Nerve and Vessel Supplying Ligamentous Suspension of the Mammary Gland

Abstract

Anatomical findings from 28 breast specimens of female corpses have shown a thin horizontal fibrous septum, originating from the pectoral fascia along the level of the fifth rib, heading toward the nipple. This fibrous septum lies in between a cranial and a caudal vascular network, and being mesentery-like, it is responsible for the supply of the nipple areola complex. The cranial vascular sheet is supplied by the thoracoacromial artery and a branch of the lateral thoracic artery, whereas the caudal sheet is supplied by perforating branches from anastomoses of intercostal arteries. The fibrous septum is also a guiding structure for the main supplying nerve of the nipple. At its borders the septum curves upward into a vertical medial and lateral ligament, which attach the breast to the sternum and the lateral edge of pectoralis minor. These ligaments also contain a regular nerve and vascular supply. In their total, the fibrous septum and its ligaments form a sling of dense connective tissue that acts as a brassiere-like suspensory system. These two structures, the fibrous sling and the vascular and nervous membranes attached to it, are consistent anatomical findings, which have not been described before. Their knowledge could be of value and relevance in clinical application.

Surgical Anatomy

“…In turn, the location of the neurovascular structures within the breast has always been unpredictable and appeared to be distributed in a haphazard, randomized pattern. A practical approach to locate these structures is desirable in order to ensure safe viability and sensibility of the nipple in breast surgery.Our investigations of the mammary gland showed a definite relationship between the course of the nerves and vessels and a coherent, strong suspension apparatus in the breast which can reliably be predicted and which displays a constant morphology (Würinger, Mader et al 1998;Würinger, Tschabitscher 2003;Würinger 2009). The ligamentous suspension consists of a horizontal fibrous septum originating from the pectoralis fascia at the level of the fifth rib heading toward the nipple and its vertical ligamentous extensions which provide a medial and lateral line of fixation on either border of the septum (Fig.…”

“…Both the large vessels and the large nerves run along the ligamentous suspension (Würinger, Mader et al 1998). To the extent that they are developed, the anterior cutaneous branches of the second to fourth intercostal nerves are guided along the medial ligament and the corresponding lateral cutaneous branches along the lateral ligament (Fig.…”

Breast reduction with the posterosuperior pedicle: a series of 200 consecutive patients

“…However, the preservation of the perforating branches of the 4th and 5th anterior intercostal artery perforators enhances the vascularization to the breast parenchyma and nipple-areola complex. 17 Their preservation can be obtained by simply avoiding any dissection over the pectoralis major muscle. Thus, the perforating branches of the anterior intercostal artery can be safely respected, and will additionally augment the vascularization to the breast parenchyma and nipple-areola complex through the posterior pedicle.…”

“…The original technique, based on the horizontal septum, was proposed by Würinger in 1999 18 and is entirely based on the perforators within the horizontal septum 17 . The good results and low complications rate in her series showed the reliability of this technique.…”

“…In 1999 Würinger et al described the importance of the horizontal septum for the vascularisation and innervations of the nipple-areola complex 17 and developed a respective technique of breast reduction 18 . Based on these anatomic fi ndings we have designed a dermoglandular pedicle based on 19 The aim of this study was to present and analyze the results of breast reduction in 200 patients operated on with the posterior-superior technique.…”