Title: Understanding the Fascial Supporting Network of the Breast
Abstract: Sir: We have read with great interest the recent article by Matousek and colleagues entitled “Understanding the Fascial Supporting Network of the Breast: Key Ligamentous Structures in Breast Augmentation and a Proposed System of Nomenclature,”1 and we would like to congratulate the authors for the accurate description of the fascial structures that form the lower pole of the breast and the inframammary fold. In the past three decades, many scientific works have investigated the structural anatomy of the breast. However, results have often been contradictory, with various anatomists advocating for one theory or another. In the article by Matousek et al., several fascial structures involved in the breast support network are described accurately and confirm results that other authors had found before. What is even more interesting is the structure supporting the inframammary fold, mainly built on a “triangular fascial condensation” that connects the derma directly to the rib periosteum, where the pectoralis major connects to the rectus abdominis and the external oblique muscle. As the authors stated, operations that interfere with the breast’s fascial supporting network may produce unaesthetic surgical outcomes. Nevertheless, the surgeon must consider also a patient’s own susceptibility to develop unaesthetic outcomes (e.g., double-bubble deformity), which always is affected by a genetic predisposition (i.e., collagen or fibroblast alteration or wound healing defects). In fact, we believe that disorders occurring during embryogenesis that impede correct formation of this fascial system can also be an explanation for some breast deformities. In other terms, an embryologic disorder of the development of an anatomical structure may sometimes be a factor that leads to an unaesthetic defect. An example is the tuberous breast, a deformity characterized by a constricting ring at the breast base, breast tissue deficiency, and herniation of breast tissue into the nipple-areola complex with areola enlargement and additional asymmetry.2 The prevailing hypothesis suggests that this deformity is caused by an abnormal thickening of the fascia corporis that constricts glandular development at the base of the breast, causing areolar herniation. Furthermore, recent studies propose that a structural congenital dermal weakness of the nipple-areola complex may be at the base of this morphologic anomaly.3 In addition, microscopic alterations of fibroblasts and differences in quantity and disposition of collagen fibers are probably also involved in the genesis of tuberous breasts.4 For these reasons, we believe that genetics plays an important role in the development of the fascial supporting network of the breast, and subsequently the knowledge of its alteration may help surgeons to fully understand most breast disorders. Thus, it would be interesting to compare these anatomical results found in tuberous breasts to finally understand the exact structural changes involved in their pathogenesis. In addition, we observed the triangular fascial condensation in the inframammary fold area also in dissected male breasts, which led us to suppose that both female and male breasts had a common fascial supporting network (Fig. 1). We encourage Dr. Matousek to persist with his studies and we ask for his opinion on this issue.Fig. 1: Right male breast inframammary fold dissection and identification of the triangular fascial condensation.DISCLOSURE The authors have no conflict of interests to disclose. Sinziana Iacob, M.D. Clinical Emergency “Floreasca” Hospital Bucharest Bucharest, Romania Pierluigi Gigliofiorito, M.D. Alfonso Luca Pendolino, M.D. Paolo Persichetti, M.D., Ph.D. Plastic and Reconstructive Surgery Unit Università Campus Bio-Medico di Roma Rome, Italy