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Surgery - Mastectomy
Indications
When lumpectomy alone is unable to achieve tumour-free margins, in situ carcinoma or multifocal tumours, patient preference, tumours fixed to underlying muscle, skin, or fungal with accompanying ulceration or bleeding, and bilateral prophylactic mastectomy (e.g., patients carrying the BRCA-1 or BRCA-2 genes) are among the indications for mastectomy in breast cancer cases.
Anatomy
There is a complex network of branching milk ducts that exit on the nipple (from 4 to 18 ducts; the anatomy originally reported by Cooper has been substantially changed in recent years). The breast tissue is composed of fatty and glandular tissue (ratio ranges from 1: 1 to 1: 2 in lactation). With an axillary tail, the base of the breast encloses the second through sixth ribs. Suspensory connective tissue ligaments support the breast tissue by extending from the dermis to the deep fascia.
Vascular: The internal mammary, intercostal, thoracodorsal, lateral thoracic, and thoracoacromial arteries, as well as their perforating arteries, provide the breast's arterial supply and associated venous drainage.
The lymphatic system While the medial half drains into the nodes along the internal mammary artery, the lateral half's lymphatics drain into the axillary nodes, which are made up of the anterior, posterior, lateral, central, and apical groups.
Investigations
Prior to surgery: A triple assessment of the clinical examination, imaging (mammography, ultrasound, or MRI scan), and cytology/histological analysis by FNA or trucut biopsy is used to diagnose tumors. Before a mastectomy, a biopsy should ideally confirm malignancy.
Investigation staging: CT, PET, ultrasonography, bone scans, and CXR scans can all be carried out.
Downsizing the tumor may be accomplished by neoadjuvant chemotherapy.
Blood tests: G&S, clotting, FBC, U&Es, LFT, or crossmatch. general evaluation of anesthesia.
Following surgery: bra insert fitting, DVT prophylaxis, analgesia, physiotherapy to avoid shoulder stiffness, counseling, and support.
Procedure
Complete mastectomy: Excision of the nipple/areola complex, surrounding skin, and all breast tissue
Revision of radical mastectomy:dissection of axillary lymph nodes during a mastectomy
'Halstead' or radical mastectomy:
Mastectomy (no longer practiced) with dissection of the axillary lymph nodes and excision of the pectoralis major and minor
Prolonged radical mastectomy:Internal mammary lymph node resection
Breast-sparing and breast-sparing mastectomy techniques:
preserves the surrounding skin and allows for quick restoration, although they are not appropriate for locally advanced or inflammatory tumors close to the nipple.
Access: To ensure that the wound borders can be approached, an elliptical incision encircling the lesion and nipple is made.
Elevate and meticulously dissect skin flaps, separating subcutaneous and mammary fat to prevent "button holing" in the modified radical mastectomy. Cut superiorly, medially, and inferiorly down to the breast tissue's edge. Dissect the breast tissue free of the fascia enveloping the pectoralis major. Should the tumor be attached, it must be removed using a muscular cuff. go with the lateral dissection until you reach the pectoralis major boundary. Then, go posteriorly to reach the anterior border of the lattisimus dorsi.
Axillary dissection: The axillary vessels, thoracodorsal nerve, artery to thelatissimus dorsi, and long thoracic nerve of Bell, which supplies the serratus anterior, are meticulously identified and preserved during the dissection of the axillary loose areolar tissue. The lateral axillary (level I), subscapular, central (level II), and, if required, subclavicular (level III) nodes are among those removed. Retraction or division of the pectoralis minor is used to remove these nodes up to the costoclavicular ligament.
Closure: After haemostasis is confirmed, two drains—one for the axillary and one for the mammary spaces—are implanted. Subcutaneous and skin sutures are used to approximate and close the wound, preventing "dog ears."
Reconstruction: Following a mastectomy, rapid reconstruction may be achieved by implant-based techniques, autologous tissue techniques (such as latissimus dorsi, transverse rectus abdominus, or deep inferior epigastric perforator flaps), or a combination of these techniques.
On the other hand, breast reconstruction can wait.
Complications
harm to the nerves (e.g., long thoracic nerve, trochodorsal nerve, and intercostobrachial nerve), flap necrosis, seroma, hemorrhage/haematoma, and wound infection.
Long-range: Poor cosmetic outcome, shoulder discomfort, ipsilateral arm lymphoedema, psychological issues, and tumor recurrence.
Indications
When lumpectomy alone is unable to achieve tumour-free margins, in situ carcinoma or multifocal tumours, patient preference, tumours fixed to underlying muscle, skin, or fungal with accompanying ulceration or bleeding, and bilateral prophylactic mastectomy (e.g., patients carrying the BRCA-1 or BRCA-2 genes) are among the indications for mastectomy in breast cancer cases.
Anatomy
There is a complex network of branching milk ducts that exit on the nipple (from 4 to 18 ducts; the anatomy originally reported by Cooper has been substantially changed in recent years). The breast tissue is composed of fatty and glandular tissue (ratio ranges from 1: 1 to 1: 2 in lactation). With an axillary tail, the base of the breast encloses the second through sixth ribs. Suspensory connective tissue ligaments support the breast tissue by extending from the dermis to the deep fascia.
Vascular: The internal mammary, intercostal, thoracodorsal, lateral thoracic, and thoracoacromial arteries, as well as their perforating arteries, provide the breast's arterial supply and associated venous drainage.
The lymphatic system While the medial half drains into the nodes along the internal mammary artery, the lateral half's lymphatics drain into the axillary nodes, which are made up of the anterior, posterior, lateral, central, and apical groups.
Investigations
Prior to surgery: A triple assessment of the clinical examination, imaging (mammography, ultrasound, or MRI scan), and cytology/histological analysis by FNA or trucut biopsy is used to diagnose tumors. Before a mastectomy, a biopsy should ideally confirm malignancy.
Investigation staging: CT, PET, ultrasonography, bone scans, and CXR scans can all be carried out.
Downsizing the tumor may be accomplished by neoadjuvant chemotherapy.
Blood tests: G&S, clotting, FBC, U&Es, LFT, or crossmatch. general evaluation of anesthesia.
Following surgery: bra insert fitting, DVT prophylaxis, analgesia, physiotherapy to avoid shoulder stiffness, counseling, and support.
Procedure
Complete mastectomy: Excision of the nipple/areola complex, surrounding skin, and all breast tissue
Revision of radical mastectomy:dissection of axillary lymph nodes during a mastectomy
'Halstead' or radical mastectomy:
Mastectomy (no longer practiced) with dissection of the axillary lymph nodes and excision of the pectoralis major and minor
Prolonged radical mastectomy:Internal mammary lymph node resection
Breast-sparing and breast-sparing mastectomy techniques:
preserves the surrounding skin and allows for quick restoration, although they are not appropriate for locally advanced or inflammatory tumors close to the nipple.
Access: To ensure that the wound borders can be approached, an elliptical incision encircling the lesion and nipple is made.
Elevate and meticulously dissect skin flaps, separating subcutaneous and mammary fat to prevent "button holing" in the modified radical mastectomy. Cut superiorly, medially, and inferiorly down to the breast tissue's edge. Dissect the breast tissue free of the fascia enveloping the pectoralis major. Should the tumor be attached, it must be removed using a muscular cuff. go with the lateral dissection until you reach the pectoralis major boundary. Then, go posteriorly to reach the anterior border of the lattisimus dorsi.
Axillary dissection: The axillary vessels, thoracodorsal nerve, artery to thelatissimus dorsi, and long thoracic nerve of Bell, which supplies the serratus anterior, are meticulously identified and preserved during the dissection of the axillary loose areolar tissue. The lateral axillary (level I), subscapular, central (level II), and, if required, subclavicular (level III) nodes are among those removed. Retraction or division of the pectoralis minor is used to remove these nodes up to the costoclavicular ligament.
Closure: After haemostasis is confirmed, two drains—one for the axillary and one for the mammary spaces—are implanted. Subcutaneous and skin sutures are used to approximate and close the wound, preventing "dog ears."
Reconstruction: Following a mastectomy, rapid reconstruction may be achieved by implant-based techniques, autologous tissue techniques (such as latissimus dorsi, transverse rectus abdominus, or deep inferior epigastric perforator flaps), or a combination of these techniques.
On the other hand, breast reconstruction can wait.
Complications
harm to the nerves (e.g., long thoracic nerve, trochodorsal nerve, and intercostobrachial nerve), flap necrosis, seroma, hemorrhage/haematoma, and wound infection.
Long-range: Poor cosmetic outcome, shoulder discomfort, ipsilateral arm lymphoedema, psychological issues, and tumor recurrence.
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