Breast Anatomy PDF

6. BREAST GROSS ANATOMY Mr Ernest A Azzopardi MD, MSc, PhD, MRCSEd, MRCSEng (Ad Eundem) MFSTEd, Dip Spec Laser, FRS Biol FRCSPLast Consultant plastic surgeon & laser specialist Royal College of Surgeons in England 2015 Hunte...

6. BREAST GROSS ANATOMY Mr Ernest A Azzopardi MD, MSc, PhD, MRCSEd, MRCSEng (Ad Eundem) MFSTEd, Dip Spec Laser, FRS Biol FRCSPLast Consultant plastic surgeon & laser specialist Royal College of Surgeons in England 2015 Hunterian Professor [email protected] With thanks to Prof M Camilleri Podesta, Thieme Publishers Lecture Structure – WHAT YOU NEED ON DAY 1 AS A DOCTOR Gross anatomy study of anatomy at the visible or macroscopic level Surgical Anatomy applied anatomy in reference to surgical diagnostics Practical and applied surgical anatomy – the basics Kindly note your lecture is meant as an introduction to the subject matter. It is EXPECTED that university students read around the topic. Gross anatomy… Lateral border of the sternum to the mid-axillary line. 2nd and 6th intercostal cartilages. Superficially to the pectoralis major and serratus anterior muscles. Body and axillary tail c axillary tail of spence. That is in the ideal, perfect, 70kg, young nulliparous female (which does not exist) Reconstrutive and Aesthetic anatomy We describe the breast as a cone with: BASE (circle where it touches the chest) Projection (the horizontal distance between the apex and base Profile (the distance from the inframammary fold to the nipple) The axillary tail Is the conduit between breast and axilla IT IS PART OF THE BREAST- DO NOT FORGET IT “NO TAIL, YOU FAIL”  NO TWO BREASTS ARE EQUAL, BUT THERE IS A DEGREE OF RELATIVITY. Think of the breasts on the chest as part of an equilateral triangle APPLIED ANATOMY The NIPPLES AND THE STERNAL NOTCH FORM THE ANGLES OF AN EQUILATERAL TRIANGLE APPROX Landmarks 21CM IN SIZE. THIS GETS BIGGER OR SMALLER DEPENDING ON STATURE THIS IS CALLED PENN’S MEASUREMENTS Remember breasts form INDEPENDENTLY FROM THE 3RD MAMMARY RIDGES, they are never equal or perfectly symmetric. -PLEASE REASSURE YOUR PATIENTS Summary of basic principles. Must know gross anatomy “book knowledge” plus: Applied anatomy “21cm triangle, varies with stature” Breast is a truncated cone, with a base, apex and a projection NO two breasts are identical. “sisters, NOT twins” Develop independently from 3rd mammary ridge Accessory breasts can develop along the milk line The Breast has important “regions or areas” “contemporary anatomy” First: Skin, fat and thoracic fascia Then: Subfascial parenchyma and stroma Posterior to the breast gland: Retromammary space also called subglandular space Posterior to pec major (anterior to pec minor): subpectoral space Structure Example of relevance skin & subcutaneous fat Preserved in “subcutaneous mastectomy The thoracic fascia When congenitally tight can impact development Posterior to breast gland and Subglandular (retromammary space): very anterior to pec major richly supplied with vessels crossing to gland. A subglandular implant is placed here retromammary space Beneath the pectoralis major but A subpectoral implant is inserted here in front of the pectoralis minor subjectoral space Classic anatomy: vasculature – breast Breast Medial aspect of the breast: internal thoracic artery The lateral part of the breast: multiple branches from the Thoraco-acromial axis Lateral thoracic Anterior intercostals VEINS The veins of the breast correspond with the arteries, draining into the axillary and internal thoracic veins and posterior intercostal veins Lymphatics Internal thoracic, axillary, posterior intercostal (following veins) Vascular supply to Nipple Areola Complex (Simple and Important!) IT IS DESCRIBED IN TERMS OF PEDICLES A pedicle is a block of tissue within which lies the blood supply to the target (in this case the nipple areola complex, NAC NAC has 4 pedicles Superior: descending branches of Thoraco acromial Medial: direct branches of internal thoracic Inferior: anterior intercostals running in gland and dermis Lateral: Lateral thoracic artery  Vascular supply to Nipple Areola Complex (Simple and Important!) Thoracoacromial artery from above Internal thoracic from medial Lateral thoracic Anterior intercostals (from inferior and deep Lymphatics Axillary lymph nodes can be divided into surgical levels by the PECTORALIS MINOR level 1: lying below pectoralis minor level 2: lying behind pectoralis minor level 3: lying between the upper border of pectoralis minor and lower border of rib 1 Nodes in higher levels imply higher surgical risk “upstaging” of the cancer Lymphatic Drainage Levels Rib 1 LEVEL 3 Pec minor LEVEL 2 Teres major ribs LEVEL 1 Questions  The Breast Contains which - approximately 15-2p independent exocrine secretory units open radially into the nipple. Location overlies rib 2 -rib from the lateral sternal angle to the mid axillary line - : 6. superficial layer of the chest wall. Blood supply subclavian artery - : axillary artery - The breast has a vast network of lymphatic vessels -> important for lymphatic drainage. Suckling of the back - the baby nipple by triggers the release of oxytocin -> causes contraction of the uterns important for the uterns to return to its original size after birth. Fascia ~ pectoralis L major minor - Areola (3cm of skin) = pigmented skin which surrounds the nipple. during pregnancy the colour of the areda becomes darker - since Montgomery's tubercles (swellings) become more prominent I apparent. The individual - secretory units of the mammary glands are separated by fibrous septae · lobule lactiferous ducts lactiferous - Direction of drainage of glands -> -> milk exits the nipple : -> sinuses mammary. Incisions made radially made parallel to septa - are -> the. The axillary tail - of spence -> extension of breast tissue. The axillary tail of spence extends upwards & laterally into the axilla , it could also penetrate the deep Fascia - unlike the actual breast which is a superficial structure. Clinical relevance it the axillary tail during breast - : is very important to examine of spence examination every. Breasts boated - are on the it doesn't attach to it pec. major -. - If breast indication diagnosis by how the breast when the lifted the becomes connected to the skin muscle -> of malignant disease observing arm is : or a moves Suspensory ligaments of Cooper-> fibrous tissue which connects breast tissue to the stain. When malignancy occurs : shortening dimpling , of overlying skint inverted nipples. With breasts stretched age are , this might also occur with fat deposition. Blood supply to the breast medial of the breast branches artery - perforating of internal thoracic : aspect :. lateral aspect of the breast : lateral mammary branches of lateral thoracic artery. the thoracoacromial artery. 2nd_gth intercostal arteries. drainage of the breast corresponding arteries mentioned above - Venous : veins of the subclavian vein brachiocephalic vein Breast Lymphatics Lymphatics follow the - veins. Subareolar lymph plexi - - located below the nipple. - Submammary plexi -> located between the pec major + the breast. Teathering in the breast to the muscle is due to the grouping of lymph nodes. between lymph plexi 3) connecting - Many vessels occur the subareolar the submammary plexi - this is the main way in which breast cancer spreads from one side to the other especially if the tumor is on the medial side of the breast). -Lymph drainage : Lateral drain in axillary nodes , then they pass in lymph vessels along the axillary artery el into the thoracic duct. Medial' drains into parasternal nodes along the internal thoracic artery and drains into the thoracic duct. ~ side By side The apical axillary nodes drain into the subclavian trunk. The pectoralis defines the 3 axillary nodes - minor levels of : Level 1 : lateral to pec miner Level 2 : deep to minor N B in mastectomies level /B level 2 removed , however the level 3 lymph nodes are pec. are. Level 3 : medial to pec minor Rept there.  * rudimentary -> limited function Peau d'Orange blockage of lymph malignancy - -> channels by Result the : breast swells up due to the undrained lymph The. breast then stretches out over the swollen skin. looks like orange peel an. -Lymphedema - swelling due to issues with lymphatic drainage. This may occur from the removal of axillary lymph nodes during an invasive breast cancer surgery. sedema of the upper limb. be confused confused - Accessory nipples when extra nipples arise These are harmless but with mole suspected melanoma may or :. a a. The male breast : resembles the female breast pre-puberty. less but fatal usually detected late carcinomas are common more in men since they are at a very stage. enlargement male breasts due to hormonal imbalances treatments gynaecomastia -> of which can occur or. Puberty females - in : Fat deposition & proliferation of secretary units occur in the breast. for lactation to occur substancial proliferation has to occur. atrophy - Menopause : of secretory units fat deposition.