Mastectomy

Published on 16/04/2015 by admin

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Last modified 22/04/2025

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Chapter 46

Mastectomy

Anthony Visioni and Julian A. Kim

Introduction

Breast cancer is the most common cancer diagnosed and the second leading cause of cancer mortality in women. Major advances in recent years, including hormonal and monoclonal antibody therapy, have greatly improved outcomes in breast cancer patients. Historically, breast cancer has primarily been a surgically treated disease. In 1894, Halsted (per Dorland’s) and Myers described the landmark radical mastectomy. This operation removes the breast tissue, nipple-areola complex, overlying skin, and pectoralis major and minor muscles, in addition to a complete axillary lymphadenectomy. While the radical mastectomy is effective at improving survival, the procedure carries a high morbidity.

Since then, surgeons have developed techniques to minimize morbidity and maximize survival rates. These procedures include partial mastectomy, simple or total mastectomy, modified radical mastectomy, and nipple-sparing mastectomy. Together these procedures have maintained survival rates in properly selected patients while greatly reducing the morbidity of the Halsted radical mastectomy. The approach to surgical intervention is made on the basis of tumor size in relation to breast size, multifocal disease, bilateral disease, specific pathologic considerations of the tumor, the patient’s genetic status, and patient preference. This chapter addresses the most common surgical interventions, the partial mastectomy and total mastectomy.

Partial Mastectomy

Breast-conserving surgery (i.e. partial mastectomy, lumpectomy, tylectomy, wide local excision, segmental mastectomy) can be considered for early-stage disease (e.g., stages 0, I, and II). When combined with radiation therapy for properly selected patients, breast-conserving surgery has the same survival rate as modified radical mastectomy. Partial mastectomy is increasingly used because the oncologic outcomes are also the same, while improving aesthetics, quality of life, and psychological impact on the patient.

Partial mastectomy is often performed with axillary sentinel lymph node biopsy (SLNB) when the diagnosis of invasive cancer is made. Partial mastectomy can also be performed as excisional biopsy (lumpectomy) without SLNB for a palpable mass or suspicious radiographic finding.

With breast conservation and aesthetics the focus of partial mastectomy, the choice of incision is of great importance (Fig. 46-1, A). Circumareolar incisions provide good cosmesis. Curvilinear incisions that parallel Langer’s lines of tension in the upper half of the breast also work well. In the inferior half of the breast, radial incisions provide good cosmesis. For palpable lesions, the incision should be made directly over the tumor. For nonpalpable tumors localized with a wire, care should be made to make the incision over the expected location of the tumor and not necessarily at the insertion of the wire.

FIGURE 46–1 Partial mastectomy.

Small skin flaps are raised, and then dissection can be performed sharply or with electrocautery. Breast tissue can be grasped with an Allis forceps to facilitate dissection, but care should be used to avoid tearing the tissues (Fig. 46-1, B).

Although currently no consensus exists on margins to obtain for breast-conserving surgery, it is important that the entire lesion is removed with negative margins. Once removed, the specimen must be oriented so that if a margin is positive, another more localized excision can be done (Fig. 46-1, C).

Depending on the size of the breast and the size of the specimen being resected, oncoplastic techniques may be used. For large specimens that may cause dimpling of the skin or obvious deformity, rotation of a portion of breast tissue into the cavity may improve aesthetics. Also, for large breasts and a large specimen, breast reduction techniques may be used to preserve symmetry.

Total Mastectomy

When patients have large tumors in relation to breast size, multifocal disease, or advanced-stage disease, total mastectomy may be the treatment of choice. Other factors, such as patient preference and genetic mutation status, also play an important role in determining surgical treatment options. There is increasing use of genetic testing to screen women at exceptionally high risk for developing breast cancer. Many of these genetically high-risk women are choosing prophylactic mastectomy over close surveillance.

Modified Radical Mastectomy

For most breast cancer patients in whom mastectomy is indicated, the procedure of choice is the modified radical mastectomy. This approach combines total mastectomy (discussed below) with axillary lymph node dissection (see Chapter 49). In the case of prophylactic mastectomy, the typical procedure is the total mastectomy.

The incision for the procedure is typically an ellipse centered on the areola (Fig. 46-2, A). This incision should encompass previous biopsy and excision scars. Methylene blue dye is injected along the superior border of the nipple for SLNB (see Chapter 48).

FIGURE 46–2 Total mastectomy with modified radical technique.

Skin flaps are then raised, typically with the use of skin hooks or rakes to provide tension (Fig. 46-2, B). The skin flaps should be approximately 7 to 10 mm and thick enough to avoid necrosis and buttonholes, but thin enough to resect all breast tissue. These flaps are carried superiorly to the level of the clavicle and inferiorly to the inframammary fold. The flaps should reach the lateral border of the sternum medially and the latissimus dorsi muscle laterally.

Figure 46-2, C, shows a lateral view of the breast with the correct plane of dissection for mastectomy being deep to the pectoral fascia.

The breast is then dissected off the chest wall, starting superiorly at the clavicle (Fig. 46-2, D and E). This dissection continues inferiorly deep to the retromammary fascia and investing fascia of the pectoralis major muscle. The breast tissue is retracted inferiorly as electrocautery is used to dissect the tissue and investing fascia of the pectoralis from the underlying muscle.

Care should be taken to identify perforating vessels from the pectoralis muscle to the breast tissue and divide them accordingly. These vessels can bleed briskly and if divided too close to the pectoralis, they may retract into the muscle.

Breast Removal and Reconstruction

For a total mastectomy, once the dissection has reached the inframammary fold, the breast can be removed and the overlying skin closed with drains in place (Fig. 46-2, F). If a modified radical mastectomy is performed, the lateral border of the breast that is attached to the axilla should be left in place, and the axillary lymph node dissection is completed. This approach will remove a single specimen containing the breast and contents of the axilla.

An important consideration of breast surgery is reconstruction options. It is important to have a candid discussion with patients before any surgical intervention. Also, it is advisable to consult with a reconstructive plastic surgeon to devise an optimal treatment plan for each patient. Some patients may be candidates for mastectomy and reconstruction at the same surgery, whereas others require delayed reconstruction.