The surgical anatomy of the breast, surgical procedures, surgical approach to a breast mass. Mastectomy types and differences. Lymphatic drainage

1. S U R G I C A L A N A T O M Y O F B R E A S T
Dr. Ahmed Almumtin

2. I N T R O D U C T I O N
• A modified sweat gland.
• Compartmentalized fat bounded
by CT septa.
• Glandular lobules drained by
15-20 lactiferous ducts.
• Lactiferous ducts converge &
open onto nipple.
• Areola surrounds nipple &
conceals sebaceous glands • (i.e.,
produce lubrication for nipple).
Compartmentalisation
Gland Lobules & Lac. Ducts

3. • lies over the 2nd - 6th rib.
• Two-thirds rests on pectoralis
major.
• One-third lies on the serratus
anterior.
• The lower medial edge overlaps
the upper part of the rectus
sheath.
• Medially from the sternal edge,
to the mid-axillary line

4. F O U R Q U A D R A N T S A N D A TA I L
• 4 quadrants.
• Majority of cancers develop
in upper outer quadrant.
• Large amount of glandular
tissue here.
• An axillary tail

5. R E T R O M A M M A RY S PA C E
• Reteromammary space: is loose
auroral tissue that separates then
breast from the pectoralis major
muscle.
• The retromammary space is often
the site of of breast implantation
due to its location away from key
nerves and structure that support
the breast.

6. S U R FA C E A N D A E S T H E T I C S
• The tail of Spencer.
• Determinants of
aesthetics.

7. L I G A M E N T S
• Cooper’s ligament.
• Suspensory ligament of
the breast.
• Fibrous septa anchor deep
layer of skin to deep
fascia.
• superfacial (avascular
plane) separates the
glandular portion and
adipose portion.
Astley Cooper

8. I N F R A S T R U C T U R E
• Tumors may grow through
retromammary space.
• Subsequently invade deep
fascia & pec. major m.
• Leads to fixation of malignant
breast lesion to chest wall.
• Shortens suspensory
(Cooper’s) ligs.
• Leads to irregular dimpling of
skin or retraction of nipple

9. A P P L I E D C L I N I C A L A N AT O M Y
• Skin dimpling.
• Nipple retraction.
• Peau d'orange
• Lymphoedema of
ipsilateral upper limb
post-mastectomy.

10. B L O O D S U P P LY
• Vessels of the Breast
• Enter from supr./med.
& supr./lat. aspects
• Penetrate deep
surface of breast.
• Exhibit extensive
branches. &
anastomoses.

11. A R T E R I A L S U P P LY T O T H E B R E A S T
• Lateral (mammary)
thoracic a.
• Internal (mammary)
thoracic a.
• Intercostal aa.
• Thoracoacromial a

13. V E N O U S D R A I N A G E
• Corresponds
to arterial
system.
• Cephalic vein

15. LY M P H AT I C S
• Lat. drainage is via 5
groups of axillary nodes
• Supr. drainage is via 1
group of interpectoral
nodes
• Med. drainage is via 1
group of parasternal
nodes
• Ultimate drainage is via
subclavian lymph trunk
to vv. (i.e., jxn. of
subclavian v. & IJV)

16. LY M P H AT I C S
• Pectoral nodes ( 4-5 nodes,
most drainage).
• Subscapular (posterior) nodes
(6-7),
• Lateral nodes (4-6).
• Central nodes (3-4), ?Neck?
• Apical nodes (6-12)
• Interpectoral (Rotter’s) nodes
(1-4)
• Parasternal nodes

17. LY M P H AT I C S

18. LY M P H AT I C S I N A S S O C I AT I O N W I T H
V E S S E L S
• Pectoral – lat. thoracic vessels
• Subscapular – subscapular vessels
• Humeral – distal (3rd) part of axillary v.
• Central – middle (2nd) part of axillary v.
• Apical – proximal (1st) part of axillary v.
• Interpectoral – pectoral vessels
• Parasternal – int. thoracic vessels

19. LY M P H N O D E L E V E L S ( B E R G ’ S )
• 3 Levels of surgical dissections
relative to pec. minor.
• Level I – below (lateral to) pec.
minor
• Level II – deep to pec. minor
• Level III – above (medial to)
pec. minor

20. C L I N I C A L S I G N I F I C A N C E
• Cancer cells tend to spread along lymph passages
• Typical spread is supr./laterally to axillary lymph nodes
• Unilateral lymphatic blockage may occur
• Lymph (with cancer cells) can then drain to opposite
side

21. N E R V E S U P P LY
• Cutaneous
innervation.
• Medial pectoral n.
• Lateral pectoral n.
• Long thoracic n.

22. N E R V E S U P P LY

23. N E R V E S U P P LY
• Take care!:
• LTN
• Thoracodorsal
• lateral and medial
pectoral nerve

24. T H E A X I L L A
• Axillary sheath (axillary
a. & brachial plexus).
• Axillary v. &
lymphatics (outside
sheath).
• Fat & connective
tissue
• Cutaneous nerves

25. T H E A X I L L A • very busy space.

26. S U R G I C A L A P P R O A C H T O A X I L L A
• In modified radical mastectomy
• Conservative breast surgery

28. M A S T E C T O M Y
• Radical Mastectomy.
• modified radical mastectomy
• Simple mastectomy
• skin sparing mastectomy
• Nipple-Areolar spaing mastectomy.

29. B O U N D R I E S F O R M A S T E C T O M Y
• Clavicle.
• inframammary fold
(above rectus sheath)
• Sternum (midline).
• Latissimus dorsi (ant.
border)

30. S I M P L E M A S T E C T O M Y
• Definition.
• frequency.

31. M O D I F I E D R A D I C A L M A S T E C T O M Y
• definition.
• indication

32. R A D I C A L M A S T E C T O M Y
• definition.
• success rates.

33. S K I N S PA R I N G M A S T E C T O M Y
• Definition.

34. N I P P L E - A R E O L A R S PA R I N G
M A S T E C T O M Y
• Definition.
• Criteria

35. C H O I C E O F T H E P R O C E D U R E
• Radical mastectomy - No longer used.
• Lymph node status
• Desired time of reconstruction.
• Criteria of NSM.
• Prophylactic

36. I N C I S I O N S I N B R E A S T S U R G E RY

37. I N C I S I O N S F O R M A S T E C T O M Y
• depends upon: location, size, reconstruction plans
• SSM.
• MRM
• NASM

38. Stewart!
* design
according
to tumour
location

39. • The drains are left in place until the drainage of serous
fluid has decreased to approximately 25 to 30 mL per
24-hour period