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CORT, D. F., COLLIS, J. L. (1973). Brit. J. Surg. 60: 580. DAS, S. K. (1976). Brit. J. Plasf. Surg. 29: 170. DUPONT, C.. MENARD,Y. (1972),Plasf. reconstr. Surg..49: 263. GOLDSMITH. H. S.. DELOSSANTOS. R. (1966),Rev.Surg.23: 303. GOLDSMITH, H. S . (1968), Dis. Chest. 54: 523. GOLDSMITH, H. S. (1970) Surg. Gynec. Obsfef. 130: 57.
GUE,S. (1975). AUST.N.Z. J. SURG 45: 390. KIRICUTA, I. (1963). Presse med., 71: 15. KIRICUTA, A,. GOLDSTEIN, M. B. (1961),Krebsarzf, 16: 202. MCLEAN,D. H., BUNCKE,H. J. jr.. (1972). Plast. reconstr. Surg., 49: 268. ROBERTS, B. (1967), Ann. Surg.. 166: 583.
SUBCUTANEOUS MASTECTOMY: INDICATIONS AND TECHNIQUE T. H. ACKLAND’,J. T. HUESTON*, AND T. H. ROBBINS3 Royal Melbourne Hospital and Wellington Private Hospital
For a certain group of patients, carefully selected by criteria which are here discussed, subcutaneous mastectomy offers a real prospect of minimizing the risk of breast cancer developing. It will also relieve pain in most of those for whom it has become intolerable and will usually provide the patient with both comfort and peace of mind. Performed by the technique described, subcutaneous mastectomy can now produce an aesthetically pleasing result. Regular review of all patients is, however, mandatory.
SUBCUTANEOUS mastectomy is a procedure which has for many years been viewed with suspicion. It is the belief of the present authors, however, that not only has such a level of competence in technique now been reached that an aesthetically acceptable result may be anticipated, but sufficiently valid indiqations have emerged to justify use of the procedure on certain occasions. This opinion is supported both by the personal experience of the authors, and by a considerable series of reported cases. It must be stressed however, that this is a statement of present feeling which may require modification in the light of future knowledge. The term “subcutaneous mastectomy” requires some explanation, as there would seem to be some incompatability between these words. “Subcutaneous” implies that external appearance will be little changed, remaining acceptable to the patient. “Mastectomy”, contrary to the usual understanding of the term as a total breast removal, implies, in this present context, a removal of somewhere in the region of 90% of breast tissue, leaving the nipple-areola-complex intact. The remainder of the unremoved breast tissue will be ’ Consultant Surgeon, Royal Melbourne Hospital Consultant Plastic Surgeon. Royal Melbourne Hospital Royal Melbourne Hospital
’ Assistant Plastic Surgeon,
Reprints, J T Hueston, 89 Royal Parade, Parkville. Victoria 3052
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located behind the nipple and in the infraclavicular and axillary regions, where the anatomical studies of Goldman and Goldwyn 1973) have demonstrated that breast tissue is in most cases present well beyond the clinically detectable limits of the breast. The procedure might therefore be regarded as a “radical subtotal mastectomy”, with acknowledged limits of prophylactic usefulness. The aim of the procedure is thus restricted to removal of as much breast tissue as possible, while at the same time allowing reconstruction of a personally and socially acceptable breast symbol, which will minimize the psychological sequelae of breast loss, almost inevitably sustained after classical simple mastectomy. INDICATIONS FOR SUBCUTANEOUS MASTECTOMY
( 7 ) Mammary Dysplasia Although subcutaneous mastectomy should never be employed for the management of proven breast cancer, this operation may now be regarded as an established method of treatment for several other breast disorders. Mammary dysplasia is the commonest cause of a breast lump, frequently in the form of cyst formation. When a solitary cyst is surrounded by normal breast tissue, aspiration alone will suffice, repeated should the cyst refill; but in most cases careful palpation after aspiration 551
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reveals some remaining irregularity - although perhaps very slight. Although some would then rely on cytological findings from further fine needle aspiration, the writer's (T.H.A.) experience has led him to regard this as insufficiently reliable. This situation demands open biopsy, with frozen section facilities, and this almost invariably reveals that various other manifestations of mammary dysplasia surround the main cyst - other smaller cysts, microcysts, duct ectasia, ductal epitheliosis, or fibroadenosis. But rarely a carcinoma will be found adjacent to a cyst, in the wall of it, or between the other abnormalities. Although after such an operation, with excision of an appropriate amount of tissue, there may be no further developments, unfortunately further lumps frequently occur on the same or the opposite side, and perhaps other areas calling for the same management, with the result that the woman is left with several breast scars. All such patients should be examined at intervals and instructed in breast self-examination. They should be told to report at once should they themselves observe any change, or have any doubt, and happily one, two, or even three open biopsies may be followed by no other lump developing; and further cyst formation becomes less likely with advancing years. Nevertheless, in a small group, after several biopsies, both breasts are left with many lumps, cystic or solid, and the surgeon is faced with the dilemma of not knowing where another biopsy is to be performed, if at all. There may or may not be pain in such multinodular breasts, and in any case, it is not pain which is the problem, but rather the possibility that, between the multiple nodules, there may be a small carcinoma. After many years of differing opinions and uncertainty it now seems probable, although not certain, that patients with mammary dysplasia do have a somewhat greater than average risk of developing breast cancer, especially when ductal e p i t h e l i a l p r o l i f e r a t i o n is a p r e d o m i n a n t manifestation. Warren (1940). after studying 1,200 cases over five years, found a fourfold increase in the incidence of cancer in women with mammary dysplasia, and a twelvefold increase when there was pronounced epithelial hyperplasia; and Haagensen (1971) found a fourfold increase in carcinomas in the presence of dysplasia in 1,700 patients matched for age and for period of observation. Ryan and Coady (1962), in an autopsy study of 100 women with clinically normal breasts, found that 12% had intraductal epithelial proliferaiton; while in 100 women with breast cancer the incidence of this change was four times as great. They concluded that the condition was precancerous. But this is not necessarily so, since the factor responsible for 552
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epithelial hyperplasia may be similar to that for carcinoma, rather than the one progressing to the other. Opinions differ also on the relation of papillomas and papillomatosis to breast cancer. Haagensen (1971) concluded that these conditions were benign, unassociated with increased cancer risk, basing this view o n the incidence of malignancy among women who had previously had excised specimens with the diagnosis established. On the other hand, Foote and Stewart (1945) and BuhlJorgensen et a h , (1968) found that these lesions were associated with an increase in cancer development. Thus, although evidence is insufficient to establish absolute proof of a relationship between mammary dysplasia and cancer, it is wise to regard with suspicion cases where biopsy has revealed ductal epitheliosis, especially if more than one biopsy has been needed, with similar findings. Not infrequently these patients are aware of their potential danger, and the surgeon will know that, no matter how experienced his hands may be, palpation of such breasts can fail to detect a carcinomatous change between many nodules. M o r e o v e r , r e l i a n c e c a n n o t b e p l a c e d on mammography findings under such circumstances, and there should be no hesitation in advising subcutaneous mastectomy, since mammary dysplasia may in fact predispose to malignant change, and also because accurate clinical asessment will be impossible in such patients, even if they face no more than the average risk of developing breast cancer. After subcutaneous mastectomy 90% or more of breast tissue is removed, and if by misfortune a carcinoma develops in the remaining breast tissue, it should be readily detected at the regular clinical examinations which must follow. (2) High Risk of Cancer It has been suggested that bilateral subcutaneous mastectomy should be advised for women having a particularly high risk of developing breast cancer, and there is no doubt that those with a history of the disease having occurred in other members of the family are in this category. Anderson (1973) compared the incidence of breast cancer in 567 mothers, sister and daughters of 178 patients who had breast cancer, with the incidence in 699 mothers, sisters and daughters of 217 patients who had other types of cancer. He found a twofold increase in risk in the relatives of patients with breast cancer. But the daughters of women who had bilateral breast cancer before the age of fifty years had a ninefold increase compared AUST. N.Z. J. SURG.VOL. 49-No.
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with controls, with about 50% of this group developing the disease, compared with the overall incidence of about 6%. Nulliparae and late primiparae also have an increased risk of developing breast cancer. It is impossible to give dogmatic advice applicable to all such women, some with a slightly increased risk, others with a risk enormously increased. In the case of daughters of women who have had bilateral breast cancer before the age of fifty years we have no hesitation in strongly advising subcutaneous mastectomy. For others with a smaller yet definite increased risk, those with a family history, nulliparae and late primiparae, opinions will differ. At least there should be monthly breast self-examination, and, perhaps for those over the age of fifty years, also yearly mammography. Although the possibility of cancer being radiationinduced has been emphasized, the most modern equipment delivers only a very small dose, in the region of 0.25 rad.; and it is possible that benefits resulting from mammography detection of clinically occult cancers might well outweigh the risk. Yet, a disturbing thought is that we are not sure whether the high-risk group might also be the group at high risk from ionizing radiation. Moreover, in spite of its high accuracy rate, mammography does not necessarily reveal a cancer which is present. The writer (T.H.A.) feels that for these relatively highrisk patients subcutaneous mastectomy should not necessarily be advised; and as well as breast selfexamination, and regular mammography for those over the age of fifty years, an ideal additional precaution would be yearly examination by a surgeon experienced in breast palpation. There will be Borne women in this group who are not merely aware of their special risk, but who are constantly worried, even distraught, at the prospect of developing breast cancer; and to these women it should at least be explained, although not urged, that subcutaneous mastectomy may be performed. The case against prophylactic subcutaneous mastectomy has been put fervently by Peacock (1975) and Snyderman (1978). They point out that carcinoma can still occur in the small amount of breast tissue left, that fibrocystic disease alone is usually not premalignant, and that a careful period of observation and regular examination will protect most patients. T o balance this reasonable conservatismare thefindings of Pennisi etalii (1977) that 6% of breasts removed prophylactically by subcutaneous mastectomy have been shown to contain occult carcinoma. (3) Breast Pain Breast pain with tenderness is a common symptom, usually no more than a temporary AUST. N.Z. J. SURG.VOL. 49-No. 5, OCTOBER, 1979
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premenstrual annoyance. But it may be very severe, either in women whose breasts are nodular from mammary dysplasia, perhaps with scars of previous biopsies, or less often when clinical examination reveals no abnormality. Undoubtedly, in some patients the pain is a psychosomatic presentation of an emotional disturbance, which may in fact be more important to the woman than her pain. In such cases only appropriate counselling or other such help can be expected to diminish the symptoms. But if there appears to be no reason to suspect such a basis for severe breast pain, other treatment is called for. Oestrogens should be withdrawn, the breasts adequately supported, and a mild diuretic ordered for the premenstrual week. In some patients, norethisterone acetate, taken in a dose of 5 milligrams twice daily from the 15th to the 25th day of the menstrual cycle, may suppress pain and is worthy of a trial. In the past, small dosages of radiotherapy have been used, but this treatment should no longer be advised, since it was rarely successful and is not without risk of inducing cancer. There remains then a very small group suffering severe and genuine breast pain which has become intolerable, although the precise cause of the symptom remains obscure. I n these cases subcutaneous mastectomy should at least be discussed, and if this operation is performed under such circumstances, after careful case selection, with exclusion of patients with a psychological cause, success may be anticipated, just as, in the past, bilateral simple mastectomy used on similarly rare occasions has been followed by total pain relief. One of us (T.H.A.) has used this method, although on no more than six occasions over twenty-five years; but the mutilation of this operation is no longer justified, and the purpose of this paper is to present an aesthetically acceptable technique for subcutaneous mastectomy. ( 4 ) The Contralateral Breast It is sometimes forgotten that the woman with the greatest risk of developing breast cancer is the one who has already had the disease. Moertel (1966) found that the incidence of contralateral carcinoma was highest initially, a n d then decreased exponentially with time. Other workers (Robbins and Berg, 1964; McCredie etalii, 1975) have shown that the cumulative probability of there occurring a consecutive non-synchronous breast cancer is approximately 1% per year, for all women at any one time, and remains at this level for up to twenty years. There is, however, a special risk of a new carcinoma developing in younger women, and in those whose 553
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mothers had the disease before the age of fifty years. Moreover, contralateral cancer is usually discovered late, and more than half of patients with this condition have axillary metastases. In the past, management after a single mastectomy has been repeated clinical examinations, and more recently mammography of the remaining breast, but there are good reasons for giving consideration to contralateral subcutaneous mastectomy, at least for certain tumours, since the type of tumour found on the first occasion is related to the probability of a contralateral carcinoma occurring. lntraductal carcinoma constitutes only 2% of breast cancers, but Westbrook and Gallagher (1975) have found that there isa 13% probabilityof it be i n g b i Iate ra I. Co n t ra Iate rhLI s u b c ut a n eo us mastectomy should therefore be considered tn such cases; moreover, many of these lesions are located centrally, very near the nipple, and these authors suggested that, if this operation is carried out, the nipple and areola should be sacrificed. On the other hand, if a subareolar plaque no larger than three centimetres in diameter and five millimetres in thickness is left at subcutaneous mastectomy- this being sufficient to ensure nipple viability - any carcinomatous change in such a small amount of tissue is very unlikely, and should be detected without difficulty. Moreover, the opportunity exists of coning out the residue of large ducts after sound healing of the skin flaps should there be any doubt after examination of the major subcutaneous mastectomy specimen. Between 5% and 1O0/o of breast cancers are lobular, either in situ or invasive, and about onethird of patients with such tumoursdevelopasimilar tumour on the opposite side within ten years. An added danger is that in situ lobular carcinoma is often not palpable as such, but is adjacent to a zone of mammary dysplasia. Prophylactic subcutaneous mastectomy will therefore properly be advised when this histological diagnosis has been made. Medullary carcinoma, constituting between 1% and 5% of breast cancers, has a lower than usual incidence of node invasion, with an excellent fiveyear survival in the region of 90%. Nevertheless, Haagensen (1971) found that in 140 patients with this tumour, 10% developed a carcinoma of the same or a different type on the opposite side, and here too, subcutaneous mastectomy calls for consideration when this tumour type has been found. It is therefore seen that intraductal carcinoma, lobular carcinoma, and medullary carcinoma together, form only a small proportion of all breast 554
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cancers; and therefore from the point of view of turnour type alone, contralateral subcutaneous mastectomy will be indicated only infrequently. Furthermore, this procedure should be advised only for women with a life expectancy of more than twenty years, and when axillary nodes have been found not to contain metastases. If the operation is to be performed, it should be carried out not later than twelve months after the first operation, and of course only after careful whole body investigiltion has revealed no evidence of distant spread. ( 5 ) Cancerophobia As a result of proper public education, most women are now aware of the common occurrence of breast cancer, and with the wider practice of breast self-examination, a greater number of smaller tumours are now being found. To thisextent public education programmes can be said to have generated added confidence among women, and there is also a greater prospect of cure when a cancer is small (Duncan and Kerr, 1976). However, these same programmes of public education have aroused in some women a profoundly disturbing cancerophobia. Such women may have no pain, and their breasts may be entirely normal both to clinical examination and even after mammography. A l t h o u g h i t has b e e n s u g g e s t e d t h a t subcutaneous mastectomy be offered on such occasions, we feel reluctant to agree with this, since cancerophobia alone clearly differs from the several abnormalities which have been described as calling for this operation to be considered. The removal of an important part of the body, in the absence of any evidence of disease, appears to us not to be in accordance with sound surgical practice. Evolution of the Present Technique Since the first attempt at reconstruciton of the breast after prophylactic mastectomy - as distinct from simple mastectomy without reconstruction there has been a progressive improvement in the aesthetic quality of the results. Since Thomas (1882) drew attention to the need for minimizing mutilation of the breast after wide excision for benign conditions, the inframammary approach has been favoured by many, since it affords excellent exposure of breast pathology and makes possible the insertion of local flaps of adjacent dermo-fat tissue to produce a breast symbol. This local fat f!ap repair, recommended by Lexerin 1931, wassuperiortothefreefatgraftsused by Bartlett who, in 1917, had recommended “an anatomical substitute for the female breast”. Local dermo-fat flap reconstruction evolved through the work of Shonbauer and Winkler (1953), Letterman AUST.N.Z. J. SURG.VOL. 49-No.
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FIGURE 1 (a) skin markings for rnastopexy combined with subcutaneous mastectomy of the left breast The skin envelope will be reduced by the area enclosed within the keyhole marking-The patient has previously had a mastectomy on the right side This was reconstructed at the same operation by local skin flaps and silastic implant, (b) the inferior limits of the keyhole marking are shown Triangular cross-hatched area based on the inframarnmary groove and supporting the nipple represents the surface marking of the inferior pedicle which will be de-epithelialized
and Schurter (1953), de Cholnoky (1955), and Longacre (1959); but these biological repairs were supplanted in 1962 when Freeman first described the Lase. of silicone breast prostheses. In the 17 years since Freeman's introduction of prosthetic replacement f o r breast c o n t o u r reconstruction after subcutaneous mastectomy, there have been extensive records of the limitations of this procedure from Kelly et alii (1966) to Schlenker e t afii (1978) - all stressing scar contracture around the prosthesis, infection, and secpndary extrusion of the prosthesis following wound breakdown, usually at the inverted Tjunction in the suture line at the inframammary
groove. The aesthetic results have, to say the least, been less than optimal. The safety of delayed insertion of the prosthesis has been pointed out by Horton etalii (1974), but in the same paper their technique for immediate prosthetic insertion is described. It is now accepted that immediate reconstruciton with a prosthesis is reasonable, provided that the increased protection provided by a subpectoral insertion (Dempster and Lathan, 1968) is combined with attention to viability of the nipple and areola. The blood supply to this area is so compromised by the inframammary incision that splitting the breast into two halves horizontally through the nipple has been used
FIGURE2: (a) De-epithelialization of the inferior pedicle has been completed. The other skin markings have been incised; (b) the inferior pedicle. sustaining the nipple at its apex, has been elevated
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FIGURE 3: (a) the inferior pedicle supporting the nipple has been folded inferiorly and radical excision of the glandular mass and some axillary nodes has been completed. The skin flaps have been folded away from the dissection to show the inferior border of the pectoralis major muscle and serratus anterior muscle with a muscle-splitting incision between them exposing the thoracic cage. This retropectoral space has been opened up by digital dissection for insertion of the prosthesis. Good access to the axilla is provided; (b) thesilastic implant has been placed behind the pectoralis major muscle. It is temporarily secured in place (until skin closure is completed) by guy sutures of catgut extending from the serratus anterior muscle across the exposed inferior third of the implant to the lower border of the pectoralis major muscle. It is sometimes useful to close this "lateral window" by a latissmus dorsi muscle flap. The soft tissue cover over the prosthesis will be further reinforced by the inferior pedicle when the nipple is repositioned. The inferior pedicle sustaining the nipple at its apex is being held inferiorly to show the implant in position; ( c ) the inferior pedicle has been replaced superiorlyand the nipple held in its final position by a suture through its upper pole and the appropriate point of the upper wound edge. It can be seen that the inferior pedicle provides further cover of the implant.
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(Corso and Zubiri 1975); and Horton et alii (1974) and Spira (1977) have used a technique deepithelializing the lower flap to allow "double breasting" in the closure, which reinforces the wound in depth and lessens the risk of wound breakdown with consequent exposure and loss of the prosthesis. A solution to the problem of reconstructing an aesthetically acceptable breast symbol has been made possible by Robbins (1977), who introduced to mammoplasty the use of an inferiorly based pedicle to retain the blood supply to the nippleareolar complex. Clearly this is not possible when a long inframammary incision has been used previously for the exploration of breast pathology. Many have pointed out that such an inferior pedicle is preferable to the superior or lateral pedicle which have been recommended by Hartley et alii (1978), Georgiade and Hyland (1975) and Baroudi et alii (1978), since the inferior pedicle sustains the blood supply to the nipple and areola, and usually retains sensibility as well. This latter advantage of using an inferior pedicle was pointed out by d'Alessio (1977), although he inserted no prosthesis. The need for breast integument adjustment by a simultaneous mastopexy in order to obtain an optimal aesthetic result over a smaller prosthesis has been stressed by Spira (1977) and Jarrett et alii (1978), and the authors agree that this should be done when necessary. The present procedure of subcutaneous mastectomy allows the maximum exposure for excision of breast tissue and, combined with subpectoral prosthetic insertion, the use of the inferior pedicle has provided excellent aesthetic results and minimized the risk of exposure of the breast prosthesis. Moreover, in cases where coincidental mastopexy has been required, the inferior pedicle reinforces the resultant T-junction.
TECHNICAL CONSIDERATIONS
Often there is a discrepancy between the large breast integument envelope and the optimum amount of soft tissue required to cover a prosthesis of aesthetically acceptable size. The need exists, therefore, for a technique which allows mastopexy adjustment of the integument at the time of subcutaneous mastectomy, with a safe immediate prosthetic insertion. The usual keyhole marking is drawn to indicate the area of skin excision from the inferior surface of the breast (Figure l a ) . This will result in a final scar pattern which is circumareolar and of an inverted T shape. Within this area the inferior pedicle to be AUST.N.Z. J. SURG.VOL. 49-No. 5, OCTOBER, 1979
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FIGURE 4: (a) the lateral and medial skin flaps of the mammoplasty pattern have been brought together over the inferior pedicle beneath the nipple, (b) wound closure has been completed. The reconstruction of the other side is visible: (c) preoperative view of another patient who had bilateral subcutaneous mastectomy by the method described; (d) postoperative view of the same patient AUST. N.Z. J. SURG. VOL. 49-No.
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retained and de-epithelialized is also marked (Figure l b ) . This is based on the inframammary groove and extends superiorly to include the nipple. The exact technique of determining these markings is subject to variation between breasts and between surgeons, and a detailed discussion of it is not considered relevant to this paper. The principles upon which these markings are based were laid down by Penn (1954). The triangular inferior pedicle is de-epithelialized (Figure 2a). The pedicle with the nipple attached at its apex is further defined by a peripheral incision except at its base on the inframarnmary fold. It is freed on its deep surface and hinged inferiorly away from the glandular mass of the breast (Figure 2b). A small amount of breast tissue less than 1 centimetre thick is left attached to the deep surface of the areola, but virually none on the pedicle. The pedicle retains the viability and usually the sensibility of the nipple. With the nipple-bearing pedicle hinged inferiorly, a clear wide access is provided for excision of the mammary glandulartissue, including the axillary tail, by reflecting the two lateral flaps out from the breast (Figure 3a). The axillary nodes are easily accessible for palpation, biopsy, or resection. After the excision has been completed, the inferior border of the pectoralis major muscle is identified, split, and by digital dissection, the subpectoral plane and adjacent serratus anterior are opened enough to receive an appropriately sized silicone gel-filled implant (Figure 3b). The implant is temporarily secured by catgut sutures extending across the exposed inferior third of the implant from the inferior border of the pectoralis major to the serratus anterior. A latissimus dorsi flap may be used to close this lateral muscle plane hiatus. It is important not to try to close the pectoralis major muscle over the prosthesis, as this will force the prosthesis too high on the chest wall. The nipple is then transposed up into its new site and fixed into position with asuture (Figure3c). The lateral and medial skin flaps are then brought together beneath the nipple anterior to the inferior pedicle to complete the reconstruciton with the inverted “T” suture line (Figures 4a, b). No claim is made that we perform a “total glandular mastectomy” as sought by Freeman and Weimer (1978). These authors resect the nipple leaving the areola - thus removing all ducts along with the glandular tissue. The present technique is less radical in the nipple-areolar area, but is simpler and aesthetically superior, since a free nipple graft is not required (Figures 4c. d). This preservation of the nipple-areolar-complex implies that up to 1 centimetre of large ducts will be 558
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retained, with consequent risk of intraductal carcinoma developing. Hence consideration should be given to Pennisi’s suggestion (1979)’ of coning out the nipple containing this duct system at a second-stage procedure after two or three months - particularly when intraductal papillomata have been excised in the past or have been found in the ducts of the operation specimen. Nevertheless, the removal of 90% of the breast tissue should provide a greatly increased sense of security - at least for the patient who has been subjected to multiple biopsies, with an attendant increasing fear of cancer. As has already been stressed, however, regular follow-up examinations are obiligatory; but since the prosthesis is posterior to any remaining breast tissue behind the nipple-areolar-complex, or central to any peripheral remnants, any change in residual breast tissue should be readily detectable. As distinct from Horton (1979), who feels that subcutaneous mastectomy can only be justified if it can guarantee absolute prevention of breast cancer, we would stress that while no such absolute certainly of prevention should be attributed to the present technique, it will reduce to a minimum the bulk of potentially dangerous breast tissue. Both the patient and the surgeon must recognize the responsibility to maintain regular review of the reconstructed breast and minor breast remnants for the rest of the patient’s life. CONCLUSION
For a certain group of patients, carefully selected on the basis of the criteria that have been indicated, subcutaneous mastectomy offers a real prospect of minimizing the risk that breast cancer may develop. It will also relieve pain in those for whom it has become intolerable, and will almost certainly afford its subjects some degree of peace of mind. Performed by the technique outlined above, the p r o c e d u r e s h o u l d , m o r e o v e r , p r o d u c e an aesthetically pleasing result. Regular review of all cases is, however, mandatory. REFERENCES ANDERSON, D. E. (1973), Cancer Bull, Wash., 25: 23. BAROUDI, R . , KEPPKE, E. M. and CARVALHO, C. (1978),Aesthetic Plastic Surgery, 2: 235. BUHL-JORGENSEN, S. W., FISCHERMANN, K., JOHANSEN,H. and PETERSEN, 8. (1968), Surg. Gynec. Obstet., 127: 1307. CORSO, P. F. and ZuBIRI. J. S. (1975) Plast. Reconstr. Surg., 56: 1. D’ALESSIO,E. (1977), Revista ltaliano di Churagia Plastica, 9: 449. DE CHOLNOKY. T, (1955), Plast. reconstr. Surg., 16: 226. DEMPSEY. W. E. and LATHAN. W. D. (1968) Plast. reconstr. Surg., 42: 515. ’ Personal communication
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DUNCAN, W. and KERR, G. R. (1976), Brit. med. J. 2: 781. FOOTE.F. W. and STEWART, F. S. (1945), Ann. Surg.. 121: 197. FREEMAN, B. S. (1962), Plast. reconstr. Surg, 30: 676. FREEMAN,8. S. and WEIMER. R. (1978). Plast. reconstr. Surg., 62: 167. GEORGIADE. A. and HYLAND,W. (1975), Plast. reconstr. Surg., 56: 121. GOLDMAN,C. D. and GOLDWYN, R. M. (1973), Plast. reconstr. Surg., 51: 501. HAAGENSEN, C. D. (1971). W. 8. Saunders Company, Phiadelphia. : 170. HARTLEV, H., SCHAUTEN, W E. and GRIFIN,J. (1978). Plast. reconstr. Surg., 56: 5. HORTON, c . E., ADAMSON, J. E.. MLADICK, R. A. and CARRAWAY, J. H. (1974). Plast. reconstr. Surg.. 56: 42. HORTON,C. E. ' (1979), in discussion of subcutaneous mastectomy at 7th International Congress of Plastic and Reconstructive Surgery, Rio de Janeiro. May 1979. JARRETT, J. R., CUTLER, R. G. and TEAL, D. F. (1978), Plast. reconstr. Surg.. 62: 702. KELLY, A. P., JACOBSON. H. S., FOX, J. L. and JENNY,H. (1966), Plast. reconstr. Surg.. 37: 438. LETTERMAN. G.and SCHURTER, M. (1955),Amer.Surg.,21: 335. LEXER, E. (1931), Die Gesamte Wiedersfellingchuringie, Vol. 2, Leipzig.
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M.(1975). Cancer MCCREDIE,J. A., INCH, W. R. and ALDERSON. (Philad.), 35: 1472. MLADICK,R. A. (1978), Plast. reconstr. Surg., 62: 289. MOERTEL., C. G. (1966). Springer-Verlag. New York. p. 82. PEACOCK, E. E. (1975), Plast. reconstr. Surg., 55: 14. PENN, J. (1954), Brit. J. Plast. Surg., 11: 357. PENNISI, V. R. and CAPOzzl, A. (1975), Plast. reconstr. Surg., 56: 9. PENNISI. V. R. CAPOZZI, A. and PEREZ,F. M. (1977). Plast. reconstr. Surg., 59: 55. ROBEINS,G. F. and BERG. J. W. (1964), Cancer (Philad.), 17: 1501. ROBEINS, T. H. (1977), Plast. reconstr. Surg., 59: 64. RYAN,J. A. and COADY.C. J. (1962). Canad. J. Surg.. 5: 12. SCHLENKER, J. D.,BUENO.R. A,, RICKETSON. G. and LYNCH,J. B. (1978). Plast. reconstr. Surg., 62: 853. SNYDERMAN. R. K. (1978), in Symposium on Aesthetic Surgery of the Breast, edited by OWSLEY,J. Q.. PETERSON, R. A. and MOSEY,C. V., St Louis: 149. SPIRA,M. (1977) Plast. reconstr. Surg.. 59: 200. THOMAS, T. G. (1882). N. Y. med., J. : 337. WARREN, S. (1940), Surg. Gynec. Obstet, 71: 257. WESTBROOK, K. C. and GALLAGER, H. S. (1975), Amer. J. Surg., 130: 667.
SUBCUTANEOUS MASTECTOMY USING AN INFERIOR NIPPLE PEDICLE W. GIBSON Department of Plastic and Reconstructive Surgery, Royal Prince Alfred Hospital, Sydney
EDWARD
A technique for subcutaneous mastectomy is described which permits a reduction mammoplasty or mastopexy to be performed at the same time. The nipple is based on an inferior dermal pedicle. This appears to provide a safe blood supply to the nipple and safe cover for the prosthesis. The dermal pedicle for the nipple reinforces the submammary suture line and lessens the chance of extrusion of the prosthesis. MANY patients i n whom subcutaneous mastectomy is indicated have large or pendulous breasts and would benefit from a reduction mammoplasty o r mastopexy. Accordingly an operation was designed which would permit removal of as much breast tissue as possible, refashioning of the skin brassiere, and elevation of the nipple on a dermal pedicle to the desired height. At first some trepidation was felt in regard to the survival of the nipple on a dermal pediclefrom which all the breast tissue had been removed. However, all Reprints Hengrove Hall, 193 Macquarie St. Sydney, N S W 2000
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nipples survived without arousing any concern for their blood supply
Indications for Subcutaneous Mastectomy The indications for subcutaneous mastectomy may be one or more of the following. 1. The need for repeated biopsiesfor suspicious lumps. 2. Severe pain in the breasts. 3. A strong family history of carcinoma of the breast, especially when associated with a proven carcinoma in the other breast. 559
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CORT, D. F., COLLIS, J. L. (1973). Brit. J. Surg. 60: 580. DAS, S. K. (1976). Brit. J. Plasf. Surg. 29: 170. DUPONT, C.. MENARD,Y. (1972),Plasf. reconstr. Surg..49: 263. GOLDSMITH. H. S.. DELOSSANTOS. R. (1966),Rev.Surg.23: 303. GOLDSMITH, H. S . (1968), Dis. Chest. 54: 523. GOLDSMITH, H. S. (1970) Surg. Gynec. Obsfef. 130: 57.
GUE,S. (1975). AUST.N.Z. J. SURG 45: 390. KIRICUTA, I. (1963). Presse med., 71: 15. KIRICUTA, A,. GOLDSTEIN, M. B. (1961),Krebsarzf, 16: 202. MCLEAN,D. H., BUNCKE,H. J. jr.. (1972). Plast. reconstr. Surg., 49: 268. ROBERTS, B. (1967), Ann. Surg.. 166: 583.
SUBCUTANEOUS MASTECTOMY: INDICATIONS AND TECHNIQUE T. H. ACKLAND’,J. T. HUESTON*, AND T. H. ROBBINS3 Royal Melbourne Hospital and Wellington Private Hospital
For a certain group of patients, carefully selected by criteria which are here discussed, subcutaneous mastectomy offers a real prospect of minimizing the risk of breast cancer developing. It will also relieve pain in most of those for whom it has become intolerable and will usually provide the patient with both comfort and peace of mind. Performed by the technique described, subcutaneous mastectomy can now produce an aesthetically pleasing result. Regular review of all patients is, however, mandatory.
SUBCUTANEOUS mastectomy is a procedure which has for many years been viewed with suspicion. It is the belief of the present authors, however, that not only has such a level of competence in technique now been reached that an aesthetically acceptable result may be anticipated, but sufficiently valid indiqations have emerged to justify use of the procedure on certain occasions. This opinion is supported both by the personal experience of the authors, and by a considerable series of reported cases. It must be stressed however, that this is a statement of present feeling which may require modification in the light of future knowledge. The term “subcutaneous mastectomy” requires some explanation, as there would seem to be some incompatability between these words. “Subcutaneous” implies that external appearance will be little changed, remaining acceptable to the patient. “Mastectomy”, contrary to the usual understanding of the term as a total breast removal, implies, in this present context, a removal of somewhere in the region of 90% of breast tissue, leaving the nipple-areola-complex intact. The remainder of the unremoved breast tissue will be ’ Consultant Surgeon, Royal Melbourne Hospital Consultant Plastic Surgeon. Royal Melbourne Hospital Royal Melbourne Hospital
’ Assistant Plastic Surgeon,
Reprints, J T Hueston, 89 Royal Parade, Parkville. Victoria 3052
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located behind the nipple and in the infraclavicular and axillary regions, where the anatomical studies of Goldman and Goldwyn 1973) have demonstrated that breast tissue is in most cases present well beyond the clinically detectable limits of the breast. The procedure might therefore be regarded as a “radical subtotal mastectomy”, with acknowledged limits of prophylactic usefulness. The aim of the procedure is thus restricted to removal of as much breast tissue as possible, while at the same time allowing reconstruction of a personally and socially acceptable breast symbol, which will minimize the psychological sequelae of breast loss, almost inevitably sustained after classical simple mastectomy. INDICATIONS FOR SUBCUTANEOUS MASTECTOMY
( 7 ) Mammary Dysplasia Although subcutaneous mastectomy should never be employed for the management of proven breast cancer, this operation may now be regarded as an established method of treatment for several other breast disorders. Mammary dysplasia is the commonest cause of a breast lump, frequently in the form of cyst formation. When a solitary cyst is surrounded by normal breast tissue, aspiration alone will suffice, repeated should the cyst refill; but in most cases careful palpation after aspiration 551
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reveals some remaining irregularity - although perhaps very slight. Although some would then rely on cytological findings from further fine needle aspiration, the writer's (T.H.A.) experience has led him to regard this as insufficiently reliable. This situation demands open biopsy, with frozen section facilities, and this almost invariably reveals that various other manifestations of mammary dysplasia surround the main cyst - other smaller cysts, microcysts, duct ectasia, ductal epitheliosis, or fibroadenosis. But rarely a carcinoma will be found adjacent to a cyst, in the wall of it, or between the other abnormalities. Although after such an operation, with excision of an appropriate amount of tissue, there may be no further developments, unfortunately further lumps frequently occur on the same or the opposite side, and perhaps other areas calling for the same management, with the result that the woman is left with several breast scars. All such patients should be examined at intervals and instructed in breast self-examination. They should be told to report at once should they themselves observe any change, or have any doubt, and happily one, two, or even three open biopsies may be followed by no other lump developing; and further cyst formation becomes less likely with advancing years. Nevertheless, in a small group, after several biopsies, both breasts are left with many lumps, cystic or solid, and the surgeon is faced with the dilemma of not knowing where another biopsy is to be performed, if at all. There may or may not be pain in such multinodular breasts, and in any case, it is not pain which is the problem, but rather the possibility that, between the multiple nodules, there may be a small carcinoma. After many years of differing opinions and uncertainty it now seems probable, although not certain, that patients with mammary dysplasia do have a somewhat greater than average risk of developing breast cancer, especially when ductal e p i t h e l i a l p r o l i f e r a t i o n is a p r e d o m i n a n t manifestation. Warren (1940). after studying 1,200 cases over five years, found a fourfold increase in the incidence of cancer in women with mammary dysplasia, and a twelvefold increase when there was pronounced epithelial hyperplasia; and Haagensen (1971) found a fourfold increase in carcinomas in the presence of dysplasia in 1,700 patients matched for age and for period of observation. Ryan and Coady (1962), in an autopsy study of 100 women with clinically normal breasts, found that 12% had intraductal epithelial proliferaiton; while in 100 women with breast cancer the incidence of this change was four times as great. They concluded that the condition was precancerous. But this is not necessarily so, since the factor responsible for 552
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epithelial hyperplasia may be similar to that for carcinoma, rather than the one progressing to the other. Opinions differ also on the relation of papillomas and papillomatosis to breast cancer. Haagensen (1971) concluded that these conditions were benign, unassociated with increased cancer risk, basing this view o n the incidence of malignancy among women who had previously had excised specimens with the diagnosis established. On the other hand, Foote and Stewart (1945) and BuhlJorgensen et a h , (1968) found that these lesions were associated with an increase in cancer development. Thus, although evidence is insufficient to establish absolute proof of a relationship between mammary dysplasia and cancer, it is wise to regard with suspicion cases where biopsy has revealed ductal epitheliosis, especially if more than one biopsy has been needed, with similar findings. Not infrequently these patients are aware of their potential danger, and the surgeon will know that, no matter how experienced his hands may be, palpation of such breasts can fail to detect a carcinomatous change between many nodules. M o r e o v e r , r e l i a n c e c a n n o t b e p l a c e d on mammography findings under such circumstances, and there should be no hesitation in advising subcutaneous mastectomy, since mammary dysplasia may in fact predispose to malignant change, and also because accurate clinical asessment will be impossible in such patients, even if they face no more than the average risk of developing breast cancer. After subcutaneous mastectomy 90% or more of breast tissue is removed, and if by misfortune a carcinoma develops in the remaining breast tissue, it should be readily detected at the regular clinical examinations which must follow. (2) High Risk of Cancer It has been suggested that bilateral subcutaneous mastectomy should be advised for women having a particularly high risk of developing breast cancer, and there is no doubt that those with a history of the disease having occurred in other members of the family are in this category. Anderson (1973) compared the incidence of breast cancer in 567 mothers, sister and daughters of 178 patients who had breast cancer, with the incidence in 699 mothers, sisters and daughters of 217 patients who had other types of cancer. He found a twofold increase in risk in the relatives of patients with breast cancer. But the daughters of women who had bilateral breast cancer before the age of fifty years had a ninefold increase compared AUST. N.Z. J. SURG.VOL. 49-No.
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with controls, with about 50% of this group developing the disease, compared with the overall incidence of about 6%. Nulliparae and late primiparae also have an increased risk of developing breast cancer. It is impossible to give dogmatic advice applicable to all such women, some with a slightly increased risk, others with a risk enormously increased. In the case of daughters of women who have had bilateral breast cancer before the age of fifty years we have no hesitation in strongly advising subcutaneous mastectomy. For others with a smaller yet definite increased risk, those with a family history, nulliparae and late primiparae, opinions will differ. At least there should be monthly breast self-examination, and, perhaps for those over the age of fifty years, also yearly mammography. Although the possibility of cancer being radiationinduced has been emphasized, the most modern equipment delivers only a very small dose, in the region of 0.25 rad.; and it is possible that benefits resulting from mammography detection of clinically occult cancers might well outweigh the risk. Yet, a disturbing thought is that we are not sure whether the high-risk group might also be the group at high risk from ionizing radiation. Moreover, in spite of its high accuracy rate, mammography does not necessarily reveal a cancer which is present. The writer (T.H.A.) feels that for these relatively highrisk patients subcutaneous mastectomy should not necessarily be advised; and as well as breast selfexamination, and regular mammography for those over the age of fifty years, an ideal additional precaution would be yearly examination by a surgeon experienced in breast palpation. There will be Borne women in this group who are not merely aware of their special risk, but who are constantly worried, even distraught, at the prospect of developing breast cancer; and to these women it should at least be explained, although not urged, that subcutaneous mastectomy may be performed. The case against prophylactic subcutaneous mastectomy has been put fervently by Peacock (1975) and Snyderman (1978). They point out that carcinoma can still occur in the small amount of breast tissue left, that fibrocystic disease alone is usually not premalignant, and that a careful period of observation and regular examination will protect most patients. T o balance this reasonable conservatismare thefindings of Pennisi etalii (1977) that 6% of breasts removed prophylactically by subcutaneous mastectomy have been shown to contain occult carcinoma. (3) Breast Pain Breast pain with tenderness is a common symptom, usually no more than a temporary AUST. N.Z. J. SURG.VOL. 49-No. 5, OCTOBER, 1979
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premenstrual annoyance. But it may be very severe, either in women whose breasts are nodular from mammary dysplasia, perhaps with scars of previous biopsies, or less often when clinical examination reveals no abnormality. Undoubtedly, in some patients the pain is a psychosomatic presentation of an emotional disturbance, which may in fact be more important to the woman than her pain. In such cases only appropriate counselling or other such help can be expected to diminish the symptoms. But if there appears to be no reason to suspect such a basis for severe breast pain, other treatment is called for. Oestrogens should be withdrawn, the breasts adequately supported, and a mild diuretic ordered for the premenstrual week. In some patients, norethisterone acetate, taken in a dose of 5 milligrams twice daily from the 15th to the 25th day of the menstrual cycle, may suppress pain and is worthy of a trial. In the past, small dosages of radiotherapy have been used, but this treatment should no longer be advised, since it was rarely successful and is not without risk of inducing cancer. There remains then a very small group suffering severe and genuine breast pain which has become intolerable, although the precise cause of the symptom remains obscure. I n these cases subcutaneous mastectomy should at least be discussed, and if this operation is performed under such circumstances, after careful case selection, with exclusion of patients with a psychological cause, success may be anticipated, just as, in the past, bilateral simple mastectomy used on similarly rare occasions has been followed by total pain relief. One of us (T.H.A.) has used this method, although on no more than six occasions over twenty-five years; but the mutilation of this operation is no longer justified, and the purpose of this paper is to present an aesthetically acceptable technique for subcutaneous mastectomy. ( 4 ) The Contralateral Breast It is sometimes forgotten that the woman with the greatest risk of developing breast cancer is the one who has already had the disease. Moertel (1966) found that the incidence of contralateral carcinoma was highest initially, a n d then decreased exponentially with time. Other workers (Robbins and Berg, 1964; McCredie etalii, 1975) have shown that the cumulative probability of there occurring a consecutive non-synchronous breast cancer is approximately 1% per year, for all women at any one time, and remains at this level for up to twenty years. There is, however, a special risk of a new carcinoma developing in younger women, and in those whose 553
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mothers had the disease before the age of fifty years. Moreover, contralateral cancer is usually discovered late, and more than half of patients with this condition have axillary metastases. In the past, management after a single mastectomy has been repeated clinical examinations, and more recently mammography of the remaining breast, but there are good reasons for giving consideration to contralateral subcutaneous mastectomy, at least for certain tumours, since the type of tumour found on the first occasion is related to the probability of a contralateral carcinoma occurring. lntraductal carcinoma constitutes only 2% of breast cancers, but Westbrook and Gallagher (1975) have found that there isa 13% probabilityof it be i n g b i Iate ra I. Co n t ra Iate rhLI s u b c ut a n eo us mastectomy should therefore be considered tn such cases; moreover, many of these lesions are located centrally, very near the nipple, and these authors suggested that, if this operation is carried out, the nipple and areola should be sacrificed. On the other hand, if a subareolar plaque no larger than three centimetres in diameter and five millimetres in thickness is left at subcutaneous mastectomy- this being sufficient to ensure nipple viability - any carcinomatous change in such a small amount of tissue is very unlikely, and should be detected without difficulty. Moreover, the opportunity exists of coning out the residue of large ducts after sound healing of the skin flaps should there be any doubt after examination of the major subcutaneous mastectomy specimen. Between 5% and 1O0/o of breast cancers are lobular, either in situ or invasive, and about onethird of patients with such tumoursdevelopasimilar tumour on the opposite side within ten years. An added danger is that in situ lobular carcinoma is often not palpable as such, but is adjacent to a zone of mammary dysplasia. Prophylactic subcutaneous mastectomy will therefore properly be advised when this histological diagnosis has been made. Medullary carcinoma, constituting between 1% and 5% of breast cancers, has a lower than usual incidence of node invasion, with an excellent fiveyear survival in the region of 90%. Nevertheless, Haagensen (1971) found that in 140 patients with this tumour, 10% developed a carcinoma of the same or a different type on the opposite side, and here too, subcutaneous mastectomy calls for consideration when this tumour type has been found. It is therefore seen that intraductal carcinoma, lobular carcinoma, and medullary carcinoma together, form only a small proportion of all breast 554
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cancers; and therefore from the point of view of turnour type alone, contralateral subcutaneous mastectomy will be indicated only infrequently. Furthermore, this procedure should be advised only for women with a life expectancy of more than twenty years, and when axillary nodes have been found not to contain metastases. If the operation is to be performed, it should be carried out not later than twelve months after the first operation, and of course only after careful whole body investigiltion has revealed no evidence of distant spread. ( 5 ) Cancerophobia As a result of proper public education, most women are now aware of the common occurrence of breast cancer, and with the wider practice of breast self-examination, a greater number of smaller tumours are now being found. To thisextent public education programmes can be said to have generated added confidence among women, and there is also a greater prospect of cure when a cancer is small (Duncan and Kerr, 1976). However, these same programmes of public education have aroused in some women a profoundly disturbing cancerophobia. Such women may have no pain, and their breasts may be entirely normal both to clinical examination and even after mammography. A l t h o u g h i t has b e e n s u g g e s t e d t h a t subcutaneous mastectomy be offered on such occasions, we feel reluctant to agree with this, since cancerophobia alone clearly differs from the several abnormalities which have been described as calling for this operation to be considered. The removal of an important part of the body, in the absence of any evidence of disease, appears to us not to be in accordance with sound surgical practice. Evolution of the Present Technique Since the first attempt at reconstruciton of the breast after prophylactic mastectomy - as distinct from simple mastectomy without reconstruction there has been a progressive improvement in the aesthetic quality of the results. Since Thomas (1882) drew attention to the need for minimizing mutilation of the breast after wide excision for benign conditions, the inframammary approach has been favoured by many, since it affords excellent exposure of breast pathology and makes possible the insertion of local flaps of adjacent dermo-fat tissue to produce a breast symbol. This local fat f!ap repair, recommended by Lexerin 1931, wassuperiortothefreefatgraftsused by Bartlett who, in 1917, had recommended “an anatomical substitute for the female breast”. Local dermo-fat flap reconstruction evolved through the work of Shonbauer and Winkler (1953), Letterman AUST.N.Z. J. SURG.VOL. 49-No.
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FIGURE 1 (a) skin markings for rnastopexy combined with subcutaneous mastectomy of the left breast The skin envelope will be reduced by the area enclosed within the keyhole marking-The patient has previously had a mastectomy on the right side This was reconstructed at the same operation by local skin flaps and silastic implant, (b) the inferior limits of the keyhole marking are shown Triangular cross-hatched area based on the inframarnmary groove and supporting the nipple represents the surface marking of the inferior pedicle which will be de-epithelialized
and Schurter (1953), de Cholnoky (1955), and Longacre (1959); but these biological repairs were supplanted in 1962 when Freeman first described the Lase. of silicone breast prostheses. In the 17 years since Freeman's introduction of prosthetic replacement f o r breast c o n t o u r reconstruction after subcutaneous mastectomy, there have been extensive records of the limitations of this procedure from Kelly et alii (1966) to Schlenker e t afii (1978) - all stressing scar contracture around the prosthesis, infection, and secpndary extrusion of the prosthesis following wound breakdown, usually at the inverted Tjunction in the suture line at the inframammary
groove. The aesthetic results have, to say the least, been less than optimal. The safety of delayed insertion of the prosthesis has been pointed out by Horton etalii (1974), but in the same paper their technique for immediate prosthetic insertion is described. It is now accepted that immediate reconstruciton with a prosthesis is reasonable, provided that the increased protection provided by a subpectoral insertion (Dempster and Lathan, 1968) is combined with attention to viability of the nipple and areola. The blood supply to this area is so compromised by the inframammary incision that splitting the breast into two halves horizontally through the nipple has been used
FIGURE2: (a) De-epithelialization of the inferior pedicle has been completed. The other skin markings have been incised; (b) the inferior pedicle. sustaining the nipple at its apex, has been elevated
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FIGURE 3: (a) the inferior pedicle supporting the nipple has been folded inferiorly and radical excision of the glandular mass and some axillary nodes has been completed. The skin flaps have been folded away from the dissection to show the inferior border of the pectoralis major muscle and serratus anterior muscle with a muscle-splitting incision between them exposing the thoracic cage. This retropectoral space has been opened up by digital dissection for insertion of the prosthesis. Good access to the axilla is provided; (b) thesilastic implant has been placed behind the pectoralis major muscle. It is temporarily secured in place (until skin closure is completed) by guy sutures of catgut extending from the serratus anterior muscle across the exposed inferior third of the implant to the lower border of the pectoralis major muscle. It is sometimes useful to close this "lateral window" by a latissmus dorsi muscle flap. The soft tissue cover over the prosthesis will be further reinforced by the inferior pedicle when the nipple is repositioned. The inferior pedicle sustaining the nipple at its apex is being held inferiorly to show the implant in position; ( c ) the inferior pedicle has been replaced superiorlyand the nipple held in its final position by a suture through its upper pole and the appropriate point of the upper wound edge. It can be seen that the inferior pedicle provides further cover of the implant.
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(Corso and Zubiri 1975); and Horton et alii (1974) and Spira (1977) have used a technique deepithelializing the lower flap to allow "double breasting" in the closure, which reinforces the wound in depth and lessens the risk of wound breakdown with consequent exposure and loss of the prosthesis. A solution to the problem of reconstructing an aesthetically acceptable breast symbol has been made possible by Robbins (1977), who introduced to mammoplasty the use of an inferiorly based pedicle to retain the blood supply to the nippleareolar complex. Clearly this is not possible when a long inframammary incision has been used previously for the exploration of breast pathology. Many have pointed out that such an inferior pedicle is preferable to the superior or lateral pedicle which have been recommended by Hartley et alii (1978), Georgiade and Hyland (1975) and Baroudi et alii (1978), since the inferior pedicle sustains the blood supply to the nipple and areola, and usually retains sensibility as well. This latter advantage of using an inferior pedicle was pointed out by d'Alessio (1977), although he inserted no prosthesis. The need for breast integument adjustment by a simultaneous mastopexy in order to obtain an optimal aesthetic result over a smaller prosthesis has been stressed by Spira (1977) and Jarrett et alii (1978), and the authors agree that this should be done when necessary. The present procedure of subcutaneous mastectomy allows the maximum exposure for excision of breast tissue and, combined with subpectoral prosthetic insertion, the use of the inferior pedicle has provided excellent aesthetic results and minimized the risk of exposure of the breast prosthesis. Moreover, in cases where coincidental mastopexy has been required, the inferior pedicle reinforces the resultant T-junction.
TECHNICAL CONSIDERATIONS
Often there is a discrepancy between the large breast integument envelope and the optimum amount of soft tissue required to cover a prosthesis of aesthetically acceptable size. The need exists, therefore, for a technique which allows mastopexy adjustment of the integument at the time of subcutaneous mastectomy, with a safe immediate prosthetic insertion. The usual keyhole marking is drawn to indicate the area of skin excision from the inferior surface of the breast (Figure l a ) . This will result in a final scar pattern which is circumareolar and of an inverted T shape. Within this area the inferior pedicle to be AUST.N.Z. J. SURG.VOL. 49-No. 5, OCTOBER, 1979
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FIGURE 4: (a) the lateral and medial skin flaps of the mammoplasty pattern have been brought together over the inferior pedicle beneath the nipple, (b) wound closure has been completed. The reconstruction of the other side is visible: (c) preoperative view of another patient who had bilateral subcutaneous mastectomy by the method described; (d) postoperative view of the same patient AUST. N.Z. J. SURG. VOL. 49-No.
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retained and de-epithelialized is also marked (Figure l b ) . This is based on the inframammary groove and extends superiorly to include the nipple. The exact technique of determining these markings is subject to variation between breasts and between surgeons, and a detailed discussion of it is not considered relevant to this paper. The principles upon which these markings are based were laid down by Penn (1954). The triangular inferior pedicle is de-epithelialized (Figure 2a). The pedicle with the nipple attached at its apex is further defined by a peripheral incision except at its base on the inframarnmary fold. It is freed on its deep surface and hinged inferiorly away from the glandular mass of the breast (Figure 2b). A small amount of breast tissue less than 1 centimetre thick is left attached to the deep surface of the areola, but virually none on the pedicle. The pedicle retains the viability and usually the sensibility of the nipple. With the nipple-bearing pedicle hinged inferiorly, a clear wide access is provided for excision of the mammary glandulartissue, including the axillary tail, by reflecting the two lateral flaps out from the breast (Figure 3a). The axillary nodes are easily accessible for palpation, biopsy, or resection. After the excision has been completed, the inferior border of the pectoralis major muscle is identified, split, and by digital dissection, the subpectoral plane and adjacent serratus anterior are opened enough to receive an appropriately sized silicone gel-filled implant (Figure 3b). The implant is temporarily secured by catgut sutures extending across the exposed inferior third of the implant from the inferior border of the pectoralis major to the serratus anterior. A latissimus dorsi flap may be used to close this lateral muscle plane hiatus. It is important not to try to close the pectoralis major muscle over the prosthesis, as this will force the prosthesis too high on the chest wall. The nipple is then transposed up into its new site and fixed into position with asuture (Figure3c). The lateral and medial skin flaps are then brought together beneath the nipple anterior to the inferior pedicle to complete the reconstruciton with the inverted “T” suture line (Figures 4a, b). No claim is made that we perform a “total glandular mastectomy” as sought by Freeman and Weimer (1978). These authors resect the nipple leaving the areola - thus removing all ducts along with the glandular tissue. The present technique is less radical in the nipple-areolar area, but is simpler and aesthetically superior, since a free nipple graft is not required (Figures 4c. d). This preservation of the nipple-areolar-complex implies that up to 1 centimetre of large ducts will be 558
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retained, with consequent risk of intraductal carcinoma developing. Hence consideration should be given to Pennisi’s suggestion (1979)’ of coning out the nipple containing this duct system at a second-stage procedure after two or three months - particularly when intraductal papillomata have been excised in the past or have been found in the ducts of the operation specimen. Nevertheless, the removal of 90% of the breast tissue should provide a greatly increased sense of security - at least for the patient who has been subjected to multiple biopsies, with an attendant increasing fear of cancer. As has already been stressed, however, regular follow-up examinations are obiligatory; but since the prosthesis is posterior to any remaining breast tissue behind the nipple-areolar-complex, or central to any peripheral remnants, any change in residual breast tissue should be readily detectable. As distinct from Horton (1979), who feels that subcutaneous mastectomy can only be justified if it can guarantee absolute prevention of breast cancer, we would stress that while no such absolute certainly of prevention should be attributed to the present technique, it will reduce to a minimum the bulk of potentially dangerous breast tissue. Both the patient and the surgeon must recognize the responsibility to maintain regular review of the reconstructed breast and minor breast remnants for the rest of the patient’s life. CONCLUSION
For a certain group of patients, carefully selected on the basis of the criteria that have been indicated, subcutaneous mastectomy offers a real prospect of minimizing the risk that breast cancer may develop. It will also relieve pain in those for whom it has become intolerable, and will almost certainly afford its subjects some degree of peace of mind. Performed by the technique outlined above, the p r o c e d u r e s h o u l d , m o r e o v e r , p r o d u c e an aesthetically pleasing result. Regular review of all cases is, however, mandatory. REFERENCES ANDERSON, D. E. (1973), Cancer Bull, Wash., 25: 23. BAROUDI, R . , KEPPKE, E. M. and CARVALHO, C. (1978),Aesthetic Plastic Surgery, 2: 235. BUHL-JORGENSEN, S. W., FISCHERMANN, K., JOHANSEN,H. and PETERSEN, 8. (1968), Surg. Gynec. Obstet., 127: 1307. CORSO, P. F. and ZuBIRI. J. S. (1975) Plast. Reconstr. Surg., 56: 1. D’ALESSIO,E. (1977), Revista ltaliano di Churagia Plastica, 9: 449. DE CHOLNOKY. T, (1955), Plast. reconstr. Surg., 16: 226. DEMPSEY. W. E. and LATHAN. W. D. (1968) Plast. reconstr. Surg., 42: 515. ’ Personal communication
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DUNCAN, W. and KERR, G. R. (1976), Brit. med. J. 2: 781. FOOTE.F. W. and STEWART, F. S. (1945), Ann. Surg.. 121: 197. FREEMAN, B. S. (1962), Plast. reconstr. Surg, 30: 676. FREEMAN,8. S. and WEIMER. R. (1978). Plast. reconstr. Surg., 62: 167. GEORGIADE. A. and HYLAND,W. (1975), Plast. reconstr. Surg., 56: 121. GOLDMAN,C. D. and GOLDWYN, R. M. (1973), Plast. reconstr. Surg., 51: 501. HAAGENSEN, C. D. (1971). W. 8. Saunders Company, Phiadelphia. : 170. HARTLEV, H., SCHAUTEN, W E. and GRIFIN,J. (1978). Plast. reconstr. Surg., 56: 5. HORTON, c . E., ADAMSON, J. E.. MLADICK, R. A. and CARRAWAY, J. H. (1974). Plast. reconstr. Surg.. 56: 42. HORTON,C. E. ' (1979), in discussion of subcutaneous mastectomy at 7th International Congress of Plastic and Reconstructive Surgery, Rio de Janeiro. May 1979. JARRETT, J. R., CUTLER, R. G. and TEAL, D. F. (1978), Plast. reconstr. Surg.. 62: 702. KELLY, A. P., JACOBSON. H. S., FOX, J. L. and JENNY,H. (1966), Plast. reconstr. Surg.. 37: 438. LETTERMAN. G.and SCHURTER, M. (1955),Amer.Surg.,21: 335. LEXER, E. (1931), Die Gesamte Wiedersfellingchuringie, Vol. 2, Leipzig.
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SUBCUTANEOUS MASTECTOMY USING AN INFERIOR NIPPLE PEDICLE W. GIBSON Department of Plastic and Reconstructive Surgery, Royal Prince Alfred Hospital, Sydney
EDWARD
A technique for subcutaneous mastectomy is described which permits a reduction mammoplasty or mastopexy to be performed at the same time. The nipple is based on an inferior dermal pedicle. This appears to provide a safe blood supply to the nipple and safe cover for the prosthesis. The dermal pedicle for the nipple reinforces the submammary suture line and lessens the chance of extrusion of the prosthesis. MANY patients i n whom subcutaneous mastectomy is indicated have large or pendulous breasts and would benefit from a reduction mammoplasty o r mastopexy. Accordingly an operation was designed which would permit removal of as much breast tissue as possible, refashioning of the skin brassiere, and elevation of the nipple on a dermal pedicle to the desired height. At first some trepidation was felt in regard to the survival of the nipple on a dermal pediclefrom which all the breast tissue had been removed. However, all Reprints Hengrove Hall, 193 Macquarie St. Sydney, N S W 2000
AUST. N.Z. J. SURG.VOL. 49-40. 5, OCTOBER, 1979
nipples survived without arousing any concern for their blood supply
Indications for Subcutaneous Mastectomy The indications for subcutaneous mastectomy may be one or more of the following. 1. The need for repeated biopsiesfor suspicious lumps. 2. Severe pain in the breasts. 3. A strong family history of carcinoma of the breast, especially when associated with a proven carcinoma in the other breast. 559
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