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ANATOMY OF PECTORAL REGION
AND BREAST
OLOKA EMMANUEL
BUSITEMA UNIVERSITY
MBChB 1
04/16/16 1aquinas emma
PECTORAL REGION
04/16/16 2aquinas emma
CLAVICLE
Shape :
• Its medial 2/3 are
convex forward.
• Its lateral 1/3 is
concave forward.
04/16/16 3aquinas emma
CLAVICLE
Functions :
• Holds the arm away from
the trunk.
• Transmits forces from the
upper limb to the axial
skeleton.
• Gives attachment to
muscles.
04/16/16 4aquinas emma
CLAVICLE
Articulations :
Medially :
• Sternum.
• 1st
costal cartilage.
Laterally :
• Scapula (acromion).
04/16/16 5aquinas emma
CLAVICLE
• It is a long bone that
lies horizontally
across the root of
the neck.
• It is subcutaneous
throughout its
length.
04/16/16 6aquinas emma
PECTORAL MUSCLES
• They are four
muscles that
move the
shoulder girdle
and attach it to
the thoracic
wall.
04/16/16 7aquinas emma
PECTORALIS MAJOR
• It triangular in shape.
• It covers the upper chest.
• Its lower border forms the
anterior wall of the axilla.
• Superiorly it is separated
from deltoid muscle along
the clavicle by the
deltopectoral triangle.
04/16/16 8aquinas emma
PECTORALIS MAJOR
Origin
• It has two heads :
Clavicular :
• from the medial half of
the clavicle.
Sternocostal:
• Anterior sternum.
• Upper six costal
cartilages.
• External oblique
aponeurosis.
04/16/16 9aquinas emma
PECTORALIS MAJOR
Insertion :
• Lateral lip of the bicipital
groove of the humerus.
Nerve supply :
• Medial and lateral
pectoral nerves.
Action :
• Adduction and medial
rotation of humerus.
• Flexion of arm (clavicular
head).
04/16/16 10aquinas emma
CLAVIPECTORAL FASCIA
• It is a strong sheet of fascia.
• Attachment :
• Superiorly :
• It is attached to the clavicle
and splits to enclose the
subclavius muscle.
• Inferiorly : It encloses the
pectoralis minor and
continues as the suspensory
ligament of the axilla and
joins the fascia of its floor.
04/16/16 11aquinas emma
CLAVIPECTORAL FASCIA
Contents :
• Nerve : lateral
pectoral.
• Artery : thoraco-
acromial.
• Vein : cephalic.
• Lymph nodes.
04/16/16 12aquinas emma
SUBCLAVIUS MUSCLE
Origin :
• 1st
costal cartilage.
Insertion :
• Inferior surface of the
clavicle.
Nerve supply :
• A branch from the upper
trunk of the brachial plexus.
Action : Depresses the clavicle.
04/16/16 13aquinas emma
PECTORALIS MINOR
• It is a thin triangular
muscle that is
covered by
pectoralis major.
Origin :
• Anterior surfaces of
3rd
-5th
ribs.
Insertion :
• Coracoid process of
scapular
04/16/16 14aquinas emma
PECTORALIS MINOR
Nerve supply :
• Medial pectoral nerve.
Action :
• Pulls the shoulder
downwards and
forwards.
• It elevates the ribs
(accessory muscle of
respiration) when the
scapula is fixed.
04/16/16 15aquinas emma
THE BREAST
04/16/16 16aquinas emma
Learning Goals
• To learn the development, histology, function
and surgical anatomy of mammary glands.
04/16/16 17aquinas emma
Development of Mammary Glands
• Are a modified and highly specialized type of
apocrine sweat glands.
• Consist of parenchyma, which is formed from ducts, and
connective tissue stroma.
• Parenchyma derives embryonically from surface ectoderm;
stroma arises from surrounding mesenchyme.
• Mammary buds begin to develop during the sixth
week as solid downgrowths of the epidermis into the
underlying mesenchyme
• These changes occur in response to an inductive
influence from the mesenchyme.
04/16/16 18aquinas emma
04/16/16 19aquinas emma
• Mammary buds develop as downgrowths from thickened mammary
crests, which are thickened strips of ectoderm extending from the axillary
to the inguinal regions
• The mammary crests (ridges) appear during the fourth week
but normally persist in humans only in the pectoral area,
where the breasts develop
• Each primary bud gives rise to several secondary mammary
buds that develop into lactiferous ducts and their branches
• Canalization of these buds is induced by placental sex
hormones entering the fetal circulation. This process continues
until late gestation, and by term, 15 to 20 lactiferous ducts are
formed.
• The fibrous connective tissue and fat of the mammary gland
develop from the surrounding mesenchyme.
04/16/16 20aquinas emma
04/16/16 21aquinas emma
• A, Ventral view of an embryo of approximately 28 days showing the mammary
crests. B, Similar view at 6 weeks showing the remains of these crests. C,
Transverse section of a mammary crest at the site of a developing mammary
gland. D to F, Similar sections showing successive stages of breast development
between the 12th week and birth.04/16/16 22aquinas emma
Development of Nipples and Areola
• During the late fetal period, the epidermis at the
site of origin of the mammary gland becomes
depressed, forming a shallow mammary pit
• The nipples are poorly formed and depressed in
newborn infants.
• Soon after birth, the nipples usually rise from the
mammary pits because of proliferation of the
surrounding connective tissue of the areola, the
circular area of skin around the nipple.
• The smooth muscle fibers of the nipple and areola
differentiate from surrounding mesenchymal cells.04/16/16 23aquinas emma
04/16/16 24aquinas emma
Postnatal Development of Female
Breast.
• A, Newborn. B, Child. C, Early puberty. D, Late puberty. E,
Young adult. F, Pregnant female. Note that the nipple is
inverted at birth
• (A). Normally the nipple elevates during childhood. Failure of
this process to occur gives rise to an inverted nipple. At puberty
(12-15 years), the breasts of females enlarge because of
development of the mammary glands and the increased
deposition of fat.
04/16/16 25aquinas emma
• The rudimentary mammary glands of newborn males and
females are identical and are often enlarged.
• Some secretion, often called "witch's milk," may be produced
caused by maternal hormones passing through the placental
membrane into the fetal circulation.
• Newborns breasts contain lactiferous ducts but no alveoli.
Before puberty, there is little branching of the ducts.
• In females, the breasts enlarge rapidly during puberty, mainly
because of development of the mammary glands and the
accumulation of the fibrous stroma and fat associated with
them
• . Full development occurs at approximately 19-20 years
• The lactiferous ducts of male breasts remain rudimentary
throughout life.
04/16/16 26aquinas emma
Gynecomastia
• The rudimentary lactiferous ducts in males normally undergo
no postnatal development.
• Gynecomastia (Gr. gyne, woman + mastos, breast) refers to
the development of the rudimentary lactiferous ducts in the
male mammary tissue.
• During midpuberty, approximately two thirds of boys develop
varying degrees of hyperplasia of the breasts. This subareolar
hyperplasia may persist for a few months to 2 years.
• A decreased ratio of testosterone to estradiol is found
• 80% of males with Klinefelter syndrome (XXY) have
gynecomastia
04/16/16 27aquinas emma
04/16/16 28aquinas emma
Absence of Nipples (Athelia) or
Breasts (Amastia)
• Rare congenital anomalies may occur bilaterally or
unilaterally.
• Result from failure of development or disappearance of the
mammary crests.
• May also result from failure of mammary buds to form.
• More common is hypoplasia of the breast, often found in
association with gonadal agenesis and Turner syndrome
04/16/16 29aquinas emma
04/16/16 30aquinas emma
Aplasia of Breast
• The breasts of a postpubertal female often differ in
size. Marked differences are regarded as
anomalies because both glands are exposed to
the same hormones at puberty.
• In these cases, there is often associated
rudimentary development of muscles of the
thoracic wall, usually the pectoralis major
04/16/16 31aquinas emma
The thorax of an infant with congenital absence of the left pectoralis major muscle.
Note the absence of the anterior axillary fold on the left and the low location of the
left nipple. (From Behrman RE, Kliegman RM, Arvin AM [eds]: Nelson Textbook of
Pediatrics, 15th ed. Philadelphia, WB Saunders, 1996.)
04/16/16 32aquinas emma
Supernumerary Breasts and Nipples
• An extra breast (polymastia) or nipple (polythelia) occurs in
approximately 1% of the female population as an inheritable
condition.
• An extra breast or nipple usually develops just inferior to the
normal breast.
• Supernumerary nipples are also relatively common in males;
often they are mistaken for moles
• Less commonly, supernumerary breasts or nipples appear in
the axillary or abdominal regions of females developing from
extra mammary buds that develop along the mammary crests.
They become more obvious in women when pregnancy
occurs.
• Approximately one third of affected persons have two extra
nipples or breasts.
• Supernumerary mammary tissue very rarely occurs in a
location other than along the course of the mammary crests. It
probably develops from tissue that was displaced from these
crests.
04/16/16 33aquinas emma
Polythelia
04/16/16 34aquinas emma
POLYMASTIA
04/16/16 35aquinas emma
A man and a female infant with
extranipples (polythelia)
04/16/16 36aquinas emma
Inverted Nipples
• Nipples fail to elevate above the skin surface after birth,
remaining in their prenatal location (A)
• May make breast-feeding of an infant difficult;
04/16/16 37aquinas emma
Mammary glands-histology
• Compound tubuloalveolar glands
• Consist of 15 to 20 lobes radiating out from the nipple
and are
• Separated from each other by adipose and collagenous
connective tissue.
• Secrete milk, a fluid containing proteins, lipids, and
lactose as well as lymphocytes and monocytes,
antibodies, minerals, and fat-soluble vitamins
• Provide the proper nourishment for the newborn.04/16/16 38aquinas emma
04/16/16 39aquinas emma
Mammary Glands Development
• Develop in the same manner and are of the same
structure in both sexes until puberty,
• At puberty changes in the hormonal secretions in
females cause further development and structural
changes within the glands.
• Secretions of estrogen and progesterone from the
ovaries (and later from the placenta) and prolactin from
the acidophils of the anterior pituitary gland initiate
development of lobules and terminal ductules.
• Full development of the ductal portion of the breast
requires glucocorticoids and further activation by
somatotropin.04/16/16 40aquinas emma
04/16/16 41aquinas emma
Mammary Glands Development
• Concomittant with these events is an increase in
connective tissue and adipose tissue within the stroma,
causing the gland to enlarge.
• Full development occurs at about 20 years of age
• Minor cyclic changes occur during each menstrual period,
• Major changes occur during pregnancy and in lactation.
• After age 40 or so, the secretory portions and some of the
ducts and connective tissue elements of the breasts begin
to atrophy, and they continue this process throughout
menopause.
04/16/16 42aquinas emma
04/16/16 43aquinas emma
Gland Structure
• The glands within the breasts are classified as
compound tubuloalveolar glands,
• Make 15 to 20 lobes radiating out from the nipple and
separated from each other by adipose and collagenous
connective tissue.
• Each lobe is drained by its own lactiferous duct leading
directly to the nipple, where it opens onto its surface.
• Before reaching the nipple, each of the ducts is dilated
to form a lactiferous sinus for milk storage and then
narrows before passing through the nipple
04/16/16 44aquinas emma
04/16/16 45aquinas emma
• Near the opening at the nipple, lactiferous ducts are
lined by a stratified squamous keratinized epithelium.
• The lactiferous sinus and the lactiferous duct leading to
it are lined by stratified cuboidal epithelium,
• Smaller ducts leading to the lactiferous duct are lined by
a simple columnar epithelium.
• Stellate myoepithelial cells located between the
epithelium and the basal lamina wrap around the
developing alveoli and become functional during
pregnancy
04/16/16 46aquinas emma
Resting (Non secreting) Mammary
Gland
• Alveoli are not developed in nonpregnant women
• nonpregnant women have the same basic
architecture as the lactating (active) mammary
gland, except that they are smaller and without
developed alveoli, which occur only during
pregnancy..
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04/16/16 47aquinas emma
Lactating (Active) Mammary Glands
• are activated by elevated surges of estrogen and progesterone
during pregnancy to become lactating glands to provide milk for the
newborn.
• Terminal portions of the ducts branch and grow and the alveoli
develop and mature
• As pregnancy progresses, the breasts enlarge as a result of
hypertrophy of the glandular parenchyma and engorgement with
colostrum,
• Colostrum is a protein-rich fluid, in preparation for the newborn.
• Within a few days after birth, when estrogen and progesterone
secretions have subsided, prolactin, secreted by acidophils of the
anterior pituitary gland, activates the secretion of milk, which
replaces the colostrum
04/16/16 48aquinas emma
Lactating (Active) Mammary Glands
• During pregnancy,
the terminal
portions of the
ducts branch and
grow and develop
secretory units
known as alveoli.
• Inset shows a
longitudinal
section of a gland
and duct of the
active mammary
gland.
04/16/16 49aquinas emma
Alveoles and Alveolar Cells
• The alveoli are composed
of cuboidal cells partially
surrounded by a meshwork
of myoepithelial cells.
• These secretory cells
possess abundant RER and
mitochondria, several Golgi
complexes, many lipid
droplets, and numerous
vesicles containing caseins
(milk proteins) and lactose.
• Not all regions of the
alveolus are in the same
stage of production,
because different acini
display varying degrees of
preparation for synthesis of
milk substances
Electron micrograph of an
acinar cell04/16/16 50aquinas emma
Milk Secretion from Alveolar Cells
• The secretions of the alveolar cells are of two kinds: lipids and
proteins.
• Stored as droplets within the cytoplasm.
• Released from the secretory cells by the apocrine mode of
exocytosis,
• Small droplets coalesce to form larger and larger droplets that
move to the periphery of the cell.
• Once there, they project as cytoplasmic blebs into the lumen;
eventually, the lipid droplets containing blebs are pinched off and
become part of the secretory product.
• Each bleb consists of a central lipid droplet surrounded by a
narrow rim of cytoplasm and enclosed by a plasmalemma.
• Proteins synthesized within these secretory cells are liberated
from the cells by the merocrine mode of exocytosis in much the
same manner as would be expected of other cells that synthesize
and release proteins into the extracellular space
04/16/16 51aquinas emma
Areola and Nipple
• The circular, heavily pigmented skin in the center of the
breast is the areola.
• Areola contains sweat glands and sebaceous glands at its
margin as well as areolar glands (of Montgomery) that
resemble both sweat and mammary glands.
• In the center of the areola is the nipple, a protuberance
covered by stratified squamous epithelium containing the
terminal openings of the lactiferous ducts.
• In fair-skinned individuals, a pinkish color is imparted to the
nipple as a result of the color of blood in the rich vascular
supply within the long dermal papillae that extend near its
surface.
• During pregnancy, the color becomes darker because of
increased pigmentation of the areola and the nipple.04/16/16 52aquinas emma
04/16/16 53aquinas emma
• The core of the nipple is composed of dense collagenous
connective tissue with abundant elastic fibers connected to the
surrounding skin or interlaced within the connective tissue and a
rich component of smooth muscle cells.
• The wrinkling of the skin on the nipple results from the
attachments of the elastic fibers.
• The abundant smooth muscle fibers are arranged in two ways:
circularly around the nipple and radiating longitudinally along the
long axis of the nipple.
• The contraction of these muscle fibers is responsible for erection
of the nipple.
• Most of the sebaceous glands located around the lactiferous
ducts open onto the surface or sides of the nipple, although some
open into the lactiferous ducts just before those ducts open onto
the surface.04/16/16 54aquinas emma
04/16/16 55aquinas emma
Mammary Gland Secretion: Milk Production
• Prolactin is responsible for the production of milk
• Oxytocin is responsible for the milk ejection reflex.
• Although the mammary gland is prepared to secrete milk
even before birth, certain hormones prohibit this.
• When the placenta is detached in the adult female,
prolactin from the anterior pituitary stimulates the
production of milk, which reaches full capacity in a few
days.
• Before that, for the first 2 or 3 days after birth, a protein-
rich thick fluid called colostrum is secreted.
04/16/16 56aquinas emma
• Colostrumis a high-protein secretion, rich in
vitamin A, sodium, and chloride, also contains
lymphocytes and monocytes, minerals,
lactalbumin, and antibodies (immunoglobulin A)
to provide nutrition and passive immunity to the
newborn.
• Milk, usually produced by the 4th day after
parturition, is a fluid that contains minerals,
electrolytes, carbohydrates (including lactose),
immunoglobulins (mostly immunoglobulin A),
proteins (including caseins), and lipids.
• Production of milk results from the stimuli of
sight, touch, handling of the newborn, and
anticipation of nursing, events that create a surge
in prolactin release.
04/16/16 57aquinas emma
• Once initiated, milk production is continuous, with the
milk being stored within the duct system.
• Concomitant with the production of prolactin, oxytocin
is released from the posterior lobe of the pituitary.
• Oxytocin initiates the milk ejection reflex by inducing
contractions of the myoepithelial cells around the alveoli
and the ducts, thus expelling the milk.
• Mothers who cannot breast-feed their infants on a
regular feeding schedule are inclined to suffer from poor
lactation. This may motivate a decision to discontinue
nursing altogether, with the result that the infant is
deprived of the passive immunity conferred by ingesting
antibodies from the mother.
04/16/16 58aquinas emma
BREAST POSITION
• Most of the gland
lies in the
superficial fascia.
• Its base extends
from :
• 2nd
-6th
ribs.
• Lateral margin of
the sternum to the
midaxillary line.
04/16/16 59aquinas emma
BREASTS
• They are surrounded by a
small colored area (areola).
• The breast tissue is formed
of little duct system
embedded in connective
tissue that is restricted to
the margin of the areola.
04/16/16 60aquinas emma
STRUCTURE
Areola glands:
• They produce tiny tubercles
on the areola.
Retromammary space of
Spence:
• It is a loose connective tissue
separating the breasts from
the underlying deep fascia.
04/16/16 61aquinas emma
STRUCTURE
Ducts :
• A main duct arises from
each lobe.
• It opens separately on
the summit of the nipple.
• Each duct has a dilatation
(ampulla) prior to its
termination.
04/16/16 62aquinas emma
STRUCTURE
lobes :
• It is formed of (15-20)
lobes radiating from the
nipple.
• The lobes are separated by
fibrous septa.
• In the upper part, they are
well developed
(suspensory ligaments)
binding the skin to the
deep fascia.
04/16/16 63aquinas emma
Axillary Tail:
• It is the part
of the gland
in the deep
fascia.
• It extends
upward and
laterally to
enter the
axilla.
04/16/16 64aquinas emma
BREAST QUADRANTS
• Regarding the lymph
drainage,
• the breast (mammary
gland) is divided into
four quadrants:
• Upper medial.
• Lower medial.
• Upper lateral.
• Lower lateral.
04/16/16 65aquinas emma
LYMPH DRAINAGE • It is of
considerable
clinical
importance
because of the
frequent
development of
cancer of the
gland and the
dissemination of
the malignant
cells along the
lymph vessels.
04/16/16 66aquinas emma
BLOOD SUPPLY Veins :
• Correspo
nd to the
arteries.
04/16/16 67aquinas emma
BLOOD SUPPLY
Arteries :
• Internal thoracic &
intercostal :
perforating
branches.
• Axillary : lateral
thoracic &
thoracoacromial.
04/16/16 68aquinas emma
CANCER BREAST
• Thoracic
metastases
(from
carcinomas) of
the medial
quadrants are
difficult to
treat.
04/16/16 69aquinas emma
• Cancer occurring
in the lateral
quadrants of the
breast spreads to
the axillary lymph
nodes which can
be removed
surgically.
• 60% of
carcinomas of the
breast occur in
the upper lateral
quadrant.
04/16/16 70aquinas emma
LYMPH DRAINAGE
• To the opposite
breast.
• To the anterior
abdominal wall.
• To the posterior
intercostal nodes
along the
posterior
intercostal
arteries.
04/16/16 71aquinas emma
LYMPH DRAINAGE
Lateral quadrants:
• To anterior axillary
(pectoral) group of
lymph nodes.
Medial quadrants:
• To internal thoracic
lymph nodes along the
internal thoracic artery
within the thoracic
cavity.
04/16/16 72aquinas emma
04/16/16 73aquinas emma

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Pectoral region and breast surgical anatomy

  • 1. ANATOMY OF PECTORAL REGION AND BREAST OLOKA EMMANUEL BUSITEMA UNIVERSITY MBChB 1 04/16/16 1aquinas emma
  • 3. CLAVICLE Shape : • Its medial 2/3 are convex forward. • Its lateral 1/3 is concave forward. 04/16/16 3aquinas emma
  • 4. CLAVICLE Functions : • Holds the arm away from the trunk. • Transmits forces from the upper limb to the axial skeleton. • Gives attachment to muscles. 04/16/16 4aquinas emma
  • 5. CLAVICLE Articulations : Medially : • Sternum. • 1st costal cartilage. Laterally : • Scapula (acromion). 04/16/16 5aquinas emma
  • 6. CLAVICLE • It is a long bone that lies horizontally across the root of the neck. • It is subcutaneous throughout its length. 04/16/16 6aquinas emma
  • 7. PECTORAL MUSCLES • They are four muscles that move the shoulder girdle and attach it to the thoracic wall. 04/16/16 7aquinas emma
  • 8. PECTORALIS MAJOR • It triangular in shape. • It covers the upper chest. • Its lower border forms the anterior wall of the axilla. • Superiorly it is separated from deltoid muscle along the clavicle by the deltopectoral triangle. 04/16/16 8aquinas emma
  • 9. PECTORALIS MAJOR Origin • It has two heads : Clavicular : • from the medial half of the clavicle. Sternocostal: • Anterior sternum. • Upper six costal cartilages. • External oblique aponeurosis. 04/16/16 9aquinas emma
  • 10. PECTORALIS MAJOR Insertion : • Lateral lip of the bicipital groove of the humerus. Nerve supply : • Medial and lateral pectoral nerves. Action : • Adduction and medial rotation of humerus. • Flexion of arm (clavicular head). 04/16/16 10aquinas emma
  • 11. CLAVIPECTORAL FASCIA • It is a strong sheet of fascia. • Attachment : • Superiorly : • It is attached to the clavicle and splits to enclose the subclavius muscle. • Inferiorly : It encloses the pectoralis minor and continues as the suspensory ligament of the axilla and joins the fascia of its floor. 04/16/16 11aquinas emma
  • 12. CLAVIPECTORAL FASCIA Contents : • Nerve : lateral pectoral. • Artery : thoraco- acromial. • Vein : cephalic. • Lymph nodes. 04/16/16 12aquinas emma
  • 13. SUBCLAVIUS MUSCLE Origin : • 1st costal cartilage. Insertion : • Inferior surface of the clavicle. Nerve supply : • A branch from the upper trunk of the brachial plexus. Action : Depresses the clavicle. 04/16/16 13aquinas emma
  • 14. PECTORALIS MINOR • It is a thin triangular muscle that is covered by pectoralis major. Origin : • Anterior surfaces of 3rd -5th ribs. Insertion : • Coracoid process of scapular 04/16/16 14aquinas emma
  • 15. PECTORALIS MINOR Nerve supply : • Medial pectoral nerve. Action : • Pulls the shoulder downwards and forwards. • It elevates the ribs (accessory muscle of respiration) when the scapula is fixed. 04/16/16 15aquinas emma
  • 17. Learning Goals • To learn the development, histology, function and surgical anatomy of mammary glands. 04/16/16 17aquinas emma
  • 18. Development of Mammary Glands • Are a modified and highly specialized type of apocrine sweat glands. • Consist of parenchyma, which is formed from ducts, and connective tissue stroma. • Parenchyma derives embryonically from surface ectoderm; stroma arises from surrounding mesenchyme. • Mammary buds begin to develop during the sixth week as solid downgrowths of the epidermis into the underlying mesenchyme • These changes occur in response to an inductive influence from the mesenchyme. 04/16/16 18aquinas emma
  • 20. • Mammary buds develop as downgrowths from thickened mammary crests, which are thickened strips of ectoderm extending from the axillary to the inguinal regions • The mammary crests (ridges) appear during the fourth week but normally persist in humans only in the pectoral area, where the breasts develop • Each primary bud gives rise to several secondary mammary buds that develop into lactiferous ducts and their branches • Canalization of these buds is induced by placental sex hormones entering the fetal circulation. This process continues until late gestation, and by term, 15 to 20 lactiferous ducts are formed. • The fibrous connective tissue and fat of the mammary gland develop from the surrounding mesenchyme. 04/16/16 20aquinas emma
  • 22. • A, Ventral view of an embryo of approximately 28 days showing the mammary crests. B, Similar view at 6 weeks showing the remains of these crests. C, Transverse section of a mammary crest at the site of a developing mammary gland. D to F, Similar sections showing successive stages of breast development between the 12th week and birth.04/16/16 22aquinas emma
  • 23. Development of Nipples and Areola • During the late fetal period, the epidermis at the site of origin of the mammary gland becomes depressed, forming a shallow mammary pit • The nipples are poorly formed and depressed in newborn infants. • Soon after birth, the nipples usually rise from the mammary pits because of proliferation of the surrounding connective tissue of the areola, the circular area of skin around the nipple. • The smooth muscle fibers of the nipple and areola differentiate from surrounding mesenchymal cells.04/16/16 23aquinas emma
  • 25. Postnatal Development of Female Breast. • A, Newborn. B, Child. C, Early puberty. D, Late puberty. E, Young adult. F, Pregnant female. Note that the nipple is inverted at birth • (A). Normally the nipple elevates during childhood. Failure of this process to occur gives rise to an inverted nipple. At puberty (12-15 years), the breasts of females enlarge because of development of the mammary glands and the increased deposition of fat. 04/16/16 25aquinas emma
  • 26. • The rudimentary mammary glands of newborn males and females are identical and are often enlarged. • Some secretion, often called "witch's milk," may be produced caused by maternal hormones passing through the placental membrane into the fetal circulation. • Newborns breasts contain lactiferous ducts but no alveoli. Before puberty, there is little branching of the ducts. • In females, the breasts enlarge rapidly during puberty, mainly because of development of the mammary glands and the accumulation of the fibrous stroma and fat associated with them • . Full development occurs at approximately 19-20 years • The lactiferous ducts of male breasts remain rudimentary throughout life. 04/16/16 26aquinas emma
  • 27. Gynecomastia • The rudimentary lactiferous ducts in males normally undergo no postnatal development. • Gynecomastia (Gr. gyne, woman + mastos, breast) refers to the development of the rudimentary lactiferous ducts in the male mammary tissue. • During midpuberty, approximately two thirds of boys develop varying degrees of hyperplasia of the breasts. This subareolar hyperplasia may persist for a few months to 2 years. • A decreased ratio of testosterone to estradiol is found • 80% of males with Klinefelter syndrome (XXY) have gynecomastia 04/16/16 27aquinas emma
  • 29. Absence of Nipples (Athelia) or Breasts (Amastia) • Rare congenital anomalies may occur bilaterally or unilaterally. • Result from failure of development or disappearance of the mammary crests. • May also result from failure of mammary buds to form. • More common is hypoplasia of the breast, often found in association with gonadal agenesis and Turner syndrome 04/16/16 29aquinas emma
  • 31. Aplasia of Breast • The breasts of a postpubertal female often differ in size. Marked differences are regarded as anomalies because both glands are exposed to the same hormones at puberty. • In these cases, there is often associated rudimentary development of muscles of the thoracic wall, usually the pectoralis major 04/16/16 31aquinas emma
  • 32. The thorax of an infant with congenital absence of the left pectoralis major muscle. Note the absence of the anterior axillary fold on the left and the low location of the left nipple. (From Behrman RE, Kliegman RM, Arvin AM [eds]: Nelson Textbook of Pediatrics, 15th ed. Philadelphia, WB Saunders, 1996.) 04/16/16 32aquinas emma
  • 33. Supernumerary Breasts and Nipples • An extra breast (polymastia) or nipple (polythelia) occurs in approximately 1% of the female population as an inheritable condition. • An extra breast or nipple usually develops just inferior to the normal breast. • Supernumerary nipples are also relatively common in males; often they are mistaken for moles • Less commonly, supernumerary breasts or nipples appear in the axillary or abdominal regions of females developing from extra mammary buds that develop along the mammary crests. They become more obvious in women when pregnancy occurs. • Approximately one third of affected persons have two extra nipples or breasts. • Supernumerary mammary tissue very rarely occurs in a location other than along the course of the mammary crests. It probably develops from tissue that was displaced from these crests. 04/16/16 33aquinas emma
  • 36. A man and a female infant with extranipples (polythelia) 04/16/16 36aquinas emma
  • 37. Inverted Nipples • Nipples fail to elevate above the skin surface after birth, remaining in their prenatal location (A) • May make breast-feeding of an infant difficult; 04/16/16 37aquinas emma
  • 38. Mammary glands-histology • Compound tubuloalveolar glands • Consist of 15 to 20 lobes radiating out from the nipple and are • Separated from each other by adipose and collagenous connective tissue. • Secrete milk, a fluid containing proteins, lipids, and lactose as well as lymphocytes and monocytes, antibodies, minerals, and fat-soluble vitamins • Provide the proper nourishment for the newborn.04/16/16 38aquinas emma
  • 40. Mammary Glands Development • Develop in the same manner and are of the same structure in both sexes until puberty, • At puberty changes in the hormonal secretions in females cause further development and structural changes within the glands. • Secretions of estrogen and progesterone from the ovaries (and later from the placenta) and prolactin from the acidophils of the anterior pituitary gland initiate development of lobules and terminal ductules. • Full development of the ductal portion of the breast requires glucocorticoids and further activation by somatotropin.04/16/16 40aquinas emma
  • 42. Mammary Glands Development • Concomittant with these events is an increase in connective tissue and adipose tissue within the stroma, causing the gland to enlarge. • Full development occurs at about 20 years of age • Minor cyclic changes occur during each menstrual period, • Major changes occur during pregnancy and in lactation. • After age 40 or so, the secretory portions and some of the ducts and connective tissue elements of the breasts begin to atrophy, and they continue this process throughout menopause. 04/16/16 42aquinas emma
  • 44. Gland Structure • The glands within the breasts are classified as compound tubuloalveolar glands, • Make 15 to 20 lobes radiating out from the nipple and separated from each other by adipose and collagenous connective tissue. • Each lobe is drained by its own lactiferous duct leading directly to the nipple, where it opens onto its surface. • Before reaching the nipple, each of the ducts is dilated to form a lactiferous sinus for milk storage and then narrows before passing through the nipple 04/16/16 44aquinas emma
  • 46. • Near the opening at the nipple, lactiferous ducts are lined by a stratified squamous keratinized epithelium. • The lactiferous sinus and the lactiferous duct leading to it are lined by stratified cuboidal epithelium, • Smaller ducts leading to the lactiferous duct are lined by a simple columnar epithelium. • Stellate myoepithelial cells located between the epithelium and the basal lamina wrap around the developing alveoli and become functional during pregnancy 04/16/16 46aquinas emma
  • 47. Resting (Non secreting) Mammary Gland • Alveoli are not developed in nonpregnant women • nonpregnant women have the same basic architecture as the lactating (active) mammary gland, except that they are smaller and without developed alveoli, which occur only during pregnancy.. r a t i f i e d s q u a m o u s ( k e r a t i n i z e d ) e p i t h e l i u m . T h e l a 04/16/16 47aquinas emma
  • 48. Lactating (Active) Mammary Glands • are activated by elevated surges of estrogen and progesterone during pregnancy to become lactating glands to provide milk for the newborn. • Terminal portions of the ducts branch and grow and the alveoli develop and mature • As pregnancy progresses, the breasts enlarge as a result of hypertrophy of the glandular parenchyma and engorgement with colostrum, • Colostrum is a protein-rich fluid, in preparation for the newborn. • Within a few days after birth, when estrogen and progesterone secretions have subsided, prolactin, secreted by acidophils of the anterior pituitary gland, activates the secretion of milk, which replaces the colostrum 04/16/16 48aquinas emma
  • 49. Lactating (Active) Mammary Glands • During pregnancy, the terminal portions of the ducts branch and grow and develop secretory units known as alveoli. • Inset shows a longitudinal section of a gland and duct of the active mammary gland. 04/16/16 49aquinas emma
  • 50. Alveoles and Alveolar Cells • The alveoli are composed of cuboidal cells partially surrounded by a meshwork of myoepithelial cells. • These secretory cells possess abundant RER and mitochondria, several Golgi complexes, many lipid droplets, and numerous vesicles containing caseins (milk proteins) and lactose. • Not all regions of the alveolus are in the same stage of production, because different acini display varying degrees of preparation for synthesis of milk substances Electron micrograph of an acinar cell04/16/16 50aquinas emma
  • 51. Milk Secretion from Alveolar Cells • The secretions of the alveolar cells are of two kinds: lipids and proteins. • Stored as droplets within the cytoplasm. • Released from the secretory cells by the apocrine mode of exocytosis, • Small droplets coalesce to form larger and larger droplets that move to the periphery of the cell. • Once there, they project as cytoplasmic blebs into the lumen; eventually, the lipid droplets containing blebs are pinched off and become part of the secretory product. • Each bleb consists of a central lipid droplet surrounded by a narrow rim of cytoplasm and enclosed by a plasmalemma. • Proteins synthesized within these secretory cells are liberated from the cells by the merocrine mode of exocytosis in much the same manner as would be expected of other cells that synthesize and release proteins into the extracellular space 04/16/16 51aquinas emma
  • 52. Areola and Nipple • The circular, heavily pigmented skin in the center of the breast is the areola. • Areola contains sweat glands and sebaceous glands at its margin as well as areolar glands (of Montgomery) that resemble both sweat and mammary glands. • In the center of the areola is the nipple, a protuberance covered by stratified squamous epithelium containing the terminal openings of the lactiferous ducts. • In fair-skinned individuals, a pinkish color is imparted to the nipple as a result of the color of blood in the rich vascular supply within the long dermal papillae that extend near its surface. • During pregnancy, the color becomes darker because of increased pigmentation of the areola and the nipple.04/16/16 52aquinas emma
  • 54. • The core of the nipple is composed of dense collagenous connective tissue with abundant elastic fibers connected to the surrounding skin or interlaced within the connective tissue and a rich component of smooth muscle cells. • The wrinkling of the skin on the nipple results from the attachments of the elastic fibers. • The abundant smooth muscle fibers are arranged in two ways: circularly around the nipple and radiating longitudinally along the long axis of the nipple. • The contraction of these muscle fibers is responsible for erection of the nipple. • Most of the sebaceous glands located around the lactiferous ducts open onto the surface or sides of the nipple, although some open into the lactiferous ducts just before those ducts open onto the surface.04/16/16 54aquinas emma
  • 56. Mammary Gland Secretion: Milk Production • Prolactin is responsible for the production of milk • Oxytocin is responsible for the milk ejection reflex. • Although the mammary gland is prepared to secrete milk even before birth, certain hormones prohibit this. • When the placenta is detached in the adult female, prolactin from the anterior pituitary stimulates the production of milk, which reaches full capacity in a few days. • Before that, for the first 2 or 3 days after birth, a protein- rich thick fluid called colostrum is secreted. 04/16/16 56aquinas emma
  • 57. • Colostrumis a high-protein secretion, rich in vitamin A, sodium, and chloride, also contains lymphocytes and monocytes, minerals, lactalbumin, and antibodies (immunoglobulin A) to provide nutrition and passive immunity to the newborn. • Milk, usually produced by the 4th day after parturition, is a fluid that contains minerals, electrolytes, carbohydrates (including lactose), immunoglobulins (mostly immunoglobulin A), proteins (including caseins), and lipids. • Production of milk results from the stimuli of sight, touch, handling of the newborn, and anticipation of nursing, events that create a surge in prolactin release. 04/16/16 57aquinas emma
  • 58. • Once initiated, milk production is continuous, with the milk being stored within the duct system. • Concomitant with the production of prolactin, oxytocin is released from the posterior lobe of the pituitary. • Oxytocin initiates the milk ejection reflex by inducing contractions of the myoepithelial cells around the alveoli and the ducts, thus expelling the milk. • Mothers who cannot breast-feed their infants on a regular feeding schedule are inclined to suffer from poor lactation. This may motivate a decision to discontinue nursing altogether, with the result that the infant is deprived of the passive immunity conferred by ingesting antibodies from the mother. 04/16/16 58aquinas emma
  • 59. BREAST POSITION • Most of the gland lies in the superficial fascia. • Its base extends from : • 2nd -6th ribs. • Lateral margin of the sternum to the midaxillary line. 04/16/16 59aquinas emma
  • 60. BREASTS • They are surrounded by a small colored area (areola). • The breast tissue is formed of little duct system embedded in connective tissue that is restricted to the margin of the areola. 04/16/16 60aquinas emma
  • 61. STRUCTURE Areola glands: • They produce tiny tubercles on the areola. Retromammary space of Spence: • It is a loose connective tissue separating the breasts from the underlying deep fascia. 04/16/16 61aquinas emma
  • 62. STRUCTURE Ducts : • A main duct arises from each lobe. • It opens separately on the summit of the nipple. • Each duct has a dilatation (ampulla) prior to its termination. 04/16/16 62aquinas emma
  • 63. STRUCTURE lobes : • It is formed of (15-20) lobes radiating from the nipple. • The lobes are separated by fibrous septa. • In the upper part, they are well developed (suspensory ligaments) binding the skin to the deep fascia. 04/16/16 63aquinas emma
  • 64. Axillary Tail: • It is the part of the gland in the deep fascia. • It extends upward and laterally to enter the axilla. 04/16/16 64aquinas emma
  • 65. BREAST QUADRANTS • Regarding the lymph drainage, • the breast (mammary gland) is divided into four quadrants: • Upper medial. • Lower medial. • Upper lateral. • Lower lateral. 04/16/16 65aquinas emma
  • 66. LYMPH DRAINAGE • It is of considerable clinical importance because of the frequent development of cancer of the gland and the dissemination of the malignant cells along the lymph vessels. 04/16/16 66aquinas emma
  • 67. BLOOD SUPPLY Veins : • Correspo nd to the arteries. 04/16/16 67aquinas emma
  • 68. BLOOD SUPPLY Arteries : • Internal thoracic & intercostal : perforating branches. • Axillary : lateral thoracic & thoracoacromial. 04/16/16 68aquinas emma
  • 69. CANCER BREAST • Thoracic metastases (from carcinomas) of the medial quadrants are difficult to treat. 04/16/16 69aquinas emma
  • 70. • Cancer occurring in the lateral quadrants of the breast spreads to the axillary lymph nodes which can be removed surgically. • 60% of carcinomas of the breast occur in the upper lateral quadrant. 04/16/16 70aquinas emma
  • 71. LYMPH DRAINAGE • To the opposite breast. • To the anterior abdominal wall. • To the posterior intercostal nodes along the posterior intercostal arteries. 04/16/16 71aquinas emma
  • 72. LYMPH DRAINAGE Lateral quadrants: • To anterior axillary (pectoral) group of lymph nodes. Medial quadrants: • To internal thoracic lymph nodes along the internal thoracic artery within the thoracic cavity. 04/16/16 72aquinas emma