1. Dr. Mayur Patel
(M.S. General Surgeon)
B.J. Medical college,
Civil Hospital,
Ahmedabad.
2. Introduction
• Latin word Breast = Mammary gland.
• Modified sweat gland.
• Accessory organ of female reproduction system.
3. Situation and extend
• Lies in superficial fascia of pectoral
region.
• Extended
Vertically - from 2nd to 6th ribs.
Horizontally – lateral border of sternum
to maxillary line
• Lies on deep fascia (pectoral fascia)
and separated from fascia by retro
mammary space.
2nd RIB
6th RIB
Pectoral fascia
Pectoralis minor
Pectoralis Major
Retro mammary
space
5. Situation and extend
• Lymphatics are present in retro
mammary space.
• That is why in MRM we dissect the
breast tissue with pectoral fascia.
6. Situation and extend
• Breast is divided in four quadrants
1. Upper inner
2. Upper outer
3. Lower outer
4. Lower inner
• Nipple areola complex should be
mentioned separately while
describing breast examination.
7. Situation and extend
• Upper lateral quadrant has lateral
extension – known as axillary tail of
Spence.
• It piers deep pectoral fascia – known
as foramen of langer.
• It has direct communication with
anterior group of axillary lymph
nodes.
• That is why we need to remove
axillary LN with breast tissue with
connecting axillary tail in continuity.
8. Structure of breast
• It can be divided in 3 components
1. Skin with nipple areola
2. Parenchyma
3. Stroma
9. Structure of breast
• Nipple
- A conical projection
- Present just below the centre of the
breast at the level of the fourth
intercostal space 10 cm from the midline.
- The nipple is pierced by 15 to 20
lactiferous ducts.
- It contains circular and longitudinal
smooth muscle fibres which can make the
nipple stiff or flatten it, respectively.
- It has a few modified sweat and
sebaceous glands.
10. Structure of breast
• Areola
- Pigmented skin surrounding Nipple.
- Rich in modified sebaceous glands,
particularly at its outer margin. These
become enlarged during pregnancy
and lactation to form raised tubercles
of Montgomery.
- Oily secretions of these glands
lubricate the nipple and areola, and
prevent them from cracking during
lactation.
11. Structure of breast
• Areola
- Apart from sebaceous glands, the
areola also contains some sweat
glands, and accessory mammary
glands.
- The skin of the areola and nipple is
devoid of hair, and there is no fat
subjacent to it.
- Below the areola lie lactiferous sinus
where stored milk is seen.
12. Structure of breast
• Langer’ lines
- Circumareolar incision Webster’s
incision
- Submammary incision Galliard
Thomas incision
- In upper quadrants – Incision if away
from NAC then it should be along the
langer’s line
- But in lower quadrants – it should be
radial to prevent NAC displacement
downward.
13. Structure of breast
• Parenchyma
- It is a compound tubulo-alveolar gland
which secretes milk.
- The gland consists of 15 to 20 lobes.
- Each lobe is a cluster of alveoli, and is
drained by a lactiferous duct.
- The lactiferous ducts converge
towards the nipple and open on it.
- Near its termination each duct has a
dilatation called a lactiferous sinus
14. Structure of breast
• Alveolar epithelium
- cuboidal in the resting phase
- columnar during lactation.
• The smaller ducts
- columnar epithelium
• The larger ducts
- two or more layers of cells
- the terminal parts of the
lactiferous ducts by stratified
squamous keratinised epithelium.
15. Structure of breast
• The passage of the milk from the
alveoli into and along the ducts is
facilitated by contraction of
myoepitheliocytes, which are found
around the alveoli and around the
ducts, lying between the epithelium
and the basement membrane.
16. Structure of breast
• Stroma
- Stroma forms the supporting
framework of the gland.
- It is partly fibrous and partly fatty.
- There are fibrous bands that provide
structural support and insert
perpendicularly into the dermis,
termed the suspensory ligaments of
Cooper.
That is why if involvement of cooper’s
ligament skin retraction
17. Blood supply
• The mammary gland is
extremely vascular.
1. Internal thoracic artery, a
branch of the subclavian
artery, through its perforating
branches.
2. The lateral thoracic, superior
thoracic and acromiothoracic
(thoracoacromial) branches of
the axillary artery.
3. Lateral branches of the
posterior intercostal arteries.
18. Blood supply
• The mammary gland is
extremely vascular.
1. Internal thoracic artery, a
branch of the subclavian
artery, through its perforating
branches.
2. The lateral thoracic, superior
thoracic and acromiothoracic
(thoracoacromial) branches of
the axillary artery.
3. Lateral branches of the
posterior intercostal arteries.
19. Blood supply
First Part –
• Origin to Medial border of scalene
anterior
1. Vertebral artery
2. Internal thoracic artery Continue
as superior epigastric artery.
3. Thyrocervical trunk
Second Part –
• Behind scalene anterior
1. Costocervical trunk
Third Part –
• Lateral border of scalene anterior and
medial border of first rib.
1. Dorsal scapular artery.
Subclavian artery
21. Blood supply
First Part –
• Superior to the pectoralis minor
1. Superior thoracic artery (Supreme
thoracic artery)
Second Part –
• Posterior to the pectoralis minor
1. Thoraco-acromian artery
2. Lateral thoracic artery
Third Part –
• Inferior to the pectoralis minor.
1. Subscapular artery
2. Anterior circumflex humoral artery
3. Posterior circumflex humoral artery
Axillary artery
25. Lymphatic drainage
• The lymphatics from the deep
surface of the breast pass through
the pectoralis major muscle and the
clavipectoral fascia to reach the
apical nodes, and also to the internal
mammary nodes.
26. Lymphatic drainage
• Lymphatics from the lower and inner
quadrants of the breast may
communicate with the sub
diaphragmatic and sub peritoneal
lymph plexuses after crossing the
costal margin and then piercing the
anterior abdominal wall through the
upper part of the linea alba.
27. Lymphatic drainage
• Three anatomic levels defined by their
relationship to the pectoralis minor
muscle.
1. Level I nodes are located lateral to
the lateral border of the pectoralis
minor muscle.
2. Level II nodes are located posterior
to the pectoralis minor muscle.
3. Level III nodes include the sub
clavicular nodes medial to the
pectoralis minor muscle.
28. Lymphatic drainage
• The anterior (pectoral) group lie along
the lateral thoracic vessels.
• The posterior (scapular) group lie
along the subscapular vessels.
• The lateral group lie along the upper
part of the numerus, medial to the
axillary vein.
• The central group lie in the fat of the
upper axilla.
• The apical (infraclaaicular) group lie
deep to the clavipectoral fascia, along
the axillary vessels.
29. Lymphatic drainage
• Lymph nodes in the space between
the pectoralis major and minor
muscles are termed the interpectoral
group, or Rotter’s nodes.
