mastectomy

Mastectomy entails removal of all the breast tissue, which extends to the clavicle superiority, to the sternum medially, to the infra mammary fold inferiorly, and to the latissimus Doris muscle laterally.

Mastectomy can be performed either with or without reconstruction. For a simple mastectomy performed without reconstruction, a large elliptical incision is made encompassing the nipple areolar complex. Enough skin should be resected such that the remaining skin lies flat against the chest wall and the lateral portion of the incision may need to be tailored to resect any redundant skin. A flat chest wall surface following mastectomy without reconstruction aids in the fitting of a breast prosthesis postoperative.

Mastectomy performed with reconstruction can be done in a skin-sparing or nipple-sparing fashion. A skin-sparing mastectomy includes resection of the nipple and areola but preserves the majority of the skin overlying the breast to allow for reconstruction. A skin-sparing incision commonly consists of a small ellipse including the nipple areolar complex, but can be oriented obliquely or vertically (such as an inverted teardrop). Incision planning should take into account the location of the tumor if it is in close proximity to the skin, and the orientation of the incision should also be planned in concert with the plastic surgeon who will be performing the reconstruction.

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You can also read:  Breast cancer symptoms

Nipple-sparing mastectomy is appropriate in some patients and preserves the entire skin envelope of the breast including the nipple and areola. The preferred options for incision placement are typically in the infra mammary fold or along the anterolateral border of the breast. An anterolateral incision allows for access to the axillary lymph nodes to perform a sentinel lymph node biopsy or an axillary lymph node dissection. Other incisions, such as a lateral horizontal incision, can also be used for a nipple-sparing approach.

Eligibility for nipple-sparing mastectomy depends on the proximity of the cancer to the nipple, as well as risk factors for poor blood supply to the nipple such as large breast size, significant breast ptosis, current smoking status, and longstanding diabetes. Additional risks inherent to nipple-sparing mastectomy include a positive sub areolar margin and nipple necrosis, both of which could necessitate removal of the nipple areolar complex at a later date. The sub areolar margin is the ductal tissue removed from directly underneath the nipple and sent to pathology for examination separately from the main mastectomy specimen. If there is evidence of malignancy in the sub areolar margin, then the nipple should be respected to ensure no disease is left behind.

A modified radical mastectomy includes the removal of the level 1 and 2 axillary lymph nodes in addition to the breast and is indicated for clinically and biopsy-proven positive lymph node involvement. A modified radical mastectomy can be performed with or without reconstruction. If immediate reconstruction is performed, a skin-sparing or nipple-sparing approach can be used.

For patients undergoing modified radical mastectomy for inflammatory breast cancer, reconstruction should be performed in a delayed fashion. Radical mastectomies with resection of the entire pectorals major and minor muscles are rarely performed in the current era, but limited resection of the pectorals muscle is recommended if there is any evidence of pectorals muscle invasion identified on preoperative imaging or discovered inoperative.

 Prevention

Farrar and Fanning50 first described the idea of Y-shaped closure of the mastectomy wound in 1988, and the term fish-shaped incision was introduced by Nowacki and associates in 1991.51 Hussein and coworkers49 performed 30 fish-tail plasties in 28 patients (27 primarily, 3 delayed) to prevent “dog-ear deformity” (Fig. 46-6). They achieved good cosmetic results in all 28 patients, and none required surgical revision. Patients who were older (>70 yr) and obese (BMI > 30) with large breasts (mean weight of resected tissue 1015 g) needed to undergo a fish-tail plasty in their study. This technique did not prolong hospitalisation.

Similarly, Gibbs and Kent52 described their technique for creating a lateral V-Y advancement flap by retracting the lateral apex medially and securing it to the approximated transverse incision about one third of the way medial in the incision (Fig. 46-7). The incision is closed with a newly created Y configuration. Other techniques include extending the ellipse (by further lengthening of the wound) and excising excess tissue. The scar may eventually extend around the back and further diminish the cosmetic result.

Flap length discrepancy is a key factor in the creation of dog ears. Gold 53 described a technique similar to the one we use at our institution whereby skin length of both the superior and the inferior flaps is measured with a silk suture to avoid length asymmetry between both limbs of the ellipse (Fig. 46-8). The technique was applied to over 250 patients and was especially effective in patients with small breasts and relatively large tumors situated large distances from the NAC.

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Breast Reconstruction

sparing mastectomy

Skin-Sparing Mastectomy

Mastectomy techniques have a significant effect on the outcome of autologous breast reconstruction. Since 1996, the skin-sparing mastectomy has been increasingly used in conjunction with immediate autologous breast reconstruction. A skin-sparing mastectomy is typically performed with a periareolar incision and is so named because the skin envelope of the breast is kept intact during the procedure (Fig. 22-1). Thus, the reconstructive surgeon must simply replace the volume of the mastectomy specimen with either autologous tissue or an implant. This approach avoids the challenges associated with shaping the breast during traditional delayed reconstruction.

Medial and superior hollowness of the reconstructed breast

When preparing the mastectomy pocket prior to inset of the TRAM, the infra mammary fold must be inspected. If it has been violated, the fold must be recreated using permanent sutures. An IMF that is obliterated or poorly defined is unsightly and unnatural in its appearance. It is advisable to create the IMF in the primary setting rather than during revisions.

During the inset of the TRAM, a common mistake is failure to secure the TRAM flap sufficiently superior and medial within the mastectomy defect. Illustrates a sub optimal aesthetic result of a TRAM reconstructed breast. The patient is dissatisfied with the medial and superior hollowness of the breast

To avoid this pitfall, the first and most important tacking suture is at the most superior-medial pole of the breast mound (see Fig. 8.17). The most difficult revisions of the reconstructed breast mound involve transposing the entire breast mound more medially and superiority. Therefore this key suture must place the TRAM flap in the mastectomy pocket that is adequately medial and superior from the onset. The next tacking sutures that follow are along the sternal border to ensure a medial flap inset position to provide medial breast volume and desirable cleavage. Superior tacking sutures are then placed with attention directed at creating upper pole fullness that may appear slightly exaggerated at the time of the OR. Super laterally, the TRAM flap is tacked to the remaining soft tissue anterior to the axillary fold. As all autologous tissue reconstructed breasts descend over time, if this step is not performed, an unsightly dis junction will appear between the axilla and breast.

Delayed mastectomy flap necrosis around the TRAM flap

Significant mastectomy flap necrosis around the TRAM flap will result in weeks of dressing changes, psychological distress and delay in adjutant therapy for the patient. The final reconstructive result will be sub optimal with a distorted breast envelope and a widened or hypertrophy scar. Figure 8.25 illustrates significant mastectomy flap necrosis following a free MS TRAM in an immediate breast reconstruction

The risk of mastectomy flap necrosis is greater when a Wise-pattern skin reduction pattern incision is used. It is important to limit this type of skin reduction pattern to situations where an experienced breast surgeon is involved who can provide dependable vascularity to these mastectomy flaps.12 This type of skin design should not be attempted if a previous lumpectomy or core biopsy incision is located on the upper mastectomy skin flaps that restricts superiority based blood supply in the already challenged mastectomy flaps.

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In the case of immediate reconstruction, viability of the mastectomy flaps must be carefully assessed. Any questionable areas of vascularity on the mastectomy flap are removed and replaced with healthy TRAM skin during breast inset. Assessment of mastectomy flap viability is particularly challenging in dark skinned women. In such a scenario or when there is a significant area of possible vascular compromise of the mastectomy flap, then the TRAM flap can be buried under the mastectomy flap with the skin loosely secured. At a second stage 5 to 7 days later after the mastectomy flap has had sufficient time to demarcate, the patient can be brought back to the OR for definitive mastectomy flap trimming and TRAM flap skin island inset.

Mastectomies

Specimen Radiography

  • Mastectomies are generally not sent for radio logic examination by surgeon, as this information is not necessary for surgical procedure
  • Radiography can be very helpful prior to sectioning to identify small lesions or lesions that are not apparent on gross examination (e.g., calcification)
  • Lesions may be lost (e.g., clips) after sectioning or more difficult to identify if transected

In rare cases, small cancer (typically marked by clip) is not removed by mastectomy due to superficial, deep, or far lateral location

Specimen radiography would demonstrate absence of cancer in specimen

Diseases of the Breast

Breast diseases

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Mastectomy versus Breast-Conserving Therapy

Six prospective clinical trials that included more than 4500 patients compared mastectomy versus breast-conserving therapy (Table 35.5). In all these trials, there was no survival advantage for the use of mastectomy over breast preservation. The largest of these trials, NSABP B-06, enrolled 1851 patients with tumors up to 4 cm in diameter and clinically negative lymph nodes. Patients were randomly assigned to undergo modified radical mastectomy, lumpectomy alone, or lumpectomy with postoperative irradiation of the breast without an extra boost to the lumpectomy site. All patients with astrologically positive axillary nodes received chemotherapy. At 20 years of follow-up, OS and DFS were the same in all three treatment groups.

NSABP B-06 provided valuable information about rates of ipsilateral breast cancer recurrence after lumpectomy, with or without breast irradiation. At 20 years of follow-up, local recurrence rates were 14.3% in women treated with lumpectomy and radiation therapy and 39.2% in women treated with lumpectomy alone (P < 0.001). For patients with positive nodes who received chemotherapy, the local recurrence rate was 44.2% for lumpectomy alone and 8.8% for lumpectomy plus radiation therapy.

Another important trial that evaluated breast-conserving therapy was the Milan I trial. This trial enrolled patients with smaller tumors and used more extensive surgery and radiation therapy than the NSABP B-06 trial. There were 701 women with tumors up to 2 cm and clinically negative nodes randomly assigned to undergo radical mastectomy or quadrantectomy with axillary dissection and postoperative irradiation. Patients with pathologically positive nodes received chemotherapy.

OS at 20 years did not differ between the two groups. Loco regional failure rates differed between the groups: Chest wall recurrence occurred in 2.3% of women who underwent radical mastectomy, and ipsilateral breast tumor recurrence occurred in 8.8% of women who underwent quadrantectomy and radiation therapy (20-year follow-up). After quadrantectomy, local failure rates were higher in younger women, with rates of 1% per year in women younger than 45 years and 0.5% per year in older women.

Three other randomised trials in patients with operable breast cancer found no survival benefit of mastectomy over breast-conserving therapy. In the European Organisation for Research and Treatment of Cancer (EORTC) Trial 10801, in which 868 women were randomly assigned to modified radical mastectomy or lumpectomy and irradiation, there was no difference in survival at 10 years. This trial included patients with tumors up to 5 cm, and 80% of women enrolled had tumors larger than 2 cm. Positive margins were allowed, and the results showed lower rates of local recurrence with clear versus involved margins.

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In the Institute Gustave-Roussy trial, 179 women with tumors smaller than 2 cm were randomly assigned to modified radical mastectomy or lumpectomy with a 2-cm margin of normal tissue around the cancer. No differences were observed between the two surgical groups in risk for death, metastases, contralateral breast cancer, or loco regional recurrence at 15 years of follow-up.

Ductal and Lobular Carcinoma in Situ of the Breast

Mastectomy

Mastectomy may be performed either at the request of the patient who may opt for bilateral mastectomy for symmetry or who is a breast cancer gene carrier or due to the extent of DCIS present relative to the volume of the breast. The mastectomy may be either a simple mastectomy, or, if undergoing immediate reconstruction, a skin-sparing mastectomy, or nipple-sparing mastectomy. Reconstruction may be via autologous tissues, tissue ex pander, or direct to implant. For skin-sparing mastectomy, clearance of the DCIS in the breast from the skin and for nipple-sparing mastectomy, a 2-cm margin on imaging between the DCIS and the nipple is recommended.

Prior to commencing a mastectomy, a sentinel lymph node biopsy should be discussed with the patient and, typically, a dual technique of technetium-99 colloid and blue dye is used. With the two injections performed before the mastectomy incision of whichever sort is made, the sentinel nodes are usually detectable and respect able though the mastectomy incision whether a simple mastectomy, skin-sparing mastectomy, or nipple-sparing mastectomy. Mastectomy is usually the only indication for sentinel node biopsy in the setting of DCIS

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For skin-sparing mastectomy, most appropriate where the patient has opted for a mastectomy and the DCIS impinges close to the nipple areolar complex, a circumareolar incision may be enlarged to form an elliptical incision incorporating resection of the nipple and areolar complex. It is, however, worth noting that central excision of the nipple areolar complex for DCIS involving tissues deep to the nipple and areola, rather than mastectomy, may be a good option to conserve the breast if the patient prefers.

A nipple-sparing mastectomy may be considered if the DCIS is no closer than 2 cm from the nipple, and thus unlikely to be involving the nipple areolar complex. For a nipple-sparing mastectomy, an infra mammary incision may be preferred to other approaches and can be extended superiority along the lateral border of the breast to allow ease of access to the axilla for the sentinel lymph node biopsy, obviating the need for a separate axillary incision for the node procedure.

Whichever type of mastectomy approach is used, great care is needed to aim to remove all the breast tissue but not compromise the subcutaneous blood supply to the skin of the breast and, if remaining, the nipple areolar complex. Immediate specimen radiography should indicate that a wide margin has been achieved around the DCIS at mastectomy. If, on final pathology, the margins adjacent to the nipple or areolar are compromised, these structures can be excised as a second procedure. Postoperative radiotherapy is not indicated after mastectomy.

Mastectomy

Mastectomy is, by far, the most effective treatment available for DCIS if our goal is simply to prevent local recurrence. Most mastectomy series reveal local recurrence rates of approximately 1% with mortality rates close to zero.71 in my own series, we have had only one breast cancer death among 467 patients treated with mastectomy (0.2%).

However, mastectomy is an aggressive form of treatment for patients with DCIS. It clearly provides a local recurrence benefit but only a theoretical survival benefit. It is, therefore, often difficult to justify mastectomy, particularly for otherwise healthy women with screen-detected DCIS, during an era of increasing use of breast conservation for invasive breast carcinoma. Mastectomy is indicated in cases of true multicentricity (multiquadrant disease) and when a unicentric DCIS lesion is too large to excise with clear margins and an acceptable cosmetic result.

Genetic positive for one or more of the breast cancer–associated genes is not an absolute contraindication to breast preservation. However, many patients who are genetically positive and who develop DCIS seriously consider bilateral mastectomy.

Mastectomy is used when it is not possible to excise the entire breast tumor with a good cosmetic result, if there is a contraindication to radiotherapy, or if it is the patient’s desire to have a mastectomy. Although there is no strict size cut-off when choosing lumpectomy or mastectomy, lesions larger than 5 cm or patients with multi focal disease are usually approached with mastectomy.

There are exceptions to this. For a patient with newly diagnosed breast cancer, if the workup were to reveal an invasive tumor larger than 5 cm, neoadjuvant chemotherapy may be offered before surgery because it might decrease tumor size and facilitate breast conservation.

Also, the demonstration of multifocal disease is now considered a relative contraindication to breast conservation rather than an absolute contraindication.

Various types of mastectomies are performed today. With a traditional mastectomy, the nipple–areolar complex is removed with an ellipse of skin and underlying breast tissue. A skin-sparing mastectomy suggests that some of the breast skin that would normally have been removed is allowed to remain. The postoperative appearance of a skin-sparing mastectomy is variable in terms of the amount of skin remaining. In some patients the skin left behind may simply be in one quadrant; at its extreme, a total skin-sparing mastectomy removes the nipple–areolar complex but leaves all the remaining breast skin intact.

In the case of a subcutaneous mastectomy, the breast tissue is removed as with a simple (total) mastectomy, except that the nipple–areolar complex is preserved. This is occasionally requested by patients who are having mastectomy for prophylactic reasons and do not want to lose the nipple–areolar complex.

More recently areolar-sparing and nipple-sparing mastectomies have been offered to patients with invasive breast cancer; hence the slightly differing nomenclature in contrast to subcutaneous mastectomy. There is more oncologic soundness in areolar-sparing mastectomy, because breast ductile tissue does not involve the skin of the areola and therefore can be removed with the underlying breast as part of the mastectomy.

In nipple-sparing mastectomy, by definition, some ductal tissue may remain within the nipple itself, as well as in the underlying bud of tissue, which ensures adequate vascularity to the nipple. Although the risk of direct nipple involvement varies among patient subgroups, it is important to point out that that no randomised trials have demonstrated the safety of nipple-sparing mastectomy compared with a traditional simple mastectomy. Typically, no radiotherapy is performed after a nipple-sparing mastectomy to help reduce local recurrence.

After mastectomy, breast reconstruction options include an implant, a latissimus dorsi flap with a tissue expander when significant breast skin has been lost, or a transverse rectus abdominis myocutaneous (TRAM) flap or one of its derivative procedures, such as a deep inferior epigastric perforator (DIEP) flap. . In the case of skin-sparing subcutaneous mastectomy, the surgeon removes the breast tissue as for simple (total) mastectomy but preserves the nipple–areolar complex and inserts a tissue ex pander. Unless there is a medical contraindication to breast reconstruction, patients who choose mastectomy are always offered breast reconstruction with a tissue ex pander or autologous tissue flap. Imaging of the reconstructed breast is typically not performed after ex pander or implant placement or after autologous tissue reconstruction.

Sometimes, reduction mammoplasty may be required on the contra lateral, unaffected breast to achieve symmetry with the treated breast. The appearances of breasts reconstructed with autologous tissue and contra lateral normal breasts that have undergone reduction mammoplasty are characteristic and should not be mistaken for cancer.

Breast cancer recurrences in the unreconstructed mastectomy site are usually detected by physical examination. Because of the low yield of breast cancer detection due to the small amount of breast tissue remaining, surveillance mammography of the mastectomy site is usually not performed.

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