2. CHAPTER SIX
THE BREAST
ï Anatomy & physiology of the breast
ï Breast examination
ï Teaching breast Self-examination to women (BSE)
ï Benign & malignant tumors of the breast
ï Management of breast disorders
ï Mammography
ï Nursing care consideration for a women with
mastectomy
2Done by Yosef A.
3. Objectives
At the end of this study the student will be able to
ï Describe the gross structure of the breast.
ï Describe the physiologies of breast.
ï Discuss the development of breast and its congenital
anomalies.
ï Give its blood supply and lymphatic drainage.
3Done by Yosef A.
4. THE BREAST
ANATOMY AND PHYSIOLOGY OF FEMALE BREAST
ï Breasts are composed of mammary glands ,connective
tissue ,blood vessels , nerves and lymph vessels.
ï The breasts are secondary reproductive glands of
ectodermal origin.
ï The breast is the upper ventral region of the torso of
a primate, in left and right sides, containing
the mammary gland.
4Done by Yosef A.
5. ContâŠ
ï Each breast consists of 12-20 conical lobes.
ï Each lobe consists of a group of lobules.
ï The lobules have several lactiferous ducts , which unit
to form a major duct
ï Each of the major ducts widens to form an ampula
ï The fatty tissue increases towards the periphery of the
lobule and gives the breast its bulk and hemispheric
shape and 80-85% of the normal breast is adipose
tissue.
Lobes---Lobules---Lactiferous ducts---Major duct---Ampula
5Done by Yosef A.
6. ContâŠ
ï In non pregnant ,non lactating breast ,the alveoli are
small and tightly packed
ï During pregnancy the alveoli hypertrophy and their
lining cells proliferate in number
ï During lactation , the alveolar cells secret proteins and
lipids which comprise breast milk
6Done by Yosef A.
7. POSITION OF BREAST
ï Extent: Vertical: 2nd to 6th rib (Base of the breast)
Horizontal: Lateral margin of the sternum to the mid
auxiliary line
ï 2/3rd of the breast lies in the superficial fascia
(Pectoral fascia) lying on Pectoralis major
ï 1/3rd of the breast lies in the superficial fascia lying
on Serratus Anterior
ï The greater part of the gland lies in the superficial fascia.
7Done by Yosef A.
8. ï A small part-axillary tail extends upward and laterally,
pierces the deep fascia at the lower border of the
pectoralis major muscle up to the apex of the axilla.
ï The breast lies upon the deep pectoral fascia, which in
turn overlies pectoralis major and serratus anterior, and
inferiorly, external oblique and its aponeurosis as the
latter forms the anterior wall of the sheath of rectus
abdominis
8Done by Yosef A.
9. PARTS OF THE BREAST
ï Nipple: Conical or Cylindrical prominence in the center of
Areola (Devoid of fat, hair & sweat gland)
ï The nipple level in the thorax varies widely, but is at the fourth
intercostal space in most young women.
ï Nipple is Usually everted
Surface anatomy: 4th intercostal space lateral to midclavicular
line!!!!
ï Areola: Circular pigmented area of the skin surrounding
the base of the nipple, containing sebaceous glands.
ï Axillary Tail : Small part of the breast extending to the
axilla. 9Done by Yosef A.
10. ï Retromammary Space: Space filled with loose connective
tissue between breast and pectoral fascia
ï Lactiferous ducts from each lobule open on the summit of the
nipple separately
ï Lactiferous duct possesses a dilated Ampulla (Lactiferous
sinus) just before its termination
ï Fibrous septa separates the lobes of the mammary gland
ï Suspensory ligaments (of Cooper):
ï Mammary gland is firmly attached to the dermis of the skin
by these fibrous septa forming suspensory ligaments
10Done by Yosef A.
12. Layers of breast
ï Mammary layer
ï Subcutaneous layer
ï Retromammary layer
Development and physiology
ï The breasts develop as an invigilation of chest wall ectoderm
ï Which forms a series of branching ducts. Shortly before birth
this site of invagination everts to form the nipple.
ï At puberty, alveoli sprout from the ducts and considerable
fatty infiltration of the breast tissue takes place.
ï With pregnancy there is tremendous development of the
alveoli which, in lactation, secrete the fatty droplets of milk. At
the menopause the gland tissue atrophies.
12Done by Yosef A.
13. ï Neonates: Occasionally, gynaecomastia may occur in the neonatal
breast, with discharge of a colostrum-like material (âwitchâs milkâ).
ï From birth until puberty, the breast consists of lactiferous ducts,
with no alveoli.
ï At puberty, the ducts start to proliferate, and their terminations
form solid masses of cellsâthe future breast lobules.
ï During pregnancy, secreting alveoli appear. During the early
weeks, ductal sprouting and lobular proliferation occur, with
increased nipple and areolar pigmentation.
ï The alveoli now display a lumen surrounded by the secretory
cells.
ï In the last days of pregnancy, the breasts secrete colostrum, a
yellow, sticky, serous fluid, which is then replaced by true secretion
of milk.
ï After the menopause, the glandular tissue of the breast atrophies,
the connective tissue becomes less cellular, and the amount of
collagen decreases. In some women, breasts shrink considerably.
13Done by Yosef A.
14. Arterial Supply
ï The blood supply of the breast is a rich anastomotic
network derived from
ï Perforating branches (Internal thoracic artery)
ï Lateral thoracic artery (Axillary artery)
ï Thoracoacromial artery (Axillary artery)
ï Intercostal arteries
ï The largest vessels arise from the internal thoracic
artery, the perforating branches of which pierce the chest
wall adjacent to the sternal edge in the first to fourth
intercostal spaces. The vessel in the second space is
usually the largest of these.
14Done by Yosef A.
15. ï second to fourth anterior intercostal arteries supply
perforating branches more laterally.
ï The axillary artery supplies blood from several branches,
namely the superior thoracic, the pectoral branches of the
thoraco-acromial artery, the lateral thoracic artery.
Venous Drainage
ï Superficial venous system lies within the subcutaneous fat
tissue; most distal veins line the superficial fascia and drain
blood centrally; provides connection between right and left
breast with potential for metastasis to occur between
breasts
ï Deep venous system consists of veins that follow the
arterial system and communicates with the axillary vein,
subclavian vein and SVC
ï Includes lateral thoracic, axillary, subclavian and
intercostal veins 15Done by Yosef A.
16. Nerve Supply
ï Anterior and lateral cutaneous branches of the
4th â 6th intercostal nerves
Lymphatic Drainage
ï 75% drains to the axilla
ï Lateral quadrants: Anterior Axillary or Pectoral nodes
ï Medial quadrants: Internal thoracic group of Nodes
(Parasternal)
ï Few lymph vessels drains into Posterior intercostal Nodes
ï Inferior quadrants: May drain into abdominal lymph Nodes
ï Some lymphatic vessels communicate with the lymphatic vessels of
the opposite breast
16Done by Yosef A.
17. Congenital Anomalies
ï Nipple Inversion: usually bilateral if congenital; associated pathology
can be present if the nipple change is a new finding and/or occurs
unilaterally
ï Athelia: absence of the nipple
ï Polythelia: accessory nipples, can develop anywhere along the milk
line; most commonly seen just inferior to the normal nipple; #1
congenital anomaly of the breast in females and males
ï Amastia: failure of the breast and nipple to develop
ï Polymastia: accessory breast tissue; most commonly forms without a
nipple; usually found in the axilla
ï Amazia: absence of development of the functional breast tissue
beneath a normal nipple/areola
17Done by Yosef A.
18. Developmental abnormalities of Breast
ï The nipple may fail to evert .
ï Supernumerary nipples or even breasts may occur along a vertical
âmilk lineâ
ï the other hand, the breast on one or both sides may be small or even
absent (amazia).
ï Accessory Breasts- is a health condition where the person afflicted
has extra breasts.
ï The extra breast can be in various forms, from a fully functional
breast with a normal appearance and capable of producing milk to a
breast that does not lactate or have an areola.
ï Both men and women can have accessory breasts, but the problem
is more commonly observed in women
18Done by Yosef A.
19. .
19
There is no known limit on
the amount of extra
nipples or breasts that can
develop on the human
body. Some women have
experienced as many as
eight nipples in addition to
the standard two.
Done by Yosef A.
20. Fascial relationships of the breast
ï The fascial relationships of the breast are of practical
importance.
ï As an ectodermal derivative, the gland lies in a pocket
of superficial fascia.
ï Superficial fascia:
ï Superficial layer
ï Deep layer
ï Fibrous processes of this layer of fascia extend to the
skin and to the nipple and are more developed
over the upper part of the breast, where they form
the suspensory ligament of Cooper.
ï Contraction of this tissue by malignant infiltration
results in the characteristic skin dimpling over a
carcinoma of
Done by Yosef A. 20
21. ï The superficial layer lies immediately beneath the
dermis and enables skinflaps to be dissected from the
glandular mass of the breast quickly, neatly, and in a
relatively avascular plane.
ï The deep layer of the superficial fascia is thicker than
the subcu- taneous component and covers the deep
aspect of the breastplate.
ï Beneath this sheath is a layer of filmy areolar tissue
that allows the breast to move freely on the
underlying fascial covering of the pectoralis major
and the serratus anterior.(Pectoralis fascia)
Done by Yosef A. 21
22. Breast examination
ï Two types of breast examination
Breast examination by a physician
Breast self examination (BSE)
Done by Yosef A. 22
23. Self Examination of the Breast
ï 90% of breast cancers are found by the woman or her
partner.
ï During pregnancy there is no special time of the
month that is best to perform the examination.
ï In non pregnant women 5days after cessation of
menstruation ,it is the optimum time to detect
changes.
âą Inspection in the shower
âą Inspection in the mirror
Done by Yosef A. 23
24. ï stand in front of the mirror for further inspection
a. With arms at sides
b. Holding arms over the head ,inspect closely in the mirror
for masses and breast symmetry
c. Press hands firmly on hips ,below slightly forward . inspect
in m Each breast should be mirror image of the other
d . Each breast should be mirror image of the other
e . Gently squeeze the nipple of each breast between your
thumb and index finger to check for signs of discharge or
bleeding . irror for lumps or pulling of the skin
Done by Yosef A. 24
25. Inspection on lying down
ï¶lying flat on your back ,with your right hand under
your head and a pillow or towel under your right
shoulder ,use your left hand to gently feel your right
breast using concentric circles to cover the entire
breast and nipple . repeat on your left breast.
Steps to Diagnosis
ï Clinical Exam
ï Mammography
ï Self Breast Exam
ï Biopsy if indicated
Done by Yosef A. 25
27. DISORDERS OF THE BREAST
Benign and malignant tumors of breast
ï What does benign means?
ï What does malignant means?
ï What is cancer?
ï Cancer is the name given to a large number of diseases.
ï Breast cancer begins in the breast tissue
ï Most kinds of cancer are named after the part of the
body where the cancer first start
27Done by Yosef A.
28. BENIGN BREAST CANCER
A. Fibrocystic breast disease
ï It is common benign breast disease in women of all
ages
ï It can occur as early as puberty when estrogen level
rises to adult level ,but is found most commonly in
women between the age of 20 and 45 year.
28Done by Yosef A.
29. Sign and symptoms
ïŒ Freely movable , well-delineated breast lump on
palpation
ïŒ Visible lump on the surface of breast
ïŒ Often occur on upper outer quadrant of the breast
ïŒ Consistency-firm and hard to soft and flexible
ïŒ Painful (may) and tender
ïŒ Round and fluid filled cyst.
29Done by Yosef A.
31. ContâŠ
Management
ï Analgesia
ï Avoidance of substances containing caffeine ,
theophylline and theobromine
ï Avoid smoking
ï Aspiration of cyst under local anesthesia
31Done by Yosef A.
32. ContâŠ
B . Fibro adenoma
ï¶Fibro adenoma are tumors consisting of both fibrotic
and glandular components that occur in response to
estrogen stimulation.
ï¶They tend to occur in young women and rarely seen
after menopause and are non malignant.
ï¶The tumors may increase in size during adolescence
,pregnancy and lactation or when a woman takes an
estrogen sources such as oral contraceptives.
32Done by Yosef A.
33. ContâŠ
Sign and symptoms
ï No pain(pain less) and freely movable
ï Round and well delineated tumors
ï Feel firmer and more rubbery
ï Occasionally calcify and feel extremely hard
ï Not cause skin retraction
ï Management
ï Surgical incision
33Done by Yosef A.
34. C. Carcinoma of the Breast
ï The carcinoma of the breast commonly occurs from30-
60 years of age.
Signs and symptoms
ï Lump and hard fixed mass
ï Pain in the breast
ï Blood stained discharge (late stage)
ï Retracted nipple of cancer has spread to the lymph
ï orange like colour of the skin .
34Done by Yosef A.