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Por José Domingo Díaz, Residente de Primer Año de Cirugía General.
Universidad de Cartagena
Embryogenesis of the BreastNormal Development
The breast is a group of large glands derived from the epidermis
Second month of gestation
Two bands of ectoderm
Milk lines
Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009
A. The milk lines in a generalized mammalian embryo. Mammary glands form along these lines. B. Common sites of formation of supernumerary nipples or mammary glands along the course of the milk lines in the human.
The glandular portion of the breast develops from the ectoderm
Twelve weeks
16 to 24 buds of ectodermal cells grow into the underlying mesoderm (dermis)
Areola fifth month onward
Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009
Development of the breast. A-D. Stages in the formation of the duct system and potential glandular tissue from the epidermis. Connective-tissue septa are derived from the mesenchyme of the dermis. E. Eversion of the nipple near birth.
Modified sweat glands
Areolar glands (Montgomery)
Connective tissue stroma forms from mesoderm
Rest of changes will reappear in puberty
Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009
Development of the mammary ducts and hormonal control of mammary gland development and function. A. Newborn. B. Young adult. C. Adult. D. Lactating adult. E. Postlactation.
Congenital Anomalies
Amastia, Athelia, and Amazia
Supernumerary Breasts or Nipples
Congenital Inversion of the Nipple
Anomalies of Breast Size
Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009
http://www.youtube.com/watch?v=druBEupr7eM
Surgical Anatomy
Topographic Anatomy and Relations
Located within the superficial fascia anterior chest wall
Base from second rib above to the six or seven rib below
External border medially to midiaxillary line laterally
Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009
2/3 of base lies anterior to the pectorally major muscle
Remainder lies anterior to the serratus anterior muscle
Tail of expense: 95%, lateral quadrant toward the axilla prolongation
Hiatus of Langer in the deep fascia
Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009
Skin
Areola and nipple distinguished from that of the surrounding skin by pink color imparted by blood vessels
Pregnancy increases melanin darkening the area (Basal cells)
Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009
Superficial Fascia
Envelopes the breast
Continuous with the superficial abdominal fascia below and superficial cervical fascia above
Anteriorly with the dermis of the skin
Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009
Diagrammatic sagittal section through the nonlactating female breast and anterior thoracic wall.
Deep Fascia
Envelopes the pectoralis major muscle continuous with the abdominal fascia below
Medially attached to externum
Above and laterally clavicle and axillary fascia
Anteriorly pectoralis minor fascia
Inferiorly serratus anterior posterior extension
Fascia of the latissimus MusclesSkandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009
Muscle Origin Insertion Nerve supply CommentsPectoralis major Medial half of clavicle, lateral half of
sternum, 2nd to 6th costal cartilages, aponeurosis of external oblique muscle
Lateral lip, bicipital groove Lateral and medial pectoral nerves
Clavicular portion of pectoralis forms upper extent of radical mastectomy; lateral border forms medial boundary of modified radical mastectomy; both nerves should be preserved in modified radical procedure
Pectoralis minor 2nd to 5th ribs Coracoid process of scapula Lateral and medial pectoral nerves
Deltoid Lateral half of clavicle, lateral border of acromion process, spine of scapula
Deltoid tuberosity of humerus
Axillary nerve
1. 1st and 2nd ribs Costal surface of scapula at superior angle
Long thoracic nerve Injury produces "winged scapula"
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 intertubercular groove of humerus
Thoracodorsal nerve The anterior border forms the lateral extent of radical mastectomy; injury results in weakness of rotation and abduction of arm
Subclavius Junction of 1st rib and its cartilage Groove of lower surface of clavicle
Subclavian nerve
Subscapularis Costal surface of scapula Lesser tubercle of humerus Upper and lower subscapular nerves
Subscapular nerves should be spared
External oblique aponeurosis
External oblique muscle Rectus sheath and linea alba, crest of ilium
Remember the interdigitation with serratus anterior and pectoralis muscles
Rectus abdominis Ventral surface of 5th to 7th costal cartilages and xiphoid process
Crest and superior ramus of pubis
Branches of 7th-12th
thoracic nerves
The rectus sheath is the lower limit of radical mastectomy
Serratus anterior (3 parts)
Muscles and Nerves Involved in MastectomyMuscles Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009
Morfology
15 and 20 lobes
Lobes, together with their ducts, are anatomic units, but not surgical units
Lobes and ducts arranged radially
Lactiferous sinuses, milk storage
Papilomas
Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009
The retromammary space. 1. Membranous layer of superficial fascia. 2. Retromammary space. 3. Muscle fascia.
Breast topography. From a dissection photograph. 1. Retinacula cutis. 2. Membranous layer. 3. Serratus anterior fascia. 4. Serratus anterior muscle. 5. Pectoral fascia. 6. Pectoralis major muscle. 7. Suspensory ligament of axilla. 8. Lobe of breast parenchyma. 9. Lactiferous duct. 10. Ampulla.
Dimpling of the breast, resulting from involvement of Cooper's ligaments by invasive disease. The dimpling is emphasized by the pressure of the hand of the examiner. From a clinical photograph.
Blood SupplyBlood supply of the breast; drawing from a dissection photograph. The arterial supply is here derived chiefly from (A) direct mammary branches of the axillary artery; (B) branches of the lateral thoracic artery; (C) perforating branches of the internal thoracic artery. The venous drainage is comparable, and is illustrated on the right side of the drawing. The rib levels are indicated by numbers.
A. The breast may be supplied with blood from the internal thoracic, the axillary, and the intercostal arteries in 18 percent of individuals.
B. In 30 percent, the contribution from the axillary artery is negligible.
C. In 50 percent, the intercostal arteries contribute little or no blood to the breast. In the remaining 2 percent, other variations may be found.
Lymphatic Drainage
Lymph nodes of the breast and axilla. Classification of Haagensen.
Arrangement of Lymph Nodes and Metastasis
Level I: lateral to the lateral border of the pectoralis minor muscle
Level II: under the pectoralis minor muscle
Level III: medial to the medial border of the pectoralis minor muscle
Skandalaki’s Surgical Anatomy, Chapter 3, Breast. 2009
Level I (low axilla), Level II (midaxilla), Level III (apical axillary)Google Images
Diagram of lymphatic drainage of the breast.
Innervation
Diagrammatic representation of important peripheral nerves encountered during mastectomy.
Images
Pet/Tac of inflamatory cancer of the breast. The Journal of Nuclear Medicine
Imagen sospechosa de una mamografía.Foto: NCI
Eco quiste mamarioGoogle Images
Eco tumor mamarioGoogle Images
Eco fibroadenoma mamarioGoogle Images
Nucleus Medical Art, 2009
Nucleus Medical Art, 2009