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Clinical Anatomy Clinical Anatomy of the Breastof the BreastDr. Roger A. Dashner
Clinical Anatomist & CEOAdvanced Anatomical Services
Adjunct Associate ProfessorOU College of Health Sciences & Professions
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Introduction to the BreastIntroduction to the Breast• Breasts (mammary glands) = modified sweat glands
• Lie in supf. fascia ant. to deep fascia of pec. major
• Btwn. glands & deep fascia is retromammary space
• (i.e., loose CT plane allowing free movement)
• Thus, glands NOT firmly attached to deep fascia
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Suspensory (Cooper’s) Ligaments
• Glands ARE firmly attached to skin via CT
• Fibrous septa anchor deep layer of skin to deep fascia
• These CT septa are called suspensory ligs.
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Pec. Fascia & Susp. Ligs.Pec. Fascia & Susp. Ligs.
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Structure of the Breast• Compartmentalized fat bounded by CT septa
• Glandular lobules drained by 15-20 lactiferous ducts
• Lactiferous ducts converge & open onto nipple
• Areola surrounds nipple & conceals sebaceous glands
• (i.e., produce lubrication for nipple)
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CompartmentalizationCompartmentalization
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Gland Lobules & Lac. DuctsGland Lobules & Lac. Ducts
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Four QuadrantsFour Quadrantsof the Breastof the Breast
• Upper outer (superolateral) quadrant
• Upper inner (superomedial) quadrant
• Lower outer (inferolateral) quadrant
• Lower inner (inferomedial) quadrant
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4 Quadrants of the Breast4 Quadrants of the Breast
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Clinical Notes onClinical Notes onBreast CancerBreast Cancer
• Majority of cancers develop in upper outer quadrant
• Large amount of glandular tissue here
• An axillary tail of breast tissue often extends into axilla
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Axillary Tail of the BreastAxillary Tail of the Breast
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Early Breast CarcinomaEarly Breast Carcinoma
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Advanced Breast CancerAdvanced Breast Cancer• Tumors may grow thru retromammary space
• Subsequently invade deep fascia & pec. major m.
• Leads to fixation of malignant breast lesion to chest wall
• Shortens suspensory (Cooper’s) ligs.
• Leads to irregular dimpling of skin or retraction of nipple
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Advanced CarcinomaAdvanced Carcinoma
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Four BoundariesFour Boundariesfor a Mastectomyfor a Mastectomy
• Clavicle – superior boundary
• Inframammary fold (above rectus sheath) – inferior boundary
• Sternum (midline) – medial boundary
• Latissimus dorsi (ant. border) – lateral boundary
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Mastectomy BoundariesMastectomy Boundaries
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The AxillaThe Axilla
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Contents of the AxillaContents of the Axilla• Axillary sheath (axillary a. & brachial plexus)
• Axillary v. & lymphatics (outside sheath)
• Fat & connective tissue
• Cutaneous nerves
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Contents of the AxillaContents of the Axilla
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The Axillary ArteryThe Axillary Artery• Arises from subclavian a. at lat. border of 1st rib
• Becomes brachial a. at infr. border of teres major
• Surrounded by cords & brs. of brachial plexus
• Can be divided into 3 parts relative to pec. minor
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Axillary Artery (Exposed)Axillary Artery (Exposed)
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Axillary Artery (Concealed)Axillary Artery (Concealed)
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3 Parts of the Axillary Artery 3 Parts of the Axillary Artery • Part 1 – btwn. 1st rib & pec. minor
• (i.e., gives off supr. thoracic a.)
• Part 2 – deep to pec. minor
• (i.e., gives off thoracoacromial & lat. thoracic aa.)
• Part 3 – btwn. pec. minor & teres major
• (i.e., gives off subscapular, ant. & post. circ. humeral aa.)
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3 Parts of the Axillary A.3 Parts of the Axillary A.
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Vessels of the BreastVessels of the Breast• Enter from supr./med. & supr./lat. aspects
• Penetrate deep surface of breast
• Exhibit extensive brs. & anastomoses
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Anastomoses of the BreastAnastomoses of the Breast
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Arterial SupplyArterial Supplyof the Breastof the Breast
• Lateral (mammary) thoracic a.
• Internal (mammary) thoracic a.
• Intercostal aa.
• Thoracoacromial a.
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Lateral (Mammary)Lateral (Mammary)Thoracic ArteryThoracic Artery
• Branch of axillary a. (under pec. minor)
• Located along lat. aspect of thorax
• Supplies lat. thorax & lat. mammary gland
• Specific blood supply from lat. mammary brs.
• Runs with lat. thoracic v. & long thoracic n.
• Vein is a tributary to axillary v.
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Internal (Mammary)Internal (Mammary)Thoracic ArteryThoracic Artery
• Branch of subclavian a.
• Located inside thorax just lat. to sternum
• Descends vertically across intercostal spaces
• Supplies ant. thorax & med. mammary gland
• Specific blood supply from med. mammary brs.
• Runs with int. thoracic v.
• Vein is a tributary to brachiocephalic v.
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Lateral & Internal Thoracic Aa.Lateral & Internal Thoracic Aa.
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Lateral & Internal Thoracic Vv.Lateral & Internal Thoracic Vv.
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Intercostal ArteriesIntercostal Arteries• Brs. of aorta or int. (mammary) thoracic aa.
• Located in intercostal spaces (btwn. ribs)
• Supply ant., post. & lat. thorax & breast
• Specific blood supply is from lat. mammary brs.
• (i.e., lat. cutaneous brs. of post. intercostal aa.)
• Run with intercostal vv. & nn.
• Veins are tributaries to azygos v. or int. thoracic v.
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Lateral Mammary Brs.Lateral Mammary Brs.
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Intercostal ArteriesIntercostal Arteries
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Intercostal VeinsIntercostal Veins
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Thoracoacromial ArteryThoracoacromial Artery• Branch of axillary a. (under pec. minor)
• Located in ant. shoulder region
• Sends off 4 subsequent brs.
• Not generally major source of blood supply to breast
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Four Branches of theFour Branches of theThoracoacromial ArteryThoracoacromial Artery
• Pectoral br. – supplies pectoral region & upper breast
• Clavicular br. – supplies clavicle region
• Acromial br. – supplies upper shoulder region
• Deltoid br. – supplies lower shoulder region
• All accompanying vv. are tributaries to axillary v.
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Thoracoacromial ArteryThoracoacromial Artery
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Additional Venous Additional Venous Drainage of the BreastDrainage of the Breast
• Cephalic v.
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Cephalic VeinCephalic Vein• Tributary to axillary v.
• Only major supf. v. in vicinity of breast
• Primarily drains UL into deltopectoral triangle
• Some supf. venous drainage of breast
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Cephalic VeinCephalic Vein
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Nerves of the BreastNerves of the Breast• Cutaneous innervation
• Medial pectoral n.
• Lateral pectoral n.
• Long thoracic n.
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Cutaneous InnervationCutaneous Innervation• Via general sensory brs. of T1-T6
• (i.e., lat. & ant. cutaneous brs. of intercostal nn.)
• Note: T2 is of specific clinical significance
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Cutaneous InnervationCutaneous Innervation
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Intercostobrachial NerveIntercostobrachial Nerve• Lat. cutaneous branch of T2
• Emerges from 2nd intercostal space
• Supplies skin on med. & post. arm
• Assoc. with referred pain from angina or heart attacks
• Heart symp. nn. carry afferents back to upper thoracic cord
• Visceral heart pain referred to somatic thoracic nn.
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Intercostobrachial NerveIntercostobrachial Nerve
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Medial Pectoral NerveMedial Pectoral Nerve• Branch of med. cord of brachial plexus
• Derived from ventral rami of C8-T1
• Pierces pec. minor to enter pec. major
• Supplies pec. minor & part of pec. major
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Lateral Pectoral NerveLateral Pectoral Nerve• Branch of lat. cord of brachial plexus
• Derived from ventral rami of C5-C7
• Runs above pec. minor to enter pec. major
• Supplies remainder of pec. major
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Med. & Lat. Pectoral Nn.Med. & Lat. Pectoral Nn.
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Long Thoracic NerveLong Thoracic Nerve• Derived from ventral rami of C5-C7
• Supplies serratus anterior superficially
• (i.e., holds UL to thoracic wall)
• Damage to this n. can occur during mastectomy
• Results in “winged scapula”
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Long Thoracic NerveLong Thoracic Nerve
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““Winged ScapulaWinged Scapula””
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Lymphatics of the BreastLymphatics of the Breast• Drain lymph from breast to series of nodes
• Lat. drainage is via 5 groups of axillary nodes
• Supr. drainage is via 1 group of interpectoral nodes
• Med. drainage is via 1 group of parasternal nodes
• Ultimate drainage is via subclavian lymph trunk to vv.
• (i.e., jxn. of subclavian v. & IJV)
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Lymphatic DrainageLymphatic Drainage
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Lymph Nodes of the BreastLymph Nodes of the Breast• Pectoral (anterior) nodes
• Subscapular (posterior) nodes
• Humeral (lateral) nodes
• Central nodes
• Apical nodes
• Interpectoral (Rotter’s) nodes
• Parasternal nodes
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Lymph Nodes of the BreastLymph Nodes of the Breast
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Vascular Associations ofVascular Associations ofthe Breast Lymph Nodesthe Breast Lymph Nodes
• Pectoral – assoc. with lat. thoracic vessels
• Subscapular – assoc. with subscapular vessels
• Humeral – assoc. with distal (3rd) part of axillary v.
• Central – assoc. with middle (2nd) part of axillary v.
• Apical – assoc. with proximal (1st) part of axillary v.
• Interpectoral – assoc. with pectoral vessels
• Parasternal – assoc. with int. thoracic vessels
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Vascular AssociationsVascular Associations
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Clinical Notes on AxillaryClinical Notes on AxillaryLymph Node DissectionsLymph Node Dissections
• 3 Levels of surgical dissections relative to pec. minor
• (i.e., opposite arrangement of 3 parts of axillary vessels)
• Level I – below (lateral to) pec. minor
• Level II – deep to pec. minor
• Level III – above (medial to) pec. minor
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Pectoralis Minor DissectionsPectoralis Minor Dissections
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Clinical Significance ofClinical Significance ofBreast LymphaticsBreast Lymphatics
• Cancer cells tend to spread along lymph passages
• Typical spread is supr./laterally to axillary lymph nodes
• More than 75% of drainage via axillary lymph nodes
• Most remaining drainage is medially to parasternal nodes
• Unilateral lymphatic blockage may occur
• Lymph (with cancer cells) can then drain to opposite side
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Drainage to Opposite SideDrainage to Opposite Side
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The EndThe End
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ReferencesReferences• Agur, A.M.R. & A.F. Dalley. Grant’s Atlas of Anatomy, 12th Ed.,
Lippincott Williams & Wilkins, Baltimore, MD, 2009.• Clemente, C. Anatomy: A Regional Atlas of the Human Body,
5th Ed., Lippincott Williams & Wilkins, Baltimore, MD, 2006.• Moore, K.L., A.F. Dalley & A.M.R. Agur. Clinically Oriented
Anatomy, 6th Ed., Lippincott Williams & Wilkins, Baltimore, MD, 2010.
• Netter, F.H. The CIBA Collection of Medical Illustrations, Volume 2: Reproductive System. CIBA-Geigy, Summit, NJ, 1986.
• Netter F.H. Atlas of Human Anatomy, 4th Ed., Saunders Elsevier, Philadelphia, PA, 2006.
• Tank, P.W. Grant’s Dissector, 14th Ed., Lippincott Williams & Wilkins, Baltimore, MD, 2009.