S U R G I C A L A N A T O M Y O F B R E A S T

Dr. Ahmed Almumtin

I N T R O D U C T I O N

• A modified sweat gland.

• 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).

Compartmentalisation Gland Lobules & Lac. Ducts

• lies over the 2nd - 6th rib.

• Two-thirds rests on pectoralis major.

• One-third lies on the serratus anterior.

• The lower medial edge overlaps the upper part of the rectus sheath.

• Medially from the sternal edge, to the mid-axillary line

F O U R Q U A D R A N T S A N D A TA I L

• 4 quadrants.

• Majority of cancers develop in upper outer quadrant.

• Large amount of glandular tissue here.

• An axillary tail

R E T R O M A M M A R Y S PA C E

• Reteromammary space: is loose auroral tissue that separates then breast from the pectoralis major muscle.

• The retromammary space is often the site of of breast implantation due to its location away from key nerves and structure that support the breast.

S U R FA C E A N D A E S T H E T I C S

• The tail of Spencer.

• Determinants of aesthetics.

L I G A M E N T S

• Cooper’s ligament.

• Suspensory ligament of the breast.

• Fibrous septa anchor deep layer of skin to deep fascia.

• superfacial (avascular plane) separates the glandular portion and adipose portion.

Astley Cooper

I N F R A S T R U C T U R E

• Tumors may grow through 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

A P P L I E D C L I N I C A L A N AT O M Y

• Skin dimpling.

• Nipple retraction.

• Peau d'orange

• Lymphoedema of ipsilateral upper limb post-mastectomy.

B L O O D S U P P LY

• Vessels of the Breast

• Enter from supr./med. & supr./lat. aspects

• Penetrate deep surface of breast.

• Exhibit extensive branches. & anastomoses.

A R T E R I A L S U P P LY T O T H E B R E A S T

• Lateral (mammary) thoracic a.

• Internal (mammary) thoracic a.

• Intercostal aa.

• Thoracoacromial a

V E N O U S D R A I N A G E

• Corresponds to arterial system.

• Cephalic vein

LY M P H AT I C S • 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)

LY M P H AT I C S

• Pectoral nodes ( 4-5 nodes, most drainage).

• Subscapular (posterior) nodes (6-7),

• Lateral nodes (4-6).

• Central nodes (3-4), ?Neck?

• Apical nodes (6-12)

• Interpectoral (Rotter’s) nodes (1-4)

• Parasternal nodes

LY M P H AT I C S

LY M P H AT I C S I N A S S O C I AT I O N W I T H V E S S E L S

• Pectoral – lat. thoracic vessels

• Subscapular – subscapular vessels

• Humeral – distal (3rd) part of axillary v.

• Central – middle (2nd) part of axillary v.

• Apical – proximal (1st) part of axillary v.

• Interpectoral – pectoral vessels

• Parasternal – int. thoracic vessels

LY M P H N O D E L E V E L S ( B E R G ’ S )

• 3 Levels of surgical dissections relative to pec. minor.

• Level I – below (lateral to) pec. minor

• Level II – deep to pec. minor

• Level III – above (medial to) pec. minor

C L I N I C A L S I G N I F I C A N C E

• Cancer cells tend to spread along lymph passages

• Typical spread is supr./laterally to axillary lymph nodes

• Unilateral lymphatic blockage may occur

• Lymph (with cancer cells) can then drain to opposite side

N E R V E S U P P LY

• Cutaneous innervation.

• Medial pectoral n.

• Lateral pectoral n.

• Long thoracic n.

N E R V E S U P P LY

N E R V E S U P P LY

• Take care!:

• LTN

• Thoracodorsal

• lateral and medial pectoral nerve

T H E A X I L L A

• Axillary sheath (axillary a. & brachial plexus).

• Axillary v. & lymphatics (outside sheath).

• Fat & connective tissue

• Cutaneous nerves

The AxillaThe Axilla

T H E A X I L L A • very busy space.

S U R G I C A L A P P R O A C H T O A X I L L A

• In modified radical mastectomy

• Conservative breast surgery

M A S T E C T O M Y

• Radical Mastectomy.

• modified radical mastectomy

• Simple mastectomy

• skin sparing mastectomy

• Nipple-Areolar spaing mastectomy.

B O U N D R I E S F O R M A S T E C T O M Y

• Clavicle.

• inframammary fold (above rectus sheath)

• Sternum (midline).

• Latissimus dorsi (ant. border)

S I M P L E M A S T E C T O M Y

• Definition.

• frequency.

M O D I F I E D R A D I C A L M A S T E C T O M Y

• definition.

• indication

R A D I C A L M A S T E C T O M Y

• definition.

• success rates.

S K I N S PA R I N G M A S T E C T O M Y

• Definition.

N I P P L E - A R E O L A R S PA R I N G M A S T E C T O M Y

• Definition.

• Criteria

C H O I C E O F T H E P R O C E D U R E

• Radical mastectomy - No longer used.

• Lymph node status

• Desired time of reconstruction.

• Criteria of NSM.

• Prophylactic

I N C I S I O N S I N B R E A S T S U R G E R Y

I N C I S I O N S F O R M A S T E C T O M Y

• depends upon: location, size, reconstruction plans

• SSM.

• MRM

• NASM

Stewart!

* design according to tumour location

• The drains are left in place until the drainage of serous fluid has decreased to approximately 25 to 30 mL per 24-hour period