anatomy, physiology, problems of breast feeding, effective breast feeding techniques, begin and malignant lesions

1. Breast…

3. Contents…
• Anatomy
• Physiology

4. Introducion…
• Breast is a tear-shaped, modified sweat gland
and forms the secondary sexual features of
female.
• No role in reproduction but provides essential
nourishment to newborn and infant.
• Present in males: but rudimentary.

5. Composition…
• Mass of glandular, fatty and fibrous tissues,
containing no muscles
• Layer of fat surrounds the glands giving it a soft
consistency.
• Consists of
– Acini/lobes
– Milk glands (lobules)
– Ducts
– Ampulla
– Nipple

6. • Location
– In the superficial fascia of the pectoral region
• Boundary
– Vertically: 2nd to 6th ribs
– Horizontally: lateral border of sternum to mid
axillary line
• Extension
– Above: clavicle
– Below: 7th to 8th rib
– Medially: midline
– Posteriorly: to the edge of latissimus dorsi

9. Structures…
• Skin
– Nipple
– Areola
– Montgomery’s glands
• Parenchyma
– Lobuleslobes ductules lactiferous ducts
lactiferous sinus(ampulla) nipple
• Stroma
– Partly fibrous and partly fatty
– Ligament of Cooper: anchors breast with skin

12. Male Vs Female breast…
• Male:
– Composed of fat with some glandular tissue
– Also show areolas and nipples
• Female:
– Have similar structures but also contains
• Glandular elements
• Acini, ducts
• Coopers ligaments
• Montgomery’s glands

13. Development…

14. • Breast tissues begin to develop from 4-6th
week of fetal life.
• Initially develop along milk line/ridge
• By 9th wk, regresses to chest area, leaving two
breast bud
• Columns of cells grows inward from each bud,
becoming separate sweat glands with ducts
leading to nipple.

15. • Female breast does not begin to grow until
puberty (10 – 12 yrs)
• Estrogen and progsterone signals the
development of the glandular elements.

16. 2nd Class

17. Blood Supply…
• Arterial Supply
– Internal thoracic artery
– perforating branches
– Axillary artery
1. Lateral thoracic art.
2. Superior thoracic art.
3. Acromiothoracic art.
– Posterior intercostal
arteries – lateral braches
• Venous drainage
• Veins first converge around
nipple to form anastomotic
venous circle then forms 2
sets of veins
– Superficial veins – drain
into internal thoracic
veins and superficial
veins of lower part of
neck
– Deep veins – drain into
internal thoracic,
axillary and posterior
intercostal veins.

20. Nerve supply
• 4th to 6th intercostal
nerves by their
anterior and lateral
cutaneous branches.

21. Factors influencing the breast size:
• Volume of breast tissue
• Family history
• Age
• Weight loss or gain
• History of pregnancy and lactation
• Thickness and elasticity of breast skin
• Degree of hormonal influence on the breast
• Menopause

23. Developmental anomalies…
• Amastia (absence of breast)
• Polymastia (supernumerary breasts)
• Athelia (absence of nipples)
• Polythelia (supernumerary nipples)
• Gynaecomastia (as in liver disease or
chromosomal abnormalities)

25. Physiology…

26. Hormones
• Major hormones involved:
– Progesterone
– Estrogen
– Prolactin
– Oxytocin

27. Changes during pregnancy…
• Best evident in primigravida.
• Size:
– Increase in size evident in early weeks
– Estrogen: marked hypertrophy and proliferation of
ducts
– Progesterone: marked hypertrophy of acini and lobes
– Hypertrophy of the stroma
• Enlarged and painful axillary tail of spence
• Striation due to stretching of the skin

28. • Nipples and areolas:
– Larger, erectile and deeply pigmented
• Hypertrophy of Montgomery’s glands
• Appearance of secondary areolas
• Secretions:
– Can be squeezed out at about 12th wk POG – sticky
– 16th wk – thick and yellowish
– Later 34th wks and above – colustrum

29. Lactation…
• 4 phases:
• Preparation of breast (Mammogenesis)
• Synthesis and secretion from the glands
(Lactogenesis)
• Ejection of milk (Galactokinesis)
• Maintenance of lactation (Galactopoiesis)

30. • Mammogenesis:
• Remarkable growth of both the ductal and
lobuloalveolar systems.
• Lactogenesis:
• Milk secretion starts on 3rd to 4th postpartum
day
• Breast are engorged, tense, tender and warm
• Following delivery: progesterone and estrogen
are withdrawn, prolactin begins its milk
secretory activity

31. • Secretory activity is enhance directly or
indirectly by growth hormone, thyroxine,
glucocorticoids and insulin (facilitates
mobilisation of nutrients and minerals
required for lactation.)
• Prolactin stimulates mammary glandular
ductal growth and epithelial cell proliferation
and induces milk protein synthesis.

32. • Galactokinesis
• Discharge of milk depends upon
– Suction exerted by baby during suckling
– Contractile mechanism that expresses milk from
alveoli into ducts
• Galactopoiesis
– Continuous suckling and removal of milk from
glands also releases prolactin
– Secretion is a continuous process unless
suppressed by external factors.

33. • Sucking reflex: activates touch
receptors in mammary glands
• Impulses are carried by
afferent nerves to Supraoptic
and paraventricular nuclei in
the hypothalamus
• Efferent impulses causes the
release of oxytocin and
prolactin
• Oxytocin causes contraction
of myoepithelial cells –
leading to ejection of milk.
• Prolactin secretion leads to
increase in milk production.

34. Colostrum…
• First milk secreted by mother
• Deep yellow serous fluid
• Contains high protein, vitamin A, high Na/Cl
but low carbohydrate andpotassium.
• Antibodies ( IgA, IgG, IgM) and humoral
factors (lactoferrin) – provide immunological
defence
• Large fat globules have laxative action

35. When is lactation supression
needed???

36. Blood Supply…
• Arterial Supply
– Internal thoracic artery
– perforating branches
– Axillary artery
1. Lateral thoracic art.
2. Superior thoracic art.
3. Acromiothoracic art.
– Posterior intercostal
arteries – lateral braches
• Venous drainage
• Veins first converge around
nipple to form anastomotic
venous circle then forms 2
sets of veins
– Superficial veins – drain
into internal thoracic
veins and superficial
veins of lower part of
neck
– Deep veins – drain into
internal thoracic,
axillary and posterior
intercostal veins.

39. Nerve supply
• 4th to 6th intercostal
nerves by their
anterior and lateral
cutaneous branches.

41. Factors influencing the breast size:
• Volume of breast tissue
• Family history
• Age
• Weight loss or gain
• History of pregnancy and lactation
• Thickness and elasticity of breast skin
• Degree of hormonal influence on the breast
• Menopause

43. Developmental anomalies…
• Amastia (absence of breast)
• Polymastia (supernumerary breasts)
• Athelia (absence of nipples)
• Polythelia (supernumerary nipples)
• Gynaecomastia (as in liver disease or
chromosomal abnormalities)

45. Physiology…

46. Hormones
• Major hormones involved:
– Progesterone
– Estrogen
– Prolactin
– Oxytocin

47. Changes during pregnancy…
• Best evident in primigravida.
• Size:
– Increase in size evident in early weeks
– Estrogen: marked hypertrophy and proliferation of
ducts
– Progesterone: marked hypertrophy of acini and lobes
– Hypertrophy of the stroma
• Enlarged and painful axillary tail of spence
• Striation due to stretching of the skin

48. • Nipples and areolas:
– Larger, erectile and deeply pigmented
• Hypertrophy of Montgomery’s glands
• Appearance of secondary areolas
• Secretions:
– Can be squeezed out at about 12th wk POG – sticky
– 16th wk – thick and yellowish
– Later 34th wks and above – colustrum

49. Lactation…
• 4 phases:
• Preparation of breast (Mammogenesis)
• Synthesis and secretion from the glands
(Lactogenesis)
• Ejection of milk (Galactokinesis)
• Maintenance of lactation (Galactopoiesis)

50. • Mammogenesis:
• Remarkable growth of both the ductal and
lobuloalveolar systems.
• Lactogenesis:
• Milk secretion starts on 3rd to 4th postpartum
day
• Breast are engorged, tense, tender and warm
• Following delivery: progesterone and estrogen
are withdrawn, prolactin begins its milk
secretory activity

51. • Secretory activity is enhance directly or
indirectly by growth hormone, thyroxine,
glucocorticoids and insulin (facilitates
mobilisation of nutrients and minerals
required for lactation.)
• Prolactin stimulates mammary glandular
ductal growth and epithelial cell proliferation
and induces milk protein synthesis.

52. • Galactokinesis
• Discharge of milk depends upon
– Suction exerted by baby during suckling
– Contractile mechanism that expresses milk from
alveoli into ducts
– Oxytocin/milk ejection reflex
• Galactopoiesis
– Continuous suckling and removal of milk from glands
also releases prolactin
– Secretion is a continuous process unless suppressed
by external factors.
– Prolactin/milk secretion reflex

53. • Sucking reflex: activates touch
receptors in mammary glands
• Impulses are carried by
afferent nerves to Supraoptic
and paraventricular nuclei in
the hypothalamus
• Efferent impulses causes the
release of oxytocin and
prolactin
• Oxytocin causes contraction
of myoepithelial cells –
leading to ejection of milk.
• Prolactin secretion leads to
increase in milk production.

54. Colostrum…
• First milk secreted by mother
• Deep yellow serous fluid
• Contains high protein, vitamin A, D, E, K, high
Na/Cl but low carbohydrate andpotassium.
• Antibodies ( IgA, IgG, IgM) and humoral
factors (lactoferrin) – provide immunological
defence
• Large fat globules have laxative action

55. Breastmilk…
• EXCLUSIVE BREASTFEEDING FOR 6 MONTHS
• High carbohydrate (lactose – 6-7gm/dl)
• Low protein(0.9-1.1gm/dl)
– Lactalbumin &lactoglobulin – easily digestable
– Taurine and cysteine – neural growth
• Fats – PUFA – myelination of nervous system
• Vitamins n minerals
• Water 88%
• IgA, macrophages, lymphocytes, lactoferrin, lysozymes,
interferon – immunologic
• Growth factors, enzymes, hormones

56. Decreased production…
• Pacifiers, bottle feeding
• Supplemental feeding (honey, formula, suger)
• Sore/cracked nipples, engorged breast
• No night feeding
• Inadequate breast emptying

57. When is lactation suppression
needed???
• Stillbirth/ neonatal death
• Breast feeding contraindicated.
• What needs to be done?
– Tight brassier support
– Avoid milk ejection
– Drugs (bromocriptine 2.5mg 1 tab daily for 2
weeks)

58. Effective breast feeding techniques…
• Position of mother should be comfortable
• Position of baby
– Whole body should be supported
– Head and body should be in one line
– Body turned towards mother
– Nose at the level of nipple
• Attachment
– Baby mouth wide open
– Nipple and most of lower areola in mouth
– Chin touches the breast
– Lower lip everted

60. Signs of effective breastfeeding…
• Well satisfied
• Sleeps for 2-3 hours after feed
• Passes urine at least 6-8 times/day
• Gains weight

61. Common problems of breast feeding…

62. Common problems…
• Inverted nipples
• Sore nipples
• Breast engorgement
• Not enough milk

63. • Inverted / retracted nipples
– Manually everting, stretching and rolling out several
times a day
– Plastic syringe to draw out the nipple
• Sore nipples
– Due to sucking on nipple rather than areola.
– Vigorous sucking  biting the nipple
– Frequent washing with soap and water
– Treatment
– Correct positioning and attachment/latching
– Hind milk applied to nipple after feed, and allowed to
be aired with enough rest between feeds
– Not to wash nipples many times a day or apply any
ointment/cream

66. • Breast engorgement
– Due to delayed/infrequent feeding, incorrect
positioning
– Increased accumulation  swollen warm hard
painful breast.
– Pain, tenderness/heaviness, malaise, fever, painful
breastfeeding
– Prevention: early and frequent feeding
– Treatment: Breast support, manual expression
– Local warm packs, breast massage and analgesic
to relieve pain

68. Not enough milk
• Rule out other causes
– Incorrect method of breastfeeding
– Supplementary/bottle feeding
– No night feeding
– Breast engorgement
– Any illness, painful condition, maternal illness/stress
or insufficient sleep
• Treatment
– Sufficient rest and adequate fluids
– Baby feeding on demand

69. Breast eczema…
• Erythematous, pruritic disorder with appearance
of dry scaly/crusted lesions on the skin.
• Usually bilateral, associated with eczema in other
areas of the body
• Unknown cause
• Treatment:
• Regular cleaning/hydrotherapy
• Corticosteroid ointment/emmolients

71. Acute mastitis…
• Inflammation of the breast parenchyma.
• Causes: Staphylococcus aureus, Staph.
epidermidis, streptococci spps.
• Generalised malaise, high grade fever with chills
and rigor, severe tenderness
• Treatment:
– Breast support, plenty of oral fluids
– Antibiotics and analgesics
– Manual drainage of breast
– Continue breast feeding

73. Breast abscess…
– Localized collection of pus is called abscess.
– Due to congested engorged breast, cracked nipple,
mastitis  high fever and increased WBC
– Throbbing pain, tense tender breast, high grade fever,
brown edema of skin
– Asymmetrically enlarged breast, tachycardia, altered
coloration(red, shiny)
– Treatment:
– analgesics and antibiotics
– Incision and drainage, then packing regular dressing
and irrigation

76. Breast Lump…

77. • Any palpable mass in the breast parenchyma.
• Types:
– Consistency:
• Solid
• Cystic
– Pathology:
• Benign
• Malignant
– Infection: (antibioma)

78. Aberation of normal breast development and involution…
Age(years) Normal process Aberration
<25 Breast development
Stromal
Lobular
Juvenile hypertrophy
Fibroadenoma
25-40 Cyclical activity Cyclical mastalgia
Cyclical nodularity
30-55 Involution
Lobular
Stromal
Ductal
Palpable cysts
Sclerosing lesions
Duct ectasia
Benign Malignant
Fibroadenoma
Sclerosing adenosis
Phyllodes tumor
Carcinoma of breast

79. • Juvenile hypertrophy:
– Uncontrolled overgrowth of stromal tissues in
adolescent girls, bilateral/unilateral
– Large breast, pain over shoulders/neck/back
– Treatment: reduction mammoplasty
• Fibroadenoma:
– Well circumscribed, firm, smooth, mobile lump,
single/multiple, unilateral/bilateral lesions involving
whole lobule rather than a single cell
– Hormonal dependence
– Treatment:
– <4 cm – reassurance or excision
– >4cm – excision and to rule out malignancy

80. • Cyclical mastalgia
– Pre-menstrual breast discomfort of unknown cause
– If interferes with daily activites and quality of life:
moderate/severe mastalgia.
– Treatment: no specific treatment
– Evening primrose oil, danazol, tamoxifen
• Nodularity
– Diffuse/focal pre-menstrual lumpiness/nodularity that
often fluctuated in size in relation to menstrual cycle.
No specific treatment
• Non-cyclical mastalgia
– Pain in the breast but often originates from ribs or
chest wall.
– Treatment: analgesics (NSAIDS)
– If severe: local anesthetic with corticosteroids

81. • Palpable cysts
– Painful smooth discrete lumps in perimenopausal
women representing distended, involuted lobules
– Treatment: aspiration of cysts
– If blood stained aspiration: excision done
• Sclerosis
– Area of excessive fibrosis of stroma  radial scar,
complex lesions or sclerosing adenosis with or
without calcification
• Duct ectasia
– Dilatation and shortening of major subareolar duct
with age  duct ectasia
– Presents with cheesy discharge and slit like retraction

82. Benign lesions
• Lipoma
– Soft lobulated benign tumor of fat cells.
– Treatment: excision
• Phyllodes tumor
– Fibro-epithelial neoplasm presenting as localised
discrete mass usually >4cm, in perimenopausal
women
– Large capsulated area with cystic spaces
– Microscopically: leaf like projection with cystic spaces.
– Treatment: excision or mastectomy

83. Clinical features…
• Solid or cystic mass
• Breast discomfort
• Asymmetrical breast size/swelling/inflammation
• Breast distortion
• Peau d’ orange of the skin
• Nipple dischage – bloody/cheesy/black/green
• Nipple retraction
• Scaling nipple or eczema