If a patient has a carcinoma, or a suspicious lump in her breast, you have a choice of 5 operations: (1) You can ''shell out' a suspected fibroadenoma from the breast tissue around it. (2) You can do an excision biopsy or ''lumpectomy' to remove the mass and 2 cm of normal breast around it. (3) You can do a simple mastectomy. (4) You can do Patey's modified radical mastectomy as described in the next section. (5) You can excise an intraduct carcinoma.
In operations (1) and (2) you do not remove the nipple or any skin, in (3) and (4) you always do. In (5) you remove some skin but leave the nipple. Dissection of the axilla is only described here as part of Patey's operation.
There are two operations to avoid. (1) If either your histological services or the patient are unreliable, don't take a biopsy, and then hope to do another operation later. She may not return, the report may be lost, and there will be too long an interval between the biopsy and the definitive operation. (2) Don't do a full radical mastectomy[md]it is mutilating and has no advantages over the modified radical operation described here.
SIMPLER BREAST OPERATIONS ''SHELLING OUT' [s7]A LUMP INDICATIONS. This is only indicated if you suspect a fibroadenoma.
METHOD. Proceed exactly as for lumpectomy except that you should shell out the mass without removing 2 cm of normal breast around it.
''LUMPECTOMY' [s7]FOR A MASS IN THE BREAST INDICATIONS. (1) Any suspicious lump less than 5 cm in diameter. (2) A lump of unknown nature more than 5 cm in diameter.
ANAESTHESIA. Ketamine (A 8.1) or general anaesthesia.
INCISION. If you are removing a fibroadenoma from a young woman, try not to scar her breast or to compromise future lactation. Use a periareolar, or circumferential (less satisfactory), or submammary incision (21-5). If these are difficult, use any incision which will give good exposure and allow you to remove the lump.
If you make a periareolar incision, you can remove a lump up to 5 cm or even 8 cm from the nipple. Gently dissect radially through the patient's breast from her areola, in line with the ducts.
If you make an inframammary incision and approach the lump from the back, this will be less easy than removing it through a periareolar or circumferential incision. Use it for deep inferiorly placed lumps.
Cut round the infra-lateral quadrant of her breast. In Caucasians and most Asians the crease under it usually forms a pigmented line. Hold her breast up while you make your incision in this line, and free it from her pectoral fascia. Continue to hold it up while you remove the lump from the back. Incise the posterior surface of her breast, until you have exposed the lump. Grasp it with forceps, and then free it from its bed with a scalpel or curved scissors. Remove it with a margin of at least 2 cm of macroscopically normal tissue.
If an inframammary incision is too difficult, make a circumferential one directly over the lump. This may be necessary, but produces an obvious scar. It will however be less obvious than a radial one.
With all incisions, use a sharp knife. If you suspect malignancy, excise the lump with a margin of at least 2 cm of normal breast. Otherwise (as in a fibroadenoma) shell it out. If necessary, remove the lump with an elliptical segment of breast tissue, with its long axis placed radially. Bleeding is not usually much of a problem. If it is difficult to control immediately, pack the wound with swabs, apply pressure for 5 to 10 minutes, remove the swabs, and then either transfix and tie the bleeding vessels, or control them with diathermy. Close the cavity with interrupted sutures of plain catgut on a half-circle needle.
If the cavity is too large to be completely obliterated by sutures, consider inserting a drain (some surgeons never insert one). Close her subcutaneous tissue with more interrupted sutures, and her skin with 3/0 or 4/0 monofilament. Postoperatively, apply a tight binder (uncomfortable), or a pressure dressing of adhesive strapping (better).
Fig. 21-7 SIMPLE MASTECTOMY. A, make an oblique elliptical incision, centred over the patient's nipple, from its superolateral to its inferomedial margin. B, dissect superolateral and inferomedial flaps. C, continue dissection in all directions to the periphery of her breast. D, dissect it off her pectoralis major. E, close the wound with a drain. A suction drain (preferably ''Redivac') as shown for Patey's mastectomy would be better than the corrugated rubber drain shown here. After Rob C and Smith R, ''Operative Surgery', Vol. 1 (2nd edn), (Butterworth), with the kind permission of Hugh Dudley.
SIMPLE MASTECTOMY INDICATIONS. A lump which is known or suspected to be malignant, and which is too large to remove by lumpectomy.
CONTRAINDICATIONS. An uncertain diagnosis[md]never remove a whole breast when the diagnosis is not proven histologically, and the lump can be removed by lumpectomy (with a 2 cm margin of normal breast). If you don't know the diagnosis, do a lumpectomy.
ANAESTHESIA. Anaesthetize the patient as above. If the mass is ulcerated, suture some gauze squares to it after she is anaesthetized, to minimize contamination.
INCISION. Make an oblique incision from the tail of the her breast superolaterally to its inferomedial margin. Ask your assistant to stretch her skin as you cut. Excise an ellipse of skin to include her nipple. Make it wide enough to let you dissect her breast adequately, and yet not so wide as to make closure difficult. Control bleeding by asking your assistant to press firmly with gauze as you cut.
Dissect back the superomedial and inferolateral flaps, in the plane between her subcutaneous fat (usually 1 to 2 cm thick), and the fat of her breast. Continue the dissection in all directions to the periphery of her breast, where you will meet her pectoralis major muscle. Dissect her breast off this muscle (usually with a knife), clamping bleeding points as you proceed, until you have removed it in toto with the ellipse of skin.
CAUTION ! (1) Don't make the skin flaps too thin, or open up tissue planes more than is necessary. The flaps should be at least 1 cm thick. (2) Don't remove her pectoral fascia, or muscle, unless the tumour is sticking to it. (3) Make the flaps of even thickness.
Then enter her axilla, but only far enough to remove the axillary tail of her breast. The tail only extends a short way into the axilla.
If the tumour is fixed to her pectoral muscle, remove part of it with her breast. You can, if necessary, remove most of it. But if you dissect it along her clavicle, be careful not to damage the vessels deep to the muscle. Remember that this is a Stage Three tumour, and you are not expecting a cure, so don't attempt anything too difficult.
Now control bleeding points by diathermy or tie them with 2/0 plain catgut. Irrigate the wound with warm saline before you close it. Remove any redundant skin, so that the edges of the incision come together cleanly. If you cannot close the wound completely, cover the bare area with a split skin graft (57.2).
Insert a suction drain inferolateral to the incision. A ''Redivac' tube and reusable suction bottle are best. Or use a catheter with extra holes connected to a suction bottle, or, less satisfactorily, to a drainage bag.
Close her wound with plain catgut for the fatty layer, and 2/0 interrupted monofilament sutures for the skin.
POSTOPERATIVELY, cover her breast with layers of gauze and cotton wool, and hold them firmly in place with adhesive strapping. Apply a pressure dressing for 3 or 4 days. Remove the drain when no more blood or serous fluid comes, usually at 3 to 7 days. Remove the stitches after 7 to 10 days, the alternate ones first. Let her use her arm as much as she wishes. Encourage active movement from the 4th day.
Fig. 21-8 EXCISING AN INTRADUCT PAPILLOMA. A, carefully palpate all round the breast to find out which segment the discharge is coming from. B, a lesion in the wall of a duct which might equally well be a duct papilloma or a carcinoma. C, pass a fine probe down the duct, and excise it with some of the surrounding tissue.
EXCISING A DUCT PAPILLOMA [s7]OR CARCINOMA Aim to excise a single duct system with its surrounding tissue. Try to make sure that neither the patient, nor anyone else, squeezes her breast during the 2 or 3 days before you do so in the theatre.
Under general anaesthesia, find the orifice of the affected duct by squeezing the secretion out of it. You may be able to feel the lesion under her areola (see the method for examining a breast for this condition in Section 21.3). Pass a fine probe or a hypodermic needle with a blunt end along the duct. Ask your assistant to hold this, while you excise an oval of skin and breast tissue with the duct and the lesion. Make sure that you excise the probe with a margin of at least 2 cm of macroscopically normal tissue horizontally and vertically all round the duct, except at the nipple. Suture the deeper layers with plain 2/0 catgut to obliterate the dead space. Close her skin with 2/0 or 3/0 monofilament. There is no need for a drain. If haemostasis is not good (unusual), apply a pressure dressing. Send the specimen for histology. Remove alternate stitches at 7 days.
At the first review, if the pathologist reports a papilloma (75% chance), reassure her. If he reports a carcinoma (15%), follow her up carefully each month for at least 6 months. These carcinomas are low-grade, so the operation itself may be sufficient.
DIFFICULTIES [s7]WITH TUMOURS OF THE BREAST If she presents with a GIANT FIBROADENOMA, simple removal may not be practical, and you may have to do a a simple mastectomy. If it only occupies part of the breast, you may be able to shell it out. If you preserve normal breast tissue where you can, her breast may retain its normal shape afterwards.
If a MASS FORMS IN THE SCAR after you have done a lumpectomy or mastectomy for carcinoma, consider the possibility of a local excision.
Fig. 21-9 EXCISING A GIANT FIBROADENOMA. If the mass only occupies part of the breast, you may be able to shell it out like this. Otherwise, you may have to do a simple mastectomy. After Rob C and Smith R, ''Operative Surgery', Vol. 1 (2nd edn), (Butterworth), with the kind permission of Hugh Dudley.