located in the center of the breast mound. The areola contains
sebaceous glands, sweat glands, and visibly elevated accessory glands called Mont-
gomery’s tubercles, which provide lubrication during lactation. Beneath the skin of
the areola, smooth muscle fibers are arranged radially and circumferentially as well
as longitudinally along the lactiferous ducts up to the nipple. These muscles respond
to tactile as well as autonomic sympathetic stimulation and are responsible for nip-
ple erection and areolar constriction. The entire complex, particularly the nipple,
has a rich sensory innervation that is important during lactation and milk letdown.
Glandular Anatomy
The 15 to 20 lactiferous ducts extend from deep within the breast lobules and ter-
minate as openings in the nipple. These ducts define the lobes of the breast, each of
which consists of all the lobules and alveoli that drain into a single excretory duct.
In the subareolar tissue, each lactiferous duct dilates to form a lactiferous sinus. The
ducts are lined with stratified squamous epithelium and gradually transition to a
double layer, then a single layer of cuboidal cells toward the nipple.
Each duct drains 15 to 20 breast lobules. The lobule is the functional unit of the
breast. Each lobule drains from 10 to 100 alveoli. The walls of the alveolar ducts
consist of an inner layer of columnar glandular cells overlying a stratum of myoep-
Nipple duct
Central collecting duct
Lactiferous duct
Breast lobule
Interlobular duct
Nipple duct
Central collecting duct
Lactiferous duct
Breast lobule
Superficial layer
of superficial fascia
ithelial cells. Connective tissue surrounds the lobules, but there is no distinct fascia
separating the lobules. The stroma surrounding the lobules contains lymphatic ves-
sels that bring lymph to the collecting ducts. Adipose tissue around the lobules ac-
counts for most of the mass of the breast. There is a defined subcutaneous layer be-
tween breast tissue and the overlying skin, and this is often used as a plane of
dissection in mastectomies. Most of the glandular tissue is found in the central and
upper portions of the breast mound, particularly the upper-outer quadrant. This
probably accounts for the higher incidence of breast cancer in this region.
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Chapter 59 Applied Anatomy of the Breast
Cooper’s
ligaments
Fibrous septum
Inframammary
crease ligament
Ligamentum
suspensorium
mammae
Ligamentum
suspensorium
mammae
Cooper’s
ligaments
The breast is enveloped by skin and subcutaneous tissue, but no true fascial layer.
There are fibrous thickenings scattered between breast lobules and extending from
the pectoral fascia to the overlying skin. These structures, known as the suspensory
ligaments of Cooper, provide some structural framework to the breast parenchyma.
These ligaments have a degree of laxity and stretch to them that allows breast mo-
bility while maintaining structural integrity. Such factors as weight fluctuation, preg-
nancy, and aging can attenuate these ligaments and lead to mammary ptosis. On the
other hand, breast malignancies can surround and shorten these ligaments, causing
the dimpling of the skin known as peau d’orange.
Although Sir Astley Cooper was probably one of the first anatomists to delineate
the internal support structures of the mammary gland, others have described addi-
tional ligaments that aid in breast suspension. Biesenberger described the ligamen-
tum suspensorium mammae, which starts at the clavicle and reaches to the upper
border of the breast and the retromammary space. His work, as well as more recent
anatomic study, confirms the great variety in the development of this ligament: it is
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Part XI Breast Surgery
a rather robust and well-defined structure in some individuals, yet almost indistinct
in others. This may well correlate to the individual development of ptosis in some
women but not in others.
Intraoperative experience, particularly with implant insertion, has demonstrated a
fibrous bridge between the pectoralis muscle and the skin of the inframammary
crease. This inframammary crease ligament gives rise to the inframammary fold and
acts as a sling for the breast parenchyma. Cadaver studies have elucidated the rela-
tionship of the inframammary crease ligament to the underlying bony framework.
The ligamentous structure was found to be continuous with the fifth rib medially
and the fascia between the fifth and sixth ribs laterally. Histologic sections show the
presence of fibrous tissue abutting rib perichondrium. Medially this structure seems
to be a condensation of the rectus abdominis fascia and laterally the fascia of the
serratus anterior and external oblique muscles. The firm and fixed nature of this
structure, particularly in comparison to Cooper’s ligaments, has clinical relevancy.
During an augmentation mammaplasty, release of the pectoralis muscle with preser-
vation of the ligament to the bony framework will minimize the risk of the breast’s
bottoming out. In reconstructive surgery, maintaining the integrity of this structure
helps to create a more natural breast and maximize symmetry with the contralat-
eral breast.
Further investigation has demonstrated a horizontal septum at the level of the fifth
rib that traverses the glandular tissue. This septum thickens along the medial and
lateral edges and curves upward into vertically oriented ligaments that attach the
breast to the thoracic wall. These ligaments appear to have a superficial and a deep
component; medially they connect to the inframammary crease ligament and later-
ally to the axillary fascia. Tension on these structures acts as an internal brassiere
that lifts the breast superiorly. By corollary, decreased elastin in these ligaments or
their stretching over time probably contributes to loss of shape and firmness. Thus
knowledge of these ligament locations and variations is important as we continu-
ally look to newer and longer-lasting techniques to address mammary ptosis.
Microscopic Anatomy
In response to the hormonal stimulus of puberty, the layers lining the ducts and alve-
oli increase in number and form additional buds. The mature female breast has three
cell types lining the ducts: superficial A cells, basal B cells, and myoepithelial cells.
The A cells contribute to milk production. They are rich in cytoplasmic RNA and
ribosomes within the cytoplasm. B cells, also known as chief cells, are abundant and
provide energy for the luminal secretory cells. Myoepithelial cells contain myofila-
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Chapter 59 Applied Anatomy of the Breast
ments and perform a contractile function. They surround the alveoli of the milk duct
and contract in response to sex steroids and prolactin. This provides the mechanism
whereby a milk-filled alveolus can empty into the milk ducts and ultimately up to-
ward the lactiferous sinuses.
Hormonal Regulation
Breast growth, development, and function occur in response to a variety of hormones
and growth factors. Intracellular receptors and cell membrane receptors allow bind-
ing of these substances, which in turn triggers physiologic responses in the tissues.
Estrogen is the principal hormone responsible for breast growth and maintenance.
Because it is lipid soluble, estrogen can diffuse through the cell membrane of both
normal and malignant breast cells, where it binds with estrogen receptors. This com-
plex initiates messenger RNA (mRNA) transcription and subsequently protein trans-
lation. This mechanism mediates ductal maturation, metabolism, and new receptor
development. The result is proliferation of ductal epithelium, myoepithelial cells,
and surrounding stroma. The drug tamoxifen prevents the binding of hormones to
target receptors, thereby inhibiting the growth of estrogen receptor–positive mam-
mary tumors.
Released from the ovaries, progesterone contributes to lobular development. It ini-
tiates the formation of the secretory components of the mammary epithelium, lo-
cated at the terminal aspects of the ductules. Both progesterone and estrogen can in-
crease connective tissue and fat in the breast, thereby leading to the rounded form
of the fully developed breast. Gonadotropic-releasing hormone from the hypothal-
amus stimulates the release of leuteinizing hormone (LH) and follicle-stimulating
hormone (FSH) from the anterior pituitary. LH and FSH are responsible for ovar-
ian synthesis and release of progesterone and estrogen, respectively.
Prolactin acts synergistically with estrogen in ductal development and with proges-
terone in lobuloalveolar development. It is the hormone responsible for lactogene-
sis in the postpartum period. Cortisol and insulin are required along with prolactin
to differentiate alveolar cells into milk-secreting cells. Prolactin is secreted by the
acidophilic cells of the anterior pituitary at parturition.
The menstrual cycle is characterized by alternating levels of hormones. In the pre-
menstrual phase, rising levels of LH and FSH contribute to a rise in estrogen. After
ovulation, estrogen levels continue to increase and progesterone rises. These elevated
hormones cause an increase in breast volume from water retention, increased base-
ment membrane thickness, ductal dilation, widened alveolar diameter, and increased
intraalveolar secretions. After the onset of menses and withdrawal of sex steroids,
the breast volume decreases in response to edema regression, reduction in glandu-
lar and alveolar cell size, and diminished secretions.
With pregnancy, high levels of estrogen and progesterone are maintained, initially
by the corpus luteum, and, after the twelfth week of gestation, the placenta. In the
first trimester, estrogen causes the ducts and lobules to proliferate. Glandular epithe-
lium replaces fatty tissue. The latter part of the first trimester is characterized by
breast enlargement, venous dilation, and increased pigmentation of the nipple-areola
complex. In the second trimester, the secretory epithelium becomes active in response
to progesterone. By the third trimester, colostrum fills the alveolar and ductal spaces,
accompanied by increased blood flow and enlargement of myoepithelial cells. To-
ward the end of pregnancy, prolactin circulates and initiates synthesis of milk fat
and proteins.
Following delivery, the placentally induced sex steroids cease and the breast is influ-
enced by prolactin. The milk released in the first few days after parturition, called
colostrum, has a low lipid content but is rich in antibodies; 4 to 5 days after partu-
rition, the milk becomes laden with lipids, protein, carbohydrates, and immunoglob-
ulins. The ongoing secretion of prolactin by the anterior pituitary is necessary to sus-
tain milk production and secretion. A nursing infant’s tactile stimulation of the
nipple-areola complex maintains this and will also initiate release of oxytocin from
the posterior pituitary. Oxytocin causes myoepithelial cells to contract, which pushes
milk from the lobules into the lactiferous ducts. The presence of milk in the ductal
system provides an ideal culture medium for bacterial overgrowth. Obstruction to
flow along the ducts, usually from areolar inflammation, leads to suppurative mas-
titis. With cessation of nursing there is regression of the extralobular stroma and at-
rophy of the formerly proliferative glandular and ductal elements. The breast usu-
ally returns to its prepartum state over the next 3 months.
During menopause, the body no longer produces sex steroids as a consequence of
diminished ovarian function, and there is actual loss of glandular tissue. Adipose tis-
sue can replace lobular elements, although there is usually a loss in total mass of fat
volume in the breast. The result is decreased breast volume, and the breast takes on
a flatter, more pendulous shape.
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Part XI Breast Surgery
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Chapter 59 Applied Anatomy of the Breast
Blood Supply
Most of the breast mass receives its blood supply from the internal mammary ar-
tery. Branches of this artery must pass through the intercostal muscles along the sec-
ond to fifth ribs, a few centimeters lateral to the parasternal border. Once these ven-
tral branches enter the breast, they collateralize with two other major sources of
blood supply: the lateral thoracic artery and the cutaneous branches from the poste-
rior intercostal arteries. The lateral thoracic artery originates from the axillary ar-
tery and traverses along the lower border of the pectoralis minor muscle. Along its
course of the muscle, the lateral thoracic artery gives off the external mammary ar-
tery, which will eventually come ventrally through the muscle to supply the upper-
outer quadrant of the breast. Branches of the third through fifth posterior intercostal
arteries supply the lower outer quadrant of the breast.
The veins parallel the arteries, with primary drainage into the axilla. Significant veins
include the perforating branches of the internal thoracic vein, tributaries of the ax-
illary vein, and perforating branches of the posterior intercostal veins. A notable pat-
tern of superomedial and inferior pole drainage appears responsible for the bulk of
venous drainage. Although the dominant drainage route appears to be through the
third and fourth intercostal spaces, superomedial drainage to the second and third
intercostal spaces and lower pole drainage to the fourth and/or fifth intercostal space
have been consistently identified and appear to represent anatomic norms.
Subclavian artery
Internal mammary
artery
Internal mammary
perforators
Anteromedial
intercostal perforator
External mammary artery
Anterolateral
intercostal perforators
Thoracodorsal
artery
Axillary artery
Thoracoacromial
artery
Lateral thoracic artery
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Part XI Breast Surgery
Although venous anatomy is less explored than arterial anatomy, most vascular com-
promise encountered during breast reduction surgery results from venous compro-
mise. This underscores the importance of maintaining venous architecture in breast
surgery to minimize complications. Developments in infrared photography have
helped to elaborate the venous architecture of the breast. A subareolar plexus has
been identified, with venous radiation from this plexus, probably to the deep venous
structures. Preservation of this plexus with deepithelialization techniques should the-
oretically minimize the risk of venous outflow problems in breast surgery by main-
taining a connection between superficial and deep vessels.
Relatively recent cadaver studies have reinforced these well-established vascular pat-
terns, but more closely pinpoint location and demonstrate a consistent anatomic
course for the supplying vessels. A horizontal fibrous septum has been shown to arise
from the pectoralis fascia at the level of the fifth rib, similar to an intestinal mesen-
tery. This septum lies in between a cranial and caudal vascular network and courses
toward the nipple-areola complex. The cranial portion carries inflow from the tho-
racoacromial artery at the level of the fourth intercostal space and a branch of the
lateral thoracic artery. The caudal network is supplied by perforating branches from
the fourth and fifth and occasionally sixth intercostal arteries. Along the breast bor-
ders, this septum coalesces into medial and lateral ligaments, attaching the breast to
the sternum and pectoralis minor, respectively. Medially, the ligament contains per-
forating branches from the internal thoracic artery, across the second to fourth in-
tercostal spaces. Laterally, branches off the lateral thoracic artery from the second to
the fourth intercostal spaces are found.
Thoracoacromial
artery
Intercostal
arteries
4
5
Pectoralis major
muscle
Fibrous septum
Deep branches
of intercostal
nerves
4
5
6
Inframammary
crease ligament
Pectoral fascia
These vessels within the septum essentially bisect the breast into cranial and caudal
parts. This division may well be rooted in embryology, with the formation of cra-
nial and caudal ingrowths of ectoderm separated by a mesenchyme that ultimately
forms the vascular network. Histologically, the glandular tissue in these two parts
is identical. However, there is clinical significance to this anatomy, particularly as it
relates to breast reduction surgery and the goal of maintaining the blood supply to
the nipple-areola complex. This has led to the development of the septum-based
mammaplasty popularized by Hamdi and colleagues that consists of a two-part glan-
dular resection both above and below the septum. The remaining pedicle maintains
the septal attachment of the gland to the thorax. Because this septum contains the
vascular perforators, the blood supply to the pedicle and nipple-areola complex is
maintained, and the risk of fat necrosis and nipple loss is minimized. Additionally,
because this technique maintains a dual blood supply to the pedicle, with inflow
both medially and laterally via the septum, more lateral breast resection can be per-
formed, which is often an area of preoperative concern for patients.
Innervation
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Chapter 59 Applied Anatomy of the Breast
Sensory innervation to the skin overlying the breast is principally derived from lat-
eral and anterior cutaneous branches of the second through sixth intercostal nerves.
A portion of skin along the superior pole is also supplied by branches from the supra -
clavicular nerve, off of the cervical plexus. The lateral branches of the intercostal
Intercostobrachial nerve
Anterolateral
intercostal
nerves
Cervical plexus
Anteromedial
intercostal
nerves
3
4
5
6
Lateral cutaneous
branch of the third
intercostal nerve
3
4
5
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Part XI Breast Surgery
nerves exit through the intercostal spaces to supply the breast. The third through
sixth branches are known as lateral mammary branches. The lateral branch of the
second intercostal nerve is the intercostal brachial nerve and supplies the upper me-
dial aspect of the arm and axilla.
Of utmost importance to plastic surgeons is preservation of the sensitivity of the
nipple-areola complex. The fourth lateral cutaneous branch has long been held to
be the most important nerve for sensation to the nipple. Its course, however, is some-
what more controversial, largely because of the difficulty in dissecting this small
nerve as well as its anatomic variations. Schlenz et al performed a relatively large
number of cadaver dissections to confirm the importance of the fourth lateral inter-
costal nerve, which supplied the nipple in 93% of specimens. They showed that while
a superficial course of the nerve exists as a variant, the overwhelming majority of
the time the lateral cutaneous nerve takes a subglandular course within the pectoral
fascia to approach the nipple from the posterior surface. Resections at the base of the
breast are therefore more likely to jeopardize sensation to the nipple-areola complex.
Medial nipple innervation is most commonly derived from anterior cutaneous
branches of the third and fourth intercostal nerves. Unlike the lateral counterparts,
these nerves take a more superficial approach in the subcutaneous tissue and become
more superficial as they reach the medial areola. Incisions around the medial areo-
lar edge are therefore more likely to injure these nerves.
The same septum that carries the vascular network to the nipple-areola complex
also guides the main nerves to the nipple. Overwhelmingly, this consists of a deep
branch of the lateral cutaneous branch off the fourth intercostal nerve. The nerve
consistently runs down the fibrous septum along the retromammary space from lat-
eral to medial, passing through the gland to redirect toward the nipple. Once again,
preservation of the septum in breast surgery procedures will maximize the chances
of maintaining sensation in the nipple-areola complex.
Lymphatic Drainage
The majority of lymphatic flow from the breast is into the axilla; the remainder of
flow is through the internal mammary nodes. This anatomy is reflected in the ten-
dency of breast cancer to involve axillary nodes. Both the axillary nodal groups and
the internal mammary nodal group are pathways for the metastatic spread of breast
cancer to the systemic circulation.
The lymph nodes within the axilla are divided into three levels based on the loca-
tion of the nodes relative to the pectoralis minor muscle. Level I nodes are lateral to
or below the level of the lower border of the pectoralis minor muscle. This group
includes the external mammary, axillary vein, and scapular lymph nodes. Nodes deep
to or behind the pectoralis minor muscle are level II lymph nodes and include the
central lymph node group and the subclavicular nodes. Nodes above the upper bor-
der of the pectoralis minor muscle are level III; the subclavicular and apical node
groups contribute to level III.
Lymphatic drainage from the breast can occur by lateral, medial, transpectoral, and
retropectoral routes. The lateral route is the most important. The majority of breast
and breast skin lymph will drain laterally through the external mammary node group.
Lymph that drains medially will drain via the parasternal lymphatics and ultimately
into the internal mammary lymph node chain. The lymph that drains medially can
originate from all quadrants of the breast and is not limited to the medial aspects of
the breast. Transpectoral drainage is via Rotter’s nodes, which are located beneath
the lateral aspect of the pectoralis major muscle. Rotter’s nodes will drain into lym-
phatics along the thoracoacromial artery to the subclavicular group of level III. The
final route of drainage is retropectoral, in which the superior and internal aspects
of the breast drain into lymphatic vessels located along the lateral and inferior por-
tions of the pectoralis muscles and eventually terminate in the subclavicular node
group in the axilla.
The development of breast lymphatic mapping has assumed greater importance as
the sentinel lymph node biopsy in breast cancer has become the standard of care.
The vastness of the lymphatic system poses a challenge, and until recently most
knowledge of breast lymphatic anatomy was derived from gross clinical studies dat-
ing back to antiquity. More modern techniques incorporate injection, cross-sectional
analysis, and radiography to elucidate lymphatic structures. These methods verify
that lymph-collecting vessels along the anterior torso drain preferentially into the
axillary lymph nodes. The previously held dogma relating breast lymphatics to up-
per torso lymphatics was that the two were connected by a subareolar plexus that
ultimately drained into the axilla. Undoubtedly this is the case for some lymph chan-
nels located within breast parenchyma. However, it appears that there are also some
lymphatics that drain breast tissue without passing through the subareolar plexus
and instead drain directly into the axilla. Additionally, there are perforating lymph
vessels that course beside the branches of the internal mammary vessels and drain
into the ipsilateral internal mammary lymphatics. In some studies, one sentinel node
in the axilla drained almost the entire breast. In most, more than one sentinel node
is represented.
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Chapter 59 Applied Anatomy of the Breast
The prevalence of breast cancer and now-standard performance of sentinel lymph
node biopsy raises the question of whether transaxillary breast augmentation inter-
feres with breast lymphatic drainage patterns and ultimately the detection of can-
cer. Lymphoscintigraphy has been employed to evaluate lymphatic patterns in pa-
tients immediately before, immediately after, and in the long term following
transaxillary breast augmentation. No statistically significant differences in patterns
or time of uptake have been identified among the subjects at the various time inter-
vals. The accepted consensus is that preserved axillary drainage patterns from the
breast allow successful sentinel lymph node biopsies in those who later require this
procedure after a transaxillary augmentation.
Concluding Thoughts
Performing safe and high-caliber surgery of the breast, aesthetic or reconstructive,
requires thorough knowledge of its structures. The study of breast anatomy contin-
ues to be of clinical importance as newer techniques for breast surgery evolve.
Clinical Caveats
Continued research and technique refinements have enhanced our knowledge of
breast anatomy and the breast’s structural framework.
In particular, the concept of an internal breast septal system has been shown to
consistently predict neurovascular structures that are important to preserve in all
types of breast surgery.
Appreciation of this septal system may help to formulate surgical techniques that
reinforce such a structure in attempting to correct mammary ptosis and the bottom-
ing out phenomenon.
Understanding both the established and newer tenets of breast anatomy is impor-
tant to be able to effectively examine, diagnose, and surgically treat conditions in-
cluding breast cancer, hypomastia, macromastia, mammary ptosis, and congeni-
tal breast deformities.
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Part XI Breast Surgery
Annotated Bibliography
Bayati S, Seckel BR. Inframammary crease ligament. Plast Reconstr Surg 95:501-508, 1995.
Anatomic and histologic findings that identify the presence of this ligament and its bony
origins. Additional discussion focuses on the importance of determining the location of
this structure preoperatively and preserving it during breast surgery.
Bostwick J III, Jones GE. Anatomy and physiology. In Jones GE, ed. Bostwick’s Plastic and
Reconstructive Breast Surgery, 3rd ed. St Louis: Quality Medical Publishing, 2010.
A fundamental text on all aspects of breast surgery, both aesthetic and reconstructive.
Relevant basic science and background are included, particularly as they relate to breast
surgery techniques.
Corduff N, Rozen WM, Taylor GI. The superficial venous drainage of the breast: a clinical
study and implications for breast reduction surgery. J Plast Reconstr Aesthet Surg 63:809-
813, 2010.
A modernized technique to evaluate the venous architecture of the breast.
Hamdi M, Hammond DC, Nahai F. Septum-based lateral or medial mammaplasty. In
Hamdi M, Nahai F, Hammond DC, eds. Vertical Scar Mammaplasty. Berlin: Springer-
Verlag, 2005.
The authors use new information about the vessel- and nerve-containing horizontal sep-
tum in the breast to develop a technique that preserves these structures and minimizes
the risk of complications.
Hamdi M, Van Landuyt K, Tonnard P, et al. Septum-based mammaplasty: a surgical tech-
nique based on Würinger’s septum for breast reduction. Plast Reconstr Surg 123:443-
454, 2009.
Description of a customized technique for breast reduction surgery that relies on anatomic
structures for determining pedicle preservation and appropriate areas for resection.
Schlenz I, Kuzbari R, Gruber H, Holle J. The sensitivity of the nipple-areola complex: an
anatomic study. Plast Reconstr Surg 105:905-909, 2000.
The authors examined a relatively large number of cadavers to clarify the course and
distribution of nerves that supply the breast.
Suami H, O’Neill J, Pan W, Taylor GI. Superficial lymphatic system of the upper torso: pre-
liminary radiographic results in human cadavers. Plast Reconstr Surg 121:1231-1239,
2008.
The authors elucidate the anatomy of the superficial lymphatics of the upper torso and
breast.
Würinger E, Mader N, Posch E, Holle J. Nerve and vessel supplying ligamentous suspension
of the mammary gland. Plast Reconstr Surg 101:1486-1493, 1998.
These investigators used modern dissection techniques to focus on the localization of
vessels and nerves that supply the breast.
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Suggested Readings
Biesenberger H. Die Fixation der Brustdrüse. In Deformitäten und Kosmetische Operatio-
nen der Weibliched Brust. Vienna: Maudrich, 1931.
Cooper AP, ed. On the Anatomy of the Breast. London: Longman, Orme, Green, Brown &
Longmans, 1840.
Farina MA, Newby BG, Alani HM. Innervation of the nipple-areola complex. Plast Recon-
str Surg 66:497-501, 1980.
Greenfield LJ. Breast. In Greenfield LJ, ed. Surgery: Scientific Principles and Practice, 2nd
ed. Philadelphia: Lippincott-Raven, 1997.
Hamdi M, Hammond DC, Nahai F. Vertical scar mammaplasty with the inferocentral pedi-
cle. In Hamdi M, Nahai F, Hammond DC, eds. Vertical Scar Mammaplasty. Berlin:
Springer-Verlag, 2005.
Maillard GF, Garey LJ. An improved technique for immediate retropectoral reconstruction
after subcutaneous mastectomy. Plast Reconstr Surg 80:396-408, 1987.
O’Leary JP. The breast. In O’Leary JP, ed. The Physiologic Basis of Surgery, 2nd ed. Balti-
more: Williams & Wilkins, 1996.
Schwartz SI, Shires GT, Spencer FC, ed. Breast. In Schwartz SI, Morton JH, eds. Principles
of Surgery, 6th ed. New York: McGraw-Hill, 1994.
Suami H, Pan WR, Mann GB, Taylor GI. The lymphatic anatomy of the breast and its im-
plications for sentinel lymph node biopsy: a human cadaver study. Ann Surg Oncol 15:
863-871, 2008.
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Part XI Breast Surgery
Clinical Decision-Making
in Breast Surgery
FOAD NAHAI
CHAPTER 60
A
lthough only breast reduction actually treats or improves any symptoms, I con-
sider any operation on the female breast to be an aesthetic procedure—not
only augmentation and mastopexy, but also reduction and reconstruction. Whether
we are restoring body image and self-confidence in a woman who has lost a breast,
or enhancing the appearance of a “normal” breast in an effort to boost a woman’s
self-confidence, our goals are the same as for any aesthetic procedure.
Principles of Breast Aesthetics
Breast aesthetics consist of the “four S’s”:
Shape
Size
Symmetry
Scars
Shape and Size
Breasts come in all shapes and sizes, some more aesthetic than others. Although the
ideal size will vary according to personal and cultural preferences, there is more con-
sensus on what constitutes the ideal shape. I believe shape to be of the utmost im-
portance. The ideal aesthetic breast is projecting, with adequate volume above and be-
low the nipple-areola complex, more below than above. The nipple-areola complex
should be located at the point of maximal breast projection. Although breast size is
subject to individual taste and societal preference, and is too often influenced by me-
dia images, it is also true that disproportionately large or small breasts do not com-
plement a woman’s figure. They may also have physical ramifications. Careful coun-
seling is required when a thin, 5 feet 4 inch, 100-pound woman requests a D cup
breast size. Conversely, a well-proportioned teenager whose body development is ad-
vanced beyond that of her peers may seek breast reduction to avoid what she feels
is unwanted attention.
Symmetry
Ideally, a woman’s breasts are uniform in color and symmetrical in size, shape, and
nipple-areolar position. Although minor asymmetry is the rule rather than the ex-
ception, gross asymmetry is not only distracting but of practical importance to a
woman in terms of bra cup size and appearance in clothing. When a surgeon is coun-
seling a woman seeking breast surgery, minor asymmetries of her breasts must be
pointed out. Most women are very accepting of these asymmetries preoperatively,
but this is not the case after aesthetic breast surgery.
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Part XI Breast Surgery