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Clinical Anatomy 5: Breast, Pectoral, and Axilla
Dr. Michael H. Alay-Ay | September 19, 2019.

OUTLINE
I. CA of the breast, pectoral,
and axilla.
 Anatomy of the breast
 Importance of
Suspensory Ligaments
of Cooper/ Fibrous
septa
 Sensory/Sympathetic
innervations
 Breast examinations
 Lymphatic drainage
 Breast cancer
 Nerve injury in the
axilla
 Brachial plexus nerve
block
 Arterial anastomosis
and ligation of arterial
artery

I. CA of the Breast, Pectoral, and Axilla.

Objectives
❖ Discuss the importance of the fibrous septa/suspensory Figure 1. Quadrants of the breast
ligaments in acute infection of the mammary gland IMPORTANCE OF SUSPENSORY LIGAMENTS OF
❖ Discuss the anatomical basis for the skin retraction in breast COOPER/FIBROUS SEPTA
cancer ❖ Ligaments of Cooper compartmentalize the breast into 15 to 20
❖ Discuss the anatomical basis for the following after mastectomy: lobules
➢ Numbness in the lateral side of the chest wall and medial ❖ All lobules and ducts converge into the nipple
aspect of the arm
Carcinoma and Infections
➢ Winging of the scapula
➢ Deep pectoral fascia anterior to the pectoralis muscle
❖ Discuss the anatomical basis for the enlargement of axillary extends and inserts to the skin around the areolar area
lymph nodes in breast cancer and infections of upper extremity
❖ Discuss the anatomical basis for upper extremity block via Carcinoma
brachial plexus nerve block in the axilla ❖ A carcinoma in the breast can pull on the fibrous septa and
➢ pull the nipple inwards causing RETRACTION
ANATOMY OF THE BREAST ➢ skin causing DIMPLING
Breast anatomy ❖ In infection, fibrous septa are localized to one compartment
➢ Composed of fat, glands, ducts, ligaments, neurovascular ❖ Indications for breast tumor
supply ➢ Behind septum - retraction
➢ Lactating women: bigger breasts due to presence of lobes ➢ Consumes septum - dimpling and retraction
filled with milk MASTITIS
Nipple ● Milk- a good culture medium for infection
➢ is located at the 4th rib in males and varies in females due to ● Source of infection
lax in connective tissue in multiparous women ○ Accidental bites from infant (oral bacteria)
➢ Color of nipple: varies depending on race, age, and gravida ○ Poor hygiene
➢ Non-symmetrical in females ○ Cuts or lesions
● Results to abscess in the breast
Blood supply ● Infection in fibrous septa localizes to one compartment or
● Perforating branches of the internal thoracic artery lobe - ligament of cooper blocks the compartment
● Pectoral branches of the thoracoacromial artery ● Treatment: Radial incisional drainage to avoid the
● Lateral thoracic artery which gives off external spread of infection into neighboring compartment.
mammary artery ● Incision should not be circumareolar, but rather
radially; following the longitudinal direction of one lobule
Quadrants of the breast to prevent spread of infection into another lobule.
1. Inner upper quadrant ● Mastitis can happen to non-lactating women but it is
2. Inner lower quadrant rare compared to lactating women.
3. Outer upper quadrant
4. Outer lower quadrant PEAU D’ORANGE
❖ Resembles peel of an orange hence its name
❖ Occurs when cancer cells are present in the lymphatic
channels of the breast and the breast skin accumulates with
the fluid
❖ Skin dimpling evident
❖ Edematous- breast skin accumulates with fluid
❖ Found in advanced cases of breast CA only.
❖ In early cases - palpable breast mass only; undergoes biopsy
and gets treated. Rarely ever reaches this stage.

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 LYMPHATIC DRAINAGE AND BREAST CANCER ● Check for skin dimpling, nipple retraction etc.
❖ Medial Quadrant - 2nd, 3rd, and 4th Intercostal spaces → near ➢ Stand in front of mirror
➢ Put hands in waist
thorax → along the side with the internal thoracic artery
■ Check for asymmetries and abnormalities.
(Internal thoracic nodes) ➢ Put hands at the back of the head
❖ Lateral Quadrant Lymph Nodes - anterior pectoral groups of ■ Check for asymmetries and abnormalities.
the LN; axillary node - 60% of abnormalities are found in the ➢ Palpation
upper quadrant ■ Palpate the breast systematically, doesn’t matter which
❖ Lymphadenopathy - enlargement of the lymph nodes way you go as long as you don’t miss a portion of the
➢ Infection can go to the internal thoracic nodes or axillary breast.
■ Palpate axilla for axillary nodes
nodes.
● Start with the anterior group (lateral border of pectoralis
❖ Upper Outer Quadrant - most common area of malignancy/ major), then towards the apex of the axilla.
infection of the breast ■ Use the palmar surface of the distal phalanx when
➢ Location of the Axillary Tail of Spence palpating.
➢ Contains 60% of breast tissue
❖ Invasive ductal cancer - most common type of breast CA
➢ Ductal - starts within the duct
➢ Duct attached to gland, gland and duct compartmentalized
between fibrous septa.
➢ If there are lesions in the ducts, it can invade the fibrous
septa, thus pulling the nipple inwards → nipple retraction
❖ Trivia/Additional info:
➢ There are people born with an inverted nipple.
➢ So in history taking of patients, it should be new onset of
inverted nipple to be associated with breast CA.
➢ The most common presentation of breast CA is neither skin
dimpling, or nipple retraction; but rather palpable breast
mass.
Figure 2. Self-breast-exam
Cancers
Classification Clinical Breast Exam
■ T - tumor size (T1, T2, T3, T4) ❖ Same procedure as the aforementioned, but done by a
■ N- nodes (presence) - N0, N1, N2 doctor in the clinic.
■ M- metastasis
Risks
● Can spread from the lungs BREAST CANCER
● Spread to the opposite side ● More common on the upper outer quadrant
● Spread to the abdominal cavity - lung and liver ● Signs of breast cancer:
● Spread to the supraclavicular nodes
● Spread to the bone (spine) - to the brain through the B- Breast Mass: hard, inconsistency, ill-defined border
veins at the back R- Retraction of the nipple
Most common site of metastasis is BLBL or bone, lungs, brain, E- Edema (Peau d’orange)
liver. A- Axillary node is positive
S- Skin Dimpling, Satellite nodule, Skin Ulceration
SENSORY/SYMPATHETIC INNERVATIONS T- Tumor metastasis
● Skin
● Receptors in the areola and nipple area: abundant ➢ Breast biopsies
● Innervation: Intercostal nerves ■ For patients above 40 years of age
● Doesn’t matter if there is no family history, even if there
SYMPATHETIC NERVE is a benign looking mass, as long as patient is above 40.
● Myoepithelial cells that surrounds the glands and ducts ■ Younger age group (late teens to 20s)
● Smooth muscle of the nipple areola and blood vessels ● When to opt for a biopsy?
● If physical examination findings are indicative:
INTERCOSTOBRACHIAL NERVE ◆ Palpable mass is hard with irregular borders.
● Can be removed during mastectomy ● Mammogram/ultrasound shows suspicious findings
● Hard to distinguish from adipose tissue (e.g. calcifications)
● Results to: Numbness on one side ➢ Biopsy types
● Myocardial infarction: This nerve is responsible for ■ FNAB (Fine needle aspiration biopsy)
spread of pain into other organs ■ Core needle biopsy
● Acceptable complication ■ Excisional biopsy
■ Incisional biopsy
BREAST EXAMINATIONS Modified Radical Mastectomy
❖ Self-breast exam Excised mass:
➢ Aids in early diagnosis of breast CA. ● Breast fat
➢ Done in the first 7 to 10 days after the first day of ● Skin overlying the tumor
menstruation. ● Nipple and areola
■ This is the most accurate time frame. Don’t do it during, ● Pectoral deep fascia
don’t do it prior. ● Lymph nodes
■ Likewise, imaging, ultrasound, mammogram, etc. should
be done within this time frame. Intercostobrachial nerve - may be removed in the process of
➢ How is it done? mastectomy; hard to distinguish from fat
■ First inspection

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 a. Long Thoracic Nerve
NERVE INJURY IN THE AXILLA
CITATION
LONG THORACIC NERVE INJURY Wineski, L. E., & Snell, R. S. (2019). Snell’s clinical anatomy by
● Injury during a radical mastectomy surgical procedure regions (10th ed.). Philadelphia, PA: Wolters Kluwer.
● Innervation of the serratus anterior
● Function: pulls the medial border of the scapula to the REFERENCES
posterior wall and stabilizes it Wineski, L. E., & Snell, R. S. (2019). Snell’s clinical anatomy by
● WINGED SCAPULA - patient pushes against a wall → regions (10th ed.). Philadelphia, PA: Wolters Kluwer.
medial border of the scapula will be pushed away from
the thoracic wall and protrude like a wing END OF TRANSCRIPT
Transcribed by: D2023 TG-14 Proofread by: D2023 TG-2
Tan, Abraham D. Rangel, Johann Eric T.
Tan, Danielle Grace S. Regala, Erin Claire, K.
Tan, Danielle Louise G. Repato, Philyn Candice B.
Tan, Harold Williams O. Reyes, Eric Benjamin M.
Tan, Jazelle S. Reyes, Zachary Raphael P.

Figure 3. Winged scapula

THORACODORSAL NERVE INJURY

● Injury during a radical mastectomy surgical procedure
● Innervation of the latissimus dorsi
○ Function: Adduction of arm
○ Muscles with the same function: Pectoralis
major, Teres major, Teres minor
○ Function: Extension and medial rotation of arm
○ Muscles with the same function: Teres major,
Deltoid
● Damage is not pronounced as there are other muscles
with the same function

INTERCOSTOBRACHIAL NERVE INJURY

● Common injury after a modified radical mastectomy
● Hard to distinguish from adipose tissue  may be
removed in the process of mastectomy
● Numbness in the lateral side of the chest wall and
medial aspect of the arm

BRACHIAL PLEXUS NERVE BLOCK

❖ Loss of sensation only
❖ Easily obtained via the axilla or posterior triangle
➢ Injecting a local anesthetic solution to the axillary sheath
➢ Massaging along the sheath producing a nerve block

ARTERIAL ANASTOMOSIS AND LIGATION OF AXILLARY

ARTERY
❖ Exits between the branches of the subclavian and axillary artery
→ ensures adequate blood flow to the upper limb
❖ The existence of the anastomosis around the shoulder joint is
vital to preserving the upper limb should it be necessary to
ligate the axillary artery
Shoulder Anastomosis
❖ Anterior and posterior humeral circumflex
❖ Circumscapular anastomosis

REVIEW QUESTIONS
1. Give the structure of the breast that results to nipple
retraction and skin dimpling
a. Fibrous Septa/Suspensory Ligaments of Cooper
2. What nerve is usually damaged during mastectomy?

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