breast and the axilla

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THE

BREAST

AND

THE

AXILLA

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ALL IMAGES, PICTURES

AND CLIPS

ARE TAKEN FROM VALID

RESOURCES FOR

EDUCATIONAL PURPOSES

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CONTENTSI. ANATOMY AND

PHYSIOLOGY

IV. PATHOPHYSIOLOGIC STATES AND OTHER FINDINGS

III. ASSESSMENT

V. DOCUMENTATION

I. ANATOMY AND PHYSIOLOGYA. BREAST

a. Location

b. Structures

c. Size, Shape and Appearance

d. Development

B. AXILLA, LYMPHATICS and BLOOD SUPPLY

a. Blood Supply

b. Lymph System

II. HEALTH HISTORY

II. HEALTH HISTORY

A. Ask about reason for seeking care.

B. Ask about personal and family medical

history

C. Ask about her current health

III. ASSESSMENT

A. BREAST

INSPECT

PALPATE

B. AXILLAE

INSPECT

PALPATE

IV. PATHOPHYSIOLOGIC STATES

a. Breast Nodule

b. Breast Dimpling

c. Peau d’orange

d. Nipple Retraction

e. Nipple Discharge

f. Pain

g. Visible Veins

h. Mastitis

V. DOCUMENTATION

B R E A S T

OF

THE

A N A T O M Y

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BREAST AND AXILLAI. ANATOMY AND PHYSIOLOGY

A. BREASTa. *Location

Anterior chest wallBetween 2nd / 3rd and the 6th / 7th ribsOver the pectoralis major muscleBetween the sternal border and the midaxillary line Superior lateral quadrant of breast extends diagonally upwards towards the axillae known as the tail of Spence.

I. ANATOMY AND PHYSIOLOGY / BREAST / Location

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b Structures

I. ANATOMY AND PHYSIOLOGY / BREAST / Structures

- pigmented erectile tissue located in the center of each breast

Areola

Nipple

– pink / brown pigmented region surrounding the nipple

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Glandular lobes – contains the alveoli that produce milk

Adipose tissue – surrounds glands and extends throughout the breast, gives the breast its size, shape and a soft consistency

Lactiferous ducts* – transport milk from each lobe to the nipple

Cooper’s ligaments * – fibrous bands attached to the chest wall musculature that support each breast

Connective tissues - collagen and elastin, gives breast its characteristic bounce

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! The male breast

resembles the rudimentary

female breast and has

no lobules or alveoli.

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c. Shape, Size & Appearance Depends on the support

Internal Support: Cooper’s ligaments, and the underlying chest on which they rest

External Support: Skin covering

I. ANATOMY AND PHYSIOLOGY / BREAST / Shape, Size and Appearance

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c. Shape, Size & Appearance

Factors that may influence a woman’s breast size include:

Volume of breast tissueThickness and elasticity of the

breast skinFamily historyAgeWeight loss or gainDegree of hormonal

influences on the breast such as estrogen and progesterone during pregnancies and lactation, and menopause

I. ANATOMY AND PHYSIOLOGY / BREAST / Shape, Size and Appearance

It is typical for a woman's breasts to be unequal in size particularly while the breasts are developing. Statistically it is slightly more common for the left breast to be larger.

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d. Development

I. ANATOMY AND PHYSIOLOGY / BREAST / Development

Before puberty Early puberty Late puberty - Adulthood

the breast is flat except for the nipple that sticks out from the chest

the areola becomes a prominent bud; breasts begin to fill out

glandular tissue and fat increase and becomes elastic, areola becomes flat

During pregnancy After pregnancy After menopause

the breast increase in size, areola darkens, nipples become larger and more erect, blood vessels within the breast enlarge

revert to previous size with some sagging and stretch marks

(p19)

decreased estrogen levels cause atrophy of breast tissue and fatty replacements, flabbier, nipples flatten, ducts feels like firm strings (p22)

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Human breast tissue begins to develop in the sixth week of fetal life.

I. ANATOMY AND PHYSIOLOGY / BREAST / Development (Uterine development)

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Breast tissue * initially develops along the lines of the armpits and extends to the groin (called the milk ridge).

I. ANATOMY AND PHYSIOLOGY / BREAST / Development (milk ridge & supernumerary nipples)

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I. ANATOMY AND PHYSIOLOGY / BREAST / Development (milk ridge & supernumerary nipples)

Supernumerary nipples develop

along the mammary line.

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Anne BoleynSecond wife to Henry VIII of England, and mother of Elizabeth I, is said have had a third nipple or even a third breast. This may well have been a slanderous rumour, as in Tudor times these "malformations" were considered to be a sign of the person having been a witch. The circumstances of her marriage to the king, who had divorced his first wife, made her a controversial figure.

Carrie Underwood

During her American Idol audition admitted to have had a third nipple which looked like a mole

Famous personalities or characters known to have Extra or Supernumerary nipples are….

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Krusty the Klown

In an episode of The Simpsons, Bart, among other things knows Krusty the Klown has a third nipple, to see if he isn't an imposter.

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I. ANATOMY AND PHYSIOLOGY / BREAST / Development / Tanner’s Stage

Tanner’s Stage expounds the 1st 3 columns on Breast Development found in page 11

Tanner's stages are based on studies of white English girls. An American survey found that black girls tended to advance more quickly. Genital and pubic hair development is also classified by Tanner.

Tanner's

stages

The preadolescent breast (Stage 1 per Tanner's sex maturity ratings) consists of a small elevated nipple with no significant underlying breast tissue.

Puberty begins (usually between ages of 8 and 13, average age is 11) with the development of breast tissue and pubic hair. With the hormonal changes of puberty, breast buds form. This second stage of breast development is the breast bud stage. Here, there is elevation of the breast and nipple as a small mound; the areola begins to enlarge. Milk ducts inside the breast begin to grow.

In Stage 3, there is further enlargement and elevation of the breast and areola (with no separation of their contours) The areola begins to darken in color. The milk ducts give rise to milk glands that also begin to grow.

Next, there is projection of the areola and nipple to form a secondary mound (stage 4).

In the mature adult breast (stage 5), there is projection of the nipple only (though in some woman the areola continues to form a secondary mound.

Edward Tanner also developed different Bra Classifications based on his Stages of Breast Development

B 36

32 B C 38

D 42

C 34

32 AA

36 A32A

30 AA

D / F / G / H

D / F / G / H

I. ANATOMY AND PHYSIOLOGY / BREAST / Development / Tanner’s Bra Classificaion

Breast and bra classification is as follows (from smallest to largest): A, B, C, D, and DD F, G, H (and larger) also exist. These biggest bra sizes are often needed by very large-breasted women, or women whose size increases with pregnancy and nursing. A training bra for developing girls (usually Tanner Stage 2, 3, or 4) is also available and is smaller than the A cup. This is sometimes called AA. (also known as Double D or sometimes called E). Though less common, the larger cup sizes of (double A)

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D 40

The breasts grow further during pregnancy. This growth is much more uniform than that at adolescence.

ANATOMY AND PHYSIOLOGY / BREAST / Development

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ANATOMY AND PHYSIOLOGY / BREAST / Development

Breasts sag if the ligaments become elongated, a natural process that can occur over time and by gravity (like the breast bouncing while exercising).

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After pregnancy

The breasts revert to previous size with some sagging and stretch marks

To avoid the post-pregnancy effects on the breast, some women wears Pregnancy Support bras. This woman admits to wear Support bras during pregnancy.

“I wear Support bras

almost 24 hrs. a day. I only remove

it when taking the shower!

-Sweet Life

The breasts of an aging woman diminish in size as the milk glands degrade. The breasts often become more saggy as this occurs and as the effects of gravity pull the breast tissue downwards.

I. ANATOMY AND PHYSIOLOGY / BREAST / Development / Tanner’s Stage

Because the breasts become less dense after menopause, it is often easier for radiologists to detect breast cancer on an older woman’s mammogram films, since abnormalities are not hidden by breast density.

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B. AXILLA, LYMPHATICS and BLOOD SUPPLY

a. Blood Supply:Arterial – internal & lateral thoracic artery, thoracoacromial artery, posterior intercostal arteries

ANATOMY AND PHYSIOLOGY / AXILLA, LYMPHATICS & BLOOD SUPPLY / Lymph System

The internal thoracic artery arises from the subclavian artery near its origin.

It travels downward on the inside of the ribcage, approximately a centimeter from the sides of the sternum, and thus medial to the nipple.

It runs posterior to the internal intercostal muscles, but anterior to the transverse thoracic muscles.

It continues downward until it divides into the musculophrenic artery and the superior epigastric artery around the sixth intercostal space.

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Arteries carry oxygen rich blood from the heart to the chest wall and the breasts and veins take de-oxygenated blood back to the heart. The axillary artery extends from the armpit and supplies the outer half of the breast with blood; the internal mammary artery extends down from neck and supplies the inner portion of the breast.

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Venous – axillary vein, internal thoracic vein, intercostal veins


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b. Lymph system - cleansing system for cellular waste in the body. It picks up leaked fluid, disposes of debris in the lymphatic stream and houses white blood cells involved in immunity.


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They are thin channels similar to blood vessels;

they do not carry blood but collect and carry tissue fluid which ultimately re-enters

the blood stream.

Debris moves through the balancing processes of various pressure gradients.

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It is a one-way transport system that can get easily clogged because it doesn’t have a pumping system of its own but rather the lymph itself is contractile that could propel the fluid ahead or, as a resistance vessel which have valves tending to stop the lymph in its place.

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c. Lymph systems: * Pectoral nodes

- Anterior, along the border of the pectoralis major inside the anterior axillary fold

- drains the anterior chest wall (upper half of the trunk) and much of the breast.

Subscapular nodes - Posterior nodes, along the lateral border of the scapula;

palpated deep in the posterior axillary fold- drains posterior chest wall, axillary tail of the breast and

portion of the arm

Brachial / Humeral nodes- Lateral nodes, located along the upper humerus- drains most of the arm

Midaxillary nodes- Central nodes, lie along the chest wall, high in the axilla,

midway between the anterior and posterior axillary folds, most frequently palpable

- drains 3 other groups of lymph nodes which are seldom palpable

I. ANATOMY AND PHYSIOLOGY / AXILLA, LYMPHATICS & BLOOD SUPPLY / Lymph System

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I. ANATOMY AND PHYSIOLOGY / AXILLA, LYMPHATICS & BLOOD SUPPLY / Lymph System *

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I. ANATOMY AND PHYSIOLOGY / AXILLA, LYMPHATICS & BLOOD SUPPLY / Lymph System *

The lymphatic drainage of the breasts and other organs is particularly relevant to oncology, specifically to the diagnosis and treatment of cancer.

The lymphatic system, because of its physical proximity to many tissues of the body, is responsible for carrying cancerous cells between the various parts of the body in a process called metastasis.

The intervening lymph nodes can trap the cancer cells. If they are not successful in destroying the cancer cells the nodes may become sites of secondary tumors.

The cancer cells can also break away from a tumour and spread to other parts of the body through the lymph system.

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CONTENTS

II. HEALTH HISTORY

II. HEALTH HISTORY


B. Ask about personal and family medical

history

C. Ask about her current health

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II. HEALTH HISTORY


• *Breast pain

• Nipple discharge

• Nipple rash

• Lumps

• Masses

• Other changes

II. HEALTH HISTORY / REASON FOR SEEKING CARE

II. HEALTH HISTORY / REASON FOR SEEKING CARE

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Ask about personal and family medical history

a. Personal history – benign breast disease with biopsy findings of atypical

hyperplasia or lobular carcinoma in situ carry significantly increased risks

• Breast lumps• Biopsy• *Breast surgery – enlargement or reduction• *Breast disease – breast cancer,

fibroadenoma, fibrocystic disease

II. HEALTH HISTORY / PERSONAL AND FAMILY MEDICAL HISTORY

Capsular fibrosis

Gynecomastia in males

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II. HEALTH HISTORY / PERSONAL AND FAMILY MEDICAL HISTORY

a.2. Periods and pregnancies *Patient’s menstrual cycleDate of last menstruationNumber of pregnancies and live birthsPatient age during pregnanciesComplicationsBreastfeeding

b. *Family history Breast disorder

Breast cancerOther types of cancer

early menarche, late

menopause, and 1st live

birth after age 35 or no

pregnancy all raise the risk

of breast cancer two or

three-fold

!

having

a close

relative with

breast cancer

greatly

increases the

patient’s risk

of having the

disease

!

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c. Breast Health Exams • Breast Health Practices

• Self-breast exam• Mammography• Clinical Breast Exam

• *Frequency of Health Exams

II. HEALTH HISTORY / CURRENT HEALTH

Women with a family

history of or a

genetic

predisposition for

breast cancer – as

well as women who

have a personal

history of cancer –

may need earlier or

more frequent

screening tests and

examinations.

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Ask about her current healtha. Breast changes

• Description - pain, tenderness, discharge, rash• Age- some parts of changes are a normal part of aging• Time of occurrence • Underarm changes• *Medications

Birth control pills – cause breast swelling and tenderness

*Contraceptive patches Vaginal ring with estrogen

• *Diet – caffeine, linked to fibrocystic disease of breasts• Lifestyle – has a possible link to breast cancer

Stress*Smoking *Alcohol drinking

II. HEALTH HISTORY / CURRENT HEALTH

If you smoke, you’re also inhaling arsenic, benzene,

cadmium, hydrogen cyanide, lead,

mercury, including 44 types of poison,

of which 43 are proven cancer-

causing substances.-Sun.Star Cebu

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An increase in breast size is a common side effect of use of contraceptive pill.

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III. ASSESSMENT

III. ASSESSMENT

A. BREAST

INSPECT

PALPATE

B. AXILLAE

INSPECT

PALPATE

CONTENTS

breast and the axilla

Education

breast nodule

breast dimpling

left breast

physiology breast shape

physiology breast location

womans breast size

atrophy of breast tissue

human breast tissue