General Principle of Mastectomy

Bland KI, Copeland EM, KlimbergVS, Gradishar WJ. 2015.
The Breast: Comprehensive Management of Benign and Malignant Diseases 5th Edition.
Elsiever: Section X page 386-421.
EVOLUTION OF SURGICAL TECHNIQUES FOR
MASTECTOMY
1. Halsted insisted on primary resection of the breast and pectoral muscles before dissection of the axillary contents.
2. Haagensenremoval of the thoracodorsal neurovascular bundle (with neural innervation to the latissimus dorsi
muscle) to allow clearance of the subscapular and external mammary lymphatics that follow the course of this
neurovascular structure.
3. contemporary modifications of the Halsted or Meyer radical mastectomy, with preservation of the long thoracic
nerve, can be performed with little or no increase in morbidity compared with simple mastectomy
4. Patey acknowledged the importance of the complete axillary dissection (levels I, II, and III) and appreciated the
anatomic necessity for preservation of the medial and lateral pectoral (anterior thoracic) nerves, which may serve
as dual innervation to the pectoralis major. In contrast, Auchincloss and Madden advocated modified radical
mastectomies with preservation of both the pectoralis major and minor muscles.
5. All skin flaps should be designed so that the incision incorporates skin and parenchyma at minimum of 1 cm from
the periphery of the tumor in three dimensions. In principle, less skin is excised when lesions are located deep
within the breast and T size is small in transverse diameter (T1 <2 cm)
6. Total mastectomy for operable cancer that is not amenable to conservation surgical techniques has been
addressed previously. In principle, advanced primary lesions (T2 or T3), with pectoralis major fixation, high-lying
lesions, and perhaps some lesions with “grave” signs should be treated with radical or modified radical techniques
Bland KI, Copeland EM, KlimbergVS, Gradishar WJ. 2015. The Breast: Comprehensive Management of Benign and Malignant Diseases 5th Edition.
Variants of the radical mastectomy incision used in the therapy of primary carcinoma of the breast by various surgeons. The
original Halsted incision was revised to avoid encroachment on the cephalic vein, which was preserved in subsequent
procedures.
DESIGN OF INCISIONS FOR MASTECTOMY IN THE TREATMENT OF BREAST CANCER
Central and Subareolar Primary Lesions

depicts the design of the classic Stewart elliptical skin Incision
that is used for mastectomy of subareolar or central breast modified Stewart incision
primaries
LESIONS OF THE UPPER OUTER OR LOWER INNER QUADRANTS
LESIONS OF THE UPPER INNER QUADRANTS
Minimal skin margins of 1 to 2 cm from the primary neoplasm are incorporated in a modified Orr incision
that is slightly oblique from the transverse line with cephalad extension toward the axilla.
HIGH-LYING (INFRACLAVICULAR) LESIONS
SKIN-SPARING MASTECTOMY
Total Mastectomy With Limited Skin Excision: Rationale and Technique of the “Skin-
Sparing” Total Mastectomy
Limited skin excision can be Limited skin excision mastectomy Standards of practice have sequentially
defined as excision of the has the advantage of providing evolved as follows:
nippleareola complex, the better reconstructions, (1) total excision of the breast skin, to
skin around the biopsy site, particularly with myocutaneous
(2) wide excision without primary
and the skin within 1 to 2 cm flaps performed immediately
of the tumor margin. after the mastectomy because it closure, to
saves the entire chest skin and (3) wide excision with primary closure,
almost the entire skin envelope. and finally to
(4) the “skin-sparing total mastectomy.”
FACTORS AFFECTING LOCAL RECURRENCE
Gilliland and coworkers and Johnson and associates determined the necessity of total
mastectomy with and without node dissection; with the exception of:
1. advanced disease (T3 and T4 tumors)
2. immediate breast reconstruction can be completed without any effect on the
quality or duration of survival.
Kurtz(1992) determined that the significant features that correlate with increased risk
are young age at time of primary therapy and the presence of an extensive intraductal
component within the invasive index (primary) neoplasm.
Biologic Factors: Effect on Local Tumor Volume (Size): Effect on Local Recurrence Breast Skin Excision: Effect on Local
Recurrence Recurrence
For patients who are not treated with irradiation after
Contemporary oncologic treatment breast conservation surgery, tumor size is an important Moreover, Dao and Nemoto53 concluded
planning necessitates the determinant of risk for local recurrence, as reported in that “skin recurrence is nothing more than
incorporation of biologic factors data from the NSABP by Fisher and coinvestigators. metastasis at an additional site
related to the tumor phenotype and in patients with widespread disease.
cellular characteristics. The current serial subgross sectioning of mastectomy specimens
method, which uses one variant of that
the mastectomy for all patients, can the percentage of breasts harboring residual foci 2 cm
then be improved through the distal to the edge of the index tumor was similar for T1
design of individual treatment. (T1a, T1b, T1c) cancers (≤2 cm) and those between 2
and 5 cm (T2) in transverse diameter.
Bland KI, Copeland EM, KlimbergVS, Gradishar WJ. 2015. The Breast: Comprehensive Management of Benign and Malignant Diseases 5th Edition. Elsiever: Section X page 386-421.
EVOLUTION OF BREAST SKIN EXCISION WITH MASTECTOMY
Near-Total Excision of the Breast Skin Without Undermining to Develop Skin

Flaps.
- extremely wide skin excision because of the advanced presentation of disease

Radical Mastectomy
at that time (T3, T4) for most patients.
- Primary closure was rarely attempted, except by skin grafting. The wound was
The halstedian principles of complete
routinely allowed to granulate.
mastectomy embodied an anatomic basis
for cancer surgery, which presumed an
improved survival rate with the more Wide Dissection of Skin Flaps With Extensive Skin Removal.
radical extirpative approach.
- Popularized dissection of the breast skin away from the breast tissue
This premise dictated therapy of breast as a thin skin flap.
cancers managed in the halstedian era,
because the majority were T3 and T4
neoplasms. Extremely wide excision of Wide Dissection of Thin Skin Flaps With Less Extensive Skin
skin was estabolished as an absolute Removal.
dictum for the cancer cure;
- Developed thin skin flaps but with less extensive skin removal.
- Primary closure of the skin flaps was usually attempted. A
wide skin excision was essential to cancer control because of the
histologic proximity of the ductal tissue and the breast skin and their
lymphatic-venous connections.
MODIFIED RADICAL
MASTECTOMY Preserved the pectoralis major and minor muscles and advocated low
axillary node dissection (levels I and II) with less extensive skin
resection.
Auchincloss used a horizontal skin closure, whereas Madden used a

vertical skin closure. technique routinely allowed the surgeon to close
the breast skin, with survival results comparable to those of the
operations championed and advocated by Halsted, Meyer, and Patey.
Skin Preservation Procedure
• Breast conservation treatments (lumpectomy radiation and quadrantectomy radiation) 
introduced concept of minimal skin removal in the quadrant of the tumor and nipple-areola
complex preservation, if the latter was clinically uninvolved
• First coined by Bland and associates (1986), and Toth and Lappert (1991)  skin sparing
mastectomy
• In patients with relatively favorable disease
• These patients had limited skin resection, which included the biopsy site, the nipple-areola
complex, and any additional breast skin adjacent to the tumor needed to provide an
adequate histologically free margin of tumor excision.
• skin resection is limited, and all ductal tissue is completely extirpated, as would be completed
for any total glandular mastectomy
• Goal: breast symmetry, form (cleavage), and contour,
• Primarily for patients with AJCC TNM stage 0, I, and early II
• Multicentricity of disease (ductal in situ, any invasive histology)
• Invasive carcinoma associated with an extensive intraductal component that is 25% or more of tumor
volume
• T2 tumors (2–5 cm), especially those with unfavorable features on radiographic or physical examination
that defy confidence in follow-up examination
• A central tumor that would require removal of the nipple-areola complex
• Additional indications include
• In situ cancers of lobular and ductal origin
• Multifocal, minimal breast cancer (Tmic, T1a, T1b)
• All T1 and possibly T2a tumors deep within the breast parenchyma, after neoadjuvant therapy, with
significant cytoreduction of tumor volume
• A positive family history (first-degree relatives) or genetically confirmed oncogene mutagenesis (e.g., BRCA1,
BRCA2) together with worrisome histologic features such as atypical lobular or ductal hyperplasia
• Patients with and without familial inheritable (genetic) disease when physical or radiographic features, or
both, defy confidence in follow-up examination, especially when multiple biopsies are indicated
• Conversely, for patients with large tumors (e.g., ≥5 cm, T3, T4), with attachment to skin and subcutaneous
tissues, with or without ulceration, the SSM technique is inadvisable.
• To achieve total glandular mastectomy, some clinics advocate preservation of the areola by nipple-coring to
enhance esthetic
• May prove ill advised for oncologic procedures that attempt total extirpation of mammary ducts of the nipple-
areola complex
Skin Sparing Mastectomy – Technical
Aspects
Incision Design
• Design of incisions is guided foremost by oncologic principles that place paramount the concern for
locoregional disease control.
• Incision planning jointly by oncologic and plastic surgeons ensures optimal appearance and functional
outcome with mastectomy techniques that enhance these disease control measures.
• Exposure is gained through ample skin incisions, which are placed precisely parallel to the lines of skin
tension
• Incisions are placed below the level of the nipple, laterally and inferiorly, passing around the areola.
• The most satisfactory incisions extend from the areola at 2 to 3 o’clock and 6 to 8 o’clock.
• The lateral incision is contoured upward toward the axilla exactly in the lines of skin tension
Hammond DC, et al. Use of a skin-sparing reduction pattern to create a combination skin-muscle flap pocket in immediate breast reconstruction. Plast Reconstr Surg. 2002;110:206.
Flap Elevation
• After circumscribing the nipple and areola, the skin flaps are elevated widely to reach the axilla and beyond
the entire circumference of the peripheral boundaries of breast parenchyma
• The flaps are dissected on an avascular plane at the level of the Cooper ligaments to preserve the
subcutaneous vascular plexus  decrease incidence of skin flap necrosis
• The most likely complication of SSM is chest skin flap necrosis (18%–20% in most series)
• Inferiorly, dissection should not extend below the inframammary line, which is tattooed with methylene blue
or demarcated with sutures preoperatively.
• Thereafter, skin flaps should be elevated at the subcutaneous tissue level, not at the subdermal level
• Skin flap mobilization is commenced after elevation of periareolar tissues centrally and those continuous with
margins of the excised biopsy scar. T ypical thickness of the skin flap is 6 to 8 mm
Flap Elevation
• With completion of flap elevation in superior and medial boundaries, attention is focused to the inferior most
extent of the boundary dissection. Preoperative marking allows to determine readily the caudad extent of
mammary parenchymal resection
• The mammary bursa facilitates mobilization of the breast off the pectoralis major fascia.
• With axillary dissection, when sentinel nodal sampling of levels I and II or Patey dissection (levels I–III) is
indicated (see Chapters 30 and 31), preservation of the thoracodorsal neurovascular bundle and the long
thoracic nerve are requisite to ensure intact motor innervation of the latissimus dorsi and serratus anterior
muscles
• it is most important to protect the subscapular vascular pedicle and its thoracodorsal branch, which supplies
the latissimus dorsi muscle. Injury of these vessels eliminates the vascular supply and survival of the
latissimus myocutaneous flap
Nipple Sparing Mastectomy
• Nipple-sparing mastectomy (NSM) is now applied for selected breast cancer cases.
• Since the first long-term follow-up studies were published, there is growing evidence of the oncological
safety of these procedures.
• Most commonly used criteria to consider patients for an NSM include
• a distance equal or greater than 2 cm from the nipple-areola complex
• at least 1-cm distance from the skin
• smaller tumors
• low axillary burden of disease
• Preservation of the nipple-areola complex makes this procedure more technically challenging because the
surgeon needs to accomplish the same oncological goals through a smaller access
Reconstruction Considerations
• A well-performed mastectomy will also preserve the subdermal plexus, maintaining good
perfusion to the skin flaps, a critical requirement for immediate breast reconstruction
techniques.
• The essential factor in breast reconstruction is symmetry between the normal breast and
the reconstructed breast.
• There is freedom from concern of developing another cancer in the contralateral breast,
assurance of symmetry, and even improvement of the esthetics of the original breast.
• Increasing experience suggests that no increase in the risk of locoregional recurrence in
the reconstituted breast exists; this locoregional failure rate approximates the recurrence
rate of the modified radical mastectomies.
A B C
D E
A) Anterior-posterior view of a 49-year-old woman presenting

for delayed breast reconstruction. (B and C) Intraoperative
surgical planning of right transverse upper gracilis flap harvest
and inset in the left chest wall using microsurgical techniques
for free tissue transfer. (D and E) Esthetic outcome 6 months
after the initial operation demonstrating a larger native breast
on the right; patient will undergo right breast reduction for
symmetry.
Overview of Reconstruction
• There are two reasons to consider skin conservation in this setting: (1) little justification
exists to remove the usual 10- by 20-cm ellipse of breast skin around the nipple and (2)
preservation of the native breast skin dramatically enhances the quality of the
reconstruction.
• Surgical literature often purports that the purpose of the SSM is to improve “cosmesis.”
• It can be expected in the future that wide skin excision will have limited indications, such
as direct skin invasion or a massive tumor.
Mota BS, Riera R, Ricci MD, et al. Nipple- and areola-sparing mastectomy for the treatment of breast cancer. Cochrane Database Syst Rev. 2016;(11):CD008932.
Factors Influencing Immediate or Delayed
Postmastectomy Reconstruction
• The principal deterrent for breast reconstruction consideration often follows anecdotal ill-
advised consideration of the general oncologic surgeon; previous opinions for an
increased probability of failed (and delayed) tumor detection with recurrent disease in the
reconstructed breast were not supported by objective data.
• only 20% to 50% of patients with early-stage disease choose breast conservation
procedures.
• Overall, the most influential factor for consideration of a procedure was the “fear of
cancer.”
Nold RJ, et al. Factors influencing a woman’s choice to undergo breast-conserving surgery versus modified
radical mastectomy. Am J Surg. 2000;180:413.
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General Principle of Mastectomy

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General Principle of Mastectomy

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Bland KI, Copeland EM, KlimbergVS, Gradishar WJ. 2015.

Central and Subareolar Primary Lesions

Near-Total Excision of the Breast Skin Without Undermining to Develop Skin

- extremely wide skin excision because of the advanced presentation of disease

Auchincloss used a horizontal skin closure, whereas Madden used a

A) Anterior-posterior view of a 49-year-old woman presenting

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