Applied Anatomy And Clinical Study Of Dual-plane Augmentation Mammoplast

Prosthetic augmentation mammoplasty is a breast augmentation mainstream. Which plane prosthesis being placed is directly related to breast shape, feel, nipple sensation and function of pectoralis major and so on. Traditionally, there were two planes to implant breast prosthesis: retromammary space and subpectoral space. These two procedures both have their advantages and disadvantages. How to integrate their advantages, and while possibly, avoid their disadvantages? This is an issue which large numbers of scholars have been explored and dual-plane breast augmentation is the outcome of exploration in recent years. Currently, two-plane breast augmentation incision site due to the different points of pectoralis major can be distinguished into three types of surgery, as inframammary fold line pectoralis major arc incision, criss-cross incision under nipple projection area, and the pectoralis major muscle fiber horizontal part incision. What are the anatomic bases for these surgeries? Which is more reasonable and safe surgical procedure? How is the clinical application effects for two-plane breast augmentation? There was a shortage of relevant reports in this area. Therefore, in this study, the applied anatomy and clinical studies of dual-plane breast augmentation were observed.PART I: APPLIED ANATOMY OBSERVATION OF DUAL-PLANE AUGMENTATION MAMMOPLASTYObjective:To study the female breast and pectoralis major, in order to provide anatomical evidences for Dual-Plane Augmentation Mammoplasty.MethodSelect 6 Chinese adult female bodies, observations include: (1) blood supply and nerve distribution of breast and especially areola of nipple; (2) structure of subpectoral space, pectoralis major muscle fibers, blood vessels and nerves ( beginning and ending, distribution ); (3) simulate dual plane Augmentation Mammoplasty on the body: A type -- 1 ~ 2cm above inframammary fold line, arc incision being made to cut off the pectoralis major origin points, leaving the starting point of parasternal pectoralis major untouched, prosthesis 2 / 3 in subpectoral space and 1 / 3 in the inframammary space. B type -- In the pectoralis major at point of nipple projection, a criss-cross incisions (4cm per incision) being made, to form a diameter of 4cm "button hole" in the pectoralis major, thus, the prosthesis was in subpectoral space and the central part intrude into inframammary space. C type. In the breast muscle fiber horizontal part, an incision was made along the muscle fibers, prosthesis 1 / 3 in subpectoral space and 2/ 3 in the inframammary space. Observe and compare breast section after three types of surgical procedures, to find out if there were large vessels or nerve damage, in order to clarify rationality and safty of three types of dual-plane Augmentation Mammoplasty.Results:1. Breast vascular distribution and innervation characters: in the coronal plane of breast, of fan-shaped region from 4 to 8 hour centered by areola of nipple is the area for the vessel and nerve distribution where relatively sparse;2. Breast blood supply: from internal thoracic artery intercostal perforating branches, branches of lateral thoracic artery, intercostal artery perforating branches and the thoracoacromial artery branches, the first two were considered with great importance; internal thoracic artery perforating branches piercing in the 7.7 ~ 13.3 mm outer edge of the sternum; the four branches of the arterial formed superficial and deep artery network which hold the nipple as the center, and provide nourishment for deep glands and shallow skin. The vessle terminals ring together under the nipple to form a vascular network.3.Breast nerve: all the lateral cutaneous branch and anterior cutaneous branches of the 2 to 6 intercostal nerves are arrived and dominated the breast. Nerves of nipple and areola area are from the 3, 4, 5 intercostal nerve lateral cutaneous branch and anterior cutaneous branches. The 4 intercostal nerve hold the dominant position; the lateral cutaneous branches in the superficial fascia were mostly at 4 o'clock of the left breast and 8 o'clock of right breast into the nipple and areola area.4. In the front or behind the pectoralis major, there are loose connective tissue spaces.5.The pectoralis major muscle is fan-shaped myoides can be divided into three parts: clavicular part with up-outward muscle fibers; sternocostal part with horizontal muscle bundle in 3rd costa and oblique muscle fibers; abdominal part: fibers concentration down-outward.6. The pectoralis major blood supply and innervation: nutrient artery comes from thoraco-acromial artery, lateral thoracic artery, internal thoracic artery intercostal perforating branches. The most important is the chest acromial artery with vein accompanied. Running up-down direction, and the part which closest to breast augmentation projected on the line from xiphoid to the acromion; nerve controls the pectoralis major are the lateral and medial thoracic nerve, medial thoracic nerve origin from fasciculus medialis plexus brachialis, entering pectoralis major through the outer edge of pectoralis minor and controls abdominal and Sternocostal part of pectoralis major; lateral thoracic nerve origin from fasciculus lateralis plexus brachialis, accompanied with thoraco-acromial artery and dominate the clavicular part and sternocostal part of pectoralis major. 7. Body simulation of dual-plane breast augmentation, A-type surgery will not hurt large blood vessels and nerves, while the B, C type are easy to harm thoracoacromial artery and accompanied vein.ConclusionFrom anatomical analysis, dual-plane Augmentation Mammoplasty is feasible:1. In the coronal plane of breast, of fan-shaped region from 4 to 8 hour centered by areola of nipple is the area for the vessel and nerve distribution where relatively sparse, this region is more appropriate operative selection.2.To avoid injure the nerve terminal which controls areola of nipple and to easily perform the surgical procedure, incision should be made in the lower edge in the "4" ~ "9" hour on the left areola and "3" ~ "8" hour on the right areola.3.After get into the subcutaneous tissue layer, unnecessary separation should not be made between the nipple and under skin, in order to avoid damage to vascular and neural network.4.Pectoralis major exposure : As the gland has no dense network of blood vessels and nerves, so through the edge of the areola incision can longitudinal directly incise gland and arrive pectoralis major surface. This method is with less tissue damage, and a clear surgical vision.5. Dual plane dissection: A type is the most safety pectoralis major incision, cut started from 2.0cm outside on the outer edge of the sternum and 6th rib, curved incision to cut the outer edge of pectoralis major. This prevents B, C type's disadvantages such as: easy to damage thoracoacromial vessle, lateral and medial thoracic nerve defects.Besides, from the morphological analysis, A type surgical procedure can have bettter results than B, C types.PART II: DUAL-PLANE AUGMENTATION MAMMOPLASTY CLINICAL APPLICATIONObjectiveAnatomical study guide dual plane breast augmentation surgical options, evaluate the safety and effect of surgical procedures.Methods1. clinical data: 11 cases adult women accepted Dual-plane augmentation mammoplasty, age: 21 to 42. 4 cases with no childbearing history, breast too small, or dysplasia; 7 cases with breast gland atrophy after breastfeeding, including 4 patients with mild breast ptosis.2.Surgical Methods: A type dual-plane breast augmentation surgical procedures,â‘ 1 ~ 2cm above inframammary fold line, arc incision being made to cut off the pectoralis major origin points, leaving the starting point of parasternal pectoralis major untouched. Thus, prosthesis 2 / 3 in subpectoral space and 1 / 3 in the inframammary spaceâ‘¡when cases with slightly breast ptosis, their pectoralis major incision will be up- inward extension (height does not exceed the lower edge of the areola), so that prosthesis will move downward: the lower 2 / 5 in the inframammary space, the 3 / 5 in the subpectoral space, so to increase the fullness of the lower breast and improve the ptosis appearance.3. Follow-up 4 to 14 months, an average of 8 months.4.Evaluation: combined surgeon evaluation and patients questionnaire; evaluation include breast appearance, breast flexibility, with or without implant displacement, capsular contracture or deformity, implant edge visibility, nipple sensation, breast ptosis improvement, both upper extremities function. Surgeon evaluations were divided into 4 grades: excellent, good, middle and poor; patients questionnaire divided into: very satisfied, satisfied, almost satisfied, not satisfied.Results11 patients, 22 breasts, according to all the indicators, the excellent&good rate (excellent+good/ the number of cases) and patients satisfied rate (very satisfied+satisfied/ the number of cases) were: breast appearance 82%, 91%; breast flexibility, 95%, 86%; implant edge visibility of 91%, 100%; nipple sensation 95%, 95%, both upper extremities function 100%, 100%; breast ptosis improvement 88%, 88%.ConclusionA type dual-plane augmentation mammoplasty is an integration of the advantages of breast implant placed under the plane and the pectoralis major advantages of the plane, after good results with few complications, no significant effect on the pectoralis major muscle function, it is safe feasible method of breast augmentation surgery.