YL5: 06.

07 Anatomy of the Chest Wall and Breast

11/22/2018 Cardiovascular and Respiratory System
13:00-HH:MM Michelle Rivera P. Nuez, MD, FPCS

TABLE OF CONTENTS Thoracic Cavity and its Contents

• 3 components and their respective contents
I. OVERVIEW OF THE ANATOMY OF THE THORAX ........................... 1 ® Right and left pulmonary cavities: Lungs
A. THORAX .................................................................................... 1 ® Central mediastinum: Heart and other structures
B. SURFACE ANATOMY ............................................................... 1 transporting air, blood, and food
C. PLANES ..................................................................................... 2
II. THORACIC WALL ............................................................................... 3
A. THORACIC SKELETON ............................................................ 4
B. THORACIC APERTURES .......................................................... 5
C. JOINTS OF THE THORACIC WALL .......................................... 6
D. MUSCLES OF THE THORACIC WALL ..................................... 6
D. VASCULATURE ......................................................................... 8
III. SURGICAL APPLICATIONS .............................................................. 9
A. FLAP SURGERY ........................................................................ 9
B. SURGICALLY IMPORTANT MUSCLES .................................... 9
IV. OVERVIEW OF THE ANATOMY OF THE BREAST ....................... 11
A. PORTIONS OF THE BREAST ................................................. 12
B. ARTERIAL SUPPLY ................................................................. 13
C. VENOUS DRAINAGE .............................................................. 13
D. LYMPHATIC DRAINAGE ......................................................... 13
E. INNERVATION ......................................................................... 14
V. BREAST MALIGNANCIES ............................................................... 14
A. PEAU D’ORANGE .................................................................... 14
VI. BREAST RECONSTRUCTION ........................................................ 14
A. KINDS ...................................................................................... 14
B. TRANSVERSE RECTUS ABDOMINIS MUSCLE FLAP
RECONSTRUCTION (TRAM FLAP) ............................................ 14 Figure 2. Thoracic Cavity (Biology Dictionary, 2018)
QUICK REVIEW .................................................................................... 14 https://biologydictionary.net/thoracic-cavity/
SUMMARY OF TERMS ................................................................ 14
REVIEW QUESTIONS ................................................................. 16 B. SURFACE ANATOMY
REFERENCES ...................................................................................... 16 • Study of anatomical landmarks on the exterior of the human body
REQUIRED ................................................................................... 16 • Practical applications
® Medical examination in a clinical setting: Landmarks on the
body’s surface that can be used to locate deep structures and
I. OVERVIEW OF THE ANATOMY OF THE THORAX to assess function by auscultation and percussion
A. THORAX ® Essential for both invasive and non-invasive laboratory
• Common term is ‘chest’ procedures
• Location: Extends from the root of the neck inferiorly to the upper
part of the abdominal cavity
• Function: Transit structure from neck to the thorax or to the
abdomen or vice versa
• Composition: Thoracic cavity, contents, and thoracic wall
• Appearance
® Thoracic wall and cavity is shaped like a truncated cone with
apex and base obliquely cut
® Flattened anteroposteriorly to accommodate the scapula and
to withstand the pull of the upper limb muscles

Figure 4. Surface features of male anterior thorax (Nuez, 2018)

Figure 1. Thoracic Wall and Cavity (ASMPH, 2022)

Figure 5. Surface features of female anterior thorax (Nuez, 2018)

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 Figure 7. Midsternal and Midclavicular Line (Nuez, 2018)

Lateral
• Anterior Axillary Line (AAL): Runs vertically anterior of axial fold
• Posterior Axillary Line (PAL): Runs along the post-axillary fold
Figure 6. Surface markings on anterior thorax (Nuez, 2018) • Midaxillary Line (MAL): Runs from the apex of the axillary fossa
Surface Markings
• Nipple
® Male: 4th intercostal space
® Female: No definite level, depending on how pendulous the
breast tissue is
• Thoracic notch
• Clavicle
• Subcostal angle
• Sternal angle
• Breasts

C. PLANES
Vertical Planes

Anterior
• Midsternal or Anterior Median Line (AML): Intersection of the
median plane with the anterior thoracic wall, running down the
middle of sternum
• Midclavicular Line (MCL): Intersects the midpoint of the clavicle
(i.e. between the sternal notch and the acromion)
• Lateral Sternal Line: Intersects the lateral border of sternum (i.e.
where the sternum articulates with the clavicle)
• Parasternal Line: Vertical line between lateral sternal line and Figure 9. Lateral Lines (Nuez, 2018)
midclavicular line
Posterior
• Midvertebral or Posterior Median Line (PML): Vertical lines
running along the tips of the spinous processes of the vertebrae
• Scapular Lines (SL): Vertical lines intersecting the inferior angle
of the scapula

Figure 10. Midvertebral Line and Scapular Line (Clinical Gate, 2018)

Figure 8. Lateral Sternal and Parasternal Line (Nuez, 2018)

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 Horizontal Planes Table 1. Features and corresponding vertebral levels
• Suprasternal Plane: Runs above the margin of the manubrium at Feature/Line Ribs Vertebral Intercostal
vertebral level T2-T3 Level Space
• Sternal Angle Plane or Transverse Thoracic Plane: Intersects Jugular notch or T2
at the junction of the manubrium and the body of the sternum at the suprasternal plane
level of the 2nd rib and T4-T5 Manubrium Ribs 1, (2) T3-T4
® Defines superior and inferior mediastinum
Sternal angle or Ribs 2 T4-T5
• Xiphisternal Plane: Intersects the xiphoid process at the level of
transverse thoracic
the T9 vertebra
plane
• Other planes
Nipple ICS 4
® Costal margin: Portion of the inferior aperture of the thorax
formed by the articulated cartilages of the seventh to tenth ribs Breast Ribs 2-6
(Medical Dictionary, n.d.)
® Infrasternal angle or subcostal angle: Intersects the inferior Sternum body Ribs 2-6, T5-T9
portion of the sternum spanning from 7th to 10th rib and (false ribs
formed by the 10th rib 7-10)
§ Convex, smooth and marked by a prominent line Xiphisternal plane T9
directed downward and lateral (IMAIOS, n.d.)

Figure 11. Vertebral Level (Nuez, 2018)

II. THORACIC WALL

Figure 11. Horizontal Planes (Yellow: Suprasternal plane, Green:
Sternal Angle plane, Purple: Xiphisternal plane) (Nuez, 2018)
• Functions
® Provides a bony shell for the protection of vital visceral organs
® Provides a flexible frame for respiratory movement
® Muscular component actively contributes to inspiration and
expiration
® Chest wall muscles attached to the clavicle, scapula, and
humerus contribute to the movement of the shoulder and arm

Figure 12. Horizontal Planes and Surrounding Features (Nuez, 2018)

Levels
• Clavicle
• Jugular notch, T2
• Manubrium of sternum: Ribs 1-2, T3-T4
• Sternal angle or transverse thoracic plane: Rib 2, T4/T5
• Sternal body: T5-T9
• Nipple (males: Intercostal space 4; female: variable)
• Xiphisternal plane: T9
Figure 3. Thoracic Wall (Nuez, 2018)
• Breast: ribs 2-6
• Infrasternal angle: Where the costal margins converge

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 A. THORACIC SKELETON
Ribs
Types of Ribs According to Attachment
• 1st to 7th true ribs: Attached directly to the sternum through costal
cartilage
• 8th to 10th false ribs: Attached directly to each other through
costal cartilage and indirectly to the sternum
• 11th to 12th unattached or floating ribs: Do not connect directly
with the sternum and is associated with the posterior abdominal
musculature
Figure 14. Three types of Ribs (Nuez, 2018)
Figure 12. Thoracic Skeleton (Nuez, 2018)
Figure 13. Thoracic Ribs (Antranik, 2018)
https://antranik.org/thoracic-cage-ribs-fontanelles/
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Types of Ribs According to Shape
4 Typical: 3rd to 9th
® Head: Portion that is wedge-shaped with two facets
® Neck: Portion that connects the head to the body at the
tubercle area which has articular (i.e. attaches to transverse
process of vertebra) and non-articular parts)
® Body: Portion that is thin, flat, and curved most markedly at
the costal angle;
§ Costal groove: A concave internal surface which is
parallel to the inferior border of the rib
4 Atypical: 1st, 2nd, and 10th to 12th ribs
® 1st rib
§ Appearance: Broadest, shortest, and most sharply
curved of the seven true ribs
§ Features
o One facet which articulates with the body of T1
o Transversely directed grooves for the subclavian
vessel
o Scalene tubercle: Muscle attachment between
grooves
® 2nd rib
§ Appearance: Thinner, less curved, and substantially
longer than 1st
§ Features
o Two facets which articulate with the body of T1 and
T2
o Serratus anterior originates from rough area on the
upper surface
® 10th to 12th ribs
§ Similar to the 1st rib, only has one facet which articulates
with a single vertebra
§ 11th and12th have no neck or tubercle
Figure 15. Typical Ribs (Nuez, 2018)
Figure 16. Atypical Ribs (Nuez, 2018)
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 Sternum
• Palpated readily
• Midline bony structure
• Composition
® Manubrium
® Body
® Xiphoid process
• Synchondrosis: Joints between the parts of the sternum which
ossifies in middle to late adulthood

Figure 19. Body of the Sternum (Nuez, 2018)

Xiphoid Process
• Appearance: Thin, elongated, smallest, and most variable
• Location: Inferior end at the level of T10
• Indicates the inferior limit of the central part of the thoracic cavity
because the thoracic cavity can still dip to the side
• Xiphisternal joint: Midline marker for the superior limit of the liver,
the central tendon of the diaphragm, and the inferior border of the
Figure 17. Sternum (Nuez, 2018) heart

Manubrium
• Easily palpated
• The widest and thickest of the three parts of the sternum
• Synchondrosis of the first rib

Figure 20. Xiphisternal Joint (Nuez, 2018)

Figure 18. Joint between first rib and manubrium (Nuez, 2018)
B. THORACIC APERTURES
Body
• Appearance: Longer, narrower and thinner than the manubrium
• Location: Level of T5-T9 vertebrae
• Features
® Four sternebrae: Primordial segments of the sternum
® Three variable transverse ridges
® Sternal angle or Sternal angle of Louie
§ Distinct bony ridge continuous with the 2nd rib
§ Can be felt as an elevation between the manubrium and
the body
§ Often used as a landmark for counting the ribs
§ Corresponds with
o Level of bifurcation of the trachea
o Upper border of the atria of the heart

Figure 21. Thoracic Apertures (Pink=superior thoracic aperture, Blue=

inferior thoracic aperture) (Nuez, 2018)

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 Superior Thoracic Aperture
• Appearance
® Kidney-shaped
® 6.5 cm anteroposteriorly and 11 cm transversely
• Boundaries
® Anteriorly: Superior border of the manubrium
® Laterally: 1st pair of ribs and their costal cartilages
® Posteriorly: Vertebra T1, the body of which protrudes
anteriorly into the opening

Figure 24. Joints of Thoracic Wall (Nuez, 2018)

D. MUSCLES OF THE THORACIC WALL

• True muscles of the thoracic wall
Figure 22. Superior Thoracic Aperture (Nuez, 2018) ® Serratus posterior
® Levatores costarum
Inferior Thoracic Aperture ® Intercostal muscles
• Boundaries ® Subcostal muscles
® Posteriorly: 12th thoracic vertebra, body of which protrudes ® Transversus thoracis
anteriorly into the opening
® Posterolaterally: 11th and 12th pair of ribs
® Anterolaterally: Joined costal cartilages of 7th-10th rib,
forming the costal margins
® Anteriorly: Xiphisternal joint

Figure 25. Thoracic Musculature (Nuez, 2018)

Figure 23. Inferior Thoracic Aperture (Nuez, 2018)
C. JOINTS OF THE THORACIC WALL
• Function: The joints enable and determine movements of the
thoracic wall
• Attachments:
® Posteriorly: ribs articulate with the semiflexible thoracic
vertebral column
® Anteriorly: ribs articulate with costal cartilages via
costochondral joints
• Costal cartilages: 1st to 7th ribs articulate directly while the 8th to
10th ribs articulate indirectly with the sternum via the
synchondrosis of the 1st rib, synovial sternocostal joints, and
interchondral joints
Serratus Posterior
• Serratus Posterior Superior
® Contributes to the movement and stabilization of vertebral
column and thorax
§ Originally thought to be inspiratory muscles based on
their attachments, however the claim has not been
supported
§ Recent studies show that the muscles serve more
proprioceptive functions rather than motor
® Origin: Nuchal ligament, spinous processes of C7 to T3
vertebrae
® Insertion: Superior borders of 2nd to 4th ribs
® Innervation: 2nd to 5th intercostal nerves
® Action: Proprioception (elevate ribs)
• Serratus Posterior Inferior
® Thought to depress inferior ribs preventing them from being
pulled by the diaphragm
® Origin: spinous processes of T11 to L2 vertebrae
® Insertion: Inferior borders of 8th to 12th ribs near their angles
® Innervation: anterior rami to T9 to T12 thoracic spinal nerves
® Action: proprioception (depress ribs)

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 ® Structure
§ Intermediary layer
§ Fibers are oriented superoposteriorly
§ Extends from the sternum to the angle of the rib
posteriorly
§ Fibers caudally interdigitates with the internal oblique
muscle
® Function: Acts by moving the anterior chest wall downwards
and backwards
® Origin: Inferior border of ribs
® Insertion: superior border of ribs below
® Innervation: intercostal nerve
® Action
§ Interosseous part: depresses ribs
§ Interchondral part: elevates ribs
§ During active (forced) inspiration: respiration
• Intercostalis intimus
® Innermost internal intercostal muscle
® Structure
§ Deepest layer of the intercostal musculature
§ Least developed
§ Fibers are oriented vertically
§ Extends anteriorly from the plane of the costochondral
articulation
§ Posteriorly: plane of the medial margin of the scapula
® Origin: Inferior border of ribs
® Insertion: superior border of ribs below
Figure 26. Serratus Posterior Muscles (Nuez, 2018)
® Innervation: intercostal nerve
Levatores Costarum ® Action
§ Interosseous part: depresses ribs
• 12 fan-shaped muscles that elevate the ribs and are thus crucial
§ Interchondral part: elevates ribs
for spinal health
§ During active (forced) inspiration: respiration
• Origin: transverse processes T7 to 11
• Insertion: Subjacent ribs between tubercle and angle
• Innervation: posterior primary rami of C8-T11 nerves
• Action: Elevate ribs

Figure 28. Intercostal Muscles (Nuez, 2018)

Figure 27. Levatores Costarum (Nuez, 2018)

Intercostal Muscles
• External Intercostals
® Structure
§ Form the outer layer of the intercostal spaces
§ Extends posteriorly from the costal tubercle to the plane
of costochondral articulation
§ Fibers are oriented inferoanteriorly
§ Fibers at the lower intercostal spaces interdigitate with
the external oblique muscles
® Function
§ Contraction causes the ribs to move upward and
outward, similar to the raising of a bucket handle
§ Serves to stabilize the rib cage, making it more rigid
§ Oppose the tendency of the rib cage to collapse under
negative pressure
§ Prevents rib cage distortion
§ Enhances mechanical efficiency of the diaphragm Figure 29. Intercostalis Muscles (Nuez, 2018)
§ Brings about twisting movements
§ Also brings about stiffening of the rib cage during lifting, Subcostal Muscles
pushing, and pulling movements • Variable in size and shape, but usually well-developed only in the
® Origin: inferior border of ribs lower thoracic wall
® Insertion: superior border of ribs below • Origin: internal surface of lower ribs near their angles
® Innervation: intercostal nerve • Insertion: superior borders of 2nd or 3rd ribs below
® Action: elevate ribs during forced inspiration • Innervation: intercostal nerve
• Internal Intercostals • Action: In the same manner as internal intercostal muscles

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 Figure 30. Subcostal Muscles (Nuez, 2018)

Transversus Thoracis
• Four or five slips radiating superolaterally from the posterior of the Figure 32. Diaphragm (Nuez, 2018)
inferior sternum, continuous inferiorly with the transversus
abdominis muscle D. VASCULATURE
• Origin: posterior surface of lower sternum Arteries
• Insertion: internal surface of costal cartilages 2-6 • Thoracic aorta
• Innervation: intercostal nerve ® Posterior intercostal artery
• Action: weakly depress ribs, proprioception ® Subcostal artery
• Subclavian artery
® Internal thoracic artery
® Supreme intercostal artery
• Axillary artery
® Superior thoracic artery
® Lateral thoracic artery

Figure 31. Transversus Thoracis (Nuez, 2018)

Diaphragm or Thoracic Diaphragm

• Primary muscle of inspiration
• Separates the chest from the abdomen
• Attachments
® Spine: Upper 2-3 lumbar vertebrae
® Ribs: Lower 6 ribs
® Sternum: Xiphoid process Figure 33. Thoracic Arteries (Nuez, 2018)
• Action
® When we inhale, the diaphragm is drawn downward until it is Veins
flat • Intercostal veins accompany the intercostal arteries and nerves,
® The muscle around the ribs pull them up like a hoop skirt lying most superior in the costal grooves
® The chest, or thoracic cavity, becomes deeper and larger, ® 11 posterior intercostal veins
making more space for air 4 Anastomose with the anterior intercostal veins
(tributaries of internal thoracic veins)
4 Receives a (1) posterior branch at the vertebral column,
(2) intervertebral vein
4 Most (veins 4-11) ends in the azygos / hemi-azygos
venous system which drains to the superior vena cava
(SVC)
4 Posterior intercostal vein of the 1st intercostal space
enters directly into the right & left brachiocephalic veins
4 Posterior intercostal vein of the 2nd & 3rd (occasionally
4th) intercostal spaces unite to form the superior
intercostal vein

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 4 Right superior intercostal vein → azygos vein or right
brachiocephalic vein → SVC
4 Left superior intercostal vein → left brachiocephalic vein
→ SVC
4 Important: typically communicates with the accessory
hemi-azygos vein
® 1 subcostal vein on each side
• Internal thoracic veins are the companion veins of the internal
thoracic arteries
• Posterior intercostal veins anastomose with the anterior
intercostal veins
• Tributaries:
® Right superior Intercostal veins
® 8 lower right posterior intercostal veins
® Mediastinal veins
® Superior hemiazygos veins Figure 36. Neurovascular Bundle Overview (Nuez, 2018)
® Inferior hemiazygos veins
III. SURGICAL APPLICATIONS
A. FLAP SURGERY
• Technique in plastic and reconstructive surgery where any type of
tissue is lifted from a donor site and move to a recipient site with an
intact blood supply
• Relevance of anatomy
® Requires a very good grasp of the functional anatomy
(muscles, vessels, nerve) and pathophysiology of the chest
® A thorough knowledge of anatomy is the foundation for a clear
operative plan and fall back procedure
• Basic principles of flap reconstruction
® Contouring
® Resurfacing exposed surfaces (carotid, skin defect)
® Recreating resected lumen
§ Ex. esophagus and drank muriatic acid - create a flap
and reconstruct lumen to have a continuity with upper
and lower GI tract
® Improving function by providing tissue bulk
§ You can stitch it together with facial nerves
® Bringing healthy tissue into defect site

B. SURGICALLY IMPORTANT MUSCLES

• Thoracic musculatures are used in treating chest wall defects and
Figure 34. Thoracic Veins (Nuez, 2018) dysfunctions
• Chest wall defect and/or dysfunction is associated with significant
Neurovasculature Bundle morbidity and life-threatening consequences
• Location • Applications
® Protected in the costal groove ® Tumor resection (primary or recurrent)
® Threaded between the intermediary and deep muscle layer ® Infection
® The intercostal nerves run a posterior to anterior course along ® Radiation injury or ulcers
the length of the intercostal space ® Trauma
® The anterior and posterior intercostal arteries and veins ® Congenital defects
converge toward and anastomose in approximately the ® Or combination of above
anterior axillary line • Management and reconstruction of complex chest wall defects
• Function: Responsible for the vasculature and innervation of the involves the application of muscle and musculocutaneous FLAPS
intercostal musculature

Figure 35. Neurovascular Bundle (Nuez, 2018)

Figure 37. Muscles of the thoracic wall (ASMPH Batch 2022)

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 Pectoralis Major
• Appearance: Triangular shaped muscle
• Location: Covers the anterior superior portion of the chest wall
• Borders
® Superior: medial half of clavicle
® Inferior: cartilaginous portion of 6th-7th ribs
® Medial: lateral border of sternum
® Lateral: proximal sulcus of humerus
• Origin
® Clavicular head: anterior surface of medial half of the clavicle
® Sternocostal head
§ Anterior surface of the sternum
§ Superior six costal cartilages
§ Aponeurosis of the external oblique
• Insertion: lateral lip of the bicipital groove of the humerus
• Nerve supply
® Lateral Pectoral Nerve
§ Travels medially on deep surface of the muscle
® Medial Pectoral nerve
§ Pierces pectoralis minor
§ 2-3 branches to pectoralis major Figure 37. Sternal Wound Closure with Pectoralis Muscle Flaps
• Action (medivisuals1.com)
® Flexion of the humerus (throwing a ball side arm)
® Adduction of humerus (flapping the arm)
® Rotates the humerus medially (arm wrestling)
• Vascular supply
® Dominant supply
§ Pectoral branch of thoracoacromial artery
o Forms segmental blood supply
® Adjunctive supply
§ Lateral thoracic artery
§ Pectoral branches of intercostal arteries

Pectoralis Major Flap

• Main workhorse for complex sternal wound
• May be raised as a muscle or as musculocutaneous flap
® May be raised as an advancement flap base on the
thoracoacromial axis
§ Flap’s remaining attachment is distal
® May be raised as a turn over flap base on the internal
mammary segmental artery
§ Flap’s remaining attachment is medial
• Are also used in head and neck reconstruction
® Intraoral defects (tongue, FOM, tonsillar fossa) Figure 38. Pectoralis Major (PM) Myocutaneous Flap
® External cutaneous defects (medivisuals1.com)
® Combined intraoral and cutaneous defects
Latissimus Dorsi
® Circumferential pharyngo-esophageal defects
• Borders:
® Laryngopharyngectomy with skin defect
® Medial: posterior spine
® Temporal bone resection
® Lateral: posterior axillary fold
® Orbital or facial defects
• Vascular supply
® Esophageal stricture with esophageal reconstruction
® Predominant supply: thoracodorsal artery
® Pyriform fossa defect
§ arising from the subscapular artery
® Exposed carotid artery § enters the latissimus muscle 12 cm below the axilla
• Myocutaneous island flap along the posterior axillary fold
® A compound flap of skin and muscle with adequate vascularity ® Adjunctive supply: perforating branches of intercostal arteries
to permit sufficient tissue to be transferred to the recipient site
® Reconstruct lateral neck and lower chin area Latissimus Dorsi Muscle Flap
® Skin and subcutaneous is alive underneath so when you raise • Latissimus dorsi covers most of back
it, it will be covered
• Versatile flap with large amount of skin and soft tissue
• Portions of it may be used at a time
• Indications
® Extensively used in chest wall reconstruction
® Used in breast reconstruction
• Extended arc of rotation makes it suitable for spinal coverage and
humeral defect
• Can also reach median chest and sternotomy wound

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 ® Use rectus abdominis with skin and subcutaneous tissue to
conserve blood
® Open up transverse fascia to make a tunnel through the
inferior pedicle and superior pedicle
® Flip then lift the muscle
® Fat will become the breast mound
• Breast reconstruction with transverse rectus abdominis muscle flap
(TRAM FLAP)
• Patients who have moderate excess abdominant tissue are
candidates for breast reconstruction
Figure 39. Latissimus Dorsi Flap for Breast Reconstruction • Lower abdominal fat and skin is harvested with one of the rectus
(myhealth.alberta.ca) abdominis muscle which is transferred to the chest in a surgically
created tunnel that connects the chest and abdomen
Serratus Anterior
• Border
® Averages 10 x 20 cm
® Lateral surface of first 8-9 rib
® Medial border of scapula
• Origin: from the lateral scapula and fans anteriorly
• Insertion: first 9 ribs
• Innervation: long thoracic nerve
• Blood supply:
® Upper slip: Lateral thoracic artery
® Lower slip: Thoracodorsal artery
Figure 41. Rectus Abdominis Muscle Flap (Nuez, 2018)
® related to the latissimus and axillary vessel
® Subscapular artery, descends inferiorly to supply the serratus
artery
® Gives off circumflex scapular branch of thoracodorsal artery

Serratus Anterior Muscle Flap

• a good source of a medium to small sized muscle for free flap
coverage
• Only a portion of the muscle is used in flap reconstruction
• The lower three slips of muscle arise at the very inferior scapula
and have an independent blood and nerve supply
• One, two, or three slips can be harvested depending on
requirements, and the muscle can be neurotized to form a
functional unit
• Can be raised on a vascular pedicle up to 11 cm giving it an arc of
rotation that can reach the anterior chest wall and neck
• Excellent option for intrathoracic defects
• May also be raised with vascularized rib for composite chest wall
defects
Figure 42. Rectus Abdominis Muscle Blood supplies (Nuez, 2018)

IV. OVERVIEW OF THE ANATOMY OF THE BREAST

• Modified sweat gland
• Conical in shape
• Non-lactating: 150-225 g
• Lactating: > 500 g
• 3 portions:
® Gland: Glandula mammariae
® Mammy papilla: Papilla mammariae
® Areola: Areola mammae

Figure 40. Serratus Anterior Muscle Flap (microsurgeon.org)

Rectus Abdominis
• Blood supply:
® Superior deep epigastric artery - terminal branch of internal
mammary artery
® Inferior deep epigastric artery - branch of the external iliac
artery

Rectus Abdominis Muscle Flap

• Useful for lower anterior chest reconstruction
• Used in autologous breast reconstruction: replace soft, living tissue
removed at the time of mastectomy with similar tissue from the Figure 43. Anterior view and cut-section view of the breast (Nuez,
abdomen 2018)
• Example:
® Use superior pedicle for reconstruction
® Make a CS incision to harvest the fat

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 Figure 44. Anatomy of the Breast (Nuez, 2018)

Gross Anatomy
• Location: Sternum to anterior axillary line, at the level of 2nd to 6th
ribs
• Appearance: Base is circular and measures around 10-12 cm with
variable volume
• Significant structures
® Tail of Spence: Mammary tissue extending toward the axilla
as an axillary process
® Suspensory ligament of Cooper’s: Fascicles of connective
tissues permeates the lobes and lobules, coresses Figure 48. Suspensory ligament of Cooper’s (Nuez, 2018)
anteroposteriorly from the dermis to the fascia
§ Connects the inner side of the breast skin and the A. PORTIONS OF THE BREAST
pectoral muscles Mammary Gland
§ Contribute to general support and shape of the breast • Formed by 15-20 lobes arranged radially
§ Clinical significance • Parenchyma is more abundant in the upper half of the gland
o A comprehensive breast exam must be done to (superolateral quadrant)
properly diagnose neoplasms. If you find dimpling • Significant structures
over the skin of the breast there might be a ® Lactiferous duct: Give rise to buds that develop into 15-20
neoplasm that may affect it. lobules of the mammary gland
o Neoplasm of the breast may affect the suspensory ® Bed of the breast: extends transversely from the lateral
ligaments and caused localized retraction of the border of the sternum to the midaxillary line and vertically from
overlying skin the 2nd through 6th ribs
® Retromammary space: A loose subcutaneous tissue plane
or potential space which contains small amount of fat that
allows the breast some degree of movement of the pectoral
fascia

Figure 45. The breast and the lactiferous ducts (Nuez, 2018)

Mammary Papilla
• Location: Apex of the cone
Figure 46. The retromammary space (Nuez, 2018) • Significant structures
® Lactiferous duct: principal duct of each lobe
® Lactiferous sinus: distal sac like dilation of each duct

Areola
• Appearance: Slightly raised, disc-shaped, and pigmented area
around the nipple
® Rosy hue but becomes irreversibly pigmented (chestnut
brown) from the 2nd month of gestation
• Significant structures
® Montgomery’s tubercles
§ Granular and pointlike elevations on the surface of the
areola
§ Representation of glands with intermediate histological
structure between sudoriparous and mammary gland
(areolar glands)

Figure 47. Axillary tail of Spence (Surdudi, 2014)

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 • Lymphatic plexus
® Cutaneous plexus: located in the dermis
® Subcutaneous plexus: located in the subcutaneous region
® Fascial plexus: located in the fascia of the pectoralis major
muscle
® Glandular plexus: located in the mammary gland
® Subareolar lymphatic plexus
§ Lymph passes from the nipple, areola, and lobules of the
gland to the subareolar lymphatic plexus
§ From the subareolar lymphatic plexus most lymph drains
to the axillary lymph nodes, initially to the anterior or
pectoral nodes for the most part
§ Lymph from the skin of the breast (except the nipple and
Figure 49. Surface Anatomy of the Breast (Nuez, 2018)
areola) drains into
o The ipsilateral axillary inferior deep cervical and
B. ARTERIAL SUPPLY infraclavicular lymph nodes
• Medial o And into the parasternal lymph nodes of both sides
® From the internal thoracic artery • Lymph nodes
• Lateral § Pectoral axillary
® Superior thoracic artery § Apical axillary
® Lateral thoracic artery § Central axillary
® Pectoralis branch of the thoracoacromial artery § Lateral axillary
® Penetrating branches of the posterior intercostal § Parasternal
• Predominantly supplied by the internal mammary artery over the § Supraclavicular and infraclavicular
lateral thoracic artery in 68-74% of patients • Clinical Importance
® Breast examination needs to be done on both breasts and to
the axilla where cancer can spread because breast cancer
cells can metastasize from one breast to the other through the
intermammary connection.
§ Medial efferent vessels of one breast may anastomose
with those of the contralateral breast via the
intermammary communication
§ This explains the occasional metastatic involvement of
the contralateral axillary lymph node
® If nodes are palpable, this may indicate metastasis.
• Lymph
® Lateral quadrants
§ >75% of drain to the Axillary Lymph Nodes
§ Continues to the Infraclavicular and Supraclavicular
Lymph Nodes
Figure 50. Arterial Supply of the Breast (Haque, 2015) § Continues to the Subclavian Lymphatic Trunk, which
also drains lymph from the upper limb
C. VENOUS DRAINAGE ® Medial quadrants
• Medial: Internal thoracic vein § Lymph from here drain to the Parasternal Lymph
• Lateral Nodes of the opposite breast
® Axillary vein § Continues to the Bronchomediastinal Lymphatic
® Posterior intercostal vein Trunks, which also drains lymph from the thoracic
viscera
® Posterior
§ Lymph located in the inferior quadrants of the breasts
may drain deeply to abdominal lymph nodes (Inferior
Phrenic Lymph Nodes)
§ Cisterna Chyli also receives lymphatic drainages from
the inferior regions of the breast (according to Dr Nuez)
o Located already in the abdominal area, not the
chest
® Termination of Trunks
§ Trunks on the right form the right lymphatic trunk or duct
which empties at the junction of the right internal jugular
vein and the right subclavian vein
§ Trunks on the left form the thoracic duct which empties
at the junction of the left internal jugular vein and the left
subclavian vein
® Clinical application: Since majority of the lateral quadrant
drains into the axillary lymph nodes, palpation of the axilla
region is required for a complete PE of the breast

●
Figure 51. Venous Drainage of the Breast (Nuez, 2018)

D. LYMPHATIC DRAINAGE
• Plays a very important role because of the metastasis of tumors,
thus examination must be carefully done on both the breasts and
the axilla
® Can be difficult to trace drainage because it is both diffused
and variable

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 V. BREAST MALIGNANCIES
A. PEAU D’ORANGE
• Skin Dimpling and abnormal contours
® Due to lymphedema (edema, excess fluid in the
subcutaneous tissue)
® The skin is tethered by the sweat ducts such that it cannot
swell, leading to an appearance like orange skin
® Shortening or tensing of the suspensory ligaments occurs,
which causes the dimpling
® Due to cancerous invasion of the glandular tissue and fibrosis
(fibrous degeneration)
• Retraction of the nipple
® The retraction caused by similar mechanisms involving the
lactiferous ducts
® Due to Subareolar Breast Cancer

Figure 52. The Lymphatic Drainage of the Breast (Nuez, 2018)

Figure 54. Peau D’ Orange (Nuez, 2018)

VI. BREAST RECONSTRUCTION

A. KINDS
• Implants: implanting an inflatable silicon and replace with a more
permanent one afterwards
• Autologous: using a segment/flap of tissue from another part of
Figure 53. Subareolar plexus, The Breast Lymphatic Drainage (Nuez, the body. Must be sourced from a part that has excess tissue
2018)
B. TRANSVERSE RECTUS ABDOMINIS MUSCLE FLAP
RECONSTRUCTION (TRAM FLAP)
• One kind of autologous reconstruction
• Similar to tummy tuck
• Very favorable because the tissue would still have blood supply
• Lower abdominal fat and skin harvested with one of the rectus
abdominis muscle and transferred to the chest that connects to the
abdomen through a surgically created tunnel
• Types (breastcancer.org)
® Free: Fat, skin, blood vessels, and muscle are cut from the
wall of the lower belly and moved up to your chest to rebuild
your breast, which are to be reattached in the chest
® Pedicled (attached)
§ Components are moved under your skin up to your chest
Figure 53. Quadrants of the Breast (Moore) to rebuild your breast
§ Vessels are left attached to their original supply/drainage
E. INNERVATION
• Anterior and lateral cutaneous branch of the 4th to 6th QUICK REVIEW
intercostal nerve SUMMARY OF TERMS
• Location: Intercostal nerve passes through pectoralis major, • Thorax
reaches subcutaneous tissue and skin of the breast and traverses ® Location: Extends from the root of the neck inferiorly to the
to the substance of the breast upper part of the abdominal cavity
• Function: Conveys sensory fibers of the skin and sensation of the ® Function: Transit structure from neck to the thorax or to the
nipple abdomen or vice versa
® Composition: Thoracic cavity, contents, and thoracic wall
® Cavities and contents: Right and left pulmonary cavities
contain their respective lungs and the central mediastinum
contains the heart and other structures transporting air, blood,
and food
• Surface markings
® Nipple
® Thoracic notch
® Clavicle
® Subcostal angle
® Sternal angle
® Breasts
• Planes
® Vertical
Figure 55. Innervation of the Breast (Scielo.org) § Anterior
o Midsternal or anterior medial line
o Midclavicular line
o Lateral sternal line

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 o Parasternal line § Neurovasculature bundle: Responsible for the
§ Lateral vasculature and innervation of the intercostal
o Anterior axillary line musculature
o Posterior axillary line
• Surgical applications
o Midaxillary line
® Flap surgery: Technique in plastic and reconstructive surgery
§ Posterior
where any type of tissue is lifted from a donor site and move
o Midvertebral or posterior median line
o Scapular lines to a recipient site with an intact blood supply
® Basic principles of flap reconstruction
® Horizontal
§ Suprasternal plane § Contouring
§ Resurfacing exposed surfaces (carotid, skin defect)
§ Sternal angle plane or transverse thoracic plane
§ Recreating resected lumen
§ Xiphisternal plane
§ Other planes § Improving function by providing tissue bulk
o Costal margin • Breast
o Infrasternal angle or subcostal angle ® Significant structures
• Levels § Tail of Spence: Mammary tissue extending toward the
axilla as an axillary process
® Clavicle
§ Suspensory ligament of Cooper’s: Fascicles of
® Jugular notch, T2
connective tissues permeates the lobes and lobules,
® Manubrium of sternum: Ribs 1-2, T3-T4
coresses anteroposteriorly from the dermis to the fascia
® Sternal angle or transverse thoracic plane: Rib 2, T4/T5 § Retromammary space: A loose subcutaneous tissue
® Sternal body: T5-T9 plane or potential space which ontains small amount of
® Nipple (males: Intercostal space 4 fat that allows the breast some degree of movement of
® Xiphisternal plane: T9 the pectoral fascia
® Breast: ribs 2-6 ® Portions of the breast
® Infrasternal angle: Where the costal margins converge § Mammary gland
• Thoracic wall o Lactiferous duct: Give rise to buds that develop into
® Skeleton 15-20 lobules of the mammary gland
§ Ribs o Bed of the breast: extends transversely from the
o Types of ribs according to attachment lateral border of the sternum to the midaxillary line
st th
® True ribs: 1 to 7 and vertically from the 2nd through 6th ribs
th th
® False ribs: 8 to 10 § Mammary papilla
th th
® Unattached or floating ribs: 11 to 12 o Lactiferous duct: principal duct of each lobe
o Types of ribs according to shape o Lactiferous sinus: distal sac like dilation of each
® Typical ribs: 3 to 9
rd th
duct
st nd th
® Atypical ribs: 1 , 2 , and 10 to 12
th § Areola
§ Sternum o Montgomery’s tubercles: Granular and pointlike
o Manubrium elevations on the surface of the areola
o Body ® Representation of glands with intermediate
o Xiphoid process histological structure between sudoriparous
® Thoracic apertures and mammary gland (areolar glands)
§ Superior thoracic aperture ® Arterial supply: Predominantly supplied by the internal
§ Inferior thoracic aperture mammary artery over the lateral thoracic artery in 68-74% of
® Joints of the thoracic wall patients
§ Costal cartilages: 1st to 7th ribs articulate directly while ® Venous drainage
the 8th to 10th ribs articulate indirectly with the sternum § Medial: Internal thoracic vein
via the synchondrosis of the 1st rib, synovial sternocostal § Lateral: Axillary vein and posterior intercostal vein
joints, and interchondral joints ® Lymphatic drainage
® Muscles of the thoracic wall § 4 lymphatic plexus
§ True muscles of the thoracic wall o Cutaneous plexus: located in the dermis
o Serratus posterior o Subcutaneous plexus: located in the subcutaneous
o Levatores costarum region
o Intercostal muscles o Fascial plexus: located in the fascia of the
o Subcostal muscles pectoralis major muscle
o Transversus thoracis o Glandular plexus: located in the mammary gland
® Vasculature o Subareolar lymphatic plexus
§ Arteries § Lymph nodes
o Thoracic aorta o Pectoral axillary
® Posterior intercostal artery o Apical axillary
o Central axillary
® Subcostal artery
o Lateral axillary
o Subclavian artery o Parasternal
® Internal thoracic artery o Supraclavicular and infraclavicular
® Supreme intercostal artery § Lymph
o Axillary artery o Lateral quadrants
® Superior thoracic artery ® Axillary Lymph Nodes
® Lateral thoracic artery ® Infraclavicular and Supraclavicular Lymph
§ Veins Nodes
o Intercostal veins accompany the intercostal ® Subclavian Lymphatic Trunk
arteries and nerves, lying most superior in the o Medial quadrants
costal grooves ® Parasternal Lymph Nodes of the opposite
o Internal thoracic veins are the companion veins of breast
the internal thoracic arteries ® Bronchomediastinal Lymphatic Trunks
o Tributaries: o Posterior
® Right superior Intercostal veins ® Inferior Phrenic Lymph Nodes
® 8 lower right posterior intercostal veins ® Cisterna Chyli
® Mediastinal veins o Termination of Trunks
® Right lymphatic trunk or duct which empties at
® Superior hemiazygos veins
the junction of the right internal jugular vein
® Inferior hemiazygos veins and the right subclavian vein

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 ® Thoracic duct which empties at the junction of 11. The false ribs run from the 7th to 10th rib, and are attached to each
the left internal jugular vein and the left other by the sternum. True or false?
subclavian vein 12. Enumerate the atypical ribs.
® Innervation: Anterior and lateral cutaneous branch of the 4th 13. Which of the following muscles for chest wall reconstruction does
to 6th intercostal nerve not belong?
• Breast malignancies a) Serratus anterior
® Peau d’orange b) Trapezius muscle
§ Skin dimpling and abnormal contours c) Latisimus dorsi
§ Retraction of the nipple d) Rectus abdominus
• Breast reconstruction 14. What is more abundant in the upper half of the mammary gland?
® Kinds a) Parenchyma
§ Implants: implanting an inflatable silicon and replace with b) Muscles
a more permanent one afterwards c) Lobules
§ Autologous: using a segment/flap of tissue from another 15. Which of the following does not supply the thoracic wall?
part of the body. Must be sourced from a part that has a) Thoracic aorta
excess tissue b) Common carotid artery
® Transverse rectus abdominis muscle flap reconstruction c) Subclavian artery
(TRAM FLAP) d) Axillary artery
§ Free: Fat, skin, blood vessels, and muscle are cut from
the wall of the lower belly and moved up to your chest to Answers
rebuild your breast, which are to be reattached in the 1. False. The statement pertains to the lateral sternal line. The
chest parasternal line is the midpoint between the lateral sternal line and the
§ Pedicled (attached): Components are moved under your midclavicular line.
skin up to your chest to rebuild your breast 2. False. This holds true only for males, as females will have more
anatomical variation in the location of their nipples.
3. C
REVIEW QUESTIONS
4. B. Levator scapulae is not part of the musculature of the thoracic wall.
1. The parasternal line is a vertical plane located just to the side of
5D, 6A
the sternum. True or false?
7. C. Pectoralis major wasn't mentioned in doc's lecture for use in breast
2. The nipple is always located at the anatomical landmark of the 4th
construction. If rectus abdomini were included in the choices, then it
intercostal space. True or false?
would be the correct answer. Since it wasn't mentioned, the correct
3. Which of the following is true?
answer in this question should be latissimus dorsi. A picture was
a) The manubrium, the body of the sternum, and the xiphoid
included under the latissimus dorsi flap question that showed the
process are connected to one another through synchondrosis
transfer of both the muscle and the skin to the breast area, therefore
joints.
implying that it is a myocutaneous flap.
b) The first rib is connected to the sternum through a
8A, 9B
synchondrosis joint
10. False. Correct answer is suprasternal plane.
c) Both A and B are true.
11. False. The false ribs are from the 8th to the 10th, and are attached
d) Both A and B are false.
together by the costal cartilages.
4. Which of the following does not belong?
12. 1st rib, 2nd rib, 10th-12th ribs.
a) Serratus posterior
13. D. The rectus abdominus muscle is part of the abdominal muscles,
b) Levator scapulae
and not the musculature of the thoracic wall. However, this muscle is
c) Transversus thoracis
often used for chest wall reconstruction (e.g. breast reconstruction)
d) Intercostalis intima
14A, 15B
5. Which of the following is true?
a) The neurovascular bundle is located between the intercostalis
externa and the intercostalis interna. REFERENCES
b) Superiorly to inferiorly, the sequence of the structures in the REQUIRED
neurovascular bundle is: vein-nerve-artery. (1) ASMPH Batch 2022. 2017. Trans Content.
c) The anterior and posterior intercostal arteries and veins (2) Editors. “Thoracic Cavity - Definition & Organs of Chest Cavity.”
converge toward and anastomose in approximately the Biology Dictionary, Biology Dictionary, 29 Apr. 2017,
middle axillary line. biologydictionary.net/thoracic-cavity/.
d) The intercostal nerves run a posterior to anterior course along (3) “Members Area.” Antranikorg, antranik.org/thoracic-cage-ribs-
the length of the intercostal space. fontanelles/.
6. In most of the population, the breast is supplied by the (4) “The Chest.” Clinical Gate, 2 Mar. 2015, clinicalgate.com/the-
__________. chest/.
a) Internal mammary artery
b) Lateral thoracic artery
c) Penetrating branches of the thoracoacromial artery
d) Penetrating branches of the posterior intercostal artery
7. According to Marian Rivera (2011), "Story of my layf / searching
por da right / fjdnv;djkfbdfb pordami." If she were "searching por da
right" muscle to harvest from in order to perform myocutaneous flap
surgery for breast reconstruction, which should she choose?
a) Pectoralis major
b) Serratus anterior
c) Latissimus dorsi
d) Pectoralis minor
8. Which should she harvest for a laryngopharyngectomy with skin
defect?
a) Pectoralis major
b) Serratus anterior
c) Latissimus dorsi
d) Pectoralis minor
9. The ____ is the vertical line found at the midpoint between the
sternal notch and the acromion.
a) Midsternal line
b) Midclavicular line
c) Anterior axillary line
10. The sternal angle plane is found above the margin of the
manubrium. True or false?

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