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Subcutaneous mastectomy by extended periareolar incisions
Subcutaneous Mastectomy by Extended Periareolar Incisions W. Edward Dalton, MD, Oklahoma City, Oklahoma Paul Silverstein,
MD, Oklahoma City, Oklahoma
J. Michael Kelly, MD, Oklahoma City, Oklahoma
Complete removal of all breast tissue cannot be accomplished by subcutaneous mastectomy. However, by simply transferring the incision from the routine inframammary position to the periareolar area and extending it laterally, one has access to the axillary extension of the breast as well as to the superior and medial glandular elements that are difficult to excise from below. Hicken [1] has stated that “simple mastectomy is an operation frequently attempted but seldom accomplished.” He demonstrated by dye injection the anatomic extension of the mammary gland, and he suggested an operative technic that would ensure the maximal removal of breast tissue. Except for the tissue left with the nipple and areolar area, we believe an extended periareolar incision will allow dissection of the breast and axilla as completely as the oblique incision advocated by Hicken [I]. The chief advantage of this technic is that it allows removal of tissue from the axilla that might later undergo pathologic changes. Technic
The arms are abducted, and the breasts, axillae, shoulders, neck, and upper abdomen are prepared and draped. The incisions extend around the inferior margin of the areolar area through an arc of 180 degrees and then continue to the anterior axillary line. (Figure 1.) Dissection is in t,he subcutaneous space close to the skin. Care is taken to avoid dissecting into the mammary tissue except where a small amount of ductal tissue extends into the nipple. The dissection is under direct vision medially to the sternum, laterally to the midaxilla, superiorly to the clavicle, and inferiorly to the rectus fascia. The breast is then freed
From the Department of Surgery, Divison of Plastic Surgery, Oklahoma University Health Science Center, and The Oklahoma Baptist Medical Center, and Mercy Health Center, Oklahoma City, Oklahoma. Reprint requests should be addressed to Edward Dalton, MD, Department of Surgery, Oklahoma University Health Science Center, Oklahoma City, Oklahoma 73106. Presented at the Thirtieth Annual Meeting of the Southwestern Surgical Congress, Palm Springs, California, April 17-20, 1976.
Volume 136, December
1976
from the underlying pectoralis and serratus muscles. The axillary breast frequently extends beneath the lateral margin of the pectoralis major muscle and high into the axilla. The resected tissue is submitted to the pathologist, and reconstruction is delayed until frozen section examination indicates that no malignancy is present. Our reconstruction utilizes submuscular insertion of saline- or gel-filled prostheses (round, without backing). We originally detached the pectoralis muscle inferiorly and to the fifth interspace medially to allow for low placement of the prosthesis. We have subsequently changed to subpectoral and subserratus insertion of the implants via incisions in the serratus anterior. Suction catheters are left in the submuscular and subcutaneous spaces, and the wounds, including the muscle incisions, are closed in layers of nonabsorbable sutures. Moderate pressure is applied with elastic bandages to prevent the implants from riding high beneath the pectoralis major muscle and into the axilla. We modify our incisions in the pendulous breast so that the nipple-areolar complex can be repositioned either by dermal pedicle or, preferably, by a free graft. This modification includes a vertical component to the extended periareolar incision which allows for the removal of redundant skin. Clinical Experience
In a series of fifty-six consecutive patients who underwent subcutaneous mastectomy with at least an eight month follow-up, we found many indications for surgical consultation. These included: fibrocystic disease with numerous breast biopsies (48 patients, 86 per cent); fibrocystic disease with mastodynia unrelieved by medical management (34 patients, 61 per cent); radiographic changes in breast tissue indicating a risk of mammary cancer (5 patients, 9 per cent); intraductal disease with atypical mucosal changes; and cancer phobia in patients with numerous breast masses and positive history of mammary cancer (7 patients, 13 per cent). A particularly troublesome patient is one who has multiple breast masses which the referring physician finds difficult to evaluate and which may harbor breast cancer.
719
Dalton, Silverstein,
and Kelly
TABLE I
Surgical Complications No. of Patients
Capsular contraction Unilateral Bilateral Skin necrosis Minor Major (exposed implant) Hematoma Asymmetry
9 10 2 3 4 5
stricting the prosthesis has been quite helpful in relieving breast firmness’. All exposed prostheses were removed and later replaced after the skin healed. Comments
Figure 1. Patient with numerous breast biopsies and muttipte breast masses. A, before subcutaneous mastectomy. B, three months after subcutaneous mastectomy via an extended periareolar incision (outlined).
Frequently, several of these conditions exist in the same patient. Histologic evaluation demonstrated a wide specranging from fibrocystic disease (28 patients) and fibrosclerosis (28) to lobular carcinoma in situ (1) and invasive intraductal carcinoma (1). Sclerosing adenosis (9) and intraductal papillomatosis (ll), sometimes with dysplasia, were frequent associated findings, as were mammary dysplasia (2), intraductal hyperplasia (5), adenosis (2), and granulomas (silicone) (2). Among our complications (Table I), skin slough with exposure of the prosthesis was the most severe, and capsular scarring with breast firmness was the most common. Surgery to release scar tissue con-
720
Subcutaneous mastectomy is not proposed as a surgical procedure to treat mammary cancer. It is a technic that may be used in patients who have troublesome breast lesions that previously had been treated by simple mastectomy. This includes those patients who might be in a high risk group [2] of developing mammary cancer and those unfortunate women who have debilitating mastodynia and concurrent fibrocystic disease. It must be emphasized that this is not a cosmetic operative procedure. Complications are frequent, and the patients must be made aware of the risks of the surgical procedure. We discussed the possibility of breast firmness, breast asymmetry, skin and nipple slough, and implant exposure with all patients. With experience we have been able to reduce our complications. Implant capsular contractions have been markedly reduced by the complete submuscular placement of the prosthesis, as advocated by Jarrett, Cutter, and Teal 131.Two of the authors (WED and JMK) believe that saline-filled implants reduce the tendency for capsular scarring, whereas the third (PS) uses an underfilled gel with good results. In addition, complete muscular cover of the implant prevents exposure even if there is an area of skin slough. Skin slough is the problem most frequently encountered in the patient with pendulous breasts. The problem relates simply to the length of the dissected skin flaps. We have been able to reduce the number of skin sloughs by transplanting the nipple and areolar complex to a position nearer the sternum and clavicle while excising the redundant skin. Care is taken not to use too large an implant which might impede venous return. In most cases implants of smaller volume than the volume of mammary tissue excised are used.
The American Journal of Surgery
Subcutaneous
Our pat.ients with in situ lobular carcinoma and invasive intraductal carcinoma had xeromammography reports that indicated a risk of mammary cancer. We believe that in treating patients with such preoperative radiographic findings, reconstruction m..ght best be delayed until the final pathology repcrts are available, and it is known that invasive carcinoma is not present. Summary A technic is described wherein a transverse incision starting in the inferior periareolar area provides expc”sure of the breast to allow nearly complete mastectomy. Submuscular mammary reconstruction is facilitated by this approach.
References 1. Hicken NF: Mastectomy: a clinical pathologic study demonstrating why most mastectomies result in incomplete removal of the mammary gland. Arch Surg 40: 6, 1940. 2. Pennisi VR: The prevention of breast cancer by subcutaneous mastectomy. Surg C/in North Am 57: 1023, 1977. 3. Jarrett JR, Cutler RG, Teal DF: Subcutaneous mastectomy with immediate submuscular reconstruction for small, large, or ptotic breasts. Presented at the Annual Meeting of the American Society for Plastic and Reconstructive Surgery, San Francisco, 1977.
Discussion Ronald C. Elkins (Oklahoma City, OK): Could you explain or expand on your patient population, with some information concerning age, previous pregnancy, and whether or not the patients whose major complaint was mastodynia had undergone attempts at hormonal manipulation, particularly with some of the newer progestational agents which have been successful? Would you amplify on the mammographic report that would warrant or encourage subcutaneous mastectomy? In addition, when would you consider subcutaneous mastectomy as the preferred treatment for in situ lobular carcinoma in preference to the usual recommended total mastectomy? The alternatives presented in this paper allow the surge,.m dealing with the high risk patient who has a history of mult,iple biopsies, a very difficult mammographic report, and a very difficult physical examination to at least offer a procedure somewhat less extensive than that usually recommended, simple or total mastectomy. Gerard Martin (Monterey, CA): What do you do with your subcutaneous incision, particularly if you find a carcinoma with one positive lymph node? How does this modify your procedure?
Volume 136, December 1978
Mastectomy
W. Edward Dalton (closing): As regards hormonal therapy, most of these patients were referred by surgeons; some patients were referred by their endocrmologists or by their gynecologists. All patients with mastodynia underwent some attempt to relieve the problems by progestational agents, and often by testosterone. Very rarely did patients have mastodynia alone; most had had previous biopsies or multiple masses in addition. The mammographic reports indicated that we had four or five patients in whom questions arose. The findings on mammography in general were dense tissue. The term “dysplasia” was frequently given, but I do not know how you can use dysplasia as a term in a mammographic report. However, uniform densities which would obscure the usual patterns were the features that I could identify, at least in my mind, as being what the radiologists were describing. Finally, we had one instance of carcinoma in situ, and one patient had invasive carcinoma on the permanent section. There have been numerous reports as to whether or not this procedure, subcutaneous mastectomy, might be applicable for treating carcinoma in situ. I think it depends on the individual surgeon; some have a very aggressive approach to carcinoma and perform radical mastectomies in all instances; others are changing and perform a more modified procedure. In lobular carcinoma, subcutaneous mastectomy is probably a very good operation. Dr. Martin brought up a question which caused us substantial problems in only one instance. We had a patient who has referred to us who had no previous biopsies. She had breasts which were exceedingly dense, with numerous masses. The radiographic report was as strong as one could have in advising mastectomy. She was referred to us by her surgeon, who believed he would have to perform simple mastectomy, and he hoped that we might be able to help her. We performed subcutaneous mastectomy. Of numerous areas biopsied on frozen section, none demonstrated carcinoma. We then performed submuscular reconstruction. The next morning we got a more complete report, which indicated that the patient had one area of intraductal invasive carcinoma which was in the lower outer quadrant of the breast, squarely in the middle of the specimen, and had not been involved in any way that we could see in our dissection. The carcinoma was approximately 9 mm in greatest diameter. We took numerous other sections throughout to best determine what might be done. We presented the case to our Tumor Hoard, who believed that under the circumstances, with the subpectoral placement, we had essentially obliterated any chance of a true cancer operation, and the patient should be left as she was and be given a course of chemotherapy, which she subsequently received. Metastases did develop later in the region of the axillary nodes, and she underwent more widespread dissection.
721
MD, Oklahoma City, Oklahoma
J. Michael Kelly, MD, Oklahoma City, Oklahoma
Complete removal of all breast tissue cannot be accomplished by subcutaneous mastectomy. However, by simply transferring the incision from the routine inframammary position to the periareolar area and extending it laterally, one has access to the axillary extension of the breast as well as to the superior and medial glandular elements that are difficult to excise from below. Hicken [1] has stated that “simple mastectomy is an operation frequently attempted but seldom accomplished.” He demonstrated by dye injection the anatomic extension of the mammary gland, and he suggested an operative technic that would ensure the maximal removal of breast tissue. Except for the tissue left with the nipple and areolar area, we believe an extended periareolar incision will allow dissection of the breast and axilla as completely as the oblique incision advocated by Hicken [I]. The chief advantage of this technic is that it allows removal of tissue from the axilla that might later undergo pathologic changes. Technic
The arms are abducted, and the breasts, axillae, shoulders, neck, and upper abdomen are prepared and draped. The incisions extend around the inferior margin of the areolar area through an arc of 180 degrees and then continue to the anterior axillary line. (Figure 1.) Dissection is in t,he subcutaneous space close to the skin. Care is taken to avoid dissecting into the mammary tissue except where a small amount of ductal tissue extends into the nipple. The dissection is under direct vision medially to the sternum, laterally to the midaxilla, superiorly to the clavicle, and inferiorly to the rectus fascia. The breast is then freed
From the Department of Surgery, Divison of Plastic Surgery, Oklahoma University Health Science Center, and The Oklahoma Baptist Medical Center, and Mercy Health Center, Oklahoma City, Oklahoma. Reprint requests should be addressed to Edward Dalton, MD, Department of Surgery, Oklahoma University Health Science Center, Oklahoma City, Oklahoma 73106. Presented at the Thirtieth Annual Meeting of the Southwestern Surgical Congress, Palm Springs, California, April 17-20, 1976.
Volume 136, December
1976
from the underlying pectoralis and serratus muscles. The axillary breast frequently extends beneath the lateral margin of the pectoralis major muscle and high into the axilla. The resected tissue is submitted to the pathologist, and reconstruction is delayed until frozen section examination indicates that no malignancy is present. Our reconstruction utilizes submuscular insertion of saline- or gel-filled prostheses (round, without backing). We originally detached the pectoralis muscle inferiorly and to the fifth interspace medially to allow for low placement of the prosthesis. We have subsequently changed to subpectoral and subserratus insertion of the implants via incisions in the serratus anterior. Suction catheters are left in the submuscular and subcutaneous spaces, and the wounds, including the muscle incisions, are closed in layers of nonabsorbable sutures. Moderate pressure is applied with elastic bandages to prevent the implants from riding high beneath the pectoralis major muscle and into the axilla. We modify our incisions in the pendulous breast so that the nipple-areolar complex can be repositioned either by dermal pedicle or, preferably, by a free graft. This modification includes a vertical component to the extended periareolar incision which allows for the removal of redundant skin. Clinical Experience
In a series of fifty-six consecutive patients who underwent subcutaneous mastectomy with at least an eight month follow-up, we found many indications for surgical consultation. These included: fibrocystic disease with numerous breast biopsies (48 patients, 86 per cent); fibrocystic disease with mastodynia unrelieved by medical management (34 patients, 61 per cent); radiographic changes in breast tissue indicating a risk of mammary cancer (5 patients, 9 per cent); intraductal disease with atypical mucosal changes; and cancer phobia in patients with numerous breast masses and positive history of mammary cancer (7 patients, 13 per cent). A particularly troublesome patient is one who has multiple breast masses which the referring physician finds difficult to evaluate and which may harbor breast cancer.
719
Dalton, Silverstein,
and Kelly
TABLE I
Surgical Complications No. of Patients
Capsular contraction Unilateral Bilateral Skin necrosis Minor Major (exposed implant) Hematoma Asymmetry
9 10 2 3 4 5
stricting the prosthesis has been quite helpful in relieving breast firmness’. All exposed prostheses were removed and later replaced after the skin healed. Comments
Figure 1. Patient with numerous breast biopsies and muttipte breast masses. A, before subcutaneous mastectomy. B, three months after subcutaneous mastectomy via an extended periareolar incision (outlined).
Frequently, several of these conditions exist in the same patient. Histologic evaluation demonstrated a wide specranging from fibrocystic disease (28 patients) and fibrosclerosis (28) to lobular carcinoma in situ (1) and invasive intraductal carcinoma (1). Sclerosing adenosis (9) and intraductal papillomatosis (ll), sometimes with dysplasia, were frequent associated findings, as were mammary dysplasia (2), intraductal hyperplasia (5), adenosis (2), and granulomas (silicone) (2). Among our complications (Table I), skin slough with exposure of the prosthesis was the most severe, and capsular scarring with breast firmness was the most common. Surgery to release scar tissue con-
720
Subcutaneous mastectomy is not proposed as a surgical procedure to treat mammary cancer. It is a technic that may be used in patients who have troublesome breast lesions that previously had been treated by simple mastectomy. This includes those patients who might be in a high risk group [2] of developing mammary cancer and those unfortunate women who have debilitating mastodynia and concurrent fibrocystic disease. It must be emphasized that this is not a cosmetic operative procedure. Complications are frequent, and the patients must be made aware of the risks of the surgical procedure. We discussed the possibility of breast firmness, breast asymmetry, skin and nipple slough, and implant exposure with all patients. With experience we have been able to reduce our complications. Implant capsular contractions have been markedly reduced by the complete submuscular placement of the prosthesis, as advocated by Jarrett, Cutter, and Teal 131.Two of the authors (WED and JMK) believe that saline-filled implants reduce the tendency for capsular scarring, whereas the third (PS) uses an underfilled gel with good results. In addition, complete muscular cover of the implant prevents exposure even if there is an area of skin slough. Skin slough is the problem most frequently encountered in the patient with pendulous breasts. The problem relates simply to the length of the dissected skin flaps. We have been able to reduce the number of skin sloughs by transplanting the nipple and areolar complex to a position nearer the sternum and clavicle while excising the redundant skin. Care is taken not to use too large an implant which might impede venous return. In most cases implants of smaller volume than the volume of mammary tissue excised are used.
The American Journal of Surgery
Subcutaneous
Our pat.ients with in situ lobular carcinoma and invasive intraductal carcinoma had xeromammography reports that indicated a risk of mammary cancer. We believe that in treating patients with such preoperative radiographic findings, reconstruction m..ght best be delayed until the final pathology repcrts are available, and it is known that invasive carcinoma is not present. Summary A technic is described wherein a transverse incision starting in the inferior periareolar area provides expc”sure of the breast to allow nearly complete mastectomy. Submuscular mammary reconstruction is facilitated by this approach.
References 1. Hicken NF: Mastectomy: a clinical pathologic study demonstrating why most mastectomies result in incomplete removal of the mammary gland. Arch Surg 40: 6, 1940. 2. Pennisi VR: The prevention of breast cancer by subcutaneous mastectomy. Surg C/in North Am 57: 1023, 1977. 3. Jarrett JR, Cutler RG, Teal DF: Subcutaneous mastectomy with immediate submuscular reconstruction for small, large, or ptotic breasts. Presented at the Annual Meeting of the American Society for Plastic and Reconstructive Surgery, San Francisco, 1977.
Discussion Ronald C. Elkins (Oklahoma City, OK): Could you explain or expand on your patient population, with some information concerning age, previous pregnancy, and whether or not the patients whose major complaint was mastodynia had undergone attempts at hormonal manipulation, particularly with some of the newer progestational agents which have been successful? Would you amplify on the mammographic report that would warrant or encourage subcutaneous mastectomy? In addition, when would you consider subcutaneous mastectomy as the preferred treatment for in situ lobular carcinoma in preference to the usual recommended total mastectomy? The alternatives presented in this paper allow the surge,.m dealing with the high risk patient who has a history of mult,iple biopsies, a very difficult mammographic report, and a very difficult physical examination to at least offer a procedure somewhat less extensive than that usually recommended, simple or total mastectomy. Gerard Martin (Monterey, CA): What do you do with your subcutaneous incision, particularly if you find a carcinoma with one positive lymph node? How does this modify your procedure?
Volume 136, December 1978
Mastectomy
W. Edward Dalton (closing): As regards hormonal therapy, most of these patients were referred by surgeons; some patients were referred by their endocrmologists or by their gynecologists. All patients with mastodynia underwent some attempt to relieve the problems by progestational agents, and often by testosterone. Very rarely did patients have mastodynia alone; most had had previous biopsies or multiple masses in addition. The mammographic reports indicated that we had four or five patients in whom questions arose. The findings on mammography in general were dense tissue. The term “dysplasia” was frequently given, but I do not know how you can use dysplasia as a term in a mammographic report. However, uniform densities which would obscure the usual patterns were the features that I could identify, at least in my mind, as being what the radiologists were describing. Finally, we had one instance of carcinoma in situ, and one patient had invasive carcinoma on the permanent section. There have been numerous reports as to whether or not this procedure, subcutaneous mastectomy, might be applicable for treating carcinoma in situ. I think it depends on the individual surgeon; some have a very aggressive approach to carcinoma and perform radical mastectomies in all instances; others are changing and perform a more modified procedure. In lobular carcinoma, subcutaneous mastectomy is probably a very good operation. Dr. Martin brought up a question which caused us substantial problems in only one instance. We had a patient who has referred to us who had no previous biopsies. She had breasts which were exceedingly dense, with numerous masses. The radiographic report was as strong as one could have in advising mastectomy. She was referred to us by her surgeon, who believed he would have to perform simple mastectomy, and he hoped that we might be able to help her. We performed subcutaneous mastectomy. Of numerous areas biopsied on frozen section, none demonstrated carcinoma. We then performed submuscular reconstruction. The next morning we got a more complete report, which indicated that the patient had one area of intraductal invasive carcinoma which was in the lower outer quadrant of the breast, squarely in the middle of the specimen, and had not been involved in any way that we could see in our dissection. The carcinoma was approximately 9 mm in greatest diameter. We took numerous other sections throughout to best determine what might be done. We presented the case to our Tumor Hoard, who believed that under the circumstances, with the subpectoral placement, we had essentially obliterated any chance of a true cancer operation, and the patient should be left as she was and be given a course of chemotherapy, which she subsequently received. Metastases did develop later in the region of the axillary nodes, and she underwent more widespread dissection.
721