Introduction
INTRODUCTION
besity is a global disease with epidemic proportion, Owhere severe cases are associated with multiple co morbidities, which reduce life expectancy and markedly impair the quality of life (Marema et al., 2011).
Management of obesity includes several modalities, such as; regulation of diet, exercise and the bariatric surgery. However, bariatric surgeries became the most expected modalities for sustained weight loss (Sebastian, 2008).
Bariatric surgery or modified life style go a long way in diminishing the vast weight gain. Patients following these interventions usually undergo massive weight loss, which result in redundant tissues of lower trunk, upper back, breast, arms and thighs (Kwei et al., 2006).
Massive weight loss (MWL) is defined as 50% or greater loss of excess weight (Shrivastava et al., 2008).
The body contour deformities that develop in morbidly obese patients following massive weight loss involve almost all areas of body (Gusenoff et al., 2009).
MWL can lead to considerable breast deformities commonly seen, including excess sagging of the skin, ptosis, loss or deficiency of breast volume secondary to atrophy and deflated flattened glands (Kwei et al., 2006).
1 Introduction
After MWL, one of the stigmas that affect women is the remaining breast deformity. It's crucial to understand these deformities in fact. Management is done for aesthetic reasons. The breasts become flaccid and drooping. The upper pole is absent or flat. The striae of the skin are seen frequently due to loss of elasticity. Namely, the dermal elastin contents of skin matrix with no or poor ability to retract (Losken, 2010). Plastic surgeons have been involved in dealing with such kind of patients, who present that unique challenge that requires more than just the traditional techniques, because of the distribution and the quantity, as well as the quality of inelastic skin and fat left behind (Buckley, 2007). Techniques that are described for breast contouring include: breast augmentation, mastopexy or augmentation mastopexy. They are chosen according to the deformities that occur after MWL (Hurwitz, 2004). Mastopexy and augmentation mastopexy are the most frequently performed plastic surgical procedures for post bariatric surgery patients. Different techniques were described to achieve the goal mainly according to the severity of the deformities as regard volume loss, degrees of ptosis, nipple position and skin redundancy (Aly, 2006). The goal in female breast reshaping after MWL is to restore symmetry, projection, aethetic breast shape, medial and upper pole fullness, appropriately placed nipple areola complex (NAC) with minimal scarring (Bishara and Costagliola, 2012).
2 Aim of the Work
AIM OF THE WORK he aim of the essay is to review the different modalities of T bariatric surgery and to spot light on the recent trends for breast reshaping following massive weight loss.
3 Anatomy of the Breast
ANATOMY OF THE BREAST
he breast develops as a skin appendage enclosed within the T superficial fascia. There is a bursa between the deep layer of this superficial fascia (on the deep surface of the breast) and the pectoral (deep) fascia of the thoracic wall. This retro mammary bursa is traversed by fibrous attachments, which are much denser inferiorly in nulliparous women. The bursa plane is relevant during surgical dissection in the retro glandular plane and contributes to the mobility of the breast on the chest wall (Romrell, 1991).
The ideal youthful breast is teardrop in shape with gentle curvature of the lateral breast and a nipple areolar complex centered at the apex of the breast mound just above the inframammary fold (IMF) (Colwell et al., 2009) .
With MWL, significant volume is lost and the ligamentous support of the breast is severely attenuated. The skin is inelastic and the dermis is relatively thin. This typically results in ptosis and a lowered IMF position. The lateral curvature of the breast is commonly blunted and blends gradually with the redundant axillary tissue. This aggregate of defects results in a ptotic, deflated breast with severe upper pole deficiency and no lateral definition (Colwell et al., 2009) (Fig. 1).
4 Anatomy of the Breast
The mature female breast is located within the superficial fascia of the anterior thoracic wall and extends from the level of the second or third rib to the inframammary fold at approximately the sixth or seventh rib. Transversely, it extends from the lateral border of the sternum to the anterior axillary or midaxillary line (Romrell & Bland, 2006).
Two thirds of the base of the breast lies anterior to the pectoralis major muscle; the remainder lies anterior to the serratus anterior muscle. A small part may lie over the aponeurosis of the external oblique muscle (Velanovich, 1995).
Figure (1): Sagittal cut section of the breast (Elsevier, 2008).
5 Anatomy of the Breast
Superficial Fascia
The superficial fascia is considered to be continued in an envelope of superficial fascia that is continuous with the superficial cervical and abdominal fascia (Gardner et al., 1986).
A small amount of breast tissue travels toward the axilla in the majority of women. It is well known as the tail of Spence, and enters the axilla through an opening of the deep fascia along the medial axillary wall. This opening is the well known hiatus of Langer (Donegan, 1980).
The fascia completely envelops the breast lobes; each breast is formed by 15–20 lobes of glandular tissue. The lobes and lobules are separated by connective tissue, and septa. The subcutaneous tissue is thin or thick and travels deeply, forming the septa (Bland, 2007). Between the superficial fascia behind the gland and the deep fascia covering the pectoralis major muscle lays the retromammary space in which the lymphatics run (McMinn, 1999) . Deep Fascia The deep fascia, known as the deep pectoral fascia, envelops the pectoralis major muscle and travels below with the deep abdominal fascia. The deep fascia also attaches medially to the sternum, laterally and above to the clavicle and axillary fascia and inferiorly with the fascia of the serratus anterior. A
6 Anatomy of the Breast posterior extension of this fascia is continuous with the fascia of the latissimus dorsi and forms the so called suspensory ligament of the axilla (Colborn & Skandalakis, 1993). The retro mammary space is a bloodless plane containing some loose areolar tissue, small blood vessels and posterior suspensory ligaments which extend from the deep surface of breast to the deep pectoral fascia (Iglehart, 1991). Another bloodless plane lies just deep to the dermis. This plane is 2 3 mm deep to the skin. Fibrous tissue strands extend from the deep fascia to the skin. These are called the ligaments of Asteley Cooper, which are responsible for the protuberant appearance of the young female breast. With age, they become atrophic and allow the breast to drop (Colborn & Skandalakis, 1993) .
These ligaments are believed to be essential to breast support, and the preservation of the relationship between the gland and the overlying skin. It provides the rationale for reduction techniques that minimize skin undermining, theoretically helping in postoperative glandular ptosis (Ricbourg, 1992).
The breast parenchyma
It consists of a branching duct system of 15 to 20 lobes, which radiate from the nipple and bound together by fairly dense connective tissue septa, the interlobular connective
7 Anatomy of the Breast tissue. Each lobe is roughly pyramidal in shape with the apex toward the nipple. Bands of connective tissue, the suspensory ligaments, extend from the interlobular connective tissue to attach to the dermis (McVay, 1984).
Each ductal system drains through a separate main duct, the lactiferous duct, which terminates and exits the breast at the nipple via a secretory pore. Immediately deep to the areola, each lactiferous duct dilates to form the lactiferous sinus, in which milk can accumulate, and beyond the sinus extends through successive branches of diminishing size, the large and intermediate (interlobular) ducts (Iglehart, 1991).
The ducts are continuous with the functional units of the breast, the terminal duct lobular units (TDLU). The TDLU consists of the intralobular duct, along whose lumen end protrude blunt or round saccules called ductules, which differentiate into the secretory units or acini during lactation. Individual lobes vary greatly in size and typically about less than half enlarge to become functional during lactation. The TDLUs are embedded in specialized, hormonally responsive connective tissue stroma, the intralobular stroma (McVay, 1984).
For the anatomical location and description of tumors and cysts, the surface of the breast is divided into four quadrants (Fig 2) (Ahya et al., 2001).
8 Anatomy of the Breast
Figure (2): Quadrants of the breast (Ahya et al., 2001).
The breast contains adipose tissue, as well as glandular, neurovascular, and connective tissue components. The amount of fatty tissue is extremely variable and depends on the patient's weight, genetics, age, and hormonal status (Lejour, 1998).
Nipple –Areola complex
The nipple and aerola are located at the 4 th intercostals space slightly lateral to the midclavicular line with the nipple facing slightly outward and upwards, and is composed of 15 25 irregular lobes that terminate as lactiferous ducts in the nipple (Bloom and Fawcett, 1975).
9 Anatomy of the Breast
Arterial blood supply:
The arterial blood supply to the breast is rich and varied, with overlapping territories, allowing diverse reduction techniques to be safely performed. It depends on the subdermal plexus, which is in communication with deeper underlying vessels supplying the breast parenchyma. The reduction will be successful as long as sufficient number of vessels remain to support the breast tissue, regardless of the direction from which the blood supply comes (Dowden, 1999).
The major blood supply of the breast comes from superiomedial perforating branches of the internal mammary artery accounting for around 60%. Then comes the lateral branches of the posterior intercostal arteries, and branches from the axillary artery (Romrell, 1991) .
The blood supply from the axillary artery includes: the pectoral branches, the highest thoracic artery and the lateral thoracic artery. Those vessels from the pectoral branches enter underneath the muscle, then come up through it to supply the breast tissue (Lejour, 1998) .
The vessels from the lateral thoracic artery, known as the lateral mammary branches, wrap around the lateral border of the pectoralis muscle to supply the lateral breast (Romrell, 1991) .
The second, third, and fourth perforating branches from the internal mammary artery, known as the medial mammary
10 Anatomy of the Breast arteries, enter the medial aspect of the breast. The perforating branches from the second, third and fourth posterior intercostal arteries, known as the mammary branches, enter the breast laterally (Ricbourg , 1992).
Intercostal Arteries:
The lateral half of the breast may also receive branches of the 3rd, 4th, and 5th intercostal arteries. Only about 18% of breasts are supplied by all three of these sources, occasionally all three arterial sources remain separate (Romrell and Bland, 2006).
Figure (3): Blood supply to breast (Grant et al., 1999).
11 Anatomy of the Breast
Venous drainage:
There are two venous plexuses providing venous drainage of the breast. One following the path of the arteries, and the other (an extensive superfical and subcutaneous network of veins) is anastomotic with the deep plexus and all of the surrounding regions (Ricbourg, 1992).
This network anastomoses freely and forms a circle around the nipple, transmitting blood to the periphery of the breast (Romrell, 1991).
The axillary, internal thoracic and 3rd–5th intercostals veins drain the mammary gland. The perforating tributaries of the internal thoracic vein carry the greater part of the venous drainage from the medial half of the breast, which joins the brachiocephalic vein. The axillary vein is formed by the junction of the basilic and brachial veins. It lies medial or superficial to the axillary artery and receives one or two pectoral branches from the breast as stated by Morehead (1982).
The intercostal veins communicate posteriorly with the vertebral venous system, which enters the azygos, homozygous, and accessory homozygous veins, which drain to the superior vena cava, and anteriorly they communicate with the brachiocephalic vein by way of the internal thoracic veins. The inferior parts of the breast below the level of the nipple are almost free of major vessels (Romrell and Bland, 2006).
12 Anatomy of the Breast
Nerve supply:
Innervation to the breast comes from the cervical plexus (superior breast), anterior branches of the second to sixth intercostal nerves (medial breast), and anterior rami of the lateral cutaneous branches of the third to sixth intercostal nerves (lateral breast), the third, fourth, and fifth branches of the cervical plexus contribute to the supraclavicular branches that supply the superior portion of the breast (Lejour, 1998).
The lateral intercostal branches divide into anterior and posterior branches upon exiting the intercostal spaces at the attachment sites of the serratus muscle, and the anterior branches course medially into the breast, the nipple is thought to be primarily innervation by the lateral branches of the fourth intercostal nerve (Lejour, 1998).
Thoracodorsal Nerve:
The nerve (middle sub scapular) arises deeply from the posterior cord of the brachial plexus, ventral to the subscapularis muscle. It passes downward and medially to reach and innervate the latissimus dorsi muscle. The nerve and its associated vessels can best be found near the medial border of the latissimus dorsi (Feller & Woodburne, 1958).
13 Anatomy of the Breast
Long Thoracic Nerve:
The long thoracic nerve innervates the serratus anterior muscle and lies on it. When the superficial fascia is reflected, the nerve or branches from it can be reflected also, making identification of the nerve difficult. Unless actually invaded by cancer, this nerve should be spared to avoid “winging” of the inferior angle of the scapula (Feller, 1958 & Sarhadi, 1997).
Anterior Thoracic Nerves (Pectoral):
The site of the medial pectoral nerve is superficial to the axillary vein and lateral to the pectoralis minor muscle. The lateral pectoral nerve is larger than the medial nerve and superficial to the axillary vein and lies at the medial edge of the pectoralis minor muscle. The medial pectoral nerve joins the lower part of the lateral pectoral nerve, forming a neural loop of varying size (Skandalakis et al., 1983).
Intercostobrachial Nerve:
The intercostobrachial nerve is the lateral cutaneous branch of the 2nd or 3rd intercostal nerve, or a combination of the two intercostal nerves. Dividing the intercostobrachial nerves causes an annoying dysesthesia of the inner aspect of the upper arm. It is usually possible to spare the intercostobrachial nerves during an axillary dissection (Skandalakis et al., 1983).
14 Anatomy of the Breast
Lymphatic drainage of breast
It is well known and accepted that the primary pathway of lymphatic drainage of the mammary gland is through lymph nodes in the axilla. About three quarters of all lymphatic drainage of the breast passes to the axillary nodes; the remainder drains principally to the internal thoracic group. Any part of the breast may drain to either group (Bland, 2007).
Lymph drained from the upper limb and breast passes through nodes arranged irregularly in groups of axillary lymph nodes: (a) Pectoral, along the inferior border of the pectoralis minor muscle. (b) Subscapular, along the subscapular artery and veins. (c) Humeral, along the distal part of the axillary vein. (d) Central, at the base of the axilla, embedded in axillary fa. (e) Apical, along the axillary vein between the clavicle and the pectoralis minor muscle (Lejour, 1998).
Anatomists describe four groups of axillary lymph nodes, whereas surgeons describe six groups (Bland, 2006) presents the following grouping of the 24–38 nodes: 1 Axillary vein group (lateral group): four to six lymph nodes.
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