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During mastectomy using the Madden technique full dissection of the axillary and supraclavicular lymph nodes can readily be achieved by the anterior approach, after transverse separation of the upper fibers of the pectoralis major.
The Authors, in a review of 162 patients submitted to mastectomy for cancer, have considered the incidence of local recurrences related to the type of operation and to the clinical stage of primitive neoplasia. Particularly, the percentage of local recurrences does not seem to be related to the type of surgical procedure employed but rather to the presence of metastatic lymph nodes at the time of the first treatment of neoplasia. Is also related the treatment of the local recurrences observed and the detained data are compared with that reported in the literature, particularly about the mechanisms of formation, the incidence and the types of treatment.
The medial anterior thoracic nerve supplies the pectoralis minor muscle and costal portion of the pectoralis major muscle. The lateral anterior thoracic nerve supplies the clavicular head and separately, three muscle groups of the sternal head. Any combination of these different muscle groups will become atrophic if the branches of the anterior thoracic nerves are injured. Muscle atrophy of the various groups of muscle bundles may not be apparent for as long as one year after the operation. These observations may be of some importance in the plastic reconstruction after modified radical mastectomy.
From a group of 928 randomly allocated women that had undergone mastectomy for cancer, 475 were examined with respect to the somatic sensations and discomfort in the arm on the side of the operation. The women rated psychological variables such as sensations and discomfort according to an 8-degree scale. The variables investigated were: heaviness of the arm and hardness of the arm tissue, tension, weakness and paresthesia. Eighty per cent of the women recorded a rating of 0. For most of the variables the means were thus low and corresponded to a rating of less than 1. The standard deviation was fairly large. In the women with a rating of 1 or more there was a weak but significant correlation between some of the psychological and somatic variables, including volume (positive correlation) and gripping force (negative correlation). Women with 15% oedema or more recorded the highest rating for the variables heaviness, hardness, weakness. The sensation and discomfort were rated significantly higher by the patients with than by those without discomfort or pain in the cervical and thoracic spine, chest and shoulder. The ratings were significantly higher by the women receiving radiotherapy than in those receiving only surgical treatment. There was no significant difference between the ratings for the women given radiotherapy before and those so treated after the operation.
In spite of all the conflicting literature concerning carcinoma of the breast, there has been little data available on the very common problem of postmastectomy skin flap necrosis. Other than age, the dominant predisposing factor appears to be the type of incision employed. Transverse incisions are associated with a significantly lower incidence of skin flap necrosis. The incidence of postmastectomy lymphedema is increased after adjuvant irradiation and in patients who have had skin flap necrosis. These data will hopefully be of practical use to the surgeon performing mastectomy, as an aid in reducing postoperative morbidity.
After a review of the techniques of subcutaneous mastectomy and of reconstruction of the breast, the authors analyze the cause of the most common complications and suggest a method which is shown to prevent their occurrence: it is based on a wide exposure of the glands to be excised and of the following defect. A dermofat flap based inferiorly is interposed between the skin and the prosthesis. Complications have been very rare in a series of 35 cases and the results have been cosmetically very satisfactory. The method is therefore indicated in all the cases where some degree of ptosis is associated with the mammary condition.
A new mastectomy technique, offering partial preservation of the greater pectoral muscle at the axilla, and immediate reconstruction with a greater dorsal myocutaneous flap is proposed.
The technique for the application of areola and nipple in the mastectomy for the mammary carcinoma is proposed. It is pointed out that the preservation of the nipple with its areola is psychologically important for the patient. It is also showed how the application of a silicone prosthesis, volumetrically restoring the extirpated tissue, is afterwards possible. During the operation, a disk of tissue is drawn under nipple and areola and histologically tested; if this tissue certainly results without neoplastics cells, the reapplication is achieved.
Over 30 patients have had bilateral subcutaneous mastectomies through the lateral S incision, with nipple preservation and subpectoral implantation of a gel-bag prosthesis. Although the incision is more noticeable than those located in the inframammary fold, the total cosmetic result has been comparable to other techniques. The technique has permitted the resection of a maximal amount of breast tissue, including the tail of Spence, with fewer complications when compared to other techniques.
For repair of radical mastectomy defects the surgical approach with the latissimus dorsi myocutaneous flap is presented. The application of this flap and complication are described. In addition 2 cases are presented illustrating a personal modification of the technics.
A case of Stewart-Treves-syndrome is presented in which the sarcoma appeared seven years after mastectomy and irradiation.
After radical mastectomy in some cases reconstruction of the female breast can be established. The plastic can only be performed as a staged procedure (2 to 5 operations). The timing to start reconstruction has to be individualized with regard to he psychical situation of the woman concerned and the TNM grade of the tumour. In case of a T1N0M0-tumour the reconstruction can already be begun after one year, that means after finshing adjuvant anticancer-chemotherapy. Till today there exist no criteria that early reconstruction of the female breast by pedicded flap and silicone prosthesis will veil local recurrences or promote metastases.
A temporary intraoperative molding device for the reconstruction of a breast after mastectomy is presented. It is a low-cost, throw-away Silastic rubber product. It follows the principle of a tailor's wooden model, to allow an easier forming of a breast.
Subcutaneous mastectomy with immediate silicone prosthetic implantation has been performed on 32 patients. The main indications for this were severe fibrocystic disease and non-invasive carcinoma. Five patients with advanced invasive carcinoma were also included. An improved operative technique is described. The indications and results are discussed.
20 women were subjected to clinical follow-ups after subcutaneous mastectomy and augmentation graft, the psycho-social consequences being investigated by means of a semi-structured interview and psychodiagnostic tests. With an average dwelling time of the prostheses of 22.6 months, cosmetic results were rated very good or good in 41.7% only of the cases from an objective viewpoint. However, the patients themselves arrived at a much more favourable subjective evaluation. All women complained of disturbed sensitivity. About one-half of the patients experienced pain as well as a feeling of tension in the breast. In 4 women there was also restricted mobility of the shoulder joint. The women did not feel impaired regarding their social activities, after having overcome an initial feeling of uncertainty. General sexual enjoyment, however, was definitely impaired. With one exception, none of the couples included the operated breast in the sexual foreplay.
The authors report on up to date knowledge of the risk of endometrial carcinoma women operated on mastectomy for breast carcinoma and treated with TAM. Starting from their own clinical and scientific experience, the authors follow a group of such patients with a strict monitoring, to ascertain the eventual comparison of dysplastic and neoplastic endometrial pathologies. The group numbers 18 patients and the aim of the study is to evaluate the importance of hysteroscopy as a diagnostic approach for this iatrogenic pathology. The authors affirm the validity of this partially invasive diagnostic method that has to be integrated with clinical and laboratory parameters that are justified by the cost/benefit ratio always favourable for the diagnosis of a neoplastic pathology.
This study reviews 16 cases of lymphangiosarcoma of the upper extremity after mastectomy for breast cancer (Stewart-Treves syndrome) was done at the author's institution from 1970 to 1992. Lymphangiosarcoma was diagnosed an average of 10.6 years (range, 5.6-18 years) after the diagnosis of breast cancer. Presenting signs included a bruise (6 patients); increased swelling (4); a red, raised lesion (2); a palpable mass (2); a blister appearance (1); and a non-healing eschar with continual bleeding (1). After biopsy, surgical treatment included forequarter amputation (8 patients), wide excision with grafting (5), and above-elbow amputation (1). Local recurrence of the lymphangiosarcoma occurred on the chest wall in 11 of the 16 patients after an average of 10.9 months. Metastasis occurred in 11 patients. (Metastasis occurred in 1 patient without local recurrence, and 1 patient with locally recurrent lymphangiosarcoma died of breast cancer before evidence of metastatic lymphangiosarcoma.) There are 2 long-term survivors who have lived 9.3 and 6 years, respectively, since the operation. One had been treated with a forequarter amputation and the other with wide excision. Early recognition and surgical treatment seem to offer the only chance for long-term survival.
Of 35 patients undergoing subcutaneous mastectomy performed within the last 15 years, 25 were evaluated for follow-up studies. Reconstruction had been achieved either using silicone implants or autologous tissue formed from the resulting dermal-fat pedicles. The patients were interviewed for subjective results. In addition, firmness of the breast according to the classification of Baker was investigated. The compressibility of the breast was electronically measured, employing a new compression device. In 13 patients, the breast was distorted after reconstruction with implants. The deformity did not correlate with submuscular or subcutaneous placement of the implants. The aesthetic results after dermal-fat pedicle techniques were superior to reconstruction with silicone implants. Compressibility to 32% of breast diameter was defined to be a border value between a soft and firmer breast, correlating with clinical conditions between Baker 2 and Baker 3.