Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1054_Библиотеки_им_академика_М_И_Перельмана

As breast surgery has evolved from an ablative specialty to reconstructive subspecialty, various characteristics of breast anatomy are not only important in effective planning of treatment but also for a good surgical outcome. Most of the sur­gical treatment in oncoplastic breast surgery is nowadays reliant on tissue-based planning.

Any pre-existing asymmetries, spinal curva­tures, or chest wall deformities must be recog­nized and demonstrated to patients as these may be difcult to correct and become more notice­able in the postoperative period.

The subclavian, axillary, the intercostal arteries and their branches form the arterial vasculariza­tion of breast. This knowledge is very important in planning pedicles in mammoplasties and maintaining ap circulation in nipple and skin sparing mastectomies. Internal mammary artery contributes 60% of arterial circulation through their second to fth perforators (Fig.1.2). Second main system is from axillary artery: the pectoral branch of thoracoacromial artery, subscapular artery, lateral mammary branches of lateral tho­racic artery constitute 30% of breast arterial sup­ply. Third source of breast blood supply comes from lateral cutaneous branches of intercostal arteries. Carr and van Deventer studies suggest that perforators from the internal mammary artery in the upper 4 intercostal spaces supply breast and most prominent supply is from second perforator [8]. Loukas etal. suggested that lateral

thoracic artery originates from axillary artery in

17.02%, it originates from acromiothoracic artery in 67.62% and absent in 3.3% cases [9]. Several fasciocutaneous aps can be raised based on per­forator vessels around the breast on the chest wall and these aps have become a major volume replacement technique in oncoplastic breast sur­gery (Fig.1.3).

in nipple sparing mastectomies. Unfortunately, there is lack of consensus on the dominant blood supply to nipple–areolar complex in various cadaveric studies. Marcus etal. suggested three possible combinations [10]: (1). Internal Mammary artery plus lateral thoracic artery. (2). Internal mammary artery plus intercostal arteries (3). Supply by all 3 sources.

Cunnigham suggested the blood supply to NAC is from lateral thoracic and internal mam­mary arteries [11]. Nakajima et al. again con­cluded that NAC blood supply is from internal mammary and lateral thoracic arteries [12]. Wuringer et al. described a horizonal septum which extends towards the nipple that divided blood supply to cranial and caudal networks. Cranial network consists of branches from acro­miothoracic and lateral thoracic arteries and the latter consisted of branches from anterior inter­costal arteries [3].

drainage from the breast [13]. However, there are no consensus exists regarding the course of lymphatic ow between the breast tissue and the nodal basins. Conventional description of lymphatic drainage of breast is divided into supercial (Sappey’s) and deep aponeurotic plexuses [14]. Sappey’s suggested collection of breast lymphatics in the subareolar plexus and further drainage to axillary lymph nodes. There are many sceptics of this centripetal lymphatic route towards subareolar plexus and various lymphoscintigraphy examinations suggested that there is no constant route via subareolar plexus [13, 15]. Suami et al. suggested exis­tence of a perforating lymphatics coursing with similar branches of the internal mammary artery and vein and existence of lymphatics coursing through the breast tissue and not fol­lowing the conventional centripetal drainage to subareolar plexus [14]. 75% drain to the axil­lary lymph nodes [15]. Another important site of drainage is internal mammary chain of nodes. Other less common drainage sites are supraclavicular, retrosternal drainage to contra­lateral internal mammary chain. There is also accessory network such as intermammary lym­phatics or lymphatics draining to hepatic and subdiaphragmatic lymph nodes. This variabil­ity in the lymphatic drainage can play a role in false negative results in sentinel lymph node biopsy. There is signicant variation in the injection site for tracers in sentinel lymph node biopsy such as peritumoral, dermal and subder­mal, or peri- areolar and subareolar [14]. Some of these techniques are based on the principle that the breast and overlying skin share the same lymphatic drainage as the mammary gland is embryologically developed from the ectoderm [16]. Subareolar injection is based on Sappey’s concept of lymphatic drainage. Studies have shown that identication of an internal mammary sentinel lymph node occurs in up to 35% of cases where the injection site is peri- or intratumoral [13].