Breast surgery

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