Station 1: Breast, Superficial Fascia, Muscles of the Pectoral Region

• Fascial layers - epidermis, dermis, tela subcutanea (superficial fascia), investing fascia (deep fascia): a common theme
• Breast support tissue
  • Cutis retinaculum, suspensory ligaments
  • Shortening and dimpling with cancer: scarred to deep fascia
  • Lactiferous glands and ducts: glandular cancer
  • Invasion of pectoral muscles - decisions about radical masectomy
• Lymphatic drainage of the breast
  • Left/right differences, subcutaneous drainages and spread when deep drainages are blocked
  • Breast to superficial inguinal nodes by superficial vessels
  • Breast to other Breast
  • Medial lateral differences
  • Apical nodes and sentinel nodes
• Intercostal brachial cutaneous nerve - lateral branch of T2
  • Theories of referred pain
  • Referred pain from the perturbed heart - male vs. female
  • Lateral thoracic vein: shunt between axillary vein, femoral vein, and paraumbilical veins - caput Medusae
• Surface projections to ribs and vertebra
  • Jugular notch - projection to T2. Imaginary line to T1 - superior border of superior mediastinum
  • Sternal angle - projection to T4 - inferior border superior mediastinum * Counting ribs from T2 (T1 hidden by clavical)

Station 2: Skeleton and Muscles

• Mechanisms/movements of breathing - pump handle (ant/post), bucket handle (transverse), and longitudinal (diaphragm)
  • Joints: costovertebral, costotransverse, costochondral, sternochondral
  • cupped vs planar costotransverse articulation and rotation (pump handle) versus sliding (bucket handle) - articular surfaces
  • Costochondritis
• Breathing movements - babies and pregnant women
  • Babies - Diaphragmatic and minimal thoracic
  • Pregnant women - thoracic and minimal diaphragmatic
• Dermatomal projections versus vertebral projections
  • Use xyphisternal junction as an example - projection = T9(10); dermatome= T7(T8)

Station 3: Thoracic Wall

• Discuss the merit of superficial/deep and anterior/posterior terminology
• Layers of intercostal muscles - external, internal, and innermost intercostal muscles or derivatives
  • Anterior: external intercostal membrane, internal intercostal, transversus thoracis
  • Mid-axillary line: external, internal, and innermost intercostal muscles
  • Posterior external intercostal muscle, internal intercostal membrane, subcostal muscle.
  • Transversus thoracis, innermost intercostal, subcostal muscles are on same fascial plane, define the deep plane of the neurovascular plane
• Costral groove and VAN
  • VAN superior in intercostal space
  • Collateral vessels inferior in intercostal space
  • Two finger method for pleural tap
• Vasculature
  • Internal thoracic artery
  • Anterior posterior intercostal arteries
  • Parent arteries
  • Collateral circulation and coarctation of the aorta