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BACKGROUND: Many surgeons are under the impression that the blood supply is clearly defined in textbooks. Unfortunately, the majority of textbooks supply inadequate information and illustrations can be misleading in many instances. None of the textbooks describe a segmental pattern of blood supply when in actual fact a basic segmental pattern does exist. The reason for inadequate information is the perpetuation of facts since the work of the pioneers Cooper and Manchot from one textbook to another. A paucity of research studies thereafter and the fact that the results of some of these studies did not find their way into textbooks is another contributing factor. METHODS: The findings of research studies since the descriptions by Cooper and Manchot are analyzed and compared in an effort to find common ground and its clinical implication. RESULTS: Researchers concurred on the main sources of blood supply; these are internal thoracic, lateral thoracic, anterior intercostal, and acromiothoracic (thoracoacromial) arteries. However, the different research studies showed considerable variation in the branches from the main sources to supply the nipple-areola complex. CONCLUSIONS: Even though the locations of the main sources of blood supply are constant, partial or complete absence of branches from the main sources does occur and therefore the blood supply to the nipple-areola complex is unpredictable. Cognizance of the basic segmental pattern and the variations resulting from embryologic development will be helpful for the surgeon to use or adapt a technique to minimize the risk of nipple necrosis.

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BACKGROUND: The reasons for recurrent ptosis in mastopexy and breast reduction procedures are twofold. First, available surgical techniques do not reconstruct the normal breast anatomy responsible for maintaining breast shape. Second, in many instances the techniques rely on atrophied tissue to provide long-term support. The discovery in 1997 of the ligamentous suspension (the supporting system of the breast) gave rise to the concept that reconstruction of this anatomical structure was needed to ensure a sustained postoperative result. Applying the latest knowledge regarding the structural and vascular anatomy of the breast in the surgical technique and utilizing material other than atrophied breast tissue enabled us to prevent the recurrence of breast ptosis. METHODS: A surgical technique was developed to replace the supportive function of a failed ligamentous suspension in 112 patients with ptotic breasts. This was done by reconstructing an internal breast-supporting system (IBSS) with biocompatible mesh. RESULTS: Satisfactory breast shape, nipple projection, and upper breast fullness was obtained with this technique in mastopexy patients with moderate-sized ptotic breasts. In patients with larger breasts good results were obtained with a simultaneous breast reduction. The longest follow-up is 6 years 3 months. CONCLUSIONS: With this technique recurrent breast ptosis can be prevented in mastopexy and breast reduction procedures. The results are such that it eliminates the need for silicone prostheses to obtain satisfactory upper-breast fullness. The surgical technique is especially indicated in patients with skin of poor quality or patients with high expectations.

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Repair of full-thickness defects of the lower eyelids poses a challenge because a graft in combination with a flap is typically used to replace either the posterior or the anterior lamella. This often results in aesthetically and functional unsatisfactory outcomes. A rotation-advancement tarsoconjunctival cheek flap, which reconstructs both posterior and anterior lamellae with vascularized tissue similar to the native eyelid, is described. Nine patients underwent reconstruction with a rotation-advancement tarsoconjunctival cheek flap. Indications, complications, and outcomes were evaluated. The follow-up time ranged from 6 to 60 months, with a mean of 23 months. The main indication for use of this flap is full-thickness defect of the lower eyelid between 25% and 75%, typically after tumor ablation. All patients had a functional and aesthetically satisfactory outcome. One patient underwent a revision canthoplasty. The rotation-advancement tarsoconjunctival cheek flap adheres to basic plastic surgery principles resulting in a satisfactory outcome: vascularized tissue is used to reconstruct the defect, the flap composition is similar to the native eyelid, that is, replace like with like, and the flap makes use of tissue that is in excess and therefore limits donor morbidity.

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BACKGROUND: Nipple necrosis, a potential postoperative complication of breast surgery procedures, should be avoided. Because of the great variation in the blood supply to the nipple, it is advisable to include as many arteries in the pedicle as possible. According to the literature, the perforators of the internal thoracic artery are the most constant and reliable sources of blood to the nipple-areola complex. It is also supplied by the lateral thoracic artery and the anterior intercostal arteries. If two of the above-mentioned main vessel branches are included in the pedicle, the vascular supply to the breast will be more reliable. According to the anatomical studies of Würinger and van Deventer, we can safely include the dual blood supply to the nipple-areola complex. METHODS: In the authors' technique, a pedicle is raised that includes the horizontal septum and the medial vertical ligament of the breast (i.e., inferior and superomedial pedicles), but with the breast tissue remaining attached to the pectoral fascia. The second, third, and fourth perforators of the internal thoracic artery are found in the medial vertical ligament, and the inferior mammary branches of the anterior intercostal arteries are in the horizontal septum. The authors have performed this technique in 106 consecutive patients (211 breasts) between 2001 and 2009. RESULTS: Good results regarding breast shape, nipple projection, and upper breast fullness were obtained. CONCLUSIONS: The posteroinferomedial pedicle technique is safe and versatile and can be used with a periareolar, vertical scar, or inverted-T skin approach. The technique is easy to perform and has a short learning curve.

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The main sources of blood supply to the breast are described in textbooks as the internal thoracic, lateral thoracic, and posterior intercostal arteries. Textbooks, however, do not describe the contribution of each to the nippie-areoia complex (NAC), nor do they describe the pattern of supply. To investigate this issue, 15 female cadavers were injected intraarterially with latex, and dissections were performed on 27 breasts. The results were as follows: In all the dissected breasts (27/27), the NAC received at least one or more vessels from the internal thoracic artery. In 20 of 27 dissected breasts, the NAC received vessels from the anterior intercostal arteries, In 19 of the 27 dissected breasts, the NAC received vessels from the lateral thoracic artery. Direct branches from the axillary artery supplied the NAC in 2 of the 27 breasts. The posterior intercostal arteries supplied the NAC in only 1 of the 27 dissected breasts. An underlying segmental pattern could be detected that can be explained by the embryological development. According to this study, the internal thoracic arteries are to be considered the main and constantly reliable source of blood supply to the NAC.

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