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1 Cosmetic Surgery oftheBreast: “Art, Science & Safety”
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9
account her medical history and comorbid conditions
may indicate that this patient is a candidate for a
Mastopexy with simultaneous breast augmentation.
Additionally, in 2017 Gupta showed in a review of 73,608
cases that these type of patients have a signicant increase
in risk of postop complications following combined procedures due to her risk factors. Presenting this patient
with a staged approach doing a Mastopexy rst and then
a possible breast augmentation at a later date may be safer
for the patient.
1.5 Treatment
Treat the patient as a whole rst and then treat the condition.
The cosmetic surgeon must account for multiple factors
when determining the best treatment option for the patient.
Only when the individual patient history and comorbid conditions, if any, are considered and addressed, should surgical
interventions be carried out. Cosmetic surgery of the breast
involves a complex algorithm and preoperative surgical planning is essential for consistent outcomes. (Table1.7).
Training, education, and years of clinical experience are
the mainstay recipe for surgical success in treating the breasts
in the cosmetic surgical patient. Cosmetic breast surgery has
evolved over the past several years due to patient awareness
through social media, increased demand, societal inuences,
and new technology. An example of these new technologies
can be seen in the energy devices that focus on skin and subcutaneous connective tissue contraction. Based on the degree
of ptosis, availability of the new technology, the patient’s
desires and the surgeon’s clinical experience, the use of heat
and energy can be incorporated into the armamentarium
Table 1.7 Breast anomalies are handled on an individual basis and in
general require a combination of the above-mentioned approaches
Breast
problem
Breast
hypoplasia
Breast
hyperplasia
Degree
of ptosis Implant placement
O Total submuscular or subpectoral
I Subpectoral or dual plane, ±
superior pole heating technology
II Subpectoral or dual plane ±
crescent lift, ± superior pole
heating technology
III Total submuscular with vertical
mastopexy via superior or
superomedial pedicle.
I–II Liposuction alone or in
combination with heating
technology
III Superomedial pedicle or inferior
central pedicle wise pattern
keyhole reduction based on the
distance between NAC and
inframammary fold.
NAC
elevation
1–2cm
2–3cm
>4cm
when treating breast ptosis and thus, limiting or completely
eliminating scars when lifting the breast. Depending on the
degree of ptosis or deformity, the use of these technologies
can be combined with breast enhancement procedures such
as fat grafting or implant placement to shape, modify, and lift
the breast into a more youthful position (Fig.1.6).
There are two specic technologies currently worth men-
tioning for skin tightening.
1. Known as radiofrequency assisted lipolysis (RFAL by
InMode-BodyTite), this product provides a threedimensional contraction to the dermis, sub-dermal connective tissue matrix and deep fat. This technology has
become quite popular over the last 5years.
2. Newer to the arena is a product by Apyx Medical that
provides deep dermal and deep connective tissue contraction by the use of heat generated by combining helium
plasma with a proprietary form of radio frequency to
deliver cold energy (Renuvion).
Both of these technologies are continually gaining ground
in the minimally invasive surgical space for skin and underlying connective tissue lifting and tightening.
No matter which approach the surgeon uses, he or she
must be comfortable and condent in their choice. As a general rule it is wise to have multiple plans going into a cosmetic breast surgery and it is recommended that younger,
less experienced surgeons begin with the most conservative
approach when addressing the cosmetic breast patient. That
said, as experience is gained, the surgeon will become more
comfortable with more complex cases and will develop an
algorithm that is reliable and predictable.
With over 20 years of experience and over 5000 breast
surgeries performed, I have developed my preferred approach
to the esthetic breast patient that provides me with the tools
to achieve consistent results. In my mind, preventing complications and revision surgeries along with a happy patient are
indeed true signs of success. With that said, I implement the
following as much as possible.
• Always have a thorough informed consent signed by the
patient at the time of initial consultation.
• During the initial consultation, create realistic expecta-
tions by under promising and over producing.
• During the initial consultation, have patients try on
implants and make the nal implant size decision. If she
changes her mind, have her come back in to resize so that
you can guide her in the process.
• When going to surgery, always have a plan “B.”
• Use implant sizers whenever necessary.
• Always be concerned of blood supply to the NAC by
choosing appropriate pedicle based on anatomy and the
planned surgery.
10
Before 10 weeks 5 months
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M. S. Kluska
Breast Aumentation with Left Upper Pole Body Tite
Fig. 1.6 Patients before and after using energy-based heating devices for controlling breast ptosis
• When using implants, always cover the implant with as
much muscle as possible.
• Limit touch to the implant as much as possible.
• Maintain the patient’s IMF as much as possible and adjust
surgery and implant size around it.
• Use implants to aid in repositioning the breast to create
shape whenever possible.
• Always try to prevent capsular contracture by:
(a) Ensuring meticulous hemostasis when placing an
implant.
(b) Always irrigating the implant pocket and surgical
(d) Using a “no touch” technique as much as possible
when placing the implant, i.e., introduce the implant
using a sleeve.
• Always limit the lateral dissection of the implant pocket
until the sizer is in place. Using blunt nger dissection at
this point will help ensure that the pocket will be adequate
and will help prevent long-term lateralization of the
implant.
• Never perform complicated elective breast surgery on a
smoke.
• Trust your technique once you have mastered it (Fig.1.7).
eld with antibiotic solution.
(c) Never packing the breast implant pockets with
sponges unless absolutely necessary.
cd
1 Cosmetic Surgery oftheBreast: “Art, Science & Safety”
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11
a
b
Fig. 1.7
Example of simultaneous mastopexy/augmentation. Intraoperative views showing high prole silicone gel implants (a) being used in a
total submuscular pocket (b) to maintain superior pole fullness. Preop (c, d) and 2-month postop (e, f) photos
12
ef
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M. S. Kluska
Fig. 1.7 (continued)
1.6 Complications
No matter how simple or complex the chosen breast surgery
may be, complications will inevitably arise (Table 1.8). I
always tell my fellows,
You are only as good as your ability to handle your surgical
complications.
Most of the time, surgical complications are a result of
poor preoperative planning, lack of attention to detail intraoperatively, or the surgeon’s inability to manage the patient’s
initial expectations. Creating realistic expectations is essential for both the patient and the surgeon and doing so will
limit any unforeseen medicolegal issues as well.
Understanding and identifying risk factors associated with
Table 1.8 Common complications and their incidence in cosmetic
breast surgery
Common complications in cosmetic breast surgery
Complications
1. Poor scarring 5%
2. Poor wound healing 4%
3. Implant malposition 2%
4. Recurrent breast ptosis 3.3%
5. Capsular contracture 8–38%
6. Seroma 1%
7. Hematoma 1%
8. Infection <1%
9. Partial or complete nipple areolar or ap necrosis <1%
10. NAC paraesthesia 1%
11. Overall complication rate 17–22%
12. Reoperation rate 8–16.6%
increased complication rates for each patient will most of the
time eliminate major complications.
1 Cosmetic Surgery oftheBreast: “Art, Science & Safety”
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13
Factors such as age, increased BMI, smoking, and other
comorbid conditions all play a signicant role in breast surgery outcomes and should always be reviewed with the
patient prior to surgical intervention. Furthermore, the
combination of multiple procedures at the same time statistically increases the rate of complications. According to Gupta,
V, etal., as more surgical procedures are combined simultaneously with breast surgery, the overall complication rate rises.
After reviewing 73,608 surgical cases, Gupta showed that the
overall complication rate doubled when the breast procedure
was combined with another body procedure.
If and when complications do occur, it is paramount that
they are addressed immediately. Patients should be evaluated
in person and the potential treatment options for the complication should be discussed and instituted. Time and time
again I see doctors that don’t handle the problem head on and
use diversionary tactics to deal with the patient. This only
leads to angst in the patient and builds animosity between the
patient and the physician. The majority of the time, prompt
treatment will circumvent a complex situation and reinforce
the doctor–patient relationship and ultimately decrease the
chance for any medicolegal issues (Fig.1.8).
1.7 Conclusions
Anatomically, surgeons are challenged everyday to provide
the patient with a youthful breast despite many external
inuences such as age, gravity, atrophy, social media, and the
never ending desire of the patient to obtain youth!
Additionally, as new technology arises, treatment options
will continue to evolve in the ever changing landscape of
cosmetic breast surgery.
With that said, having set routines, an artistic eye and a
keen grasp of three-dimensional applied breast anatomy
affords the cosmetic surgeon the opportunity to master critical thinking in cosmetic breast surgery.
The proper diagnosis leads to the proper surgery and ultimately
to the optimum nal result!
Further Reading
American Society of Plastic Surgery. ASPS 2018 Plastic surgery statis-
tics report. www.plasticsurgery.org.
Bayram Y, etal. Challenging breast augmentations: the inuence of
preoperative anatomical features in the nal result. Aesthet Surg J.
2016;36(3):313–20. https://doi.org/10.1093/asj/sjv181.
Bostwick III J.Plastic and reconstructive breast surgery. 2nd ed; 2000.
Gabriel A, etal. Incidence of breast and chest wall asymmetries: 4D
photography. Aesthet Surg J. 2011;31(5):506–10.
Gupta V, etal. Aesthetic breast surgery and concomitant procedures:
incidence and risk factors for major complications in 73,608 cases.
Aesthet Surg J. 2017;37(5):515–27. https://doi.org/10.1093/ASJ/
SJN238.
Javed A, Lteif A.Development of the human breast. Semin Plast Surg.
2013;27:5.
Kluska MS. Balloon-Assisted Transaxillary Augmentation
Mammoplasty (BAAM): a simplied 3 step approach. Am J Cosmet
Surg. 2008;25(1):39–44.
Kornstein AN.The benet of acellular dermal matrix placement in pri-
mary breast surgery may outweigh the cost in patients at high risk
of capsular contracture. Aesthet Surg J. 2020;40:NP434. https://doi.
org/10.1093/asj/sjaa041.
Nahai F.The art of aesthetic surgery: principles & techniques; 2005.
Pereira RT, etal. Global prole of cosmetic surgical procedures: “aes-
thetic journeys: a review of cosmetic surgery tourism”. J Travel
Med. 2018;25(1).
Regnault P. Breast ptosis: denition and treament. Clin Plast Surg.
1976;3:193–203.
Spear SL, Boehmler JH IV, Clemens MW.Augmentation/ mstopexy: a
3-year review of a single Surgeon’s practice. Plast Reconstr Surg.
2006;118(7S):136S–47S.
Wagner DS, Mirhaidari SJ. Capsulectomy, implant exchange and
placement of acellular dermal matrix is effective in treating cap-
sular contracture in breast augmentation patients. Aesthet Surg J.
2019;41:304. https://doi.org/10.1093/asj/sjz358.
Fig. 1.8 A rare case of Pyoderma Gangrenosum. Patient treated with
topical and oral antibiotics, wound care, and steroids. She took 1year
for complete healing and re-epithelialization
Anatomy oftheBreast
https://t.me/medicina_free
andPre- operative Assessment
forBreast Surgery
AngeloCuzalina, PasqualeG.Tolomeo,
andVictoriaA.Mañón
2
Aesthetic surgery is the harmony between science and art
based on the relationship of human morphology and anthropometric principles. The perception of beauty is in the eye of
the beholder and is inuenced by the environment as well as
symmetrical proportions. Breast surgery is one of the most
sought-after cosmetic treatments, specically with breast
augmentation being the most common aesthetic procedure
(Plasticsurgery.org 2020). Breast surgery can be divided into
breast augmentation, mastopexy, reduction mammaplasty or
a combination of these procedures. The aesthetic outcomes
of breast surgery are dependent on breast symmetry, size,
and shape.
The surgical aspects of breast surgery continue to evolve
over time with advancements in surgical techniques, development of imaging modalities, and a deeper knowledge of
anatomy and its variants. The surgeon must be well versed in
various surgical techniques and be able to offer treatments
that promise both aesthetic results and longevity with minimal complications. As the technical aspect of surgery keeps
changing and improves, the single aspect of breast surgery
that remains consistent is the anatomy. Knowledge of the
breast anatomy allows the surgeon to identify and preserve
important structures, therefore decreasing the risk of complications and improving the aesthetic results.
For aesthetic surgery, the provider must follow a systematic pre-operative patient evaluation while ensuring that the
patient is properly educated and all expectations are
addressed. The initial encounter during consultation is the
most important aspect of the surgery and heavily inuences
the patient’s decision. Most patients seek evaluations from
multiple surgeons, and it is crucial to make a great impres-
A. Cuzalina (*)
Tulsa, OK, USA
e-mail: angelo@tulsasurgicalarts.com
P. G. Tolomeo
Exquisite Aesthetics, New York, NY, USA
V. A. Mañón
University of Texas Health Science Center, San Antonio, TX, USA
sion. The consultation does not begin once the surgeon and
patient meet, but rather it starts from the initial phone call/
email with the front ofce and ends with the surgeon and
patient discussion. The goal of the consult is to determine the
patient’s surgical goals, gather medical information, perform
a physical exam, develop a diagnosis, explain the recommended procedures with associated risks and benets, and
set the patient’s expectations.
2.1 Embryology
The breast is derived from ectodermal tissue and begins to
develop as early as weeks 4–6 of gestation. At week 6, there is
a proliferation of paired epithelial cells in the thoracic region
extending from the axilla to the groin, with development of
two ridges known as the milk lines or mammary crests. From
weeks 8–10, breast growth continues with differentiation of
the paired ridges in the area of the fourth intercostal space,
while atrophy of the remaining lines ensues. This process
allows for the formation of the primary mammary buds.
Failure of the remaining milk lines to atrophy leads to the
presence of accessory mammary glands (polymastia) and nipples (polythelia). The axilla and chest wall below the primary
nipple are the most common locations of extra-glandular tissue and supernumerary nipples, respectively (Fig.2.1) (Nahai
2011; Janis 2017; Hammond 2009).
Near the end of the rst trimester, the primary mammary
buds enlarge and move into a more ventral position. As the
primary bud grows, indentations become prevalent along the
bud. These indentations contain cells that evaginate into the
stroma and develop into the secondary epithelial buds. The
secondary buds extend into the mesenchyme, canalize, and
coalesce to form secondary mammary buds. These secondary buds will eventually develop into the lactiferous ducts at
around weeks 20–24 of gestation (Hammond 2009). At the
end of the second trimester, the surrounding mesenchyme
has developed a tubular framework with dense broconnective tissue stroma (Javed and Lteif 2013).
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
M. Thomas, J. D‘silva (eds.), Manual of Cosmetic Medicine and Surgery, https://doi.org/10.1007/978-981-99-3726-4_2
15
16
er of
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A. Cuzalina et al.
Superficial lay
superficial fascia
Breast lobule
Lactiferous duct
Central collecting
duct
Nipple duct
Fig. 2.2 Nipple formation (Nahai 2011)
Fig. 2.1 Mammary crests
The mammary pit develops during the third trimester and
is the future nipple. The lactiferous ducts drain into terminal
ducts, the retro-areolar ampullae, and converge into epithelial pits. As the lactiferous ducts drain into the pits, the pits
elevate and form the nipple (Fig.2.2). Failure of elevation of
the epithelial pits lead to an inverted nipple; occurring in
2–4% of females (Nahai 2011; Janis 2017). A key aspect in
nipple development is the invagination of the ectoderm that
stimulates the proliferation of the mesoderm. This subsequently differentiates into smooth muscle bers that align in
a circular and longitudinal fashion. The areola develops from
the ectoderm at the fth month of gestation (Javed and Lteif
2013; Mugea and Shiffman 2016).
Near the end of the gestational period, there is an increase
in the vascularity of the breast stroma due to the hormonal
interactions between fetus and mother. At birth, the breast
contains approximately 15–20 lobules with an associated
lactiferous duct draining into the mammary pit (Nahai 2011;
Janis 2017; Javed and Lteif 2013; Mugea and Shiffman
2016).
2.2 Development
2.2.1 Infant Breast
Although breast growth remains dormant from age 2 until
puberty, minor changes are seen to occur within the rst 2
years. Once the infant is born, the absence of maternal hormones stimulates the pituitary gland to secrete prolactin,
which may lead to breast enlargement or milk secretion in
the neonates. In female infants, the breast tissue is supported
by the production of estradiol. As stated previously, the nipple remains inverted until birth when proliferation of the
mesoderm causes eversion of the tissue and pigmentation of
the areolae. During the rst 2 years of life, the breast is
undergoing morphological and functional maturation that
leads to the development of the various ducts and glands of
the breast (Javed and Lteif 2013).
2.2.2 Pubertal Breast
Pubertal breast development is dependent on the presence of
sex hormones. Estrogen plays a pivotal role in the initial
breast development in addition to growth hormone and
insulin- like growth factor. In response to these hormones,
Long thoracic ner
orating branches
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there is an increase in the brous and fatty tissue of the
stroma as well as development of the breast lobules and ductal system (Javed and Lteif 2013).
2.3 Anatomy
2.3.1 Vascular Supply oftheBreast
2.3.1.1 Arterial
The breast is perfused by three main arteries: the internal
mammary (internal thoracic artery), the lateral thoracic, and
the intercostal arteries. The majority of the breast, more specically the medial aspect, is supplied by the internal mammary artery (IMA) via anterior and posterior perforating
branches, which accounts for approximately 60% of total
blood ow (Hamdi etal. 2005). The anterior branches pass
through the intercostal space along the second to fth ribs
and exit approximately 2 cm from the parasternal border.
Alternatively, the posterior branches travel laterally from the
intercostal space and supply the posterior aspect of the
breast. The second through fth branches of the IMA perforate through the intercostal muscles and collateralize with
the lateral thoracic, thoracoacromial, and intercostal arteries
to supply the breast parenchyma. More specically, the second and third anterior branches perfuse a majority of the
breast parenchyma (Hamdi etal. 2005).
The external mammary artery, or lateral thoracic artery, is
a branch of the axillary artery and is responsible for perfu-
sion of the lateral and upper outer breast. Prior to convergence with the IMA branches, the external mammary artery
supplies the lateral and upper outer pole of the breast. The
inferior aspect of the breast is supplied by the third to fth
intercostal arteries. The skin is perfused by the subdermal
plexus which communicates with the intercostal breast perforators (Hamdi etal. 2005).
The nipple areola complex receives both parenchymal
and subdermal blood supply via the internal and external
mammary arteries. The arteries travel along the subcutaneous plane and converge to provide communicating vessels to
the surrounding areola tissue and nipple (Fig. 2.3) (Janis
2017; Hammond 2009; Hamdi etal. 2005).
2.3.1.2 Venous
Venous drainage parallels the arterial supply and is divided
into two systems (Hamdi etal. 2005). The supercial system
is situated below the supercial layer of the supercial fascia
and involves the transverse and longitudinal veins. The transverse veins perform a majority of the drainage along the subcutaneous layer and empty into the internal mammary vein
(internal thoracic vein) while the longitudinal veins drain the
breast towards the suprasternal notch and empty into the
supercial veins of the lower neck. The deep venous system
comprises of the perforating branches of the internal mammary vein, the tributaries of the axillary vein, and the perforating branches of the posterior intercostal veins. The
perforating branches of the internal mammary vein drain a
majority of the superomedial and inferior poles of the breast
Fig. 2.3 Arterial supply
Subclavian artery
Brachial plexus
ve
Lateral thoracic artery and
lateral mammary branches
Internal thoracic
artery and
perf
Medial mammary
branches
18
Posterior cutaneous branch
Dorsal ramus
Latissimus dorsi muscle
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A. Cuzalina et al.
through the third and fourth intercostal spaces, eventually
emptying into the brachiocephalic veins. The perforating
branches of the posterior intercostal veins drain the posterior
aspect of the breast and combine with the vertebral and azygos veins to empty into the superior vena cava (Nahai 2011;
Janis 2017; Hammond 2009; Hamdi etal. 2005).
2.3.1.3 Innervation
Innervation of the breast was rst demonstrated by Sir Astley
Cooper over 135 years ago and has since evolved. Sensory
innervation to the breast is based on the dermatomal distribution of the thoracic intercostal nerves’ levels T2–T6 via the
anterior and lateral intercostal branches. The superior and
outer pole of the breast is innervated by the supraclavicular
nerves from the cervical plexus (C3,C4) (Nahai 2011; Janis
2017; Hammond 2009; Mugea and Shiffman 2016; Hamdi
etal. 2005).
The anterolateral cutaneous branches travel through the
intercostal muscles and deep fascia to penetrate the breast.
The lateral branch of the second intercostal nerve, the intercostobrachial nerve, supplies the axillary tissue and upper
medial arm. The third to sixth lateral cutaneous branches, the
lateral mammary branches, travel along the surface of the
serratus anterior and divide into supercial and deep
branches. The deep branches course within the pectoral fascia towards the midclavicular line where it gives off several
branches to the overlying parenchyma. The supercial
branches course through the subcutaneous tissue and innervate the skin of the lateral breast (Nahai 2011; Janis 2017;
Hammond 2009; Mugea and Shiffman 2016; Hamdi etal.
2005).
The anteromedial cutaneous branches innervate the
medial aspect of the breast. The branches travel through the
deep fascia and divide into lateral and medial branches. The
medial branch innervates the area along the lateral border
of the sternum while the lateral branch travels along the
inferolateral aspect of the breast and innervates the skin
and areolar region (Fig. 2.4) (Nahai 2011; Janis 2017;
Hammond 2009; Mugea and Shiffman 2016; Hamdi etal.
2005).
Many studies have reported various distribution patterns
and course taken by the nerves innervating the nipple-areola complex (NAC). Innervation of the NAC is achieved by
the anterior and lateral cutaneous branches of the third to
fth intercostal nerves, with the lateral cutaneous branch of
the fourth intercostal nerve being the most prevalent (93%
Fig. 2.4 Axial view of breast
innervation
Lateral cuntaneous branch
Pectoralis major muscle
Serratus anterior muscle
External intercostal muscle
Internal intercostal muscle
Innermost intercostal muscle
Transversus thoracis muscle
Nipple-areola complex
Anterior cutaneous branch
Intercosrobrachial n.
es
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Fig. 2.5 Breast innervation
Lateral cutaneous branch
of the intercostal n.
Anterolateral
intercostal nerves
19
Cervical plexus
Anteromedial
inercostal nerv
of breasts) (Hamdi etal. 2005). In 93% of cases, the nerve
courses below the pectoralis fascia and once at the midclavicular line, travels anteriorly through the glandular tissue
to the posterior aspect of the nipple. In the remaining 7% of
breasts, the nipple is innervated by the fourth lateral cutaneous branch as it travels through the subcutaneous tissue
and supplies the skin and lateral nipple (Hamdi etal. 2005).
Innervation of the medial aspect of the NAC is provided by
the anterior cutaneous branches of the third to fth intercostal nerves, mostly from the third and fourth branches.
These two branches travel along the supercial aspect of
the subcutaneous tissue and innervate the medial areola.
The preservation of the sensation to the NAC is pivotal to
the patient’s quality of life and the surgeon must understand the course of the innervating nerves to minimize and
protect the NAC sensitivity (Fig. 2.5) (Nahai 2011; Janis
2017; Hammond 2009; Mugea and Shiffman 2016; Hamdi
etal. 2005).
2.3.1.4 Lymphatic Drainage
Lymphatic drainage of the breast originates from the breast
lobules, which drain into the intramammary nodes and subsequently into the subareolar plexus, known as Sappey’s
plexus. Lymphatic drainage occurs along the venous tributaries via three routes: axillary, internal mammary, and retromammary. A majority of this lymphatic drainage is performed
by the ipsilateral axillary nodes (Nahai 2011). The axillary
pathway drains the lateral quadrants of the breast and traverse along the inferior border of the pectoralis muscle. The
internal mammary pathway drains the medial and lateral
quadrants of the breast as it passes through the intercostal
spaces and pectoralis muscle, before emptying into the para-
sternal/internal mammary lymph nodes. The retromammary
pathway originates from deep within the breast tissue and
drains into the subclavicular plexus (Fig.2.6) (Nahai 2011;
Janis 2017; Hammond 2009; Mugea and Shiffman 2016;
Hamdi etal. 2005).
The axillary lymph nodes are arranged into six groups
and divided surgically into three levels based on the position
of the nodes in relation to the pectoralis minor muscle. The
axillary groups are anterior (pectoral), posterior (subscapular), lateral, central, infraclavicular (deltopectoral), and apical. The Level I nodes are located lateral and/or inferior to
the border of the pectoralis muscle and include the external
mammary, axillary, and scapular lymph nodes. Level II
nodes are posterior to the pectoralis minor muscle and
include the central and subclavicular lymph nodes. Level III
nodes are positioned superiorly to the superior border of the
pectoralis minor muscle and include the subclavicular and
apical lymph nodes. Transpectoral drainage occurs via
Rotter’s nodes. These nodes are inferior to the lateral pectoralis major muscle and drain into the Level III nodes (Nahai
2011). Lymphatic drainage of the breast plays a critical role
in the metastasis of breast carcinoma to other parts of the
body (Nahai 2011; Janis 2017; Mugea and Shiffman 2016).
2.3.1.5 Breast
The breast is located on the anterior thoracic wall and overlies the pectoralis major, serratus anterior, external oblique,
and upper rectus muscles (Janis 2017). The majority of the
breast extends from the second to seventh ribs in the midclavicular line and spans from the sternocostal junction medially to the mid-axillary line laterally. A portion of the breast
gland, known as the axillary Tail of Spence, extends into the
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