Arterial Anatomy of the Breast

Arterial Anatomy of the Breast – A Practical Summary for Breast Surgeons
- Understanding the arterial supply of the breast is essential for:
  - Oncologic resections
  - Reconstructive planning
  - Oncoplastic surgery
  - Complication avoidance
- The breast receives a rich, redundant blood supply primarily from branches of the:
  - Subclavian and axillary arterial systems:
    - Which explains its generally good healing capacity:
      - But also the risk of bleeding if anatomy is not respected
Primary Arterial Sources:
- Internal Mammary (Internal Thoracic) Artery:
  - Most important medial blood supply to the breast
  - Arises from the:
    - Subclavian artery
  - Gives rise to anterior intercostal perforators, especially:
    - 2nd to 4th intercostal perforators:
      - Dominant contributors
  - Supplies:
    - Medial breast
    - Retroareolar complex
  - Key surgical relevance:
    - Critical during medial lumpectomies
    - Important for nipple-areolar complex (NAC) viability
    - Used as recipient vessels in free flap breast reconstruction
- Lateral Thoracic Artery:
  - Branch of the axillary artery
  - Runs along the lateral chest wall
  - Supplies:
    - Lateral breast
    - Skin and glandular tissue
  - Key surgical relevance:
    - At risk during axillary dissection
    - Important contributor in lateral oncoplastic flaps
- Thoracoacromial Artery (Pectoral Branch):
  - Branch of the axillary artery
    Supplies:
    - Upper outer quadrant
    - Pectoralis major muscle
  - Key surgical relevance:
    - Important during subpectoral dissection:
    - Preservation helps reduce skin flap ischemia
- Posterior Intercostal Arteries:
  - Arise directly from the thoracic aorta
  - Provide deep perforating branches
  - Supply:
    - Deep parenchyma
    - Chest wall interface
  - Key surgical relevance:
    - Contribute to deep tissue perfusion
    - Source of bleeding during deep resections
Perforator System and Anastomoses:
- The breast has an extensive subdermal and intraparenchymal anastomotic network
- Major perforators:
  - Medial (internal mammary)
  - Lateral (lateral thoracic)
- Clinical implications:
  - Explains tolerance of wide local excisions
  - Allows for oncoplastic rearrangements
  - Supports skin- and nipple-sparing mastectomy when flaps are well designed
Surgical Implications for Breast Surgeons:
- Breast-Conserving Surgery:
  - Medial tumors:
    - Respect internal mammary perforators
  - Lateral tumors:
    - Anticipate supply from lateral thoracic artery
- Mastectomy (Skin- or Nipple-Sparing):
  - Preserve:
    - Subdermal plexus
    - Medial perforators
  - Excessive cautery near the NAC increases ischemia risk
- Oncoplastic Surgery:
  - Knowledge of arterial territories guides:
    - Pedicle choice
    - Flap orientation
    - Central and medial pedicles rely heavily on internal mammary perforators
- Reconstruction:
  - Internal mammary vessels are preferred recipient vessels for free flaps
  - Axillary system preservation is important in implant-based reconstruction
Key Take-Home Points:
- Breast arterial supply is dual and redundant, centered on:
  - Internal mammary system (medial dominance)
  - Axillary system (lateral dominance)
  - 2nd to 4th internal mammary perforators are the most critical vessels
  - Surgical planning should always consider vascular territories, especially in:
    - Re-operations
    - Radiation-treated breasts
    - Large resections or complex oncoplastic cases
References:
- Arterial Anatomy of the Breast
  - Cunningham L.The anatomy of the arteries and veins of the breast.
    J Surg Oncol. 1977;9(1):71–85.
    → Classic anatomic description of breast vascular supply.
  - Salmon RJ. Vascularization of the breast and implications for surgery.
    Surg Clin North Am. 1990;70(4):877–885.
    → Foundational surgical anatomy review.
  - Hall-Findlay EJ. Breast anatomy and vascular supply.
    Clin Plast Surg. 2002;29(3):371–384.
    → Highly cited reference for oncoplastic and reconstructive surgery.
  - Sappey M. Traité d’Anatomie Descriptive. Paris: Delahaye; 1874.
    → Early detailed descriptions of breast perforators (historical reference).
  - Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body.
    Br J Plast Surg. 1987;40(2):113–141.
    → Angiosome concept applied to breast perfusion and flap design.
- Internal Mammary & Perforator Anatomy:
  - Cormack GC, Lamberty BG. The arterial anatomy of skin flaps.
    Edinburgh: Churchill Livingstone; 1994.
    → Describes internal mammary perforators relevant to breast surgery.
  - Saint-Cyr M, Wong C, Schaverien M, et al. Perforator flaps: anatomy, technique, and clinical applications. Plast Reconstr Surg. 2009;124(1 Suppl):e1–e17.
    → Detailed perforator anatomy with relevance to NAC perfusion.
  - Hamdi M, Van Landuyt K, Monstrey S, Blondeel P. Pedicled perforator flaps in breast reconstruction. Semin Plast Surg. 2006;20(2):73–83.
- Surgical & Oncoplastic Relevance:
  - Losken A, Hamdi M. Partial breast reconstruction: current perspectives. Plast Reconstr Surg. 2009;124(3):722–736.
    → Links vascular anatomy to oncoplastic pedicle choice.
  - Clough KB, Kaufman GJ, Nos C, Buccimazza I, Sarfati IM. Improving breast cancer surgery: a classification and quadrant-based approach. Plast Reconstr Surg. 2010;125(2):418–428.
  - Mast BA. Breast reduction and mastopexy: pedicle selection and vascular considerations. Clin Plast Surg. 1996;23(3):567–576.
- Nipple–Areolar Complex (NAC) Perfusion
  - van Deventer PV, Graewe FR. Blood supply of the nipple–areolar complex. Plast Reconstr Surg. 1984;74(4):499–504.
  - Russo V, Della Corte A, et al. Nipple–areola complex vascular anatomy and surgical implications. Aesthetic Plast Surg. 2017;41(2):267–274.
- Reconstruction-Focused References:
  - Blondeel PN, Morris SF, Hallock GG, Neligan PC. Perforator Flaps: Anatomy, Technique, and Clinical Applications. St. Louis: Quality Medical Publishing; 2006.
- Nahabedian MY. Breast reconstruction and internal mammary vessels.
  Plast Reconstr Surg. 2012;130(4):883–891.