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Modified Radical Mastectomy

Background
A modified radical mastectomy is a procedure in which the entire breast is removed, including the skin,
areola, nipple, and most axillary lymph nodes; the pectoralis major muscle is spared. Historically, a
modified radical mastectomy was the primary method of treatment of breast cancer. As the treatment of
breast cancer evolved, breast conservation has become more widely used. However, mastectomy still
remains a viable option for women with breast cancer.
Indications
It currently remains the patients choice to undergo breast conservation or mastectomy with or without
reconstruction. However, there are a few contraindications to breast conservation for which a mastectomy
is recommended.
According to the National Comprehensive Cancer Network guidelines, indications for mastectomy
include the following:
Prior radiation therapy to the breast or chest wall
Radiation therapy contraindicated by pregnancy (except patients in the third trimester who can receive
radiation postpartum)
Inflammatory breast cancer
Diffuse suspicious or malignant-appearing microcalcifications
Widespread disease that is multicentric, located in more than one quadrant, and cannot be removed
through a single incision with negative margins
A positive pathologic margin after repeat re-excision and suboptimal cosmetic outcome
Relative indications for mastectomy include the following:
Active connective tissue disease involving skin (eg, scleroderma, lupus)
Tumors greater that 5 cm in diameter
Patients who are younger than 35 years of age or premenopausal with known BRCA1/2 mutations have
an increased risk of local recurrence. Prophylactic bilateral mastectomy may be considered for risk
reduction.
Contraindications
There are very few contraindications to a modified radical mastectomy. For patients who present with
metastatic disease, the primary mode of treatment remains systemic therapy. Mastectomy is currently not
the standard of care for patients with metastatic disease. Additional contraindications involve patients
who are unable to receive general anesthesia.
[8]

Procedure Planning
Patients who undergo a mastectomy have the option for immediate or delayed reconstruction using
autologous tissue or implants. Prior to the mastectomy, patients should be referred to a plastic surgeon.
The decision for immediate or delayed reconstruction is made based on the need for postmastectomy
radiation and surgeon preference.
Complication Prevention
Complications associated with a modified radical mastectomy include issues associated with wound
healing, such as hematoma, infection, dehiscence, chronic seroma, and skin necrosis. The risk of skin
necrosis often involves the superior flap and the wound edges. It is often treated with only local
debridement and wound care.
Patients at a higher risk for postoperative complications are patients with diabetes, smokers, patients with
a history of prior chest wall radiation, and other patients with diffuse small vessel disease. After an
axillary dissection, along with the normal local healing issues, the alteration of the regional lymphatic
system puts patients at an increased risk of complications.
For patients undergoing sentinel lymph node biopsy prior to axillary dissection, there is a risk of
anaphylaxis related to the isosulfan blue contrast agent. The anesthesiologist and patient should be aware
of this rare complication, which often resolves intraoperatively.
[9]

Patients who have undergone a completion axillary dissection have an increased risk of
developing lymphedema. They also are at increased risk of numbness under the axilla or even
hypersensitization and chronic pain in that area. Patients are encouraged to ambulate the arm early with
stretching exercises to prevent decreased shoulder function and scarring of the muscle, which can lead to
cording and chronic pain syndromes.
Why the Procedure is Performed
WOMAN DIAGNOSED WITH BREAST CANCER
The most common reason for a mastectomy is breast cancer.
If you are diagnosed with breast cancer, talk to your doctor about your choices:
Lumpectomy is when only the breast cancer and tissue around the cancer are removed. This is
also called breast conservation therapy or partial mastectomy. Part of your breast will be left.
Mastectomy is when all breast tissue is removed. Mastectomy is a better choice if the area of
cancer is too large to remove without deforming the breast.
You and your doctor should consider:
The size and location of your tumor
How many tumors there are in the breast
How much of the breast is affected
The size of your breast
Your age
Family history
Your general health and whether you have reached menopause
The choice of what is best for you can be difficult. You and the health care providers who are treating
your breast cancer will decide together what is best.
WOMEN AT HIGH RISK FOR BREAST CANCER
Women who have a very high risk of developing breast cancer may choose to have a preventive (or
prophylactic) mastectomy to reduce your risk of breast cancer.
You may be more likely to get breast cancer if one or more close family relatives has had it, especially at
an early age. Genetic tests (such as BRCA1 or BRCA2) may help show that you have a high risk.
Prophylactic mastectomy should be done only after very careful thought and discussion with your doctor,
a genetic counselor, your family, and loved ones.
Mastectomy greatly reduces, but does not eliminate, the risk of breast cancer.
Periprocedural Care
Equipment
The following equipment is needed to perform a modified radical mastectomy:
Sterile gloves and gowns
Sterile drapes
Preoperative skin preparation supplies
No. 15 blade
Bovie electrocautery
Sterile sponges
Suction system
Sterile irrigation solution (water and normal saline)
Standard mastectomy tray
Freeman face lift or skin hooks
Richardson retractors
Several types of sutures and ties, silks available for ties, nylon for drain sutures, Vicryl, and Monocryl
for skin closure
Clips for the axillary dissection
Drains for the axilla and chest wall under the mastectomy flaps (eg, Jackson-Pratt round 15-Fr)

Patient Preparation
Anesthesia
General anesthesia is used without a neuromuscular blocking agent for the mastectomy and axillary
dissection. If the patient is undergoing immediate breast reconstruction at the same time as the
mastectomy, a paralytic is often used after completion of the axillary lymph node dissection.
A thoracic paravertebral block may also be used to provide both procedural and postprocedural analgesic
effects, leading to a reduction in postoperative pain both immediately and over the following 24 hours.
Positioning
Patients are placed in the operating room table in the supine position, with the arm at a 90-degree angle
from the body.
Technique
Approach Considerations
There are several different techniques for a modified radical mastectomy, including simple or total
mastectomy, skin-sparing mastectomy, nipple sparing, sentinel lymph node biopsy, and/or axillary lymph
node dissection. This topic describes a simple mastectomy with an axillary lymph node dissection.
Simple Mastectomy with an Axillary Lymph Node Dissection
The anatomy of the breast and its boundaries include the clavicle superiorly, the sternum medially, the
inframammary fold inferiorly, and the latissmus along the pectoralis major fascia laterally. The total
mastectomy involves removal of the entire mammary gland including the nipple-areolar complex and
pectoralis fascia.
In a simple mastectomy with no immediate reconstruction, the outline of the breast is marked and the
medial and lateral endpoints of the breast are marked. The breast is then pulled downward and a
horizontal line connecting the two endpoints is drawn to mark the upper incision. The breast is then pulled
up and a second line connecting the endpoints is drawn to identify the lower incision. These lines form an
ellipse around the nipple and can be adjusted to include prior incisions. See the image below.
Anatomy markings prior to mastectomy.
These markings are checked to confirm that there is adequate skin for closure with minimal tension. The
skin is then incised.
The next step is to make viable skin flaps that leave subcutaneous tissue and superficial vasculature but
do not compromise the need to remove the entire mammary gland. These flaps are approximately 5 mm in
thickness. The plane is identified by careful retraction with skin hooks and adequate countertraction,
allowing the surgeon to identify the avascular plane (superficial breast fascia) between the breast and
subcutaneous tissue. Either a knife, scissors, harmonic scalp, or electrocautery can be used, depending on
the surgeons preference.
Tumescent solution of dilute epinephrine hydrochloride in lactated Ringer solution is commonly used in
association with liposuction.
[10]
The solution is infused into the avascular plane to facilitate dissection and
minimize blood loss during the surgery.
The flaps are raised to the borders of the breast as previously defined. The pectoralis fascia is divided
both superiorly and medially. The pectoralis fascia is removed with the breast; muscle should only be
removed when there is gross involvement. The dissection proceeds to the lateral edge of the pectoralis.
See the images below.
Superior flap dissection.
Superior flap dissection up to the pectoralis muscle facia.
Depending on surgeon preference, the breast may now be completely removed or axillary dissection may
continue, allowing the breast to give gravity traction and assist with exposure. See the image below.
Lifting the breast off the pectoralis muscle with the facia in the
specimen.
The axillary lymph node dissection follows the borders of the axilla and includes level I and II lymph
nodes. The axilla is bordered by the axillary vein superiorly, the latissimus dorsi laterally, pectoralis
muscle medially, and the serratus muscle anteriorly.
When performing an axillary dissection with a simple mastectomy, a separate incision is not required.
However, if a skin-sparing mastectomy is performed, a separate incision may be needed.
The axilla is first entered by opening the clavipectoral fascia. See the image below.
Entering the axilla at the lateral boder of pectoralis major muscle.
The axillary vein is identified by locating the lateral border of the pectoralis major; the vein is identified
as it runs posterior to the pectoralis muscle with careful blunt dissection and retraction inferiorly of the
axillary contents. Once identified, lymphatics can be tied, clipped, or cauterized, depending on surgeon
preference.
After the vein is identified, careful steps are taken to preserve its branches; the thoracodorsal bundle is
identified as it runs in the axillary fat pad and then enters the latissimus dorsi. The long thoracic nerve
should be preserved; it runs medial to the thoracodorsal bundle and is identified close to the chest wall
posteriorly. See the image below.
Preserving the axillary vein and long thoracic nerve to the
latissimus dorsi and serratus anterior in the axillary dissection.
Once these nerves and vein are identified, the axillary contents are dissected off the thoracodorsal bundle
superiorly and medially up to the level of the axillary vein. The contents are then retracted inferiorly, the
medial attachments to the serratus muscle are divided, and the specimen is handed off.
Once the axillary dissection is completed, two drains are placed: one in the axilla and one anterior to the
pectoralis muscle. Drains should be shortened to allow for placement of the drain within a pocket for
patient comfort and to avoid clotting in the tubing. The skin is then closed in an interrupted or running
fashion according to the surgeons preference. See the image below.
Drain placement and skin closing after mastectomy.
Patients are normally discharged the next morning and drains are removed when the output is less than 30
mL in a 24-hour period. Patients are encouraged to ambulate early and begin arm stretches.
After the Procedure
Most women stay in the hospital for 1 - 3 days. But this depends on the type of surgery you had. If you
have a simple mastectomy, you might go home on the same day. You may be in the hospital longer if you
have breast reconstruction.
Many women go home with drainage tubes still in their chest. The doctor will remove them later during
an office visit. A nurse will teach you how to look after the drain, or you can have a home care nurse help
you.
You may have pain around the site of your cut after surgery. The pain is moderate after the first day and
then quickly goes away. You will receive pain medicines before you are released from the hospital.
Fluid may collect in the area of your mastectomy after all the drains are removed. This is called a seroma.
It usually goes away on its own, but it may need to be drained using a needle (aspiration).