1. Por José Domingo Díaz, Residente de Primer Año de Cirugía General.
Universidad de Cartagena

2. Embryogenesis of the Breast
Normal Development
 The breast is a group of large glands derived
from the epidermis
 Second month of gestation
 Two bands of ectoderm
 Milk lines
Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009

3. A. The milk lines in a generalized mammalian embryo. Mammary glands form along these lines.
B. Common sites of formation of supernumerary nipples or mammary glands along the course of
the milk lines in the human.

4.  The glandular portion of the breast develops
from the ectoderm
 Twelve weeks
 16 to 24 buds of ectodermal cells grow into the
underlying mesoderm (dermis)
 Areola fifth month onward
Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009

5. Development of the breast. A-D. Stages in the formation of the duct system and potential glandular tissue from
the epidermis. Connective-tissue septa are derived from the mesenchyme of the dermis. E. Eversion of the
nipple near birth.

6.  Modified sweat glands
 Areolar glands (Montgomery)
 Connective tissue stroma forms from mesoderm
 Rest of changes will reappear in puberty
Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009

7. Development of the mammary ducts and hormonal control of mammary gland development and function.
A. Newborn. B. Young adult. C. Adult. D. Lactating adult. E. Postlactation.

8. Congenital Anomalies
 Amastia, Athelia, and Amazia
 Supernumerary Breasts or Nipples
 Congenital Inversion of the Nipple
 Anomalies of Breast Size
Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009

9. http://www.youtube.com/watch?v=druBEupr7eM

10. Surgical Anatomy
Topographic Anatomy and Relations
 Located within the superficial fascia anterior
chest wall
 Base from second rib above to the six or seven
rib below
 External border medially to midiaxillary line
laterally
Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009

11.  2/3 of base lies anterior to the pectorally
major muscle
 Remainder lies anterior to the serratus
anterior muscle
 Tail of expense: 95%, lateral quadrant toward
the axilla prolongation
 Hiatus of Langer in the deep fascia
Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009

12. Skin
 Areola and nipple distinguished from that of the
surrounding skin by pink color imparted by blood
vessels
 Pregnancy increases melanin darkening the area
(Basal cells)
Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009

13. Superficial Fascia
 Envelopes the breast
 Continuous with the superficial abdominal fascia
below and superficial cervical fascia above
 Anteriorly with the dermis of the skin
Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009

14. Diagrammatic sagittal
section through the
nonlactating female breast
and anterior thoracic wall.

15. Deep Fascia
 Envelopes the pectoralis major muscle
continuous with the abdominal fascia below
 Medially attached to externum
 Above and laterally clavicle and axillary fascia
 Anteriorly pectoralis minor fascia
 Inferiorly serratus anterior posterior extension
 Fascia of the latissimus Muscles
Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009

16. Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009
Muscles
Muscles and Nerves Involved in Mastectomy
Muscle Origin Insertion Nerve supply Comments
Pectoralis major Medial half of clavicle, lateral half of Lateral lip, bicipital groove Lateral and medial Clavicular portion of pectoralis
nd th pectoral nerves forms upper extent of radical
sternum, 2 to 6 costal cartilages,
aponeurosis of external oblique mastectomy; lateral border forms
muscle medial boundary of modified
radical mastectomy; both nerves
should be preserved in modified
radical procedure
Pectoralis minor nd th Coracoid process of scapula Lateral and medial
2 to 5 ribs
pectoral nerves
Deltoid Lateral half of clavicle, lateral border Deltoid tuberosity of Axillary nerve
of acromion process, spine of humerus
scapula
Serratus anterior st nd Costal surface of scapula at Long thoracic nerve Injury produces "winged scapula"
1. 1 and 2 ribs
(3 parts) superior angle
nd th Vertebral border of scapula
2. 2 to 4 ribs
th th Costal surface of scapula at
3. 4 to 8 ribs
inferior angle
Latissimus dorsi Back, to crest of ilium Crest of lesser tubercle and Thoracodorsal nerve The anterior border forms the
intertubercular groove of lateral extent of radical
humerus mastectomy; injury results in
weakness of rotation and
abduction of arm
Subclavius st Groove of lower surface of Subclavian nerve
Junction of 1 rib and its cartilage
clavicle
Subscapularis Costal surface of scapula Lesser tubercle of humerus Upper and lower Subscapular nerves should be
subscapular nerves spared
External oblique External oblique muscle Rectus sheath and linea alba, Remember the interdigitation with
aponeurosis crest of ilium serratus anterior and pectoralis
muscles
Rectus abdominis Ventral surface of 5th to 7th costal Crest and superior ramus of Branches of 7th-12th The rectus sheath is the lower limit
cartilages and xiphoid process pubis thoracic nerves of radical mastectomy

17. Morfology
 15 and 20 lobes
 Lobes, together with their ducts, are anatomic
units, but not surgical units
 Lobes and ducts arranged radially
 Lactiferous sinuses, milk storage
 Papilomas
Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009

18. The retromammary space. 1. Membranous layer of superficial fascia.
2. Retromammary space. 3. Muscle fascia.

19. Breast topography. From a dissection photograph. 1. Retinacula cutis. 2. Membranous layer. 3. Serratus
anterior fascia. 4. Serratus anterior muscle. 5. Pectoral fascia. 6. Pectoralis major muscle. 7. Suspensory
ligament of axilla. 8. Lobe of breast parenchyma. 9. Lactiferous duct. 10. Ampulla.

20. Dimpling of
the breast,
resulting from
involvement
of Cooper's
ligaments by
invasive
disease. The
dimpling is
emphasized
by the
pressure of
the hand of
the examiner.
From a
clinical
photograph.

21. Blood Supply
Blood supply of the
breast; drawing
from a dissection
photograph. The
arterial supply is
here derived chiefly
from (A) direct
mammary
branches of the
axillary artery; (B)
branches of the
lateral thoracic
artery; (C)
perforating
branches of the
internal thoracic
artery. The venous
drainage is
comparable, and is
illustrated on the
right side of the
drawing. The rib
levels are indicated
by numbers.

23. A. The breast may be supplied with
blood from the internal thoracic, the
axillary, and the intercostal arteries
in 18 percent of individuals.
B. In 30 percent, the contribution from
the axillary artery is negligible.
C. In 50 percent, the intercostal arteries
contribute little or no blood to the
breast. In the remaining 2 percent,
other variations may be found.

24. Lymphatic Drainage
Lymph nodes
of the breast
and axilla.
Classification
of Haagensen.

25. Arrangement of Lymph Nodes and Metastasis
 Level I: lateral to the lateral border of the
pectoralis minor muscle
 Level II: under the pectoralis minor muscle
 Level III: medial to the medial border of the
pectoralis minor muscle
Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009

26. Level I (low axilla), Level II (midaxilla), Level III (apical axillary)
Google Images

27. Diagram of lymphatic drainage of the breast.

28. Innervation
Diagrammatic representation of important peripheral nerves encountered during
mastectomy.

29. Images
Pet/Tac of inflamatory cancer of
the breast.
The Journal of Nuclear Medicine

30. Imagen sospechosa de una
mamografía.
Foto: NCI

31. Eco quiste mamario
Google Images

32. Eco tumor mamario
Google Images

33. Eco fibroadenoma mamario
Google Images

34. Nucleus Medical Art, 2009

35. Nucleus Medical Art, 2009