227
Chapter 8
Breast
Development and changes during life 227
Blood supply 228
Lymphatic drainage 228
The base of the adult female breast or mammary gland
extends from the second to the sixth ribs and overlies
mostly the pectoralis major. Its lower part overlies the
serratus anterior laterally and the rectus sheath and the
external oblique medially (Fig. 8.1). The gland is
subcutaneous. A small part of the upper outer quadrant may
prolong into the axilla (the axillary tail). This extension also
often lies in the superficial fascia but occasionally may be
deep and next to the lymph nodes in the axilla.
The breast is made up of 15–20 lobules consisting of
glandular tissue and fat. Fat forms the main bulk of the
breast tissue, contributing to its size and shape. In between
the lobules there are strands of fibrous tissue, the
suspensory ligaments of Cooper, connecting the
subcutaneous tissue to the fascia covering the chest muscles.
The glandular tissue in each lobule has a lactiferous duct
which converges and opens on the tip of the nipple. The
nipple is surrounded by an area of pigmented skin, the
Pectoralis major
Serratus anterior
External oblique
abdominis
Fig. 8.1 Anterolateral dissection showing surface anatomy and structure of the breast.
areola, which has large sebaceous glands (tubercles of
Montgomery) – these enlarge during pregnancy.
Behind the breast the superficial fascia is condensed to
form a posterior capsule. The retromammary space
containing loose connective tissue lies between the capsule
and the underlying fascia covering the pectoralis major (the
pectoral fascia).
The male breast is rudimentary and consists of a few
ducts surrounded by connective tissue and fat. Though
structurally insignificant it is susceptible to the diseases
affecting the female breast.
Development and changes during life
The breasts develop from the ectoderm of the chest wall as a
series of branching ducts invaginating from the surface.
Shortly before birth the developing site everts to form the
nipple. Until puberty ducts are the principal glandular
tissue. At puberty oestrogens and progesterone secreted
cyclically by the ovaries influence the growth of the duct
system, fat and connective tissue. During early pregnancy,
ducts proliferate further and form buds that expand to form
alveoli. During the second half of pregnancy glandular
Suspensory ligaments
(of Cooper)
Nipple
Areola
Areolar glands
Lactiferous
ducts
Ampulla
Fat
Gland lobules
228 HUMAN ANATOMY

Clinical box 8.1

Breast cancer
Cancer of the breast is a common cancer that affects
women. About 1 in 8 women in the Western World
develops breast cancer in her lifetime.
Cancer develops in the cells of the acini and ducts and
spreads to the surrounding tissues as well as into the
lymphatics and veins.
Mammography (Fig. 8.2), which is an x-ray examination
of the breast, is used as a screening device to detect early
breast cancer. High breast tissue density seen on a
mammogram shows an increased risk.
Anatomical changes occur as a result of the spread of
carcinoma. Growth of tumour into the ligaments of
Cooper causes dimpling of the skin, but when it involves
the ducts it can produce retraction of the nipple.
Removal of breast (mastectomy) is the surgical
treatment of breast cancer. In a simple mastectomy only
the breast tissue is removed. This may be accompanied by
a surgical dissection of the axilla (axillary clearance) to
remove the lymph nodes draining the breast (see Clinical
box 2.7). In some cases the surgeon removes the breast
and the underlying pectoral muscles, a procedure known
as radical mastectomy.
To find out whether the cancer cells have spread
into the lymph nodes the surgeon does a biopsy of the
lymph nodes (removal for histological examination)
before more radical treatment is undertaken. In a sentinel
lymph node biopsy a dye or radioactive tracer is injected
into the area around the tumour. The path taken by the
dye is the most probable direction of tumour spread, and
these are the nodes which are most likely to be involved
by cancer cells. The surgeon then removes and
histologically examines just the lymph nodes which are
stained by the dye. If no cancer cells are found in the
nodes no further nodes are removed.
Developmental abnormalities may be present in the
breast. One breast or both may be small or absent
(amazia). On the other hand supernumerary nipples or
even breasts may occur, along a ‘milk line’ extending from
the axilla to the groin. The nipple may fail to evert.
Retraction of the nipple can also occur as a result of
carcinoma and hence it is important to verify, while
taking patient’s history, whether the condition was
present since birth.

proliferation slows, but alveoli enlarge and begin to form

secretory material influenced by oestrogen and
progesterone from the ovaries and the placenta and
prolactin from the anterior pituitary. At parturition the
oestrogen and progesterone levels fall but the prolactin
secretion increases. Maintenance of lactation requires
continuous prolactin secretion. After cessation of lactation
the gland undergoes regressive changes and returns to a
resting state. After menopause the gland involutes, leaving
only a few remnants of the ducts.

Blood supply
The breast is supplied by branches from the axillary,
internal mammary and intercostal arteries, the first two
being the main source. Branches from the axillary artery
(p. 17) are the lateral thoracic and the acromiothoracic and
those from the internal mammary (pgs 52, 187) are its
perforating branches. The venous drainage is to the
corresponding veins. The venous connection to the
intercostal veins is a route by which malignancy can spread
into the vertebrae as these veins drain into the vertebral
venous plexus (Batson’s veins, p. 133) Fig. 8.2 Mammogram showing normal fibroglandular pattern.

Lymphatic drainage
Malignant tumours of the breast spread through the
lymphatics and hence the lymphatic drainage is of
considerable clinical importance. Lymph vessels draining
the breast, like those from any other organ, accompany the
blood vessels. Lymphatics accompanying the branches of
the axillary artery drain about 75% of the lymph from the
breast into the axillary lymph nodes (see p. 18). The
remainder mostly drains into the parasternal nodes lying
along the internal mammary artery. Though the lymphatic
vessels in the substance of the breast form a plexus, lymph
from the lateral part of the breast drains mostly into the
axillary nodes and that from the medial part into the
parasternal nodes. The subareolar plexus of Sappey and the
plexus over the pectoral fascia were thought to be important
in draining the superficial and deep tissues respectively. But
these are now thought to be less important.