4 Pectoral Region

62

description

Anatomy of pectoral region designed by me is related all anatomical aspect of Pectoral area in an easy way

Transcript of 4 Pectoral Region

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PECTORAL REGION

Farrukh ShahzadBSPT, PPDPT

Isra University, Islamabad Campus

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The pectoralThe pectoral regionregion

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The pectoral regionThe pectoral region

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Pectoral regionThe pectoral region consists of structures that connect the upper limb to the anterolateral chest wall. surface land marks.Clavicle The jugular notch ( interclavicular notch or suprasternal notch).The sternal angle or angle of Louis.The epigastric fossa.The midclavicular line The infraclavicular fossa or deltopectoral triangle.The tip of the coracoid processThe acromion.The deltoidThe axilla or arm pitThe midaxillary line.

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Dr. BahgatDr. Bahgat

Cutaneous nerve supply of the pectoral regionCutaneous nerve supply of the pectoral region

The skin skin of the pectoral regionpectoral region

Is divided into 2 parts bya horizontal line passing through

the sternal angle.the sternal angle.

The area above this line is supplied by

the supraclavicular nervessupraclavicular nerves.

The area below the horizontal lineis divided into 2 parts by the midclavicular line :

1- The area medial to the midclavicular line:

is supplied by the anterior cutaneous branches of

the second to 6th intercostal nerves

Each anterior cutaneous nerveEach anterior cutaneous nerve supply the skinthe skin from the midline to

the midclavicular line.

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Cutaneous nerve supplyCutaneous nerve supply - The skin skin of the pectoral regionpectoral region is divided into 2 parts by a horizontal line passing through the sternal angle.the sternal angle. - The areaThe area above above this linethis line is supplied by the supraclavicular nervessupraclavicular nerves. These nerves are branches from the cervical plexus (C (C 3, 43, 4 ventral rami). ventral rami).The areaThe area below below the horizontal line is divided into 2 parts by the midclavicular line :

1- The area1- The area medialmedial to to the the midclavicular linemidclavicular line:: It is supplied by the anterior cutaneous branchesanterior cutaneous branches

of the second to 6of the second to 6thth intercostal nervesintercostal nerves

Each anterior cutaneous nerveEach anterior cutaneous nerve divides into a smaller mediala smaller medial and larger lateral brancheslarger lateral branches to supply the skinthe skin from the midlinethe midline to the midclavicular line.the midclavicular line.

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Cutaneous nerve supply of the pectoral regionCutaneous nerve supply of the pectoral region

2- The area2- The area laterallateral to to the midclavicular line:

is supplied by the lateral cutaneous branchesthe lateral cutaneous branches of of

the the third to 9th intercostal nervesthird to 9th intercostal nerves

divides into 2 branches:A- An anterior branchA- An anterior branch:: suppleis the skinthe skin from

the midclavicular line to the midaxillary line

Each lateral cutaneous nerveEach lateral cutaneous nerve

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B- B- A posterior branchA posterior branch::

suppleissuppleis the skinthe skin fromfrom

the the midaxillary linemidaxillary line toto

the the lateral border oflateral border of

Cutaneous nerve supply of the pectoral regionCutaneous nerve supply of the pectoral region

the the erector spinae muscleerector spinae muscle

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Muscles of theMuscles of the pectoral regionpectoral region

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Bones of the pectoral regionBones of the pectoral region

ClavicleClavicle

ScapulaScapula

HumerusHumerus

SternumSternum

Upper ribs andUpper ribs and their costal cartilagetheir costal cartilage

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Bones of the pectoral regionBones of the pectoral regionCoracoid process of the scapulaCoracoid process of the scapula

TipTip

Medial borderMedial border

Upper surfaceUpper surface

ofof

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Bones of the pectoral regionBones of the pectoral regionHumerusHumerus

Intertubercular orIntertubercular orBicipital grooveBicipital groove

Lateral lipLateral lip

Medial lipMedial lip

FloorFloor

It hasIt has

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Dr. BahgatDr. Bahgat

Pectoralis major (6)Pectoralis major (6)1- Sternocostal head:1- Sternocostal head:

From half of the breadth of theFrom half of the breadth of theanterior surface of anterior surface of the sternumthe sternum

And upperAnd upper 6 6 costal cartilages costal cartilages

2- Clavicular head:2- Clavicular head:From the medial half of the From the medial half of the

anterior aspect of the clavicle.anterior aspect of the clavicle.

Pectoralis minor (3)Pectoralis minor (3)from the from the 3d , 4th and 53d , 4th and 5thth ribs ribs (3)(3)near their near their costochondral junctionscostochondral junctions

OriginOrigin of theof the pectoral musclespectoral muscles

Subclavius (1)Subclavius (1)from the from the firstfirst costochondral junction costochondral junction (1)(1)

(6, 3, 1)(6, 3, 1)

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Pectoralis major (largest)Pectoralis major (largest)

Pectoralis minor (medium)Pectoralis minor (medium)

InsertionInsertion of theof the pectoral musclespectoral muscles

Subclavius (Smallest)Subclavius (Smallest)

into the medial border & upper surface of the coracoid process of the scapula

into the Subclavius groove.on the lower surface of

the intermediate third of the clavicle

According to sizeAccording to size

into the lateral lipof the Bicipital groove of

the humerus

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The nerve supply of the pectoral muscleThe nerve supply of the pectoral muscle

According to theAccording to the name of the musclename of the muscle

Medial and lateralMedial and lateral pectoral nervespectoral nerves

The pectoralis majorThe pectoralis majorAnd minor musclesAnd minor muscles

Subclavius muscleSubclavius muscle

Nerve to subclaviusNerve to subclavius from thefrom the upper trunk upper trunk of theof the brachial plexus brachial plexus

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The pectoralis major musclesThe pectoralis major muscles

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OriginOrigin

Insertion Insertion

The pectoralis major muscleThe pectoralis major muscle

1- Sternocostal head:1- Sternocostal head:From half of the breadth of theFrom half of the breadth of theanterior surface of anterior surface of the sternumthe sternum

And upper 6 costal cartilagesAnd upper 6 costal cartilages

2- Clavicular head:2- Clavicular head:From the medial half of the From the medial half of the

anterior aspect of the clavicle.anterior aspect of the clavicle.

into the lateral lip of the bicipital groove of the humerus

Nerve supply:Nerve supply: Medial and lateral pectoral nervesMedial and lateral pectoral nerves

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The pectoralis major muscleThe pectoralis major muscle

Action:Action:

medial rotation of the arm with latissimus dorsi and teres major muscles.

2- Approximation of the trunk to the abducted arm as in

climbing a tree, swimming and playing gymnastics.

3 -Flexion of the arm

4 -Helps in deep & forced inspiration.

Shoulder jointShoulder joint

1- Adduction and

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The pectoralis major muscleThe pectoralis major muscle

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I- Pectoralis major muscle I- Pectoralis major muscle Origin:Origin:

1- Sternocostal head:1- Sternocostal head: From half of the breadth of the

anterior surface of the sternum.And upper 6 costal cartilages.2- Clavicular head:2- Clavicular head: From the medial half of the anterior

aspect of the clavicle.Insertion:Insertion: into the lateral lip of the bicipital

groove of the humerus Nerve supply:Nerve supply:

Medial and lateral pectoral nerves.

Action:Action:1- Adduction and medial rotation of the arm (shoulder) with latissimus dorsi and teres major muscles.

2- Approximation of the trunk to the abducted arm as in climbing a tree, swimming and playing gymnastics.

3- Flexion of the arm.

4- Helps in forced inspiration.

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The pectoralis minor muscleThe pectoralis minor muscle

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OriginOrigin

Insertion Insertion

The pectoralis minor muscleThe pectoralis minor muscle

Nerve supply:Nerve supply: Medial and lateral pectoral nervesMedial and lateral pectoral nerves

from the from the 3d , 4th and 53d , 4th and 5thth ribsribs

near their near their costochondral junctionscostochondral junctions

into the medial border & upper surface of the coracoid process of the scapula

Action:Action:1-1- Pulls the scapula forwardsPulls the scapula forwards (protraction of the shoulderprotraction of the shoulder) with the Serratus anterior muscle.

2- Pull the scapula downwards2- Pull the scapula downwards (depression of the shoulder)(depression of the shoulder)

with the lower fibers of the trapezius muscle.

3-3- Medial (downward) rotationMedial (downward) rotation of the of the scapula:scapula: with the levator scapulae muscle44 - -Helps in deep & forced inspirationHelps in deep & forced inspiration

scapulascapula

RibsRibs

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The pectoralis minor muscleThe pectoralis minor muscle

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II- Pectoralis minor muscle II- Pectoralis minor muscle Origin:Origin:

from the from the 3d, 43d, 4th th and 5and 5thth ribs ribs near their near their costochondral costochondral

junctionsjunctions

Insertion:Insertion:

into the medial border & upper surface of

the coracoid process of the scapula

Nerve supply: Nerve supply: Medial and lateral pectoral Medial and lateral pectoral

nerves.nerves.

Action:Action:1-1- Pulls the scapula forwardsPulls the scapula forwards (protraction of the shoulderprotraction of the shoulder) with the Serratus anterior muscle.2- Pull the scapula downwards2- Pull the scapula downwards

(depression of the shoulder)(depression of the shoulder) with the lower fibers of the trapezius muscle.

3-3- Medial (downward) rotationMedial (downward) rotation of the of the scapula:scapula:

with the levator scapulae muscle.

4- 4- Helps in forced inspirationHelps in forced inspiration. .

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Dr. BahgatDr. Bahgat

The subclavius muscleThe subclavius muscle

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OriginOrigin

Insertion Insertion

The subclaviusThe subclavius musclemuscle

Nerve supplyNerve supply Nerve to subclavius from theNerve to subclavius from the upper trunk of the brachial plexusupper trunk of the brachial plexus

from the from the firstfirst costochondral junctioncostochondral junction

into the Subclavius groove. on the lower surface of

the intermediate third of the clavicle

Action:Action: 1- Fixation of the clavicle1- Fixation of the clavicle during movements of the shoulder.movements of the shoulder.

2- Helps in inspiration.2- Helps in inspiration.

ClavicleClavicle

RibRib

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III- Subclavius muscleIII- Subclavius muscle Origin:Origin:

from the from the firstfirst costochondral junction.costochondral junction.Insertion:Insertion: into the Subclavius groove. on the lower surface of the intermediate third of the clavicle Nerve supply:Nerve supply:

Nerve to subclavius.Nerve to subclavius.

Action:Action: 1- Fixation of the clavicle 1- Fixation of the clavicle during movements of the shoulder.movements of the shoulder. 2- Helps in inspiration. 2- Helps in inspiration.

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The The clavipectoral clavipectoral

fasciafascia

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Dr. BahgatDr. Bahgat

The clavipectoral fasciaThe clavipectoral fascia

It It is a strong sheet of

- ItIt lies between

the subclavius musclethe subclavius muscle and

pectoralis minor muscle pectoralis minor muscle

fibrous tissue.fibrous tissue.

The The clavipectoral fascia clavipectoral fascia (anterior view)(anterior view)

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The clavipectoral fasciaThe clavipectoral fascia - It It is a strong sheet of fibrous tissuefibrous tissue deep to the clavicular headclavicular head of the pectoralis major musclepectoralis major muscle. - ItIt lies between the subclaviusthe subclavius and pectoralis minor musclespectoralis minor muscles. - Its Its upper partupper part splits into 2 layers to enclose the subclavius musclethe subclavius muscle and attaches to the margin of the subclavius groovethe subclavius groove.

- Its Its lower partlower part splits to enclose the pectoralis minor musclethe pectoralis minor muscle and then extends from its its lower borderlower border to attach to the axillary fasciathe axillary fascia forming what is called the suspensory ligamentsuspensory ligament of the axillaof the axilla. - Its - Its medial partmedial part is attached to the 1the 1stst and 2 and 2ndnd costal costal

cartilagescartilages and its its lateral partlateral part is attached to the coracoid process.the coracoid process.

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The costocoracoid membraneThe costocoracoid membrane

is pierced by:

1- The cephalic vein.1- The cephalic vein.

2- The lymphatics2- The lymphatics along along the cephalic veinthe cephalic vein,,

3- The thoracoacromial artery.3- The thoracoacromial artery.

4- The lateral pectoral nerve.4- The lateral pectoral nerve.

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The clavipectoral fasciaThe clavipectoral fascia. - The clavipectoral fascia - The clavipectoral fascia is pierced by: 1- The cephalic vein.1- The cephalic vein. 2- The lymphatics2- The lymphatics along along the cephalic veinthe cephalic vein,, 3- The thoracoacromial artery.3- The thoracoacromial artery. 4- The lateral pectoral nerve.4- The lateral pectoral nerve.

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The female breastThe female breast

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The female breastThe female breastThe basic anatomybasic anatomy of the breastthe breast is of considerable clinical importanceconsiderable clinical importance

because of the frequent developmentfrequent development of cancer cancer in the glands glands and the subsequent migration of the malignant cellsmigration of the malignant cells along the lymph vesselsthe lymph vessels to

the lymph nodeslymph nodes in the armpitthe armpit.

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Dr. BahgatDr. Bahgat

The female breastThe female breastconsists of :

1- The mammary gland.1- The mammary gland.

2- The superficial fascia2- The superficial fascia )the stromathe stroma of the glandthe gland

3- The overlying skin.3- The overlying skin.and the surrounding fatthe surrounding fat.(

The female breastThe female breast

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Dr. bahgatDr. bahgat

* Shape and position:* Shape and position:- The breastThe breast is

conical in shape.

Its baseIts base is circular and has

a constant positiona constant position.

ItIt extends from the sternumthe sternum

to the midaxillary linethe midaxillary line at the level of the 4th ribthe 4th rib.

Vertically, it it extends from the 2nd ribthe 2nd rib to the 6th ribthe 6th rib

the midclavicular linethe midclavicular lineat the level of The female breastThe female breast

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Structure of the breastStructure of the breast ** The female breast The female breast consists of :1- The mammary gland.1- The mammary gland.2- The superficial fascia2- The superficial fascia (the stromathe stroma of the glandthe gland and the surrounding fatthe surrounding fat).3- The overlying skin.3- The overlying skin.

* Shape and position:* Shape and position:- The breastThe breast is conical in shape.- Its baseIts base is circular and has a constant positiona constant position.- ItIt extends from the sternumthe sternum to the midaxillary linethe midaxillary line at the level of the 4the 4thth rib rib.- Vertically, it it extends from the 2the 2ndnd rib rib to the 6the 6thth rib rib at the midclavicular linethe midclavicular line.

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Dr. BahgatDr. Bahgat

The nippleThe nipple of the breastthe breast

is a conical or cylindrical prominence prominence.

ItIt lies belowthe center of the breastcenter of the breast

opposite the

4th intercostal space4th intercostal space

1010 CmCm from

the midlinethe midline

The female breastThe female breast

11223344

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Structure of the breastStructure of the breast- A processA process of the glandthe gland extends from the upper lateral partupper lateral part along the lower border of the pectoralis major musclethe pectoralis major muscle. This processThis process is called the axillary tailthe axillary tail of the breastthe breast. The axillary tailThe axillary tail may pierce the axillary fasciathe axillary fascia and enter the axillathe axilla and becomes in close relation to the axillary vesselsthe axillary vessels.

The nippleThe nipple of the breastthe breast - It It is a conical or cylindrical prominence prominence. - ItIt lies below the center of the breastcenter of the breast opposite the 44thth intercostal space intercostal space 10 Cm10 Cm from the midlinethe midline. Its summitIts summit carries the openings openings of the lactiferous ductslactiferous ducts of the mammary glandmammary gland.

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Structure of the breastStructure of the breast - The nippleThe nipple contains many smooth myocytessmooth myocytes, whichwhich are arranged in 2 directions. Most myocytesMost myocytes are circularly arranged and their stimulationtheir stimulation (e.g. by suckling suckling) leads to erection of the nipplethe nipple. Other myocytesOther myocytes are longitudinally arranged and retract the nipplethe nipple.

The areolaThe areola: - The nippleThe nipple is surrounded by a circular patcha circular patch of pigmented skin

called the areolathe areola. The areolaThe areola contains many sebaceous glandssebaceous glands.

- The areolaThe areola undergoes the following changesfollowing changes with pregnancypregnancy:1- Its colorIts color becomes darkerdarker: This changeThis change is permanentpermanent and can be used as a diagnostic signa diagnostic sign of the first pregnancythe first pregnancy. After labourAfter labour, the colorthe color lightens but never returns to its original stateits original state. 2- The sebaceous glandsThe sebaceous glands enlarge and their secretionstheir secretions are useful for lubrication of the nipplethe nipple during lactationduring lactation. 3- Some small mammary glandsSome small mammary glands within the areolathe areola increase in size and appear as tuberclestubercles known as Montgomery’s tuberclesMontgomery’s tubercles. These tuberclesThese tubercles are considered as a sign ofa sign of pregnancy pregnancy.

- The nippleThe nipple and areola areola are devoid of fat.fat.

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Dr. BahgatDr. Bahgat

Relations of the base of the breastRelations of the base of the breast

The upper medial 2/3 The upper medial 2/3 Of the base of the breastthe breast

lie on

the pectoralis major musclethe pectoralis major muscle

ItsIts lower lateral 1/3lower lateral 1/3

lies on the serratus anterior musclethe serratus anterior muscle

and external oblique muscleexternal oblique muscle.

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Dr. BahgatDr. Bahgat

ClavicleClavicle

Upper 7 ribsUpper 7 ribsIntercostal musclesIntercostal muscles

Pectoralis majorPectoralis major

Pectoralis minor Pectoralis minor

Subclavius Subclavius

deep fasciadeep fascia of the pectoral regionthe pectoral region

breastbreastSkin of the breastSkin of the breastNipple and areolaNipple and areola

deep membranous layerdeep membranous layer of superficial fasciasuperficial fascia

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Dr. BahgatDr. Bahgat

is separated from

The pectoral muscles byThe pectoral muscles by

by a layer ofa layer of loose connective tissueloose connective tissue

called

the submammarythe submammary or

retromammary spaceretromammary space

This spaceThis space lies between

deep membranous layerdeep membranous layer of superficial fasciasuperficial fascia

and

deep fasciadeep fascia of the pectoral regionthe pectoral region

The breastThe breast

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Relations of the breastRelations of the breastRelations:Relations: - The upper medial 2/3 The upper medial 2/3 of the breastthe breast lie on the pectoralis major musclethe pectoralis major muscle. ItsIts lower lateral 1/3 lower lateral 1/3 lies on the serratus anterior musclethe serratus anterior muscle and external oblique muscleexternal oblique muscle.

The breastThe breast is separated from these musclesthese muscles by a layer of a layer of loose connective tissueloose connective tissue called the submammarythe submammary or retromammary space. retromammary space. This spaceThis space lies between the deep membranous layerdeep membranous layer of superficial fasciasuperficial fascia and deep fasciadeep fascia of the pectoral regionthe pectoral region. The retromammary spaceThe retromammary space is relatively avascular but traversed by lymph vesselslymph vessels and some blood vesselssome blood vessels.

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Relations of the breastRelations of the breastThe retromammary space The retromammary space is important important because: 1- ItIt may be the site of an abscessan abscess. 2- The breast prosthesesThe breast prostheses are usually inserted into this spacethis space. 3- ItIt permits free movements of the breastthe breast over the musclesthe muscles.

4- ItIt is the spacethe space (line of cleavageline of cleavage) where the breastthe breast is separated from the underlying musclesthe underlying muscles during simple mastectomysimple mastectomy. 5- ItIt is the site of the deep lymphatic plexus deep lymphatic plexus of the breastthe breast.

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Structure of the mammary glandStructure of the mammary gland- The glandThe gland is a modified sweat glanda modified sweat gland. - It It consists of parenchymaparenchyma and stromastroma.- The parenchymaThe parenchyma consists of 15 – 20 lobes. 15 – 20 lobes. Each lobeEach lobe consists of several lobulesseveral lobules.

- Each lobuleEach lobule has a ductulea ductule. The ductulesThe ductules within each lobeeach lobe

unite with each othereach other to form a single duct a single duct for the lobethe lobe. This ductThis duct is called the lactiferous ductthe lactiferous duct. - The lactiferous ducts The lactiferous ducts (15 - 20)(15 - 20) converge towards the nipplethe nipple. Each ductEach duct dilates under the areolathe areola to form lactiferous sinuslactiferous sinus which narrows again and open separately on the summit of the nipplesummit of the nipple.

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Dr. BahgatDr. Bahgat

Arterial supply of the breastArterial supply of the breast

The breastThe breast is supplied by1- Perforating branches1- Perforating branches of

the internal mammary arterythe internal mammary artery

in the 2nd, 3d and 4th intercostal spacesthe 2nd, 3d and 4th intercostal spaces

)main arterial supplymain arterial supply.(

22 - -Mammary branchesMammary branches of

the lateral thoracic arterythe lateral thoracic artery

and pectoral branchpectoral branch of

the thoraco-acromial arterythe thoraco-acromial artery

3- Perforating branches3- Perforating branches from

the 2nd, 3d and 4th posterior intercostal arteriesthe 2nd, 3d and 4th posterior intercostal arteries..

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Blood supply of the breastBlood supply of the breast I- Arterial supply of the breast :I- Arterial supply of the breast :The breastThe breast is supplied by the following arteriesthe following arteries: 1- Perforating branches1- Perforating branches of the internal mammary artery the internal mammary artery in the 2the 2ndnd, 3d and 4, 3d and 4thth intercostal spaces intercostal spaces (main arterial supplymain arterial supply). 2- Mammary branches2- Mammary branches of the lateral thoracic arterythe lateral thoracic artery and pectoral branchpectoral branch of the thoraco-acromial arterythe thoraco-acromial artery (branchbranch from the 2the 2ndnd part part of the axillary arterythe axillary artery). 3- Perforating branches3- Perforating branches from the 2the 2ndnd, 3d and 4, 3d and 4thth posterior intercostal arteries. posterior intercostal arteries.

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Dr. BahgatDr. Bahgat

The breastThe breast

adjacent veinsadjacent veins

1- The internal mammary vein1- The internal mammary vein

22 - -Axillary veinAxillary veinthroughthrough

the lateral thoracic veinthe lateral thoracic vein

33 - -The posterior intercostal veinsThe posterior intercostal veins

The venous blood of the

Venous drainage of the breastVenous drainage of the breast

Is drained into

This is the mainmain venous drainagevenous drainage

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the intercostal nervesintercostal nerves

Nerve supply of the breastNerve supply of the breast

The breastThe breastis supplied by

the anterior cutaneous branchesanterior cutaneous branches and

the laterallateral cutaneous branchescutaneous branches ofthe 4th, 5th and 6th 4th, 5th and 6th intercostal nervesintercostal nerves

445566

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Nerve supply of the breastNerve supply of the breastThe breastThe breast is supplied by the anterior and lateralanterior and lateral cutaneous branchescutaneous branches of the 44thth, 5, 5thth and 6 and 6thth intercostal nervesintercostal nerves.

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Lymphatic drainage of breast

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Dr. BahgatDr. Bahgat

TheThe lymphaticslymphatics from the breastthe breast

radiate into many directions

1 -The central and lateralThe central and lateral partsparts of the glandthe gland

drain intothe anterior (pectoral) groupthe anterior (pectoral) group

of axillary lymph nodesof axillary lymph nodes..

2 -The tail of the breastThe tail of the breast

the subscapular groupthe subscapular group

3 -The upper partThe upper part of the glandthe gland

drains into

the apical group of axillary lymph nodesthe apical group of axillary lymph nodes and lower deep cervical lymph nodeslower deep cervical lymph nodes

drain into

4 -The medial partThe medial part of the glandthe gland the parasternal lymph nodesthe parasternal lymph nodesdrains into

Lymphatic drainage of the breastLymphatic drainage of the breast

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Dr. BahgatDr. Bahgat

5 -The lymphaticslymphatics from the skinthe skin of

the medial partthe medial part of the breastthe breast

cross the midline and

anastomose with

the lymphaticsthe lymphatics of

the other breastthe other breast

Lymphatic drainage of the breastLymphatic drainage of the breast

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Dr. BahgatDr. Bahgat

6- The lymphaticslymphatics from the skinthe skin of

the infero-medial partthe infero-medial part of the breastthe breast

anastomose with the lymphaticsthe lymphatics of

the anterior wall of the rectus sheaththe anterior wall of the rectus sheath

Lymphatic drainage of the breastLymphatic drainage of the breast

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Lymphatic drainage of the breastLymphatic drainage of the breast

7- The lymphaticslymphatics from

anastomose with

the subdiaphragmatic plexussubdiaphragmatic plexus

the inferomedial partthe inferomedial part of the glandthe gland

and then through the diaphragmthe diaphragm

to the medistinal lymph nodesthe medistinal lymph nodes

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Lymphatic drainage of the breastLymphatic drainage of the breast - Through the lymphaticsthe lymphatics, cancer breastcancer breast may spread to: 1- The axillary lymph nodesThe axillary lymph nodes. 2- The other breastThe other breast and parasternal lymph nodesparasternal lymph nodes. 3- TheThe lower deep cervical lymph nodeslower deep cervical lymph nodes. 4- The rectus sheathThe rectus sheath and then to the liverthe liver through the the

falciform ligamentfalciform ligament. 5- The subdiaphragmatic plexusThe subdiaphragmatic plexus and then through the the

diaphragmdiaphragm to the mediastinal lymph nodesthe mediastinal lymph nodes.

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