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Supporting a Comprehensive Theory of Breast Fascial Anatomy

Wongkietkachorn, Apinut M.D.; Surakunprapha, Palakorn M.D.; Rudtanatip, Tawut Ph.D.; Sakaew, Waraporn Ph.D.; Vachirodom, Pimtawan M.D.; Wongkietkachorn, Nuttapone M.D.; Wongkietkachorn, Supawich M.D.

Plastic and Reconstructive Surgery: October 2019 - Volume 144 - Issue 4 - p 706e-707e
doi: 10.1097/PRS.0000000000006032
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Division of Plastic and Reconstructive Surgery, Department of Surgery, Faculty of Medicine, Mae Fah Luang University, Chiang Rai, Thailand

Division of Plastic and Reconstructive Surgery, Department of Surgery

Department of Anatomy

Division of Plastic and Reconstructive Surgery, Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand

Division of Plastic and Reconstructive Surgery, Department of Surgery, Q Clinic, Bangkok, Thailand

Department of Surgery, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand

Related digital media are available in the full-text version of the article on www.PRSJournal.com.

Correspondence to Dr. Surakunprapha, Department of Surgery, Faculty of Medicine, Khon Kaen University, 123 Mittraparp Highway, Muang District, Khon Kaen 40002, Thailand, apinutresearch@gmail.com, apinutme@gmail.com, Facebook: Ome Apinut Wongkietkachorn

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Sir:

We would like to praise Dr. Rehnke and colleagues for their excellent work on the anatomy of the superficial fascia system of the breast.1 Although there were several previous works published,2–4 the work by Rehnke et al.1 appears to be the most comprehensive and understandable three-dimensional fascial framework. Moreover, the work demonstrated intraoperatively where all the structures were. This method of demonstration facilitates intraoperative anatomical learning and enhances the clinical utility of the authors’ findings. This intraoperative demonstration is also their work’s advantage among other anatomical works2,3 that were demonstrated on cadavers.

However, the existence of the superficial fascia of the breast is controversial in the literature. Some works argue that it exists only in some people and has an undulate appearance.4 According to Dr. Rehnke’s superficial fascia theory,1 this fascia should be present in every person and be consistent throughout the breast. We believe this theory. The anterior fascia is suggested to be a plane of dissection in breast surgery,5 and we also use it in our routine surgery. Feeling inspired and wanting to support Dr. Rehnke’s theory, we confirmed the existence of this fascia using a different method. Although most previous works have demonstrated this fascia in breast reduction procedures or in cadavers,1–5 we used the breast specimen obtained from mastectomy with sentinel lymph node biopsy of the breast and injected with isosulfan blue. [See Video (online), which demonstrates the superficial fascia of the breast that was injected with isosulfan blue.] We noticed from our practice that the superficial fascia of the breast that was injected with the blue dye could be identified more easily. The blue dye diffused and became a blue background in the fascial area, which made the white fascia more obvious. To demonstrate that the fascia was consistent in the entire breast and was not undulated, we made incisions at four quadrants of the breast and sent the tissue for histologic evaluation, which also confirmed the existence of superficial fascia. Despite controversy on the existence of superficial fascia of the breast, we support Dr. Rehnke’s anatomical theory that the fascia three-dimensionally encloses the breast.

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DISCLOSURE

The authors have no financial interest to declare in relation to the content of this communication.

Apinut Wongkietkachorn, M.D.
Division of Plastic and Reconstructive Surgery
Department of Surgery
Faculty of Medicine
Mae Fah Luang University
Chiang Rai, Thailand

Palakorn Surakunprapha, M.D.
Division of Plastic and Reconstructive Surgery
Department of Surgery

Tawut Rudtanatip, Ph.D.
Waraporn Sakaew, Ph.D.
Department of Anatomy

Pimtawan Vachirodom, M.D.
Division of Plastic and Reconstructive Surgery
Department of Surgery
Faculty of Medicine
Khon Kaen University
Khon Kaen, Thailand

Nuttapone Wongkietkachorn, M.D.
Division of Plastic and Reconstructive Surgery
Department of Surgery
Q Clinic
Bangkok, Thailand

Supawich Wongkietkachorn, M.D.
Department of Surgery
Faculty of Medicine
Thammasat University
Pathum Thani, Thailand

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REFERENCES

1. Rehnke RD, Groening RM, Van Buskirk ER, Clarke JM. Anatomy of the superficial fascia system of the breast: A comprehensive theory of breast fascial anatomy. Plast Reconstr Surg. 2018;142:1135–1144.
2. Matousek SA, Corlett RJ, Ashton MW. Understanding the fascial supporting network of the breast: Key ligamentous structures in breast augmentation and a proposed system of nomenclature. Plast Reconstr Surg. 2014;133:273–281.
3. Würinger E, Mader N, Posch E, Holle J. Nerve and vessel supplying ligamentous suspension of the mammary gland. Plast Reconstr Surg. 1998;101:1486–1493.
4. Beer GM, Varga Z, Budi S, Seifert B, Meyer VE. Incidence of the superficial fascia and its relevance in skin-sparing mastectomy. Cancer 2002;94:1619–1625.
5. Larson DL, Basir Z, Bruce T. Is oncologic safety compatible with a predictably viable mastectomy skin flap? Plast Reconstr Surg. 2011;127:27–33.
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