1. Understand clinical anatomy.
2. Take advantage of positioning.
3. Feel all areas of breast tissue.
4. Expert use of hands.

Breast exams are clinically useful and be successfully employed using a variety of techniques, positions, and one or two hands.

The breasts consist of milk glands and their ducts, but most of the breast is fat tissue. This gives the breast a somewhat nodular, or tapioca-like consistency.

Breast size, density, and nodularity vary with the menstrual cycle. This means that a lumb discovered by the patient at midcycle may disappear just after the menstrual cycle. It is often a good idea to recheck your findings.

During pregnancy, breasts grow in size and density, making accurate detection of abnormalities more difficult.

Beneath the areolar skin are Montgomery’s glands.

The individual ducts are difficult to see, unless the patient is lactating or has a nipple discharge.

There is a bowl-like depression underneath the nipple. While sensitive, it should be palpated during the exam.

While breasts are usually symmetrical, they are not usually identical in size, shape or position. This left breast is substantially larger than the right.

While some view the breast as round, with the nipple in the middle, breast tissue is found more widely on the chest wall and extends into the axilla. The boundaries are the mid-axillary line, the infra-mammary ridge, the sternal border, to the clavicle and back to the axilla. This forms an uneven pentagon.

It is important to not miss any breast tissue. One way to accomplish this is the use of the vertical strip method. Small circles are made with your hands, following a verticle strip pattern. Shift your hands medially until the entire area within the pentagon has been palpated.

Disregard the normal breast nodularity. You are feeling for a mass that is separately identifiable against the background nodularity.Don’t mistake the underlying ribs for a mass.

Axillary, supraclavicular and subclavicular lymph nodes may be palpated if they are enlarged. The supraclavicular and subclavicular nodes are easier to feel if the patient is sitting up, but may also be felt while she is reclining.

Axillary nodes, if they are enlarged, are usually easier to feel with the patient reclining, and with her arm either up or down.

Observing for dimpling or retraction, either through arm raising or squeezing the hips, is best performed while sitting. Sometimes, changing the angle of observation will allow for a better view of any abnormality.

Whenever a patient reports a mass, let her find it for you in the same position she found it in at home. You may then want to change her position for further evaluation of the mass.

When evaluating a breast mass, don’t forget to evaluate the opposite side.

Avoid using the palm of your hand. It is too insensitive. Instead, use these areas of your hands.

This type of exam, using one or two fingers, in an unsystematic fashion, has a fair probability of missing an important breast mass. In contrast, this application of hands using the vertical strip method is not likely to miss anything important. Other systematic approaches may also give good results. The important thing is that all areas of breast tissue are felt.

You will feel some abnormalities using light pressure. Others will be better appreciated with moderate pressure, and some require firm pressure for evaluation.