The document provides a comprehensive overview of breast anatomy, including its structure, blood supply, lymphatic drainage, and surgical techniques related to breast surgery. It details various biopsy methods, mastectomy types, breast conservation surgery, and reconstruction techniques, emphasizing the importance of clear margins and patient eligibility for procedures. Additionally, it discusses the role of lymph nodes in breast cancer management and the evolving strategies in surgical oncology.

1. Breast
Anatomy
Dr. SAI DEEPIKA
DEPT OF GENERAL SURGERY

2. Introduction
• Latin word Breast = Mammary gland.
• Modified sweat gland.
• Accessory organ of female reproduction system.

3. Situation and extend
• Lies in superficial fascia of pectoral
region.
• Extended
Vertically - from 2nd
to 6th
ribs.
Horizontally – lateral border of sternum
to maxillary line
• Lies on deep fascia (pectoral fascia)
and separated from fascia by retro
mammary space.
2nd
RIB
6th
RIB
Pectoral fascia
Pectoralis minor
Pectoralis Major
Retro mammary
space

4. Situation and extend

5. Situation and extend
• Lymphatics are present in retro
mammary space.
• That is why in MRM we dissect the
breast tissue with pectoral fascia.

6. Situation and extend
• Breast is divided in four quadrants
1. Upper inner
2. Upper outer
3. Lower outer
4. Lower inner
• Nipple areola complex should be
mentioned separately while
describing breast examination.

7. Situation and extend
• Upper lateral quadrant has lateral
extension – known as axillary tail of
Spence.
• It piers deep pectoral fascia – known
as foramen of langer.
• It has direct communication with
anterior group of axillary lymph
nodes.
• That is why we need to remove
axillary LN with breast tissue with
connecting axillary tail in continuity.

8. Structure of breast
• It can be divided in 3 components
1. Skin with nipple areola
2. Parenchyma
3. Stroma

9. Structure of breast
• Nipple
- A conical projection
- Present just below the centre of the
breast at the level of the fourth
intercostal space 10 cm from the midline.
- The nipple is pierced by 15 to 20
lactiferous ducts.
- It contains circular and longitudinal
smooth muscle fibres which can make
the nipple stiff or flatten it, respectively.
- It has a few modified sweat and
sebaceous glands.

10. Structure of breast
• Areola
- Pigmented skin surrounding Nipple.
- Rich in modified sebaceous glands,
particularly at its outer margin. These
become enlarged during pregnancy
and lactation to form raised tubercles
of Montgomery.
- Oily secretions of these glands
lubricate the nipple and areola, and
prevent them from cracking during
lactation.

11. Structure of breast
• Areola
- Apart from sebaceous glands, the
areola also contains some sweat
glands, and accessory mammary
glands.
- The skin of the areola and nipple is
devoid of hair, and there is no fat
subjacent to it.
- Below the areola lie lactiferous sinus
where stored milk is seen.

12. Structure of breast
• Langer’ lines
- Circumareolar incision  Webster’s
incision
- Submammary incision  Galliard
Thomas incision
- In upper quadrants – Incision if away
from NAC then it should be along the
langer’s line
- But in lower quadrants – it should be
radial to prevent NAC displacement
downward.

13. Structure of breast
• Parenchyma
- It is a compound tubulo-alveolar gland
which secretes milk.
- The gland consists of 15 to 20 lobes.
- Each lobe is a cluster of alveoli, and is
drained by a lactiferous duct.
- The lactiferous ducts converge
towards the nipple and open on it.
- Near its termination each duct has a
dilatation called a lactiferous sinus

14. Structure of breast
• Alveolar epithelium
- cuboidal in the resting phase
- columnar during lactation.
• The smaller ducts
- columnar epithelium
• The larger ducts
- two or more layers of cells
- the terminal parts of the
lactiferous ducts by stratified
squamous keratinised epithelium.

15. Structure of breast
• The passage of the milk from the
alveoli into and along the ducts is
facilitated by contraction of
myoepitheliocytes, which are found
around the alveoli and around the
ducts, lying between the epithelium
and the basement membrane.

16. Structure of breast
• Stroma
- Stroma forms the supporting
framework of the gland.
- It is partly fibrous and partly fatty.
- There are fibrous bands that provide
structural support and insert
perpendicularly into the dermis,
termed the suspensory ligaments of
Cooper.
That is why if involvement of cooper’s
ligament  skin retraction

17. Blood supply
• The mammary gland is
extremely vascular.
1. Internal thoracic artery, a
branch of the subclavian
artery, through its perforating
branches.
2. The lateral thoracic, superior
thoracic and acromiothoracic
(thoracoacromial) branches of
the axillary artery.
3. Lateral branches of the
posterior intercostal arteries.

18. Blood supply
• The mammary gland is
extremely vascular.
1. Internal thoracic artery, a
branch of the subclavian
artery, through its perforating
branches.
2. The lateral thoracic, superior
thoracic and acromiothoracic
(thoracoacromial) branches of
the axillary artery.
3. Lateral branches of the
posterior intercostal arteries.

19. Lymphatic drainage
• Specialized lymphatic channels
collect under the nipple and areola
and form Sappey’s plexus.
75% axillary nodes
20% internal mammary nodes
5% posterior intercostal nodes

20. Lymphatic drainage
Breast lymph
Anterior and
Posterior group
Central and
Lateral group
Supraclavicular group
Apical group

21. Lymphatic drainage
• The lymphatics from the deep
surface of the breast pass through
the pectoralis major muscle and the
clavipectoral fascia to reach the
apical nodes, and also to the internal
mammary nodes.

22. Lymphatic drainage
• Lymphatics from the lower and inner
quadrants of the breast may
communicate with the sub
diaphragmatic and sub peritoneal
lymph plexuses after crossing the
costal margin and then piercing the
anterior abdominal wall through the
upper part of the linea alba.

23. Lymphatic drainage
• Three anatomic levels defined by their
relationship to the pectoralis minor
muscle.
1. Level I nodes are located lateral to
the lateral border of the pectoralis
minor muscle.
2. Level II nodes are located posterior
to the pectoralis minor muscle.
3. Level III nodes include the sub
clavicular nodes medial to the
pectoralis minor muscle.

24. Lymphatic drainage
• The anterior (pectoral) group lie along
the lateral thoracic vessels.
• The posterior (scapular) group lie
along the subscapular vessels.
• The lateral group lie along the upper
part of the numerus, medial to the
axillary vein.
• The central group lie in the fat of the
upper axilla.
• The apical (infraclaaicular) group lie
deep to the clavipectoral fascia, along
the axillary vessels.

25. Lymphatic drainage
• Lymph nodes in the space between
the pectoralis major and minor
muscles are termed the interpectoral
group, or Rotter’s nodes.

26. Anatomy of Axilla
• A pyramidal component that is
tightly invested between upper
extremity and thoracic wall.
• Base – dense axillary fascia
• Apex – aperture that extends into
posterior triangle of neck via
cervicoaxillary canal.
• Anterior wall of axilla – pectoralis
muscles and fascia
• Posteriorly – subscapularis
• Floor – teres major and latissmus
dorsi
• Lateral wall – bicipital groove
• Medial wall – serratus anterior

27. Biopsy
1) FNA : performed using a 1.5 inch, 22-G needle attached to a 10ml
syringe.
- needle is placed in mass, suction is applied while needle is moved back and
forth. Cellular material is expressed into slides, air dried and 95% ethanol
fixed sections are prepared.
- Combination of diagnostic mammography, USG or stereotactic localisation
with FNA achieves almost 100% accuracy in pre-op diagnosis.

28. 2) Core- Needle biopsy : Performed using 14 G needle such as Tru-cut.
- Core needle permits for analysis of breast tissue architecture and
allows to determine whether invasive cancer is present or not.
- Molecular sub-typing can be done.

29. Vacuum assisted core-biopsy :
• 8-10 gauge needles are
used, where 4-12
samples are acquired
from area of mass,
architectural distortion,
microcalcifications.
• If the target lesion is
microcalcifications, the
specimen should be
radiographed. A
radiopaque marker
should be placed at the
site of the biopsy to mark
the area for future
intervention.
• Therapeutic usage : upto
4-5cm fibroadenoma can
be removed.

30. Needle biopsy
Tissue for histological examination can be obtained under
local anaesthesia using a large-diameter core needle biopsy
device (14G for breast tissue and 18G for axillary nodes).
● The core needle biopsy should always be taken
under image guidance. The passage of the biopsy needle can
be guided by ultrasonography, mammogram or sometimes
MRI;
● the needle tip should be used to take a sample from
only
the solid part of the mass, avoiding areas of cystic degeneration
and blood vessels in and around the lesion

33. Excision Biopsy

35. SURGICAL TECHNIQUES
1) Skin sparing mastectomy : all breast tissue + NAC + <1cm of skin
around excised scars.
2) Simple mastectomy : all breast tissue + NAC + necessary skin
without Axillary Lymph Node dissection.
3) Extended simple mastectomy : Simple mastectomy + Level I axillary
lymph nodes.

36. 4) Modified Radical Mastectomy
:
- Elliptical stewart incision is
made
- All flaps are developed.
- Breast parenchyma and
pectoralis major fascia are
elevated from underlying
pectoralis major in a plane
consistently parallel with
muscle.
- Elevation of breast
parenchyma and fascia is
continued laterally until the
lateral edge of pectoralis major
and minor are exposed.

37. - An incontinuity axillary LND is
performed. The investing fascia
of axillary space is sharply
divided. The pectoralis minor is
defined, and Rotter’s LN
between pectoralis muscles
are cleared.
- Loose areolar tissue of lateral
axillary space is elevated, the
investing layer of axillary vein is
dissected sharply. Division and
ligation of intervening venous
tributaries is done.
- Dissection continues medially
on anteroventral surface of
axillary vein and the loose
areolar tissue at juncture of
axillary vein with anterior
margin of latissmus dorsi is
swept inferomedially to include
lateral group.

38. - The lateral axillary LN group is
retracted inferomedially and anterior
to thoracodorsal neurovascular bundle
and dissected en bloc with
subscapular group of LN (level I).
- Dissection of posterior content of
axillary space exposes posterior
boundary of axilla, then dissection
proceeds with removal of central
axillary LN (level II).
- With medial dissection, the chest wall
deep and in medial axillary space, we
can identify the long thoracic nerve
lying anterior to subscapularis muscle
and close to serratus fascial
compartment of chest wall. Long
throacic nerve is then dissected from
superior to inferiorly till the point of
innervation of serratus anterior
muscle.
- Axillary contents anterior and medial
to long throacic nerve are then swept
inferomedially with dissection
specimen.

39. Breast conservation surgery
• Currently the standard of treatment for stage 0, I or II invasive breast
cancer.
• Women with DCIS only require resection of the primary cancer and
adjuvant radiation therapy without assessment of regional lymph nodes.
• Involves resection of primary breast cancer with a margin of normal
appearing breast tissue, adjuvant radiation therapy and assessment of
regional lymph node status.
• Adjuvant RT reduces recurrence incidence by half.
• Advantages : Preservation of breast shape skin, sensation and
psychological advantage of not having a body part amputated.

40. FACTORS AFFECTING ELIGIBLITY FOR BREAST CONSERVATION INCLUDE:
I) TUMOR SIZE
• lumpectomy is considered when the tumor, regardless of size, can be
excised with clear margins and an acceptable cosmetic result and
depends on the tumor to breast ratio
II) MARGIN
• “no ink on tumor” should be used as the standard for an adequate
margin in invasive breast cancer or DCIS
III) HISTOLOGY:
• Invasive lobular cancers and cancers with an extensive intraductal
component can be treated with lumpectomy if clear margins can be
achieved.

41. INDICATIONS
• T1/T2 (<5cm) , No, N1 Mo
• T2 (>4cm) in large breasts
• Mammographically detected lesion
• Clinically negative axillary nodes
• Adequate sized breast and volume to allow proper RT
• Well differentiated tumor with low S phase

42. CONTRAINDICATIONS
I) RELATIVE:
• Prior radiation therapy to chest wall or breast
• Active connective tissue disease involving the skin (e.g scleroderma)
• Extensive positive pathological margins
• Tumors > 5 cm
• Large tumor size relative to breast
• Known or suspected Li-Fraumeni syndrome ( p53 mutation)
• Patients with BRCA1 or BRCA2 mutation.

43. II) ABSOLUTE:
• First trimester of pregnancy (as radiation therapy is
contraindicated)
• Multicentric disease
• Extensive DCIS
• Tumors for which clear margins are unobtainable
with lumpectomy with favourable cosmetic results
• Homozygous for ATM mutations

44. - Incision is made directly
over tumor or around the
areola. Skin and
subcutaneous fat are
dissected off breast
tissue.
- Skin flaps should be
elevated 1 to 2 cm
beyond the edge of
cancer.
- Finger of non dominant
hand to be placed over
palpable cancer and
breast tissue , can be
divided 1cm beyond the
limit of palpable mass,
1cm deep to deepest
aspect of tumor and then
breast tissue under
cancer is divided.

45. • Oriented with sutures, ligaclips, or
metal markers. Using metal
markers and ligaclips or attaching
the specimen to an orientated
grid has the advantage of allowing
orientated anteroposterior-
intraoperative specimen
radiography to be performed.
• This helps the surgeon to
determine first that the target
lesion has been excised and
second allows assessment of
completeness of excision at the
radial margins.
• If inspection of the specimen
radiograph shows that the cancer
or any associated
microcalcification is close to a
radial margin, then the surgeon
should remove further tissue
from the margin of concern.

46. • After excision, a small defect (<5% breast volume) can be left
and usually produces good cosmetic result.
• Larger defects should be closed by moblising surrounding
breast tissue from overlying skin and subcutaneous tissue.
• Defect is closed with a series of interrupted absorable sutures.
• Larger defects can be filled by local flaps, or more major breast
reshaping as part of U/L or B/L therapeutic mammoplasty.

47. Margin Probe
• Intra-operative assessment
tool
• based on near-field radio
frequency (RF) spectroscopy
• designed to detect differences
between dielectric properties
of malignant and normal
breast tissue adjacent to the
probe’s sensor.
• The MarginProbe System was
approved by the U.S. Food
and Drug Administration in
January 2013.

48. Sentinel Lymph Node Biopsy
Principle : - Sentinel node is the first LN that drains the area under consideration (tumor).
- When mapping agents are injected subareola/subdermally in site of primary
tumor(peritumorally), the material passes through lymphatics to sentinel node, which is
then identified and biopsied.
Indications :
- Early breast cancer with clinico-radiologically node negative axilla.
Contraindications :
- Inflammatory breast cancer
- Biopsy proven metastasis
- DCIS without mastectomy

49. Procedure :
- Pre-operative lymphoscintigraphy – A
dose of 2.5mCi of Tc99m labelled sulfur
colloid is injected on the day prior to
surgery and films are obtained.
- On day of surgery – 0.5mCi of Tc99m
sulfur colloid injected peritumorally or in
subareolar location or at the prior biopsy
site.
- On operating table – 3-5ml of blue dye
(isosulfan/methylene blue) is injected
into breast parenchyma near the
tumor/subareolar.
- Using a hand held gamma camera, the
area of increased radioactivity in axilla is
identified transcutaneously : Incision is
made over it, blue lymphatic channels
are visualised leading upto sentinel node.
- Best result is obtained when we remove
all the blue LN alongwith >10% of
radioactivity of the 10sec ex-vivo count of
SN harvested.

50. Breast Reconstruction
• After lumpectomy or a BCS with adjuvant radiotherapy, post-radiation
contracture can cause contour deformities of the breast and nipple areolar
deviation toward the location of the lumpectomy.
• Oncoplastic breast reconstruction, prevents these deformities, lower
morbidity, improves quality of life, and gives a more natural aesthetic
outcome.
• Goals of oncoplastic breast reconstruction are –
• obliteration of dead space, vascular support of the nipple, and tailoring the local tissues to
place the NAC and the remaining skin and parenchyma in an aesthetically acceptable shape.
• It encompasses three main techniques: reduction/mastopexy, intrinsic tissue
rearrangement, and adjacent tissue transfer/locoregional flaps.

51. Indications and Contraindications
• Breast cancer for which a standard BCS is seemingly impossible – larger tumors
(>10-20% breast volume), multifocal disease.
C/I :
• Large tumors requiring mastectomy for clear margins.
• Insufficient residual breast tissue after excision
• Multicentric disease
• Inflammatory carcinoma
• Previous irradation
• Multiple co-morbidities
• Chronic smoker

52. Types of Oncoplastic Surgeries
1) Volume displacement – Resected defect is reconstructed by moving
local glandular/dermoglandular tissue into the defect.
2) Volume replacement – Extensive resections in breast should be
replaced with a similar volume of autologous tissue from an
extramammary site.

54. Grisotti advancement rotational flap

55. Round Block – Doughnut mastopexy

56. • Radiation therapy has a role to decide
which type of reconstruction is to be
performed.
• As the pre-operative radiation
damages the recipient field and intra-
mammary vessels increasing the risk of
intra-operative vascular complications,
minor complications, skin loss, and
infection in autologous reconstruction.
• The higher risk of reconstructive
failure (reported to be as high 50%),
capsular contracture, infection,
mastectomy flap necrosis, and seroma
have led implant-based reconstruction
to fall out of favor in the setting of prior
radiation.
• Autologous reconstruction is the ideal
method of reconstruction in a patient
with prior chest wall irradiation.

57. • Local flaps include intrinsic parenchymal flaps to support nipple areolar complex
vascularity or to fill in dead space.
• Regional flaps include lateral, medial, and anterior intercostal artery perforator
flaps (LICAP, MICAP, and AICAP), as well as the lateral thoracic artery perforator
(LTAP), thoracodorsal artery perforator (TDAP), and internal mammary artery
perforator (IMAP) flaps.
• These flaps can be chosen and tailored based on patient breast size, location of
the tumor, planned size of resection/anticipated defect, and understanding of
radiation effects on this local flap.
• Final choice must take into account the extent of skin resection, need for
neoadjuvant or adjuvant radiation and chemotherapy, patient body habitus,
aesthetic desires, and activity level.

58. Timing of Reconstruction
1) Delayed reconstruction in the setting of implant-based reconstruction is
classically accomplished with two stages using a tissue expander to gradually
expand the mastectomy flaps and breast pocket followed by exchange for
permanent implant.
2) Immediate breast reconstruction, a newer concept, means that the final
reconstructive modality is done at the time of the mastectomy.
- It may be the choice of reconstruction for a young, thin, healthy, non-smoker with
small breasts, who has thick and well-perfused mastectomy skin flaps.
3) Delayed-immediate reconstruction - immediate placement of tissue
expanders at the time of skin-sparing mastectomies followed by delayed
reconstruction in the case of radiation and immediate reconstruction
(implants or autologous) in the case of no radiation.

59. Implant Reconstruction
• Breast reconstruction should not be
limited to focusing on the affected breast
and attaining symmetry to the native
breast but must consider patient goals and
satisfaction for both breasts.
• There are two most widely used plane of
Implant placement – Pre-pectoral and Sub-
pectoral.
• Pre-pectoral reconstruction is performed
by creating a new pocket anterior to the
pectoralis muscle and can be done
immediately or delayed, in one or two
stages, with saline or air in the tissue
expander, and with or without acellular
dermal matrix.

60. Plane of Implant

61. Complications
• Hematoma
• Wound dehiscence
• Malposition
• Deflation
• adverse scarring
• capsular contracture
• mastectomy skin flap necrosis
• Infection
• Seroma
• extrusion
• reconstructive failure
• Venous thromboembolic events

62. Autologous Breast reconstruction
• Provides a more natural shape, texture, proportional changes in size
and contour of the breast with the rest of the body following weight
changes, as well as potential improvement in the contour of other
parts of the body that serve as donor sites.
• Divided broadly into – Pedicled flaps and Free flaps.

64. Nipple Areola Reconstruction
• The goal is to create symmetric nipples and areolas on both breasts.
• Technique depends on the size and position of the contralateral breast.
• Commonly, a nipple-areola reduction technique enhances the aesthetics of the
contralateral breast, offering tissue that can be utilized for reconstruction of the
affected breast.
• The nipple can be reconstructed with multiple techniques, including local flaps, grafts,
injectable fillers, engineered tissue substitutes, or combinations of the these.
• Postoperative contraction is to be anticipated so the reconstructed nipple is designed
25% to 50% larger than the desired final size.
• Areola can be reconstructed either by using skin grafts or medical tattoo. Skin grafts
can be harvested from the groin area, which is naturally more hyperpigmented, or
from the contra-lateral areola combined with mastopexy

66. THANK
YOU