Technique: Mastectomy

Definitions of Standard Mastectomy Types

• Modified Radical Mastectomy (or Total Mastectomy with formal ipsilateral axillary dissection): This surgical procedure removes the entire breast parenchyma including the nipple-areolar complex. The pectoralis muscles (minor and major) are left intact unless part of it needs to be resected to obtain clear margins. An ipsilateral axillary dissection is included.
• Simple Mastectomy (or Total Mastectomy): This surgical procedure removes the entire breast parenchyma including the nipple-areolar complex. The pectoralis muscles (minor and major) are left intact unless part of it needs to be resected to obtain clear margins. No axillary dissection is included.
• Simple Mastectomy with Sentinel Lymphadenectomy: This surgical procedure removes the entire breast parenchyma including the nipple-areolar complex. The pectoralis muscles (minor and major) are left intact unless part of it needs to be resected to obtain clear margins. An ipsilateral sentinel lymphadenectomy is included.
• Subcutaneous Mastectomy: The entire breast parenchyma is resected while preserving the nipple-areolar complex and its vascular viability. No axillary dissection is performed.
• Skin Sparing Total Mastectomy (or reconstruction ready Mastectomy): This is the equivalent of a total mastectomy (with or without axillary dissection). The skin flaps however are designed to be long and the skin resection is minimal. The actual resection site for the mastectomy is a round incision. This mastectomy is used for immediate reconstruction with breast implants (Becker or standard).

Technical Consideration - Understanding the Anatomy

It is essential for any surgeon and for patients to understand the anatomy of the region. The surgeon should be familiar with the neural structures and the lymphatic drainage patterns as described below.

CLICK TO VIEW THE ANATOMY: BREAST AND REGIONS

The Technique

• Operating Room Setup

The patient is in supine position. The arm on the mastectomy side is extended on a side table. The entire chest and arm are prepped with an antiseptic solution. The patient is draped so the affected breast and axilla are exposed.

• Instructions to the Anesthesiologist

No paralyzing agents should be used for the entire procedure. If needed, short acting agents should be used. Patient should be fully reversed prior to performing the axillary dissection.

Prophylactic antibiotics should be given immediately after induction: Cefizox 2 gm IV.

• The Instruments

• Major instruments tray
• Vascular Hemoclips or USSC atraumatic clip applier (regular size)
• Lahey Clamps
• 2 Blake Drains
• Skin Stapler or Marking Pen

• Technical Steps for THE TOTAL MASTECTOMY

• STEP 1: Drawing and Mapping the Incision and Skin Flap-It is essential for the surgeon to map the procedure. This is crucial in order for the skin flap to be created to have optimal approximation without redundant skin. The best maneuver is to lift the breast upward at the level of the nipple and draw the incision lines at this time. The incisions should create an island of skin which include the nipple-areola complex and the most recent biopsy site. If an immediate reconstruction is considered or planned, the marking on the skin will be different. The oncologic surgeon should plan this initial step of the procedure in conjunction with the plastic-reconstructive surgeon. As a rule, the skin flaps are always longer for immediate reconstruction.

CLICK TO SEE RECONSTRUCTION READY MASTECTOMY

• STEP 2: Making the Incision-The incision is made using a #11 scalpel. The subcutaneous planes are exposed. Hemostasis is obtained with a Bovie/electrocautery.

• STEP 3: Creating the Skin Flaps-Lahey clamps are placed on each edge of the incision. The upper skin flap is first developed by raising the Lahey clamps upward using the electrocautery. The skin flap should be of appropriate thickness. The best maneuver to identify the plane of dissection is to apply significant counter traction. The plane of transection will then become apparent.. The upper skin flap is extended to the clavicula. The lower skin flap is then developed using the electrocautery. It is extended to the aponevrosis recti. Laterally the dissection is extended to the edge of the latissimus dorsi muscle.

• STEP 4: Dissecting and Removing the Breast-Starting at its medial aspect, the skin flaps are retracted and the breast meticulously dissected from the pectoralis major muscle using the electrocautery. Hemostasis is also controlled with the electrocautery. Perforator vessels can be electrocoagulated with the electrocautery. The dissection is extended to the lateral aspect of the pectoralis major muscle.

• STEP 5: Initiating the Axillary Dissection-The Axillary dissection can be performed either as a standard axillary lymphadenectomy or as a Sentinel lymphadenectomy. Refer to the Sentinel Lymphadenectomy Section for additional instructions.

STANDARD AXILLARY LYMPHADENECTOMY

SENTINEL LYMPHADENECTOMY

• STEP 6: Placing the Blake Drain and Closing the Wound-If the patient has opted not to undergo immediate reconstruction, the drain is inserted and the incision closed.

FOR RECONSTRUCTION OPTIONS

If an axillary lymphadenectomy has been completed, two Blake Drains are inserted. One under the skins flaps and one in the axilla at the site of the axillary dissection.

The wound is usually closed either with skin staples or with a subcuticular closure. We do not close the subcutaneous layer. A subcuticular closure can be achieved with a USSC SUBCUTICULAR STAPLER WITH ABSORBABLE PINS*.

Complications

• Injury to the Intercostobrachial ( Sensory) Nerve: This is a common injury to this sensory nerve which can be transected during the axillary dissection. It will result in a permanent numbness in the lateral aspect of the axillary and the inferior aspect of the arm.
• Injury to the Long Thoracic (Motor) Nerve: Although the literature reports it occurs as frequently as in 10% of all cases, we find this is a rare occurrence. It will result in a palsy of the Serratus anterior muscle and clinically will create a classical winged scapula.
• Injury to the Thoracodorsal (Motor) Nerve: This will result in a palsy of the latissimus dorsi muscle.
• Lymphedema: This is a complication which occurs less frequently with the standard axillary dissections performed nowadays. However, it is commonly seen when an axillary dissection is combined with axillary radiation.
• Seroma: One of the main reasons for placing drains is to avoid seromas. Although these drains are left in place for approximately four to five days, occasionally this is not long enough and some patients will develop seromas. Our protocol is to drain these seromas percutaneously with a large gauge needle. This procedure may have to be repeated several times. If more than five times, a serocath or a formal drain is placed in the seroma. Some authors have reported the use of fibrin glue or sealant to decrease the postoperative rate of seromas. Currently, this has not become common practice.
• Redundant Axillary Fat Pad: Upon completion of the procedure, a redundant fat pad may be noticed in the axilla. It is important to resect this fat pad and extra skin, as the patient will complain of the annoying rubbing sensation. In some case, this will only be noticed at a later date and may require a revision of the incision.