From an oncological point of view, the lymphatic system of the mammary gland is of great importance, through which tumor cells primarily spread. Distinguish between intraorgan and extraorganic lymphatic system of the gland. Knowledge of features lymphatic system the mammary gland is of great importance in the choice of the method of intervention and its radicality.
The intraorgan lymphatic system of the gland consists of capillaries and plexuses of lymphatic vessels of the parenchyma of the gland and its outer cover, skin and subcutaneous adipose tissue.
From the anterior parenchyma, lymph flows through the plexuses of the lymphatic vessels along the milk ducts, blood vessels, nerves and flows into the podareolar lymphatic collector. Lymph from the posterior parts of the gland flows into the retromammary plexus.
The lymphatic capillaries of the skin of the gland form two networks: superficial (in the papillary layer) and deep (in the deep layer of the dermis). The loops of both layers of capillaries are connected by anastomoses. The outflow of lymph from the skin is in two directions. From the skin of the central parts of the gland, the lymph flows through the vessels of the subcutaneous fatty tissue into the podareolar lymphatic plexus. From the peripheral parts of the skin, the outflow of lymph is carried out partially into the lymphatic vessels of the anterior chest wall and into the subcutaneous lymphatic vessels of the other mammary gland. The possibility of cancer metastasis along the cutaneous and subcutaneous lymphatic network should be remembered when the tumor is located close to the skin and along the edge of the mammary gland.
The extraorganic lymphatic system of the mammary gland is represented by the discharge vessels and regional nodes.
There are the following ways of outflow of lymph from the mammary gland:
1. Axillary path. Normally, about 97% of the lymph flows along this path. Usually it is represented by 1 - 2 vessels flowing into the axillary lymph nodes. The number of these nodes can be from 8 to 75 (on average, 18 to 30). Lymph flows into the axillary nodes not only from the mammary gland, but also from the upper limb, front, lateral and posterior surfaces chest, the abdominal wall. This fact is important in the differential diagnosis of breast cancer (when there is a metastatic axillary lymph node, but there is no clear node in the mammary gland).
2. The subclavian way. Through it, lymph is diverted from the lymphatic plexuses of the upper and posterior sections of the gland. This pathway is subdivided into transpectoral (vessels pierce the pectoralis major muscle and immediately flow into the subclavian lymph nodes or pass through Rotter's intermuscular nodes to the subclavian) and interpectoral (the vessels bend around the pectoralis major, sometimes pectoralis minor from the lateral side and flow into the subclavian lymph nodes). Closely anastomoses with the supraclavicular lymphatic collector.
3. Parasternal pathway. Lymphatic drainage occurs mainly from the medial part of the gland (more often the deep sections) through the chest wall into the parasternal lymph nodes of the I-V intercostal space.
With tumor blockade of parasternal lymph nodes, cancer cells with retrograde lymph flow can enter the organs of the chest (lungs, mediastinal lymph nodes) and abdominal (peritoneum, liver, ovaries, retroperitoneal lymph nodes) cavities.
From the parasternal lymph nodes, lymph flows more often into the subclavian lymph nodes, but it can also enter the supraclavicular, especially into the node lying in the region of the venous node (Troisier sentinel node). Its metastatic lesion is manifested by the presence of a dense node in the medial corner of the supraclavicular region.
4. Intercostal path. Lymphatic drainage is carried out from the posterior and external parts of the mammary gland through the vessels that pierce the muscles of the II-IV intercostal space and then anastomose with the parasternal collector in front or with the lymphatic vessels of the vertebral bodies in the back.
5. The retrosternal path. The outflow of lymph occurs through the vessels originating from the central and medial sections of the gland and piercing the chest wall at the sternum. They do not flow into the parasternal lymph nodes, but, bypassing them, approach the mediastinal and further to the bronchopulmonary nodes (the path of metastasis to the lungs).
6. Cross path. The movement of lymph occurs along the skin and subcutaneous lymphatic vessels chest wall to the opposite axillary nodes. Direct connections between the lymph vessels of the parenchyma of both mammary glands have not been established, but cross metastasis to the other mammary gland is possible through the cutaneous and subcutaneous lymphatic network of the other mammary gland, as well as retrograde from opposite lymph nodes.
7. The path of Gerota. When the main axillary collector is blocked, lymph outflow occurs through the vessels of the epigastric region, which pass through the rectus abdominis muscle into the preperitoneal tissue. The lymphatic network of the preperitoneal tissue is connected by anastomoses with the lymphatic vessels of the mediastinum and the coronary ligament of the liver, through which metastasis can occur.
Thus, the mammary gland has many lymph drainage pathways, the main of which is the axillary. The abundance of lymphatic vessels and a variety of possible pathways for lymph outflow are factors contributing to the very frequent and rather early metastatic spread of breast cancer.
It is necessary to distinguish between regional and distant lymph nodes, which receive lymph from the mammary gland.
Regional lymph nodes include axillary, subclavian (apical axillary) and parasternal lymph nodes.
1. Axillary (on the affected side) and interpectoral (Rotter) nodes are located along the axillary vein and its tributaries and are subdivided by levels:
a) the first level - the lower axillary lymph nodes located laterally (outward) in relation to the lateral border of the pectoralis minor;
b) the second level - the middle axillary lymph nodes located behind the pectoralis minor, that is, between its medial and lateral edges, as well as Rotter's interceptor nodes;
c) the third level - subclavian, or apical axillary, lymph nodes located medially from the medial edge of the pectoralis minor.
2. Parasternal (internal) lymph nodes (on the affected side) are located in the intercostal spaces along the edge of the sternum.
Any other lymph nodes, including supraclavicular, cervical, contralateral, mediastinal, are considered distant.
Accordingly, metastases in regional lymph nodes are local (regional), in distant lymph nodes - to distant. 1 - periareolar network of lymphatic vessels (Sappaeus plexus); 2 - paramammary lymph nodes: a - Bartels' node; b - Zorgius knot; 3 - lateral axillary lymph nodes; 4 - central axillary lymph nodes; 5 - subscapular lymph nodes; 6 - subclavian lymph nodes; 7 - supraclavicular lymph nodes; 8 - parasternal lymph nodes; 9 - rethoracic lymph nodes; 10 - interthoracic lymph nodes (Rotter's node); 11 - lymphatic vessels heading to the epigastric region. 
1 - paramammary lymph nodes; 2 - central axillary lymph nodes; 3 - subclavian lymph nodes; 4 - supraclavicular lymph nodes; 5 - deep cervical lymph nodes; 6 - parasternal lymph nodes; 7 - cross lymph nodes; 8 - lymphatic vessels going into the abdominal cavity; 9 - superficial inguinal lymph nodes.
2. The second direction of lymphatic drainage - periosternal lymph nodes chest cavity going along a. thoracica interna. In them, lymph enters through chains of nodes that go next to the branches of the intercostal arteries and the internal thoracic artery through the intercostal space. Lymph is directed here mainly from the deep sections of the medial quadrants of the mammary gland.
In case of violation lymph outflow in two main directions (which can occur as a result of blockade of lymphatic vessels by multiple metastases), the outflow of lymph through additional pathways increases.
3.Part lymphatic vessels passes through the thickness of the pectoralis major muscle (transpectorally) into the intergructal nodes, nodi interpectorales, located between the pectoralis major and minor. From the interthoracic nodes, lymph flows into the deltoid, nodi deltopectorales (subclavian, infraclaviculares), nodes and further into the supraclavicular.
Sometimes lymph enters the supraclavicular nodes, bypassing the subclavian, which explains the cases of cancer of the deep cervical nodes in the absence of metastases in the axillary region. One of the supraclavicular nodes, lying behind the lateral edge of the sternocleidomastoid muscle, is the second "sentinel" node in the process of metastasis.
Comparative frequency of distant breast cancer metastases, in particular in the lungs and bones, is explained by the early penetration of tumor elements from the lymphatic into the bloodstream, even before the formation of pronounced metastases in the regional lymph nodes.
4. From the medial parts of the mammary gland lymph can drain into lymph nodes the contralateral gland and further - the axillary fossa.
5. From the lower medial departments mammary glands available lymph outflow downward, into the subcutaneous tissue of the anterior abdominal wall, and then into the preperitoneal tissue.
Innervation of the mammary gland is carried out mainly due to the anterior and posterolateral cutaneous branches of the 2-5 intercostal nerves, as well as the branches of the supraclavicular nerves that innervate the skin covering the gland. The greatest density nerve plexuses reach in the nipple area.
Breast
Breast
The lymphatic system of the mammary gland is represented by a network of lymphatic vessels located in three floors.
Most superficially, under the base of the breast nipple, is the submuscular lymphatic plexus. Superficial lymph drainage from the mammary gland is carried out intradermally and goes to the opposite side.
Deeper within the areola lies the superficial pericircular plexus.
The deep pericircular plexus is located even deeper.
Lymph node groups
Axillary lymph nodes are the main group of lymph nodes that receive lymph from the breast. Some of them lie superficially, subfascial. Axillary lymph nodes are divided into five subgroups: lateral (external), middle (central), posterior (subscapularis), medial (thoracic, paramammary), and apical (apical).
- Lateral (external) axillary lymph nodes are located on the lateral wall of the axillary cavity near the beak brachialis muscle outward from the neurovascular bundle. Lymph is mainly taken from the free upper limb.
- Middle (central) axillary nodes are located along the axillary vein, mainly along its anterior and medial surfaces. Lymph flows to these nodes from the outer quadrants of the mammary gland, the anterior and lateral sections of the chest wall and upper section the anterior abdominal wall.
- Rear (subscapularis) axillary nodes are located along the subscapularis artery. They receive lymph from the posterior chest, subscapularis, and sometimes from the breast.
- Medial (chest, paramammary) axillary lymph nodes, localized along the outer edge of the pectoralis major muscle along the lateral thoracic vessels, are the nodes of the first stage for the outer quadrants of the mammary gland. The lymph node, located on the third tooth of the serratus muscle, is the first stage lymph node (Zorgius' lymph node). The lymph node, localized on the fourth tooth, is Bartels' lymph node.
- Apical (apical) axillary lymph nodes - common name a large group of lymph nodes located in the subclavian region. Lymph is taken from the remaining groups of axillary lymph nodes, as well as from the upper quadrants of the mammary gland, coming through the lymphatic vessels that pierce the pectoralis major muscle. Thus, they simultaneously serve as nodes of the first stage for the upper sections of the mammary gland. The outflowing vessels from the apical lymph nodes flow into the supraclavicular lymph nodes, which in this case are the lymph nodes of the second stage.
- Parasternal lymph nodes are located retrosternal in the first to seventh intercostal space along the internal thoracic artery. They receive lymph from the lower-inner quadrant and central departments glands. The parasternal lymph nodes lying in the second to fourth intercostal spaces are the lymph nodes of the first stage of outflow from the mammary gland, and the nodes of the first intercostal space are the nodes of the second stage, since the outflow vessels of the axillary lymph nodes flow into them.
From the base of the gland, the lymphatic vessels go to the lymph nodes of the retromammary space, then they penetrate the pectoralis major muscle and flow into the intersectoral nodes, from where the lymph flows into the central axillary lymph nodes. Part of the lymphatic vessels pierces not only the large, but also the pectoralis minor and through the intercostal space penetrates to the parasternal lymph nodes (the first stage). The non-permanent lymph nodes of the mammary gland include the nodes lying between the pectoralis minor and pectoralis major muscles. They receive lymph from the upper quadrants of the gland. The efferent vessels carry lymph to the axillary lymph nodes.
Under the pectoralis minor muscle, there are subpectoral lymph nodes that receive lymph from the upper quadrants of the breast. From the subpectoral lymph nodes, lymph flows to the apical axillary lymph nodes.
Lymphatic metastasis in breast cancer can occur in several directions.
To the medial axillary lymph nodes and further to the apical axillary lymph nodes. They are noted most often (60-70% of cases).
To the apical axillary lymph nodes. They are noted in 20-30% of cases.
To the parasternal axillary lymph nodes. They are noted in 10% of cases.
In the axillary lymph nodes of the opposite side and in the mammary gland. They are noted in 5% of cases.
To the mediastinal lymph nodes, bypassing the parasternal. They are noted in 2% of cases.
Sometimes there is metastasis to the epigastric lymph nodes and nodes abdominal cavity, in the inguinal lymph nodes and central axillary lymph nodes.
Lungs
The lymphatic vessels of the lungs are divided into superficial and deep. Superficial vessels form a dense network under the pulmonary pleura. Deep lymphatic vessels follow from the alveoli and accompany the branches of the pulmonary veins. Along the course of the initial branches of the pulmonary veins, they form numerous pulmonary lymph nodes. Further, following the bronchi, they form many bronchial lymph nodes. Having passed the root of the lung, the lymphatic vessels flow into the system of bronchopulmonary lymph nodes, which represent the first barrier on the way of lymph from the lung. Above, the lymphatic vessels enter the lower tracheobronchial lymph nodes located at the tracheal bifurcation, then, following upward, the lymph passes into the upper right and left tracheobronchial lymph nodes. Above, the lymphatic vessels pass the last barrier - the right and left tracheal lymph nodes. From here, the lymph already leaves the chest cavity and flows into the supraclavicular lymph nodes.
Pericardium
The outflow of lymph from the pericardium occurs mainly in two directions: forward into the sternal lymph nodes, and also into the anterior mediastinal lymph nodes.
The parasternal lymph nodes are located on the side of the sternum along the course of the internal mammary vessels. Lymphatic vessels from the mammary gland, anterior pericardium and intercostal space flow into them.
The anterior mediastinal lymph nodes lie on the anterior surface of the aortic arch. From here, the lymph is directed through the anterior mediastinal lymphatic vessels into the nipple lymphatic duct on both sides.
The upper diaphragmatic lymph nodes are located on the diaphragm at the level of the xiphoid process.
The posterior mediastinal lymph nodes are divided into upper and supraphrenic (located in the posterior part of the diaphragm above its upper surface). Lymph flows here from back wall pericardium.
Lymphatic vessels of the first three groups - the sternum, anterior mediastinal and upper diaphragmatic - flow through the nipple lymphatic duct into the thoracic duct on the left, and into the right lymphatic duct on the right.
Lymphatic vessels from the posterior mediastinal nodes flow into the broncho-mediastinal trunk, along which the lymph on the left reaches the thoracic duct, and on the right - the right lymphatic duct.
Heart
Lymphatic vessels of the heart are divided into superficial and deep. The former lie under the epicardium, the latter are located in the thickness of the myocardium. Lymph flows follow the course coronary arteries from bottom to top and sent to the first barrier - the heart lymph nodes located on the anterior surface of the ascending aorta. From here, the lymph through the anterior mediastinal vessels enters the nipple lymphatic duct on both sides.
Thoracic part of the esophagus
Lymphatic drainage from the esophagus occurs through its two networks located in the mucous membrane and muscular membranes... V cervical spine lymph flows into the deep cervical lymph nodes, in the chest - into the para-aortic lymph nodes, in the abdominal - into the left gastric lymph nodes.
The lymph nodes chest cavity
In the chest cavity, parietal and visceral lymph nodes are distinguished.
The parietal nodes are in two groups: posterior and anterior. TO back group include intercostal lymph nodes and prevertebral nodes located on the anterior and lateral surfaces of the spine. The anterior group includes the peri-sternal lymph nodes located along the internal thoracic artery.
Visceral intrasternal lymph nodes are divided into anterior mediastinal, posterior mediastinal, tracheobronchial. The pathways for lymph outflow from the esophagus, heart and lungs pass in the lower tracheobronchial (bifurcation) nodes that occupy the interval between the tracheal bifurcation, the beginning of the main bronchi and the pulmonary veins.
Esophagus
The outflow of lymph from the esophagus occurs in the tracheobronchial and prevertebral nodes. From the lower esophagus, the flow of lymph is directed towards the stomach (left gastric nodes), as well as in the parietal and prevertebral nodes.
The mammary gland is a paired soft tissue organ consisting of glandular, connective and adipose tissue
The mammary gland is located at the level from III to IV ribs, on the fascia covering the pectoralis major muscle, In the middle of the gland is breast nipple,papilla mammaria, with pinholes on its top, which open the outlet milky streams, ductus lactiferi. Breast body, corpus mammae, consists of 15-20 lobes, separated from each other by layers of adipose tissue, penetrated by bundles of loose fibrous connective tissue. The lobes, which have the structure of complex alveolar-tubular glands, open with their excretory ducts at the apex of the nipple of the mammary gland. On the way to the nipple, each duct has an extension - lactiferous sinus, sinus lactiferi.
Blood supply The mammary glands are carried out mainly by a.thoracica lateralis (from a.axillaris), a.thoracica interna (from a.subclavia) and a.intercostales.
The branches of the internal thoracic artery, approaching from the medial side, supply blood to the lobules of the gland, the areola, the nipple and the skin from the medial side. The branches of the lateral thoracic artery feed the same structures from the lateral side. The posterior surface of the gland is supplied with blood by the branches of the intercostal arteries. All of these arteries form two anatomical networks: superficial and deep. Deep veins accompany the arteries, superficial - form a subcutaneous network associated with the axillary vein.
The lymphatic system of the mammary gland is divided into intraorgan and extraorganic. The intraorgan system consists of a network of capillaries surrounding each lobule. It also includes the lymphatic network of the skin and subcutaneous adipose tissue. The extraorganic system is formed by the efferent lymphatic vessels and regional lymph nodes, which include the axillary, subclavian, supraclavicular, parasternal and intersectoral nodes.
There are several ways of outflow of lymph from the mammary gland:
Axillary path (normally 97% of lymph flows out along it). Axillary lymphatic trunks start from the subareolar lymphatic plexus and flow into the axillary lymph nodes.
Subclavian path. It carries out the outflow of lymph from the upper and posterior parts of the mammary gland to the subclavian lymph nodes.
Parasternal path. It carries out the outflow of lymph from the medial sections of the mammary glands to the parasternal lymph nodes.
The retrosternal pathway. Through it, lymph from the central and medial parts of the mammary gland flows through the vessels that perforate the chest wall into the mediastinal and further into the bronchopulmonary lymph nodes.
Intercostal path. It carries out the outflow of lymph from the posterior and external parts of the mammary gland into the intercostal lymphatic vessels and further, partly into the parasternal nodes, partly into the paravertebral lymph nodes.
Cross path. It is carried out along the cutaneous and subcutaneous lymphatic vessels, passing the middle line.
Gerot's Way. It carries out the outflow of lymph during the blockade by tumor emboli of the main outflow pathways. Through the lymphatic vessels located in the epigastric region and perforating both sheets of the sheath of the rectus abdominis muscle, lymph enters the preperitoneal tissue and from there - into the mediastinum and through the coronary ligament - into the liver. Part of the lymph flows through the vessels of the subcutaneous fatty tissue from the epigastric region to the inguinal lymph nodes of the same side.
The first two of the listed ways of lymph outflow are the main ones.
Innervation the mammary glands comes from the cervical plexus through the supraclavicular nerves and from brachial plexus- through the anterior pectoral nerves, as well as the 4th-6th intercostal nerves.
Vascular suture (carrel, donetsk, nightingale)
Circular (circular) seam. It can be continuous, nodal, mattress (Fig. 2.).
Rice. 2. Schemes of the circular vascular suture: a - Carrel's suture; b - the method of A. I. Morozova; c - seam from the inside of the lumen of the posterior wall of a large-caliber vessel; d - everting mattress, continuous and interrupted sutures.
The technique of applying a continuous (twisted) suture was developed by the English surgeon Carrel (1902).
Carrel's technique (fig. 2,3). The suture begins with the convergence of the ends of the sutured vessel using three sutures - holders, applied at an equal distance from each other (120 °). For this, both ends of the vessel are stitched with three atraumatic threads through all layers (one - from the side of the adventitia membrane, the other - from the intima), 1.0-1.5 mm away from the edge. The ends of the vessel are brought together and the threads are tied. When stretched by the ends of the threads, the lumen of the vessel acquires a triangular shape, which guarantees that the needle does not grip the opposite wall when a winding continuous suture is applied between the holders. After suturing one of the edges, the main ligature is tied to the thread with a holder. The rest of the edges are sutured in the same way.
Rice. 3. Carrel's circular twisted seam. a - the imposition of sutures-holders, b - the convergence of the edges of the vessels; c-suturing of individual edges of the vessel; d - for the finished vessel seam.
Currently, the Carrel suture is used only in microsurgery (suture of small-diameter vessels). In surgery of secondary and large vessels its modification is applied - the method of A.I. Morozova (1909).
Donetsk way.
To connect any types of vascular anastomosis, thin-walled metal rings are used, equipped with 4 thorns to fix the edges of the vessel. The diameter of the rings is different. The size of the spikes changes in accordance with the change in the diameter of the rings. Stage I - selection of the ring. The inner diameter of the ring should be slightly less than the outer diameter of the vessel. Stage II - disassembling and fixing the cuff. A ring is put on the central section of the vessel. Alternately, starting from the back wall, the vessel wall is turned inside out and fixed on the thorns. Stage III - invagination of the central segment of the vessel into the peripheral. The wall of the peripheral segment of the vessel is strung first on the back, then on the lateral and, last of all, on the front thorns.
Soloviev's suture is an invagination suture with a double cuff. To perform the suture, the central and peripheral sections of the sutured vessel are mobilized. Stage I - the imposition of 4 invaginating sutures. Begin sewing at the center end of the vessel. The first injection is made at a distance corresponding to 1.5 times the diameter of the vessel. In a small area, its outer shell is twice stitched. Then, from the outside to the inside, all layers of the vessel wall are stitched at a distance of 1 mm from the edge. At the same distance, the peripheral section of the vessel is stitched from the inside to the outside. Four such seams are placed around the circumference of the vessel (Figure 16.11). Rice. 16.11 Soloviev's invagination vascular suture. The imposition of invaginating sutures II stage - the formation of the cuff. The holding sutures are grasped with two clamps and, pulling in the direction of the central segment, bring the ends of the artery closer. In this case, the walls of the central vessel are turned inside out and a cuff is formed (Fig. 16.12). Rice. 16.12 Soloviev's invagination vascular suture. Formation of the cuff Stage III - invagination of the cuff and tying the sutures. The ends of the vessels are brought together. Holding the central end, it is invaginated into the peripheral. If intussusception does not occur on its own, it is performed with anatomical forceps, putting its branch under the cuff (Fig. 16.13). Intussusception begins from the posterior semicircle of the vessel. When restoring blood flow through the vessel, the clamp is first removed from the central and then from the peripheral segments. Check the tightness of the seam and the permeability of the vessel. In case of insufficient tightness, additional separate interrupted sutures are applied, capturing all layers of the peripheral wall and the outer shell of the central sections of the vessel.
Skeletotopy: between III and VI ribs above and below and between the peri-sternal and anterior axillary lines from the sides.
Structure. Consists of 15–20 lobules, surrounded and separated by processes of the superficial fascia. Lobules of the gland are located radially around the nipple. Each lobule has its own excretory, or milky, duct with a diameter of 2-3 mm. The milky ducts converge radially to the nipple and at its base they expand ampoule-like, forming the lactiferous sinuses, which again narrow outwards and open at the apex of the nipple with pinpoint holes. The number of holes on the nipple is usually less than the number of milk ducts, since some of them at the base of the nipple are connected to each other.
The gland is located between the sheets of the superficial fascia, which form its capsule, and on all sides (with the exception of the nipple and areola) is surrounded by fatty tissue.
Between the fascial capsule of the gland and the breast's own fascia are retromammary tissue and loose connective tissue, as a result of which the gland is easily displaced in relation to the chest wall. A bursa sometimes forms under the mammary gland.
Numerous spurs extend from the fascial capsule of the mammary gland into its thickness, which surround individual lobules, are located along the milky ducts, delimiting the tissue in which the blood or mphatic vessels and nerves pass. The presence of connective tissue spurs contributes to the formation and delimitation of streaks during purulent-inflammatory processes in the gland, which should be taken into account when making incisions for the outflow of pus.
Blood supply: branches of the internal thoracic, lateral thoracic, intercostal arteries. Deep veins accompany the arteries of the same name, superficial ones form a subcutaneous network, individual branches of which flow into the axillary vein.
Innervation: lateral branches of the intercostal nerves, branches of the cervical and brachial plexuses.
Lymphatic drainage. The lymphatic system of the female breast and the location of regional lymph nodes are of great practical interest in connection with frequent defeat organ by a malignant process.
The lymphatic vessels of the parenchyma of the gland are larger, they form plexuses in the intralobular and peri-lobular tissue, and in the gland itself and along the ducts and blood vessels there are networks of lymphatic capillaries. The diverting lymphatic vessels pass in the direction from the areola into the deep areolar plexus, which anastomoses with the superficial cutaneous lymphatic vessels (this explains the early infiltration of skin vessels during metastasis malignant tumors- "cutaneous pathway" of metastases).
Larger abducting lymphatic vessels are formed from the plexuses, which run along the outer edge and anterior surface of the fascial sheath of the pectoralis major muscle or intrafascial. They are connected by numerous anastomoses with the lymphatic vessels of the skin and subcutaneous tissue of the abdominal wall, opposite the mammary gland, with the vessels of the intercostal spaces.
The main way of outflow of lymph from the mammary gland is the axillary path - towards a large group of axillary lymph nodes (about 4 / b lymph is drained in this direction).
The axillary group consists of 20-40 lymph nodes, which can be divided into 5 groups according to their topographic and anatomical characteristics (see “ Axillary area"). There is no strict sequence of flow into the nodes of the outflowing lymphatic vessels: they can end in the nodes located on the 2-3rd tooth of the upper dentate muscle (Zorgius nodes), but they can also pass to the nodes of other groups. In the event of a violation of the outflow along the main axillary pathway (which can occur as a result of blockage of the lymphatic vessels by multiple metastases), a roundabout lymph circulation occurs, in which the outflow of lymph through additional pathways increases:
Subclavian - into the subclavian nodes,
Transpectally - through the pectoralis major muscle and
Interceptor - to the vessels that bend around the edge of the pectoralis major muscle, to the intermuscular and subclavian nodes,
Parasternal - to the lymph nodes along the internal thoracic arteries and veins through the intercostal space (usually the second - the third), into the supraclavicular and cervical and similar lymph nodes of the opposite side; by anastomoses with the lymphatic vessels of the epigastric region - into the lymphatic network of the preperitoneal tissue with subsequent connections with the vessels of other areas.
Main way outflow of lymph - to the axillary lymph nodes in three directions:
1. through the anterior pectoral lymph nodes (Zorgius and Bartels) along the outer edge of the pectoralis major muscle at the level of the second or third rib;
2. intrapectoral - through Rotter's nodes between the pectoralis major and minor muscles;
3. transpectally - along the lymphatic vessels penetrating the thickness of the pectoralis major and minor; the nodes are located between their fibers.
Additional pathways for lymph outflow:
1.from the medial section - to the lymph nodes along the internal thoracic artery and the anterior mediastinum;
2. from the upper section - to the subclavian and supraclavicular nodes;
3. from the lower section - to the nodes of the abdominal cavity.
English grammar by level English language theory for beginners
See what "Flag" is in other dictionaries
What to catch crucian carp and carp in June, July and August
First relationship crisis
Healing plants with a description And what's inside