1) Mastectomy is the surgical removal of breast tissue, either partially or completely. It is commonly performed to treat breast cancer. 2) There are several types of mastectomy procedures including simple/total mastectomy, modified radical mastectomy, and breast conserving surgery. 3) Factors such as tumor size, lymph node involvement, and patient preferences help determine which mastectomy procedure is most suitable. Post-operative care and follow up is also important after mastectomy.

1. MASTECTOMY
Presenter:
Dr Janardhan T
Post Graduate
Moderator:
Dr Prakash M
Consultant surgeon

2. 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%.

3. 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.

4. 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.

5. 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.

7. 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.

8. 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.

9. 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

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

11. Types of mastectomy
6. Breast conserving
surgery:
– Wide local
excision/Lumpectomy
– Quadrantectomy.

12. Types of mastectomy
7. Extended radical 8. Toilet mastectomy:
mastectomy:
– Done in fungating or
– Radical mastectomy +
ulcerative growths.
enbloc resection of internal
mammary lymph nodes + – Palliative simple
supraclavicular lymph mastectomy.
nodes.
– Obsolete.

13. Which procedure is suitable for the given
patient ?
• Age • Menstrual status.
• Size of the tumor
• Size of the breast
• Axillary lymph node status.
• Availability of
• Stage of the malignancy
radiotherapy.
• Biologic aggressiveness of the
tumor • Patients choice.
• Receptor status of the tumor. • Prophylactic/therapeutic/
• Multicentricity or multifocality palliative.

14. 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.

15. 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

16. Pre-operative management
• Triple 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.

17. Anatomy of breast

18. Anatomy of axilla

19. TNM staging
Stage Tumor Node Metastasis
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage IIA T0 N1 M0
T1 N1 M0
T2 N0 M0
Stage IIB T2 N1 M0
T3 N0 M0
Stage IIIA T0 N2 M0
T1 N2 M0
T2 N2 M0
T3 N1 M0
T3 N2 M0
Stage IIIB T4 N0 M0
T4 N1 M0
T4 N2 M0
Stage IIIC Any T N3 M0
Stage IV Any T Any N M1

20. Operative procedures-Mastectomy
1. Simple mastectomy.
2. Modified radical mastectomy.
3. Breast conserving surgery.

21. 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.

22. 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

24. 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.

25. 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.

26. 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.

27. 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

28. 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.

29. 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.

30. 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.

31. 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.

32. 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.

33. 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.

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

36. Breast conserving surgery
• Method: • Indications:
– Wide local – Stage 0 (CIS), Stage I,
excision/Lumpectomy Stage IIa breast
or Quadrantectomy +
carcinoma.
axillary lymph node
– Single lesion.
clearance +
radiotherapy. – Clinically downstaged
LABC (controversial)

37. Breast conserving surgery
• Contraindications: • Advantages:
– Multicentric tumor.
– Maintenance of appearance
– Positive margins after excision.
and function of breast.
– Size > 4cm (relative).
– Disease free interval is same as
– Advanced stages.
MRM.
– No assess to radiation/ poor patient
compliance. – Better quality of life and
– C/I for radiation: SLE/ Rheumatoid psychological advantage.
arthritis/ Scleroderma/ pregnancy/
prior chest radiation.

38. Breast conserving surgery-Procedure
• Incision-circular/ radial/ subareolar incision near to the tumor,
about 3-4cm.
• Excision of the carcinoma tissue with a margin of atlaeast 1cm
of normal breast tissue to get a 2-mm cancer-free margin.
– If tumor is situated superficially then excision of that part of skin.
– If tumor is deep then tumor is excised till pectoralis major.
• Depending on post-surgical defect
– Primary closure or
– Reshaping of breast tissue is done.

39. Breast conserving surgery-
Lumpectomy
• After skin incision, subcutaneous tissue is deepened using electric
cautery.
• While dissecting the breast tissue, better to use scalpel.
• Care must be taken while dissecting to palpate the tumor, so that
entire lesion is excised. Specimen radiography can be done to check
for clear margins.
• Hemoclips are applied along the margins of the cavity.
• Wound closed in 2 layers:
– Subcutaneous tissue with interrupted inverted 3-0 absorbable suture.
– Skin with subcuticular 3-0 absorbable sutures.

40. Breast conserving surgery-Procedure
Quadrantectomy:
• Usually done for lesion in the upper outer and inner lower
quadrants.
• Radial incision is taken.
• Entire breast tissue in that quadrant is excised till pectoral fascia.
• Wound closed in multiple layers:
– Breast tissue with interrupted 3-0 absorbable suture.
– Subcutaneous tissue with interrupted inverted 3-0 absorbable suture.
– Skin with subcuticular 3-0 absorbable suture.

41. Breast conserving surgery
• Quadrantectomy v/s Lumpectomy.
– Lumpectomy has more local recurrence risk.
– Lumpectomy has better cosmetic outcome.

42. Breast conserving surgery
• After BCS, radiotherapy is essential, otherwise
the local recurrence rate is unacceptably high
• Without radiotherapy, the local recurrence can
be as high as 40%

43. Survival after BCS and
Mastectomy
Trial Endpoint Overall Survival Disease-free Survival
CS&RT Mastect CS&RT Mastect
NCI Milan 18 yrs 65% 65% N/A
Institut Gustav 73% 65% N/A
15 yrs
Roussy
NSABP B-06 12 yrs 63% 59% 50% 49%
NCI USA 10 yrs 77% 75% 72% 69%
EORTC 8 yrs 54% 61%
N/A
Danish Breast 79% 82% 70% 66%
6 yrs
Cancer Group

44. Follow-up after breast conservation
surgery
• Mammogram at 6 months after radiotherapy
• Clinical evaluation and mammogram every
yearly then after.
• If local recurrence detected, mastectomy must
be done.

45. Complications
• Most Common,
– Reduced ROM of the shoulder
– Numbness
– Lymphoedema
– Pain

46. Complications
• Less common,
– Hematoma
– Skin flap necrosis
– Fibrosis
– Winging of scapula
– Postural changes
– Psychological implications
– Chronic/phantom pain

47. Breast reconstruction surgery
• The most common reason of breast reconstruction surgery, is for
psychological well being.
• Reconstructive surgery post mastectomy can be either immediate
or delayed.
– Immediate
• Skin sparing
• Better outcomes
– Delayed
• When immediate reconstruction is contraindicated.
• Other reconstructive options

48. Breast reconstruction surgery
• Types:
– Latissimus dorsi myocutaneous flap.
– Transverse rectus abdominus myocutaneous
(TRAM) flap.

49. References
• F. Charles Brunicardi, editor. Schwartz’s Principles of
surgery. 9th ed. McGraw Hill; 2010. chapter 17.
• Fischer, Josef E, editors. Mastery of Surgery. 5th ed.
Lippincott Williams & Wilkins; 2007. chapter 41-46A.
• DeVita, Vincent T, editors. DeVita, Hellman &
Rosenberg's Cancer: Principles & Practice of Oncology.
9th ed. Lippincott Williams & Wilkins; 2008. chapter 43
• Zollingers atlas of surgical operations. 8th ed.