MASTECTOMY: EPIDEMOLOGY INCIDENCE INDICATIONS ANATOMY OF BREAST TYPES OF MASTECTOMY TYPES OF INCISIONS IN MASTECTOMY MANAGEMENT POST SURGICAL MANAGEMENT EARLY COMPLICATIONS LATE COMPLICATIONS BREAST RECONSTRUCTIVE SURGERY

1. Dr. Rohan Gupta
Assistant Professor
Department of Surgery , GMC , Surat.

2. Definition: surgical removal of breast tissue
partially or completely.
• In a study conducted in 2004,
– Highest mastectomies were done in
Europe 60-70%.
– USA- 56%.
– Australia and New Zealand: 34%.

3.  • Most common carcinoma in women.
 – 1.3 million women/ yr are diagnosed to
have carcinoma breast.
 – 77% of incidence seen in women > 50yrs.
• 2nd most common cause of death due to
carcinoma.
 – 555,000/yr deaths due to carcinoma
breast.

4.  • 549 A.D: court physician Aetius of Amida
proposed to Theodora.
 • 1882: William Halsted- Radical
mastectomy.
 • 1943: Patey and Dyson- Modified radical
mastectomy.
 • 1981: Breast conservation surgery.

5. • Most common carcinoma in women.
– 1.3 million women/ yr are diagnosed to have
carcinoma breast.
– 77% of incidence seen in women > 50yrs.
• 2nd most common cause of death due to
carcinoma.
– 555,000/yr deaths due to carcinoma breast

6. • Women with carcinoma breast.
• Men with carcinoma breast.
• Extensive benign disease of breast. •
• Prophylactic. (BRCA 1 AND BRCA 2 mutations)
• No/ minimal response to systemic therapy to
CA breast

11. 1. Total or simple mastectomy:
– Removal of the entire breast
tissue,
– No dissection of lymph nodes
or removal of muscle.
– Sometimes adjacent lymph
nodes are removed along with
the breast tissue.

12. 2. Modified Radical Mastectomy (MRM):
– Removal of breast tissue and axillary lymph
nodes.
– No removal of pectoral muscle.
– 3 modifications:
a. Patey’s
b. Scanlon’s.
c. Auchincloss.

13. 3. Halsted’s Radical
Mastectomy:
– Most extensive type.
– Breast tissue, axillary lymph
nodes and
pectoral muscles are
removed.
– Disadvantages:
• Bad scars and
unacceptable deformity.
• Reduced range of mobility
of shoulder

14. 4. Subcutaneous mastectomy:
– Simple mastectomy sparing nipple
Rarely done as large amount of breast tissue
is left in situ

15. 5. Skin sparing Mastectomy
Total/simple mastectomy or modified radical
mastectomy
with preservation of as much as
breast skin as possible needed for breast
reconstruction.
Local recurrence is acceptable, 0-3%.

16. 6. Breast conserving surgery:
– Wide local excision/Lumpectomy
– Quadrantectomy.

17. 7. Extended radical
mastectomy:
– Radical mastectomy + enbloc
resection of internal mammary
lymph nodes + supraclavicular
lymphnodes
- Obsolete.
8. Toilet mastectomy:
– Done in fungating
or ulcerative growths
-Palliative simple mastectomy

18. • Age
• Size of the tumor
• Axillary lymph node status.
• Stage of the malignancy
• Biologic aggressiveness of
the tumor
• Receptor status of the tumor.
• Multicentricity or
multifocality
• Menstrual status.
• Size of the breast
• Availability of radiotherapy.
• Patients choice.
• Prophylactic/therapeutic/
palliative.

19. • When the tumor size is ≥ 1cm, becomes
systemic.
• No single method is considered better in
terms of disease free survival or mortality.
• Suitable local therapy + systemic therapy is
the most appropriate approach

20. • Loco-Regional therapy include:
a. Surgery
b. Radiotherapy
• Systemic therapy:
a. Chemotherapy
b. Hormonal therapy
c. Monoclonal antibodies.
However surgery is important to get rid of gross cancer

21. • Triple assessment.
• Metastatic workup.
• Routine blood investigations.
• Pre-anesthetic evaluation.
• Control of medical conditions like diabetes
and hypertension.
• Counseling and written informed consent.
• Parts preparation - neck to mid thigh
including pelvic region, axilla and arm.

26.  1. Simple mastectomy.
 2. Modified radical mastectomy.
 3. Breast conserving surgery.

27. • Anesthesia
– General anesthesia.
• Position
– The patient is placed in supine position with
the arm abducted < 90 degree.
– Sandbag or folded sheet is placed under the
thorax and shoulder of affected side.

29.  • Indications:
– Stage I and stage IIa carcinoma
– Large cancers that persist after adjuvant therapy
– Multifocal or multicentric CIS.
• Incision:
– Horizontal elliptical incision is marked so as to
include the entire areolar complex.
– Should be 1-2cm away from the tumor margins.
– Skin sparing incision
- if breast reconstruction is planned
– Two skin edges should be of equivalent length

34.  • Skin incision is deepened
with electro-cautery.
 • A plane between breast fat
and the subcutaneous fat,
seen as white fibrous plane.
 • Dissection is carried in this
plane and flaps are raised
inferiorly and superiorly.
 • Ideally thickness of the flap
should be 7-10mm.

36. • Extent of dissection:
 – Superiorly till clavicle,
 – Laterally till P.major lateral border
 – Medially to the sternal border, and
 – Inferiorly till infra-mammary fold
 • Breast tissue along with the pectoral fascia
(controversial) is dissected from the P.major.

37.  • Usually started superiorly and the proceeded clock-wise
ending in the axillary region.
 • Care must be taken to ligate perforating branches of lateral
thoracic and anterior intercostal vessels.
 • Lateral branches of the medial pectoral neurovascular bundle is
carefully dissected while removing axillary tail.
 • Wound irrigated with sterile water to crenate (shrivel or shrink)
cancerous cells.
 • Subcutaneous tissue is closed using 00 absorbable interrupted
sutures.
 • Skin closed using 00 non-absorbable mattress sutures or
using staples.

38. • Indications:
– LABC
– Residual large cancers that persist after adjuvant therapy
– Multifocal or multicentric disease.
• Incision:
– Oblique elliptical incision angled towards axilla.
– Should include the entire areolar complex and previous scars,
if present.
– Should be 1-2cm away from the tumor margins.
– Two skin edges should be of equivalent length

39. • Procedure till approaching
axilla is same as simple
mastectomy.
• Extent of dissection:
– Superiorly till clavicle,
– Laterally till anterior margin
of latissimus dorsi.
– Medially to the sternal
border, and
– Inferiorly till the costal
margin near the insertion of
the rectus sheath.

40. • The specimen is retracted upwards and
laterally to expose P.minor.
• The dissection is continued to axillary lymph
node clearance.
• Care must be taken not to injure medial
pectoral nerve and vessels.
• The axillary investing fascia is incised to
expose the axillary group of lymph nodes.

41. 1.Patey’s procedure:
– The P.minor is removed for better visualization
and easy dissection of level III lymph nodes.
2. Scanlon’s procedure:
– P.minor is retracted to expose level III nodes and
dissected out.
3. Auchincloss procedure:
– Level I and II lymph nodes are cleared, level III
nodes are left behind

42. • The inter-pectoral (Rotter) group of lymph nodes are
removed.
• Then dissection can be done either from medial to
lateral or vise- versa.
• The loose lateral areolar tissue in axillary space is
dissected to expose the axillary vein.
• The investing layer of axillary vessels is cut, the
tributaries are transfixed and cut.
• Dissection is carried out laterally including lateral grp
(level I) of lymph nodes

43. • Thoracodorsal neurovascular bundle lies over the lat.dorsi,
with nerve more laterally placed, subscapular (level I) nodes
are removed.
• The level II lymph nodes between superior trunk of
intercostobranchial bundle and axillary vein are removed.
• The central grp of lymph nodes are removed carefully
separating from axillary vein and its tributaries.
• While dissecting medially, long thoracic nerve is encountered,
which lies anterior to the subscapular muscle. The dissection
carried out anterior and medial to long thoracic nerve and the
specimen delivered.

44. • Care must be taken while dissecting in axillary area
to preserve,
– Medial and lateral pectoral nerve.
– Long thoracic vessels and nerve
– Nerve to latissimus dorsi.
– Axillary vein.
• Wound irrigated with sterile water to shrink/crenate
cancerous cells
• 2 drains, 1 below and other above P.major are
secured.
• Subcutaneous tissue is closed using 00 absorbable
interrupted sutures.
• Skin closed using 00 non-absorbable mattress
sutures or using staples.

45.  • Wound examined on post-op day 3.
 • Drain can be removed when it is < 30ml.
 • Any collection is to be aspirated under aseptic
precautions.
 • Staples can be removed after 10days.
 • Arm movements started in the 1st week..
 • Active shoulder and upper limb exercises are
started from 2 weeks

46. • Method:
– Wide local
excision/Lumpectomy or
Quadrantectomy
+axillary lymph node clearance
+radiotherapy.
• Indications:
– Stage 0 (CIS),
Stage I,
Stage IIa
breast + carcinoma.
– Single lesion.
– Clinically downstaged LABC
(controversial)

47. • Contraindications:
- Multicentric tumor
– Positive margins after
excision
- Size > 4cm (relative)
– No access to radiation/ poor
patient compliance.
– Advanced stages
– C/I for radiation:
SLE/ Rheumatoid arthritis
/ Scleroderma/ pregnancy/
prior chest radiation
• Advantages:
– Maintenance of appearance.
and function of breast.)
– Disease free interval is same
as MRM.
– Better quality of life and.
- psychological advantage

48.  • Incision-circular/ radial/ subareolar incision near to the
tumor, about 3-4cm.
 • Excision of the carcinoma tissue with a margin of atlaeast
1cm of normal breast tissue to get a 2-mm cancer-free
margin.
– If tumor is situated superficially then excision of that part
of skin.
– If tumor is deep then tumor is excised till pectoralis major.
• Depending on post-surgical defect
– Primary closure or
– Reshaping of breast tissue is done.

49.  • After skin incision, subcutaneous tissue is deepened using
electric cautery.
 • While dissecting the breast tissue, better to use scalpel.
 • Care must be taken while dissecting to palpate the tumor,
so that entire lesion is excised. Specimen radiography can be
done to check for clear margins.
 • Hemoclips are applied along the margins of the cavity.
 • Wound closed in 2 layers:
 – Subcutaneous tissue with interrupted inverted 3-0 absorbable suture.
 – Skin with subcuticular 3-0 absorbable sutures.

50.  Quadrantectomy:
• Usually done for lesion in the upper outer and inner lower
quadrants.
• Radial incision is taken.
• Entire breast tissue in that quadrant is excised till pectoral
fascia.
• Wound closed in multiple layers:
– Breast tissue with interrupted 3-0 absorbable suture.
– Subcutaneous tissue with interrupted inverted 3-0
absorbable suture.
– Skin with subcuticular 3-0 absorbable suture.

51. • Quadrantectomy v/s Lumpectomy.
– Lumpectomy has more local recurrence risk.
– Lumpectomy has better cosmetic outcome.

52. • After BCS, radiotherapy is essential,
otherwise the local recurrence rate is
unacceptably high
• Without radiotherapy, the local recurrence
can be as high as 40%

54.  • Mammogram at 6 months after
radiotherapy
 • Clinical evaluation and mammogram every
yearly then after.
 • If local recurrence detected, mastectomy
must be done.

56. • Most Common,
– Reduced ROM of the shoulder
– Numbness
– Lymphoedema
– Pain

57. • Less common,
– Hematoma
– Skin flap necrosis
– Fibrosis
– Winging of scapula
– Postural changes
– Psychological implications
– Chronic/phantom pain

58.  • The most common reason of breast
reconstruction surgery, is for psychological well
being.
• Reconstructive surgery post mastectomy can be
either immediate or delayed.
– Immediate
• Skin sparing
• Better outcomes
– Delayed
• When immediate reconstruction is
contraindicated.
• Other reconstructive options

60. • Types:
– Latissimus dorsi myocutaneous flap.
– Transverse rectus abdominus myocutaneous
(TRAM) flap.

63.  • F. Charles Brunicardi, editor. Schwartz’s Principles of
surgery. 9th ed. McGraw Hill; 2010. chapter 17.
 • Fischer, Josef E, editors. Mastery of Surgery. 5th ed.
Lippincott Williams & Wilkins; 2007. chapter 41-46A.
 • DeVita, Vincent T, editors. DeVita, Hellman & Rosenberg's
Cancer: Principles & Practice of Oncology. 9th ed. Lippincott
Williams & Wilkins; 2008. chapter 43
 • Zollingers atlas of surgical operations. 8th ed.