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The Surgical Anatomy of the Mammary Gland. Vascularisation, Innervation, Lymphatic Drainage, the Structure of the Axillary Fossa (Part 2.)

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The Surgical Anatomy of the Mammary Gland. Vascularisation, Innervation, Lymphatic Drainage, the Structure of the Axillary Fossa (Part 2.) NOWOTWORY Journal of Oncology 2021, volume 71, number 1, 62–69 DOI: 10.5603/NJO.2021.0011 © Polskie Towarzystwo Onkologiczne ISSN 0029–540X Varia www.nowotwory.edu.pl The surgical anatomy of the mammary gland. Vascularisation, innervation, lymphatic drainage, the structure of the axillary fossa (part 2.) Sławomir Cieśla1, Mateusz Wichtowski1, 2, Róża Poźniak-Balicka3, 4, Dawid Murawa1, 2 1Department of General and Oncological Surgery, K. Marcinkowski University Hospital, Zielona Gora, Poland 2Department of Surgery and Oncology, Collegium Medicum, University of Zielona Gora, Poland 3Department of Radiotherapy, K. Marcinkowski University Hospital, Zielona Gora, Poland 4Department of Urology and Oncological Urology, Collegium Medicum, University of Zielona Gora, Poland Dynamically developing oncoplasty, i.e. the application of plastic surgery methods in oncological breast surgeries, requires excellent knowledge of mammary gland anatomy. This article presents the details of arterial blood supply and venous blood outflow as well as breast innervation with a special focus on the nipple-areolar complex, and the lymphatic system with lymphatic outflow routes. Additionally, it provides an extensive description of the axillary fossa anatomy. Key words: anatomy of the mammary gland The large-scale introduction of oncoplasty to everyday on- axillary artery subclavian artery cological surgery practice of partial mammary gland resec- internal thoracic artery thoracic-acromial artery tions, partial or total breast reconstructions with the use of branches to the mammary gland the patient’s own tissue as well as an artificial material such as implants has significantly changed the paradigm of surgi- cal procedures. A thorough knowledge of mammary gland lateral thoracic artery superficial anatomy has taken on a new meaning. Correct arterial blood venous plexus supply to tissues is a key element in plastic surgery and breast branches to intercostal arterioles reconstruction surgery. Vascularisation of the mammary gland Figure 1. Arterial and venous vessels of the mammary gland Arterial vessels intercostal arteries (aa. intercostales) and little vessels supplying The vascularisation of breasts is characterised by rather signi- blood to the serratus anterior [1, 2]. ficant individual diversity. Its relatively stable elements are the The internal thoracic artery (arteria mammaria interna) internal thoracic artery (arteria mammaria interna) running is a branch of the subclavian artery (arteria subclavia) which through the system of perforators, the lateral thoracic artery goes off it near the scalenus posterior (musculus scalenus) and (arteria thoracica lateralis), the thoracoacromial artery (arteria enters the chest passing the subclavian vein (vena subclavia). thoracoacromialis), end branches of the perforators of 3th–8th Within the chest, it crosses with the phrenic nerve (nervus How to cite: Cieśla S, Wichtowski M, Poźniak-Balicka R, Murawa D. The surgical anatomy of the mammary gland. Vascularisation, innervation, lymphatic drainage, the structure of the axillary fossa (part 2.). NOWOTWORY J Oncol 2021; 71: 62–69. 62 phrenicus) and continues its route on the internal surface of • the lateral thoracic artery (arateria thoracica lateralis), the front wall along the attachments of ribs to the sternum, and the following arteries branch off from the lower section: 1–2 cm laterally to its edge, between the endothoracic fascia • the subscapular artery (arteria subscapularis), (fascia endothoracica) and the parietal lamina of the pleura. • the anterior circumflex humeral vein arteria( circumflexa In each intercostal space, it divides itself into two branches: humeri anterior), 1. the anterior cutaneous branch (ramus cutaneus ventralis), • the posterior circumflex humeral vein (arteria circumflexa 2. the intercostal branch (ramus intercostalis) which connects humeri posterior). directly to the appropriate intercostal artery (arteria inter- The thoracoacromial artery (arteria thoracoacromialis) costalis) through a direct branch of the aorta. is a short stem going off on the anterior surface of the axillary The arterial blood supply of the mammary gland is primari- artery over the upper edge of the smaller pectoral muscle. After ly ensured by medial thoracic branches (rr. mammari mediales) crossing through the coracoclavicular fascia, it divides itself supplying medial and lower lateral quadrants. At the level of into four branches: thoracic, coracoid, clavian and branchial. the 6th intercostal space, the internal thoracic artery is divided The thoracic branch forms numerous connections with the in- into two end branches: the musculophrenic artery and the ternal thoracic artery, the lateral thoracic artery and intercostal superior epigastric artery. arteries. In this way, it participates in supplying blood to the The musculophrenic artery (arteria musculophrenica) is mammary gland, primarily the tail of Spence [7–9]. the final lateral branch of the internal thoracic artery with little The lateral thoracic artery (areteria thoracica lateralis) branches going off to the th,7 8th and 9th intercostal spaces. goes off below the edge of the smaller pectoral muscle, runs Eventually, it divides itself and ends at the diaphragm and downward and medially crossing with the ulnar nerve (nervus muscles of the lateral part of the abdomen [3, 4]. ulnaris) and the axillary vein (vena axillaris) at the front. Then, The superior epigastric artery (arteria epigastrica supe- on the serratus anterior, it divides itself into 2th–5th intercostal rior) is the final medial branch of the internal thoracic artery spaces. Here, it gives off its lateral thoracic branches (rami and its prolongation towards the rectus abdominis. Along its mammari laterales), which cross through the greater pectoral route, it branches off to muscles, the skin and the diaphragm. muscle to supply blood to the mammary gland and the skin Its anonymous branches at the level of the xiphoid process near it and then connect with the thoracic branches going off of the sternum connect to the branches of the opposite (as piercing branches) from the internal thoracic artery, which side. The anonymous branches going off the right superior is the main breast-supplying artery [1, 3, 8]. epigastric artery enter the falciform ligament of the liver and Numerous connections of arterial vessels supplying blood connect to the branches of the common hepatic artery. The to glandular tissue and covering the skin make three plexu- superior epigastric artery within the rectus abdominis, at the ses, which are the most important elements of arterial blood level of the navel, connects to the inferior epigastric artery, supply: a branch of the external iliac artery. The superior epigastric 1. The subdermal plexus (plexus subdermalis) – very exten- artery is the main artery supplying blood to the cutaneous- ded, formed by numerous anastomoses between the bran- -adipose flap of the hypogastrium used in TRAM flap breast ches of the thoracobrachial artery and the neighbouring reconstruction surgery. arteries: subclavian, subscapular and anterior branches The inferior epigastric artery (arteria epigastrica in- of the perforators which come from the internal thoracic ferior) is a branch of the external iliac artery. It is used in artery [10, 11]. breast reconstruction employing a DIEP flap with a vascular 2. The preglandular plexus (plexus preglandularis) – sup- microfusion with the internal thoracic artery at the level of plied by anterior and glandular branches of the lateral the 3rd rib [5, 6]. thoracic artery, the third perforator of the internal thoracic The axillary artery branches (arateria axillaris) supply artery and other anterior thoracic perforators. Two major the bones and muscles of the upper limb, pectoral muscles, arteries, lateral and medial, form connections that circu- the serratus anterior and the latissimus dorsi muscles, the mvent the areola. Additionally, the preglandular plexus shoulder joint and the mammary gland. The arteries forming has numerous connections to the subcutaneous plexus. the arterial network of the chest branch off from the axillary Together, they form an extensive network of arterial vessels artery. These branches arise at different locations and because covering the anterior surface of the gland and branching of their significant variety, they are hard to find during surgery. off, in large numbers, inside the gland, perpendicularly The following arteries branch off from the upper section to the breast surface. These arterial branches penetrate of the axillary artery: the glandular tissue along the connective tissue septa • the superior thoracic artery (the highest) (arteria thoracica surrounding lobules, lactiferous follicles and exosecreting superioris), ducts [10, 12]. the following arteries branch off from the middle section: 3. The retroglandular plexus (plexus retroglandularis) – • the thoracoacromial artery (arteria thoracoacro mialis), made by deep muscular perforators which are branches 63 chest fascia • superficial, which begins below the areola (Haller’s plexus) and drains the blood to the internal thoracic vein and subcutaneous vascular plexus superficial veins of the lower part of the neck, pre-glandular vascular plexus • deep, located at a greater depth under the superficial fascia, which transports blood to the internal thoracic extra-glandular vascular plexus vein, posterior intercostal veins and directly to the axillary vein [13, 15]. transverse fascia of the mammary gland
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