Experience with 250 cases of subcutaneous mastectomy

BritishJournalof Plastic Surgery(1982)35, 458-165 0 1982The Trustees of British Association of Plastic Surgeons

0007-1226/82/0420X1458 $02@l

Experience with 250 cases of subcutaneous mastectomy J. TOENNISSEN, Department Germany

J. SCHRUDDE

and W. NIERMANN

of Plastic Surgery, University

of Cologne,

(Director:

Prof. Dr J. Schrudde),

Federal Republic

of

Summary-Subcutaneous mastectomy is a recognised form of curative treatment in cases of carcinoma lobulare in situ and of any atypical proliferative mastopathy. Moreover a subcutaneous mastectomy should be recommended for these patients when multiple biopsies have been performed and long-term mammographic supervision is no longer possible. By using all the existing skin and subcutaneous tissue a good aesthetic result can be achieved and prostheses should only be used -in cases where the existing tissues cannot provide an adequate breast reconstruction. The operative technique developed by Schrudde is described and the results of 250 cases are presented.

The malignant tumour which occurs most frequently in the Western world is carcinoma of the breast. It, is, however, no longer the carcinoma with the highest mortality: since 1974 it has taken second place. to intestinal carcinoma. The lower mortality rate is the result of improved chances of successful treatment brought about by early detection of the disease. Between the ages of 40 and 70, between one to two of every 1000 women develop breast carcinoma so that approximately 16,000 cases present themselves each year in the Federal Republic of Germany, In the light of these facts, subcutaneous mastectomy becomes increasingly important both as a therapeutic and as a prophylactic measure. Satisfactory results in breast reconstruction strengthen still further the case for subcutaneous mastectomy (Fig. 1). Until now pathologists have been unable to give surgeons a clinical picture of the state of the subcutaneous would make breast that mastectomy mandatory and the clinician must therefore weigh the indications from case to case. Where an operation seems advisable, the decision is made easier if the surgeon can reassure the patient that the operation will not produce a mutilated breast. We believe that a subcutaneous mastectomy is equally and absolutely indicated in patients with a lobular carcinoma in situ and in III mastopathy grade patients with a (Prechtel’sclassification: 1972,1975,1982)(Table 1). The lobular carcinoma is one which initially shows no signs of infiltrative growth, frequently 458

appears multifocally and then after 5 to 10 years enters an invasive stage. In patients with mastopathy grade III with parenchymal dysplasia, intraductal proliferation of the epithelium with atypical cytomorphology and histomorphology a subsequent malignancy can be expected in 3.2% of the cases. In our view a relative indication for subcutaneous mastectomy is when long-term control by mammography or thermography becomes difficult or is no longer possible because of previous biopsies. In such cases the nature of new and suspicious changes cannot be accurately assessed without a further invasive diagnostic measure, i.e. yet another biopsy. We also believe that in cases of mastopathy grade II as well, where there is a parenchymal dysplasia

Table

1

Clinical

indications

for

mastectomy 1. Absolute indications (a) (b)

Carcinoma Mastopathy malignancy

lobulare in situ grade III (Prechtel) risk of 3.2%

with a

2. Relative indications (a) Mastopathy grade II (Prechtel) with a malignancy risk of 1.7% (b) Cases in which long term follow-up by mammography is impossible or difficult because of multiple previous biopsies (c) Combination of (a) and (b)

subcutaneous

459

EXPERIENCE WITH 250 CASES OF SUBCUTANEOUS MASTECTOMY

A

B

Fig. 1 A. The pre-operative appearance. B. The result two months after subcutaneous mastectomy.

with intraductal epithelium proliferation but without cytomorphological or histomorphological atypia a subcutaneous mastectomy is indicated. The risk of malignancy in such cases is 1.7% or 1.5 times as high as the normal rate for breast carcinomas of 1.2%. It is now well recognised that the use of a silicone prosthesis to replace the missing breast is not without problems and it is because of these difficulties that we prefer to reconstruct the breast as far as possible with the patient’s own tissues and use implants only when such tissue is insufficient to replace the “missing” volume. Up to the end of 1977 we used a silicone prosthesis in 30% of our reconstructions: since then our preference for using the local tissues has reduced this figure to 11% (Table 2). The method of reduction mammaplasty (described by Schrudde, 1972 and 1979) allows us to perform a complete subcutaneous mastectomy of a large breast and to reconstruct a new breast by using the remaining de-epithelialised tissues (Fig. 2A). In cases where this tissue alone does not suffice for reconstruction, the whole area reaching to the submammary fold is also deepithelialised (Fig. 2B). In this way two triangular dermo-fat flaps are obtained which can be transposed without difficulty under the nipple. This makes augmentation with a silicone prosthesis unnecessary.

In cases where this procedure cannot provide sufficient volume an additional sickle-shaped skin area below the submammary fold is de-epithelialised (Fig. 2C) and transposed in the same fashion. When it is clear at the outset that a simultaneous reconstruction is not possible we use a modification of Schrudde’s technique. A is dearea the areola circular around epithelialised (Fig. 2D). After removal of the mammary gland the wound is closed by invagination of the de-epithelialised zones. In this way a large amount of tissue is built up in the area of the nipple and only a periareolar scar remains. Three months later a silicone prosthesis is inserted from an axillary opening. This procedure has proved particularly successful with small breasts.

Table 2 The declining use of prosthetic implants in breast reconstruction after subcutaneous mastectomy 1, 1971-1977 Total number of reconstructions Reconstruction using a silicone prosthesis 2.

1978-1980 Total number of reconstructions Reconstruction using a silicone prosthesis

146 44

(30.1%)

104 12 (11.5%)

BRITISH JOURNAL

460

B Fig. 2 breast.

OF PLASTIC SURGERY

’

A, B, C, D. Different ways of planning the skin incision for subcutaneous mastectomy according to the size of the

Discussion

We have been using these two techniques since 1971. During the period 1971-1980 we carried out subcutaneous mastectomy of both breasts in 250 cases (Table 3). The age distribution of the

patients shows a peak between the ages of 40 and 50 and of the total number in this series, 205 patients (82%) were between 3i and 50 years of age (Table 4).

EXPERIENCE

WITH

250 CASES

OF

SUBCUTANEOUS

461

MASTECTOMY

B

A Fig. 3 A. Gross hypertrophy described in Fig. 2A.

of the breast.

B. The result four months

after subcutaneous

A Fig. 4

A. Pre-operative

appearance.

mastectomy

following

the pattern

B B. One year after subcutaneous

mastectomy

following

the pattern

described

in Fig. 28.

462

Fig. 5

BRITISH JOURNAL

OF PLASTIC

SURGERY

A. Pre-operative appearance. B. Two months after subcutaneous mastectomy following the pattern described in Fig. 2C.

A

Fig. 6 A. Hypoplasia of the breast. B. Post-operative appearance after a subcutaneous described in Fig. 2D. C. Six months after augmentation by a silicone prosthesis.

C

mastectomy following the pattern

EXPERIENCE

WITH 250 CASES OF SUBCUTANEOUS

Table 3 Bilateral cases (1971-1980)

subcutaneous

mastectomy

40 -

40-

40 37 -

34

0 3 30z k 20“E

in 250

27 19

19

19

12

1971 1972 1973 1974 1975 1976 1977 1970 1979 1980 Year

463

MASTECTOMY

carcinomas were found. This supports our belief that a subcutaneous mastectomy is indicated in such cases. Thus in 21 cases the subcutaneous was followed by a radical mastectomy mastectomy with removal of the axillary lymphatic glands (Table 6). In two other patients we found a solid intraducta- -or cribriform carcinoma with no visible signs of infiltration. In these patients in addition to the subcutaneous mastectomy only the axillary lymphatic glands Age distribution

Table 4

of 250 patients in this series

loo-

The histological diagnosis in all the subcutaneous mastectomy specimens was clearly

established (Table 5). It may appear that in the majority of cases the histological findings could not be regarded as an indication for the subcutaneous mastectomy. However, in all cases the mammography findings were ambiguous. On average, 2.03 biopsies had previously been carried out. These patients live under considerable psychic strain which increases before every new examination until such time as they may have to be told that there can no longer be any doubt and that the breast must be removed. In 25 out of 250 cases, previously undetected

Table 5 Histological mastectomies

diagnosis of the abnormalities

L 9 ‘i; &

50-

$ 2

-30

-40

-50 Age

-60

-70

Note that 205 patients (82% of the total) fell into the 4950 age group

found in 500 mammary

glands from 250 subcutaneous

364

1. Fibrous mastopathy.

2. Fibrous mastopathy with a cystic or adenomatous component

357

3. Intraductal epithelial proliferation

119

4. Sclerosing adenosis

1

117

5. Microcalcitication

74

6. Lipomatous hyperplasia

62

464

BRITISH JOURNAL

Table 6

Treatment of 25 patients with carcinoma in stage T, /T, Radical mastectomy with axillaty lymph node extirpation Subcutaneous mastectomy and axillary lymph node extirpation in cases with cribriform or intraductal carcinoma without infiltration Radical mastectomy refused after subcutaneous mastectomy

21

2 2 25

Total

The procedures we have discussed allow the surgeon to offer an aesthetically acceptable result in every case of subcutaneous mastectomy (Fig. 3). The techniques used are simple and allow a radical excision of the gland with preservation of the areola and nipple (Fig. 4). A very important consideration in our opinion is that only 56 of the 250 patients after subcutaneous mastectomy required the implantation of a silicone prosthesis and that the number of patients requiring a prosthesis has been rapidly declining during the last three years. Under these circumstances subcutaneous mastectomy can no longer be regarded as a mutilating operation (Fig. 5). Of course it is possible to argue about how reliably a carcinoma

were removed. The two remaining patients refused to undergo a radical mastectomy following the subcutaneous mastectomy. The classification of the malignant tumours according to the TNM scheme is presented (Table 7) and in Table 8 Incidence of areolar eight patients axillary metastases were already after subcutaneous mastectomy present. If we add nine previously unrecognised lobular carcinomas in situ to the 25 carcinomas which had also not been diagnosed preoperatively, we arrive at the alarmingly high 1. Partial necrosis of areola figure of 13.6%. This extremely high incidence of 2. Areola and nipple necrosis not diagnosed pre-operatively, malignancy, underlines yet again the correctness of the 3. Areola and nipple transindication for subcutaneous mastectomy. plantation first day after Areolar or nipple necrosis is a direct comsubcutaneous mastectomy plication of subcutaneous mastectomy (Table 8). In three cases an areola and nipple were transplanted on the first post-operative day because of circulatory disturbances. This complication, then, occurs in 6.7% of all operated breasts.

Table 7

Carcinoma

and carcinoma

lobulare

in situ in

250 subcutaneous mastectomies Carcinoma in situ Carcinoma stage T, N, M, Carcinoma stage T,/T, N, M,

13 17 8

Total

38 (15.2%)

Carcinoma in situ known before subcutaneous mastectomy Carcinoma and carcinoma in situ unknown before operation

4 (1.6%)

Total

34 (13.6%)

OF PLASTIC SURGERY

and/or

nipple

necrosis

(1978-1980: 104 cases) Total unilateral bilateral unilateral bilateral

4 1 3 1

4 2 3 2

3

3 14 (6.7%)

in an early stage can be identified by a mammograph. It is however certainly clear that the diagnosis of a small carcinoma presents a great problem in cases of diffuse mastopathy, breast hypertrophy or where the gland tissue has been scarred by previous biopsies. In the light of these considerations and the fact that both patient and surgeon are satisfied with the aesthetic results, we feel justified in recommending that subcutaneous mastectomy should be more widely adopted as a genuine prophylactic measure for breast carcinoma (Fig. 6). The 25 carcinomas and 13 carcinomas in situ which we found in our group of 250 patients certainly support our argument.

EXPERIENCE

WITH 250 CASES OF SUBCUTANEOUS

Note

MASTECTOMY S&wide,

J. (1972). Eine Methode der Mammaplastik.

465 In:

Transacta der III. Tagung der Vereinigung der Deutschen

This paper was presented at the Winter meeting of the British Association of Plastic Surgeons in London in December, 1981.

Plastichen Chirurgen, Kiiln. Schdde, J. (1975). Multiple possibilities of one method of mammaplasty. In: Transactions of the 6th International Congress of Plastic and Reconstructive Surgery, Paris.

References Haagensen, C. D. (1971). Diseases of the Breast. Philadelphia, Eastboume, Toronto: W. B. Saunders Company. Hemmnn, J. B. (1972). Treatment of in situ mammary carcinoma. International Surgery (Chicago), 57, 127. Marx, E., Schulz, E. and Maeeker, R. (1969). Klinische Bewertung der Epithel-proliferation in gutartigen Mammatumoren und Mastopathien. Bruns Beitraege Zur

(1981). Subkutane Mastektomie und Schrudde, J. Rekonstruktion; Zeitschrtft fur Plastische Chirurgie, 5, 208. Zippel, H. H. and Citoler, P. (1973). Klinische und morphologische Untersuchungen bei Patientinnen mit proliferierender Mastopathie und Papillomatose. Geburtshilfe und Frauenheilkunde (Stuttgart), 33, 282.

Klinischen Chirurgie, 217, 220.

Precbtel, K.

(1972). Beziehung der Mastopathie zum Mammakarzinom. Fortschritte der Medizin, 90, 43. Prwhtel, K. (1975). Die Indikation zur subkutanen Mastektomie aus der Sicht des Pathologen. In: Plustische Chirurgie des Kopf und Halsbereichs Brust. Georg Thieme Verlag: Stuttgart.

und der weiblichen

Preehtel, K., Schmidt, H. and C&m, 0. (1982). Langzeitbeobachtung von Frauen mit gesicherter Mastopathie unterschiedlicher Schweregrade (Ein Beitrag zur Fest-Stellung des Entartungsrisikos). In: Rrustkrebs und Brustrekonstruktion (Breast Reconstruction) Internationales 1980. Georg Thieme: Stuttgart.

of

Dr Jiirgen Toennissen, Consultant Plastic Surgeon, Duisburg, West-Germany, formerly Department of Plastic Surgery Cologne. Prof. Dr Dr Josef Scbrudde, Director of the Department of Plastic Surgery, Cologne. Dr Werner Niimann, Senior Registrar, Department of Plastic Surgery, Cologne.

Cancer and Breast Symposium in Miinchen.

Sehrudde, J. (1979). Subcutaneous mastectomy and reconstruction-our procedure; In: Transactions of the 7th International Congress Surgery, Rio de Janeiro.

The Authors

Plastic

and

Reconstructive

Requests for reprints to: Dr Jtirgen Toennissen, Abteilung fur Plastische und Handchirurgie, St. Barbara Krankenhaus, BarbarastraRe 67. 4100 Duisburg-Hambom.