Editing Breast duct excision


== Preparation ==

* Some suggest not expressing for 24 hours to aid identification, or placing a dressing across it for 48 hours prior

== Choice of procedure ==

* Microdochectomy: suspected intraductal papilloma or other single duct disease. Preserves sensation to the nipple and breast-feeding better
* Macrodochectomy: multiple papillomas, ductal ectasia with recurrent subareolar abscesses

== Single duct excision/microdochectomy (for isolated duct) ==

* Supine, GA, Abx, TEDs
* Localise the duct, and try to pass lacrimal probe into duct while holding nipple upward to make it taught (or 2/0 Nylon suture; or try injecting blue dye)
* Circumareolar quadrantic incision to localise duct, one quarter of circumference
** If found, dissect with scissors around duct to lift it up and excise back to nipple dermis, dissect as far as possible, which might be 3-4cm (as per probe). Ligate the lower end.
** If unable to localise duct, excise an area of the ductal system beginning at the nipple and proceeding in a peripheral direction, correlating with the suspected pathological duct. Conversion to a macrodochectomy in a woman with no future need to breastfeed is a sensible idea.
** Mark the specimen - loop to nipple, short superior, long lateral.
* Thorough wash, haemostasis
* LA
* Close subcuticular

== Central duct excision/macrodochectomy/Hadfield's procedure (for excision of more diffuse disease) ==

* Sub-areolar curved incision, up to 50% circumference
* Pass artery forceps behind the mass of ducts and divide with knife
* Dissect all ductal tissue off back of NAC
* Upside-down cone excision of obviously diseased/scarred tissue for 3-5cm proximal
** Use 'cut' on diathermy to get through scarred ductal tissue
** Try to cut back to normal fat, balancing removal of disease with cosmetic issues if too much is resected
* Figure-of-eight Vicryl suture on back of nipple to stop it becoming inverted
* LA
* Sub-cuticular Monocryl closure

== Fistulectomy - excision of the fistula tract, diseased duct, and surrounding inflammatory tissue ==

* Targeted approach
** Insert a probe into the fistula
** Radial ellipse to incorporate edge of nipple, extending laterally through areola
** Excise diseased duct and fistula
** Reconstruct nipple by apposing three sites - apex, base of nipple, and vermillion border of areola
* Another broad approach would be to just do a central duct excision

[[Category:Breast]]