Key principles
• Detailed review of imaging and pathology and in depth discussion with patient • Preservation of skin flaps while maintaining excision of all breast tissue • Planned closure or reconstruction method • Meticulous haemostasis
Mastectomy is the resection of the entire breast tissue including the nipple-areolar complex with appropriate skin closure or reconstruction, usually in the context of the management of breast malignancy.
Specific preoperative preparation
• Ensure indication for Mastectomy and no role for BCS • Review all histology and imaging with discussion in MDT setting • Mark to correct side
Operation Details
• Position supine with arm of side of mastectomy abducted to 80degrees • Prep entire side of chest wall from jaw to upper abdomen and the arm • Free draping of arm, with draping to identify clavicle, midline and costal margin • Pre-op mark appropriate incision • Elliptical incision o Aim to encompass nipple and area of skin over tumour with appropriate margin o Aim to orientate to allow cosmetically acceptable closure • Key steps o Elevate superior then inferior skin flap - Plane between SC fat and breast tissue - Avascular - Flap usually approx. 5mm thick, but differs between people - Frequently check thickness - Flaps helps up by assistant with either skin hooks or Alice forceps o Superior flap raised to upper extent of breast tissue (usually 2nd IC space), and inferior flap to the inframammary fold, both tapering down to pectoralis fascia o In Sup to Inf direction, dissect breast tissue off pectoralis muscle - Ligation of perforating vessels en route, most common in medial muscle and around the lateral edge of Pec Major - Last portion of breast left intact is lateral edge o Dissect breast tissue off lateral chest wall to the level of the anterior border of Latissimus Dorsi o Meticulous haemostasis o Suction drain(s) o Closure skin with deep dermal sutures 3/0 vicryl and 3/0 monocryl SC to skin
Relative anatomy
• Borders of breast o Base 2-6th ribs o Axiallry tail to ant axially line (or further) o Lateral to ant border lat dorsi Intraoperative complications & challenges • Bleeding from perforating vesselsàDiathermy may not be sufficient and likely require suture ligation
Post-operative complications
• Immediate o Intra-op bleeding • Early o Haematoma o Seroma o Infection o Wound dehiscence o Skin flap necrosis o Pain • Late o Scarring/cosmesis o Chronic pain (rare)
Specific post-operative care
• Drain removal once <30-50mls in 24hrs or <7days