Anatomy of the Superficial Fascia System of the Breast: A Comprehensive Theory of Breast Fascial Anatomy

Abstract

Background: It has been two centuries since Petrus Camper identified superficial fascia and over 175 years since Sir Astley Cooper wrote his book on the anatomy of the breast. In the 1990s, Ted Lockwood taught us the importance of the superficial fascia layers in body contouring procedures he pioneered. These descriptions, however, fail to explain the three-dimensional fascial system in the breast. The authors set out to discover and describe a theory of superficial fascia structures responsible for breast shape.

Methods: The nature of the superficial fascia system that surrounds the breast and its attachments to the chest were studied in 12 cadaver breast dissections and in clinical cases of both cosmetic and reconstructive breast procedures.

Results: The authors found a three-dimensional, closed system of fascia and fat surrounding the corpus mammae, which attaches to the skin by means of specialized vertical cutaneous ligaments, or Cooper ligaments, and which attaches to the chest wall by means of a three-dimensional zone of adherence at the breast's periphery.

Conclusions: The breast is shaped by a three-dimensional, fibrofatty fascial system. Two layers of this system surround the corpus mammae and fuse together around it, and anchor it to the chest wall in a structure we have called the circummammary ligament.

Video 1.

Supplemental Digital Content 1 shows part 1 of a fresh cadaver dissection, in 1995, of the circummammary ligament, using GSI 1200-cc balloon dissection. This video shows subglandular and submuscular blunt dissection, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, available at http://links.lww.com/PRS/D14.

Video 2.

Supplemental Digital Content 2 demonstrates part 2 of the cadaver dissection of the circummammary ligament, summarizing the findings of a blunt balloon dissection demonstrating a zone of fusion, between superficial and deep fascia of the chest, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, available at http://links.lww.com/PRS/D15.

Fig. 1.

(Above) Superficial fascial system; sagittal view. The corpus mammae is bounded by two layers of fascia and fat, the anterior and posterior lamina. (Used with permission by Susan Gilbert.) (Below) Superficial fascial system; transverse section. The anterior and posterior lamina connect to the deep fascia of the chest wall in a circular zone of adhesion called the circummammary ligament, which connects the breast to the chest, providing support and structure to the breast. (Used with permission by Susan Gilbert.)

Fig. 2.

(Above) Inferior view of the breast and superficial fascial system during a superior pedicle breast reduction. (Used with permission by Susan Gilbert.) (Below) Illustration of the breast and superficial fascial system during a superior pedicle breast reduction. (Used with permission by Susan Gilbert.)

Fig. 3.

Superficial fascial system; anterior and posterior lamina surround the corpus mammae, which can be seen erupting through an opening in the anterior lamina fat, the anterior lamina annulus. Also, note that the inframammary fold portion of the circummammary ligament lies over the inscription between the rectus abdominis and pectoralis major muscle. (Used with permission by Illumination Studios.)

Video 3.

Supplemental Digital Content 3 demonstrates superior pedicle breast reduction, illustrating the anterior and posterior lamella of the superficial fascia system of the breast, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, available at http://links.lww.com/PRS/D16.

Video 4.

Supplemental Digital Content 4 demonstrates breast reduction, showing the superior portion of the circummammary ligament, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, available at http://links.lww.com/PRS/D17.

Video 5.

Supplemental Digital Content 5 demonstrates breast reduction, showing the inframammary fold portion of the circummammary ligament, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, available at http://links.lww.com/PRS/D18.

Video 6.

Supplemental Digital Content 6 demonstrates breast reduction, showing the lateral portion of the circummammary ligament, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, available at http://links.lww.com/PRS/D19.

Video 7.

Supplemental Digital Content 7 demonstrates breast reduction, showing the medial portion of the circummammary ligament, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, available at http://links.lww.com/PRS/D20.

Video 8.

Supplemental Digital Content 8 demonstrates small breast reduction, illustrating the anterior lamella annulus, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, available at http://links.lww.com/PRS/D21.

Fig. 4.

Corpus lamina. The corpus lamina is a layer of fascia separating the anterior and posterior lamina, and is the layer of fascia that the corpus mammae develops in. Inferior to the corpus, at the inframammary fold, it can be seen as a layer of fascia (being held up with forceps).

Video 9.

Supplemental Digital Content 9 demonstrates breast reduction, showing the corpus lamina at the inframammary fold, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, available at http://links.lww.com/PRS/D22.

Fig. 5.

Medial circummammary ligament carrying perforating segmental vessels, nerves, and lymphatics.

Fig. 6.

Medial circummammary ligament carrying vessels, nerves, and lymphatics (higher magnification).