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Mammary Gland and Pectoral Area I) Breast A) General Info 1) Consist of glandular and supporting fibrous tissue embedded

within a fatty matrix together with BV, lymphatics and nerves 2) Mammary glands in the subcutaneous tissue overlying the pectoralis major and minor muscles 3) Overlies pectoralis major, serratus anterior and extends from 2-6 ribs 4) Modified sweat gland 5) Superficial structure 6) Accessory organ of female reproductive system 7) Superficial structures (a) Not attached to deep fascia B) Female Breasts 1) Superficial fascia splits around breasts forming deep and superficial layers (a) Suspensory ligaments (i) Firmly attach the mammary gland to the dermis of the overlying skin (ii) Run from deep superficial fascia to superficial superficial fascia (iii)Fibrous bands (iv) Most numerous in the superior portion of the breast (v) Cancer may tug on suspensory ligaments to causes dents in the skin or a skin dimple First part of a breast examination must be visual 2) Pectoral Fascia (a) Two thirds of the bed of the breast are formed by the pectoral fascia overlying the pectoralis major (b) The other third by the fascia covering the serratus anterior (c) 3) Between the breast and the pectoral fascia is a loose connective tissue plane or potential spaceretromammary space (a) Allows for some degree of movement on the pectoral fascia (b) Because deep superficial fascia lies on deep fascia, no supporting fibrous tissue in that space 4) Axillary process (a) Extension of the mammary gland into the axillary fossa or armpit (b) Enlarged during menstrual cycle C) Mammary Gland (a) Functional unit of the mammary gland (Parenchyma) (b) Glandular tissue(i) True secretary alveoli do not develop until pregnancy

(c) The lactiferous ducts give rise to buds that develop into 15-20 lobules of the mammary gland (d) Each lobule is drained by a lactiferous duct which converge to open independently on the surface (e) Most numerous upper outer quadrant (f) Male breasts remain rudimentary (i) May hypertrophy (ii) Male cancer 1% of breast cancer D) Breast Development 1) Day 37 mammary line 2) Amastia-fail of development on one side 3) Polythelia-extra nipple 4) Polymastia-supernumeratory breasts (a) May occur superior or inferior to the normal pair occasionally developing in the axillary fossa or anterior abdominal wall (b) Extra breast may appear anywhere along the line extending from the axilla to the groin (i) Location of the embryonic mammary crest 5) Gynecomastia-over development of breast tissue in male (a) Imbalance of estrogenic and androgenic hormones or from a change in the metabolism of sex hormones by the liver E) Nipple 1) Faces slightly laterally 2) Duct openings microscopic 3) Level of fourth intercostals space 4) Composed of smooth muscle fibers arrange circularly (a) Causes the nipple to become erect 5) Supplied by fourth thoracic nerve 6) Areola (a) Pigmented skin around nipple contains sweat glands and sebaceous glands F) Blood Supply 1) Artery (a) Internal thoracic artery (b) Axillary artery (lateral thoracic) (c) Intercostals arteries (i) Arise from the internal thoracic artery 2) Vein (a) Superficial plexus veins (b) Internal thoracic veins (c) Intercostals veins-vertebral plexus

(d) Axillary vein G) Lymphatic Drainage 1) Variable 2) Lymph drains from the nipple areola and lobules of the gland to the Subareolar Lymphatic plexus which then drains into: (a) Majority to axillary lymph nodes (i) Initially into the anterior or pectoral nodes 3) Contralateral breast 4) Internal mammary chain 5) Axillary lymph nodes-30 (a) Low group (b) Middle group (c) Apical group II) Pectoral Area and Axilla A) Deep Fascia 1) Pectoral Fascia (a) Deep Fascia (b) Attached to the sternum and clavicle (c) Invests the pectoralis major muscle (d) Extends to the axilla (e) Invests the latissimus dorsi and extend to thoracic vertebra 2) Suspensory ligament of axilla (a) From clavicle around pectoralis minor to skin of axilla (b) Keeps the armpit from drooping B) Pectoralis Major 1) Large fan shaped multilaminar muscle 2) Attachments (a) Proximal (i) Arises from medial clavicle, anterior sternum, first six costal cartilages aponeurosis of external oblique (b) Distal (i) Tendon inserts to the crest of greater tubercle of humerus 3) Innervation (a) Lateral and medial pectoral nerves 4) Actions (a) Adducts the arm (b) Rotates the arm medially (c) Raises body when arms fixed (d) Climbing

C) Pectoralis Minor 1) Anterior to second part of axillary artery 2) Deep to pectoralis minor 3) Attachments (a) Proximal (i) 35d and 5th ribs near costal cartilages (b) Distal (i) Medial border and superior surface of coracoids process of scapula (c) Innervations (i) Medial and lateral pectoralis nerves (d) Action (i) Depresses the shoulder (ii) Stabilizes scapula by drawing it inferiorly and anteriorly against thoracic wall D) Subclavius muscle 1) Attachments (a) Proximal (i) Junction of 1st rib and its costal cartilage (b) Distal (i) Inferior surface of middle third of clavicle 2) Innervations (a) Nerve to subclavius 3) Action (a) Depress lateral part of clavicle E) Serratus Anterior Muscle 1) Forms medial wall of axilla 2) Large muscle 3) Attachments (a) Proximal (i) External surfaces of lateral parts of 1st and 8th ribs (b) Distal (i) Anterior surface of medial border of scapula 4) Innervations (a) Long thoracic nerve (i) Superficial to muscle Clinical 1. Must be careful when taking lymph biopsy not to damage nerve paralyzing the muscle 2. Causes winged scapula 5) Action (a) Abduction of arm/elevation above horizontal

(b) Protracts scapula and holds it against thoracic wall (c) Rotates scapula F) Axilla 1) Pyramidal interval between arm and chest wall (a) Four walls and apex (i) Anterior-pectoralis major and minor Anterior axillary fold (ii) Posterior-subscapularis, teres major and latissimus dorsi Posterior axillary fold (iii)Medial-serratus anterior, ribs (iv) Lateral-intertubercular groove of humerus (v) Apex-clavicle first rib and scapula Cerivco-axillary canal 1. Passageway between the neck and axilla (vi) Base Axillary fossa 2) Pathway for vessels and nerves to arm 3) Contains (a) Axillary artery and vein (b) Brachial plexus (c) Long thoracic nerve (d) Axillary lymph node (e) Axillary sheath (i) Sleeve like extension of the cervical fascia (ii) Contains brachial and axillary artery G) Axillary Artery 1) Branch of subclavian artery 2) Begins at distal border of first rib (a) Passes posterior to the pectoralis minor into the arm and becomes the brachial artery when it passes the inferior border of the teres major (i) At this point it usually has reached the humerus 3) Divided into three parts by pectoralis minor (a) First part (i) Located between the lateral border of the first rib and the medial border of the pectoralis minor (ii) Enclosed in the axillary sheath (iii)One branch Superior thoracic artery 1. Small highly variable arises just inferior to the subclavius

2. Runs inferiorly and supplies the subclavius muscle in the 1st and 2nd intercostals space (b) Second part (i) Lies posterior to the pectoralis minor (ii) Two branches Thoracoacromial artery-medially passes pectoralis minor 1. Short wide trunk 2. Pierces the costocoracoid membrane and divided into four branches deep to the clavicular head of pectoralis major Lateral thoracic artery-laterally passes pectoralis minor 1. Usually arises as second branch of the second part of the axillary artery and ascends along the lateral border of the pectoralis minor (c) Third part (i) Extends from lateral border of pectoralis minor to the inferior border of teres major (ii) Three branches Subscapular artery-largest branch of the axillary artery 1. Descends along the lateral border of the subscapularis on the posterior axillary wall Anterior circumflex humeral artery Posterior circumflex humeral artery 1. Passes medially through posterior wall of the axilla via the quadrangular space with the axillary nerve to supply the glenonumeral joing and surrounding muscles Circumflex arteries encircle the surgical neck of the humerus 4) Ends at distal border of teres major as brachial artery

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