Technique of Mastectomy

Technique of Mastectomy

The first step is the creation of skin flaps. These are marked preoperatively (Fig. 7.5), the skin is incised with a scalpel, and flaps are raised with either scalpel or electrocautery.

Traction is maintained on the breast with the nondominant hand, and even, upward counter-traction is applied to the skin flaps (Fig. 7.6). The flaps are developed just outside the envelope of superficial fascia around the breast.

The superior extent of dissection is the position where the superficial fascia fuses with the pectoralis fascia. The inferior flap is raised in a similar manner, with the surgeon controlling the skin and the assistant retracting the breast. The inferior extent of the dissection is the fusion of the breast fascia with that over the rectus abdominus.

The breast is then removed from the pectoralis major muscle. Electrocautery or a scalpel is used to divide the fascia over the muscle. The fascia is removed with the breast; this is easier if the dissection proceeds downwards from above (Fig. 7.7). Medially, there are perforating vessels from the internal thoracic artery.

In the second and third intercostal spaces, these vessels are large and may require ligation. If an axillary dissection is part of the treatment, the mastectomy is carried to the lateral edge of the pectoralis major, then the clavipectoral fascia is excised to enter the axilla. If the operation is a total mastectomy (i.e., for DCIS), the mastectomy is continued superficial to the clavipectoral fascia to the anterior border of latissimus dorsi. The axillary tail of the breast continues around the lateral border of the pectoralis major, and this must be removed to ensure near complete excision of all breast tissue.

During this phase of the dissection, the medial pectoral nerve is at risk but may be sacrificed with no ill sequelae.

After hemostasis is confirmed, the wound is irrigated and a closed suction drain placed over the pectoralis major. The wound is approximated with interrupted subcutaneous sutures, and the skin is closed with a subcuticular suture (Fig. 7.8).

Patrick I. Borgen and Bruce Mann
Breast conservation therapy for invasive carcinoma of the breast. Current Problems in Surgery 1995; 33:189-256.

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