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Venous drainage of the upper limb (Fig. 29.1)
and hand. Lymph from this group passes to the lateral group of axillary
As in the lower limb the venous drainage comprises interconnected
lymph nodes and thence drains centrally.
superficial and deep systems.
• A small amount of lymph from the radial side of the upper limb
• The superficial system: comprises the cephalic and basilic veins. medial epicondyle. They drain lymph from the ulnar side of the forearm
• The cephalic vein commences from the lateral end of the dorsal drains directly into the infraclavicular group of nodes. This group is
venous network overlying the anatomical snuffbox. It ascends the arranged around the cephalic vein in the deltopectoral groove. From
lateral, then anterolateral, aspects of the forearm and arm and this point the efferent vessels pass through the clavipectoral fascia to
finally courses in the deltopectoral groove to pierce the clavipec- drain into the apical group of axillary nodes and thence centrally.
toral fascia and drain into the axillary vein. This information can be applied to the clinical scenario. If a patient
• The basilic vein commences from the medial end of the dorsal presents with an infected insect bite of the thumb, the infraclavicular
venous network. It ascends along the medial then anteromedial nodes would reactively enlarge. If, however, infection occurred on the
aspects of the forearm and arm to pierce the deep fascia (in the patient’s little finger, lymphadenopathy of the supratrochlear nodes
region of the mid-arm) to join with the venae comitantes of the would result.
brachial artery to form the axillary vein.
The two superficial veins are usually connected by a median cubital The breast (Fig. 29.3)
vein in the cubital fossa. The breasts are present in both sexes and have similar characteristics
• The deep veins: consist of venae comitantes (veins which accom- until puberty when, in the female, they enlarge and develop the capac-
pany arteries). ity for milk production. The breasts are essentially specialized skin
The superficial veins of the upper limb are of extreme clinical import- glands comprising fat, glandular and connective tissue. The base of the
ance for phlebotomy and peripheral venous access. The most com- breast lies in a constant position on the anterior chest wall. It extends
monly used sites are the median cubital vein in the antecubital fossa and from the 2nd to 6th ribs anteriorly and from the lateral edge of the ster-
the cephalic vein in the forearm. num to the mid-axillary line laterally. A part of the breast, the axillary
tail, extends laterally through the deep fascia beneath pectoralis to enter
Lymphatic drainage of the chest wall and the axilla. Each breast comprises 15–30 functional ducto-lobular units
upper limb (Fig. 29.2) arranged radially around the nipple. The lobes are separated by fibrous
Lymph from the chest wall and upper limb drains centrally via axillary, septa (suspensory ligaments) which pass from the deep fascia to the
supratrochlear and infraclavicular lymph nodes. overlying skin thereby giving the breast structure. A lactiferous duct
arises from each lobe and converges on the nipple. In its terminal por-
Axillary lymph node groups tion the duct is dilated (lactiferous sinus) and thence continues to the
There are approximately 30–50 lymph nodes in the axilla. They are nipple from where milk can be expressed. The areola is the darkened
arranged into five groups: skin that surrounds the nipple. Its surface is usually irregular due to
• Anterior (pectoral) group: these lie along the anterior part of the multiple small tuberclesaMontgomery’s glands.
medial wall of the axilla. They receive lymph from the upper anterior • Blood supply: is from the perforating branches of the internal
part of the trunk wall and breast. thoracic artery (p. 13) and the lateral thoracic and thoracoacromial
• Posterior (subscapular) group: these lie along the posterior part of branches of the axillary artery (p. 67). The venous drainage corres-
the medial wall of the axilla. They receive lymph from the upper pos- ponds to the arterial supply.
terior trunk wall down as far as the iliac crest. • Lymphatic drainage: from the lateral half of the breast is to the
• Lateral group: these lie immediately medial to the axillary vein. anterior axillary nodes. Lymph from the medial breast drains into the
They receive lymph from the upper limb and the breast. internal mammary nodes (adjacent to the internal thoracic vessels
• Central group: these lie within the fat of the axilla. They receive beneath the chest wall).
lymph from all of the groups named above.
• Apical group: these lie in the apex of the axilla. They receive lymph Lymph drainage in carcinoma of the breast
from all of the groups mentioned above. From here lymph is passed to The axillary lymph nodes represent an early site of metastasis from prim-
the thoracic duct (on the left) or right lymphatic trunks (see Fig. 3.3), ary breast malignancies and their surgical removal and subsequent
with some passing to the inferior deep cervical (supraclavicular) examination provide important prognostic information as well as a
group. basis for choice of adjuvant treatment. Damage to axillary lymphatics
during surgical clearance of axillary nodes or resulting from radio-
Lymph node groups in the arm therapy to the axilla increases the likelihood of subsequent upper limb
• The supratrochlear group of nodes lie subcutaneously above the lymphoedema.

The venous and lymphatic drainage of the upper limb and the breast 69