Technique of Mastectomy
The first step is the creation of skin flaps. These are marked preoperatively (Fig. 7.5), the skin is incised with a scalpel, and flaps are raised with either scalpel or electrocautery.
Traction is maintained on the breast with the nondominant hand, and even, upward counter-traction is applied to the skin flaps (Fig. 7.6). The flaps are developed just outside the envelope of superficial fascia around the breast.
The superior extent of dissection is the position where the superficial fascia fuses with the pectoralis fascia. The inferior flap is raised in a similar manner, with the surgeon controlling the skin and the assistant retracting the breast. The inferior extent of the dissection is the fusion of the breast fascia with that over the rectus abdominus.
The breast is then removed from the pectoralis major muscle. Electrocautery or a scalpel is used to divide the fascia over the muscle. The fascia is removed with the breast; this is easier if the dissection proceeds downwards from above (Fig. 7.7). Medially, there are perforating vessels from the internal thoracic artery.
In the second and third intercostal spaces, these vessels are large and may require ligation. If an axillary dissection is part of the treatment, the mastectomy is carried to the lateral edge of the pectoralis major, then the clavipectoral fascia is excised to enter the axilla. If the operation is a total mastectomy (i.e., for DCIS), the mastectomy is continued superficial to the clavipectoral fascia to the anterior border of latissimus dorsi. The axillary tail of the breast continues around the lateral border of the pectoralis major, and this must be removed to ensure near complete excision of all breast tissue.
During this phase of the dissection, the medial pectoral nerve is at risk but may be sacrificed with no ill sequelae.
After hemostasis is confirmed, the wound is irrigated and a closed suction drain placed over the pectoralis major. The wound is approximated with interrupted subcutaneous sutures, and the skin is closed with a subcuticular suture (Fig. 7.8).
Patrick I. Borgen and Bruce Mann
Breast conservation therapy for invasive carcinoma of the breast. Current Problems in Surgery 1995; 33:189-256.
Fig. 7.2. The skin and subcutaneous tissue is incised down to the vicinity of the mass.
Fig. 7.3. The mass is grasped with a clamp and excised using sharp dissection.
Fig. 7.4. The wound is closed with a subcuticular suture and steri-strips. The cavity is not closed.
Fig. 7.5. Skin flaps are marked to include the biopsy site. Enough skin is removed to result in a flat scar.
Fig. 7.6. Skin flaps are developed with upward traction on the skin, and countertraction on the breast. The breast is removed with its fascial envelope.
Fig. 7.7. The breast is removed along with the pectoralis fascia in a superomedial to inferolateral direction.
Fig. 7.8. The wound is closed over a suction drain (illustration shows a second drain in the axilla) using a subcuticular suture and steri-strips.
Fig. 7.9. Schematic diagram showing the incision for an axillary dissection and the extent to which flaps are elevated.
Fig. 7.10. Incision of the clavipectoral fascia along the lateral edge of the pectoralis minor and below the axillary vein. The position of the vein is outlined.
Fig. 7.11. Axillary dissection in progress. The anterior tributary of the axillary vein has been divided, the intercostobrachial nerve has been preserved and the long thoracic nerve identified.
Fig. 7.12. Advanced stage of axillary dissection. The thoracodorsal nerve has been preserved, and the tissue between the long thoracic and thoracodorsal nerves has been removed.
- Veronesi U, Saccozzi R, Del Vecchio M et al. Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiation therapy in patients with small cancers of the breast. N Engl J Med 1981; 305:6-11.
This is the landmark report of the first randomized prospective trial of breast-conservation therapy.
- Fisher B, Bauer M, Margolese R et al. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med 1985; 312:665-73.
This is the first report of the major North American trial of breast-conservation therapy from the NSABP.
- Borgen PI, Heerdt AS, Moore MP et al. Breast conservation therapy for invasive carcinoma of the breast. Current Problems in Surgery 1995; 33:189-256.
This is a review of all aspects of breast-conservation therapy.
- Fisher B, Costantino J, Redmond C et al. Lumpectomy compared with lumpectomy and radiation therapy for the treatment of intraductal breast cancer. N Engl J Med 1993: 1581-6.
This is the major trial of conservative therapy for DCIS
- Adair F, Berg J, Joubert L et al. Long-term follow-up of breast cancer: the 30-year report. Cancer 1974; 33:1145-50.
This is an older report from the days before adjuvant therapy that demonstrates the effectiveness of surgery in node-positive disease.
- Fisher B, Redmond C, Fisher E et al. Ten year result of a randomized clinical trial comparing radical mastectomy and total mastectomy with of without irradiation. N Engl J Med 1985; 312:674-81.
This is a very influential trial that showed that less-extensive surgery had similar results to radical mastectomy.
- Warmuth MA, Bowen G, Prosnitz LR et al. Complications of axillary lymph node dissection for carcinoma of the breast: a report based on a patient survey. Cancer 1998; 83:1362-8.
This report gives a good idea of the range of complications after axillary dissection.