This document discusses surgical management and breast reconstruction procedures for breast cancer. It describes different types of mastectomies including modified radical mastectomy, simple mastectomy, and breast-conserving surgeries. Complications of mastectomy like lymphedema and lymphangiosarcoma are also outlined. The document then discusses various methods of breast reconstruction including breast implants, flap reconstruction using latissimus dorsi or TRAM flaps, and tissue expansion. Factors influencing the choice of reconstruction and advantages of immediate versus delayed reconstruction are also summarized.

1. Surgical Management and
Breast Reconstruction
Procedures
JONATHAN ABISH DAVID
FINAL YEAR M.B.B.S
S2 UNIT

2. Management of ca breast
MULTIDISCIPINARY APPROACH
Surgery
Radiotherapy
Hormone therapy
Chemotherapy
Targeted therapy

3. Modified radical mastectomy
(AUCHINCLOSS)
 Most commonly performed mastectomy
 INDICATIONS:
•Large tumour size > 5cm.
•Multicentric tumour.
•Surgical lines after lumpectomy are not
free of tumour.

4. Position of the Patient and
Choice of Skin Incision
An elliptical incision is
made from medial
aspect of the second
and third intercostals
space enclosing the
nipple, areola and
tumour
extending laterally
into the axilla along
the anterior axillary
fold

6. Development of Flaps
Raise flaps to the level
of the clavicle
superiorly,
the midline medially,
the anterior rectus
sheath inferiorly,
and the anterior border
of the latissimus dorsi
muscle laterally

7. Removal of Breast from the
Pectoralis Major Muscle
breast and
pectoral fascia
are
removed
medially to
laterally

8. Dissection under the
Pectoralis Major Muscle
 Clean the underside of
the pectoralis major muscle by
removing fatty, areolar, node-bearing
tissue and
exposing the underlying pectoralis
minor muscle.
 Identify and preserve the medial
and lateral pectoral nerves

9. Identification of the Axillary
Vein and Initial Axillary
Dissection
Incise the fascia under the
pectoralis minor muscle
and look carefully for the
underlying
axillary vein

10. Identification of nerves

11. Skin closure and suction
drains
Two
silastic suction drains are placed,
one laterally adjacent to
latissimus
dorsi muscle; another in front of
the pectoralis major muscle

12. Patey’s operation
Tissues removed:
 TUMOUR + Clearance of
Level 1, 2 & 3 Axillary LN +
Pectoralis minor
Tissues preserved:
 Nerve to serratus anterior,
Nerve to Latissmus dorsi,
Intercostobrachial Nerve,
Axillary vein, Cephalic vein,
Pectoralis major.

13. Scanlon’s operation
Pectoralis minor incised
Level 3 LN removed

14. Radical mastectomy of
halsted
 Tissues removed:
Tumour, entire breast, areola, nipple, skin over
tumour, Pectoralis major & minor muscles, fat,
fascia, Level 1,2, 3 Axillary lymph nodes, few
digitations of Serratus anterior muscle.
 Tissues retained:) (ABC)
Axillary vein
Bell’s nerve( nerve to s.anterior)
Cephalic vein

15.  Complications:
Lymphoedema
Lymphangiosarcoma
Because of high morbidity it is not done now.

16. Extended Radical Mastectomy
 Radical Mastectomy +Removal of
Internal MammaryNodes (ipsilateral +/-
contralateral)
 Not done at present

17. Simple mastectomy
 Tumour, entire breast, areola, nipple, skin
over the breast, axillary tail of spence,
pectoral fascia
 Done mainly for phylloides tumour
 In combination with reconstructive surgery,
bilateral total mastectomy is sometimes
used for breast cancer prophylaxis in
carefully selected patients

18. complications
 Injury or thrombosis of axillary vein
 Seroma- 50 to 70%
 Shoulder dysfunction 10%
 Pain (30%) and numbness (70%)
 Flap necrosis/infection

19. Complications
Lymphoedema(15%) and its problems
Axillary hyperaesthesia(0.5-1%)
Winged scapula
Numbness – medial upper part of the
arm – due to intercostobrachial nerve
injury
Medial and lateral pectoral nerve
injury- pectoral muscles atrophy

20. Lymphangiosarcoma
 STEWART-TREVE’S SYNDROME
 Develop in the upper limb of the
patients who have developed
lymphoedema after mastectomy
with axillary clearance.
 Patient presents with multiple
subcutaneous nodules.
 Occurs 3-5 yrs after the
development of lymphoedema.
 Treatment: forequarter
amputation.
 Poor prognosis

21. Breast conservative
surgeries
 Ideally done as wide local excision with
Sentinel lymph node biopsy or axillary
lymph node dissection with RT to breast
and chest wall
 Incision : curvilinear non radial incisions
 Separate incision for axillary dissection.
 Undermining of the skin flap should be
avoided

22.  Confirm tumor clearance by frozen
section.
 RT is must to breast and chest wall.
 Indications: treatment for women
with stage 0, 1 or 2 invasive breast
ca. Stage 2 following neoadjuvant
Chemotherapy

24. INDICATIONS
 Lump <4cm
 Clinically negative axillary nodes
 Mammographically detected lesion
 Adequate sized breast to allow proper
RT to breast
 Breast of adequate size and volume
 Feasibility of axillary dissection and
radiotherapy to intact breast

25. CONTRAINDICATIONS
 Tumour > 4cm
 Pregnancy
 Multicentricity, multifocality
 Central tumour (tumour/breast ratio
more)
 Tumour beneath the nipple
 Extensive intraductal carcinoma
 Earlier breast irradiation
 Inflammatory breast cancer

26. Skin Sparing Mastectomy
 Like a key hole surgery
 Indications
central tumour
multicentral
extensive intra ductal
T1
 Excision of nipple areola complex with
very limited skin removal

27. BREAST RECONSTRUCTION
 The goals of reconstructive surgery
after mastectomy are wound
closure & breast reconstruction.
 Done in young patients with early
stage of disease
 Symmetry is the most important
factor

28. Factors deciding the
reconstruction
 amount of skin retained;
 stage of carcinoma;
 need of radiotherapy or earlier
radiotherapy;
 need for implant

29. BREAST RECONSTRUCTION
Immediate reconstruction
 in early stages and in some selected
advanced cases where response to CT has
been good and after prophylactic
mastectomy.
 not adviced in locally advanced disease.
 advantages: maximum amount of breast skin
is preserved for reconstruction.

30. Delayed reconstruction(3 to 9 months after
surgery)
Indications
 locally advanced disease
 radiation needed in postoperative period
 patient unfit for prolonged surgical procedure
Advantage
 avoids fibrosis and fat necrosis where TRAM flap
is used
 Allows for post operative radiation without
prosthesis exposure

31. Methods of Reconstruction
 Breast Implants – Silicone gel
 Expandable Saline prosthesis
 Flap with implant/expanders
 External breast prosthesis
 Flap reconstruction
1. Latissimus dorsi (LD) flap
2. Contralateral Tranversus Abdominis (TRAM)flap
3. Superior Gluteal flap
4. Ruben’s flap: soft tissue over Iliac crest

32. Breast implants
 Technically simple
 Achieve symmetry easily
 Implant in submuscular plane is better
 If muscle is removed as in radical mastectomy,
then subcutaneous implant is placed.
 Silicon gel implants are used

34. Complications of Implants;
 Pain, exposure of implant and rupture
 Displacement, extrusion
Infection
 Capsular contraction

35. Flap reconstruction

39. Thank You