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1. Arba Minch University GYNACOLOGY For 3 rd Year Midwifery By- Yosef A.

2. CHAPTER SIX THE BREAST Anatomy & physiology of the breast Breast examination Teaching breast Self-examination to women (BSE) Benign & malignant tumors of the breast Management of breast disorders Mammography Nursing care consideration for a women with mastectomy 2 Done by Yosef A.

3. ANATOMY AND PHYSIOLOGY OF BREAST Objectives At the end of this study the student will be able to Describe the gross structure of the breast. Describe the physiologies of breast. Discuss the development of breast and its congenital anomalies. Give its blood supply and lymphatic drainage . 3 Done by Yosef A.

4. THE BREAST ANATOMY AND PHYSIOLOGY OF FEMALE BREAST Breasts are composed of mammary glands ,connective tissue ,blood vessels , nerves and lymph vessels. The breasts are secondary reproductive glands of ectodermal origin. The breast is the upper  ventral  region of the  torso  of a  primate , in left and right sides, containing the  mammary gland . 4 Done by Yosef A.

5. Cont… Each breast consists of 12-20 conical lobes. Each lobe consists of a group of lobules. The lobules have several lactiferous ducts , which unit to form a major duct Each of the major ducts widens to form an ampula The fatty tissue increases towards the periphery of the lobule and gives the breast its bulk and hemispheric shape and 80-85% of the normal breast is adipose tissue. Lobes---Lobules---Lactiferous ducts---Major duct--- Ampula 5 Done by Yosef A.

6. Cont… In non pregnant ,non lactating breast ,the alveoli are small and tightly packed During pregnancy the alveoli hypertrophy and their lining cells proliferate in number During lactation , the alveolar cells secret proteins and lipids which comprise breast milk 6 Done by Yosef A.

7. POSITION OF BREAST Extent: Vertical: 2 nd to 6 th rib (Base of the breast) Horizontal: Lateral margin of the sternum to the mid auxiliary line 2/3 rd of the breast lies in the superficial fascia (Pectoral fascia) lying on Pectoralis major 1/3 rd of the breast lies in the superficial fascia lying on Serratus Anterior The greater part of the gland lies in the superficial fascia. 7 Done by Yosef A.

8. A small part- axillary tail extends upward and laterally, pierces the deep fascia at the lower border of the pectoralis major muscle up to the apex of the axilla . The breast lies upon the deep pectoral fascia, which in turn overlies pectoralis major and serratus anterior, and inferiorly, external oblique and its aponeurosis as the latter forms the anterior wall of the sheath of rectus abdominis 8 Done by Yosef A.

9. PARTS OF THE BREAST Nipple : Conical or Cylindrical prominence in the center of Areola (Devoid of fat, hair & sweat gland) The nipple level in the thorax varies widely, but is at the fourth intercostal space in most young women. Nipple is Usually everted Surface anatomy: 4 th intercostal space lateral to midclavicular line!!!! Areola : Circular pigmented area of the skin surrounding the base of the nipple, containing sebaceous glands. Axillary Tail : Small part of the breast extending to the axilla . 9 Done by Yosef A.

10. Retromammary Space : Space filled with loose connective tissue between breast and pectoral fascia Lactiferous ducts from each lobule open on the summit of the nipple separately Lactiferous duct possesses a dilated Ampulla (Lactiferous sinus) just before its termination Fibrous septa separates the lobes of the mammary gland Suspensory ligaments (of Cooper): Mammary gland is firmly attached to the dermis of the skin by these fibrous septa forming suspensory ligaments 10 Done by Yosef A.

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12. Layers of breast Mammary layer Subcutaneous layer Retromammary layer Development and physiology The breasts develop as an invigilation of chest wall ectoderm Which forms a series of branching ducts. Shortly before birth this site of invagination everts to form the nipple. At puberty, alveoli sprout from the ducts and considerable fatty infiltration of the breast tissue takes place. With pregnancy there is tremendous development of the alveoli which, in lactation, secrete the fatty droplets of milk. At the menopause the gland tissue atrophies. 12 Done by Yosef A.

13. Neonates : Occasionally, gynaecomastia may occur in the neonatal breast, with discharge of a colostrum -like material (‘witch’s milk’). From birth until puberty , the breast consists of lactiferous ducts, with no alveoli. At puberty , the ducts start to proliferate, and their terminations form solid masses of cells—the future breast lobules. During pregnancy , secreting alveoli appear. During the early weeks, ductal sprouting and lobular proliferation occur, with increased nipple and areolar pigmentation. The alveoli now display a lumen surrounded by the secretory cells. In the last days of pregnancy, the breasts secrete colostrum , a yellow, sticky, serous fluid, which is then replaced by true secretion of milk. After the menopause , the glandular tissue of the breast atrophies, the connective tissue becomes less cellular, and the amount of collagen decreases. In some women, breasts shrink considerably. 13 Done by Yosef A.

14. Arterial Supply The blood supply of the breast is a rich anastomotic network derived from Perforating branches (Internal thoracic artery) Lateral thoracic artery ( Axillary artery) Thoracoacromial artery ( Axillary artery) Intercostal arteries The largest vessels arise from the internal thoracic artery, the perforating branches of which pierce the chest wall adjacent to the sternal edge in the first to fourth intercostal spaces. The vessel in the second space is usually the largest of these. 14 Done by Yosef A.

15. second to fourth anterior intercostal arteries supply perforating branches more laterally. The axillary artery supplies blood from several branches, namely the superior thoracic, the pectoral branches of the thoraco-acromial artery, the lateral thoracic artery. Venous Drainage Superficial venous system lies within the subcutaneous fat tissue; most distal veins line the superficial fascia and drain blood centrally; provides connection between right and left breast with potential for metastasis to occur between breasts Deep venous system consists of veins that follow the arterial system and communicates with the axillary vein, subclavian vein and SVC Includes lateral thoracic, axillary , subclavian and intercostal veins 15 Done by Yosef A.

16. Nerve Supply Anterior and lateral cutaneous branches of the 4 th – 6 th intercostal nerves Lymphatic Drainage 75% drains to the axilla Lateral quadrants: Anterior Axillary or Pectoral nodes Medial quadrants: Internal thoracic group of Nodes ( Parasternal ) Few lymph vessels drains into Posterior intercostal Nodes Inferior quadrants: May drain into abdominal lymph Nodes Some lymphatic vessels communicate with the lymphatic vessels of the opposite breast 16 Done by Yosef A.

17. Congenital Anomalies Nipple Inversion : usually bilateral if congenital; associated pathology can be present if the nipple change is a new finding and/or occurs unilaterally Athelia : absence of the nipple Polythelia : accessory nipples, can develop anywhere along the milk line; most commonly seen just inferior to the normal nipple; #1 congenital anomaly of the breast in females and males Amastia : failure of the breast and nipple to develop Polymastia : accessory breast tissue; most commonly forms without a nipple; usually found in the axilla Amazia : absence of development of the functional breast tissue beneath a normal nipple/areola 17 Done by Yosef A.

18. Developmental abnormalities of Breast The nipple may fail to evert . Supernumerary nipples or even breasts may occur along a vertical ‘ milk line ’ the other hand, the breast on one or both sides may be small or even absent ( amazia ). Accessory Breasts- is a health condition where the person afflicted has extra breasts. The extra breast can be in various forms, from a fully functional breast with a normal appearance and capable of producing milk to a breast that does not lactate or have an areola. Both men and women can have accessory breasts, but the problem is more commonly observed in women 18 Done by Yosef A.

19. . 19 There is no known limit on the amount of extra nipples or breasts that can develop on the human body. Some women have experienced as many as eight nipples in addition to the standard two. Done by Yosef A.

20. Fascial relationships of the breast The fascial relationships of the breast are of practical importance. As an ectodermal derivative, the gland lies in a pocket of superficial fascia. Superficial fascia: Superficial layer Deep layer Fibrous processes of this layer of fascia extend to the skin and to the nipple and are more developed over the upper part of the breast, where they form the suspensory ligament of Cooper. Contraction of this tissue by malignant infiltration results in the characteristic skin dimpling over a carcinoma of Done by Yosef A. 20

21. The superficial layer lies immediately beneath the dermis and enables skinflaps to be dissected from the glandular mass of the breast quickly, neatly, and in a relatively avascular plane. The deep layer of the superficial fascia is thicker than the subcu - taneous component and covers the deep aspect of the breastplate. Beneath this sheath is a layer of filmy areolar tissue that allows the breast to move freely on the underlying fascial covering of the pectoralis major and the serratus anterior.( Pectoralis fascia) Done by Yosef A. 21

22. Breast examination Two types of breast examination Breast examination by a physician Breast self examination (BSE) Done by Yosef A. 22

23. Self Examination of the Breast 90% of breast cancers are found by the woman or her partner. During pregnancy there is no special time of the month that is best to perform the examination. In non pregnant women 5days after cessation of menstruation ,it is the optimum time to detect changes. Inspection in the shower Inspection in the mirror Done by Yosef A. 23

24. stand in front of the mirror for further inspection a. With arms at sides b. Holding arms over the head ,inspect closely in the mirror for masses and breast symmetry c. Press hands firmly on hips ,below slightly forward . inspect in m Each breast should be mirror image of the other d . Each breast should be mirror image of the other e . Gently squeeze the nipple of each breast between your thumb and index finger to check for signs of discharge or bleeding . irror for lumps or pulling of the skin Done by Yosef A. 24

25. Inspection on lying down lying flat on your back ,with your right hand under your head and a pillow or towel under your right shoulder ,use your left hand to gently feel your right breast using concentric circles to cover the entire breast and nipple . repeat on your left breast. Steps to Diagnosis Clinical Exam Mammography Self Breast Exam Biopsy if indicated Done by Yosef A. 25

26. Done by Yosef A. 26 Breast Self Examination

27. DISORDERS OF THE BREAST Benign and malignant tumors of breast What does benign means? What does malignant means? What is cancer? Cancer is the name given to a large number of diseases. Breast cancer begins in the breast tissue Most kinds of cancer are named after the part of the body where the cancer first start 27 Done by Yosef A.

28. BENIGN BREAST CANCER Fibrocystic breast disease It is common benign breast disease in women of all ages It can occur as early as puberty when estrogen level rises to adult level ,but is found most commonly in women between the age of 20 and 45 year. 28 Done by Yosef A.

29. Sign and symptoms Freely movable , well-delineated breast lump on palpation Visible lump on the surface of breast Often occur on upper outer quadrant of the breast Consistency-firm and hard to soft and flexible Painful (may) and tender Round and fluid filled cyst. 29 Done by Yosef A.

30. Cont… Diagnosis Careful palpation Mammography biopsy 30 Done by Yosef A.

31. Cont… Management Analgesia Avoidance of substances containing caffeine , theophylline and theobromine Avoid smoking Aspiration of cyst under local anesthesia 31 Done by Yosef A.

32. Cont… B . Fibro adenoma Fibro adenoma are tumors consisting of both fibrotic and glandular components that occur in response to estrogen stimulation. They tend to occur in young women and rarely seen after menopause and are non malignant. The tumors may increase in size during adolescence ,pregnancy and lactation or when a woman takes an estrogen sources such as oral contraceptives. 32 Done by Yosef A.

33. Cont… Sign and symptoms No pain(pain less) and freely movable Round and well delineated tumors Feel firmer and more rubbery Occasionally calcify and feel extremely hard Not cause skin retraction Management Surgical incision 33 Done by Yosef A.

34. C. Carcinoma of the Breast The carcinoma of the breast commonly occurs from30-60 years of age. Signs and symptoms Lump and hard fixed mass Pain in the breast Blood stained discharge (late stage) Retracted nipple of cancer has spread to the lymph orange like colour of the skin . 34 Done by Yosef A.