Mastectomy

Chapter 46 Mastectomy



Shawna C. Willey, MD, Elizabeth D. Feldman, MD



INTRODUCTION


Although the trend in surgical management of breast cancer is toward less extensive surgery, a significant number of patients are still not candidates for minimally invasive procedures who go on to have a mastectomy. Up to 50% of women who are diagnosed with breast cancer undergo mastectomy as their primary surgical therapy.1 Almost all women with breast cancer are candidates for mastectomy.


The approach to mastectomy has evolved since William Halsted2 first described what is referred to today as the “Halstedian” radical mastectomy in 1894. The Auchincloss modification of the radical mastectomy is most consistent with the modified radical mastectomy (MRM) of today, which includes removal of the entire breast, nipple-areolar complex (NAC), and axillary lymph nodes (levels I, II, and occasionally, III if involved) with preservation of both pectoralis muscles.3


Further modification of the MRM occurred with the development of the total mastectomy, which preserves the axillary lymph nodes as well as both pectoralis muscles. Based on the premise that breast cancer is a systemic disease,4 axillary node dissection is not performed if sentinel lymph node biopsy (SLNB) is negative, because it is unlikely to affect survival and has associated morbidity.5


In addition, skin-sparing mastectomy (SSM) has emerged as another approach to surgical therapy for breast cancer since its first description by Toth and Lappert in 1991.6 SSM involves the removal of breast parenchyma, the NAC, previous biopsy sites, and skin in close proximity to the lesion and preserves the breast envelope, which facilitates the cosmetic result of the breast reconstruction.



INDICATIONS FOR TOTAL MASTECTOMY



• Multicentricity of disease (two or more primary tumors in separate quadrants) or diffuse malignant calcifications

• Persistent positive margins after multiple attempts at breast-conserving surgical procedures

• Recurrence in a breast previously treated with partial mastectomy and radiation

• Tumor size relative to breast size that does not allow for an acceptable cosmetic outcome for breast conservation

• Contraindication to radiation

• Patient preference

The indications for MRM are similar to those for total mastectomy as they relate to treatment of the breast. However, an axillary dissection is performed in conjunction with the mastectomy if a patient has clinically suspicious axillary disease, circumstances that exclude her from undergoing an SLNB, or a positive sentinel lymph node.5


A mastectomy is an operation with low morbidity and mortality and is well tolerated by patients. However, it is not without complications including seroma, hemorrhage and hematoma, wound infection, skin flap necrosis, recurrence, and pain syndromes, and rarer complications such as pneumothorax, chylous fistula, and air embolism.



OPERATIVE STEPS



Step 1 Diagnosis with core needle biopsy (when possible) at two different sites to confirm multicentricity

Step 2 Incision

Step 3 Flap elevation

Step 4 Extent of dissection

Step 5 Wound closure

Step 6 Postoperative concerns


Preoperative Core Needle Biopsy



Wound Infection



• Consequence



Increase in cost, psychological trauma, and cosmetic consequences. Wound infections result in additional medical care including prolonged hospitalization, outpatient physician visits, antibiotics, hospital readmissions, or possible surgical drainage. The rates of wound infection are reported to range from 2.8% to 15%.7–9

Grade 1/2 complication


• Repair



Antibiotics or, if severe, surgical drainage.


• Prevention



Witt and colleagues10 demonstrated that patients who underwent core needle biopsy within 1 to 3 days of a definitive surgical procedure were at significantly higher risk for developing a wound infection (P = .001).10 This effect remained constant even with control for potential confounders such as age, diabetes, benign versus malignant disease, and preoperative marking. The authors suggested increasing the interval between core needle biopsy and definitive surgery but could not recommend an appropriate interval because most of their patients underwent surgery within 24 hours of biopsy.

The use of prophylactic antibiotics has not generally been recommended for clean procedures such as mastectomy. However, in a randomized, double-blind trial of 606 patients undergoing breast surgery (lumpectomy and MRM) with and without perioperative antibiotic prophylaxis, Platt and coworkers11 demonstrated a decrease in infectious complications from 12.2% to 6.6% in those treated with cefonicid no more than 90 minutes prior to incision.11 There were 51% fewer definite wound infections (defined as a wound with erythema and drainage, one with purulent drainage, and/or one opened and reclosed) and the incidence of purulent drainage decreased by 57%. Staphylococcus aureus was the principal pathogen, accounting for 78% of all isolates.



Incision



Skin Flap Necrosis (Fig. 46-1)



• Consequence



Local wound care and possible débridement. The incidence of skin flap necrosis has been estimated to be 11% and is similar in SSM and non–skin-sparing mastectomy.12

Grade 1–3 complication

image

Figure 46-1 A patient with skin flap necrosis after a mastectomy. A, Far-field view of a patient with skin flap necrosis after a mastectomy. B, Close-up view.



• Repair



Hultman and Daiza13 recommend conservative management if possible, including the application of topical antimicrobial creams, minimal débridement, and the use of a supportive brassiere.13 For patients with mode-rate flap loss as evidenced by full-thickness skin necrosis, stable eschars develop and separate in weeks to months, permitting salvage of the flaps. Severe flap loss involving extensive infarction of the skin envelope often requires operative intervention after demarcation of flap viability.


• Prevention



Factors believed to contribute to necrosis include inadequate blood supply to the flap, wound closure under tension, external pressure from compression dressings, obesity, and type of incision (vertical vs. transverse). Hultman and Daiza13 also found that diabetes and a history of radiation as well as increased body mass index (BMI) were associated with native skin flap complications. Interestingly, unlike previous reports, recent or active tobacco use did not seem to contribute to flap necrosis.

Vlajcic and colleagues14 described the use of an omega or inverted omega incision around the NAC in order to preserve the “mesentery-like” horizontal septum of the breast that carries the main vascular and nerve channeling structure of the NAC first noted by Wuringer and associates in 199815 (Fig. 46-2). They proposed that periareolar or circumareolar incisions were inappropriate for peripheral lesions because they mandated tunneling, which can compromise the flaps. The horizontal lateral extension of the omega can be used for tumors in the lateral hemisphere of the breast, axillary dissection, and exposure of the thoracodorsal vessels.


image

Figure 46-2 The omega incision constructed both superior and inferior to the nipple-areolar complex. A, Frontal view. B, Oblique view.


The dissection of skin flaps with a constant thickness is important in maintaining the viability of the flap. The application of clamps (Lahey or Adairs) or skin hooks on the underside of the flap with constant, even tension by the assistant at right angles to the chest wall allows visualization of the dissection plane and flap development. Similarly, long, even strokes with a cautery or knife in parallel with the flap contribute to the “evenness” of the flap and minimize accidental “burns” and “buttonholes.”



Inability to Reconstruct



• Consequence



Diminished cosmetic outcome and psychological trauma.

Grade 1 complication


• Prevention



The choice of incision is dependent both on the location of the primary tumor and on the reconstructive options considered (Fig. 46-3). Generally, a skin-sparing incision with adequate margins is used if immediate reconstruction is planned. Conventional SSM entails the excision of the NAC and previous biopsy scars with the preservation of the skin envelope. The same amount of breast parenchyma is removed. SSM benefits the aesthetic outcomes for all types of reconstruction in that it preserves or accurately restores the inframammary fold (IMF), improves shaping of the breast mound, retains sensibility of the skin envelope, and uses the breast skin in the final reconstruction.16 SSM is not indicated in patients with inflammatory carcinoma, large tumors, and locally advanced disease in which the risk of recurrence is high.17

image

Figure 46-3 Creation of an elliptical incision with respect to the location of the tumor and margins. The vector of the ellipse is modified to include the tumor with appropriate margins. A, Central. B, Upper outer. C, Upper inner. D, Lower outer. E, Lower inner.


An SSM generally includes removal of the NAC as well as all previous biopsy scars, especially if associated with a previous excision with positive margins. Laronga and coworkers18 showed that nodal positivity, subareolar tumor location, and multicentricity were significant risk factors for NAC involvement. Although these authors quoted a NAC positivity for occult carcinoma of 5.6%, a literature review by Cense and colleagues19 found that the NAC was involved in as many as 58% of mastectomy specimens. They concluded that the best candidates for NAC conservation, a new trend in mastectomy, were T1 tumors more than 4 cm from the nipple.


If no reconstruction is planned, a transverse or slightly oblique elliptical incision is used (see Fig. 46-3). Vertical incisions are avoided because they can limit upper extremity range of motion.



Flap Elevation



Seroma Formation



• Consequence



Discomfort, repeated aspiration, and wound infection. Seroma formation arises from the inflammatory exudates and the transection of blood vessels and lymphatics. Some studies have demonstrated an increase in seroma formation with the use of electrocautery compared with scalpel (38% vs. 13%, P = .01),20 whereas others have not found a statistically significant difference.21,22 Seromas not only can cause discomfort but also may delay the start of adjuvant therapy.

Grade 1/2 complication


• Repair



Treatment may include aspiration or placement of a drain if repeated aspiration is unsuccessful.


• Prevention



The use of a closed suction drain beneath the skin flaps may decrease dead-space and subsequent seromas, as first proposed by Murphy in 1947.23 However, Puttawibul and associates24 demonstrated no statistically significant difference in complications in patients with and without drains in the pectoral area. More recently, Jain and coworkers25 demonstrated that the use of suction catheter drainage did not prevent seroma formation and was associated with prolonged postoperative stay and higher postoperative pain scores. In addition, the incidence and rate of seroma formation in patients having mastectomy without drainage but with fibrin sealant installation were both significantly reduced compared with closed drainage as in the standard technique.

The type of drain placed has also been reviewed. Porter and colleagues20 noted in their comparison of Jackson-Pratt to Blake drains that Blake drains were more effective in reducing seroma formation (P = .006). In addition, Coveney and associates26 suggested that suturing the skin flaps to the underlying muscle can minimize seroma formation. They found that the incidence of seroma in patients who underwent closed suction drainage was significantly less (P < .05) and there was a decreased number of seromas in the group that had their flaps sutured compared with those that did not.


Smaller studies have examined the use of the harmonic scalpel in performing the dissection without direct comparison with either electrocautery or scalpel.27,28 It was postulated that the harmonic scalpel has decreased thermal injury compared with electrocautery and results in sealing of vascular and lymphatic channels. Deo and Shukla28 noted a diminished postoperative drain volume in patients with mastectomies performed with harmonic scalpel compared with conventional mastectomy (430 ml/patient vs. 1100 ml/patient).


In contrast to the studies by Jain and coworkers25 noted earlier, there have also been studies using intraoperative fibrin sealant29 as well as sclerosing agents such as tetracycline to reduce dead space30 that have not demonstrated statistically significant decreases in seroma formation compared with control.


The removal of the pectoralis major fascia may also contribute to seroma formation. Dalberg and coworkers31 randomized 247 patients to removal or preservation of the pectoralis major fascia and did not detect a statistically significant difference in seroma formation between groups.



Hemorrhage and Hematoma Formation



• Consequence



Anemia, blood transfusion, and wound infection. Blood transfusion has long been associated with morbidity and mortality with multiple potential and actual adverse effects including allergic reactions and transmission of communicable diseases. The detrimental effect of perioperative blood transfusion on survival after operations for cancer surgery has been reported.32–34 The percent of patients who undergo mastectomy and require blood transfusion is not consistently reported.

Patients may also suffer from postmastectomy pain syndrome secondary to axillary hematoma formation.35 This chronic neuropathic pain syndrome is a long-lasting continuous pain in the axilla, medial upper arm, and lateral chest wall beginning shortly after surgery. The pain is characterized as paroxysms of lancinating pain against a background of burning, aching, and tightening sensations.36–38


Grade 1 complication

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Jun 21, 2017 | Posted by in GENERAL SURGERY | Comments Off on Mastectomy

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