Chapter 46 Mastectomy
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
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
OPERATIVE STEPS
Preoperative Core Needle Biopsy
Wound Infection
• Consequence
• Prevention
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
• Repair
• Prevention
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.
Inability to Reconstruct
• Prevention
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
• Prevention
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
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
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