Modified Radical Mastectomy

General remarks

A modified radical mastectomy removes all breast tissue, the nipple-areola complex, necessary skin, and the level I and II axillary lymph nodes.

Currently, chemotherapy, hormone therapy, and radiation therapy for breast cancer have nearly eliminated the need for a Halstead radical mastectomy

Incisions should be made to have optimal approximation without redundant skin

Lymphedema: Thiscomplication occurs less frequently with the standard axillary dissections performed nowadays ( level I and II). It is more frequently seen when an axillary dissection is combined with axillary radiation.

Seroma: One of the main reasons for drain positioning is to avoid seromas (closed simple drain or suction drain). These drains are left in for approximately four to five days, however occasionally this is not long enough and some patients will develop seromas. This can be drained percutaneously using a large gauge needle. There is no evidence to support the role of fibrin glue to prevent seroma formation after breast surgery

Nerve damage

Long thoracic nerve (motor); Injury results in a palsy of the serratus anterior muscle. Clinically this leads to a winged scapula (scapula alata)

Thoracodorsal nerve (motor); Injury results in a palsy of the latissimus dorsi muscle

Intercostobrachial nerve (sensory); Injury of this nerve results in a numbness in the lateral aspect of the axilla and the medial aspect of the upper arm.

Step by step

1. Arm on the affected side is extended on a side table. The patient is draped and the affected breast and axilla are exposed.
2. Drawing incision line (an optimal wound closure without any redundant skin must be taken into account)
3. Skin incision and formation of upper flap
4. Proceed cranially towards the pectoralis fascia just below the clavicula and laterally until the lateral margin of the pectoralis major muscle
5. Formation of lower flap from medial to lateral
6. Continue laterally until the latissimus dorsi muscle has been reached
7. Dissection of the breast from medial to lateral including pectoralis major 's fascia
8. Follow the lateral margin of the pectoralis major muscle and opening clavipectoral fascia
9. Identification of upper axillary margin (=axillary vein)
10. Dissection of axillary top (along axillary vein)
11. Identify and preserve thoracodorsal nerve/vessels
12. Identify and preserve long thoracic nerve
13. Finalize axillary dissection and remove all level I and II lymph nodes (for a complete oncologic resection it is sometimes necessary to cut the intercostobrachial nerve)
14. Remove axillary content en bloc with the breast
15. positioning of two drains (axilla-lower flap and upper flap)
16. Woundclosure, avoid any redundant skin

References

Closed simple drains are not inferior to suction drains in mastectomy wounds and, considering the cost saving and simplicity of postoperative care, they are preferable to suction drains. Ezeome ER, Adebamowo CA. S Afr Med J. 2008 Sep;98(9):712-5 2. Modified radical mastectomy and total (simple) mastectomy. Bland KI, Chang HR, Chandler GS, et al. In: Bland KI, Copeland EM III, eds. The breast: comprehensive management of benign and malignant disorders. Philadelphia: WB Saunders, 2004:865. A randomized prospective trial of radical (Halstead) mastectomy versus modified radical mastectomy in 311 breast cancer patients. Maddox MA, Carpenter JT, Laws HL, et al. Ann Surg 1983;198(2):207. Systematic review and meta-analysis of the use of fibrin sealant to prevent seroma formation after breast cancer surgery.Carless PA, Henry DA. Br J Surg 2006 Jul;93(7):810-9.