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The Breast
a. b. c. d. e. f. g. Situation and deep relations Structure Blood supply Nerve supply Lymphatic drainage Development Human milk

1. Situation and deep relations a. Lies in superficial fascia of the pectoral region (except for tail) b. Axillary tail of Spence pierces the deep fascia & lies in the deep fascia c. Extent i. Vertically; 2nd to 6th ribs ii. Horizontally; lateral border of sternum to the mid-axillary line d. Deep relations i. Pectoral fascia: the deep fascia which the breast lies on ii. Muscles which lies deeper to the breast 1. Pectoralis major 2. Serratus anterior 3. External oblique iii. Retro mammary space: loose areolar tissue which separates the breast from the pectoral fascia

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2. Structure

a. The skin i. Nipple 1. Conical projection 2. Just below the centre of the breast 3. At the level of 4th intercostals space 4. Pierced by 15 to 20 lactiferous ducts 5. Contains circular smooth muscles : make the nipple stiff 6. Contains longitudinal smooth muscles : make the nipple flatten 7. Has few modified sweat & sebaceous glands 8. Rich in nerve supply 9. Has many sensory end organs at the termination of nerve fibres 10. Devoid of hair
Garaka Rabel 2009

ii. Areola 1. Skin surrounding the base of the nipple 2. Pigmented circular area 3. Rich in modified sebaceous glands (particularly at its outer margin) a. Become large during pregnancy & lactation (raised tubercles of Montgomery) b. Produce oily secretions i. Lubricate nipple & areola ii. Prevent them from being cracking during lactation 4. Contain some sweat glands & accessory mammary glands 5. Devoid of hair

b. The parenchyma i. glandular tissue ii. 15 to 20 lobes iii. each lobe is a cluster of alveoli iv. drained by a lactiferous duct v. lactiferous ducts converge towards the nipple & open on it vi. each duct has a dilation called a lactiferous sinus near its termination vii. Histology of parenchyma 1. Alveolar epithelium a. In resting phase : simple cuboidal epithelium b. During lactation : i. Simple columnar epithelium ii. Distended alveoli may appear cuboidal due to stretching (but much larger than those in the resting phase) 2. Smaller ducts : simple columnar epithelium 3. Larger ducts : stratified columnar epithelium (2 or more layers) 4. Terminal parts of lactiferous ducts : stratified squamous keratinized epithelium 5. Myoepitheliocytes a. Found around alveoli & ducts b. Lies between the epithelium & BM c. Facilitates the passage of milk from alveoli, into & along the ducts

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c. The stroma i. Fibrous stroma 1. Supporting framework of the gland 2. Forms septa known as the suspensory ligaments of Cooper 3. Anchor the skin to the pectoral fascia ii. Fatty stroma 1. Main bulk of the gland 2. Distributed all over the breast; 3. except beneath the areola & nipple

3. Blood supply a. Arterial supply : arteries converge on the breast & are distributed from the anterior surface; the posterior surface is relatively avascular i. Internal thoracic artery : through its perforating branches ii. Some branches of axillary artery; 1. Lateral thoracic artery 2. Superior thoracic artery 3. Acromiothoracic artery (thoracoacromial artery) iii. Lateral branches of the posterior intercostal arteries b. Venous drainage : veins follow arteries; first converge towards the base of the nipple & form an anastomotic venous circle, from where veins run in superficial & deep sets i. The superficial veins drain into; 1. Internal thoracic vein 2. Superficial veins of the lower part of the neck ii. The deep veins drain into; 1. Internal thoracic vein 2. Axillary vein 3. posterior intercostal veins

4. Nerve supply a. Anterior & lateral cutaneous branches of the 4th to 6th intercostal nerves b. Convey sensory fibres to the skin c. Convey autonomic fibres to smooth muscle & to blood vessels d. Nerves do not control the secretion of milk (controlled by prolactin hormone)
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5. Lymphatic drainage

a. Lymph nodes i. Axillary lymph nodes 75% 1. Anterior(pectoral) group chiefly 2. Posterior group 3. Lateral group directly or indirectly 4. Central group 5. Apical group ii. Internal mammary (parasternal) nodes 20% iii. Posterior intercostal nodes 5% iv. Some lymph also reaches; 1. Supraclavicular nodes 2. Cephalic(deltopectoral) node 3. Subdiaphragmatic lymph plexus 4. Subperitoneal lymph plexus
Garaka Rabel 2009

b. Lymphatic vessels i. Superficial lymphatics 1. Drain skin, except for the nipple & areola 2. Pass radially to surrounding lymph nodes; a. Axillary lymph nodes b. Internal mammary (parasternal) lymph nodes c. Supraclavicular lymph nodes d. Cephalic(deltopectoral) lymph node ii. Deep lymphatics 1. Drain parenchyma, nipple & areola iii. Important lymphatic structures: Posterior 1. Parasternal intercostal 20% 5% Breast 75%

Anterior Central

Posterior Lateral Axillary

Apical

2. 3. 4.

5.

Supraclavicular Internal mammary nodes drain lymph from both inner & outer halves of the breast Subareolar lymph plexus of Sappy (a lymphatic plexus deep to areola) drain into anterior group of axillary lymph nodes Lymphatic from deep surface pass through pectoralis major & clavipectoral fascia to reach; a. Apical nodes &, b. Internal mammary nodes Lymphatics from lower-inner quadrants may communicate with subdiaphragmatic & subperitoneal lymph plexuses, after crossing costal margin; then pierce anterior abdominal wall through upper part of linea alba

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6. Development

a. Mammary ridge (milk line or line of Schultz) i. Extends from axilla to groin ii. Appears during 4th week of intrauterine life iii. In human beings it disappears, persisting only in pectoral region iv. Breast develops from ectodermal thickening of persisting part of this ridge v. Gland is ectodermal & stroma is mesodermal in origin
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b. Formation of mammary gland i. Persisting part of the mammary ridge is first converted into a mammary pit ii. Secondary buds(15-20) grow down from floor of the pit iii. These buds divide & subdivide to form lobes iv. Entire solid system is canalized later v. At birth, nipple is everted at the original pit c. Growth of mammary gland, at puberty caused by; i. Oestrogen ii. Progesterone stimulates development of secretary alveoli d. Developmental anomalies i. Amastia absence of breast ii. Athelia absence of nipple iii. Polymastia supernumerary breasts iv. Polythelia supernumerary nipples v. Gynaecomastia development of breasts in a male (occurs in Klinefelters syndrome) 7. Human milk a. Contents i. Water 88% ii. Lactose 7% iii. Fat 4% iv. Proteins 1% (caseins, lactalbumin) v. Ions (Ca2+, PO43-, Na+, K+, Cl- ) vi. Vitamins vii. Antibodies (of IgA variety) b. Colostrum i. Milk secreted in later part of pregnancy & few days after parturition ii. Contain many immunoglobulins iii. Rich in fat & poor in nutrients iv. Fat contains in colostral corpuscles c. Witchs milk i. Milk secreted by infants breast ii. During first 1 or 2 weeks after birth iii. Under the influence of maternal oestrogen d. Lactation i. Active in mothers, for about 5-6 months after parturition ii. Thereafter, diminishes progressively iii. Thus, the infant has to be weaned by about 9 months of age
Garaka Rabel 2009