Vascular anatomy of the breast and its implications in the breast-sharing reconstruction technique.

The most frequently described breast-sharing procedure consists in a pedicled technique where the transferred lower breast pole is based on the lower perforators of the internal mammary (IM) artery. The current article investigates the vascular supply of the breast and its surgical implications in breast-sharing reconstruction. Contrast-enhanced magnetic resonance images of 55 patients (110 breasts) were retrospectively examined. A total of 473 branches of the IM, lateral thoracic (LT) and anterior intercostal (AI) arteries with a diameter greater than 0.5 mm were traced throughout their course in the breast. Distinct connections between the vessels were equally recorded. Although any vessel could vascularise any quadrant in the individual patient, blood supply to the lower quadrants came fundamentally from the AI arteries (76.2% of all the perforators). Lower IM branches (4th-5th) were seen to reach both lower quadrants in only 6.4% of the breasts, whereas LT branches did in 15.5%. In 86.4% of the breasts, at least a distinct AI perforator was seen to perfuse both lower quadrants. Well-defined connections between the IM and the LT arteries were observed in 41.8% of the breasts, always at or above the nipple-areola level. Other connections were far less common. Our study strongly indicates that the breast-sharing technique based on 4th-5th contralateral branches of the IM or LT arteries is unreliable in most patients. Given the unpredictable vascularization pattern in the lower breast pole, a preoperative imaging study is mandatory when the use of the contralateral breast is considered. Due to its accuracy, availability, and anatomical reliability, contrast-enhanced magnetic resonance is the best technique in the preoperative evaluation of the breast-sharing reconstruction.

Breast augmentation with anatomic implants: a method based on the breast implantation base.

UNLABELLED: Currently, aesthetic and reconstructive surgery of the breast should be considered in terms of contouring, and hence in terms of dimensions. Based on experience performing more than 5,000 breast augmentations with highly cohesive anatomic implants, the authors explore the aesthetic anatomy of the (augmented) breast and explain the importance of the breast implantation base (BIB), the aesthetic proportions of the lower breast pole, and the patient's somatotype in the implant selection for a natural-appearing breast augmentation. A method is described for transferring all these concepts and proportions to the preoperative marking of the individual patient. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Stiffness, compliance, resilience, and creep deformation: understanding implant-soft tissue dynamics in the augmented breast: fundamentals based on materials science.

BACKGROUND: Postoperative tissue stretch deformities are among the possible complications in breast augmentation. These deformities are responsible for many potential risks such as bottoming-out deformity, breakdown of the inframammary fold, permanent tissue atrophy, sensory loss, and breast distortion (visible implant edges and traction rippling), among others. Although the elastic properties of the breast are a major concern for plastic surgeons, concepts such as stiffness, compliance, elasticity, and resilience have not been sufficiently defined or explored in the plastic surgery literature. METHODS: Similar to any other material, living tissues are subject to the fundamentals of the mechanics of materials. Based on their experience with more than 5,000 breast augmentations, the authors explored the basic fundamentals of the mechanics of materials in search of a rational explanation for long-term results in breast augmentation and augmentation-mastopexy. RESULTS: A basic law of the mechanics of materials determines that when a material (e.g., breast) is loaded with a force (e.g., implant), it produces a stress that causes the material to deform (e.g., breast augmentation), and this behavior might be graphed in a theoretical material's stress-stress curve. This deformation will increase with time although the load (implant) remains constant, a concept termed "creep deformation." Because the breast, like all human tissues, is a viscoelastic material, the application of concepts such as elastic and plastic deformation, stiffness, compliance, resilience, and creep deformation can and should be applied to breast augmentation surgery. CONCLUSIONS: The authors have found that the principles of the mechanics of materials can provide plastic surgeons with some clues for a predictable, long-lasting good result in breast augmentation and augmentation-mastopexy. Future studies are needed to develop these concepts and evaluate how they might individually determine the mid- and long-term outcomes of augmented breasts.

Selecting the implant height in breast augmentation with anatomical prosthesis: the "number Y".

BACKGROUND: Selecting the appropriate implant is one of the most important and demanding decisions in breast augmentation with anatomical implants, because different widths, heights, and projections can be found for a given volume. Most of the related literature and surgeons' concern have focused on width and projection. Implant height selection, however, has remained deeply overlooked, and it has been assumed that it depended on the suprasternal notch-to-nipple distance and, to a large extent, on the patient's height. METHODS: With more than 5123 breast augmentations performed over the past 15 years, the authors performed an analysis of the breast and implant height with consequences in aesthetic augmentation of the breast. Two concepts--breast implantation base (or breast footprint) and somatotype--were explored. Their influence in the selection of the appropriate anatomical implant height is investigated. RESULTS: Selection of implant height should follow the patient's breast implantation base, which is highly influenced by her somatotype. With this assumption, a "number Y" is proposed that correlates the suprasternal notch-to-nipple distance with the thoracic perimeter and unveils the shape of the breast implantation base in the particular patient. CONCLUSIONS: Adjusting the implant shape/footprint to the breast implantation base/breast footprint gives the surgeon control over the upper pole of the breast and allows a predictable postoperative result. The number Y rationalizes the selection of the implant height in breast augmentation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The superolateral thigh flap: cadaver and computed tomographic angiography studies with a clinical series.

BACKGROUND: There are few references to the reconstructive possibilities of the ascending branch of the lateral circumflex femoral artery other than the tensor fasciae latae muscle flap and the so-called muscle pedicle bone grafting technique. METHODS: An anatomical study was performed to evaluate the ascending branch of the lateral circumflex femoral artery and its contribution, through direct branches, to the iliac crest and skin. RESULTS: In nine of 20 dissections, a small branch of the ascending branch of the lateral circumflex femoral artery was found to reach the iliac crest in the space defined by the rectus femoris, gluteal muscles, and tensor fasciae latae. After emergence of the tensor fasciae latae pedicle, the ascending branch coursed through an anatomical triangular space before entering the trochanteric skin as a direct terminal branch and running for a considerable distance in a posteroinferior direction in the subcutaneous fat. This pretrochanteric triangle was defined by the tensor fasciae latae, the trochanteric insertions of the vastus lateralis and gluteus medius muscles, and the greater trochanter. CONCLUSIONS: The superolateral skin of the thigh can be transferred based on terminal branches of the ascending branch of the lateral circumflex femoral artery. Although inconstant, a small branch of the ascending branch reaches the iliac crest and might support vascularized bone transfer, although more studies are needed to define its role in composite tissue transplantation. This ascending branch might be a good alternative in pedicle or microvascular skin/fat transfer, breast reconstruction, tendocutaneous reconstructions, or composite tissue transplantation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Vascularized periosteal transfer from the medial femoral condyle: is it compulsory to include the cortical bone?

BACKGROUND: The corticoperiosteal flap from the medial femoral condyle has become the workhorse in the management of recalcitrant nonunions with vascularized periosteum. Inclusion of the outer condylar cortex has been advocated to avoid damaging the osteogenic capacity of the periosteum and is at present an ordinary technical step in the procedure. PATIENTS: A clinical prospective study was undertaken to evaluate the effectiveness of periosteal-only microvascular transfers from the medial femoral condyle associated with bone grafts in the treatment of recalcitrant nonunions. A group of 8 patients with periosteal-only flaps (study group) is compared with a corticoperiosteal control group (13 patients). A statistical analysis is made of the results. RESULTS: We had 100% union rate in both the study and control groups. Evaluation of early signs of bone healing by two independent evaluators did not found differences between the groups (4.5 months in the study and 4.9 months in the control group). CONCLUSIONS: Although not statistically significant because of the small sample size, our study might support the idea that both periosteal and corticoperiosteal flaps from the medial femoral condyle are effective, when associated with a bone graft, in the treatment of recalcitrant nonunions with small gaps. A further analysis of the results suggests, albeit no statistical significant, that structural and nonstructural bone grafts are both effective when associated with a vascularized periosteal or corticoperiosteal transfer from the medial femoral condyle.