Mastectomy

Options

• Simple/total mastectomy - complete removal of mammary gland, including NAC
• Modified radical - simple mastectomy + complete axillary lymph node dissection

Preparation

• Mark side
• Imaging in theatre
• Consider need for blue dye/lymphoscintigraphy

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

When to consider NSM/SSM

• Often provides the best cosmetic result for prophylactic mastectomy with immediate recon
• Local recurrence, when done for cancer, is comparable to standard mastectomy
• Nipple-sparing mastectomy (native skin and NAC are preserved)
  • Predominantly used for women with small/moderate, non-ptotic breasts (risk of flap necrosis if the flaps are too big)
  • Indications
    • Tumour does not involve nipple or skin - small, peripherally-located tumours
    • Tumour and glandular breast tissue can be removed with a negative margin
    • Incision and reconstruction choices can bring the nipple to an aesthetically desirable level
  • Contraindications
    • IBC
    • Clinical or radiological involvement of the NAC
    • Nipple retraction
    • Paget disease
    • Bloody nipple discharge
  • Ok with large and small breast, previous radiation, future radiation, and previous mastopexy or reduction.
  • Results
    • Local recurrence rates are about the same as after skin-sparing mastectomy
    • Nipple recurrence is rare, and can be easily treated
• Skin-sparing mastectomy (NAC is removed but the overlying skin is preserved)
  • Indications
    • Prophylactic mastectomy
    • Mastectomy for DCIS
    • Early stage breast cancer with immediate reconstruction
  • Contraindications
    • IBC
  • Technique
    • Make an appropriate incision (below)
    • Elevate skin flaps - same as for mastectomy, and then removing breast tissue from chest wall
    • Handle skin flaps carefully - more fragile than with mastectomy
    • Reconstruct - autologous vs non-autologous (see separate topic)

Post-op

• Generally TEDS with no clexane
• Physio review D1
• Home D1
• Drains stay in until <30mL/24 hours for two consecutive days