Breast surgery

This book is a translation of the original German edition "Brustchirurgie" by Fansa, Hisham, published by Springer-Berlin Heidelberg in 2018. The translation was done with the help of artificial intelligence (machine translation by the service DeepL.com). A subsequent human revision was done primarily in terms of content, so that the book will read stylistically differently from a conventional translation. Springer Nature works continuously to further the development of tools for the production of books and on the related technologies to support the authors. This work is subject to copyright. 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Preface Contents I: Introduction 1: Surgical Anatomy 1.1 Structure of the Breast Conclusion 1.2 Arterial Supply Conclusion 1.3 Venous Supply 1.4 Lymph Conclusion 1.5 Sensitivity Bibliography 2: General 2.1 Breast Footprint 2.1.1 Upper Breast Border 2.1.2 Inframammary Fold (IMF) 2.1.3 Medial Breast Border 2.1.4 Lateral Breast Border 2.1.5 Midline of the Breast 2.2 Breast Shape 2.2.1 Nipple Ptosis 2.2.2 Ptosis of the Gland 2.2.3 Ptosis of Gland and Nipple 2.2.4 Pseudoptosis 2.3 Breast Size and Symmetry 2.4 Dimensions and Planning 2.5 Markings 2.6 Incisions and Drains 2.6.1 Classic Incisions 2.6.2 BCT, Oncoplastic Surgery, and Mastectomy 2.6.3 Axilla 2.6.4 Drains 2.7 Positioning on the Operating Table 2.8 Suturing Techniques 2.9 Photographs II: Breast Cancer 3: General 3.1 Breast Center 3.2 Breast Cancer 3.3 Timeline 3.3.1 Operation 3.3.2 Chemotherapy and Anti-hormonal Therapy 3.3.3 Irradiation 3.4 Family History and Genetic Testing 3.4.1 Intensified Screening 3.4.2 Risk-Reducing Mastectomy Bibliography Epidemiological Data Current Guideline Breast Cancer, Diagnosis, Therapy, Aftercare 4: Tumor Removal and Breast-Conserving Therapy (BCT) 4.1 Diagnostics 4.2 Indications 4.3 Operative Removal According to Palpation Findings 4.4 Operative Removal After Wire Marking and Specimen Radiography 4.5 Histopathological Examination and Margins 4.6 Informed Consent 4.7 Operation 4.7.1 Preoperative Markings and Incisions 4.7.2 Positioning on the Operating Table 4.7.3 Tumor Removal 4.7.4 Post-resection 4.7.5 Aftercare 4.7.6 Complications 5: Oncoplastic Surgery 5.1 Indications for Oncoplastic Techniques 5.2 Resection 5.3 Incisions and Local Tissue Transposition 5.3.1 Local Tissue Transposition in Ptotic or Large Breasts Oncoplastic Mastopexy for the Ptotic Breast Oncoplastic Reduction in the Large Breast 5.4 Local Pedicled and Microsurgical Distant Flaps Conclusion Bibliography 6: Sentinel Lymph Node and Axillary Lymphadenectomy 6.1 Anatomy 6.2 Indications 6.3 Technique of Sentinel Marking and Removal 6.4 Informed Consent 6.5 Operation 6.5.1 Preoperative Markings 6.5.2 Positioning on the Operating Table 6.5.3 Sentinel Operation 6.5.4 Axillary Lymphadenectomy 6.5.5 Isolated Metastases 6.5.6 Aftercare 6.5.7 Complications 6.5.8 Re-Sentinel Removal Bibliography 7: Mastectomy 7.1 Indication 7.2 Informed Consent 7.3 General Information on Mastectomy Surgery 7.3.1 Preoperative Markings 7.3.2 Positioning on the Operating Table 7.3.3 Operation 7.3.4 Aftercare 7.3.5 Complications 7.4 Skin-Sparing Mastectomy, SSM 7.5 Nipple-Sparing and Risk-Reducing Mastectomy 7.6 Mastectomy and Autoderm 7.7 Complete Mastectomy Without Immediate reconstruction Bibliography 8: Reconstruction with Foreign Material 8.1 Expander Reconstruction 8.1.1 Indication 8.1.2 Contraindication 8.1.3 Expander 8.1.4 Positioning 8.1.5 Expansion and Duration 8.1.6 Informed Consent 8.1.7 Preoperative Markings 8.1.8 Surgical Technique Positioning on the Operating Table Primary Expander Insert Secondary Expander Insert 8.1.9 Aftercare 8.1.10 Complications 8.2 Implant Reconstruction 8.2.1 Indication 8.2.2 Contraindication 8.2.3 Implants 8.2.4 Location 8.2.5 Informed Consent 8.2.6 Preoperative Markings 8.2.7 Surgical Technique Positioning on the Operating Table Primary Implant Placement Primary Implant Placement with Matrix Primary Implant Placement with Autoderm (Inferior Dermis Flap) Secondary Implant Placement After Expander Removal Hybrid Reconstruction: Implant and Autologous Fat 8.2.8 Aftercare 8.2.9 Complications Bibliography 9: Acellular Dermal Matrices (ADM) and Meshes 9.1 Which Matrix? 9.2 Operation 9.3 Complications 9.4 Special Features 10: Reconstruction with Autologous Tissue: Free Flaps 10.1 Timing 10.2 Perioperative Features 10.2.1 Medical History and Coagulation 10.2.2 Intraoperative Management 10.2.3 Flaps 10.2.4 Blood Pressure, Blood Flow 10.3 Anastomoses 10.3.1 Pedicle 10.3.2 Venous Anastomoses 10.3.3 Arterial Anastomosis 10.4 Postoperative Management 10.5 Vascular Complications and Management 10.6 Aesthetic Limitations and Irradiation Bibliography 11: Preparation of the Recipient Vessels 11.1 Internal Mammary Artery (IMA) 11.2 Internal Mammary Artery Perforators (IMAPs) 11.3 Subscapular Vascular Tree 11.4 Other Recipient Vessels Bibliography 12: Free Flaps 12.1 DIEP, ms-TRAM, and SIEA Flaps 12.1.1 Indication 12.1.2 Contraindication 12.1.3 Characteristics Circulation Tissue Properties 12.1.4 Informed Consent 12.1.5 Planning and Preoperative Markings CTA and Other Preoperative Perforator Visualizations Preoperative Markings and Measures 12.1.6 Surgical Technique Positioning on the Operating table Operation Mastectomy and Flap Weight Shaping and Insertion of the Flap (Buried Flap) Anastomoses 12.1.7 Monitoring 12.1.8 Aftercare 12.1.9 Complications 12.1.10 Corrective and Complementary Interventions 12.1.11 Pregnancy 12.1.12 Results After Different Flap Surgeries 12.2 Inner Thigh Flap 12.2.1 Indication 12.2.2 Contraindications 12.2.3 Characteristics 12.2.4 Informed Consent 12.2.5 Planning and Preoperative Markings 12.2.6 Surgical Technique for the Classic Transverse Skin Island Patient Position on the Operating Table Operation Mastectomy and Flap Weight Shaping and Insertion of the Flap (Buried Flap) Anastomoses 12.2.7 Monitoring 12.2.8 Aftercare 12.2.9 Corrective and Complementary Interventions 12.2.10 Results After Inner Thigh Flap Surgery 12.3 Fasciocutaneous Infragluteal Flap Reconstruction (FCI) 12.3.1 Indication 12.3.2 Contraindications 12.3.3 Characteristics 12.3.4 Informed Consent 12.3.5 Planning and Preoperative Markings 12.3.6 Surgical Technique Positioning on the Operating Table Operation Mastectomy and Flap Weight Shaping and Insertion of the Flap (Buried Flap) Anastomoses 12.3.7 Monitoring 12.3.8 Aftercare 12.3.9 Corrective and Complementary Interventions 12.3.10 Results After Fasciocutaneous Infragluteal Flap Surgery 12.4 Lymph Node Transplantation 12.4.1 Therapy of Lymphedema 12.4.2 Breast Reconstruction and Lymph Node Transplantation in One Flap Reconstruction 12.5 Special Indications 12.5.1 Bilateral Interventions 12.5.2 Extended Defect Coverage and Palliative Interventions 12.5.3 Results According to Special Indications Bibliography Section 12.1 Section 12.2 Section 12.3 Section 12.4 Bibliography on Other Flaps Lateral Thigh Flap SGAP and IGAP Lumbar Flap 13: Reconstruction with Autologous Tissue: Pedicled Flaps 13.1 Latissimus Dorsi Muscle Flap 13.1.1 Indication Conclusion 13.1.2 Contraindications 13.1.3 Characteristics 13.1.4 Informed Consent 13.1.5 Planning and Preoperative Markings 13.1.6 Surgical Technique Positioning on the Operating Table Operation Thoracodorsal Artery Perforator Flap Plasty (TDAP) 13.1.7 Monitoring 13.1.8 Aftercare 13.1.9 Corrective and Complementary Interventions Conclusion 13.1.10 Results After Latissimus Dorsi Muscle Flap Surgery 13.2 Pedicled Transverse and Vertical Rectus Abdominis Muscle Flap (TRAM/VRAM Flap) 13.2.1 Indication 13.2.2 Contraindication 13.2.3 Characteristics Circulation Tissue Properties 13.2.4 Informed Consent 13.2.5 Planning and Preoperative Markings Computed Tomographic Angiography (CTA) Preoperative Markings and Measures 13.2.6 Surgical Technique Positioning on the Operating Table Operation as a Pedicled Flap Operation as “Supercharged” or “Turbocharged” Flap Shaping and Insertion of the Flap (Buried Flap) 13.2.7 Monitoring 13.2.8 Posttreatment and Corrective and Complementary Interventions Conclusion Bibliography Section 13.1 Section 13.2 14: Secondary Reconstruction for Partial Defects 14.1 Do Nothing 14.2 Mastopexy and Reduction Contralateral or Bilateral 14.3 Volume Through Lipofilling, Scar Correction 14.4 Implants for Partial Reconstruction 14.5 Local Flap for Partial Reconstruction 14.5.1 Latissimus Dorsi Muscle Flap 14.5.2 Parascapular Flap 14.5.3 Intercostal Perforator and Thoracoepigastric Flap Reconstruction 14.6 Microsurgical Flaps for Partial Reconstruction 14.7 Complete Reconstruction Bibliography 15: Reconstruction by Lipofilling 15.1 Indications 15.2 Safety 15.3 Contraindications 15.4 Take or Healing and Frequency of Interventions 15.5 Physiology 15.6 Informed Consent 15.7 Technique 15.7.1 Tumescent Solution 15.7.2 Aspiration and Preparation 15.7.3 Filling and Grafting 15.8 Follow-Up Treatment 15.9 Complications 15.10 Results After Lipofilling Bibliography 16: Reconstruction of the Nipple-Areola Complex (NAC) 16.1 Position 16.2 Nipple Reconstruction 16.2.1 Pigmentation 16.2.2 Nipple Sharing 16.2.3 Nipple Reconstruction by Local Flaps 16.3 Areola 16.3.1 Pigmentation 16.3.2 Skin Grafting 16.4 Combinations of Nipple and Areola Reconstructions Bibliography III: Aesthetic Surgery 17: Breast Reduction and Mastopexy 17.1 Pedicles and Incisions 17.1.1 Which Incision for Which Patient? 17.1.2 Which Pedicle for Which Patient? 17.2 Surgical Planning, Preoperative Markings, and Hazards 17.2.1 Planning the Operation with an Inverted T Incision and Determining the New Upper Edge of the NAC 17.2.2 Planning of the Operation with a Vertical Incision and Definition of the New Upper Edge of the NAC 17.2.3 Informed Consent 17.3 Operation 17.3.1 Positioning on the Operating Table, Special Measures 17.3.2 Superomedial/Central Pedicle and T Incision 17.3.3 Superomedial Pedicle, Inferior Flap According to Ribeiro and T Incision 17.3.4 Superomedial Pedicle and Vertical Incision 17.3.5 Aftercare 17.4 Complications 17.5 Special Cases 17.6 Results After Breast Reduction and Mastopexy Bibliography 18: Augmentation 18.1 Augmentation by Implants 18.1.1 Implants Implant Shells, Content, and Form Problems Inherent in Implants 18.1.2 Incisions and Implant Position 18.1.3 Surgical Planning, Preoperative Markings, and Hazards 18.1.4 Informed Consent 18.1.5 Operation Positioning on the Operating Table, Special Measures Epipectoral Position Submuscular Position, Dual Plane 18.1.6 Aftercare 18.1.7 Complications 18.1.8 Special Cases 18.1.9 Secondary Procedures and Implant Changes 18.2 Augmentation with Autologous Fat 18.2.1 Which Patients Are Suitable? 18.2.2 Surgical Technique 18.2.3 Informed Consent Bibliography Further Reading 19: Augmentation Mastopexy 19.1 Special Features of Implant and Mastopexy 19.1.1 Shape and Size 19.1.2 Location 19.1.3 Incisions and Pedicles of the Mastopexy 19.2 Operation 19.2.1 Operation Planning 19.2.2 Preoperative Markings 19.2.3 Informed Consent 19.2.4 Positioning on the Operating Table and Special Measures 19.2.5 Surgical Technique Submuscular Implantation Starting with Mastopexy Epipectoral Implantation Starting with Tightening Epi- or Subpectoral Implantation Starting with Implant Insertion 19.2.6 Aftercare 19.3 Complications 19.3.1 Special Cases 19.3.2 Secondary Interventions and Implant Changes 19.3.3 Results After Augmentation Mastopexy Bibliography IV: Malformation 20: Aplasia of the Breast 20.1 Therapy 20.2 Timing 20.3 Techniques 20.3.1 Expander 20.3.2 Reconstruction 20.3.3 Lipofilling 20.3.4 NAC Bibliography 21: Tuberous Breast 21.1 Symptoms of TB 21.2 Anatomy 21.3 Classifications 21.4 Objectives of the Correction 21.5 Timing of Correction, Expectation, and Number of Interventions 21.6 Operative Techniques 21.6.1 Periareolar Approach, Gland Incision, and Implant Placement 21.6.2 Unfurling and Glandular Flaps 21.6.3 Expander 21.6.4 Mastopexy Figures 21.6.5 Lipofilling 21.6.6 Autologous Tissue 21.6.7 Timing 21.7 Results for TB Interventions Bibliography Index The book describes the entire modern breast surgery: Oncological interventions such as breast conserving therapy (BCT), oncoplastic surgery and all reconstructive procedures with implants and autologous tissue are presented at the cutting edge. The focus is on surgical techniques with which the authors themselves achieve good results. Oncological safety and aesthetics determine the approach to reconstruction. The second section is devoted to common aesthetic breast surgery. All chapters are richly illustrated, drawings show the individual surgical steps. The book is suitable for gynaecologists, surgeons and plastic and aesthetic surgeons working in the field of senology