CLINICAL OBSTETRICS AND GYNECOLOGY
Volume 54, Number 1, 91–95
Breast Development
and Anatomy
SONALI PANDYA, MD, and RICHARD G. MOORE, MD
Program in Women’s Oncology, Breast Health Center, Department
of Obstetrics and Gynecology, Women and Infants Hospital, Alpert
Medical School, Brown University, Providence, Rhode Island
Abstract: In this article, the development of the female
breast, as well as the functional anatomy, blood supply,
innervation and lymphatic drainage are described. A
thorough understanding of the breast anatomy is an
important adjunct to a meticulous clinical breast exam-
ination. Breast examination is a complex skill involving
key maneuvers, including careful inspection and palpa-
tion. Clinical breast examination can provide an oppor-
tunity for the clinician to educate patients about their
breast and about breast cancer, its symptoms, risk
factors, early detection, and normal breast composition,
and specifically variability. Clinical breast examination
can help to detect some cancers not found by mammo-
graphy, and clinicians should not override their exam-
ination findings if imaging is not supportive of the
physical findings.
Key words: breast, development, anatomy
Embryology
Mammary glands are a modified and
highly specialized type of sweat gland.1
At the fifth or sixth week of fetal devel-
opment, 2 ventral bands of thickened
ectoderm, the mammary ridges, are evi-
dent in the embryo.2 The mammary ridges
through development extend from the
axillary to the inguinal regions.1,2 Mam-
mary buds begin to develop as solid down
growths of the epidermis into the under-
Correspondence: Richard G. Moore, MD, Department of
Obstetrics and Gynecology, Women & Infants Hospital
of Rhode Island, Providence, RI. E-mail: rmooremd@
msn.com
CLINICAL OBSTETRICS AND GYNECOLOGY
r 2011, Lippincott Williams & Wilkins
lying mesenchyme.3 In the human em-
bryo, the mammary ridges disappear as
the embryo develops, except for small
portions that may persist in the pectoral
regions. When normal regression of the
mammary ridge fails, accessory breasts
(polymastia) or accessory nipples (poly-
thelia) may develop along the milk line, a
condition that affects less than 1% of
infants.1,2 Supernumerary breasts or ac-
cessory nipples are most frequently found
between the normal nipple location and
the symphysis pubis.
The primary bud is formed as a result of
ingrowth of the ectoderm, leading to devel-
opment of each breast. The primary bud
leads to development of 15 to 20 secondary
buds that develop into lactiferous ducts
and their branches.1 Major lactiferous
ducts develop, opening into a shallow
mammary pit, which during infancy trans-
form into a nipple. At birth the nipple is
inverted and elevates above the skin during
childhood. If this elevation does not occur,
it gives rise to an inverted nipple.1
Only the main lactiferous ducts are
formed at birth and the mammary glands
remain underdeveloped until puberty.
The female breast does not develop un-
til puberty, at which point the breast
enlarges under the influence of ovarian
/ VOLUME 54 / NUMBER 1 / MARCH 2011
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92 Pandya and Moore

estrogen and progesterone production breast shrinkage and loss of contour.

leading to proliferation of epithelial and
connective tissue elements. At puberty,
the breast enlarges due to the develop-
ment of the mammary glands and in-
creased deposition of fatty tissue.
Pregnancy, Lactation,
and Involution
During the onset of pregnancy the breast
completes development. At this time, the
breast enlarges with increases in volume
and density. The hormones influencing
this growth include estrogen, progesterone,
growth hormone, prolactin, and placental
hormones. Clinically, the breast enlarges,
superficial veins dilate, and the nipple-
areola complex darkens.4 During the first
trimester, the stromal elements of the breast
are gradually replaced by the proliferating
glandular epithelium. During the third tri-
mester, the epithelium differentiation re-
sults into the development of secretory
cells that are able to synthesize and secrete
milk proteins. Oxytocin induces myoepithe-
lial proliferation and differentiation.2,4
Immediately after delivery, estrogen
and progesterone levels fall resulting in
lactation. Prolactin, along with growth
hormone and insulin, induce production
and secretion of milk. Oxytocin regulates
the secretion of milk, which is released in
response to neural reflexes activated by
suckling. Involution occurs when lacta-
tion is weaned, and the glandular, ductal,
and stromal elements atrophy resulting in
decrease in breast size.
Menopause
During menopause the breast regresses
and the ductal and glandular elements
involute resulting in the breast predomi-
nantly containing fat and stroma. As well
with aging, there is an overall reduction in
the number of ducts and lobules. Over
time, there is a progressive decrease in the
fat and stromal elements resulting in
The suspensory ligaments of Cooper relax
with time and eventually result in breast
ptosis.
Breast Anatomy
The female breast lies on the anterior
thoracic wall with the base extending
from the second to the sixth rib.3 The
anatomic boundaries of the breast are
from the level of the second or third rib
superiorly to the inframammary fold in-
feriorly, and its transverse boundary from
the lateral border of the sternum medially
to the midaxillary line laterally. About
two-thirds of the breast overlies the pec-
toralis major muscle, and remainder of
the breast contacts with the serratus ante-
rior muscle and the upper portion of the
abdominal oblique muscle. The breast
tissue frequently extends into the axilla
as the axillary tail of Spence.
The breast is composed of skin, sub-
cutaneous tissue, and breast tissue. There
are 2 fascial layers.5 The superficial fascia
lies deep to the dermis and the deep fascia
lies anterior to the pectoralis major mus-
cle fascia.6 The breast tissue lies in the
superficial fascia just deep to the dermis.
It is attached to the skin by the suspensory
ligaments of Cooper and is separated
from the investing fascia of the pectoralis
major muscle by the retromammary bur-
sa. The retromammary bursa or space is
filled with loose areolar tissue, and along
with the suspensory ligaments of Cooper
allows the breast to move freely against
the thoracic wall.6 The suspensory liga-
ments of Cooper are fibrous bands of
connective tissue that run through the
breast parenchyma, and insert perpendi-
cularly to the dermis. Contraction of the
suspensory ligaments can lead to dim-
pling of the skin clinically associated with
breast tumors.3
The breast tissue includes epithelial
parenchymal elements and the stroma.
The epithelial component takes about

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10% to 15% of the overall breast volume,
and remainder of the volume is consisted
of the stromal elements.6 The breast is
composed of 15 to 20 lobes. The lobes of
the breast are divided further into lobules,
which range from 20 to 40. The lobules are
made up of branched tubuloalveolar
glands. Each lobe drains into a major
lactiferous duct. The lactiferous ducts
dilate into a lactiferous sinus beneath the
areola and then open through a con-
stricted orifice onto the nipple. The space
between the lobes is filled by adipose
tissue.
The breast is divided into quadrants—
upper inner, upper outer, lower inner, and
lower outer quadrants. The majority of
the breast volume is present in the upper
outer quadrant, also being the most com-
mon location of tumors of the breast. The
most important feature to keep in mind is
that there is considerable variation in the
size, contour, and density of the breast
between individuals. A variation in the
breast size among individuals is ac-
counted for by the volume of adipose
tissue between the lobes rather than the
epithelial component itself.
Nipple-areola Complex
The nipple is located over the fourth
intercostal space in a nonpendulous
breast and is surrounded by a circular
pigmented areola. During puberty, the
pigment becomes darker and the nipple
elevates from the surface. During preg-
nancy, the areola enlarges and the pig-
mentation becomes more prominent.6
The areola contains sebaceous glands
and apocrine sweat glands, but no hair
follicles. The tubercles of Morgagni are
nodular elevations formed by the open-
ings of the Montgomery glands at the
periphery of the areola.4 These glands
can secrete milk and represent a stage
between sweat and mammary glands.
Smooth muscle bundle fibers extend up-
ward into the nipple where they are re-
Breast Development and Anatomy 93
sponsible for the nipple erection that
occurs with various sensory stimuli. Over-
all, the nipple-areolar region and the re-
mainder of the breast are richly supplied
with sensory innervation. This innerva-
tion is of functional importance because
its stimulation by the sucking infant initi-
ate events leading to milk letdown.
Arterial and Venous Supply
The breast receives its blood supply
through 3 major arterial routes: (1) medi-
ally from anterior perforating intercostal
branches,6 which arise from the internal
thoracic artery also known as internal
mammary artery, supply the medial and
central portion of the breast, and ac-
counts for 60% of the blood supply to
the breast. (2) Branches of the lateral
thoracic artery originating from the axil-
lary artery, and the pectoral branches of
the thoracoacromial artery,6 also branch
of the axillary artery supply the upper
outer quadrant of the breast and are
responsible for 30% of the blood supply
to the breast. (3) Branches from the
posterior intercostal arteries2,6 supply
the remainder of the blood to the breast.
The blood supply to the breast skin
depends on the subdermal plexus, which
is in communication with the deeper ves-
sels supplying the breast parenchyma.
The internal thoracic artery is an impor-
tant and constant contributor of blood
supply to the nipple-areola complex by
means of its perforating branches and
anterior intercostals branches.7
The venous drainage of the breast and
chest wall follows the course of the ar-
teries with the venous drainage being to-
wards the axilla. The veins form an
anastomotic circle, called the circulus
venosus around the nipple.6 Ultimately,
the veins from this circle and the gland
drain into vessels joining the internal
thoracic and axillary vein. The 3 main
veins are the perforating branches of the
internal thoracic vein (largest venous
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94 Pandya and Moore
plexus to provide drainage of the mam-
mary gland), the perforating branches of
the posterior intercostal veins and the
tributaries of the axillary vein.2,6
Sensory Innervation
The sensory innervation of the breast and
the anterolateral chest wall comes from
the lateral and anterior cutaneous
branches of the second through sixth in-
tercostal nerves.6,8 The skin of the upper
portion of the breast is supplied from
anterior branches of the supraclavicular
nerve arising from the cervical plexus. The
nipple and areola receive nerve supply
from the lateral and anterior cutaneous
branches of the second through the fifth
intercostal nerves, which joined a plexus
in the subdermal region. The nerves that
supply the breast communicate freely and
converge towards the axilla. The intercos-
tobrachial nerve is the lateral cutaneous
branch of the second intercostal nerve.2
This nerve is encountered during axillary
dissection and the resection of this nerve
leads to loss of sensation over the medial
aspect of the arm.
Lymphatic Drainage
More than 75% of the lymphatic drainage
of the breast is through the axillary lymph
nodes.2,6 There are usually 20 to 30 nodes
in the axillary region.3 The 6 axillary
lymph node groups recognized by sur-
geons are axillary vein group, external
mammary group, scapular group, the cen-
tral group, the subclavicular group, and
the interpectoral group (Rotter nodes lo-
cated between the pectoralis major and
minor muscles).6 The lymph node groups
are named according to their relationship
to the pectoralis minor muscle. Lymph
nodes located lateral to the pectoralis
minor muscle are referred to as level I
lymph nodes (axillary vein, external mam-
mary, and scapular groups).2 Lymph
nodes located superficial and deep to the
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pectoralis minor muscle are referred to as
level II lymph nodes (central and inter-
pectoral group).2 Lastly, lymph nodes
located medial to the pectoralis minor
muscle is referred to as level III lymph
nodes (subclavicular group).2
The medial aspect of the breast is
drained through the lymph vessels accom-
panying the perforating branches of the
internal mammary artery and entering
the parasternal group of lymph nodes.2
Superficial lymphatics may communicate
with the opposite breast and the anterior
abdominal wall. There may be direct drai-
nage to the supraclavicular (deep cervical)
nodes and its involvement is indicative
of advanced disease. Lymphatic drai-
nage of the epithelial and mesenchymal
components of the breast is the primary
route of metastatic spread of breast
cancer.
Physical Examination
of the Breast
After taking a thorough history, and a
careful and detailed physical assessment,
a thorough examination of the breast is
critical in diagnosing breast problems.9,10
A clinical breast examination can provide
an opportunity for the clinician to have a
dialog with their patients and help to
educate them about their breast and edu-
cate the patient about breast cancer, its
symptoms, risk factors, early detection,
and normal breast composition, and spe-
cifically variability. Clinical breast exam-
ination can help to detect some cancers
not found by mammography and despite
imaging findings; clinicians should not
override their examination findings if the
imaging is not supportive of the physical
findings.
A breast examination should be per-
formed in both sitting and supine posi-
tion. In the sitting position, the breast is
examined with arms relaxed, raised, and
with hands on the hips and pectoralis

muscle contracted.4,10,11 In sitting posi-
tion with arms relaxed, the patient’s
breast is examined for symmetry, skin,
or nipple changes with any obvious skin
dimpling or nipple retraction. With arms
raised, the lower half of the breast is
examined. After inspection is completed,
a bimanual inspection of the breast is
performed in sitting position. In addition
with patient’s ipsilateral arm being sup-
ported by the examiner to help relax the
pectoralis major muscle, the axilla is pal-
pated for adenopathy. If adenopathy is
identified, it should be noted for size,
character, number, and whether the nodes
are mobile, fixed, or matted.
The breast examination is complete
when patient is in supine position. With
ipsilateral arm raised above the head,
each quadrant of the breast is system-
atically examined. This examination can
be variable amongst examiners (radial or
concentric circular pattern), but the key is
to remain consistent. The examination
should keep in mind the boundaries of
the breast and should extend superiorly to
the clavicle, medially to the sternal bor-
der, inferiorly to the lower rib cage and
inframammary fold, and laterally to the
midaxillary line.11,12 A careful examina-
tion of the nipple-areolar complex and
subareolar breast tissue should also be
carried out in supine position.
The examination of premenopausal fe-
male patients with nodular breasts can be
difficult. The majority of nodularity is pre-
sent in the upper outer quadrant of the
breast where the glandular element of the
breast is highly concentrated. If increased
nodularity is appreciated in one breast,
then the contralateral breast in the same
quadrant should be examined for symme-
try. If a dominant mass is not appreciated,
and the breast is noted to be nodular, then a
repeat examination at a different time dur-
ing menstrual cycle can be helpful. If there
is any concern or a dominant mass is
appreciated, then appropriate imaging
should be performed. Ultrasound is paired
Breast Development and Anatomy 95
with mammography to help evaluate any
palpable abnormalities.
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