The fascia of the breast and gluteal region and its relevance to plastic and reconstructive surgery

Abstract

Introduction: Various methods have been used to study the ligamentous anatomy of the breast. Previous techniques to define the macroscopic fascial architecture of the breast have been limited by using only a combination of blunt and sharp dissection. Other studies to demonstrate the presence of ligaments and their bony attachments in the breast have been done with histological studies. No study to date has yet clearly defined these structures macroscopically in whole breast sections. Until now, these have produced conflicting results, most likely due to dissection artefact. In particular, the inframammary fold has been studied but never had its precise attachments or histology defined. Two new methods to study the breast fascial system have been developed to provide a much more accurate demonstration of the ligamentous attachments in specific regions of the breast to bone and the underlying muscle fascia. Examination of the histological features of this area with special stains was undertaken. These findings were correlated with MRI scans, which further enabled analysis of the fascial architecture of the breast, as well as allowing observation of the fascia in congenital breast malformations and changes in the breast ligaments in response to surgical manoeuvres.

The same applies to the gluteal fold, where no study has precisely defined its attachments and supporting structures.

Methods: Forty-six cadavers in total were examined to better define the ligamentous anatomy of the breast. Both embalmed and fresh cadavers were initially dissected in situ and then in sagittal, oblique and horizontal sections. To visualise the ligaments in these sectioned specimens, two new methods of fat dissolution were developed, one used sodium hydroxide and another a combination of absolute ethanol and xylene immersion.

Constant fascial connections between the breast parenchyma, superficial fascia, pectoralis muscle (deep) fascia and bone were observed. Histology slides were prepared from 20 cadaveric specimens to look at the microscopic structure of the inframammary fold.

The same techniques were used to define the fascial anatomy of the gluteal fold using 11 in situ dissections and 8 sectioned specimens. Histological specimens were taken from 5 gluteal folds.

Sagittal and axial MRI scans were analysed in InteleViewer and 3D reconstructions in OsiriX software were used to further define the fascial anatomy of the breast in 38 patients.

Clinical correlation with pre- and post-surgical cases was undertaken. Ligaments were observed intraoperatively and the effects of surgical procedures on their structure and surface landmarks.

Results: Specimens clearly demonstrated internal ligamentous structures responsible for the surface landmarks of the breast. The precise configuration of the inframammary fold was clearly visible and new ligamentous structures were identified and named. The same applied to the gluteal fold, where its attachments were precisely defined and it was found to have a similar arrangement to the inframammary fold.

Conclusions: Reappraisal of the anatomy in both the breast and gluteal area was made possible through new dissolution techniques. This enabled precise identification and nomenclature of ligamentous structures that need to be preserved, and those that require release, repositioning or reconstruction during surgery.