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Brava and Autologous Fat Transfer
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Brava and Autologous Fat Transfer
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COSMETIC
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View Article
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Understanding the Fascial Supporting
Network of the Breast: Key Ligamentous
Structures in Breast Augmentation and a Proposed
System of Nomenclature
Simone A. Matousek,
F. R . A . C . S .
Russell J. Corlett, F.R.A.C.S.
Mark W. Ashton, F.R.A.C.S.
Potts Point, New South Wales,
Australia
Background: The fascial system of the breast has, to date, only been
described in general terms. This anatomical study has developed two distinct
methods for better defining existing breast structures such as the inframammary fold, as well as defining previously unnamed ligamentous structures.
Methods: The authors harvested and examined 40 frozen, entire chest wall
cadavers. Initially, 15 embalmed cadavers were studied with a combination
of blunt and sharp dissection, which proved to be inaccurate. A further 20
fresh and five embalmed chest walls were harvested, frozen, and then sectioned with a bandsaw (3-cm slices) and knife (1.5- to 4-cm slices) depending
on the area studied. Sagittal, horizontal, and oblique sections along the length
of the ribs were created and then dissolved using either sodium hydroxide or
alcohol dehydration followed by xylene immersion. Constant fascial connections between the breast parenchyma, superficial fascia, pectoralis muscle
(deep) fascia, and bone were observed.
Results: Specimens clearly demonstrated internal structures responsible
for the surface landmarks of the breast. The precise configuration of the
infra mammary fold was clearly visible, and new ligamentous structures were
identified and named.
Conclusions: Knowing the location and interrelationship of these structures is particularly important in breast augmentation. Reappraisal of the
anatomy in this area has enabled precise identification of ligamentous struc-
earch Journa
ind a Previous Iss
iew Articl
arious methods have been used to study the
ligamentous anatomy of the breast. Until now,
V
ing results, possibly because of dissection artifact. With
advancing breast implant technology and expansion
of its role in the treatment of breast deformity, a concomitant need exists for a more detailed anatomical
many of these methods have produced conflict-
tures in the breast. Correlation of the findings in this article to specific clinical
conditions or modes of treatment can be proven only by a clinical series that
scientifically addresses the necessity and ecacy of preserving, releasing, or
repositioning any of these structures. (Plast. Reconstr. Surg. 133: 273, 2014.)
knowledge of the fascial and ligamentous structure of
the breast. We describe two new methods to study the
breast fascial system. These provide a more accurate
assessment over existing techniques.
According to classic anatomic descriptions, the base
of the nonptotic breast overlies the pectoralis major
muscle between the second and sixth ribs.
1
From Taylor Laboratory, Department of Anatomy and Neuroscience,
University of Melbourne, Royal Melbourne Hospital.
Received for publication April 6, 2013; accepted August 16, 2013.
Copyright © 2014 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000436798.20047.dc
97
!"#$%&'()*+,-+.(/012"-%-3(45-(/"&6&'#"(7#$%-+$(08(!9)(:(;+-#$%(<*,1-6%#%&06
Disclosure: The authors have no financial interest to
declare in relation to the content of this article.
Fascial Supporting Network
The breast overlies the fascia investing the chest wall
musculature—most significantly, the pectoralis major
muscle, the rectus abdominis muscle inferomedially, serratus anterior superolaterally, and a small portion of the
external oblique inferolaterally.
The gland is anchored to the pectoralis major fascia
by the suspensory ligaments first described by Astley
Cooper in 1840.
2
These ligaments run throughout the
breast tissue parenchyma from the deep fascia beneath
the breast and attach to the dermis of the skin.
Overlying this is the superficial fascial system of the
breast, first described by Scarpa3 and Colles4 and then
further defined by Lockwood.5 It is continuous with
the superficial fascial system of the trunk and is best
described as a connective tissue network extending from
the subdermal plane to encase the fat and lobular tissues of the breast. This superficial fascial network has
correct position of the inframammary fold. Sections
were obtained either with a bandsaw (3 cm wide) or a
knife (1.5 to 4 cm wide, depending on the area studied,
which allowed for greater precision).
We obtained a more accurate demonstration of the
fascial network with sagittal (18), horizontal (five), and
oblique (two specimens along the length of the ribs in
the intercostal spaces) sectioning, and correlated the
results from the dierent sections.
In 15 specimens, we used a gradual fat dissolution
technique using four subsequent treatments with 10%
sodium hydroxide and washing with water to demonstrate the fascial network. This gradual removal of fat
maintains the fascial structure and allows for better definition of the ligaments of the breast. Constant fascial
connections among the breast parenchyma, superficial
fascia, pectoralis muscle (deep) fascia, and bone were
posterior extensions connecting it to the fascia overlying
the muscles of the chest wall and, in certain regions, to
the periosteum. Anteriorly, it has more numerous extensions, where it is inserted into the dermis.
While this superficial fascial system has been studied
in the literature, there is a paucity of fine detail regarding
its anatomical structure, particularly in the lower pole
and inframammary fold. In addition, some of the studies directly conflict with each other, and some describe
structures, such as the horizontal septum, that are not
mentioned elsewhere.
We aimed to develop techniques that allow a more
detailed study of the breast’s fascial system. In particular, we aimed to provide specific information about
the fascial structures that constitute the lower pole and
inframammary fold and the interrelationship between
these structures and other elements of the breast, par-
examined.
In 10 specimens, we used a dierent dissolution technique. This involved using absolute ethanol baths with
increasing concentrations of 50%, 75%, and 100% for
24 hours, followed by immersion in xylene for several
days (the immersion time depended on the fat content
of the specimen). This accurately demonstrated bony
attachments of the ligamentous network.
RESULTS
Although the superficial fascial system varies according to age, degree of ptosis, and adiposity, we observed
specific recurring ligamentous patterns in the cadavers
we studied. As expected, fascial quality deteriorated with
increasing age of the specimens; there was a greater
degree of ptosis and ligaments were more lax and less
dense in older specimens. However, the configuration of
ticularly the suspensory ligaments of Astley Cooper and
the superficial fascial system of Scarpa.
MATERIALS AND METHODS
We dissected 40 female cadavers using dierent
approaches to define the ligamentous anatomy of the
breast. All cadavers ranged in age from 58 to 95 years,
with an average age of 83 years. We examined a broad
range of breast sizes from those with hypoplasia or involution to overweight specimens with significant ptosis.
We initially studied 15 embalmed cadavers with a
combination of blunt and sharp dissection to define key
structures. This was, however, as previously stated, limited by dissection artifact.
A further 20 fresh and five embalmed female chest
walls were harvested from whole cadavers from the midsternum to the posterior axillary line. The chest walls
the structures was the same across all ages.
The anterior breast capsule (or superficial layer of the
breast fascia) is well defined to the level of the fourth
rib, after which it becomes obscured by glandular tissue
and ducts as they form the nipple-areola complex. It
is not visible inferior to the fourth intercostal space,
because it gives way to direct dermal insertions, which
fan out from the fifth rib and pectoral fascia superior to
it. The posterior breast capsule creates a gliding plane
between the pectoral fascia and breast, which is called
the retromammary space (Fig.1).
Commencing medially with the parasternal area,
there are many dense transverse connections between
the periosteum of the sternum and dermis, which firmly
anchor the fused superficial and deep fascial system in
this region. These medial sternal ligaments are short,
run horizontally along the length of the sternum, and
were then frozen and fixed with needles to maintain the
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are stronger and thicker than in the remainder of the
Fascial Supporting Network
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sternal heads of the pectoralis major muscle (deep clavicular ligament). These are direct insertions between periosteum and dermis without intervening anterior breast
capsule, which commences inferior to these attachments
at the level of the second rib.
There is a fascial thickening between the pectoral
fascia and superolateral breast at the lateral aspect of
the pectoralis major as its fibers converge to form its
tendinous insertion to the humerus, the lateral pectoralis major ligament (Fig.3). This is a firm superolateral
anchor point for the breast.
In the inferior pole of the breast, the ligaments run
obliquely and inferiorly to insert directly into the dermis, with no intervening anterior breast capsule. At the
level of the fifth rib, they fan out in a triangular fashion
Fig. 1. Diagram of a sagittal section through the nipple, dem-
onstrating the anterior and posterior breast capsule, ligaments,
and triangular fascial condensation.
from a well-defined bony attachment where they are
fused to the periosteum of the superior aspect of the
fifth rib (the apex of the triangle) in the intermuscular
septum between the rectus abdominis and pectoralis
major. The most inferior of these fibers insert into the
dermis of the inframammary fold. The remaining superior fibers insert into the inferior pole of the breast. This
forms what we have named the triangular fascial condensa-
tion (Figs. 4 and 5).
In addition to the oblique fibers seen in sagittal sections, the condensation has radial fibers running perpendicular to these along the length of the fold. The
amount and density of the criss-crossing insertions here
create the degree of constriction of the lower pole, and
also the degree of fold definition.
There are a few short horizontal ligaments inserting
into inferior limit of the fold directly from the deep fascia
overlying the rectus abdominis, with no intervening
breast because there is little fat and no glandular tissue
interspersed in this region. This creates a very firm zone
of adherence medially (Fig.2).
As the pectoralis major muscle takes its origin from
the sternum and the first to fifth ribs, these ligaments
extending from the pectoral fascia through to the anterior breast capsule and dermis gradually become longer,
especially in the retroareolar portion of the ptotic, larger
breast. This region has the greatest amount of glandular
tissue and fat. The ratio of fat to glandular tissue varies
greatly when comparing dierent breasts. With greater
degrees of fatty infiltration in this area, the ligaments are
more stretched, resulting in a greater degree of ptosis.
Superiorly, two direct bony anchor points to the clavicle were observed: one superior to its superficial aspect
through the pectoral fascia (superficial clavicular liga-
superficial fascial layer. The superficial fascial layer
(Scarpa’s fascia) is once again visible approximately
1 cm inferior to the fold. The fold is supported from below
over the region of the sixth rib and superior portion
of the seventh rib by very short horizontal ligaments
connecting the deep fascia of the rectus abdominis to
Scarpa’s fascia, from which short ligaments run inserting
into the dermis (Fig.4).
The triangular fascial condensation is therefore a
zone that forms a break in the continuity of the superficial fascial layer.
The inframammary fold lies at the level of the sixth
rib or sixth/seventh rib depending on the degree of ptosis (and the length of these inferior ligaments).
The limit of the lateral third of the breast is defined
by the fusion of the layers of fascia arising from fascia
overlying the pectoralis major and minor muscles and
ment) and one to the deep inferior aspect of the clavicle
through the fascial septum between the clavicular and
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the fascia overlying the serratus anterior, which has been
named the lateral fascial confluence.
Fascial Supporting Network
Fig. 2. Sagittal section through the sternum (left) with a close-up of the medial sternal
ligaments (right). Sodium hydroxide dissolution.
The fascia between the interdigitations of the serratus
anterior anchors the breast directly to the fourth, fifth,
and sixth ribs, and this creates the lateral continuation
of the inframammary fold. The confluence of three
fasciae (pectoralis major, pectoralis minor, and serratus
anterior) creates the continuous curve of the inframammary fold as it merges laterally into the suspensory ligament of the axilla (an extension of the pectoralis minor
fascia) (Fig.6).
A dense fascial adhesion that is continuous with the
fascia surrounding pectoralis minor (the clavipectoral
fascia) attaches to the coracoid process, runs inferiorly,
and emerges inferior and lateral to the pectoralis major
muscle to fuse with its investing fascia and the fascia
overlying the serratus anterior. Inferiorly, its fibers insert
directly into the breast parenchyma approximately
4 cm lateral to the nipple and into the inferior pole of
the breast, forming the pectoralis minor suspensory
ligament (Fig.7).
These fixed points create the surface topography
known as the breast footprint, which varies in its position in each individual, depending on the length and
laxity of these ligaments.
DISCUSSION
Knowledge of the fascial attachments of the breast is
integral to understanding the aesthetic ramifications of
breast surgery. Symmastia, the double bubble deformity,
Fig. 3. General view of a horizontal section at the level of the second rib (left) and its close-up showing the lateral pectoralis major
ligament (right). Xylene dissolution.
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Fascial Supporting Network
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Fig. 4. General view of a sagittal section medial to the nipple (left) with a close-up of the
attachment of the triangular fascial condensation to the fth rib (right). Xylene dissolution.
lateral implant migration, prolapse of a breast implant
below the inframammary fold, and destruction of the
inframammary fold following mastectomy are just some
examples of surgery interfering with the breast’s fascial
network to produce unaesthetic surgical outcomes.
The study of the breast’s fascial network and supporting ligaments dates back to late eighteenth century. As
early as 1809, Scarpa3 described the superficial fascia of
the abdominal wall, and in 1811, Colles4 described its
continuation in the perineum. Perhaps Sir Astley Cooper should be recognized as the first to comprehensively
and systematically describe and depict the fascial network of the breast, in 1840.2 Astley Cooper described
in detail the deep and superficial fascial system of the
breast and the horizontal supporting ligaments that still
bear his name today.
Fig. 5. General view of a sagittal section medial to nipple (left) with a close-up of
the attachment of the triangular fascial condensation to the fth rib (right). Xylene
dissolution.
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Fascial Supporting Network
Fig. 6. General view of a horizontal section through the fth (pink pin) and sixth (blue pin) ribs (left). Close-up of the area of fusion
of the pectoralis major, pectoralis minor and serratus anterior forming the lateral fascial conuence (right). Xylene dissolution.
However, there are some structures described and
illustrated by Sir Astley Cooper that we were unable to
find, particularly the splitting of the fascial layers into
anterior and posterior lamellae: “The gland of the breast
is enclosed in a fibrous tissue, which as in the female,
should be traced from the sternum outward … when it
reaches the breast it divides into two portions, an anterior and posterior layer. The anterior part passes upon
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Fig. 7. Left breast oblique section through the lateral inframammary
fold (sodium hydroxide dissolution). Pectoralis minor suspensory
ligament is visible attaching to the coracoid process (orange pin) and
running inferiorly to insert into the breast tissue.
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Fascial Supporting Network
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the fore part of the gland and sends forth its ligamenta
suspensoria to unite the breast to the inner part of the
skin … with which it becomes incorporated.”
2
This splitting of Scarpa’s fascia into the anterior
and posterior lamellae of the breast capsule has subsequently been accepted as fact in the literature. It has
been described by others, and it is said to occur in the
region of the inframammary fold.
6
However, in our specimens using fat dissolution, no
such division point was visible. Moreover, this is the region
of a direct insertion point from both the periosteum of
the fifth rib to the dermis of the inframammary fold and
inferior pole (the triangular fascial condensation).
This is not the only anatomical structure described in
the literature that we were unable to replicate. Würinger
and colleagues described a thin horizontal fibrous septum originating from the pectoral fascia along the level
of the fifth rib heading toward the nipple.
7,8
This fibrous
ligament was described as originating from the fifth rib
and inserting into the deep dermis of the skin.
11
Muntan etal.
described the fascia of the fold as having dierent configurations; the deep fascia being fused
with the superficial fascia at the fold level or alternatively,
bundles of fibers arising from the superficial fascial layer
and inserting into dermis. Boutros etal.
12
in a later study
said that there was no evidence of a ligamentous structure in the area of the inframammary fold and that it is
an intrinsic dermal structure consisting of regular arrays
of collagen held in place by a zone of adherence that is
a specialized area of the superficial fascial system.
In a more recent study of the pectoral fascia, Jinde
and colleagues13 described a dense connective tissue
structure at the level of the inframammary crease
connecting it to the underlying pectoral fascia.
The structural anatomy of the breast is aected by
skin quality, fat, glandular tissue connections to under-
septum is said to be mesentery-like and lies between a
cranial and caudal vascular network, and is responsible
for the blood supply of the nipple-areola complex. While
there was a thin structure visible transmitting neurovascular supply to the breast in the specimens, there was
no distinct septum dividing the breast superiorly and
inferiorly.
The inframammary fold has also been subject to
several conflicting descriptions. Maillard and Garey
described a crescent-shaped ligament stretching
between the superficial aspect of the pectoralis muscle
and skin just inferior to the inframammary fold.9 Bayati
and Seckel’s results corresponded closely to our findings
(however, excluding the lateral extent of the fold).10 The
lying musculature (pectoralis major, pectoralis minor,
serratus anterior, and rectus abdominis), and the fascial
architecture.
Our study shows that the fascial architecture of the
breast forms a ring around the breast, and between this
fixed framework are attachments between deep muscle
fascia and anterior breast capsule. The concept of such
zones of adhesion has been well described by Lockwood,5 particularly the medial sternal adhesion zone.
This ring is formed (summarized in Fig.8):
1. Superiorly by the superficial clavicular ligament
and deep clavicular ligament
2. Medially by the medial sternal ligaments
Fig. 8. The surface anatomical landmarks created by the ring of fascial attachments of the breast.
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