The female breast

The female breast overlies the 2nd to the 6th rib; two-thirds of it rests on pectoralis major, one-third on serratus anterior, while its lower medial edge just overlaps the upper part of the rectus sheath.

Structure
The breast is made up of 1520 lobules of glandular tissue embedded in fat; the latter accounts for its smooth contour and most of its bulk. These lobules are separated by brous septa running from the subcutaneous tissues to the fascia of the chest wall (the ligaments of Cooper). Each lobule drains by its lactiferous duct on to the nipple, which is surrounded by the pigmented areola. This area is lubricated by the areolar glands of Montgomery; these are large, modied sebaceous glands which may form sebaceous cysts which may, in turn, become infected. The male breast is rudimentary, comprising small ducts without alveoli and supported by brous tissue and fat. Insignicant it may be, but it is still prone to the major diseases that affect the female organ.

Blood supply
1From the axillary artery via its lateral thoracic and acromiothoracic branches. 2From the internal thoracic (internal mammary) artery via its perforating branches; these pierce the rst to the fourth intercostal spaces, then traverse pectoralis major to reach the breast along its medial edge. The rst and second perforators are the largest of these branches. 3From the intercostal arteries via their lateral perforating branches; a relatively unimportant source. The venous drainage is to the corresponding veins.

Lymphatic drainage
This is of considerable importance in the spread of breast tumours. The lymph drainage of the breast, as with any other organ, follows the pathway of its blood supply and therefore travels: 1along tributaries of the axillary vessels to axillary lymph nodes; 2along the tributaries of the internal thoracic vessels, piercing pectoralis major to traverse each intercostal space to lymph nodes along the internal mammary chain; these also receive lymphatics penetrating along the lateral perforating branches of the intercostal vessels. Although the lymph vessels lying between the lobules of the breast freely communicate, there is a tendency for the lateral part of the breast to 159

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The upper limb

Fig. 113Diagram of the principal pathways of lymphatic drainage of the breast. These follow the venous drainage of the breastto the axilla and to the internal mammary chain.

drain towards the axilla and the medial part to the internal mammary chain (Fig. 113). A subareolar plexus of lymphatics below the nipple (the plexus of Sappey) and another deep plexus on the pectoral fascia have, in the past, been considered to be the central points to which, respectively, the supercial and deep parts of the breast drain before communicating with main efferent lymphatics. These plexuses appear, however, to be relatively unimportant, the vessels, in the main, passing directly to the regional lymph nodes. The axillary lymph nodes (some 2030|in number) drain not only the lymphatics of the breast, but also those of the pectoral region, upper abdominal wall and the upper limb, and are arranged in ve groups (Fig. 114): 1anterior lying deep to pectoralis major along the lower border of pectoralis minor; 2posterioralong the subscapular vessels; 3lateralalong the axillary vein; 4centralin the axillary fat; 5apical (through which all the other axillary nodes drain) immediately behind the clavicle at the apex of the axilla above pectoralis minor and along the medial side of the axillary vein. Clinicians and pathologists often dene metastatic axillary node spread simply into three levels:

The female breast

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Fig. 114The lymph nodes of the axilla.

level Inodes inferior to pectoralis minor; level IInodes behind pectoralis minor; level IIInodes above pectoralis minor. From the apical nodes emerges the subclavian lymph trunk. On the right, this either drains directly into the subclavian vein or else joins the right jugular trunk; on the left it usually drains directly into the thoracic duct. Lymphatic spread of a growth of the breast may occur further aeld when these normal pathways have become interrupted by malignant deposits, surgery or radiotherapy. Secondaries may then be found in the lymphatics of the opposite breast or in the opposite axillary lymph nodes, the groin lymph nodes (via lymph vessels in the trunk wall), the cervical nodes (as a result of retrograde extension from the blocked thoracic duct or jugular trunk), or in peritoneal lymphatics spreading there in a retrograde manner from the lower internal mammary nodes: this in addition, of course, to spread via the blood stream.

Development
The breasts develop as an invagination of chest wall ectoderm, which forms a series of branching ducts. Shortly before birth this site of invagination everts to form the nipple. At puberty, alveoli sprout from the ducts and considerable fatty inltration of the breast tissue takes place. With pregnancy there is tremendous development of the alveoli which, in lactation, secrete the fatty droplets of milk. At the menopause the gland tissue atrophies.

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The upper limb

Clinical features
1Developmental abnormalities are not uncommon. The nipple may fail to evert and it is important to nd out from the patient whether or not an inverted nipple is a recent event or has been present since birth. Supernumerary nipples or even breasts may occur along a vertical milk line a reminder of the line of mammary glands in more primitive mammals; on the other hand, the breast on one or both sides may be small or even absent (amazia). 2An abscess of the breast should be opened by a radial incision to avoid cutting across a number of lactiferous ducts. Such an abscess may rupture from one fascial compartment into its neighbours, and it is important at operation to break down any loculi which thus form in order to provide ample drainage. 3Dimpling of the skin over a carcinoma of the breast results from malignant inltration and brous contraction of Coopers ligaments as these pass from breast to skin, their shortening results in tethering of the skin to the underlying tumour. This may also occur, however, in chronic infection, after trauma and, very rarely, in broadenosis, so that skin xation to a breast lump is not necessarily diagnostic of malignancy. 4Retraction of the nipple, if of recent origin, is suggestive of involvement of the milk ducts in the brous contraction of a scirrhous tumour. 5The excision of a breast carcinoma by radical mastectomy involves the removal of a wide area of skin around the tumour, all the breast tissue, the pectoralis major (through which lymphatics pass to the internal mammary chain), the pectoralis minor (which lies as a gateway to the axilla), and the whole axillary contents of fatty tissue and contained lymph nodes. This excision also removes the bulk of the lymphatics from the arm which pass along the anterior and medial aspects of the axillary vein. A few lymph vessels from the upper limb pass above the axillary vein and are therefore saved. Most surgeons today perform less extensive surgery for breast cancer; for example, a simple mastectomy, in which the breast alone is removed, or an extended simple mastectomy, which combines this with clearance of the axillary fat and its contained nodes. Oedema of the arm after mastectomy usually only occurs if further damage is done to this precarious lymph drainage by infection, malignant inltration or heavy irradiation, or if additional strain is put on the evacuation of uid from the limb by ligation or thrombosis of the axillary vein.

Surface anatomy and surface markings of the upper limb

Much of the anatomy of the limbs can be revised on oneself; otherwise choose a thin colleague.