1

For 3rd Year Midwifery

By- Yosef A

CHAPTER SIXTHE BREAST

Anatomy amp physiology of the breast

Breast examination

Teaching breast Self-examination to women (BSE)

Benign amp malignant tumors of the breast

Management of breast disorders

Mammography

Nursing care consideration for a women with mastectomy

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ObjectivesAt the end of this study the student will be able to

Describe the gross structure of the breast

Describe the physiologies of breast

Discuss the development of breast and its congenital anomalies

Give its blood supply and lymphatic drainage

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THE BREASTANATOMY AND PHYSIOLOGY OF FEMALE BREAST

Breasts are composed of mammary glands connective tissue blood vessels nerves and lymph vessels

The breasts are secondary reproductive glands of ectodermal origin

The breast is the upper ventral region of the torso of a primate in left and right sides containing the mammary gland

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Conthellip Each breast consists of 12-20 conical lobes

Each lobe consists of a group of lobules

The lobules have several lactiferous ducts which unit to form a major duct

Each of the major ducts widens to form an ampula

The fatty tissue increases towards the periphery of the lobule and gives the breast its bulk and hemispheric shape and 80-85 of the normal breast is adipose tissue

Lobes---Lobules---Lactiferous ducts---Major duct---Ampula

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Conthellip In non pregnant non lactating breast the alveoli are

small and tightly packed

During pregnancy the alveoli hypertrophy and their lining cells proliferate in number

During lactation the alveolar cells secret proteins and lipids which comprise breast milk

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POSITION OF BREAST

Extent Vertical 2nd to 6th rib (Base of the breast)

Horizontal Lateral margin of the sternum to the mid

auxiliary line

23rd of the breast lies in the superficial fascia

(Pectoral fascia) lying on Pectoralis major

13rd of the breast lies in the superficial fascia lying

on Serratus Anterior The greater part of the gland lies in the superficial fascia

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A small part-axillary tail extends upward and laterally pierces the deep fascia at the lower border of the pectoralis major muscle up to the apex of the axilla

The breast lies upon the deep pectoral fascia which in turn overlies pectoralis major and serratus anterior and inferiorly external oblique and its aponeurosis as the latter forms the anterior wall of the sheath of rectus abdominis

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PARTS OF THE BREAST

Nipple Conical or Cylindrical prominence in the center of Areola (Devoid of fat hair amp sweat gland)

The nipple level in the thorax varies widely but is at the fourth intercostal space in most young women

Nipple is Usually everted

Surface anatomy 4th intercostal space lateral to midclavicularline

Areola Circular pigmented area of the skin surrounding the base of the nipple containing sebaceous glands

Axillary Tail Small part of the breast extending to the axilla

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Retromammary Space Space filled with loose connective

tissue between breast and pectoral fascia

Lactiferous ducts from each lobule open on the summit of the

nipple separately

Lactiferous duct possesses a dilated Ampulla (Lactiferous

sinus) just before its termination

Fibrous septa separates the lobes of the mammary gland

Suspensory ligaments (of Cooper)

Mammary gland is firmly attached to the dermis of the skin

by these fibrous septa forming suspensory ligaments

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Layers of breast Mammary layer

Subcutaneous layer

Retromammary layer

Development and physiology

The breasts develop as an invigilation of chest wall ectoderm

Which forms a series of branching ducts Shortly before birth

this site of invagination everts to form the nipple

At puberty alveoli sprout from the ducts and considerable

fatty infiltration of the breast tissue takes place

With pregnancy there is tremendous development of the

alveoli which in lactation secrete the fatty droplets of milk At

the menopause the gland tissue atrophies

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Neonates Occasionally gynaecomastia may occur in the neonatal breast with discharge of a colostrum-like material (lsquowitchrsquos milkrsquo)

From birth until puberty the breast consists of lactiferous ducts with no alveoli

At puberty the ducts start to proliferate and their terminations form solid masses of cellsmdashthe future breast lobules

During pregnancy secreting alveoli appear During the early weeks ductal sprouting and lobular proliferation occur with increased nipple and areolar pigmentation

The alveoli now display a lumen surrounded by the secretory cells

In the last days of pregnancy the breasts secrete colostrum a yellow sticky serous fluid which is then replaced by true secretion of milk

After the menopause the glandular tissue of the breast atrophies the connective tissue becomes less cellular and the amount of collagen decreases In some women breasts shrink considerably

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Arterial Supply The blood supply of the breast is a rich anastomotic

network derived from

Perforating branches (Internal thoracic artery)

Lateral thoracic artery (Axillary artery)

Thoracoacromial artery (Axillary artery)

Intercostal arteries

The largest vessels arise from the internal thoracicartery the perforating branches of which pierce the chestwall adjacent to the sternal edge in the first to fourthintercostal spaces The vessel in the second space isusually the largest of these

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second to fourth anterior intercostal arteries supplyperforating branches more laterally

The axillary artery supplies blood from several branchesnamely the superior thoracic the pectoral branches of thethoraco-acromial artery the lateral thoracic artery

Venous Drainage

Superficial venous system lies within the subcutaneous fat tissue most distal veins line the superficial fascia and drain blood centrally provides connection between right and left breast with potential for metastasis to occur between breasts

Deep venous system consists of veins that follow the arterial system and communicates with the axillary vein subclavian vein and SVC

Includes lateral thoracic axillary subclavian and intercostal veins 15Done by Yosef A

Nerve Supply Anterior and lateral cutaneous branches of the

4th ndash 6th intercostal nerves Lymphatic Drainage

75 drains to the axilla

Lateral quadrants Anterior Axillary or Pectoral nodes

Medial quadrants Internal thoracic group of Nodes (Parasternal)

Few lymph vessels drains into Posterior intercostal Nodes

Inferior quadrants May drain into abdominal lymph Nodes

Some lymphatic vessels communicate with the lymphatic vessels of the opposite breast

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Congenital Anomalies Nipple Inversion usually bilateral if congenital associated pathology

can be present if the nipple change is a new finding andor occurs

unilaterally

Athelia absence of the nipple

Polythelia accessory nipples can develop anywhere along the milk

line most commonly seen just inferior to the normal nipple 1

congenital anomaly of the breast in females and males

Amastia failure of the breast and nipple to develop

Polymastia accessory breast tissue most commonly forms without a

nipple usually found in the axilla

Amazia absence of development of the functional breast tissue

beneath a normal nippleareola

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Developmental abnormalities of Breast

The nipple may fail to evert

Supernumerary nipples or even breasts may occur along a vertical

lsquomilk linersquo

the other hand the breast on one or both sides may be small or even

absent (amazia)

Accessory Breasts- is a health condition where the person afflicted

has extra breasts

The extra breast can be in various forms from a fully functional

breast with a normal appearance and capable of producing milk to a

breast that does not lactate or have an areola

Both men and women can have accessory breasts but the problem

is more commonly observed in women

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There is no known limit on the amount of extra nipples or breasts that can develop on the human body Some women have experienced as many as eight nipples in addition to the standard two

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Fascial relationships of the breast The fascial relationships of the breast are of practical

importance As an ectodermal derivative the gland lies in a pocket

of superficial fascia Superficial fascia

Superficial layer Deep layer

Fibrous processes of this layer of fascia extend to the skin and to the nipple and are more developed over the upper part of the breast where they form the suspensory ligament of Cooper

Contraction of this tissue by malignant infiltration results in the characteristic skin dimpling over a carcinoma of

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The superficial layer lies immediately beneath the dermis and enables skinflaps to be dissected from the glandular mass of the breast quickly neatly and in a relatively avascular plane

The deep layer of the superficial fascia is thicker than the subcu- taneous component and covers the deep aspect of the breastplate

Beneath this sheath is a layer of filmy areolar tissue that allows the breast to move freely on the underlying fascial covering of the pectoralis major and the serratus anterior(Pectoralis fascia)

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Breast examination Two types of breast examination

Breast examination by a physician

Breast self examination (BSE)

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Self Examination of the Breast 90 of breast cancers are found by the woman or her

partner

During pregnancy there is no special time of the month that is best to perform the examination

In non pregnant women 5days after cessation of menstruation it is the optimum time to detect changes

bull Inspection in the shower

bull Inspection in the mirror

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stand in front of the mirror for further inspection

a With arms at sides

b Holding arms over the head inspect closely in the mirror for masses and breast symmetry

c Press hands firmly on hips below slightly forward inspect in m Each breast should be mirror image of the other

d Each breast should be mirror image of the other

e Gently squeeze the nipple of each breast between your thumb and index finger to check for signs of discharge or bleeding irror for lumps or pulling of the skin

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Inspection on lying down

lying flat on your back with your right hand under your head and a pillow or towel under your right shoulder use your left hand to gently feel your right breast using concentric circles to cover the entire breast and nipple repeat on your left breast

Steps to Diagnosis

Clinical Exam

Mammography

Self Breast Exam

Biopsy if indicated

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Breast Self Examination

DISORDERS OF THE BREASTBenign and malignant tumors of breast

What does benign means

What does malignant means

What is cancer

Cancer is the name given to a large number of diseases

Breast cancer begins in the breast tissue

Most kinds of cancer are named after the part of the body where the cancer first start

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BENIGN BREAST CANCERA Fibrocystic breast disease

It is common benign breast disease in women of all ages

It can occur as early as puberty when estrogen level rises to adult level but is found most commonly in women between the age of 20 and 45 year

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Sign and symptomsFreely movable well-delineated breast lump on

palpation

Visible lump on the surface of breast

Often occur on upper outer quadrant of the breast

Consistency-firm and hard to soft and flexible

Painful (may) and tender

Round and fluid filled cyst

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ConthellipDiagnosis

Careful palpation

Mammography

biopsy

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ConthellipManagement

Analgesia

Avoidance of substances containing caffeine theophylline and theobromine

Avoid smoking

Aspiration of cyst under local anesthesia

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ConthellipB Fibro adenoma

Fibro adenoma are tumors consisting of both fibrotic and glandular components that occur in response to estrogen stimulation

They tend to occur in young women and rarely seen after menopause and are non malignant

The tumors may increase in size during adolescence pregnancy and lactation or when a woman takes an estrogen sources such as oral contraceptives

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ConthellipSign and symptoms

No pain(pain less) and freely movable

Round and well delineated tumors

Feel firmer and more rubbery

Occasionally calcify and feel extremely hard

Not cause skin retraction

Management

Surgical incision

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C Carcinoma of the Breast

The carcinoma of the breast commonly occurs from30-60 years of age

Signs and symptoms

Lump and hard fixed mass

Pain in the breast

Blood stained discharge (late stage)

Retracted nipple of cancer has spread to the lymph

orange like colour of the skin

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