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Fig. 2.6 Lymphatic drainage
axilla and provides the breast with its teardrop appearance.
The breast is conical in shape with a base width of 10–12cm
and thickness of 5–7cm (Nahai 2011).
The breast consists of parenchymal and stromal elements
originating from ectodermal and mesenchymal tissue. The
breast parenchyma is made up of a series of ducts while the
stroma contains the adipose tissue. The functional unit of the
breast is the lobule. The lobule drains approximately 10–100
acini, which ultimately drain into the lactiferous ducts (Janis
2017). For every lactiferous duct, there are 15–20 breast lob-
ules and for every breast, there are 15–20 lactiferous ducts.
Surrounding the lobules is the connective tissue/stroma that
contains the lymphatic system and adipose tissue, all of
which contribute to the size of the breast. Most of the glandular tissue is found along the central and upper portions of
the breast mound (Fig. 2.7) (Nahai 2011; Janis 2017;
Hammond 2009; Mugea and Shiffman 2016; Hamdi etal.
2005).
The breast tissue is encased by the supercial and deep
layers of the supercial fascia that is connected to the dermis and breast tissue. Between the breast and pectoralis fas-
A. Cuzalina et al.
cia lies a layer of loose connective tissue called the
retromammary space (Hamdi et al. 2005). This space is
commonly used as an ideal plane of dissection in breast
reconstruction. The breast stroma contains multiple ligaments that support the parenchyma. The deep layer of the
supercial fascia extends into the pectoralis fascia and
forms the posterior suspensory ligament. The stroma forms
the Cooper’s ligaments and functions to secure the breast to
the dermis and underlying pectoral fascia, as well as divide
the secretory lobules of the breast. The ligamentous system
of the breast acts as a conduit for the nerves and vasculature
of the breast and nipple- areola complex. The horizontal septum originates at the attachment of the pectoralis muscle to
the fth rib and travels vertically along the medial and lateral aspect of the breast. The horizontal septum divides the
glandular tissue cranially and caudally creating a distinct
separation in the parenchyma. The cranial parenchyma varies in size depending on the patient’s breast, while the caudal parenchyma maintains a constant thickness of 2 cm
(Hamdi etal. 2005). This separation can assist with achieving symmetry during breast surgery. Along the vertical limb
of the septum, the medial limb thickens and attaches the
sternum to the inframammary crease while the lateral limb
attaches the axillary fascia to the thoracic wall. The medial
and lateral limbs of the horizontal septum function as an
internal sling for the parenchyma and assist with breast elevation. The ligamentum suspensorium mammae runs from
the clavicle to the upper pole of the breast and assists with
breast suspension; this may correlate with a decreased incidence of ptosis in patients. The inframammary crease ligament functions as a parenchymal sling and forms the
inframammary fold. The inframammary crease ligament
attaches to the fth rib medially and the fth/sixth rib laterally; this ligament assists with prevention of bottoming out
after augmentation mammaplasty (Figs.2.8 and 2.9) (Nahai
2011; Janis 2017; Hammond 2009; Mugea and Shiffman
2016; Hamdi etal. 2005).
The nipple areola complex (NAC) is situated at the center
of the breast mound and measures 2–3cm in diameter (Nahai
2011). More specically, the NAC is approximately 1/3rd of
the overall breast width while the nipple is 1/3rd the diameter
of the areola (Hauben etal. 2003). Montgomery glands are
sebaceous glands that are located within the nipple-areolar
complex. These glands are transitional between sweat glands
and mammary glands that have the capacity to secrete milk
as well as lubricate the areola during lactation (Janis 2017).
The Montgomery glands drain out into Morgagni tubercles,
raised papules along the areola (Janis 2017; Nicholson etal.
2009).
Suspensor
Lactif
vius muscle
Cooper’s
ligaments
Ligamentum
t
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Fig. 2.7 Breast anatomy
y retinacula
of breast
erous ducts
and sinus
Clavicle
Subcla
2nd rib
Pectoralis muscle
Pectoral fascia
Skin
Intercostal
vessels and nerve
Intercostal
muscles
Fat
Cooper’s ligaments
Fig. 2.8 Ligamentous system
Ligamentum
suspensorium mammae
suspensorium mammae
Fig. 2.9 Ligamentous system
Clavicle
Fibrous septum
Inframammary
crease ligamen
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2.4 Breast Aesthetics
Breasts present in various sizes and shapes, and one must
note that perfect symmetry is rare. When evaluating the
breasts, there should be a proportional harmony between the
chest, torso, and buttocks (Janis 2017). The aesthetic breast
is one that is symmetrical in size, shape, volume. and position and the goal is to achieve identical parameters in both
breasts. According to Mallucci and Branford, the four pivotal
elements in breast aesthetics are: proportion of the upper
pole to lower pole, angulation of the nipple, upper pole slope,
and lower pole convexity (Mallucci and Branford 2012). The
provider must focus on the patient’s stage of development,
clinical exam, patient’s perception of the breasts, and the
patient’s desires.
2.4.1 Patient Evaluation
Prior to a physical examination, it is very important to obtain
the patient’s medical history and chief complaint. The chief
complaint should be in the patient’s own words and should
be the primary area of discussion. The provider should allow
the patient to describe their concerns and assist the patient
with open ended questions. The provider should obtain a
complete list of medical diagnoses, medications with proper
dosage and frequency, allergies, and past surgical history. An
important aspect of the history gathering is review of family
history; the provider should ascertain if there is a family history of breast cancer and the date of the last mammogram.
The patient’s social history should also be reviewed, and the
discussion must focus on the use of tobacco or nicotine containing products due to their effects on vasculature and
wound healing. Additionally, social history should also
include the patient’s profession (as surgery may affect workrelated duties), number of children and nursing history, and
if the patient plans to have additional children.
2.4.2 Breast Evaluation
Once the medical history is obtained, a physical exam is performed. It is prudent to perform a breast exam following
menses due to the possibility of engorgement and tenderness
secondary to hormonal changes (Janis 2017).
The exam begins with inspection of the breasts. Identify
any signicant size discrepancies between breasts, while
keeping in mind that minimal size differences (<10%) is
within normal limits (Janis 2017). It is important to note any
skin changes, dimpling or nipple abnormalities. Next, the
patient should be evaluated for any chest or spinal deformities. The breasts and surrounding areas are palpated to assess
A. Cuzalina et al.
Fig. 2.10 Breast measurements
for any masses/lesions or lymphadenopathy. For this purpose, it is important to palpate the supraclavicular and axillary lymph nodes.
The objective aspect of the clinical examination is continued with measurements and photos of the breasts (Figs.2.10
and 2.11). The measurements and ndings include (Nahai
2011; Janis 2017; Mallucci and Branford 2012; Atiye and
Chahine 2018; Bolletta etal. 2019):
1. Breast width (BW): measurement of the most medial to
the anterior axillary line
2. Breast thickness (BT): measurement of the thickness of
the upper pole
3. Sternal notch to nipple (SN-N): ideal measurement of
19–21cm
4. Mid-clavicle to areola (MC-A): ideal measurement of
19–21cm
5. Inter-nipple distance: ideal measurement of 19–21cm
6. Areolar width (AW): ideal measurement of 3.5–4.5cm
7. Nipple to inframammary fold (N-IMF): ideal measure-
ment of 7–8cm
8. Intermammary distance (IMD): ideal measurement of
21cm from nipple to nipple
9. Ptosis: nipple position in reference to inframammary
fold
10. Mid-humeral point (MHP): mid-point between the acro-
mion and lateral epicondyle; the ideal location of the
nipple
11. Breast parenchyma size: lower pole is greater than the
upper pole
12. Skin quality
13. Parenchyma quality and elasticity.
The most important measurements in breast surgery are
the BW, SSN-N, and N-IMF.BW determines the maximal
implant width for that patient. SSN-N determines the proper
position of the NAC along the breast. N-IMF is important for
the overall breast shape and lower pole aesthetics. It is
2 Anatomy oftheBreast andPre-operative Assessment forBreast Surgery
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a
b
cd
Fig. 2.11 Clinical breast measurements. (a) Inter-nipple distance. (b) Breast width (BW). (c) Nipple to inframammary fold (N-IMF). (d) Sternal
notch to nipple (SN-N)
important to respect the limitations of the breast tissue and
position and avoid violating these parameters (Fig. 2.12)
(Nahai 2011). Along with the patient’s desires, these measurements/ndings allow for an informed and educated
approach to all types of breast surgery as well as proper
implant selection and placement. Following the clinical
examination, breast pictures should be obtained to demonstrate ndings to the patient and establish a comparison for
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Fig. 2.12 Ideal breast
measurements
A. Cuzalina et al.
future evaluation. The pictures should include a frontal, lateral, and oblique views with arms relaxed and raised in all
positions.
2.4.3 Patient Discussion
After completion of the examination, it is pivotal to discuss
the clinical ndings and the proposed treatments with the
patient. The rst step is to address the patient’s chief complaint and demonstrate the ndings. The clinical ndings
should be presented in a manner that ensures the patient
understands what is being described. To assist with this
aspect of consultation, the use of photography and anatomic
models is highly recommended. Once the patient is informed
of the clinical problems, treatment options should be
proposed along with the associated risks, benets, complications and if any alternative therapies are available. Never
assume that the patient has a complete appreciation of the
discussion and encourage the patient to ask questions or for
clarications.
2.5 Conclusion
Aesthetic breast surgery outcomes are reliant on a thorough
knowledge of anatomy, proper preoperative planning, and
precise surgical technique. The surgeon must respect the
anatomy and understand how the underlying structures correlate with the overall appearance. With this knowledge, one
can avoid complications and create a successful result.
The surgeon must focus on the patient’s desires while
maintaining sound surgical parameters. The patient should
play an active role in the consultation by providing chief concerns as well as being an active participant in the clinical
exam. An educated patient is one who understands the indications for various breast procedures and is aware of any limitations or possible complications. This ensures for a great
provider-patient experience with an aesthetic outcome.
References
Atiye B, Chahine F.Metrics of the aesthetically perfect breast. Aesthet
Plast Surg. 2018;42(5):1187–94.
Bolletta E, Mcgoldrick C, Hall-Findlay E.Aesthetic breast surgery: what
do the measurements reveal? Aesthet Surg J. 2019;40(7):742–52.
Hamdi M, Würinger E, Schlenz I, Kuzbari R. Anatomy of the breast:
a clinical application. In: Hamdi M, Hammond DC, Nahai F (eds)
Vertical Scar Mammaplasty. Berlin, Heidelberg: Springer; 2005.
Hammond D.Atlas of aesthetic breast surgery. Edinburgh: Saunders/
Elsevier; 2009.
Hauben D, Adler N, Silfen R, Regev D.Breast–areola–nipple propor-
tion. Ann Plast Surg. 2003;50(5):510–3.
Janis J.Essentials of aesthetic surgery. NewYork: Thieme; 2017.
Javed A, Lteif A.Development of the human breast. Sem Plast Surg.
2013;27(1):5–12.
Mallucci P, Branford O. Concepts in aesthetic breast dimensions:
analysis of the ideal breast. J Plast Reconstr Aesthet Surg.
2012;65(1):8–16.
Mugea T, Shiffman M.Aesthetic surgery of the breast: a clinical appli-
cation. Berlin: Springer; 2016.
Nahai F, Nahai F. Art of aesthetic surgery. 2nd ed. New York: Thieme
Medical; 2011.
Nicholson B, Harvey J, Cohen M. Nipple-areolar complex: normal
anatomy and benign and malignant processes. Radiographics.
2009;29(2):509–23.
Plasticsurgery.org. 2020 [cited 9 August 2020]. https://www.plasticsur-
gery.org/documents/News/Statistics/2019/plastic- surgery- statistics-
full- report- 2019.pdf.
Regional Blocks forPeri
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andPost- operative Analgesia
NitinBhorkar
3
For decades Cosmetic Surgeons have relied on inltration of
local anaesthetics in their eld of surgery either as a part of
tumescent uid or as local inltration. However, there has
been an emergence of various tissue plane blocks that have
been introduced over the last 10–15 years due to the introduction of ultrasound in the operation theatres. These blocks
have been proven to provide good postoperative analgesia
and signicantly reduced the opioid requirements. In this
chapter we will focus our attention on newer tissue plane
blocks that have been introduced in anaesthesia practice that
can be used in cosmetic surgery cases for good peri operative
and immediate postoperative analgesia.
They have gained popularity for several reasons.
1. They target only sensory nerves and hence there is no
muscle weakness involved as in neuraxial blocks.
2. Unlike neuraxial blocks, they do not cause any sympathetic blockade and hence do not cause any haemodynamic disturbance.
3. They can be administered with minimal training.
4. They can be given even by the surgeon.
5. They give long lasting analgesia.
6. These can even be given to the patients on blood
thinners.
7. They are associated with far less complications as compared to neuraxial blocks.
The major drawbacks of the tissue plane blocks are as
follows.
for good visualization of the needle tip during the
procedure.
3. Most tissue plane blocks require the maximum possible
upper limit for the safe dose of local anaesthetic for being
effective. If surgery involves multiple areas outside the
coverage of the tissue plane block, there are no guidelines
currently available as to how much xylocaine dose can be
used safely in the tumescent uid being inltrated in
those other areas. If the block has been given before start
of the surgery, it is best to avoid addition of xylocaine in
the tumescent uid being inltrated in the areas already
covered by the block.
All the tissue plane blocks require large volume of local
anaesthetic solution and hence the total dose being used
with respect to patient’s weight must be carefully monitored. Ropivacaine has a far better safety prole than bupivacaine in terms of cardiac and central nervous system
toxicity and should be the drug of choice for providing
long-acting analgesia. Typically all these blocks require a
volume ranging from 40 to 80ml and a total dose of 3mg/
kg of ropivacaine should not be exceeded at any time.
Addition of many adjuvants to the local anaesthetic mixture
has shown signicant prolongation of the action of the
block up to 12–24 h. Commonly used adjuvants are epinephrine, dexamethasone, clonidine, dexmedetomidine,
and opioids such as fentanyl, morphine, buprenorphine, tramadol, etc.
1. One requires an ultrasound machine in the operating
theatre.
2. There is a learning curve involved in understanding sono
anatomy and acquiring hand eye coordination required
N. Bhorkar (*)
Consultant Anesthesia, Cosmetic Surgery Institute and Saifee
Hospital, Mumbai, India
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
M. Thomas, J. D‘silva (eds.), Manual of Cosmetic Medicine and Surgery, https://doi.org/10.1007/978-981-99-3726-4_3
3.1 Breast Surgeries
The nerve supply to the breast is complex. The major share
of the nerve supply to the breast comes from the anterior and
posterior branches of the intercostal nerves from T1 to T6
(Fig.3.1). The posterior branches supply the lateral aspect of
the breast while anterior branches emerge anterior in the
parasternal area and supply the skin and the breast tissue on
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Pectoralis minor muscle
Thoracodorsal nerve
N. Bhorkar
Lateral pectoral nerve
Pectoralis major muscle
Intercostobrachial nerve
Pectoralis major
muscle
Long thoracic nerve
Medial pectoral nerve
Fig. 3.1 Relevant anatomy for the PECS block
the medial aspect. The breast also receives nerve supply from
medial and lateral pectoral nerves which are branches of the
cervical nerves.
For breast surgeries most commonly used blocks are
PECS 1 and 2 blocks, serratus anterior plane block, and parasternal block. Due to the complex innervation of the breast
no single block sufces and the combination of these blocks
is necessary for proper coverage of the breast. Typically a
total volume of around 60ml of 0.2–0.25% Ropivacaine is
used and with addition of different adjuvants it is possible to
achieve good analgesia lasting up to 12–24 h. In case of
bilateral inltration of breasts, Ropivacaine can be diluted to
0.15% and a total of 100ml of inltration is prepared and
50cc can be used on each side.
Indications: These blocks are usually used in combination
and most extensively used in breast cancer surgeries. In cosmetic surgery practice, it can be used for breast augmentation, Mastopexy, breast reduction, and gynaecomastia
correction surgery.
Contraindications: There are no real contraindications
except for existence of local infection.
Complications:
1. The only major complication is pneumothorax which can
happen while using the blind technique, if the needle is
passed inadvertently beyond the rib. The chances of
Anterior divisions of lateral
cutaneous branches of the
intercostal nerves (T3-T6)
Serratus anterior muscle
pneumothorax are extremely rare if these blocks are performed under USG guidance or by the open technique.
2. Haematoma formation is possible in a case of accidental
puncture of an artery.
3.2 Pectoralis Major Block (PECS 1 Block)
This was rst described by Blanco in 2011. It blocks medial
and lateral pectoral nerves in the plane between pectoralis
major and minor muscles (Fig.3.2).
Technique: It involves inltration of local anaesthetic
solution in the plane between pectoralis major and pectoralis
minor. It is best given under ultrasound guidance but can also
be given by the surgeon when these muscles are exposed during surgery. One can also give it by a blind method by the
loss of resistance technique using a slightly blunt needle.
While using an ultrasound, the operator stands at the head
end of the patient and the high frequency linear probe is
placed in para sagital orientation below the lateral part of the
clavicle and axillary artery is identied. The probe is then
moved caudally and laterally towards axilla and then angled
slightly towards the rib cage. The third rib is identied and
the pectoralis major and minor muscles are identied lying
below the subcutaneous fatty tissue (Fig.3.3). The needle is
introduced in plane from cranial to caudal direction and the
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Fig. 3.2 Difference between
PECS I and PEC II blocks
PEC II BLOCK
PEC I BLOCK
The USG technique remains the same as for pectoralis
major block except the probe is slightly angled towards the
rib cage to get the rib into the view. Pectoralis minor and serratus anterior muscles are identied and the needle is
advanced in the plane and about 10ml of the local anaesthetic solution is deposited in the plane between these two
muscles at the level of third or fourth rib.
Fig. 3.3 Ultrasound image of the tissues at the level of the third rib
needle tip is advanced to the plane between pectoralis major
and minor muscle and 15–20ml of local anaesthetic solution
is deposited in that plane.
3.2.1 Pectoralis Minor Block (PECS 2 Block)
This was rst described by Blanco in 2012 and blocks long
thoracic nerve and posterior branches of upper intercostal
nerves.
Technique: It involves deposition of local anaesthetic
solution in the plane between pectoralis minor and serratus
anterior muscle which lies just over the ribs (Fig.3.2). It is
best instituted under ultrasound guidance but can also be
given by the surgeon under direct vision when these muscles
are exposed during surgery. It can also be injected by a blind
technique by appreciating a second loss of resistance after
the needle has passed through pectoralis major muscle which
is felt as rst loss of resistance.
3.2.2 Serratus Anterior Plane Block
This was rst described by Blanco in 2013 and it blocks the
posterior branches of the intercostal nerves which supply the
lateral aspect of the breast.
Technique: It involves deposition of local anaesthetic
solution in the plane between latisimus dorsi and serratus
anterior muscle in the posterior axillary line roughly at the
level of the fourth or fth rib. Even deposition of anaesthetic
solution deeper to serratus anterior muscle and above the ribs
also works equally well. However, the duration of action has
been found to be relatively shorter by this approach probably
due to faster removal of the drug due to higher blood supply
in this area. It is best performed under ultrasound guidance
but can also be injected by the surgeon under direct vision
when these muscles are exposed during surgery (Fig.3.4).
Deposition of local anaesthetic between the latissimus
dorsi and serratus anterior muscle by blind technique is very
difcult and unreliable. Instead, it is relatively easy to deposit
the solution below the serratus anterior muscle and above the
rib. For the blind technique one has to palpate the highest
possible rib close to the axilla in the posterior axillary line
and keeping one nger on the rib, the needle is advanced till
it hits the rib (Fig.3.5). After withdrawing the needle by a
millimetre local anaesthetic solution is deposited on the surface of the rib so that the drug spreads in the plane below
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Fig. 3.4 Serratus anterior plane block under USG guidance showing the plane of injection
Even a subcutaneous inltration of local anaesthetic solution
in the parasternal area is said to sufce. Alternately it can be
done by using an USG by placing the probe in the sagittal
plane in the parasternal area. Needle is introduced in plane
and the local anaesthetic is deposited either between pectoralis major and internal intercostal muscle (IIM) and deep to
IIM or directly over the rib. One must carefully avoid internal mammary artery which runs parallel to the sternum just
Thumb on the rib
below IIM.Any accidental puncture can cause a huge haematoma. Therefore, the safest approach is to either inject just
below pectoralis major or directly over the costal cartilage.
About 20ml of local anaesthetic solution will cover the anterior bres of the intercostal nerves from T2 to T6. Alternately
Fig. 3.5 Serratus anterior plane block using the blind technique
one can do multiple injections of 5ml each at the alternate
rib level. This block can also be performed by blind tech-
serratus anterior muscle and on the rib surface. A single
injection of 15–20ml will spread the drug along this plane
covering about 3–4 intercostal nerve branches. One can also
give multiple 4–5ml injections on lower alternate ribs by
same technique. Multiple injection assures better coverage
of the intercostal nerve branches at lower levels too. Extreme
care should be exercised while advancing the needle so that
nique in which sternocostal junction is identied by placing
a nger over it and needle is advanced vertically down till it
hits the costal cartilage. Five milliliter of local anaesthetic
solution is injected and this is repeated at three different levels below. Extreme care should be exercised to make sure
that the needle tip does not go beyond the rib for fear of
creating a pneumothorax (Fig.3.6).
it does not go beyond the rib to avoid a pneumothorax.
3.2.3.1 Abdominal Wall Tissue Plane Blocks
Neuraxial and paravertebral blocks have been in existence
3.2.3 Parasternal Block
for long and have been used extensively over the decades in
surgeries involving abdominal wall. Abdominal wall tissue
This block is not frequently used but when undertaken it has
been shown to give superior pain relief after breast surgery.
This involves blocking the anterior branches of the intercostal nerves as they travel anteriorly in the parasternal area.
plane blocks are relatively new entrants. Two main blocks of
our interest are the transverse abdominis plane block (TAP)
and erector spinae block (ES) (Fig.3.7). Major advantage of
these blocks are that they block only the sensory bres and
N. Bhorkar
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motor bres are completely spared resulting in good analgesia without any loss of muscle power. However, they are
insufcient by themselves for undertaking surgery, have to
be given bilaterally to cover the entire abdomen and have to
be used as part of multimodal plan for pain management.
3.2.3.2 Transverse Abdominis Plane Block (TAP
Block)
This was rst described around 2001 and probably the rst
reference of its use in plastic surgery can be found in 2010
when the surgeon injected the local anaesthetic solution in
the TAP plane during abdominoplasties. It is indicated when
the surgeries are intended only on the anterior aspect of the
abdomen as it covers the sensory area of the abdomen anterior to the mid axillary line. As a result it is most ideal for
liposuction of abdomen, abdominoplasty and for abdomen
based free micro-vascular ap for breast reconstruction. The
block involves deposition of local anaesthetic solution in the
Fig. 3.6 Blind technique being used to block the parasternal area
plane between internal oblique and transversus abdominal
muscles on both sides of the abdomen.
Furthermore, there are two main varieties of TAP block
1. The Classic TAP block and the other is subcostal TAP
block. The classic block is meant for analgesia from T10
to L1 segments innervating infra umbilical area of the
abdomen and involves depositing local anaesthetic solution at the level of umbilicus in the anterior axillary line,
just above the iliac crest. Now this is also referred to as
lateral approach.
2. The posterior approach.
3.2.4 Technique forLateral Approach
1. USG technique for classic lateral approach: High frequency linear probe is placed in the area just above the
iliac crest in the anterior axillary line in a transverse
direction and three abdominal muscles external oblique
(EO), internal oblique (IO), and transverse abdominis
(TA) are identied as they run parallel to each other
(Fig.3.8a). Internal oblique muscle is seen as the thickest
of the three and darker than the other two. Needle is
advanced either in plane or across the plane so that the
needle tip is located in the plane between internal oblique
and transverse abdominis (Fig. 3.8b) and 15–20 ml of
local anaesthetic solution is deposited. After opening up
the plane, the needle is walked laterally to open up the
plane as laterally as possible (Fig.3.8c).
2. Blind technique: In this technique the needle used is
intentionally made slightly blunt in order to appreciate
loss of resistance while passing it through the tissues.
This needle is passed perpendicular to the skin just above
the iliac crest in the mid-axillary line appreciating rst
loss of resistance as it passes through external oblique
Fig. 3.7 Tissue planes for
transverse abdominis and
erector spinae block
Transverse
Abdominis BIock
Erector Spinae BIock
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