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