Por José Domingo Díaz, Residente de Primer Año de Cirugía General.

Universidad de Cartagena

Embryogenesis of the BreastNormal Development

The breast is a group of large glands derived from the epidermis

Second month of gestation

Two bands of ectoderm

Milk lines

Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009

A. The milk lines in a generalized mammalian embryo. Mammary glands form along these lines. B. Common sites of formation of supernumerary nipples or mammary glands along the course of the milk lines in the human.

The glandular portion of the breast develops from the ectoderm

Twelve weeks

16 to 24 buds of ectodermal cells grow into the underlying mesoderm (dermis)

Areola fifth month onward

Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009

Development of the breast. A-D. Stages in the formation of the duct system and potential glandular tissue from the epidermis. Connective-tissue septa are derived from the mesenchyme of the dermis. E. Eversion of the nipple near birth.

Modified sweat glands

Areolar glands (Montgomery)

Connective tissue stroma forms from mesoderm

Rest of changes will reappear in puberty

Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009

Development of the mammary ducts and hormonal control of mammary gland development and function. A. Newborn. B. Young adult. C. Adult. D. Lactating adult. E. Postlactation.

Congenital Anomalies

Amastia, Athelia, and Amazia

Supernumerary Breasts or Nipples

Congenital Inversion of the Nipple

Anomalies of Breast Size

Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009

http://www.youtube.com/watch?v=druBEupr7eM

Surgical Anatomy

Topographic Anatomy and Relations

Located within the superficial fascia anterior chest wall

Base from second rib above to the six or seven rib below

External border medially to midiaxillary line laterally

Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009

2/3 of base lies anterior to the pectorally major muscle

Remainder lies anterior to the serratus anterior muscle

Tail of expense: 95%, lateral quadrant toward the axilla prolongation

Hiatus of Langer in the deep fascia

Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009

Skin

Areola and nipple distinguished from that of the surrounding skin by pink color imparted by blood vessels

Pregnancy increases melanin darkening the area (Basal cells)

Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009

Superficial Fascia

Envelopes the breast

Continuous with the superficial abdominal fascia below and superficial cervical fascia above

Anteriorly with the dermis of the skin

Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009

Diagrammatic sagittal section through the nonlactating female breast and anterior thoracic wall.

Deep Fascia

Envelopes the pectoralis major muscle continuous with the abdominal fascia below

Medially attached to externum

Above and laterally clavicle and axillary fascia

Anteriorly pectoralis minor fascia

Inferiorly serratus anterior posterior extension

Fascia of the latissimus MusclesSkandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009

Muscle Origin Insertion Nerve supply CommentsPectoralis major Medial half of clavicle, lateral half of

sternum, 2nd to 6th costal cartilages, aponeurosis of external oblique muscle

Lateral lip, bicipital groove Lateral and medial pectoral nerves

Clavicular portion of pectoralis forms upper extent of radical mastectomy; lateral border forms medial boundary of modified radical mastectomy; both nerves should be preserved in modified radical procedure

Pectoralis minor 2nd to 5th ribs Coracoid process of scapula Lateral and medial pectoral nerves

Deltoid Lateral half of clavicle, lateral border of acromion process, spine of scapula

Deltoid tuberosity of humerus

Axillary nerve

1. 1st and 2nd ribs Costal surface of scapula at superior angle

Long thoracic nerve Injury produces "winged scapula"

2. 2nd to 4th ribs Vertebral border of scapula

3. 4th to 8th ribs Costal surface of scapula at inferior angle

Latissimus dorsi Back, to crest of ilium Crest of lesser tubercle and intertubercular groove of humerus

Thoracodorsal nerve The anterior border forms the lateral extent of radical mastectomy; injury results in weakness of rotation and abduction of arm

Subclavius Junction of 1st rib and its cartilage Groove of lower surface of clavicle

Subclavian nerve

Subscapularis Costal surface of scapula Lesser tubercle of humerus Upper and lower subscapular nerves

Subscapular nerves should be spared

External oblique aponeurosis

External oblique muscle Rectus sheath and linea alba, crest of ilium

Remember the interdigitation with serratus anterior and pectoralis muscles

Rectus abdominis Ventral surface of 5th to 7th costal cartilages and xiphoid process

Crest and superior ramus of pubis

Branches of 7th-12th

thoracic nerves

The rectus sheath is the lower limit of radical mastectomy

Serratus anterior (3 parts)

Muscles and Nerves Involved in MastectomyMuscles Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009

Morfology

15 and 20 lobes

Lobes, together with their ducts, are anatomic units, but not surgical units

Lobes and ducts arranged radially

Lactiferous sinuses, milk storage

Papilomas

Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009

The retromammary space. 1. Membranous layer of superficial fascia. 2. Retromammary space. 3. Muscle fascia.

Breast topography. From a dissection photograph. 1. Retinacula cutis. 2. Membranous layer. 3. Serratus anterior fascia. 4. Serratus anterior muscle. 5. Pectoral fascia. 6. Pectoralis major muscle. 7. Suspensory ligament of axilla. 8. Lobe of breast parenchyma. 9. Lactiferous duct. 10. Ampulla.

Dimpling of the breast, resulting from involvement of Cooper's ligaments by invasive disease. The dimpling is emphasized by the pressure of the hand of the examiner. From a clinical photograph.

Blood SupplyBlood supply of the breast; drawing from a dissection photograph. The arterial supply is here derived chiefly from (A) direct mammary branches of the axillary artery; (B) branches of the lateral thoracic artery; (C) perforating branches of the internal thoracic artery. The venous drainage is comparable, and is illustrated on the right side of the drawing. The rib levels are indicated by numbers.

A. The breast may be supplied with blood from the internal thoracic, the axillary, and the intercostal arteries in 18 percent of individuals.

B. In 30 percent, the contribution from the axillary artery is negligible.

C. In 50 percent, the intercostal arteries contribute little or no blood to the breast. In the remaining 2 percent, other variations may be found.

Lymphatic Drainage

Lymph nodes of the breast and axilla. Classification of Haagensen.

Arrangement of Lymph Nodes and Metastasis

Level I: lateral to the lateral border of the pectoralis minor muscle

Level II: under the pectoralis minor muscle

Level III: medial to the medial border of the pectoralis minor muscle

Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009

Level I (low axilla), Level II (midaxilla), Level III (apical axillary)Google Images

Diagram of lymphatic drainage of the breast.

Innervation

Diagrammatic representation of important peripheral nerves encountered during mastectomy.

Images

Pet/Tac of inflamatory cancer of the breast. The Journal of Nuclear Medicine

Imagen sospechosa de una mamografía.Foto: NCI

Eco quiste mamarioGoogle Images

Eco tumor mamarioGoogle Images

Eco fibroadenoma mamarioGoogle Images

Nucleus Medical Art, 2009

Nucleus Medical Art, 2009