Aesth Plast Surg (2015) 39:396–397 DOI 10.1007/s00266-015-0472-1
EDITOR’S INVITED COMMENTARY
BREAST
Commentary on ‘‘Anatomy of the Surface Layer of Superficial Fascia Around the Nipple-Areola Complex’’ Guillermo Va´zquez1
Received: 19 February 2015 / Accepted: 20 February 2015 / Published online: 15 April 2015 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2015
Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
To the Editor After reading the paper: ‘‘Anatomy of the Surface Layer of Superficial Fascia around the Nipple-Areola Complex’’ I would like to comment on the following: The authors raise a point of inflection with an hyperdense superficial fascial system (SFS) area, diagnosed by ultrasound. It is proposed as a surgical point to consider at the closing of the periareolar and hemiareolar incisions, or in different mastoplasty techniques, whether augmentative, reduction, mastopexies, or breast reconstructions with NAC conservation, which would allow for better areolar scarring.
This very old anatomical description was the basis of current breast operations. Cooper’s ligaments attach the breast to the nipple and to the deep dermis. The cavity within is filled with glandular tissue including a variable amount of fat, the nipple being the only structure lacking fat. In the presence of breast cancer, fibrosis produces shortening of Cooper’s ligaments and can sometimes cause skin retraction and stippling. Another important aspect to this Comment is to remember that in the areolar region, Cooper’s ligaments intersect with the SFS producing a thickening of the fascia, which can be seen by high-resolution ultrasound, as the authors have shown, being more obvious in its proximity to the nipple. The upper layer of the subcutaneous tissue (between the skin and the anterior rectus fascia superficialis) is composed of connective tissue, adipose tissue, and retinacula cutis, connective fibers formed by very thin skin descending from chorion and intertwine with climbing the fascia superficialis. These anatomical elements are differentiable with highresolution ultrasound.
From the Anatomical Point of View From the Surgical Point of View I must refer to Sir Astley Cooper, who published ‘‘On the Anatomy of the Breast’’ in 1840 [1]. In this book, Cooper describes the suspensory ligaments, known worldwide as Cooper’s ligaments. & Guillermo Va´zquez [email protected] 1
Cirugia Plastica GV, Buenos Aires, Argentina
123
The authors have demonstrated the importance which would have SFS closing in this hyperdense area, which it is to 1 cm from the nipple. This statement deserves several comments: The work does not have a surgical clinical study to support it. If the area described by the authors is included, logically the periareolar incision should be placed 1 cm from the
Aesth Plast Surg (2015) 39:396–397
nipple and this situation would not be asthetically acceptable in the West. If the NAC, after surgery, had a size from 2.5 to 3 cm diameter with a periareolar incision to include this hyperdense area of the SFS, neither is acceptable. An incision furthest from the nipple could not suture this area as the authors suggest. The SFS is continuously below the areola smooth muscle and this muscle is an easily identifiable surgical structure. In our paper published in this journal, ‘‘The Importance of the Areolar Smooth Muscle in Augmentation Mastoplasty’’ [2], we point out that full suturing of the muscle (myorraphy) in augmentative mastoplasty, or reattachment in reductive mastoplasty, mastopexy, or reconstructive surgery, decreases the tension suffered by retraction of the muscle and we have confirmed that the SFS runs underneath the muscle. We are including the SFS when we make a stitch in the muscle covering the entire thickness thereof. We have shown in our work, the muscle being the only structure from the surgical point of view that can be applied in a technical, covering the entire diameter of the areola, no matter if the areola is small or large [3–5]. Myorraphy or reattachment can be performed, depending upon the surgery, and this will prevent tension, which is the cause of an unacceptable scar. It is important to clarify that the areolar incision for breast augmentation is not the same, rather is usually only hemiareolar. Otherwise different is a periareolar incision used in mastopexy or breast reductions, where skin resection likely increase the suture tensio´n.
397
Therefore, it is not appropriate to infer that this layer suture could make a difference in the evolution of the scars, reiterating that the area proposed by the authors, is 1 cm from the nipple. It is striking that the authors have not cited our article in their references although we report obtaining almost imperceptible scars, and it is currently a reference paper for all surgeons who perform breast surgery. A scientific paper of this kind, to reach a particular conclusion, must perform a prospective study with and without this type of proposed closure to have academic value. Finally, I believe that this paper is only an anatomical study of the structures around the NAC, which lacks clinical trials for surgical application. Conflict of interest interest to disclose.
The author declares that he has no conflicts of
References 1. Cooper A. P (1840) On Anatomy of the Breast. Longmans, London 2. Va´zquez G et al (2009) The Importance of the Areolar Smooth Muscle in Augmentation Mastoplasty. Aesthetic Plast Surg 33(3):298–301 3. Williams P, Warwick R, Gray H (1985) Gray’s anatomy, 36th edn. Salvat Editores, Barcelona 4. Latarjet M, Ruiz Liard A (2004) Anatomı´a Humana, 4th edn. Editorial Me´dica Panamericana, Me´xico City 5. Testud-Lastarjet. (1978) Tratado de Anatomı´a Humana, Salvat Ed
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EDITOR’S INVITED COMMENTARY
BREAST
Commentary on ‘‘Anatomy of the Surface Layer of Superficial Fascia Around the Nipple-Areola Complex’’ Guillermo Va´zquez1
Received: 19 February 2015 / Accepted: 20 February 2015 / Published online: 15 April 2015 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2015
Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
To the Editor After reading the paper: ‘‘Anatomy of the Surface Layer of Superficial Fascia around the Nipple-Areola Complex’’ I would like to comment on the following: The authors raise a point of inflection with an hyperdense superficial fascial system (SFS) area, diagnosed by ultrasound. It is proposed as a surgical point to consider at the closing of the periareolar and hemiareolar incisions, or in different mastoplasty techniques, whether augmentative, reduction, mastopexies, or breast reconstructions with NAC conservation, which would allow for better areolar scarring.
This very old anatomical description was the basis of current breast operations. Cooper’s ligaments attach the breast to the nipple and to the deep dermis. The cavity within is filled with glandular tissue including a variable amount of fat, the nipple being the only structure lacking fat. In the presence of breast cancer, fibrosis produces shortening of Cooper’s ligaments and can sometimes cause skin retraction and stippling. Another important aspect to this Comment is to remember that in the areolar region, Cooper’s ligaments intersect with the SFS producing a thickening of the fascia, which can be seen by high-resolution ultrasound, as the authors have shown, being more obvious in its proximity to the nipple. The upper layer of the subcutaneous tissue (between the skin and the anterior rectus fascia superficialis) is composed of connective tissue, adipose tissue, and retinacula cutis, connective fibers formed by very thin skin descending from chorion and intertwine with climbing the fascia superficialis. These anatomical elements are differentiable with highresolution ultrasound.
From the Anatomical Point of View From the Surgical Point of View I must refer to Sir Astley Cooper, who published ‘‘On the Anatomy of the Breast’’ in 1840 [1]. In this book, Cooper describes the suspensory ligaments, known worldwide as Cooper’s ligaments. & Guillermo Va´zquez [email protected] 1
Cirugia Plastica GV, Buenos Aires, Argentina
123
The authors have demonstrated the importance which would have SFS closing in this hyperdense area, which it is to 1 cm from the nipple. This statement deserves several comments: The work does not have a surgical clinical study to support it. If the area described by the authors is included, logically the periareolar incision should be placed 1 cm from the
Aesth Plast Surg (2015) 39:396–397
nipple and this situation would not be asthetically acceptable in the West. If the NAC, after surgery, had a size from 2.5 to 3 cm diameter with a periareolar incision to include this hyperdense area of the SFS, neither is acceptable. An incision furthest from the nipple could not suture this area as the authors suggest. The SFS is continuously below the areola smooth muscle and this muscle is an easily identifiable surgical structure. In our paper published in this journal, ‘‘The Importance of the Areolar Smooth Muscle in Augmentation Mastoplasty’’ [2], we point out that full suturing of the muscle (myorraphy) in augmentative mastoplasty, or reattachment in reductive mastoplasty, mastopexy, or reconstructive surgery, decreases the tension suffered by retraction of the muscle and we have confirmed that the SFS runs underneath the muscle. We are including the SFS when we make a stitch in the muscle covering the entire thickness thereof. We have shown in our work, the muscle being the only structure from the surgical point of view that can be applied in a technical, covering the entire diameter of the areola, no matter if the areola is small or large [3–5]. Myorraphy or reattachment can be performed, depending upon the surgery, and this will prevent tension, which is the cause of an unacceptable scar. It is important to clarify that the areolar incision for breast augmentation is not the same, rather is usually only hemiareolar. Otherwise different is a periareolar incision used in mastopexy or breast reductions, where skin resection likely increase the suture tensio´n.
397
Therefore, it is not appropriate to infer that this layer suture could make a difference in the evolution of the scars, reiterating that the area proposed by the authors, is 1 cm from the nipple. It is striking that the authors have not cited our article in their references although we report obtaining almost imperceptible scars, and it is currently a reference paper for all surgeons who perform breast surgery. A scientific paper of this kind, to reach a particular conclusion, must perform a prospective study with and without this type of proposed closure to have academic value. Finally, I believe that this paper is only an anatomical study of the structures around the NAC, which lacks clinical trials for surgical application. Conflict of interest interest to disclose.
The author declares that he has no conflicts of
References 1. Cooper A. P (1840) On Anatomy of the Breast. Longmans, London 2. Va´zquez G et al (2009) The Importance of the Areolar Smooth Muscle in Augmentation Mastoplasty. Aesthetic Plast Surg 33(3):298–301 3. Williams P, Warwick R, Gray H (1985) Gray’s anatomy, 36th edn. Salvat Editores, Barcelona 4. Latarjet M, Ruiz Liard A (2004) Anatomı´a Humana, 4th edn. Editorial Me´dica Panamericana, Me´xico City 5. Testud-Lastarjet. (1978) Tratado de Anatomı´a Humana, Salvat Ed
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