Risk Management Considerations of Treating Patients With Altered or Painful Breast Structures Instructor: Dr. Paul Evans Outline and CV Hour 1 of 7: Anatomy of the Breast and Anterior Thoracic Cage Course Summary: This a seven-hour course that is designed to teach the anatomy and physiology of the breasts and anterior thoracic structures while focusing on the risks associated with the prone position. Dr. Paul Evans delves into the many abnormalities, conditions, dangers, and precautions that should be taken concerning treating patients or clients in the prone position. This course also describes the common dysfunctions, surgical procedures and alterations that are done to the breasts along with the risks associated with them. This course teaches crucial information that should be understood before treating patients with altered breast structures, especially in the prone position. Learning Objective: On completion of this course each participant will have a thorough understanding of the common dysfunctions, surgical procedures and alterations of the breasts. It is designed to give a comprehensive understanding of the appropriate clinical treatment considerations of individuals with painful or altered breast structures. Risk Management exposure of practitioners, particularly with regard to patients treated in a prone position is reduced and the overall care and comfort of patients is enhanced. Outline: I. Breast Anatomy and Physiology: A. Breasts are comprised of mammary glands, ducts and fat surrounded by connective tissue. Connected to the anterior thoracic cage by suspensory ligaments of Cooper. These fibro- collagenous septa help maintain structural integrity and are often referred to as “nature’s bra”. B. Breast tissue is anterior to the Pectoralis major chest muscle. The composition of the breast tissues and the thoracic cage shape predominantly determine the breast shape, size and position. C. The ducts converge on the nipple composed of the areola (NAC) and sebaceous glands. Breasts begin developing between the ages of 9 and 14, associated with the start of puberty. D. Breast tissue is highly sensitive to the hormones estrogen and progesterone throughout the menstrual cycle and influence breast size and sensitivity to loading. Prolactin triggers milk production within the breast. E. Breasts are not fixed rigid structures, the loose connective tissue and deep fascia of the retro-mammary space allows for movement of the breast in a natural loose motion. With aging and time, connective tissue integrity decreases eventually resulting in breast ptosis. F. Four Quadrants of the Breast: 1. Upper outer (superolateral) 2. Upper inner (superomedial) 3. Lower outer (inferolateral) 4. Lower inner (inferomedial) G. Each breast lays lateral to the sternum composed of the Manubrium, body and xiphoid. Ribs 2-6 are generally posterior to the breast. The manubrium is the superior aspect and attaches to the body at the sternal angle / angle of Louis (manubriosternal junction). It is a secondary cartilaginous joint and is generally the most anterior point of the sternum at the T4 level. H. Deformity of anterior projection of the sternum is known as ‘pigeon chest’. The xiphoid is a cartilaginous process that ossifies in adulthood where it fuses to the body in a fibrous joint. I. Postpartum the xiphoid can protrude anteriorly of the body and is known as xiphodynia. Pain and sensitivity to touch and loading result. It is susceptible to fracture and can break away from the body, generally from a trauma. Laceration to the diaphragm or liver puncture may result. J. Ribs 1-7 attach directly to the sternum via the costal cartilages in sternocostal articulations which are cartilaginous joints and have generally no movement. (#1 is synarthrodial) K. Ribs 8-10 attach via their costal cartilages to each other and ultimately to rib 7. Costal cartilage articulations between Ribs 6-9 are synovial joints whilst ribs 9-10 are fibrous. L. Ribs 11-12 are floating and have no articulations. Costochondral articulations attach the sternal ends of the ribs to their costal cartilages and are hyaline cartilaginous joints. M. The blood supply to the breast skin is from the sub-dermal plexus. Communicating vessels supplying the breast parenchyma is derived from The internal mammary perforators (most notably the second to fifth perforators) The thoracoacromial artery The vessels to serratus anterior The lateral thoracic artery The terminal branches of the third to eighth intercostal perforators The supero medial perforator (from internal mammary perforators) supplies approximately 60% of breast blood supply. N. Sensory innervation of the breast is dermatomal, mainly derived from the anterolateral and antero-medial branches of thoracic intercostal nerves T1-T5. Supraclavicular nerves from the lower fibers of the cervical plexus also provide innervation to the upper and lateral portions of the breast. Nipple sensation is derived predominantly from the lateral cutaneous branch of T4. O. Lymph glands are important in cancer care because any cancer cells that have migrated from the tumor can be carried by the lymphatic fluid to the nearest lymph glands. In patients with damaged prosthetic devices migrating material can also be found in the nodes P. Lymphatic nodes are found near the breast, in the axilla, and posterior to the sternum with typical metastatic spread to the supero-lateral axillary lymph nodes. More than 75% of breast drainage via axillary lymph nodes with the remainder medially to the parasternal nodes. II. Current US Breast Statistics: 2012 US (Mexico) breast augmentation and reconstructions were approx. 500,000 Breast cancer diagnosis was 234,450 in the US with 40,350 deaths 50% of female patients between 20-45 have fibrocystic changes to their breasts with pain, tenderness and lumps. III. Patient Management- Competent Risk Management: A. Practitioners have a responsibility to manage patients with conditions of the breast and this course will educate you into what are the risks and why, what precautions you made and documentation of these corrections to protect yourself. B. HISTORY You have a patient who you did not capture the history of altered of painful breast structures. C. UNDERSTANDING Failure to demonstrate an understanding of the ramifications of the functional implications of the patients breast D. DOCUMENTATION You failed to document the fact that you realized their was a risk and that you modified and adapted your treatment. ie. Patient return with a silent rupture implant failure and blames you and you haven’t documented that you altered the patients management. Hour 2 of 7: Breast Pain, Disease and Dysfunction Course Summary: This a seven-hour course that is designed to teach the anatomy and physiology of the breasts and anterior thoracic structures while focusing on the risks associated with the prone position. Dr. Paul Evans delves into the many abnormalities, conditions, dangers, and precautions that should be taken concerning treating patients or clients in the prone position. This course also describes the common dysfunctions, surgical procedures and alterations that are done to the breasts along with the risks associated with them. This course teaches crucial information that should be understood before treating patients with altered breast structures, especially in the prone position. Learning Objective: On completion of this course each participant will have a thorough understanding of the common dysfunctions, surgical procedures and alterations of the breasts. It is designed to give a comprehensive understanding of the appropriate clinical treatment considerations of individuals with painful or altered breast structures. Risk Management exposure of practitioners, particularly with regard to patients treated in a prone position is reduced and the overall care and comfort of patients is enhanced. Outline: I. Breast Abnormalities: A. Most breast lumps in women age 20 to 50 are not cancerous and generally identified by observation and palpation of the breast. Benign changes in breast tissue can affect women (and men) of any age and are generally caused by fibrosis scar-like (fibrous) tissue and / or fluid-filled cysts. B. Fibrosis primarily is composed of the same material as ligaments and scar tissue are rubbery, firm, or hard to the touch. Fibrosis generally do not need any special treatment. Fibroadenomas are generally not removed. These benign tumors enlarge with pregnancy and breast-feeding. C. There is a type of fibroadenoma that has been associated with an increased risk of cancer, particularly in those women with a family history of the disease Cysts are movable lumps that are generally tender which build up inside the breast. Round or oval shaped fluid sacs, are generally larger and more painful pre-menstrual. Diagnosis is confirmed by mammography or ultrasound and fine-needle aspiration. They are generally aspirated. D. Lipomas are benign fatty tumors that can appear almost anywhere in the body, including the breast. They are usually not tender. Other benign lumps or tumors include, hemangiomas , hematomas, adenomyoeptheliomas, and neurofibromas. E. Sclerosing adenosis is excessive growth in the breast's lobules, often resulting in breast pain. Being microscopic and seen on mammograms as calcifications and can result in lumps. Biopsy distinguishes this condition from cancer. These lumps are usually removed through surgical biopsy. F. Fat necrosis is generally painless, presenting as round, firm lumps caused by damaged