Oncological status is not a determinant of refraining from breast reconstruction among 490 candidates for mastectomy and post-mastectomy radiotherapy.

BACKGROUND: Although breast reconstruction in the setting of post-mastectomy radiotherapy (PMRT) is controversial, we offer nipple-sparing mastectomy and immediate implant-based breast reconstruction ([N]SSM/IIBR) to women needing primary mastectomy regardless of PMRT. Nevertheless, some of these women have no reconstruction. PURPOSE: To assess the uptake of breast reconstruction in women who undergo PMRT and the patient characteristics associated with such uptake. Additionally, we assessed the determinants of forgoing breast reconstruction. METHODOLOGY: Demographic, physical and oncological characteristics of women who underwent mastectomy, PMRT and breast reconstruction were compared to the characteristics of those who did not undergo breast reconstruction from 2013 through 2018. As determinants of delaying or refraining from breast reconstruction, we distinguished between an oncological reason, patient's preference, patient's co-morbidity, combined tobacco abuse and obesity and the need for PMRT. RESULTS: 490 women received PMRT. Of these, 396 women (81%) underwent combined [N]SSM/IIBR and PMRT or mastectomy and PMRT with delayed breast reconstruction. Ninety-four additional women (19%) did not undergo breast reconstruction. The latter group differed significantly from those who did in demographic and physical characteristics but not in terms of oncological diagnosis and history. Patient's preference was the single most frequent determinant of not performing either immediate or delayed breast reconstruction among these 94 women. Oncological status was not a major determinant in refraining from reconstruction. CONCLUSION: The significant difference in non-oncological characteristics between the reconstructed and non-reconstructed women confirms the importance of these characteristics in the preference for either reconstruction or non-reconstruction.

An Algorithm for Labia Minora Reduction Based on a Review of Anatomical, Configurational, and Individual Considerations.

A variety of reduction labiaplasty techniques have been introduced to date, but no single technique will offer the optimal solution for every patient. Rather, the technique should be chosen based on anatomical, configurational, and technical considerations, as well as on patients' personal preferences regarded maintenance of the labial rim, maintenance of labial sensitivity, and prevention of iatrogenic thickening of the labium. We reviewed, defined, and assessed labial configurational variety, neurovascular supply, reduction techniques, and patient's preferences as the considerations relevant to the choice of labiaplasty technique. Based on this review, an algorithm was constructed that leads to a choice of reduction technique through five decisions to be made regarding (1) resection or (partial) retention of the labial free rim, (2) the measure of required labial width reduction, (3) labial vascular status, (4) prevention of iatrogenic labial thickening, and (5) preservation of labial sensibility. The choice of techniques includes edge trimming, central spindle form de-epithelialization or full-thickness resection, and three modifications of the wedge resection or de-epithelialization technique. These three modifications comprised a modified anterior resection or de-epithelialization combined with posterior flap transposition, a custom flask resection or de-epithelialization, and a modified posterior wedge resection or de-epithelialization combined with anterior flap transposition. Use of the five decisional steps and the inclusion of modifications of all three conventional reduction techniques offer an improved algorithm for the choice of labioplasty technique.

Surgical flap delay to allow primary transabdominal transplantation of extended rectus abdominis myocutaneous flaps in increasingly complex pelvic wound reconstructions.

Primary intra- or transabdominal transplantation of an extended rectus abdominis myocutaneous (ERAM) flap may help prevent surgical complications of pelvic resections. Surgical delay of the ERAM flap may help prevent intra-abdominal (partial) flap loss after transplantation in highly complex situations including previous irradiation. We report on the outcome of this approach and the risk-factors associated with an eventful outcome. From 2012 to 2020, 105 delayed ERAM flaps were consecutively applied immediately following extended pelvic resections after chemoradiation or hyperthermic intraperitoneal chemotherapy. We addressed the increased reconstructive demands by designing the flap in line with the 10th rib and delaying the flap's skin island. All post-operative complications were assessed in light of patient-related or procedure-related potential risk-factors. Major complications occurred in 39 patients. These were correlated with surgery for residual or recurrent malignancy (p < 0.01), with tip necrosis after flap delay (p = 0.02), and with the use of a mesh to close the abdominal donor site (p < 0.01). (Partial) flap loss occurred in 4 cases. We observed a comparably high rate of major complications after ERAM transplantations for increasingly extending indications of perineal-pelvic resections. We consider this to be attributable to poorer patients' conditions and disease processes, rather than to flap viability. Delay of the flap allowed for the use of large and voluminous flaps with comparably little (partial) flap loss.

Short-Term Surgical Complications of Skin-Sparing Mastectomy and Direct-to-Implant Immediate Breast Reconstruction in Women Concurrently Treated with Adjuvant Radiotherapy for Breast Cancer.

Background Postmastectomy radiotherapy (PMRT) is allegedly associated with a higher risk of complications of combined nipple-sparing or skin-sparing mastectomy and subpectoral direct-to-implant immediate breast reconstruction ([N]SSM/SDTI-IBR). For this reason, this combination is usually advised against or, even, refused in women who need to undergo PMRT. Because this advice has never been justified, we assessed the short-term complications that may potentially be associated with PMRT after [N]SSM/SDTI-IBR. Methods We compared the complications requiring reintervention and implant loss occurring after 273 [N]SSM/SDTI-IBR that were exposed to PMRT within the first 16 postoperative weeks (interventional group) to those occurring in 739 similarly operated breasts that were not (control group). Additionally, we compared the fraction of complications requiring reintervention occurring after the onset of radiotherapy in the interventional group to that occurring after a comparable postoperative period in the control group. Results The fraction of breasts requiring unscheduled surgical reinterventions for complications and the loss of implants did not differ significantly between both groups but significantly more reinterventions were needed among the controls ( p = 0.00). The fraction of events after the onset of radiotherapy in the interventional group was higher than the fraction of events after 6.2 weeks in the control group, but not significantly so. Conclusion We found no prove for the alleged increase of short-term complications of adjuvant radiotherapy. Therefore, we advise that these should not be considered valid arguments to advice against [N]SSM/SDTI-IBR.

Combined skin-sparing mastectomy and immediate implant-based breast reconstruction: Outcome following mantle field irradiation versus outcome following whole-breast irradiation.

BACKGROUND: Mastectomy may be needed in the context of previous radiotherapy in cases of breast carcinoma following mantle field radiotherapy for Hodgkin lymphoma or in cases of local relapse or second primary tumours after breast conserving therapy including whole-breast irradiation (BCT). The outcome of combined skin-sparing mastectomy and immediate implant-based breast reconstruction (SSM-IIBR) has been reported to be unfavourable in these cases. PURPOSE: To compare the outcome of SSM-IIBR after mantle field radiotherapy to that after BCT and to compare both to the outcome observed in non-irradiated breasts. METHODOLOGY: The prevalences of short-term events, device loss, long-term corrections and secondary reconstructions, and reversion to autologous tissue techniques of 42 SSM-IIBRs performed after mantle field irradiation were compared to those of 47 salvage SSM-IIBRs following BCT. Both outcomes were compared to the outcome in the contralateral, non-irradiated breast of the subgroup of 23 women in the BCT group. RESULTS: The groups were comparable in terms of patient- and procedure-related risk factors, except for time lapse after previous therapy, intraoperative device weight, and the fraction of immediate use of a definitive implant. The outcome of SSM-IIBR after mantle field irradiation significantly differs favourably from that after BCT. It matches the outcome observed in non-irradiated breasts. CONCLUSION: Skin-sparing mastectomy combined with immediate implant-based breast reconstruction is a fully justifiable option for women who previously underwent mantle field irradiation for Hodgkin lymphoma. We feel that the unfavourable outcome observed in women who previously underwent BCT necessitates an alternative reconstructive modality.

Reconstruction of the Meatus Urethrae After Oncologic Vulvectomy: Outcome of 42 Vaginal Flap Advancements in 41 Women.

BACKGROUND AND AIM: Resection of the distal part of the urethra is performed in 15% to 55% of women with vulvar cancer to achieve radicality of vulvectomy. Urinary reconstruction in these women may be complicated by urethral stenosis resulting from circular inset of the meatus. We report on our experience with 2 surgical techniques of noncircular inset to prevent such stenosis. METHODS: From January 2005 to January 2020, 42 urethral meatus reconstructions were performed in 41 women after vulvectomy for (pre)malignant skin disorders by a "limited" (n = 17) or "extended" (n = 25) anterior vaginal wall advancement technique, including V-Y insertion of part of the vaginal flap in a posterior longitudinal urethrotomy. Preoperative characteristics, procedural details, and surgical outcomes were reviewed. RESULTS: We observed 1 neomeatal stenosis and 1 case of partial vaginal wall flap necrosis as major complications following the "limited" technique and 1 circumferential neomeatal dehiscence and occlusion as major complication after the "extended" technique. Both the neomeatal stenosis and the dehiscence/occlusion are felt to have been preventable and not caused by a flaw of design of the advancement technique. CONCLUSIONS: We advocate applying these vaginal wall advancement techniques to prevent circular inset of the neomeatus. The "extended" technique offers a solution in cases where the periurethral vulvar defect cannot be closed by transpositioning of labial skin.

The ban of the ipsilateral limb as a skin graft donor site after melanoma excision: A critical review.

Split-thickness skin grafts are often applied in the management of primary cutaneous melanoma. It is routine surgical practice to use the contralateral limb because of the alleged risk of donor site metastases that may occur when the ipsilateral limb is used. The rationale and clinical evidence for this routine were assessed in light of current understanding of pathways of metastasis of melanoma. We found the preference for the contralateral limb to go back to Paget's ideas on melanoma spread from 1889, and the clinical observation of five cases of split-thickness skin graft donor site metastases in a series of 226 tumours, published in 1962. We traced ten additional reported cases of melanoma metastases occurring in the skin graft donor site. Contralateral donor sites were involved in seven of these cases. In light of current knowledge, the occurrence and the location of any split skin donor site metastasis are to be considered as mere indicators of an aggressive course of systemic disease. Any location of a split skin donor site, whether ipsilateral or contralateral in relation to the primary tumour, may become the location of metastases but chances that such metastases occur are extremely rare. Because of the lack of evidence in favour of the use of the contralateral limb and because of sound considerations in favour of using the ipsilateral limb, we conclude that there is no objective argument to sustain the dogmatic ban of the ipsilateral limb as a donor site for a split-thickness skin graft in melanoma surgery.

Surgical Complications of Skin-Sparing Mastectomy and Immediate Implant-Based Breast Reconstruction in Women Concurrently Treated With Adjuvant Chemotherapy for Breast Cancer.

BACKGROUND AND AIM: To date, studies on adjuvant chemotherapy as a risk factor for the surgical outcome of combined mastectomy and breast reconstruction were hampered by the inclusion of mixed reconstructive cohorts of both delayed and immediate timing and of both autologous and implant-based techniques. Consequently, there is a paucity of data on the impact of adjuvant chemotherapy on surgical complication rates after combined skin-sparing mastectomy and immediate implant-based breast reconstruction. METHODOLOGY: We compared the postoperative complications that occurred within 16 weeks after this combined procedure in 131 women (139 breasts) treated with adjuvant chemotherapy with those in a control group of 491 women (517 breasts) not receiving any adjuvant therapy within 16 weeks. RESULTS: In line with the clinically indicated selection of women to undergo adjuvant chemotherapy, the interventional group differed significantly from the control group in 7 of the 12 patient- and procedure-related characteristics. The prevalence of minor complications (13.7% and 12.4%, respectively, P = 0.68) and major complications (31.7% and 29.4%, respectively, P = 0.60) did not differ significantly between the interventional group and the controls. The fraction of breasts that needed unscheduled surgery (0.29 and 0.24, respectively, P = 0.20), the fraction of total number of interventions (0.34 and 0.33, respectively, P = 0.24), and the fraction of implants lost (0.72 and 0.67, respectively, P = 0.86) did not differ significantly between both groups. The onset of chemotherapy, furthermore, seemed not to influence the occurrence or severity of complications. CONCLUSIONS: Like other women who have to undergo mastectomy, women who need to undergo adjuvant chemotherapy can potentially benefit from combined skin-sparing mastectomy and immediate implant-based breast reconstruction.

Andreas Vesalius (1515-1564) on animal cognition.

Until well in the 19th century, the Aristotelian concept of the scala naturae (ladder of nature) was the most common biological theory among Western scientists. It dictated that only humans possessed a rational soul that provided the ability to reason and reflect. Michel Eyquem de Montaigne (1533-1592) was the first philosopher influential enough to lastingly posit that animals are cognitive creatures. His view stirred a fierce controversy, with René Descartes (1596-1650) leading among his many adversaries. Only after it became accepted that animals and humans alike have cognitive abilities, did the research on the influence of conscious awareness and intention on the behavior of an animal become possible in the 20th century. We found the anatomist Andreas Vesalius (1515-1564) to have already rejected the Aristotelian view on the lack of the rational soul in animals in his 1543 opus magnum De Humani Corporis Fabrica Libri Septem. His observation "that there is a difference in size according to the amount of reason that they seem to possess: man's brain is the largest, followed by the ape's, the dog's, and so on, corresponding to the amount of rational force that we deduce each animal to have" resonated some 330 years later when Darwin concluded that "the difference in mind between man and the higher animals, great as it is, certainly is one of degree and not of kind." We conclude that Vesalius was instrumental in breaking with two millenniums of dominance of the concept of lack of animal cognition.

Rembrandt's Aging Face in Plastic Surgical Perspective.

BACKGROUND AND AIM: When the painter Rembrandt van Rijn (1607-1669) died 350 years ago, he left us some 90 self-portraits showing his aging face. Recognizing aging characteristics of the male face is fundamental to the planning of a surgical procedure and a prerequisite when communicating to the male patient. Rembrandt's recordings through the years might offer an optimal aid to train such recognition, provided that they are truthful. In this article, we present an inventory of age-related changes observed in these self-portraits to assess whether they are truthful. METHODS: High-quality photographs of 25 self-portraits that are generally accepted as works by Rembrandt were independently assessed in a standardized fashion for the presence of 25 aging characteristics, by 2 plastic surgeons and a physician-portraitist. RESULTS: The observed proportion of agreement between assessments reached 0.87 (κ = 0.68, indicating good agreement). We found Rembrandt's self-portraits to reflect his facial aging as a chronologically increasing process. Observed characteristics set in as of 1642, the year that he lost his beloved first wife, Saskia. His face appears to have particularly aged from 1652 to 1659, in which period Rembrandt's second great love Hendrickje was summoned because of her living in sin with Rembrandt, and Rembrandt himself faced financial problems. As of 1660, Rembrandt seems to have been less intended to depict his facial aging characteristics. CONCLUSIONS: We conclude that Rembrandt truthfully reflected his ongoing age in the self-portraits, up to 1660. These self-portraits therefore may allow for training the art of observation of such characteristics.

History Off-Hand: Bunnell's No-Man's Land.

Background: To date, it remains unclear what inspired Dr Sterling Bunnell to start using the typical World War I military term no-man's land in hand surgical context, only in 1948. To commemorate that Bunnell passed away 60 years ago on August 20, I report on my quest to clarify this. Methods: An extensive bibliography of Bunnell was made up by use of the McDowell Series of Plastic Surgery Indexes and cross-checked by use of a PubMed search. Bunnell's round-robin letters were searched for in the Sterling Bunnell Hand Surgery Archives of the California Pacific Medical Center Health Services Library in San Francisco, California. In addition, some of the second-generation hand surgeons were personally approached to try and trace the round-robin letters. Finally, the publications of the chiefs of the 9 hand surgical centers and 6 coworkers of Bunnell were checked for referrals to the term no-man's land. Results: Prior to 1948, no-man's land was not used in print in hand surgical context. Bunnell's nearness to the trenches during World War I appears not to have inspired him immediately to start using the term. The reconnaissance tunnels dug through the soil of the no man's land between the Allied and German trenches likely inspired him to replace a cut tendon through incisions proximal and distal to no-man's land. Conclusions: Bunnell must have associated his tendon grafting techniques to that of the World War I trenches and tunnels at some time between 1947 and 1948.

Repeated Use of Gluteal Fold Flaps for Post-Oncologic Vulvoperineal Reconstruction.

BACKGROUND AND AIM: Because of the associated high recurrence rate, future reconstructive options should be reckoned with during surgical treatment of primary or recurrent (pre)malignant vulvoperineal lesions. One of the claimed advantages of the gluteal fold flap is the possibility of repeated use of the flap in case of recurrence. We present our experience with such reuse of gluteal fold flaps to illustrate this possibility. METHODS: A mean of 27 months after initial use, 10 subcutaneously pedicled or perforator-based V-Y advancement or propeller-rotation flaps were elevated from previously used gluteal fold flaps in 9 women presenting with recurrent vulvoperineal (pre)malignancy. Five of these women had undergone radiotherapy prior to flap reuse. RESULTS: Although short-term complications were observed in 3 women, all flaps survived and healed completely. CONCLUSIONS: We showed the feasibility of successful reuse of subcutaneous pedicled or perforator-based gluteal fold flaps for repeated vulvoperineal reconstruction, both in nonirradiated and irradiated women. This concept of reuse of the gluteal fold flap is useful for recurring (pre)malignant vulvoperineal defects, and reconstructive surgeons and patients may benefit from this potential option.

Internal Mammary Artery Perforator Flap for Immediate Volume Replacement Following Wide Local Excision of Breast Cancer.

BACKGROUND: Breast-conserving therapy is defined as a breast-conserving wide local excision (WLE) of a mammary tumour combined with postoperative radiotherapy. Immediate restoration of the mammary shape by use of breast reduction techniques (volume displacement) or tissue replacement techniques (volume replacement) is gaining popularity to prevent breast malformation. METHODS: To date, using the internal mammary artery perforator (IMAP) flap has been suggested for immediate volume replacement after WLE, but has never been evaluated in a published study. RESULTS: We applied this flap in 12 women (mean age, 56.1 years) after WLE (mean specimen weight, 46.5 g) of the medial aspect of the breast. Over a median follow-up of 35.3 months (standard deviation, 1.2 months), 4 women needed repeated surgery for dog-ear correction of the donor site. CONCLUSIONS: In our experience, the use of an IMAP flap was a reliable technique with good cosmetic outcomes after oncoplastic reconstruction. In this series, donor site revision often proved necessary initially, but we showed that this may easily be prevented.

Peptide mimetics of immunoglobulin A (IgA) and FcαRI block IgA-induced human neutrophil activation and migration.

The cross-linking of the IgA Fc receptor (FcαRI) by IgA induces release of the chemoattractant LTB4, thereby recruiting neutrophils in a positive feedback loop. IgA autoantibodies of patients with autoimmune blistering skin diseases therefore induce massive recruitment of neutrophils, resulting in severe tissue damage. To interfere with neutrophil mobilization and reduce disease morbidity, we developed a panel of specific peptides mimicking either IgA or FcαRI sequences. CLIPS technology was used to stabilize three-dimensional structures and to increase peptides' half-life. IgA and FcαRI peptides reduced phagocytosis of IgA-coated beads, as well as IgA-induced ROS production and neutrophil migration in in vitro and ex vivo (human skin) experiments. Since topical application would be the preferential route of administration, Cetomacrogol cream containing an IgA CLIPS peptide was developed. In the presence of a skin permeation enhancer, peptides in this cream were shown to penetrate the skin, while not diffusing systemically. Finally, epitope mapping was used to discover sequences important for binding between IgA and FcαRI. In conclusion, a cream containing IgA or FcαRI peptide mimetics, which block IgA-induced neutrophil activation and migration in the skin may have therapeutic potential for patients with IgA-mediated blistering skin diseases.

A Prospective Assessment of Surgical Risk Factors in 114 Gluteal Fold Flap Reconstructions After Oncological Vulvoperineal Resection.

BACKGROUND AND AIM: To date, clinically relevant selection criteria have not been established for the use of the gluteal fold flap after oncological vulvoperineal resection. We prospectively assessed the surgical risk factors of this reconstructive technique in a large series. METHODOLOGY: From April of 2000 through December of 2015, 114 gluteal fold flaps were used for vulvoperineal reconstruction after excision of (pre)malignant skin disorders in 75 women. The possible influence of 10 patient-related and 6 procedure-related risk factors on flap-related postoperative complications was statistically analyzed. RESULTS: We observed a major complication in 13 flaps (11%) and a minor complication in 19 flaps (17%). Previous radiotherapy (P = 0.01) was associated with significantly more complications, and a rotation flap design rather than VY advancement (P = 0.02) was associated with major complications. Recurrent disease, multifocal tumor localization, incomplete removal of tumor, and bilateral flap procedure were found to be clinically relevant risk factors, but not significantly so. The same applied to recurrence of disease during postoperative follow-up. CONCLUSIONS: We identified surgical risk factors for gluteal fold flap use after oncological vulvoperineal resection. These observations may potentially allow for more favorable future surgical outcomes by adaption of selection of patients or procedure.

Andreas Vesalius' 500th Anniversary: Initial Integral Understanding of Voice Production.

BACKGROUND: Voice production relies on the integrated functioning of a three-part system: respiration, phonation and resonance, and articulation. To commemorate the 500th anniversary of the great anatomist Andreas Vesalius (1515-1564), we report on his understanding of this integral system. METHODS: The text of Vesalius' masterpiece De Humani Corporis Fabrica Libri Septum and an eyewitness report of the public dissection of three corpses by Vesalius in Bologna, Italy, in 1540, were searched for references to the voice-producing anatomical structures and their function. We clustered the traced, separate parts for the first time. RESULTS: We found that Vesalius recognized the importance for voice production of many details of the respiratory system, the voice box, and various structures of resonance and articulation. He stressed that voice production was a cerebral function and extensively recorded the innervation of the voice-producing organs by the cranial nerves. CONCLUSIONS: Vesalius was the first to publicly record the concept of voice production as an integrated and cerebrally directed function of respiration, phonation and resonance, and articulation. In doing so nearly 500 years ago, he laid a firm basis for the understanding of the physiology of voice production and speech and its management as we know it today.

Andreas Vesalius' understanding of pulmonary ventilation.

The historical evolution of understanding of the mechanical aspects of respiration is not well recorded. That the anatomist Andreas Vesalius (1515-1564) first recorded many of these mechanics in De Humani Corporis Fabrica Libri Septem has received little attention. We searched a digital copy of De Fabrica (1543) and its English translation as provided by Richardson and Carman (1998-2009) for references to aspects of pulmonary ventilation. We found that Vesalius grasped the essentials of tidal and forced respiration. He recognized that atmospheric pressure carried air into the lungs, approximately 100 years before Borelli did. He described an in vivo experiment of breathing, some 120 years before John Mayow produced his artificial model. He reported on positive pressure ventilation through a tracheotomy and on its life-saving effect, some 100 years before Robert Hook did. In publicly recording his insights over 450 years ago, Vesalius laid a firm basis for our understanding of the physiology of respiration and the management of its disorders.

Effect of latissimus dorsi flap breast reconstruction on the strength profile of the upper extremity.

OBJECTIVE: Dissection of the latissimus dorsi (LD) flap may have a distinct impact on upper extremity function and strength. To date, insufficient differentiation has been made between loss of muscular strength and shoulder function by dissection of the LD muscle per se and loss of function resulting from all excisional surgery, radiation therapy, and reconstructive procedures at the donor site and the recipient site that may have been combined near the shoulder region. METHODS: This study determines the long-term effect of the LD breast reconstruction on the strength profiles of the upper extremity by measuring the isometric torque strength both in seven synergistic- and two contra-movement directions. The Biodex System 3 Pro (Biodex Medical Systems, New York, NY) was used in 12 patients at a mean of 3.5 years after surgery, and in 20 matched controls. Because loss of LD muscle may not result in significant impairment of activities of daily live (ADL) even in cases where objective measurements are decreased, this study simultaneously assessed the subjective function by use of the standardised Disability of Arm, Shoulder and Hand (DASH) questionnaire. RESULTS: This study observed a significant long-term loss of 8.8 Nm or 19% LD torque strength in synergistic movement directions after transplantation of the LD muscle. This loss correlated significantly with an increase of the mean DASH score among the patients. CONCLUSIONS: Because no significant loss of contra-movement torque strength was observed, it was concluded that the loss of synergistic torque strength appears to result from the loss of LD function per se.

Andreas Vesalius' 500th Anniversary: First Description of the Mammary Suspensory Ligaments.

Sir Astley Paston Cooper has, to date, been acknowledged to be the first to describe the suspensory ligaments of the breast, or Cooper's ligaments, in 1840. We found these ligaments to be recorded in the first edition of 'De Humani Corporis Fabrica Libri Septem' by Andreas Vesalius, published in 1543. To commemorate Vesalius' 500th birthday, we quote and discuss this earlier record. Vesalius' record of the nature and function of the fleshy membrane between mammary gland and pectoral muscle, the hard fat intervening the mammary glands, and the fibers running from the fleshy membrane to the skin are a clear representation of posterior layer of the superficial fascial system, the fibro-adipose stroma surrounding and linking the mammary glandular elements, and the suspensory ligaments as we know them. Vesalius recorded the anatomy and function of the latter structures nearly 300 years before Sir Astley Paston Cooper did.