Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_611_Библиотеки_им_академика_М_И_Перельмана
.pdf
14 Mammary Tissue Changes During Pregnancy andBreastfeeding
https://t.me/medicina_free
255
14.3.5 Secretions
Colostrum is less dense than milk, and it provides different immune qualities. It is the perfect
From the midpregnancy, the rst “milk products”
are prepared. Colostrum (also known as “rst
milk”) is a yellow uid that may be secreted after
the rst months of pregnancy with a slight nipple
massage that discharges oxytocin over the lactiferous ducts.
nurture product for the newborn in its rst days.
Milk is ejected in the third or fourth days postpartum. The breast mechanism by which colostrum switches to milk is unknown.
Main breast changes during pregnancy are
summarized in Table14.1:
After childbirth, the suction reex stimulates
the production of new colostrum and milk.
Table 14.1 Main breast changes during pregnancy
Change Physiology
Volume and
density
Ptosis Nipple-areola complex is more than
Symmetry Change in volume between both
Nipple-areola
complex
Skin Stretch marks Quick breast weight change
Vascularization Increase blood volume
Paresthesia and
pain
Secretions Colostrum and milk secretion See the description on lactogenesis
Breasts grow and become less stiff Increasing in gland tissue and decreasing in
21cm away from the suprasternal
notch
breasts
Montgomery glands appear Unknown
Hyperpigmentation Estrogens are melanocyte stimulating, and human
Little veins slightly noticeable on the
breast surface
Tenderness and paresthesia Breast enlargement
connective and fatty tissue
Hormonal changes during pregnancy and
breastfeeding, together with the fast change in
volume
Estrogen and progesterone receptors are different in
each breast
chorionic gonadotropin (HCG) is biochemically
similar to melanotropin
Estrogen and oxytocin
Estrogen and progesterone could stimulate
neurological receptors
256
https://t.me/medicina_free
T. Costas et al.
14.4 Breastfeeding
andPregnancy Breast
Illnesses: Diagnostic
Challenges
The mammary tissue changes and the presence of
new uid, such as colostrum and milk, make
identifying breast conditions during pregnancy
and breastfeeding a cumbersome challenge.
There are also some typical benign conditions
in this stage.
14.4.1 Galactocele
It is milk accumulation outside the lactiferous
ducts in breast tissue due to extravasation. It is
the most prevalent pathology during pregnancy
and breastfeeding. Milk accumulation forms a
rm mass inside the breast that is palpable.
Women should not have other local or systemic
symptoms such as erythematous breasts, fever, or
malaise. In ultrasounds, it appears as a cystic
mass without Doppler ow. Galactocele does not
require treatment: it does not interfere with
breastfeeding, and it may be resolved on its own.
If it is very painful, it may be drained [20].
with increasing vascularity). Treatment is also
antibiotics, but this is often not enough, and aspiration drainage may be necessary. Breastfeeding
should also be maintained in this case.
14.4.3 Lactating Adenoma
The etiology and composition of lactating adenoma are not clear. Some theories claim that it is
a “de novo” lesion that appears due to hormonal
changes. On the other hand, other theories argue
that it is a variation of broadenoma.
It is a benign mass that is often palpable and
bilateral. It is painless and soft, and it may be
compressive. In an ultrasound, it generally shows
benign characteristics: solid, well-dened margins and longitudinal diameter larger than the
transversal one. But in some cases, they may
present malignant characteristics such as irregular margins or mixed echogenicity. In case of
doubt, it should be biopsied [20].
Lactating adenoma usually disappears after
the breastfeeding period.
There are other benign and malign pathologies that can change their appearance during
pregnancy and breastfeeding:
14.4.2 Mastitis inBreastfeeding
This is an inammation and infection of lactiferous glands due to breastfeeding (there may also
be mastitis with no associated breastfeeding, but
it is less common). Mastitis is produced by milk
accumulation in lactiferous glands. The most
common isolated organism is Staphylococcus
aureus followed by Streptococcus. Symptoms are
tender, edematous, and erythematous breasts.
There may be thickening of the breast skin, and
systemic symptoms are fever and malaise.
It should be treated with antibiotics, and
breastfeeding should be maintained (it promotes
breast emptying).
The severe spectrum of mastitis is an abscess:
infection causes an abscess in the breast tissue. It
should be conrmed by ultrasounds (cystic mass
14.4.4 Fibroadenoma
It is mass proliferation of stromal and epithelial
component. It is the most common breast mass in
women. Many times, broadenomas exist before
pregnancy, but with breast enlargement, they
become more evident at this time. It should be a
palpable mass, painless, and mobile. Ultrasound
images are usually a solid circumscribed mass.
Breastfeeding could change echogenicity. It
should be biopsied if there is any doubt [20].
14.4.5 Malignant Mass
Breast cancer has an incidence of 1 case out of
every 1000–3000 pregnant women. The most
common type is poorly differentiated, with nega-
14 Mammary Tissue Changes During Pregnancy andBreastfeeding
https://t.me/medicina_free
257
Table 14.2
Pathology Physiopathology Symptoms Ultrasound appearance Biopsy Treatment
Galactocele Milk
Lactating
adenoma
Fibroadenoma Hypertrophy Painless and rm
Malignant
mass
Mastitis Infection and
Abscess Infection and
Basic characteristics of breast pathologies during breastfeeding and pregnancy
Painless mass Cyst mass without
accumulation
inside breast
Unknown Bilateral, painless,
Depends on
cancer histology
inammation
inammation
and compressible
mass
mass
Painless, rm, and
irregular mass
Tender,
erythematous
breast. Fever and
malaise
Mass and same
symptoms as
mastitis
Doppler
Hypoechoic mass with
benign characteristics (in
some cases, malignant
appearance)
Variable
Solid mass
Malignant appearance Always Oncologic
Edema in tissue No Antibiotics
Cyst mass with Doppler
surrounding caption
No None. If
May be
needed
May be
needed
No Antibiotics,
severe, it could
be drained
None.
Biopsy
Monitoring
treatment
drainage
tive receptors. The symptoms and ultrasound
images are similar to those of nonpregnant
women. But it is more difcult to identify due to
changes in the surrounding tissue.
The basic characteristics of these pathologies
are summarized in Table14.2.
There are also typical pathologies of the nip-
ple-areola complex:
14.4.6 Mammary Fissures
They are injuries in the nipple area that are caused
by an incorrect suction technique during breastfeeding. Fissures may be very painful, and the
most important element is prevention with an
adequate technique.
There is not a wide range of treatment options:
many experts recommend spreading the mother’s
own milk before suction or applying massages
with olive oil (Fig.14.13).
14.4.7 Inverted Nipple
Inverted nipple is an intussusception of the nipple
(Figs. 14.14 and 14.15). It could be a genetic
problem or caused by breastfeeding. It is caused
Fig. 14.13 Nipple ssure in breastfeeding breast. The
ssure may be seen below the white arrowhead
by the failure of the mechanisms that support the
nipple.
It causes breastfeeding failure (in these cases,
a breast pump may be useful) and aesthetic
changes.
258
https://t.me/medicina_free
Figs. 14.14 and 14.15 Inverted nipple in front (left) and left side (right) views. This may be seen below the white
arrowhead. Image courtesy of Dr. Olivas-Menayo (Madrid)
T. Costas et al.
It can be classied into different grades:
– Grade I: nipple may be pulled manually.
– Grade II: nipple may be pulled manually but it
reverts to its original position.
– Grade III: surgery is the only method to pull
the nipple because it is xed by brous
tissue.
There are different surgical and nonsurgical
procedures than can resolve this problem (see
reshaping after breastfeeding).
14.4.8 Nipple Hyperkeratosis
This is a condition called pregnancy-associated
hyperkeratosis of the nipple. In addition to physiological skin changes during pregnancy, there are
other changes such as seborrheic keratosis or skin
tags that may be developed in the nipple
Fig. 14.16 Nipple hyperkeratosis is indicated with white
arrowhead. Image courtesy of Dr. Olivas-Menayo
(Madrid)
(Fig.14.16). Furthermore, diseases such as nipple hyperkeratosis may appear.
It is composed by verrucous and conuent
lesions in both nipples. Its mechanism is unclear,
although it seems to be caused by exposure to
estrogens. It usually resolves spontaneously [21].
Periareolar scar Upright scar
14 Mammary Tissue Changes During Pregnancy andBreastfeeding
https://t.me/medicina_free
259
14.5 Reshaping After
Breastfeeding
After pregnancy and breastfeeding, the breasts
suffer dramatically. Sometimes, breast recovery
is satisfactory, or the woman simply accepts the
changes. In other cases, the alteration requires
surgical correction.
The most common problems are changes in
size or volume, empty breasts, or ptosis.
There are many surgical interventions that
may solve the main problems:
14.5.1 Mastopexy forPtosis
The correction of ptosis is called mastopexy.
There are different types of surgery depending on
the grade of ptosis and the woman’s condition.
It is important to determine volume problems
apart from ptosis:
If there are empty or slightly empty glands, we
should practice mastopexy with prostheses (mas-
topexy plus mammoplasty) in order to increase
breast volume.
If, in contrast, the pregnancy has caused
gigantomastia, the correct surgery would be a
reduction mammoplasty and mastopexy [22].
Types of mastopexy (Fig.14.17):
Periareolar scar: When ptosis is Regnault
grade I and we only have to elevate the breast tissue 2 cm or less, it is a suitable option. It also
makes it possible to reduce the size of the areola.
Upright scar: It is indicated in grades I and
II. It makes it possible not only to reduce the
breast size, but also to reduce the areolar and
periareolar size.
“Y shape”: It is indicated in pseudoptosis
because it does not make it possible to elevate the
nipple-areola complex. It is only indicated to correct the excess of mammary tissue in the inferior
mammary pole.
“T shape”: This is indicated when ptosis is
severe (grades IV or III) and preferably in cases
of gigantomastia. This type of operation could
affect breastfeeding.
Preoperatory design
Surgical scars
Preoperatory design
Surgical scars
Y shape T shape
Surgical scars Surgical scars
Fig. 14.17 Surgical procedures for ptosis. Redrawn with permission of Olivas Menayo J.Available at https://www.
cirugiasdelamama.com/elevacion- de- la- mama
Preoperatory designPreoperatory design
260
https://t.me/medicina_free
T. Costas et al.
There are other surgical procedures for
extreme cases.
Complications could range from numbness to
paresthesia. Also, the nipple-areola complex
could be affected if the irrigation is not correct.
14.5.2 Breast Reduction or
Augmentation
Empty breasts are one of the most common problems after breastfeeding. They are often accompanied by size problems.
When the size after pregnancy and breastfeeding is too big, reduction techniques may be
applied.
When there is no ptosis, breast liposuction
could be enough, but in many occasions, gigantomastia is accompanied by ptosis. In these cases,
techniques similar to those used for ptosis should
be applied.
In other cases, fat tissue is reduced by gland
expansion in pregnancy and breastfeeding. The
subsequent gland regression may make the
breasts feel lighter and sagging. Augmentation
mammoplasty surgery could be useful for this
problem.
There are different mammoplasty types
depending on the type of prosthesis, surgical
incision, or location of the prosthesis [22].
14.5.2.1 Prostheses
Choosing the correct prosthesis is crucial for surgical success. On the one hand, big prostheses
cause deformation and back pain; and on the
other hand, smaller ones may not meet the woman’s expectations.
Implants may be saline or silicone based. Both
of them are useful. Silicone implants may create
a more physiological aspect, but their rupture
could cause several problems (the latest generation minimizes this risk).
In addition, their shape may be round or anatomical. Anatomical implants usually create a
more physiological shape. Round implants are
useful in case of rotation, because they maintain
the shape of the breast.
The surface of the implant may be smooth or
rough. Rough ones have less migration capacity,
and they usually cause less encapsulation than
smooth ones [22].
14.5.2.2 Surgical Incisions
There are different incision approaches: inframammary fold, axillary, navel, or periareolar. All of
them have advantages and disadvantages.
Nowadays, the inframammary fold is the most
widely used due to its practicality and versatility
and the low risk of encapsulation [15].
14.5.2.3 Location
There are different planes in the breast in which
the implants may be placed.
Submuscular pocket: The prosthesis rests
below the pectoral muscle. This is indicated in
cases of scant breast tissue. It causes less encapsulation than others. However, prostheses can
rotate easily.
Subglandular pocket: When the breast has
enough tissue, this is the standard choice. If the
gland has not enough tissue, the woman may perceive roughness.
There is an intermediate plane called “dual”
in which prostheses are placed below the muscle
in the upper pole and below the gland in the
lower pole. It tries to take advantage of both
planes.
The most important factor in augmentation
mammoplasty is to have an individualized plan
for each patient and case. Each prosthesis, plane,
and surgical incision has its own benets [15].
14.5.3 Nipple-Areola Complex
Surgeries
The most common problems after breastfeeding
and pregnancy are macrothelia and inverted
nipple.
Macrothelia is the enlargement of the nippleareola complex compared to the rest of the breast.
The surgical procedure is a circular reduction
of the area. Wound healing is good due to the
changes of pigmentation in this zone [22].
14 Mammary Tissue Changes During Pregnancy andBreastfeeding
https://t.me/medicina_free
261
14.5.3.1 Inverted Nipple
There are different surgical and nonsurgical procedures that could help:
In the less serious grades: nipple massages
(Hoffman massage) could help after pregnancy
(it should never be applied during pregnancy
because it could trigger premature childbirth). In
addition, rubber bands or a different suction process could be useful. However, all these techniques have a high recurrence rate.
In the more serious cases, surgical procedures
are needed. There are different types: On the one
hand, there are techniques that preserve the lactiferous ducts but are less effective (such as differently shaped sutures); on the other hand, there
are more damaging but effective surgical procedures (transxion suture) [22].
14.6 Conclusions
Breasts are a dynamic tissue affected by hormonal changes. Their shape and physiology are
perfect for their breastfeeding and aesthetic
functions.
Throughout a woman’s life, breasts are constantly changing and suffering alterations, but it
is during pregnancy and breastfeeding that these
changes are deeper. Our goal as physicians
should be to take care of the woman’s breasts
during this part of her life and help her in her
recovery if she needs it.
References
1. Olivas Menayo J. Anatomía de la mama. In:
Cirugíasdelamama.com; Revised: 2017. Last
accessed: October 2019. https://www.cirugiasdela-
mama.com/anatomia- de- la- mama.
2. Gray M, Gray H.Gray’s anatomy for students. 15th
ed. Philadelphia: Elsevier/Churchill Livingstone;
2005.
3. Humphreys RC, Lydon J, Omalley BW, Rosen
JM. Mammary gland development is mediated by
both stromal and epithelial progesterone receptors.
Mol Endocrinol. 1997;11:801–11.
4. Subbaramaiah K, Howe LR, Bhardwaj P, Du B,
Gravaghi C, Yantiss RK, etal. Obesity is associated
with inammation and elevated aromatase expression in the mouse mammary gland. Cancer Prev Res.
2011;4:329–4.
5. Ford NA, Devlin KL, Lashinger LM, Hursting
SD.Deconvoluting the obesity and breast cancer link:
secretome, soil and seed interactions. J Mammary
Gland Biol Neoplasia. 2013;18:267–75.
6. Vaysse C, Lømo J, Garred Ø, etal. Inammation of
mammary adipose tissue occurs in overweight and
obese patients exhibiting early-stage breast cancer.
NPJ Breast Cancer. 2017;3:19.
7. Salazar H, Tobon H, Josimovich JB.Developmental,
gestational and postgestational modications of the
human breast. Clin Obstet Gynecol. 1975;18:113–37.
8. Canoy JM, Mitchell GS, Unold D, etal. A radiologic
review of common breast disorders in pregnancy
and the perinatal period. Semin Ultrasound CT MR.
2012;33(1):78–85.
9. Bayer C, Mayada B, et al. Assessment of breast
volume changes during human pregnancy using a
three-dimensional surface assessment technique in
the prospective CGATE study. Eur J Cancer Prev.
2014;23(3):151–7.
10. Raug C, Faschingbauer F, etal. Factors inuencing
breast changes after pregnancy. Eur J Cancer Prev.
2013;22(3):259–61.
11. Zelazniewick A, etal. Maternal breast and body symmetry in pregnancy and offspring condition. Am J
Phys Anthropol. 2018;166(1):127–38.
12. Olivas Menayo J.La mama. Cambios en el embararazo. In: Cirugíasdelamama.com; Revised: 2017. Last
accessed: October 2019. https://www.cirugiasdela-
mama.com/cambios- en- el- embarazo.
13. Tebbets J. Augmentation mastopexy. Augmentation
mammaplasty. 1st ed. Missouri: Mosby; 2010.
14. Regnault P. Breas ptosis: denition and treatment.
Clin Plast Surg. 1976;3:193–203.
15. Rinker B, Veneracion M, Walsh CP. Breast ptosis:
causes and cure. Ann Plast Surg. 2010;64(5):579–84.
16. Zelazniewick A, etal. Breast size and asymmetry during pregnancy in dependence of a fetus’s sex. Am J
Hum Biol. 2015;27:690–6.
17. Montagna W, etal. The glands of Montgomery. Br J
Dermatol. 1972;86(2):126–33.
18. Bieber A, etal. Pigmentation and pregnancy. Obstet
Gynecol. 2017;129(1):168–73.
19. Ogawa K, et al. Changes in breast hemodynamic in breastfeeding mothers. J Hum Lact.
2008;24(4):415–21.
20. Scott P, Saettele M, etal. Spectrum of pregnancy- and
lactation-related benign breast ndings. Curr Probl
Diagn Radiol. 2017;46(6):432–40.
21. Higgins HW, etal. Pregnancy-associated hyperkeratosis of the nipple. JAMA Dermatol. 2013;149(6):722–6.
22. Olivas Menayo J. Elevación de la mama. In:
Cirugíasdelamama.com; Revised: 2018. Last
accessed: October 2019. https://www.cirugiasdela-
mama.com/elevacion- de- la- mama.
Reduction ofthePostpartum
https://t.me/medicina_free
Breast
CristinaGómezMartínezde Lecea,
BernardoHontanilla, JuliaSanzIrigoyen,
andJesúsOlivas-Menayo
15
Take-Home Points
• Anatomical considerations for ensuring breast
blood supply.
• The moment recommended for undergoing a
breast reduction is at least 3–6 months after
stopping breastfeeding or after the last
pregnancy.
• Pedicles for the nipple-areola complex (NAC)
may be superior, medial, lateral, inferior, central, and superomedial.
• The breast reduction approaches include inverted
T, vertical, horizontal, periareolar, and liposuction-only reduction mammoplasty patterns.
Supplementary Information The online version contains
supplementary material available at https://doi.org/
10.1007/978- 3- 030- 43840- 1_15.
C. G. M. de Lecea · J. S. Irigoyen
Plastic, Aesthetic and Reconstructive Surgery
Department, University Clinic of Navarra,
Pamplona, Spain
e-mail: cgomezmarti@unav.es; mjsirigoyen@unav.com
B. Hontanilla (*)
Plastic, Aesthetic and Reconstructive Surgery
Department, University Clinic of Navarra,
Pamplona, Spain
Plastic Surgery, Faculty of Medicine, University of
Navarra, Pamplona, Spain
e-mail: bhontanill@unav.es
J. Olivas-Menayo
Department Plastic Reconstructive and Aesthetic
Surgery, MS Medical Institutes, Lisbon, Portugal
e-mail: doctor@olivasmenayo.com
15.1 Introduction
The aim of breast reduction after pregnancy is to
reshape the breast by removing the excess of
parenchyma, repositioning the NAC, and tailoring the lax leftover skin.
15.1.1 History
Since the 1920s and 1930s, many surgeons
started to publish about the procedures to reduce
and reshape pendulous and hypertrophic breasts,
as well as to preserve their function. Surgeons
such as Biesenberger (1931) or Gillies and
McIndoe (1939) rst based their mammoplasty
reductions on a one-pedicle method. The former
performed the breast reduction supported mainly
in the internal mammary network supply [1, 2].
Postoperative complications in wound healing
were described frequently in their procedures [3].
For this reason, later on, other surgeons such as
Ragnell (1946), Maliniac (1950), Strombeck
(1960), or McKissock (1972) started to employ
bipedicle methods in an attempt to preserve
breast vascularization as well as decrease the risk
of skin necrosis [2, 4]. In 1963, Skoog described
a technique for breast reduction which transpositioned the nipple based on a dermal- glandular
pedicle coming from the lateral side [5]. In 1967,
Pitanguy introduced the superior pedicle breast
reduction, which allowed the avoidance of at-
© Springer Nature Switzerland AG 2023
M. Gomes-Ferreira, J. Olivas-Menayo (eds.), Post-maternity Body Changes,
https://doi.org/10.1007/978-3-030-43840-1_15
263
264
https://t.me/medicina_free
C. G. M. de Lecea et al.
tening the superior breast pole as well as the nipple vertical rotation upward maintaining the
breast blood supply [1]. A decade later, Robbins
(1977) introduced the inferior pedicle which also
demonstrated to have a reliable blood supply for
the NAC [6].
Meanwhile, in 1956, Robert Wise described a
skin resection pattern for the treatment of the leftover skin of patients with moderate-to-large
breasts [3]. His design pattern was made from the
shape of a brasserie called “Cordelia of
Hollywood” [1, 2]. The resultant scars laid on the
periareolar, vertical breast axis and horizontally
on the inframammary fold and became known as
the inverted T pattern. Marchac and de Olarte
(1982) [7], Lassus (1987) [8], and Lejour (1990)
[9] popularized the vertical technique with a
superior pedicle in an attempt to eliminate the
horizontal scar in smaller breast reductions.
Nowadays, all the different pedicles are
adapted to the inverted T and vertical patterns
depending on the surgeon’s preference and
experience.
Since the 1980s, breast liposuction started to
be performed. It has become a new method to
reduce slight amounts of volume and avoid scars
from direct skin and parenchyma resection
approaches.
15.1.2 Breast Anatomy
Breast reduction surgery involves a thorough
breast anatomy understanding to encompass both
functional and aesthetic goals. The NAC standard
position lies approximately 19–21 cm from the
sternal notch. Therefore, its successful repositioning into the corresponding position requires
the maintenance of its blood supply as well as, if
possible, its sensation and breastfeeding potential. At the same time, this procedure accomplishes a combination of different skin and breast
parenchymal resection patterns, which need an
optimal breast neurovascular supply for ensuring
good outcomes and minimizing possible postoperative complications.
The breast is predominantly vascularized from
four main vascular systems [10]: the internal
mammary artery for the parasternal medial
region, the lateral thoracic artery and some perforators from the posterior intercostal arteries for
the lateral area, and the thoracoacromial system
for nourishing the superior edges. These vessels
travel deeply around the breast periphery and
become more supercial as they reach the nipple
[11].
The mammoplasty reduction can be performed based on different pedicles depending on
the patient’s physical examination and breast
functional desire (Fig.15.1).
• The superior pedicle comes from the descend-
ing branch of the internal mammary artery and
travels supercially in the subcutaneous layer
through the second and third rib interspaces.
The NAC viability may be compromised if a
big rotation of this pedicle is needed. For this
reason, some surgeons are currently more
condent employing the superomedial pedi-
cle. An adequate vascularity of the NAC can
be ensured by incorporating some more
medial parenchyma to the pedicle. Moreover,
adding the medial pedicle improves the full-
ness of the upper and medial poles with a
superior cosmetic appearance of the cleavage.
• The inferior pedicle is supplied by deep
branches of the anterior intercostal vessels,
which come from the internal mammary sys-
tem along the 4th–6th interspaces. Their close
and deep pathway along the inframammary
fold is the reason for leaving undisturbed the
attachment of the breast tissue to the chest
wall when using this pedicle.
• The central pedicle is based on deep branches
that come from the thoracic lateral artery and
from the internal mammary artery, as well as
from pectoralis major perforators coming
from the intercostal and the thoracoacromial
vessels [12].
• The lateral pedicle receives blood from a
supercial branch of the lateral thoracic artery
that lays in the subcutaneous tissue.
15 Reduction ofthePostpartum Breast
https://t.me/medicina_free
Superior Superomedial Inferior Lateral Medial
Fig. 15.1 Pedicle designs for NAC. (a) Superior. (b) Superomedial. (c) Inferior. (d) Lateral. (e) Medial
265
• The medial pedicle is based mainly on the
internal mammary artery branches coming
from the 3rd–4th rib interspaces and runs
supercially toward the nipple.
Tip
Almost all the veins travel alone supercially and
can easily be identied through the skin.
However, the veins running deeply at the 4th–5th
rib interspaces accompany the corresponding
arteries.
Only the inferior and the central pedicles have
concomitant veins travelling along their deep
arteries.
The inferior and central pedicles must be a
full-thickness dermoglandular pedicle to survive.
In contrast, the superior, medial, and lateral pedicles can all be thinned because both their venous
and arterial blood supply are supercial.
Regarding the main innervation to the nipple-
areola, it comes from the anterolateral fourth
intercostal nerve. It gives a supercial and a deep
branch. The former travels around the periphery
of the breast, whereas the latter curves up and
enriches the NAC at the breast meridian. The lateral and inferior pedicles preserve the deep
branch of the lateral fourth intercostal as it runs
just above the pectoralis fascia. It is important to
leave tissue on the fascia to preserve this nerve
and protect sensation. On the other hand, several
other nerves such as the anteromedial intercostal
branches or the supraclavicular branch from the
cervical plexus are also important in breast
sensation.
Tip
The inferior pedicle has become the workhorse
for maintaining blood supply, sensation, and
breastfeeding potential for the nipple-areola
complex [13].
The breast is an organ that undergoes dramatic
changes in size, shape, and function through the
different phases of life. The full development and
differentiation of the female breast are completed
after the rst full-term pregnancy [14]. The structural breast changes during pregnancy and lactation are mediated by a complex interplay between
multiple hormones (placental hormones, estrogen,
progesterone, prolactin, glucocorticoids, and oxytocin) [15]. The formation of new lobules and the
differentiation of the alveoli into milk secretory
units are the main reasons for the breast to enlarge
during pregnancy [14]. In addition, during pregnancy and breastfeeding, there are skin and breast
tissue changes related to the variations in weight
and in water retention. After the cessation of
breastfeeding, withdrawal of prolactin and oxytocin leads to involution of the gland. These breast
volume changes are responsible for the stretching
and relaxing forces on Cooper’s breast suspensory
ligaments, as well as on the skin. The loss of the
skin and Cooper’s ligament elasticity with age, as
well as the gravity effect on the body, makes the
Соседние файлы в папке Библиотека им академика М.И. Перельмана