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

Coopers 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 (Coopers) 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 (Rotters) 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