The Slide contains the operative procedure and technique for breast removal.

2. ANATOMY OF BREAST

3. ANATOMY OF AXILLA

4. INTRODUCTION
• Definition: surgical removal of breast tissue partially or
completely.
• In a study conducted in 2004,
• Highest mastectomies were done in Europe 60-70%.
• USA- 56%.
• Australia and New Zealand: 34%.

5. INTRODUCTION
• Most common carcinoma in women.
• 1.3 million women/ yr are diagnosed to have carcinoma breast.
• 77% of incidence seen in women > 50yrs.
• 2nd most common cause of death due to carcinoma.
• 555,000/yr deaths due to carcinoma breast.

6. HISTORY
• 549 A.D: court physician Aetius of Amida proposed to
Theodora.
• 1882: William Halsted- Radical mastectomy.
• 1943: Patey and Dyson- Modified radical mastectomy.
• 1981: Breast conservation surgery.

7. WHEN IS MASTECTOMY INDICATED ?
• Women with carcinoma breast.
• Men with carcinoma breast.
• Extensive benign disease of breast.
• Prophylactic.
• No/ minimal response to systemic therapy to CA breast.

9. TYPES OF MASTECTOMY
1. Total or simple mastectomy:
• Removal of the entire breast
tissue,
• No dissection of lymph
nodes or removal of muscle.
• Sometimes adjacent lymph
nodes are removed along
with the breast tissue.

10. TYPES OF MASTECTOMY
2. Modified Radical
Mastectomy (MRM):
• Removal of breast tissue and
axillary lymph nodes.
• No removal of pectoral
muscle.
• 3 modifications:
a. Patey’s
b. Scanlon’s.
c. Auchincloss.

11. TYPES OF MASTECTOMY
3. Halsted’s Radical Mastectomy:
• Most extensive type.
• Breast tissue, axillary lymph
nodes and pectoral muscles are
removed.
• Disadvantages:
• Bad scars and unacceptable
deformity.
• Reduced range of mobility of
shoulder

12. TYPES OF MASTECTOMY
4. Subcutaneous
mastectomy:
• Simple mastectomy
sparing nipple.
• Rarely done, as a large
amount of breast tissue is
left in situ.
5. Skin sparing mastectomy:
– Total/simple mastectomy or
modified radical mastectomy
with preservation of as much
as breast skin as possible
needed for breast
reconstruction.
– Local recurrence is
acceptable, 0-3%.

13. TYPES OF MASTECTOMY
6. Breast conserving
surgery:
• Wide local excision/Lumpectomy
• Quadrantectomy.

14. TYPES OF MASTECTOMY
7. Extended radical mastectomy:
• Radical mastectomy + enbloc resection
of internal mammary lymph nodes +
supraclavicular lymph nodes.
• Obsolete.
8. Toilet mastectomy:
• Done in fungating or
ulcerative growths.
• Palliative simple
mastectomy.

15. WHICH PROCEDURE IS SUITABLE FOR THE
GIVEN PATIENT ?
• Age
• Size of the tumor
• Axillary lymph node status.
• Stage of the malignancy
• Biologic aggressiveness of the
tumor
• Receptor status of the tumor.
• Multicentricity or multifocality
• Menstrual status.
• Size of the breast
• Availability of radiotherapy.
• Patients choice.
• Prophylactic/therapeutic/ palliative.

16. WHICH PROCEDURE IS BEST ?
• When the tumor size is ≥ 1cm, becomes systemic.
• No single method is considered better in terms of disease free survival or mortality.
• Suitable local therapy + systemic therapy is the most appropriate approach.

17. WHICH PROCEDURE IS BEST ?
• Loco-Regional therapy include:
a. Surgery
b. Radiotherapy
• Systemic therapy:
a. Chemotherapy
b. Hormonal therapy
c. Monoclonal antibodies.
However surgery is important to get rid of gross cancer

18. PRE-OPERATIVE MANAGEMENT
• Assessment.
• Metastatic workup.
• Routine blood investigations.
• Pre-anesthetic evaluation.
• Control of medical conditions like diabetes and hypertension.
• Counseling and written informed consent.
• Parts preparation- neck to mid thigh including pelvic region, axilla
and arm.

19. OPERATIVE PROCEDURES-MASTECTOMY
1. Simple mastectomy.
2. Modified radical mastectomy.
3. Breast conserving surgery.

20. OPERATIVE PROCEDURE
• Anesthesia
• General anesthesia.
• Position
• The patient is placed in supine position with the arm abducted < 90
degree.
• Sandbag or folded sheet is placed under the thorax and shoulder of
affected side.

21. OPERATIVE PROCEDURES- SIMPLE
MASTECTOMY
• Indications:
• Stage I and stage IIa carcinoma
• Large cancers that persist after adjuvant therapy
• Multifocal or multicentric CIS.
• Incision:
• Horizontal elliptical incision is marked so as to include the entire areolar
complex.
• Should be 1-2cm away from the tumor margins.
• Skin sparing incision- if breast reconstruction is planned
• Two skin edges should be of equivalent length

23. SIMPLE MASTECTOMY-PROCEDURE
• Skin incision is deepened with electro-
cautery.
• A plane between breast fat and the
subcutaneous fat, seen as white fibrous
plane.
• Dissection is carried in this plane and flaps
are raised inferiorly and superiorly.
• Ideally thickness of the flap should be 7-
10mm.

24. SIMPLE MASTECTOMY-PROCEDURE
• Extent of dissection:
• Superiorly till clavicle,
• Laterally till P.major lateral border
• Medially to the sternal border, and
• Inferiorly till infra-mammary fold
• Breast tissue along with the pectoral fascia (controversial) is dissected from
the P.major.

25. SIMPLE MASTECTOMY-PROCEDURE
• Usually started superiorly and the proceeded clock-wise ending
in the axillary region.
• Care must be taken to ligate perforating branches of lateral
thoracic and anterior intercostal vessels.
• Lateral branches of the medial pectoral neurovascular bundle is
carefully dissected while removing axillary tail.
• Wound irrigated with sterile water to crenate (shrivel or shrink)
cancerous cells.
• Subcutaneous tissue is closed using 00 absorbable interrupted
sutures.
• Skin closed using 00 non-absorbable mattress sutures or using
staples.

26. OPERATIVE PROCEDURES- MODIFIED RADICAL
MASTECTOMY
• Indications:
• LABC
• Residual large cancers that persist after adjuvant therapy
• Multifocal or multicentric disease.
• Incision:
• Oblique elliptical incision angled towards axilla.
• Should include the entire areolar complex and previous scars, if present.
• Should be 1-2cm away from the tumor margins.
• Two skin edges should be of equivalent length

27. MODIFIED RADICAL MASTECTOMY-PROCEDURE
• Procedure till approaching axilla is
same as simple mastectomy.
• Extent of dissection:
• Superiorly till clavicle,
• Laterally till anterior margin of
latissimus dorsi.
• Medially to the sternal border, and
• Inferiorly till the costal margin near
the insertion of the rectus sheath.

28. MODIFIED RADICAL MASTECTOMY-PROCEDURE
• The specimen is retracted upwards and laterally to expose P.minor.
• The dissection is continued to axillary lymph node clearance.
• Care must be taken not to injure medial pectoral nerve and vessels.
• The axillary investing fascia is incised to expose the axillary group of lymph
nodes.

29. MODIFIED RADICAL MASTECTOMY-PROCEDURE
1. Patey’s procedure:
• The P.minor is removed for better visualization and easy dissection of level III
lymph nodes.
2. Scanlon’s procedure:
• P.minor is retracted to expose level III nodes and dissected out.
3. Auchincloss procedure:
• Level I and II lymph nodes are cleared, level III nodes are left behind.

30. MODIFIED RADICAL MASTECTOMY-PROCEDURE
• The inter-pectoral (Rotter) group of lymph nodes are removed.
• Then dissection can be done either from medial to lateral or vise-
versa.
• The loose lateral areolar tissue in axillary space is dissected to
expose the axillary vein.
• The investing layer of axillary vessels is cut, the tributaries are
transfixed and cut.
• Dissection is carried out laterally including lateral grp (level I) of
lymph nodes.

31. MODIFIED RADICAL MASTECTOMY-PROCEDURE
• Thoracodorsal neurovascular bundle lies over the lat.dorsi, with
nerve more laterally placed, subscapular (level I) nodes are removed.
• The level II lymph nodes between superior trunk of
intercostobranchial bundle and axillary vein are removed.
• The central grp of lymph nodes are removed carefully separating
from axillary vein and its tributaries.
• While dissecting medially, long thoracic nerve is encountered, which
lies anterior to the subscapular muscle. The dissection carried out
anterior and medial to long thoracic nerve and the specimen
delivered.

32. MODIFIED RADICAL MASTECTOMY-PROCEDURE
• Care must be taken while dissecting in axillary area to
preserve,
• Medial and lateral pectoral nerve.
• Long thoracic vessels and nerve
• Nerve to latissimus dorsi.
• Axillary vein.
• Wound irrigated with sterile water to shrink/crenate
cancerous cells.
• 2 drains, 1 below and other above P.major are secured.
• Subcutaneous tissue is closed using 00 absorbable
interrupted sutures.
• Skin closed using 00 non-absorbable mattress sutures or
using staples.

34. PROCEDURES:
Mastectomy

35. POST-OPERATIVE CARE
• Wound examined on post-op day 3.
• Drain can be removed when it is < 30ml.
• Any collection is to be aspirated under aseptic precautions.
• Staples can be removed after 10days.
• Arm movements started in the 1st week..
• Active shoulder and upper limb exercises are started from 2 weeks

38. SCREENING

39. MAMMOGRAM