Breast surgery 1 (dr. M.

Mosad)
Surgical anatomy of the breast
➢ It is a modified Sweat (sebaceous) Gland between the skin on the pectoral Fascia and
chest wall.
➢ Extents vertically from 2nd rib to 6th rib & transversally from ant. Axillary line to the
lateral border of the sternum, nipple or areola faces the 4th intercostal space.
➢ Architecture:
- Acini are the main unit of the breast tissue that collect together to form lobules, that
collect together to form lobes. Each lobe has main lactiferous duct.
- There are 15-20 lactiferous ducts (of 15-20 lobes) which open into the nipple by
separate openings.
- Adipose tissue to contour the shape of the breast.
- Fibrous tissue septa around the breast lobules pass between the skin and pectoral
fascia (Cooper’s Ligament/ suspensory ligament).

➢ Some anatomical variations: Left breast is usually slightly larger, Base is circular,
either flattened or concave.
➢ Separated from pectoralis major muscle by fascia, retromammary space
➢ Structure:
- Outer surface convex, skin covered
- Nipple: Small conical/cylindrical prominence below center, situated in front of fourth
intercostal space.
➢ Vessel & nerves:
1.Arteries: derived from thoracic branches of three pairs of arteries
a. Axillary arteries:
- continuous with subclavian a.
- gives rise to external mammary (= lateral thoracic) artery

b. perforating branches of Internal mammary (thoracic) artery:

- first descending branch of subclavian artery
- supply intercostal spaces (2,3,4) & breast
- used for coronary bypass surgery.

c. lateral branches of Intercostal arteries(2,3,4) :

- numerous branches from internal & external mammary arteries
- supply intercostal spaces & breast.
2. venous drainage
- Superficial veins form a ring around the base of the nipple (“circulus venosus”),
accompanies lymphatics.
- Deep/large veins pass from circulus venosus to circumference of mammary gland,
then to
- External mammary v to axillary v
- Or Internal mammary v to subclavian v
- or intercostal vein

3.Innervation: derived from:

- anterior & lateral cutaneous nerves of thorax (4th - 6th intercostal nerves.
- sympathetic secretory branches from 2nd to 6th intercostal nerves.
- spinal segments T3 – T6.

4. Lymphatics: clinically significant!

a. Glandular lymphatics drain into anterior axillary (pectoral) nodes then central axillary
nodes, apical nodes, deep cervical & sub clavicular(subclavian) nodes
- Axillary lymph nodes get the most of the drainage.
- Axillary lymph nodes groups
• Anterior group: behind anterior axillary fold
 • Posterior group: anterior to the posterior axillary fold
• lateral group: around axillary vessels
• central group: in the fat of the floor of the axilla
• apical: lateral border of the first rib
b. Medial quadrants drain into parasternal nodes

d. inter-pectoral lymph nodes of rotter which are one or two groups situated in between
pectoralis major and minor.
e. Internal mammary groups along parasternal line in 2nd, 3rd, 4th intercostal space
around internal mammary vessels.
f. supraclavicular (subclavian) and infraclavicular lymph nodes anterior to clavipectoral
fascia
 Congenital anomalies
1. Excess breast Tissue:
- Polymastia (Accessory Breast tissue), Polythelia (Accessory nipple)
- additional breasts or nipples along milk/mammary line (from anterior axillary line to
mid inguinal ligament), axillary tail is the most common site
2. Absence or deficiency of the breast tissue
- Amastia (absent breast)
- Athelia (absent nipple)
3. Congenital retracted nipple: due to congenital short lactiferous ducts that tends the
nipple backward
Diseases of the breast
1. Traumatic
2. Inflammatory
3. Fibro adenosis
4. Tumors

1- Traumatic disorders
Traumatic Fat Necrosis
- Cause: History of breast trauma / prior surgery.
- Pathogenesis:
1. Trauma causes rupture of fat cells and liberation of fatty acids, free fatty acids in
intracellular space combine with calcium ions from local tissue fluid leading to
calcium saponification.
2. Foreign body reaction leads to aggregation of phagocytes and foreign body giant
cells with multiple fibrosis around which forms a mass.
- Clinical picture:
• Mass related to the site of the trauma: painless, palpable, hard, with ill- defined
borders.
• limited mobility and tender breast due to fibrosis
• skin thickening (when it is attached to the skin)
• nipple retraction (due to extensive fibrosis near the nipple),
• a mammographic density, or calcifications.
• Usually there is no axillary lymph nodes affection.
-hard, ill-defined white chalky
mass

Mammographic density or
calcification.

-Acute lesions: hemorrhagic +

-central areas of liquefactive fat
necrosis.
-Subacute lesions - areas of fat
necrosis
- Ill-defined, firm, gray-white
nodules containing small chalky
white foci or dark hemorrhagic
debris. Central region of necrotic
fat cells
-intense neutrophilic infiltrate +
macrophages.
-Proliferating fibroblasts + new
vessels + chronic inflammatory
cells surround
the injured area
-Giant cells, calcifications, and
hemosiderin appear
- focus- replaced by scar tissue

- Treatment: excision& biopsy to exclude malignancy.

Breast hematoma
Cause, pathogenesis &clinical picture:
- history of trauma > bleeding > bluish discoloration of the skin > blood clot >
organization > foreign body reaction > fibrosis > mass.
- Nipple retraction in cases of extensive necrosis near nipple.
- Probable superadded infection > breast abscess.
- Or calcification > very hard mass lesion.
Fate of hematoma:
- Complete resolution.
- Infection & abscess formation.
- Blood cyst.
- Calcification and hard mass.
Treatment:
- Early detection: cold fomentation for 24h (vasoconstriction to reduce bleeding)
followed by hot fomentation for 24 h (increase absorption of hematoma).
- Infection: antibiotics.
- Abscess: incision &drainage.
- Organized hematoma and calcified mass: excision and biopsy to exclude
malignancy. Modified radical mastectomy in cases of malignancy.
2- Inflammatory disorders:
1. Acute mastitis
- common esp. acute lactational mastitis.
- Occurs to the mother in first month of
breastfeeding.
- can occur in any age, in infants called
mastitis neonatorum.
- Types of mastitis:
• Acute: aseptic, bacterial
• Chronic = chronic breast abscess: specific e.g. tb mastitis, non-specific

Mastitis neonatorum:

• It is due to retention of mother hormones i.e. (maternal prolactin) stimulates

lactation in infant.
• Affects both males and females.
• c/p: swollen breasts on 3rd ,4th day with few drops of colorless milk (witch’s milk)
• subsides spontaneously within 2-3 weeks.
• avoid surgical intervention to drain the breast, as it can cause complete injury of
duct system &subsequent failure to lactate in future.

Mastitis of puberty

• The condition affect adolescent boys at age 14,15.

• c/p: pain + swelling of breast, retro areolar indurated button like mass &
suppuration never occur.
• Usually, it subsides spontaneously. It predisposes for gynecomastia.

Granulomatous mastitis
• Rare.
• Causes:
Systemic granulomatous ds. Sarcoidosis, Wegener’s.
Granulomatous inf. d/t Mycobacteria, Fungi.
• Granulomatous Lobular Mastitis – Parous women, confined to lobules, d/t
hypersensitivity reactions to the antigens – expressed by the lobular epithelium
during lactation.
 Acute lactational mastitis

• It is an infection in the breast during lactation, cracks / fissures in the nipple are
portal of entry of bacteria.

• Etiology:
- predisposing factors:
1. Injury of buccal mucosa of the infant.
2. Abrasions of nipple so it allows to transmit infection from infant’s oropharynx
3. Lack of breast hygiene
-organism: staph aureus (g +ve) is the most common
-it always starts milk engorgement which is a good media for bacterial proliferation>
severe edema & inflammation > suppurative stage > if neglected > liquefaction &
multiloculated abscess formation.

MORPHOLOGY:
Staph. Inf.: localized area of inflammation.
Strep. Inf.: Diffuse, spreading.
HPE: Involved breast tissue –necrotic, neutrophil
infiltration.

• Clinical picture: differs according to stage

1. stage of milk engorgement:
- general symptoms: some sort of mild systemic manifestations, persistent low-grade
fever.
- dull aching pain, part or whole of the breast is swollen or indurated, normal breast
milk.
- Diffuse tense& tenderness.
- No physical signs of inflammation: no hotness or tenderness.
2. stage of acute mastitis:
- general symptoms: increase fever up to 40 associated with generalized malaise, loss
of appetite & easy fatigue.
- dull aching pain get worse.
- more enlargement of breast
- physical signs of inflammation: redness, hotness
- turbid milk
- inflammation & tenderness of axillary lymph node.

3. Stage of abscess formation:

- General symptoms: hectic fever associated with headache, malaise& anorexia.
- Throbbing pain which is more at night.
- Localized tense and tender
- Physical signs of inflammation
- Inflammation 7tenderness of axillary lymph nodes
- Pitting edema of skin overlying the abscess
- Fluctuation in some parts which gives pus by aspiration

• Management
- Milk engorgement: good milk evacuation by using a pump or manual.
- Acute cellular mastitis: broad spectrum antibiotics & analgesics, hot fomentation,
elevation of the breast. 30% become breast abscess.
- Breast abscess: abscess drainage is necessary even before fluctuation.
Technique:
✓ Under general anesthesia
✓ Incision: Drain is brought out through the most dependent part = that shows
maximal manifestations) .
✓ Destruction of all loculi in the breast cavity (surgeon’s finger breaks all loculi to
form single cavity) is necessary to avoid recurrence or fibrosis leading to chronic
breast abscess
✓ If abscess is in the upper segment of the breast: counter incision in the most
dependent part of the breast to communicate with each other to allow good
drainage of the abscess.
 Complications:
✓ If abscess is neglected or not well treated, it can lead to destruction of breast tissue.
✓ If duct system is injured during surgery it may lead to
- milk fistula,
- anti-bioma
- galactocele (retention cyst) due to scarring, fibrosis or narrowing of the
lactiferous duct after injury.
- May be septic focus leading to sepsis.
Regions in which abscess must be drained fast even before fluctuation:
1- Breast: to avoid tissue destruction.
2- Parotid: to avoid facial nerve injury.
3- Pulp of the finger: to avoid ischemia.
4- Perianal abscess to avoid fistula.
5- Perinephric abscess to avoid spread of infection to the kidney.
6- Ear lobule to avoid destruction of cartilage in the ear lobule and perichondritis.

2. Chronic breast abscess

1- non-specific chronic pyogenic breast abscess

- etiology:
1- following neglected or improperly treated acute breast abscess
2- chronic from the start e.g. on top of superficial lesion (cyst or a tumor), blood
borne infection by attenuated organism.
3- Spontaneous rupture of an acute abscess doesn’t cure but leads to chronicity.
- Pathology: a cavity that contains sterile pus surrounded by thick fibrous wall.
- c/p: hard, painless, ill-defined (due to surrounding fibrous tissue) and limited-
mobility mass. May be associated with nipple retraction, peau d orange …etc. so
similar to cancer breast. Axillary lymph nodes may be tender.
- Treatment: radial excision & biopsy to exclude malignancy. Modified radical
mastectomy in cases of malignancy.
 2- Specific chronic abscess: T.B
- Route of infection:
1- via lymphatic spread, either retro grade from cervical lymph nodes, or
from lung: tracheobronchial lymph nodes > para tracheal > mediastinal>
internal mammary lymph nodes to the breast.
2- Blood spread (rare)
3- Direct invasion of the breast: tubercular osteomyelitis in ribs.
- C/p: nodular presentation or extensive fibrosis
1- Nodular presentation:
• Nodules may be solitary or multiple, unilateral or bilateral, fixed to the
breast tissue, firm to hard, ill-defined, associated with nipple retraction.
• In cases of superadded bacterial infection: enlargement of axillary lymph
node.
• fate:
✓ develops to tubercular ulcer
✓ central necrosis (caseation) to form cold abscess (it is called cold
due to absence off tenderness, hotness & redness)
• site of nodules:
✓ pre mammary
✓ subcutaneous
✓ intra mammary within breast tissue
✓ retro mammary behind deep fascia of the breast (usually due to
ribs osteomyelitis & lead to sinus formation & caseation)
2- Extensive fibrosis: excessive atrophic structure of the breast

- Management:
1- Nodules: excision
2- Abscess: valvular aspiration (insert needle first with angle of 45 and then 90 then
45 in cavity to avoid being in one line during aspiration to protect the patient from
tubercular sinus) + injection of antitubercular drug after aspiration
3- Extensive fibrosis and destruction: simple mastectomy of the breast.

2.Duct ectasia (plasma cell mastitis)

- Definition: dilatation of major lactiferous ducts. They are totally benign

inflammatory lesions of the breast.
- Etiology: unknown, associated with female smokers
 - Pathogenesis: chronic inflammation of duct system leads to dilatation of major
ducts > stagnation and inspissation of secretions > peri ductal inflammation
&infiltration of small lymphocytes and plasma cells so called plasma cell mastitis.
May affect one duct or multiple ducts.

- HPE: Dilated ducts filled by granular debris, numerous

lipid-laden macrophages, inspissation of breast
secretions, marked periductal and inter ductal
(dense)infiltrate of lymphocytes and macrophages, and
variable numbers of plasma cells.

- Clinical picture:
✓ Age: perimenopausal (around forties: 5th – 6th decade), multiparous women.
✓ Mass: Poorly palpable peri areolar hard
mass.
✓ Due to shortening of ducts, it may be
associated with slit like nipple retraction,
peau d orange ...etc. so similar to cancer
breast.
✓ Subareolar pain or tenderness due to inflammation & subareolar abscess
formation.
✓ Discharge: creamy, greenish.
✓ Eventual fibrosis > skin & nipple retraction.
✓ Principal significance: produces an irregular palpable mass mimics the
mammographic appearance of carcinoma.
 - Investigations:
✓ Ultrasonography: indicates dilated, filled duct in subareolar region, so it is
more evident.
✓ Mammography
- Management:
✓ Stop smoking
✓ Antibiotics: broad spectrum, for anaerobic bacteria e.g. Metronidazole.
✓ If there is no improvement by medical treatment:
Hadfields procedure: affected major duct excision via circum-areolar incision.

3- fibrocystic disorders:
Fibro adenosis
- Most common benign breast condition.
- It is a type of ANDI [Aberration of Normal Development & Involution].
- Etiology: unknown.
✓ may be due to hyperestrogynemia unopposed by progesterone
✓ or hyperprolactinemia.
✓ Autoimmune disorder in breast
- Primarily affects terminal duct–lobular unit (TDLU).
- Pathology:
✓ localized (affect one quadrant) or diffuse
✓ Unilateral or bilateral (usually)
✓ 3 principle changes: adenosis, fibrosis & cystic change with apocrine
metaplasia.
1- Adenosis: Increase in the number of acini per lobule.
Pregnancy: Normal physiologic adenosis.
Nonpregnant women :adenosis - focal change
Acini – enlarged, not distorted (blunt-duct adenosis).
Calcifications may occur occasionally within the lumens.
Acini - lined by columnar cells benign / atypical features (“flat epithelial
atypia”), Earliest recognizable precursor of epithelial neoplasia
2- Interlobular fibrosis: fibrous
proliferation between the ducts & acini.
Usually diffuse (shrunken breast) or may
be Localized (breast lump). Cysts rupture
> Secretory material > Adjacent stroma >
Chronic inflammation > Fibrosis >
Palpable firmness of the breast

3- Cystic changes:
• Retention cyst due to mechanical
obstruction of duct lumen by epitheliosis
from inside or fibrosis from outside.
• Dilation & unfolding of lobules: small
cysts – coalesce- large cysts.
• Calcification – common.
• “MILK OF CALCIUM” –
Mammographers
• Diagnosis – confirmed – disappearance of
the cyst after FNAC.
• Types of cysts
a. Blue-dome cyst of bloodgood:
solitary, large
Lined by flattened atrophic epithelium/metaplastic apocrine cells
(Abundant granular eosinophilic cytoplasm + round nuclei).
Contains clear fluid, bluish discoloration due to shinig blood vessels
Unopened cysts seem brown/blue in colour and to have turbid, semi
translucent fluid.
b. Microcysts: multiple small cysts lined by tall columnar epithelium, intra
cystic papillary growths are usually seen in the cyst due to epithelial
proliferation
4- Epitheliosis: hyperplasia of epithelium lining duct and acini
5- duct papillomatosis (localized form of epitheliosis) may lead to bleeding
per nipple.
- Clinical picture:
✓ Incidence: 10 – 20 % of adult women, fertile.
✓ Age: 25 – 45 yrs.
✓ Characterized by cyclic mastalgia (mastodynia): dull ache increases before
menses & decreases after it & stops with pregnancy.
✓ Heaviness & swelling of the breast, pain radiates to the axilla and inner aspect of
the arm
✓ May be presented by mass
(solitary or multiple), (unilateral or bilateral)
Firm, irregular due to fibrosis
Fixed to breast tissue, not adherent to the skin or the underlying fascia
✓ Nipple discharge : serous, green or bloody (in cases of duct papillomatosis)
✓ May be presented by a cyst
When is a cyst considered suspicious (more liable to malignant transformation)?
1- There is blood during cyst aspiration
2- Rapid refilling of the cyst occurred after aspiration
3- There is felt residual mass or lump in the cyst after aspiration
- Clinical types of fibro adenosis:
1- Diffuse:
✓ most common
✓ adenosis is more predominant
✓ no association with malignancy
2- localized:
✓ common in elderly
✓ lead to breast lump
3- lobar or sectoral
✓ old age
✓ usually in the apex of the breast: lying towards the nipple.
✓ firm, ill defined
✓ epitheliolosis is more predominant
4- cystic
- Investigations: laboratory assessment
• Hormonal assay for prolactin or estrogen level
• Mammography
• Ultrasound to detect cyst formation
• Fine needle aspiration cytology
• Excisional biopsy
- Management:
1- Assure the patient that there is no malignant transformation esp. in the diffuse
type.
2- Medications:
• ALA (alpha-linolenic acid): potent anti-inflammatory
• Danazol: synthetic androgen suppresses FSH & LH, avoid in young
female
• Bromocriptine: anti-prolactin in cases of hyperprolactinemia.
• Tamoxifen: anti-estrogen in cases of hyperestrogenemia
• Analgesics
• Elevation of the breast by adhesive strap or firm bra
3- Surgical intervention:
• Excisional biopsy to exclude malignancy in localized type.
• Subcutaneous mastectomy in diffuse type with intractable pain +
silicon processes esp. in young females
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