1. No category

BY
PROF. MOHAMED A. EL GHARBAWI
e-mail: [email protected].
OBJECTIVES
BY THE END OF THIS TALK WE
SHOULD KNOW
 EMBRYOLOGY & ANATOMY
 CONGENITAL ANOMALIES
 TRAUMA
 ACUTE INFLAMMATIONS & ABSCESSES
 EMBRYOLOGY
Breast is a gland embedded in fat.
It is a big lipoma in which glandular tissue is
embedded.
ECTODERMAL in origin
2 ectodermal ridges
From Axilla to Groin
( MILK LINE)
Normally disappear except at the thoracic area
To form 15 -20 milk ducts and lobes (each is a collection of
lobules).
MILK LINES
SUPERNUMERARY
NIPPLES
AND ACCESSORY
BREASTS MAY
OCCUR ALONG
THIS LINE
CONGENITAL ANOMALIES
A. Anomalies of
the nipple:
1. Absence of the nipple
(Athelia)
2. Supernumerary
nipple
(Polythelia)
Occurring along the
MILK LINE
3. Old (Congenital) retraction of nipple





Nipple fail to develop fully
Bilateral in 25% of cases
Dating since puberty
No groove around
Complications: Difficult suckling, nipple fissuring and possible
abscess
 Should be differentiated from RECENT RETRACTION
which may indicate cancer or inflammation
 Treatment: Daily pulling of the nipple, Apply negative
suction on the nipple by test tube or rubber
B.ANOMALIES OF
THE BREAST
1. Amazia: Absence of
breast, usually
unilateral
2. Polymazia :
supernumerary
breast, may be at
axilla, groin or thigh
(milk line)
May be mistaken for
a lipoma if nipple is
absent.
3. Micromazia:
congenitally small
breast, unilateral or
bilateral
B.ANOMALIES OF
THE BREAST
4.Diffuse Hypertrophy
of the Breast:
 Occur at puberty
 May be unilateral
or Bilateral
 May be due to
abnormal sensitivity
to Estrogen

Hypertrophy of both
stroma and fat

Need reduction
mammoplasty with
preservation of nipple
& areola
The Gladular tissue of the breast is embedded in the
subcutaneous fat (stroma) to get its rounded shape.
Shape: Conical.
Position: From the lateral border of the sternum to Anterior
axillary line and from the level of the 2nd rib to the
level of the 6th rib.
Rests on: Pectoralis major muscle (Upper medial 2/3rd )
Serratus anterior muscle & External Oblique muscle
(Lower lateral 1/3rd )
Suspensory ligaments of Cooper: Fibrous bands extending
from skin to the Pectoralis Fascia , it prevents fall of the
breasts. These ligaments become lax with age and
lactation leading to lax redundant breasts.
 Axillary Tail of Spence: It is an upper outer extension of the
breast along the lower border of the pectoralis major
to the axilla through an opening in the axillary fascia
called FORAMEN OF LANGER
Structure: A collection of acini to form a lobule.
A group of lobules form a lobe.
They are 15 – 20 lobes, each lobe is drained into
a Lactiferous duct that open at the nipple
AREOLA: It is the colored circular area surrounding the
nipple.
CROSS SECTION OF
THE BREAST
1. CHEST WALL
2. PECTORALIS
MUSCLE
3. LOBULES
4. NIPPLE
5. AREOLA
6. MILK DUCT
7. BREAST FAT
8. SKIN
ARTERIAL SUPPLY & VENOUS DRAINAGE
Arterial Supply:
Venous Drainage:
 1.Axillary artery
 Drain into the Axillary &
Through :
Superior Thoracic A.
Pectoral branches of
Acromio-thoracic A.
Lateral Thoracic A.
 2. Internal Mammary A.
 3. 2nd,3rd and 4th intercostal
Arteries (Lateral cutaneous
branches).
Internal Mammary veins
 Superficial veins anastmose
with the other breast veins.
 Deep veins drain to Azygos
vein that communicate with
the vertebral veins (AXIAL
BONE METASTASES)
LYMPHATIC DRAINAGE 1:
A. LYMPHATIC VESSELS:
Lymph from the breast
tissue is drained into 2
lymphatic plexuses:
1. Subareolar plexus of Sappy:
Drains the Nipple, areola
and superficial part of
breast.
Drained to the Deep
lymphatic plexus.
2. Deep lymphatic plexus:
Over the Pectoralis Fascia
Drains superficial plexux,
skin and deep part of breast
Drained to Axillary and
Internal Mammary LNs
LYMPHATIC DRAINAGE 2:
B. LYMPH NODES 1:
Lymph of breast drains
into the Axillary & internal
Mammary Lymph nodes:
I. AXILLARY Lymph Nodes:
They are 20-30 lymph nodes
arranged in 6 groups:
1. Anterior (Pectoral)group
On lateral border of
pectoralis major
2. Posterior (subscapular) g.
On subscapularis muscle
3. Lateral (Humeral) group
on upper part of
humerus
4. Intrpectoral (Rotor's) LN
Between 2 pectoral Ms
5. Central (Basal) in center of
axilla
LYMPHATIC DRAINAGE 3:
B. LYMPH NODES 2:




6. Apical group of LNs:
It is (important) as they
receive lymph from the other
groups.
Drain directly to Jugular
trunk to blood stream, so
distant metastases may occur
with no Supraclavicular LN
affection
Communicate with
Supraclavicular LN
Isolated Apical LNs enlargement may occur as they
receive lymph directly from
the breast.
LYMPHATIC DRAINAGE 4:
B. LYMPH NODES 3:
II. INTERNAL MAMMARY
LYMPH NODES:

Located behind upper 4
intercostal spaces
(Parasternal)

Drain lymph from medial
half of breast

Drain into Jugular trunk
and Thoracic duct

Communicate with
supraclavicular LNs

May communicate with
cutaneous lymphatics
of other breast across
midline. So, breast cancer
may metastasize to contra
lateral breast
OPERATIVE CLASSIFICATION OF LNs:
THERE ARE 3 LEVELS OF
AXILLARY LYMPH NODES:
Level 1: Below (Lateral)
to Pectoralis
minor m.
 Level2: Behind Pectoralis
minor m.
 Level 3: Above ( medial)
to Pectoralis
minor m.
OTHER LYMPHATIC
CONNECTIONS:
Lymphatics from inner lower
quadrant communicate with sub
peritoneal lymph plexus through
LINEA ALBA . Malignant cells may
go to peritoneum and liver.
Also, through FALCIFORM
LIGAMENT, malignant cells from
the breast can form a nodule
around the umbilicus ( SISTER
JOSEPH NODULE)
Malignant breast cells may
migrate through the peritoneum to
the pelvis and implant on the
ovaries (KRUKEBERG”S
TUMOUR)
HISTOLOGY:
1. Breast is a glandular tissue embedded in SC fat/stroma.
2. It is formed of ducts and lobules .
3. Lobules consist of acini and form 15-20 lobes.
PHYSIOLOGY:
HORMONAL CONTROL
 DUCT SYSTEM:
1. Estrogen
2.Growth hormone
3. Corticosteroids
 ALVEOLAR (ACINI)
SYSTEM:
1.Progesterone
2. Prolactin
TRAUMATIC BREAST INJURY1
 NIPPLE CRACKING:
Etiology: Trauma by teeth of baby
Bad hygiene during lactation
Clinical Picture: Pain &may be bleeding especially during lactation
Fissure of the nipple on examination
May complicate to Acute mastitis
Prophylaxis: Frequent wash & dryness of nipple
Use of nipple shield in presence of retracted nipple
Treatment: Stop lactation from the affected breast (Avoid milk
engorgement by use of suction pump)
Wash & clean nipple, dry and then apply a soothing
agent( Lanoline ointment ,Tincture Benzweni Co.)
Apply local antibiotic cream
Nipple Cracking
TRAUMATIC BREAST INJURY2
 Ecchymosis & Hematoma of breast:
Due to trauma to the breast
May be operative trauma
Trauma may be unnoticed (-ve history)
At first apply cold foments to stop and then apply
hot foments to help absorption
Old and calcified hematoma is hard and mimic
malignancy, so excision biopsy may be indicated
Ecchymosis & Hematoma of breast
TRAUMATIC BREAST INJURY3

Traumatic Fat Necrosis:
Etiology: Direct or Indirect trauma to the breast
Needle biopsy or subcutaneous injection
Pathology: Trauma lead to fat hydrolysis with libration Glycerol & Fatty
acids. Glycerol will be absorbed. Fatty acids combine with
tissue calcium forming SOAP. Soap induces foreign body
reaction with aggregation of phagocytes, fibroblasts and
giant cells. The formed hard mass shows Chalky white
appearance of the cut surface without the yellow streaks
and gritty sensation characteristic to carcinoma.
Clinical picture: 50% of cases have no clear history of trauma
On examination, there is a painless hard breast
mass with possible nipple retraction or dimpling
of the skin (suspicious of malignancy).
Treatment: Excision biopsy to verify the diagnosis.
Traumatic Fat Necrosis
TRAUMATIC BREAST INJURY4
 Milk Fistula:
Etiology: Incision (drainage of breast abscess) or injury of
a milk duct in lactating breast.
Rupture of a breast abscess.
Clinical Picture: History of drained or neglected breast
abscess.
Fistula opening discharging milk.
Treatment: Stop lactation. Bromocryptin (Parlodel)
may be given to stop milk formation.
If failed to close, fistulectomy with excision
of the related sector of the gland.
TRAUMATIC BREAST INJURY5
 Traumatic Mastitis:
Etiology: In females, tight brassier .
In Men, tight suspender.
Clinical picture: Presence of a cause.
Pain and mild redness due to irritation.
Treatment: Removal of the cause.
• Wounds:
Cut, contused or penetrating wounds according to the
type of trauma. Like wounds in othe parts of the body.
Repair should be cosmotic with a special attention to
close dead spaces and to avoid more milk ducts.
INFLAMMATORY CONDITIOS OF BREAST
 ACUTE MASTITIS:
1. Neonatal mastitis
2. Mastitis of puberty
3. Traumatic mastitis
4. Mastitis of Mumps
5. Lactation mastitis
6. Bacteria mastitis
(Acute breast abscess)
 CHRONIC MASTITIS:
A. Non-specific
1. Chronic abscess
2. Plasma cell mastitis
B. Specific
1. T.B.
2. Syphilis
3. Actinomycosis
CHRONIC MASTITIS WILL BE DISCUSSED IN THE NEXT
LECTURE
ACUTE MASTITIS 1
 NEONATAL MASTITIS:
Etiology: 1. Presence of maternal prolactin in infant blood.
2. Withdrawal of maternal estrogen from infant blood,
stimulates the infant’s pituitary gland to secrete prolactin.
Prolactin stimulates infant’s breast. It swells and secretes
little milk).
Clinical picture: 1. Swelling of the baby’s breast on 3rd or 4th day.
2. Few drops of milk is squeezed (WITCH’S MILK).
3. May be unilateral or bilateral.
4. Spontaneous subsidence on the 3rd week.
Treatment: No treatment as it subside spontaneously.
NEONATAL MASTITIS
ACUTE MASTITIS 2
 MASTITIS OF PUBERTY:
Etiology: Disturbance of hormones at puberty.
Clinical Picture: 1. May be unilateral (commoner)or bilateral.
2. Males (commoner)& Females may be affected.
3. At puberty.
4. Complaint: Pain and swelling of affected breast.
5. On Examination: Breast is swollen, tender
and indurated. Never suppurate.
6. Spontaneous resolution in few weeks.
Treatment: No treatment as it subsides spontaneously.
ACUTE MASTITIS 3
 TRAUMATIC MASTITIS:
DISCUSSED UNDER TRAUMA TO BREAST
 MASTITIS OF MUMPS:
1. A rare complication of mumps
2 Commoner in females
3. Usually unilateral
4. Spontaneous subsidence
ACUTE MASTITIS 4
 Lactation Mastitis (Milk Engorgement):
Etiology: 1. During weaning from breast feeding, breasts are engorged.
2. Obstruction of lactiferous ducts by epithelial debris.
3. Non bacterial and no suppuration.
Clinical Picture: 1. Occur in active lactating women.
2. Commoner in early lactation and weaning periods.
3. Complaint: Painful swollen breasts with fever
due to absorption of accumulated
milk protein.
4. On examination: Swollen tender breast in
whole breast engorgement Or swollen
and tender sector in SECTOR MASTITIS
if a single lactiferous duct is obstructed.
ACUTE MASTITIS 5
 LACTATION MASTITIS (CONT.):
Complication: May be infected leading to abscess.
Treatment: 1. Antibiotic to protect against infection
2. Stop lactation and evacuate milk using breast pump
regularly if temporary. For permanent weaning use
Parlodel to stop milk formation.
3. Analgesics and antipyretics.
4. Hot foments.
5. Elevation of breast is not bacterial.
6. If suppuration happed, deal with the case as Acute
bacterial mastitis ( Acute Breast Abscess).
Lactation Mastitis (Milk Engorgement)
ACUTE MASTITIS 6
 ACUTE BACTERIAL MASTITIS ( ACUTE BREAST
ABSCESS)1:
Etiology:
A. Predisposing factors: Milk engorgement
Fissure or cracks of nipple
Bad hygiene of nipple & areola
B. Organisms: Staph. Aureus ( Commoner/ localized inflammation).
Streptcocci (Less common/ Diffuse inflammation).
C .Route of Infection: Direct (Common), through fissure or crack of
nipple.
Lymph or Blood born (rare)
D. Incidence: Common in lactating women especially at early
lactation and weaning periods.
ACUTE MASTITIS 7
 ACUTE BACTERIAL MASTITIS (ACUTE BREAST
ABSCESS)2:
Pathology:
A. Stages: Pass in 2 stages. 1. Cellulitis (pre- suppurative) stage.
2. Abscess ( suppurative) stage.
B. Sites of breast abscess: 1. Retro mammary ( sub mammary).
Behind the breast, on pectoral
fascia.
2. Intra mammary ( in the breast tissue)
3. Pre mammary (Supra mammary)
Under the skin.
CELLULITIS STAGE
ACUTE MASTITIS 8
 ACUTE BACTERIAL MASTITIS (ACUTE BREAST
ABSCESS)3:
Clinical Picture:
Commonly in a lactating woman, especially early in lactation
or in the weaning period.
A. Cellutitis Stage: Symptoms & signs of acute inflammation.
General: Fever, malaise and headache
Local: Painful, red, hot and tender breast.
Enlarged and tender axillary lymph nodes.
ACUTE MASTITIS 9
 ACUTE BACTERIAL MASTITIS (ACUTE BREAST
ABSCESS)4:
Clinical Picture (Cont.):
B. Suppuration ( Abscess formation) Stage:
Swollen, painful, red, hot and tender breast.
May be subcutaneous dilated veins.
Enlarged and tender axillary Lymph nodes.
Pus formation is indicated by: Fever is hectic.
Pain is throbbing.
Edema is pitting.
Fluctuation is late (don’t wait)
Needle Aspiration Confirms the Diagnosis.
BREAST ABCESS (LOCALIZED)
ACUTE MASTITIS 10
 ACUTE BACTERIAL MASTITIS (ACUTE BREAST
ABSCESS)5:
Complications:
A. Systemic Complications: Baceraemia, septicemia, pyaemia,
toxaemia.
B. Damage to breast tissue.
C. Chronic sinus: if neglected and ruptured under the skin.
D. Chronic breast abscess ( Antibioma) is formed if antibiotics
are given without drainage.
Differential Diagnosis: To be differentiated from MASTITS
CARCINOMATOSA ( Inflammatory Breast Cancer)
ACUTE MASTITIS 11
 ACUTE BACTERIAL MASTITIS (ACUTE BREAST
ABSCESS)5:
Treatment:
A. In the pre supportive stage:
1. Antibiotics against Staph. & Strept ( Common).
2. Analgesic antipyretics.
3. Application of local hot foments.
4. Stop lactation with suction evacuation of milk by a breast
pump. If permanent stop of lactation, give Parlodel
( Bromocryptin).
5. Breast Support ( difficult).
ACUTE MASTITIS 12
 ACUTE BACTERIAL MASTITIS (ACUTE BREAST
ABSCESS)6:
Treatment ( Cont. ):
B. Suppurative stage:
(Abscess is formed/ Must be drained/ Don’t wait for fluctuation/
Drainage should be wide enough and dependent/ under GA)
Incision site:
1. Pre mammary Abscess: Incision over its pointing site.
2. Intra mammary Abscess: You may drain this abscess through
a. Radial incision : from the nipple to avoid cur of lactiferous
ducts.
b. Circumareolar incision: Cosmetic, hidden in the border
of the areola. Divide the skin only, then push a hemostat
into the abscess cavity. Break the septa inside the abscess
cavity by your finger to drain all pockets.
c. Counter incision: To be done in the dependent position.
3. Retro mammary abscess: to be drained through the retro
mammary fold .
INCISIONS FOR DRAINAGE OF BREAST ABSCESS
Drainage of Supra mammary abscess