Anatomy of the breast

Yapa Wijeratne
Faculty of Medicine
University of Peradeniya
Modified sweat gland- modified apocrine gland
Made up of 1520 lobules of glandular tissue
embedded in fat.
Fat accounts for its smooth contour and most of
its bulk.
These lobules are separated by fibrous septa
running from the subcutaneous tissues to the
fascia of the chest wall (the ligaments of Cooper/
Astley Cooper fibers/ suspensory ligaments)
Between the capsule and the fascia over pectoralis
major is the loose connective tissue of the
retromammary space.
Each lobule drains by its lactiferous
duct on to the nipple, which is
surrounded by the pigmented areola.
This area is lubricated by the areolar
glands of Montgomery
large,
modified sebaceous glands may form
sebaceous cysts may infected.
Surface anatomy
Naming the quadrants for the
purpose of describing a lump
Or
1. Upper medial
quadrant
2. Upper lateral
quadrant
3. Lower medial
quadrant
4. Lower lateral
quadrant
Position & extent

2/3 rests on
pectoralis major,
1/3 on serratus
anterior,
while its lower
medial edge just
overlaps the upper
part of the rectus
sheath.
Cross section
Blood supply
Axillary artery
Lateral thoracic (mainly)
Acromiothoracic branches.
Internal thoracic (internal mammary) artery
perforating branches; these pierce the 1 st
4th intercostal spaces, then traverse pectoralis
major to reach the breast along its medial
edge. The 1st & 2nd perforators are the largest
of these branches.
Intercostal arteries lateral perforating
branches- relatively unimportant source.
Venous drainage
Venous drainage
Sub areolar venous plexus
Posterior intercostal veins
communicate with internal vertebral
venous plexus veins - therefore
cancers can spread to vertebra- may
cause back pain
Lymphatic drainage
Follows the pathway of its blood supply
along tributaries of the
1. axillary vessels axillary lymph nodes;
2. internal thoracic vessels piercing
pectoralis major to traverse each
intercostal space to lymph nodes along
the internal mammary chain; these also
receive lymphatics penetrating along the
lateral perforating branches of the
intercostal vessels.
A subareolar plexus of lymphatics
below the nipple (the plexus of
Sappey)
75% axillary
15% internal mammary
Upper can go to supraclavicular
Lower 2 quadrants can go to
subdiapragmatic or abdominal nodes
Dermatomal supply
Development and structure
Begins to develop as early as the 4th week as a
downgrowth from a thickened mammary ridge
(milk line) of ectoderm along a line from the axilla
to the inguinal region.
Supernumerary nipples or even glands proper may
form at lower levels on this line.
Lobule formation occurs only in the female breast
& does so after puberty.
Each lactiferous duct is connected to a tree-like
system of ducts and lobules, intermingled &
enclosed by connective tissue to form a lobe of the
gland.
The resting (non-lactating) breast, however
consists mostly of fibrous & fatty tissue;
variations in size are due to variations in fat
content, not glandular tissue which is very
sparse.
During pregnancy alveoli bud off from the smaller
ducts & the organ usually enlarges significantly, &
more so in preparation for lactation.
When lactation ceases there is involution of
secretory tissue.
After menopause progressive atrophy of lobes &
ducts takes place.
The male breast
Resembles the rudimentary female
breast
has NO lobules or alveoli.
The small nipple and areola lie over
the 4th intercostal space.
Test your knowledge
1. The retromammary space is located
between which of the following
structures?
(A) skin and the areola
(B) pectoralis major and minor
(C) breast and deep pectoral fascia
(D) suspensory ligament and the skin
(E) lactiferous sinus and the nipple
Answer
(C) Between the breast and deep
pectoral fascia is a loose connective
tissue plane or potential space known
as the retromammary space
2.The mammary glands are modified
versions of which type of gland?
(A) sebaceous gland
(B) lymph gland
(C) sweat gland
(D) tonsillar tissue
(E) endocrine gland
Answer
(C) The mammary glands are modified
sweat glands
3. Which of the following does NOT
supply the breast with blood?
(A) lateral thoracic artery
(B) thoracoacromial artery
(C) posterior intercostals arteries
(D) internal thoracic artery
(E) costoclavicular artery
Answer
(E) The breast is supplied by the
1. internal thoracic,
2. lateral thoracic,
3. thoracoacromial, and posterior
4. intercostal arteries
4. The high death rate associated with
breast cancer is related to which of the
following?
(A) nerve supply
(B) blood supply
(C) venous drainage
(D) poor imaging techniques
(E) complex lymphatic drainage
Answer
(E)Because the axillary lymph nodes are the
most common site of metastases from a breast
cancer, enlargement of the palpable nodes in a
woman suggests the possibility of breast
cancer and may be key to early detection.
However, the absence of enlarged axillary
nodes is no guarantee that metastasis from a
breast cancer has not occurred, because the
malignant cells may have passed to other
nodes, such as the infraclavicular and
supraclavicular lymph nodes
5. Which statement most appropriately
describes the female breast?
1. It overlies the 3rd to 8th ribs.
2. It consists of 23 lobules.
3. It has suspensory ligaments, which tether
the dermis to the fascia of the chest wall.
4. The retro-mammary space lies deep to
pectoralis major.
5. The areolar glands are responsible for
lactation.
Answer
c. The dermis is tethered to the breast
ducts and the deep fascia overlying
pectoralis major by fibrous strands
known as the suspensory ligaments of
Cooper. As these atrophy and weaken
with age the breast becomes more
pendulous.
Explanations
a. The base of the adult female breast consistently overlies the
2nd to 6th ribs, from the sternal edge to the midaxillary line.
The upper outer quadrant extends towards the axilla as the
axillary tail.
b. The breast consists of 1520 lobules of glandular tissue, all
individually drained by a corresponding lactiferous duct, which
empty at the nipple via the lactiferous sinus.
d. The retro-mammary space is located between the posterior
capsule of the breast and the fascia over pectoralis major. This
space is commonly exploited in the placement of implants.
e. The areolar glands of Montgomery are modified sebaceous
glands located beneath the areola and are responsible for
lubricating the area. These glands may enlarge or become
infected, especially during pregnancy.
6. Which of these statements are true
considering the vasculature and
lymphatic drainage of the breast?
1. The main blood supply is derived from
branches of the internal mammary artery.
2. Venous drainage is predominantly to the
internal mammary vein.
3. Lymphatic drainage is divided evenly
between the axillary and internal
mammary nodes.
4. The superficial lymphatics of each breast
remain separate in healthy people.
5. All the axillary lymphatics drain through
the apical axillary nodes.
Answer
e. There are five main groups of
nodes in the axilla. The anterior,
posterior, lateral and central groups
empty into the apical group. The
apical nodes drain into the subclavian
lymph trunk.
Explanations
a.The main supply is via the lateral thoracic and thoracoacromial
branches of the axillary artery. The internal mammary (internal
thoracic) artery supplies a significant part of the medial aspect via
perforating branches. The posterior intercostal arteries also make
a minor contribution.

b. Venous drainage follows the arterial supply of the breast and is

primarily to the axillary vein.

c. Approximately 75% of drainage is to the axillary lymph nodes,

primarily to the anterior group. The majority of the remaining
drainage, especially of the medial part, is to the internal
mammary nodes.

d.The superficial lymphatics have connections with the opposite

breast and anterior abdominal wall. If the normal drainage
channels become obstructed by malignant disease, metastatic
spread may, therefore, occur to the contralateral breast or axillary
nodes.
Name the anatomical structure/s
involved
Pt who is found to have a breast lump also
having a lump in the axilla?
LN enlargement
There is a dimpling of the overlying skin of the
breast
Suspensory ligaments of Cooper- lump is
pulling down the fibers.
You suspect it is malignant & try to move the
lump while the pt presses her hip with her
hands. Lump movement reduces.
Involvement of the pectoralis major & fascia
What directions would you move the
lump?
Diagonally to the midline
Pt is now undergoing a mastectomy.
Surgeon found LN involvement. He
wants to assess the level of
involvement. What is the landmark
would you choose?
Pectoralis minor
Ifshe is willing to reconstruct the
breast, what muscles can be used?
Latissimusdorsi muscle (an LD flap)
Transversus abdominis muscle (TRAM flap)
Now the Pt has undergone the L/S
mastectomy. She complains of L/S
upper limb swelling.
Removal of axillary LNs which drains
L/s upper limb lymphatics
Pt also complains of parasthesia of
the left axillae
Damage to the left
intercostobrachial nerve
Thank you!