Overview
Definition:
Simple mastectomy, also known as total mastectomy, is the surgical removal of the entire breast tissue, including the nipple-areolar complex, but without axillary lymph node dissection or pectoral muscle removal
It is primarily performed for benign breast conditions or as part of certain breast cancer management strategies when nodal status is less critical or has been addressed separately.
Epidemiology:
Benign breast conditions requiring simple mastectomy are common, with fibrocystic changes and fibroadenomas being the most frequent
While less common than breast-conserving surgery or modified radical mastectomy for invasive breast cancer, simple mastectomy is still performed for specific indications, especially in certain high-risk or elderly populations.
Clinical Significance:
Understanding simple mastectomy is crucial for surgical residents preparing for DNB and NEET SS examinations
It represents a fundamental breast surgical procedure with specific indications, contraindications, and potential complications
Proficiency in its indications and management is vital for competent patient care in breast surgery.
Indications
Benign Conditions:
Extensive fibrocystic disease causing intractable pain
Large or symptomatic fibroadenomas
Severe mastitis or abscess unresponsive to medical management
Phylloides tumors
Gynecomastia in males requiring significant tissue removal.
Malignant Conditions:
Certain cases of ductal carcinoma in situ (DCIS) involving a large portion of the breast or multifocal disease where breast conservation is not feasible or desired by the patient
Inflammatory breast cancer, often as part of neoadjuvant chemotherapy followed by mastectomy
Invasive breast cancer in patients unsuitable for or unwilling to undergo breast-conserving surgery or sentinel lymph node biopsy
Prophylactic mastectomy in individuals with extremely high genetic risk (e.g., BRCA mutations) and bilateral involvement.
Contraindications:
Generally, inflammatory breast cancer without adequate neoadjuvant therapy
Extensive lymph node involvement might necessitate a more radical procedure
Patient refusal or inability to tolerate surgery
Local recurrence after previous breast-conserving surgery or mastectomy might require different salvage procedures.
Preoperative Preparation
Patient Evaluation:
Detailed medical history, focusing on breast symptoms, family history of breast cancer, and previous breast interventions
Thorough physical examination, including breast palpation, axillary nodal assessment, and general systemic evaluation.
Imaging And Biopsy:
Mammography, ultrasound, and MRI of the breast as indicated to delineate the extent of disease
Core needle biopsy or fine-needle aspiration to confirm diagnosis, especially for suspicious lesions.
Informed Consent:
Comprehensive discussion with the patient regarding the procedure, expected outcomes, potential risks and complications, alternatives, and reconstructive options (immediate or delayed breast reconstruction).
Anesthesia And Profilaxis:
General anesthesia is typically employed
Prophylactic antibiotics are administered to reduce the risk of surgical site infection
Blood transfusion arrangements should be considered for patients with anemia or anticipated significant blood loss.
Procedure Steps
Incision Placement:
Elliptical incision encompassing the nipple-areolar complex and extending to the margins of the breast tissue to be removed
In some cases, a periareolar incision may be used
The goal is to achieve adequate margins and facilitate closure.
Dissection:
The breast tissue is dissected from the underlying pectoralis fascia using electrocautery or sharp dissection
Care is taken to avoid injury to the pectoral muscles and nerves
The dissection proceeds superiorly, medially, laterally, and inferiorly to ensure complete removal of the breast parenchyma.
Excision And Hemostasis:
The entire breast specimen, including the nipple-areolar complex, is removed en bloc
Meticulous hemostasis is achieved using electrocautery and ligation of vessels
Drains are typically placed to manage seroma formation.
Closure:
The skin flaps are approximated, and the wound is closed in layers
Subcutaneous tissues are reapproximated, followed by skin closure with sutures or staples
A pressure dressing is applied to minimize hematoma and seroma.
Postoperative Care
Pain Management:
Adequate analgesia is provided, typically with a combination of intravenous or oral opioids and non-opioid analgesics
Patient-controlled analgesia (PCA) may be used for severe pain.
Drain Management:
Surgical drains are monitored for output
Drains are typically removed when the daily output falls below a specified threshold (e.g., 20-30 ml over 24 hours).
Wound Care:
The surgical incision is kept clean and dry
Dressings are changed as needed
Signs of infection, such as redness, swelling, increased pain, or purulent discharge, are monitored closely.
Mobilization And Rehabilitation:
Early mobilization is encouraged to prevent deep vein thrombosis and pulmonary complications
Arm exercises to regain range of motion and prevent lymphedema are initiated as tolerated, typically after drain removal.
Complications
Early Complications:
Seroma formation
Hematoma
Surgical site infection
Wound dehiscence
Skin flap necrosis
Pain
Edema of the chest wall and arm.
Late Complications:
Chronic pain
Lymphedema (less common with simple mastectomy compared to procedures with axillary dissection, but still possible)
Poor cosmesis
Phantom breast sensation or pain
Psychological distress and body image issues.
Prevention Strategies:
Meticulous surgical technique with thorough hemostasis
Appropriate use of drains
Careful wound closure
Early mobilization and physiotherapy
Patient education regarding signs of complications
Adequate pain control to facilitate movement
Careful selection of patients for reconstruction to improve cosmesis and psychological well-being.
Key Points
Exam Focus:
Differentiate simple mastectomy from modified radical mastectomy (MRM) and breast-conserving surgery (BCS)
Understand the indications for simple mastectomy in both benign and malignant conditions
Recall common complications like seroma and infection
Be aware of the role of reconstruction.
Clinical Pearls:
When performing a simple mastectomy for malignancy, always consider the possibility of occult nodal disease and the need for further axillary staging (e.g., sentinel lymph node biopsy or axillary dissection) if not contra-indicated
Adequate skin flaps are crucial for wound healing and cosmesis.
Common Mistakes:
Inadequate margins in malignant cases
Unnecessary removal of pectoral fascia
Poor hemostasis leading to hematoma/seroma
Insufficient post-operative physiotherapy leading to stiffness or lymphedema
Failure to discuss reconstructive options with the patient.