Beruflich Dokumente
Kultur Dokumente
20
From the University of Cambridge, Cambridge, United Kingdom (HE); The Medical Col-
lege of Georgia, Augusta, Georgia (GLC, JES); Emory University School of Medicine,
Atlanta, Georgia (JES); and Piedmont Hospital, Atlanta, Georgia (JES)
EMBRYOLOGY
,...,..,....;;~. Epidermis
.. Mesenchyme
B C D
--. Nipple
. Lactiferous
ducts
E
Figure 2. Development of the breast. A-D, Stages in the development of the duct system
and potential glandular tissue from the epidermis. Connective tissue septa form from the
epidermis. E, Eversion of the nipple near giving birth. (From Skandalakis JE, Gray SW,
Rowe JS Jr: Anatomical Complications in General Surgery. New York, McGraw-Hili Book
Company, 1983, P 38; with permission.)
Amastia
Amazia
Athelia
Accessory Breasts
STRUCTURE
The breast is made up of lactiferous ducts but no alveoli at birth; it
possesses no alveoli until puberty. Prior to puberty, little branching of
THE BREAST AND ITS RELATED ANATOMIC STRUCTURES 615
the ducts occurs. At puberty, however, which commences about the age
of 10 to 12 in the western world, the ducts proliferate and their terminal
branches form solid masses of polythelial cells, the future alveoli. At this
time, the nipple becomes more prominent, and the breast, which hitherto
has been flat, becomes enlarged. Most of the increase in size is due to
accumulation of fat in the connective tissue between the breast lobules.
These changes continue during the next 4 or 5 years of adolescent devel-
opment.
The adult breast comprises a collection of tuboalveolar glandular
tissue of a firm pinkish-red appearance. This tissue is arranged in 15 to
20 lobes, each of which contains many lobules, which terminate in clus-
ters of rounded alveoli.
Histologically, the duct walls are generally composed of two layers
of epithelial cells with pale cytoplasm and a pale-staining oval nucleus.
The epithelial cells rest on a basement membrane. Each duct is sur-
rounded by cellular intralobular connective tissue, and the lobules them-
selves are surrounded by relatively noncellular interlobular connective tis-
sue that contains lobules of fat, which make up the bulk of the breast
tissue. This stroma of connective tissue contains the supplying blood
vessels, lymphatics, and nerves of the breast.
Although textbook diagrams show lobules clearly differentiated
from their encasing connective tissue, a section of a fresh operative mas-
tectomy specimen will show that the epithelial elements and the connec-
tive tissue are closely bound with each other and do not allow a plane of
dissection one from the other. Moreover, although the mammary gland
is functionally segregated into lobes, dissection of the breast from the
premenopausal female demonstrates that the parenchyma forms a con-
tinuous and rather dense mass of secretory tissue, not separable into
visible "lobes."
The 15 to 20 lactiferous ducts converge under the areola of the
nipple. Here they expand into lactiferous sinuses, which are lined by a
stratified squamous epithelium. Each of these sinuses then constricts into
a terminal duct, which runs vertically upward to end at the papilla of the
nipple at a visible but narrow orifice. It is probable that the so-called
lactiferous sinuses exist only when the lumen of the lactiferous duct just
proximal to the base of the nipple is enlarged by the presence of secre-
tions or epithelial cells that have been sloughed from the lining of the
duct.
The nipple is pink in color in the nulliparous breast but becomes
pigmented to a dark brown color in early pregnancy. Some of this pig-
mentation persists post-partus. The nipple is covered by a stratified squa-
mous keratinized epithelium. Its stroma is composed of dense connective
tissue, which contains smooth muscle around the lactiferous ducts.
The skin that surrounds the nipple is the areola. The areola under-
goes the same pigment changes as does the nipple during pregnancy.
Beneath the areola and opening onto its surface are the large areolar
glands of Montgomery, which are often visible to the naked eye. Not
infrequently, one of these glands becomes obstructed, distended, and
infected, forming an abscess.
616 ELLIS et al
TOPOGRAPHY
The adult female breast extends from the second rib or upper border
of the third rib superiorly to the sixth rib below. Its medial border
extends to the lateral edge of the sternum or, in some cases, close to the
mid sternal plane, and its lateral border reaches the mid-axillary line.
Superolaterally, the breast tissue extends as a projection into the axilla
around the lateral, or inferior, border of pectoralis major (the axillary tail
of Spence). This may form a palpable or even visible swelling, and its
apex may reach as far as the pectoral group of axillary lymph nodes. A
tumor in this location may not infrequently be mistaken for an enlarged
lymph node and vice versa. The main bulk of the tissue of the breast is
concentrated in its upper outer quadrant, which is thus the most usual
site for both breast cancer and most benign breast pathologies.
The nipple is usually situated at the level of the fourth intercostal
space in men and nulliparous females, but its position is inconstant when
the breasts are pendulous.
About two thirds of the breast lies on the pectoralis major muscle.
Inferiorly it extends onto the upper part of the rectus sheath, and later-
ally it overlaps onto the serratus anterior. 5
The breast is contained within a pocket of superficial fascia (Fig. 3).
The subcutaneous layer of this lies immediately deep to the dermis. It is
in this plane that cutaneous flaps of skin are raised in the operation of
mastectomy. It is relatively avascular. Fibrous processes and irregular
strands, the retinacula cutis, extend deeply from the dermis into the
underlying tissues of the breast. Such connective tissue bands (the suspen-
THE BREAST AND ITS RELATED ANATOMIC STRUCTURES 617
Cenllcal !ascia
Aetinaculae cutiS
. Cooper's ligament
Intercostal m.-------;,;u (superficial fascia)
Pectoralis , _ _--+
majorm .
Submammary
space
Superficial
fascia
Figure 3. Sagittal cross section of the non lactating female breast and anterior thoracic wall.
(From Skandalakis JE, Gray SW, Rowe JS Jr: Anatomical Complications in General Surgery.
New York, McGraw-Hili Book Company, 1983, p 39; with permission.)
,
sory ligaments of Cooper) attach the skin of the breast, the areola, and the
nipple to the underlying elements, including the breast parenchyma. The
so-called suspensory ligaments of the breast are more developed over
the upper part of the breast. Contraction of this fascia by infiltration with
malignant cells produces the characteristic dimpling of the skin over a
carcinoma of the breast.
The deep layer, or membranous layer, of superficial fascia covers the
deep aspect of the breast and is separated by a layer of filmy areolar
tissue from the underlying fascial covering of pectoralis major and ser-
ratus anterior. This areolar layer forms the retromammary or submammary
space and enables the normal breast to move freely over the underlying
muscles. Deep infiltration of a carcinoma through this space into the
618 ELLIS et al
The deep pectoral fascia encases the pectoralis major muscle and is
continuous caudally with the deep fascia of the anterior abdominal wall.
Deep to the pectoralis major, the pectoralis minor is ensheathed with
a layer of fascia that begins cranially at the clavicle, the clavipectoral
fascia. Inferior to the clavicle, this fascial layer envelops the subclavius
muscle, and after crossing the region of the infraclavicular fossa, it
reaches and covers the pectoralis minor. Between the subclavius and the
pectoralis minor, the clavipectoral fascia is pierced by the cephalic vein,
the thoracoacromial artery, and the nerve supply to the clavicular head
of the pectoralis major. Below the lower border of the pectoralis minor,
this fascial layer joins that of the pectoralis major, forming the so-called
suspensory ligament of the axilla, by continuity with the fascia of the latis-
simus dorsi muscle. In some cases, the fascial connection between the
pectoral muscles and the latissimus dorsi may contain a more or less
distinct band of muscle, in which case it is called the suspensory muscle of
the axilla.
The axillary fascia resting at the base of the axillary pyramidal space
is an extension of the pectoralis major fascia. It continues as the fascia of
latissimus dorsi. The axillary fascia forms the axilla's dome (Fig. 6A).
The prevertebral fascia produces a sheet that covers the floor of the
posterior triangle of the neck. Where the axillary vessels and the nerves
to the arm pass through it, they carry a tubular fascial sleeve, the axillary
sheath.
The clavipectoral fascia is thus composed of four parts (see Fig. 6A):
(1) the attachment to the clavicle and the envelope of the subclavius
muscle; (2) the costocoracoid ligament, a thickening of the lateral portion
of the clavipectoral fascia between the subclavius and pectoralis minor
muscle; (3) the pectoralis minor envelope; and (4) caudally, the clavipec-
toral fascia joins the muscle fascia of the pectoralis major. The resulting
fascial layer passes posteriorly to become continuous with the fascia of
the latissimus dorsi, thereby forming the suspensory ligament of the
axilla.
MUSCLES
The muscles and nerves of the breast with which the surgeon must
be familiar are listed in Table 1.
Table 1. MUSCLES AND NERVES INVOLVED IN MASTECTOMY
Muscle Origin Insertion Nerve Supply Comments
Pectoralis major Medial half of clavicle, lateral half of Greater tubercle of humerus Lateral anterior thoracic Clavicular portion of pectoralis forms
sternum, 2nd to 6th costal nerve upper extent of radical mastectomy;
cartilages, aponeurosis of external lateral border forms medial boundary of
oblique muscle modified radical mastectomy; both
nerves should be preserved in modified
radical procedure.
Pectoralis minor 2nd to 5th ribs Coracoid process of scapula Medial anterior thoracic
nerve
Deltoid Lateral half of clavicle, lateral border of Deltoid tuberosity of humerus Axillary nerve
acromion process, spine of scapula
Serratus anterior (3 1. 1st and 2nd ribs Costal surface of scapula at Long thoracic nerve Injury produces "winged scapula."
parts) superior angle
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 Thoracodorsal nerve The anterior border forms the lateral
intertubercular groove of extent of radical mastectomy; injury
humerus results in weakness of rotation and
abduction of arm.
Subclavius Junction of 1st rib and its cartilage Groove of lower surface of Subclavian nerve
clavicle
Subscapularis Costal surface of scapula Lesser tubercle of humerus Subscapular nerve Subscapular nerve should be spared.
External oblique External oblique muscle Rectus sheath and linea alba, Remember the interdigitation with serratus
aponeurosis crest of ilium anterior and pectoralis muscles.
Rectus abdominis Ventral surface of 5th to 7th costal Crest and superior ramus of Branches of 12th thoracic The rectus sheath is the lower limit of
cartilages and xiphoid process pubis nerve radical mastectomy.
From Skandalakis JE, Gray SW, Rowe JS Jr: Anatomical Complications in General Surgery. New York, McGraw-Hili, 1983, p 42; with permission.
a-
....
~
620 ELLIS et al
BLOOD SUPPLY
of the variable distribution of the tributaries that drain into the axillary
vein (Fig. 5).
AXILLA
Sternum
A
In!. thoracic v.
to right heart .
&lungs
Figure 5. Frontal section through the right breast showing pathways of venous drainage.
A, Medial drainage through the thoracic vein to the right heart. B, Posterior drainage to
vertebral veins. C, Lateral drainage to intercostal vein, superior epigastric veins, and liver.
D, Lateral superior drainage through axillary vein to the right heart. (From Skandalakis JE,
Gray SW, Rowe JS Jr: Anatomical Complications in General Surgery. New York, McGraw-
Hill Book Company, 1983, p 44; with permission.)
622 ELLIS et al
_Clavi pectoral
fascia
\~hn--- Pectoralis
minor m. Subscapularis
~~--Suspensory
ligament
(clavi pectoral
fascia)
- Teres major
Deep fascia
of armpit
(axillary)
~~~--- Latissimus
dorsi
B .
Serratus
Humerus --4-...f,I~~ anterior
Serratus
anterior
o
major m.
c
Figure 6. The walls of the axilla. A. Anterior wall. B, Posterior wall. C, Medial wall. D, Lateral
wall. (From Skandalakis JE, Gray SW, Rowe JS Jr: Anatomical Complications in General
Surgery. New York, McGraw-Hili, 1983, P 40; with permission.)
three muscles: the subscapularis, the latissimus dorsi, and the teres ma-
jor. The medial wall is formed by the lateral chest wall, which includes
the second to sixth ribs and the serratus anterior muscle. The lateral wall,
the narrowest wall, is formed by the bicipital groove of the humerus.
The axilla contains lymph nodes, the axillary sheath, and its con-
tained elements of the brachial plexus of nerves, the tendon of the long
head of the biceps brachii, the short head of the biceps, and the coraco-
brachialis muscles.
THE BREAST AND ITS RELATED ANATOMIC STRUCTURES 623
Pectoralis
" minor
Pectoralis
. major
Medial
Lateral ~~~~~~I-- pectoral n.
thoracic a.
Th'lrl"'nrlnr~.,,1 n.
Long thoracic n.
Figure 7. Anterior view of the topography of the axilla. (From Skandalakis JE, Gray SW,
Rowe JS Jr: Anatomical Complications in General Surgery. New York, McGrawHili Book
Company, 1983, p 41; with permission.)
LYMPHATIC DRAINAGE
ing vessels to the internal thoracic chain of nodes. Some drainage occurs
along the lateral cutaneous branches of the posterior intercostal veins to
the intercostal chain of nodes near the rib heads. About three quarters of
all lymphatic drainage of the breast passes to the axillary nodes; the
remainder drains principally to the internal thoracic group. Any part of
the breast may drain to either group, although there is a greater tendency
for tumors in the medial part of the breast to disseminate to the internal
thoracic nodes than for growths in the lateral part of the breast. Involve-
ment of the supraclavicular nodes in the spread of breast cancer usually
represents retrograde spread along blocked lymphatic channels when
the apical nodes are heavily involved. However, efferent channels do
pass directly from these nodes to the inferior deep cervical chain, so that
involvement of the cervical nodes may occur via this route. Lymphatic
do not normally drain to lymphatics across the opposite side of the body.
However, in very advanced tumors, extensive blockage of lymphatic
channels allows subcutaneous lymphatic permeation to occur to the op-
posite side.
Lymphatic drainage of the breast typically accompanies the blood
supply. Drainage from any quadrant of the breast passes to axillary
nodes (75%) or to the internal mammary chain (25%), according to Hult-
born et al.13
The lymph flow was traced upward and laterally through the tail of
the breast to the central lymph nodes by HaagensenP Metastases are
most frequently found at this location. Another drainage route follows
lymphatics that pierce the pectoralis major and pass upward between
the pectoralis major and minor to reach the axillary vein group or the
sub clavicular group of nodes. A few interpectoral nodes (of Rotter) may
be encountered between the two muscles. The subclavicular group of
nodes is important, because Haagensen believes metastasis to these
nodes renders surgical cure impossible (Fig. 8).
The mortality rates from lesions in different locations in the breast
vary greatly despite anatomic evidence. The inner lower quadrant was
the least frequently affected, but it had the highest relative mortality in a
series of 142 patients recorded by Gray and Skandalakisl l (Fig. 9).
Fisher et a19 stated that regional lymph nodes are primary indicators
and not instigators of distal disease. They assert that lower axillary dis-
section is more than adequate to fulfill the aims of axillary node dissec-
tion. The qualitative axillary nodal status (positive or negative) can be
accurately determined with the removal of a few lymph nodes according
to the same authors.
Re-examination of surgical specimens taken from 24 radical mastec-
tomies by Skandalakis et aP9 revealed that 19.5% of the lymph nodes
removed during surgery escaped examination by the pathologist. In a
second group of 20 modified radical mastectomies, re-examination found
that 7.7% were not initially removed. In one patient, a malignant node
was sectioned only during re-examination. With this in mind, we agree
with Stone and Cady,2 who stated that the goals of axillary dissection
may be diagnostic or therapeutic.
Lymph nodes appear in inconstant groups of varying numbers. This
THE BREAST AND ITS RELATED ANATOMIC STRUCTURES 625
Subclavicular
(apical) nodes
Axillary nodes
/
Central nodes
I
Scapular nodes
Ext. mammary
\
(pectoral) nodes
Figure 8. Lymphatic drainage of the breast. (From Skandalakis JE, Gray SW, Rowe JS Jr:
Anatomical Complications in General Surgery. New York, McGraw-Hili Book Company,
1983, p 45; with permission.)
37
~
A
/
/
//~
13
La!. Med.
28.6
~/
B /
32.0/ 1
71.5
Figure 9. A, Localization of breast tumors in 328
patients. B, Five-year mortality from breast tu-
mors by location (percentage dying < 5 years;
142 patients, all ages). (From Skandalakis JE,
"- Gray SW, Rowe JS Jr: Anatomical Complications
~"- in General Surgery. New York, McGraw-Hili Book
50.0 Company, 1983, p 46; with permission.)
626 ELLIS et al
Internal
mammary
nodes
Axillary vein
nodes
Central
nodes
External .
mammary
nodes
Figure 10. Lymph nodes of the breast and axilla. Classification is that of Haagensen et al.'2
(From Skandalakis JE, Gray SW, Rowe JS Jr: Anatomical Complications in General Surgery.
New York, McGraw-Hili Book Company, 1983, p 45; with permission.)
Group 1: External mammary nodes (1.7 nodes). These lie under the
lateral edge of the pectoralis major, along the medial side of the axilla.
They follow the course of the lateral thoracic artery on the chest wall
from the second to the sixth rib.
Group 2: Scapular nodes (5.8 nodes). These rest on the subscapular
vessels and their thoracodorsal branches.
Group 3: Central nodes (12.1 nodes). Embedded in fat in the axilla's
center, these form the largest group of lymph nodes and are the most
easily palpated in the axilla.
Group 4: Interpectoral nodes (Rotter's nodes) (1.4 nodes). These are
located between the pectoralis major and minor muscles. Often occurring
singularly, this is the smallest group of the axillary nodes. The pectoralis
major must be removed to access these nodes.
Group 5: Axillary vein nodes (10.7 nodes). These extend on the cau-
THE BREAST AND ITS RELATED ANATOMIC STRUCTURES 627
dal and ventral surfaces of the lateral part of the axillary vein. This is the
second largest of the axillary lymph nodes.
Group 6: Subclavian nodes (3.5 nodes). These lie on the caudal and
ventral exterior of the medial portion of the axillary vein. They are
inaccessible without removal of the pectoralis minor, according to Haa-
gensen et al. 12
However classified by the surgeon, the axillary lymph nodes are
defined in three levels according to their location in relation to the pec-
toralis minor muscle (Fig. 11):
Level I: Lymph nodes that are located at the vicinity of the lower
border of the pectoralis minor muscle. This level is formed by three
groups: exterior mammary lymph nodes, axillary vein lymph nodes, and
scapular lymph nodes.
Level II: Lymph nodes located deep to (under) the pectoralis minor
muscle. This level is formed by central lymph nodes and some subcla-
vian nodes.
Level III: Lymph nodes located at the medial bonier of the pectoralis
minor. These are the sub clavicular group.
fat and connective tissue of the intercostal spaces, there are usually four
to five of these small nodes on each side. Lymphatic trunks to these
nodes arise from the liver, diaphragm, rectus sheath, and the upper
portion of the rectus abdorninis. 12 The internal thoracic trunks drain into
the right lymphatic duct or the thoracic duct. Overall, this is a shorter
route than the axillary route to the venous system.
Other Nodes
The student of breast anatomy should also remember that there are
a few other lymph nodes associated in an indirect way with the breast,
such as intercostal lymph nodes, diaphragmatic nodes, and mediastinal
nodes.
Skin
Vascular Injury
Organ Injury
Nerve Injury
Thoracodorsal Nerve
The thoracodorsal (middle subscapular) nerve arises from the pos-
terior cord of the brachial plexus and innervates the latissimus dorsi
muscle (Fig. 12). Although there will be no deformity, internal rotation
and adduction of the arm will be weakened if the nerve is cut. The nerve
and its associated vessels can best be located near the medial border of
the latissimus dorsi about 5 em above a plane passing through the third
sternochondral junction. The neurovascular bundle, when found, should
be marked with an umbilical tape. Obvious involvement of lymph nodes
around the nerve will necessitate the nerve's removal.
Upper subscapular n.
Long thoracic
n.
Pectoralis major
Thoracodorsal n. & minor (cut)
Serratus anterior
Subscapularis m. m.
Medial border of
latissimus dorsi m.
Retracted axillary
margin
(pectoralis major
a minor)
Figure 12. A, The triangular bed of a radical mastectomy. B, The triangular bed of a modified
radical mastectomy. The pectoralis muscles are retracted rather than removed. The triangle
is slightly smaller than that shown in A. (From Skandalakis LJ, Vohman MD, Skandalakis
JE, et al: The axillary lymph nodes in radical and modified radical mastectomy. Am Surg
45:552, 1979; with permission.)
ralis major, which it supplies solely. The remaining part of the lateral
pectoral nerve communicates with the medial pectoral nerve.
Injury to the lateral pectoral nerve will result in atrophy of the
clavicular head of the pectoralis major, with an accompanying severe
cosmetic deformity just inferior to the clavicle. Injury to the medial pec-
toral nerve branches will result in atrophy of the sternal and costal parts
of the pectoralis major and the pectoralis minor muscles. The nerves
should be removed if the few lymph nodes of the interpectoral group
are involved and are fixed with these nerves.
THE BREAST AND ITS RELATED ANATOMIC STRUCTURES 631
Brachial Plexus
Most injury to the plexus is the result of stretching the nerves during
surgery, although direct injury is possible. Zintel and Nay22 had one
patient in a series of 249 mastectomies suffer transient injury to the
plexus.
CONCLUSION
This article provides the general and plastic surgeon with knowl-
edge of the surgical embryology and surgical anatomy of the breast and
its associated anatomic entities. Careful anatomic technique for the sim-
plest and more radical breast operations will avoid complications and
will benefit both the patient and the surgeon.
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