Heba Kalbouneh

Breast anatomy: time to classify the subpectoral and prepectoral spaces

Vidya R 1 , Iqbal FM 2

1) Miss Raghavan Vidya, Consultant Oncoplastic Breast Surgeon, New Cross

Hospital, Wolverhampton, WV10 0QP
raghavan.vidya@nhs.net
2) Fahad Mujtaba Iqbal BSc (Hons), Final Year Medical Student, Keele
University, David Weatherall Building, Stoke on Trent, ST5 5BG
fahad.iqbal@kclalumni.net

Both authors contributed to the manuscript. No financial disclosures are to be made.

The article has not been submitted elsewhere.

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process which may lead to
differences between this version and the Version of Record. Please cite this article as an
Accepted Article, doi: 10.1002/ca.22878

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Background

Surgical intervention remains the primary treatment modality for most women who
develop breast cancer, many of whom require reconstructive surgery. Recent
advances, particularly in implant-based techniques (accounting for 40% of breast
reconstructions in the UK and 80% in the USA), devices, and biomaterials (1,2) have
led to increases in both classical techniques (e.g. subpectoral breast reconstruction)
and more novel techniques such as prepectoral (muscle-sparing) reconstruction. The
latter are becoming more popular because the pectoralis major is not detached, so the
shoulder dysfunction associated with the classical technique is precluded. In
consequence, better understanding of the anatomy of the prepectoral reconstructive
plane is required for successful results. With this in mind, we describe the subpectoral
and the prepectoral spaces.

Anatomy of the breast

The breast is a subcutaneous organ that normally extends antero-posteriorly between
the second and the sixth ribs and mediolaterally between the sternum and the anterior
axillary line (3). It is covered by skin and subcutaneous tissue anteriorly. It mainly
lies on the fascia over the chest wall muscles (pectoralis major posteriorly, serratus
anterior medially, and external oblique aponeurosis inferiorly). The breast footprint
varies depending on morphology: size, shape, and ptosis.

Pectoralis major muscle

The pectoralis major has a sternal head arising from the lateral aspects of the
manubrium and sternal body. The upper six costal cartilages and the clavicular head
arise from the medial half of the clavicle and are inserted into the bicipital groove of
the humerus and deltoid tuberosity. Their primary function is to adduct and assist with
medial rotation and shoulder flexion (4).

An anatomical space is defined as a space unoccupied by tissue. Such spaces mainly

act as pathways for transmission of neurovascular structures. However, to aid surgical
practice, we believe this should be extended to include the subpectoral and
prepectoral spaces.

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Subpectoral space
This space is vital for planning classical subpectoral breast reconstruction. The classic
subpectoral space is created by dissection of the pectoralis major. In some cases it can
be extended to dissection of the serratus anterior in order to increase the size of the
space and provide additional muscle cover.

The subpectoral space is bounded anteriorly by the pectoralis muscle, medially by

serratus anterior, and posteriorly by the rib cage. It is only partly covered by the
muscle anteriorly, while the lower aspect remains subcutaneous, covered by the
mastectomy flap.

The classic subpectoral technique involves releasing the pectoralis major from its
origin inferiorly and medially to create room for an implant (Fig. 1). It is also released
inferiorly from the external oblique aponeurosis and medially from the costal
cartilages up to the fourth rib. The serratus anterior can be incorporated from the
lateral aspect to form a good muscular pocket.

The volume of the space that can be created depends on the distribution of the muscle
span. The muscle exhibits a narrow or high distribution in about 72% of the
population (5). The extent to which it can be stretched depends on its thickness and its
development.

In the classical technique, a mesh is anchored to the lower border of pectoralis major
and the new mesh-muscle unit forms an internal bra for the implant. Although this
technique has been shown to be safe and to achieve good cosmesis, it can be
associated with animation deformity and shoulder morbidity (6).

Prepectoral space
We define the prepectoral space as the potential space between the breast skin flap
and the pectoralis fascia and the muscle (Fig. 2). It is created following removal of the
breast and preserving the skin flap as in a skin-sparing mastectomy. Its volume

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depends on the breast volume removed. The quality of the mastectomy flap dictates
the integration of a mesh and the extent to which the skin can be stretched by the
underlying implant.

The breast skin derives its blood supply from the underlying subcutaneous fat. As
such, the vascularity of the mastectomy skin flap is the key to success in this
technique: good intimate contact of the mesh is required for its integration.

Indeed, the subcutaneous layer, situated between the dermis and the breast, varies in
thickness in any breast (7). Therefore, it is not always possible to define a uniform
layer during a skin-sparing mastectomy. Accordingly, we define the degree of skin
flap vascularity using clinical assessment (Table 1).

Table 1: Grading of skin flap vascularity

Grade Definition
1 Mastectomy skin flap with good subcutaneous layer throughout
2 Mastectomy skin flap with small patchy areas lacking subcutaneous layer
(<1cm)
3 Mastectomy skin flap with medium to large patchy confluent areas lacking
subcutaneous layer (>2cm)

In the prepectoral implant-based breast reconstruction, the implant is covered by the

mesh outside (ex-vivo) and the mesh-implant wrap is placed inside the prepectoral
space to form the new breast. The mesh integration and the outcome depend on the
vascularity of the mastectomy flap (8). It could therefore be the technique of choice
for patients with grade 1 or 2 mastectomy skin flaps but perhaps avoided in grade 3
patients. The prepectoral technique avoids the potential for animation problems and
shoulder dysfunction (9).

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Conclusion
New techniques in breast reconstruction are emerging owing to better understanding
of anatomy and advancement in biomaterials and implants. We believe more
understanding of breast anatomy can improve outcomes in breast reconstruction.

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Table 1: Grading of skin flap vascularity

Grade Definition
1 Mastectomy skin flap with good subcutaneous layer throughout
2 Mastectomy skin flap with small patchy areas lacking subcutaneous layer
(<1cm)
3 Mastectomy skin flap with medium to large patchy confluent areas lacking
subcutaneous layer (>2cms)

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