Query: Cadaveric breast dissection

title: Anatomical Evaluation of a Conventional Pectoralis II Versus a Subserratus Plane Block for Breast Surgery
abstract: Pectoralis I and II (Pecs I/Pecs II) blocks are modern regional anesthetic techniques performed in combination to anesthetize the nerves involved in breast surgery and axillary node dissection. Pecs II spread and clinical efficacy is thought to be independent of whether injection occurs between pectoralis minor and serratus anterior or deep to serratus anterior. Injecting deep to serratus anterior onto the rib may be technically easier; however, our clinical experience suggests that this approach may be less effective for axillary dissection. We undertook a cadaveric study to evaluate a subserratus plane approach for use in breast and axillary surgery.  Ultrasound guided blocks using methylene blue dye were performed on 4 Genelyn embalmed cadavers to assess and compare dye spread after a conventional Pecs II and a subserratus plane block at the third rib.  Conventional Pecs II injection demonstrated staining of the intercostobrachial nerve, third intercostal nerve, thoracodorsal nerve, long thoracic nerve, medial pectoral, and lateral pectoral nerve. The subserratus plane produced significantly less axillary spread, incomplete staining of the medial pectoral, and very minimal staining of the lateral pectoral nerve. Dye spread was limited to the lateral cutaneous branches of the intercostal nerves in both injections.  In our cadaveric study, injecting deep to serratus plane produced significantly less axillary spread. For breast surgery excluding the axilla, both techniques may be effective; however, for axillary dissection, the conventional Pecs II is likely to produce superior analgesia and additionally may help achieve complete coverage of the deeper pectoral nerve branches.

title: Microscopic Examination of Findings Encountered during Cadaver Dissection: Malignant, Benign or Anatomic Variation?
abstract: Pathologic findings encountered during cadaver dissection provide an opportunity for integrating the preclinical basic sciences and encouraging critical thinking. The objective of this study was to determine whether it is possible to make a pathologic diagnosis of an unknown mass from an embalmed cadaver. Diagnoses would have to be based solely on gross and microscopic appearance of tissue, without clinical histories of the cadaveric donors. The tissue samples we removed from each mass were surprisingly well preserved and showed minimal autolysis. Indeed, some of the histological detail was as clear as may be found in any textbook. We were able to obtain a pathologic diagnosis for 6 cases that illustrate complications of malignant neoplasms arising in the colon, breast, ovary, and kidney. Our results emphasize the importance of integrating gross and microscopic anatomy with pathology to facilitate a comprehensive understanding of disease. This histopathology independent learning project could become an integral part of dissection based anatomy courses, and stimulate students to become more inquisitive when they see something out of the ordinary in their cadaver.

title: Transverse Infraclavicular Approach to the Thoracoacromial Pedicle for Microsurgical Breast Reconstruction
abstract: In microvascular breast reconstruction, the internal mammary and thoracodorsal vessels are commonly used recipients. However, these vessels are sometimes compromised or unavailable. We hypothesize that a transverse infraclavicular (TIC) incision may provide efficient and reliable exposure to perform free flap anastomosis to the thoracoacromial (TAC) vessels for breast reconstruction.  The authors present their results from a cadaveric feasibility study and a retrospective case series of 4 consecutive breast reconstruction patients in which the TIC TAC approach was used.  The cadaveric dissection demonstrated a 5.5 cm pedicle length and a 3.75 mm diameter on the left side. On the right, the pedicle measured 5 cm in length and 4 mm in diameter. The dissection time was 10 minutes on the left side and 13 minutes on the right side. Five free flap breast reconstructions were performed in 4 patients using the TIC approach to the TAC artery which served as the primary recipient. The average pedicle length was 6.25 cm with a diameter of 3.55 mm. The pedicle was isolated and delivered through the infraclavicular incision in an average of 16.3 minutes on the left (n 2) and 12.6 minutes on the right (n 3) There were no complications, such as flap compromise or reoperation.  The TIC TAC approach is feasible for microvascular breast reconstruction and can be considered for use by microvascular breast surgeons.

title: Structural anatomy of the breast
abstract: ii Acknowledgments v Chapter 1: Introduction 1 1.1 Composition 9 1.1.1 Literature Review 9 1.1.2 Textbook review 13 1.2 Gross Anatomical Structure 16 1.2.1 Fibro Adipose Structure (Literature Review) 16 1.2.2 Fibro Adipose Structure (Textbook review) 24 1.2.3 Fibro Glandular Structure (Literature Review) 28 1.2.4 Fibro Glandular Structure (Textbook review) 29 1.3 Attachment of the breast to the chest wall 30 1.3.1 Regional Anatomy (Literature Review) 30 1.3.2 Regional Anatomy (Textbook review) 31 1.3.3 Attachment of the breast to the chest wall (Literature Review) 32 1.3.4 Attachment of the breast to the chest wall (Textbook review) 39 1.4 Literature  Research Aims and Hypothesis 43 1.5.1 Composition 43 1.5.2 Gross Anatomical Structure 43 1.5.3 Attachment of the breast to the chest wall 44 Chapter 2: Methods 45 viii 2.1 Experimental Overview 46 2.2 Ethics Consideration 46 2.3 Cadaveric Selection 46 2.4 Dissection Methods 50 2.4.1 Coronal Dissection Method 50 2.4.2 Sagittal Dissection Method 58 2.5 Quantitative Outcome Measures 63 2.5.1 Composition 63 2.5.1.1 Surface Area 63 2.5.1.2 Volume 63 2.5.1.3 Fibro adipose mass 66 2.5.1.4 Fibro glandular mass 66 2.5.1.5 Breast Mass 66 2.5.1.6 Breast Composition 66 2.5.2 Gross Anatomical Structure 66 2.5.2.1 Number of fat lobule pockets 66 2.5.2.2 Adipose mass of each pocket 67 2.5.2.3 Surface area of each adipose pocket. 67 2.5.2.4 Length of the anterior extensions of the anterior lamellae 67 2.5.2.5 The number of pockets anterior and posterior to the gland 68 2.5.2.6 The cross sectional surface area 68 2.5.3 Attachment of the breast to the chest wall 68 2.5.3.1 Muscles within the perimeter 68 2.5.3.2 Perimeter 69 2.6 Qualitative Measures 69 ix 2.7 Experimental Standardisation and Reliability 69 2.7.1 Chief Investigator 69 2.7.2 Reliability Study 70 2.7.3 Cadaver Preparation and Storage 71 2.7.4 Room Conditions During Measurement 71 2.8 Normalising Data (absolute and relative) 72 2.9 Statistical Design 72 Chapter 3: Results 73 3.1 Composition 74 3.1.1 Surface Area 74 3.1.2 Volume 74 3.1.3 Fibro adipose mass 78 3.1.4 Fibro glandular mass 78 3.1.5 Breast Mass 78 3.1.6 Breast Composition 82 3.1.7 Breast mass in relation to breast volume 82 3.2 Gross Anatomical Structure 85 3.2.1 Coronal Qualitative Measures 85 3.2.2 Number of fibro adipose tissue pockets 92 3.2.3 Number of fat lobule pockets in relation to breast volume and surface area92 3.2.4 Adipose mass of each pocket 97 3.2.5 Adipose mass within each pocket in relation to breast volume and surface area 97 3.2.6 Surface area of adipose tissue pockets 101 3.2.7 Pocket mean surface area in relation to breast surface area and volume 101 x 3.2.8 Sagittal Qualitative Measures 105 3.2.9 Number (n) of pockets anterior and posterior to the gland 108 3.2.10 Length of the anterior extensions of the anterior lamellae 108 3.2.11 Pocket surface area (mm 2 108 3.3 Attachment of the breast to the chest wall 112 3.3.1 Perimeter: Regional Anatomy 119 3.3.2 Perimeter: Quantitative  3.3.3 Muscles within the perimeter 124 Chapter 4: Discussion 126 4.1 Composition 127 4.1.1 Breast Volume and Breast Surface Area 127 4.1.2 Breast Mass 130 4.1.3 Composition of Fibro adipose and Fibro glandular tissues. 131 4.2 Gross Anatomical Structure 135 4.2.1 Fibro Adipose Structure 135 4.2.2 Location of the Fibro Glandular Structure 140 4.3 Attachment of the breast to the chest wall 141 4.3.1 Posterior and Perimeter Attachments 143 4.4 Conclusion 149 References

title: Minimally invasive surgery for axillary dissection. Cadaveric feasibility study.
abstract: Axillary dissection is the major cause of morbidity in breast cancer and primary cutaneous melanoma of the extremity. In the present study, we examine the potential benefits and advantages of endoscopic axillary lymph node dissection over conventional surgery. Twenty endoscopic axillary dissections and 10 lymph node samplings were performed in 10 cadavers (four male, six female) A preperitoneal distention balloon (PDB) system was used to dissect the axilla. In four of the cadavers, the procedure was followed by open surgery. The axillary contents were examined for lymphatic tissue by a pathologist. The endoscopic technique offered easy access to the axilla and clear visualization of the axillary vein, as well as the long thoracic and thoracodorsal nerves. Results were comparable to those achieved with the classic surgical dissection. Endoscopy is feasible for axillary lymph node dissection and sampling in cases of breast cancer and primary cutaneous melanoma of the extremity. Further studies in patients are needed to reach definitive conclusions.

title: A Methodological Evaluation of Volumetric Measurement Techniques including Three Dimensional Imaging in Breast Surgery
abstract: Breast surgery currently remains very subjective and each intervention depends on the ability and experience of the operator. To date, no objective measurement of this anatomical region can codify surgery. In this light, we wanted to compare and validate a new technique for 3D scanning (LifeViz 3D) and its clinical application. We tested the use of the 3D LifeViz system (Quantificare) to perform volumetric calculations in various settings (in situ in cadaveric dissection, of control prostheses, and in clinical patients) and we compared this system to other techniques (CT scanning and Archimedes' principle) under the same conditions. We were able to identify the benefits (feasibility, safety, portability, and low patient stress) and limitations (underestimation of the in situ volume, subjectivity of contouring, and patient selection) of the LifeViz 3D system, concluding that the results are comparable with other measurement techniques. The prospects of this technology seem promising in numerous applications in clinical practice to limit the subjectivity of breast surgery.

title: The Anatomical Basis of the Profunda Femoris Artery Perforator (PAP) Flap: A New Option for Autologous Breast Reconstruction
abstract: The profunda femoris artery perforator (PAP) flap is an alternative for autologous breast reconstruction when abdominal tissue is not available. This flap is based on a perforator of the profunda femoris artery. The perforator is consistently found on cadaveric and Computer Tomography Angiogram (CTA) By cadaveric dissection the perforator was identified on average 3.5 centimeters (cm) inferior to the gluteal crease and 6.2 cm from the midline. The average pedicle length was 10.6 cm. Diameters of the artery and vein averaged 2.3 and 2.8 mm. The flaps averaged 28 x 8 cm and weighed about 200 g. On CTA the perforator was identified on average 4.4 cm caudal to the gluteal crease and 5.1 cm lateral to the midline. The consistent anatomy of the perforator allows for consistent elevation of the flap for free tissue transfer in breast reconstruction.

title: Plastic Surgery of the Breast: Keeping the Nipple Sensitive
abstract: Since its inception, reduction mammaplasty has matured considerably. Primary evolution in clinical research and practice has focused on preserving tissue viability. Surgery involves preserving not only tissue viability but also function and sensation. The nipple serves as the sensate unit of the breast and is a valuable part of women's psychological and sexual health, making preservation of nipple sensation of utmost important. Studies regarding primary innervation to the nipple are few and often contradictory. We propose an unsafe zone in which dissection during reduction mammoplasty ought to be avoided to preserve nipple sensation.  Circumareolar dissection of 22 cadaveric breasts was performed. Primary nerve branches to the nipple areola complex were identified and dissected to their origin.  Three to 5 branches of the fourth intercostal nerve primarily innervated the nipple on 18 of 22 breast dissections. Two breasts received innervation from the third intercostal nerve and 2 from the fifth intercostal nerve. In half of the specimens, accessory innervation from the third and fifth intercostal nerves provided medial branches to the nipple.  The fourth intercostal nerve provides the major innervation to the nipple areola complex. Avoiding dissection in inferolateral quadrant "unsafe zone" of the breast during reduction mammaplasty and other breast surgical procedures can reliably spare nipple sensation and maximize patient outcomes.

title: Preserving the neurovascular supply in the Hall Findlay superomedial pedicle breast reduction: an anatomical study.
abstract: The Hall Findlay superomedial pedicle technique is widely used for breast reduction, and, despite low complication rates, nipple areola complex (NAC) necrosis and denervation are still the two most common complications, particularly when resection volumes exceed 600g. An understanding of the anatomy of the neurovascular pedicle of the NAC is paramount in avoiding these complications.  An anatomical study was undertaken on 11 female cadaveric breast specimens (nine fresh and two embalmed) The neurovascular anatomy of the breast was explored through dissection, microdissection, radiographic, computed tomographic, photographic and cross sectional studies. The superomedial pedicle was mapped out on each specimen, and the course of the relevant nerves and vasculature was identified.  The arterial supply to the superomedial pedicle was found to originate from a single dominant vessel in each specimen, while the venous drainage was via an extensive branching network. Both vascular patterns traversed the pedicle in a superficial plane. The innervation of the pedicle was via intercostal branches, which coursed extremely superficially in the pedicle.  De epithelialisation or superficial thinning of the superomedial pedicle for breast reduction is at high risk for complications related to vascular compromise or denervation. Where greater resection is needed, this should be done from the deep surface or the base of the pedicle, contrary to previous descriptions.

title: The Short and Ultrashort Pedicle Deep Inferior Epigastric Artery Perforator Flap in Breast Reconstruction
abstract: Breast reconstruction using the deep inferior epigastric perforator (DIEP) flap is becoming more common and can help reduce donor site morbidity. The authors proposed that dissection of the deep inferior epigastric artery (DIEA) and vein (DIEV) to their external iliac source may not be required for safe flap transfer.  Sixteen whole fresh cadaveric hemiabdomens were used to dissect transverse abdominal based flaps. Latex injection of the DIEA system was carried out, and the diameters of the DIEA/DIEV vessels were assessed at various points along the course of the pedicle from the origin to the perforator. A clinical study of 26 patients who underwent a short and ultrashort pedicle DIEP flaps was carried out.  The average DIEA and DIEV vessel diameters were relatively similar from the external iliac origin to a point just caudal to the bifurcation. At the lateral rectus edge, the average DIEA diameter was 3.2 mm, and the DIEV diameter was 3.1 mm. The average pedicle length obtained with classic DIEP dissection was 16.9 cm, short pedicle DIEP dissection 10.4 cm, ultrashort technique 8.1 cm, and free TRAM technique 6.5 cm. Venous injection study demonstrated rich venous interconnections between both venae comitantes. In their clinical study, the authors were able to achieve average pedicle lengths of 11.0 cm when transecting cranial to the lateral edge of the rectus, with average diameters of 2.5 mm (artery) and 2.9 mm (vein)  Transection of the DIEA/DIEV pedicle at the lateral rectus edge or more proximally is safe and can help reduce operative time and donor site morbidity.