Editing Mastectomy (section)

== '''Simple mastectomy''' ==

* '''Principles'''
** Resection of all glandular tissue of the breast
** Dissection down to pectoralis fascia
* '''Pitfalls'''
** Skin flaps too thick or thin
** Tension on wound
** Failure to consider reconstruction and SLNB
* Supine, arm out at 90 degrees on arm board, IV Abx
* Horizontal elliptical incision marked. 
** At the level of the nipple, make a mark at the sternal edge, and around the mid-axillary line (this can be adjusted depending on the amount of breast tissue there). 
** Then retract the breast upwards - mark the lowest point of the inferior ellipse directly below the nipple, at the point where the breast skin sits with the breast retracted upwards. 
** Repeat while retracting the breast downwards.
** The two skin edges should be equivalent length - use a silk tie to both measure and make an impression in the skin. The incisions should come together without tension.
* Incise - just the skin. Use diathermy to go through the remainder of the sub-dermal layer. Ligate any significant vessels. 
* Skin flaps
** Elevated with Allis forceps by assistant (ensure directly upwards to avoid buttonholing), and left hand on back retracting breast tissue, and separate subcutaneous fat from fatty envelope of the breast with monopolar. 
** Constantly re-check flap thickness. 
** Proceed superiorly almost to the clavicle (textbook answer - but generally don't actually go that high), medially to the sternal edge, and inferiorly to the costal margin near the insertion of the rectus sheath. Take virtually all the glandular tissue of the breast. 
** Take lateral dissection to the edge of pec major, or a bit further depending on how much breast tissue there is laterally.
** Skin flaps can be 2-3mm in a thin or young patient, and 5-10mm in an obese or older one
** They are usually thicker in the upper outer quadrant
* Now lift breast off pectoralis major muscle (anterior to fascial layer, although can go posterior for deep or invading tumours).
** Be aware of the perforating branches of internal mammary vessel medially - put a small weck clip on the biggest branches.
* Orient specimen for pathologist.
* Perform SLNB/axillary dissection if needed
* Irrigate, careful haemostasis
* Local anaesthetic
* Place two 10Fr Blakes drains
* Approximate sub-dermal layer with 3/0 vicryl
* Monocryl