What is a radical mastectomy? Planned and preventive mastectomy: what it is, indications and results of treatment, reconstructive plastic surgery after surgery. Do they give disability after a mastectomy?

Diseases that you can't ignore. They require intense attention, examination and treatment. Breast cancer ranks first among oncological diseases in women, and second among other diseases. The consequences cannot always be predicted.

Prevention and timely treatment are important. In some cases, radical surgery is inevitable.

What is radical mastectomy

Radical, i.e., removing entirely, completely, from the roots. The concept of mastectomy is of Greek origin - mastòs “breast” and ek tome “remove”. The term is over 100 years old.

Several types of mastectomy are practiced. Each of them is effective, they differ in the degree of trauma. Radical mastectomy is a complex operation, but sometimes only it can solve the existing problem.

There are three main types of mastectomy:

• according to Madden,
• by Patey,
• according to Halstead.

Radical mastectomy according to Madden is considered the most gentle.

Carefully! The video shows a radical mastectomy (click to open)

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Kinds

According to Madden

The method involves preserving both pectoral muscles, which makes it as gentle as possible. The mammary gland is removed en bloc with lymph nodes and subcutaneous fat layer.

After removing the mammary gland, all nerve endings and vascular links are traced, which helps to avoid blood loss. This type of operation has significant advantages: preservation of radicality, relatively low morbidity, low percentage of complications.

According to Halstead

Halstead-Meyer mastectomy is a classic operation. The mammary gland, skin, subcutaneous tissue, pectoral muscles, subcutaneous fatty tissue (subclavian, axillary and subscapular region), and lymph nodes are removed as a single complex.

The method often causes complications, the main one of which is limited mobility of the shoulder joint. It is used extremely rarely when other methods do not help cope with the problem, for example, extensive ones that affect the pectoral muscle, lymph nodes, etc.

By Patey

Patey's mastectomy is a modification of the previous type and has the full name - modified radical mastectomy. Its founder, Dr. Patey, proposed wide excision of the skin and preservation of the pectoralis major muscle. During the operation, only a small muscle is removed, which makes the method more gentle and avoids serious complications.

According to Pirogov

The mammary gland and tissue of the axillary region are removed.

Simple mastectomy

The mammary gland and fascia of the pectoralis major muscle are removed.

Technique using tram flap

A technique for breast restoration, which is performed simultaneously with a mastectomy or six months after surgery. In this case, the patient's own tissue is moved, which is called a TRAM flap, which is tissue with preserved blood flow. This may be an iliofemoral flap or a greater omentum flap. Sometimes a pedicled rectus abdominis muscle flap (along with skin) is used.

Subcutaneous surgery technique

A technique that allows you to maintain the radicality of surgical intervention and achieve the best possible aesthetic results. This is a method of extended subcutaneous mastectomy, when the mammary gland with muscular fascia (sheath) and lymph nodes are removed, while preserving the muscles and fatty tissue. P

When using this technique, breast reconstruction surgery can be performed at the same time. This can be an operation using your own tissue or using an implant, for which a “pocket” is pre-formed.

Carefully! The photo shows a breast after a radical mastectomy (click to open)

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Indications for testing

• to varying degrees,
• Purulent mastopathy (in rare cases),
• Correction of previous treatment,
• Individual indications (prevention, etc.).

Contraindications

General contraindications:

• Cerebrovascular accident.

Contraindications for tumor localization:

• Swelling of the mammary gland extends to the chest wall,
• Multiple with edema of the upper limb,
• Invasion by a tumor of the chest.

Carefully! The video shows a radical mastectomy (click to open)

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Carrying out the operation

Preparation

Preparation for surgery consists of several stages:

• Medical checkup, which is a fundamental point. The doctor examines the medical history and prescribes an examination,
• Survey, including a series of tests and tests: (photography of breast tissue), and a blood test for coagulation ().
• The doctor prescribes gentle (light) diet, warns about limiting the use (or completely stopping) of medications that thin the blood (aspirin, etc.). They are excluded a week before surgery. On the day of surgery, it is unacceptable to drink or eat.

Progress of the operation

The operation is performed under general anesthesia. Its duration ranges from 1 to 3 hours.

Algorithm:

1. Markers are used to mark the upcoming cuts.
2. The skin is cut in the necessary places,
3. Subcutaneous tissue and mammary gland are separated from the skin,
4. Removal occurs as a single block, including lymph nodes,
5. Depending on the method, the pectoral muscle, fatty tissue, etc. are sequentially removed.
6. Nerve endings and vascular links are traced,
7. A drainage is installed through a special hole, which is removed on the 5th - 6th day.
8. Stitches are applied and removed on days 10-12.

Installing drainage is an important point. The doctor monitors the outflow of fluid.

Rehabilitation

After a mastectomy, rehabilitation measures are extremely important. These include gymnastics, physical therapy, and taking medications.

Gymnastics

Gymnastics, some examples of exercises:

• Squeezing a rubber ball
• Hair combing,
• Putting your hands behind your back, as if you are trying to fasten a button at the back,
• Circular movements of the arms, rocking, etc.

Physiotherapy

If there are no complications, then physical therapy can be prescribed a week after the operation. What can be done about this:

• Pool,
• Various simulators aimed at developing the shoulder joint,
• Massotherapy,
• Hydromassage,
• (apply),
• Bandage,
• Therapeutic wrap.

Rehabilitation rules

• Using an elastic bandage
• Refusal to visit the bathhouse and solarium,
• You can't lift weights for a year,
• Stay in an inclined position for a long time,
• Try to avoid injuries, do not use traumatic objects (bracelets, etc.),
• Increase the amount of fluid you drink,
• When flying by air, you must use a compression sleeve,
• An examination is required every six months,
• If you feel worse, consult a doctor immediately.

Lipofilling of the mammary glands after RM

This is a means of breast reconstruction after mastectomy, which uses the patient's tissue rather than implants. One session for the recovery procedure will not be enough; several will be required.

This is also a serious moment that requires thorough preparation.

• The surgeon determines the areas from which the necessary material can be taken,
• Prescribes an examination similar to that required for any plastic surgery,
• The operation is performed under general anesthesia,
• Before collecting adipose tissue, Klein's solution is injected into it,
• Selected fat cells are placed in a centrifuge, where they are separated into 3 parts,
• The middle part is used for direct reconstruction,
• The prepared fatty tissue is injected using a syringe in small portions into the targeted areas.

The operation is performed under general anesthesia and lasts from 2 to 5 hours. After lipofilling, and are formed, which persist for 3 - 4 weeks. Repeated surgery is possible no earlier than after 4 months. For a lasting result, 2 to 5 procedures are required.

Lipofilling involves the use of a special system (BRAVA), which protects the transplanted cells from external influences. This system is put on and worn for 7 to 14 days.

Consequences and complications

The number of complications after mastectomy continues to remain high today (from 20 to 87%), despite equipment and new technologies. Complications can be early or late.

Early

• Leakage of lymph, which may necessitate further surgery,

Prices vary greatly, which is not surprising. Each operation has its own characteristics and different methods are used. Pricing also plays a role. The estimated minimum price threshold is 35 thousand rubles. It is possible to perform a simple mastectomy at a lower cost, but this is unlikely. Average prices for surgery range from 60 to 120 thousand rubles.

In situations where the tumor is large, or a woman has aggressive breast cancer, a mastectomy is necessary, an operation in which the entire mammary gland is removed. Complete removal of breasts with small tumors is an option for women who want to avoid radiation therapy and minimize the chance of recurrence. Unlike partial resection (sectoral resection, lumpectomy, quadrantectomy), breast irradiation, as a rule, cannot be avoided.

Read in this article

Who is suitable for mastectomy surgery?

• previously received radiation therapy to the chest area;
• there are multiple tumors in the mammary gland, located in different quadrants (1/4 of the breast);
• extensive damage to breast tissue DCIS (ductal carcinoma in situ);
• large tumor compared to breast volume;
• There are clear criteria for familial breast cancer or certain genetic mutations in the BRCA1 and BRCA2 genes.

Mastectomy Options

In the last decade there have been significant changes in approaches to surgical treatment of breast cancer:

• The proportion of operations involving complete removal of the mammary gland has decreased significantly. With the advent of the so-called organ-preserving treatment, lumpectomy, sectoral resection, and quadrantectomy, in which part of the mammary gland is excised, have become more common.
• The previously widely used radical mastectomy, in which the entire mammary gland, as well as all nearby lymph nodes and chest muscles, was removed, was replaced by a modified, less traumatic operation (the pectoral muscles are not removed).
• Many large oncology clinics have begun to perform mastectomies, in which breast tissue is removed, leaving large areas of the skin, nipple and areola intact, allowing reconstructive surgery to be performed with good cosmetic results.

There are the following options for mastectomies (total removal of the breast), which are currently considered the gold standard for surgical treatment of breast cancer.

• A simple total mastectomy is the removal of the entire breast, nipple and areola. The axillary lymph nodes are not removed, and breast reconstruction is usually performed on time or after two weeks. The length of hospitalization varies: for some women it is an outpatient procedure, while for others it may require a stay in a hospital bed for several days.
• Modified radical mastectomy. In this operation, the breast, nipple and areola are removed, and axillary lymph node dissection (excision of the axillary lymph nodes) is performed. Breast reconstruction (reconstructive surgery) is usually performed after three weeks.
• Subcutaneous mastectomy. When the breast, nipple and areola are removed, the skin of the breast is left untouched. This option of mastectomy allows you to achieve a good cosmetic result and perform reconstruction of the gland during surgery. It also allows you to easily install a tissue expander during surgery if reconstruction is delayed for any reason.
• Nipple-sparing mastectomy is a new technique for removing the mammary gland, used in women who have a small tumor located not near the areola, but in the depths of the gland tissue. During this operation, the surgeon excises the skin along the outside of the breast, as well as around the edge of the areola. He then separates the gland tissue from the inside of the areola, thereby preserving the nipple. This technique involves simultaneous breast reconstruction and also allows for the placement of a tissue expander as the first stage of reconstruction.
• Nipple and areola sparing mastectomy. Using this technique, the surgeon separates the breast tissue from her skin through an incision, usually made on the outside, thereby preserving the nipple and areola. This allows for immediate breast reconstruction, or, if this fails, to install a tissue expander (perform the first stage of breast reconstruction surgery).
• Scarless mastectomy is a fairly new surgical technique that has been developed and performed in large cancer centers. The main objective of this operation is, regardless of how the breast tissue is separated from the skin, to do this through small surgical incisions, thereby avoiding the formation of noticeable scars. It is not uncommon for tissue removal to be performed through openings that are smaller than 2 inches.
• Preventive/prophylactic mastectomy - removal of one or both breasts. Its goal is to reduce the risk of developing breast cancer. Women who have mutations in genes such as BRCA1 and BRCA2 or have close relatives diagnosed with breast cancer (family history of cancer) are candidates for this surgery. They are also sometimes advised to have their ovaries removed. Genetic counseling can confirm or rule out any suspicions about the heritability of this cancer.

Since there is no evidence that prophylactic mastectomies require lymph node dissection (removal of the axillary lymph nodes), it is not performed during such operations. To ensure that “everything is in order” at the site of the removed mammary gland, after these interventions the patient must undergo regular examinations for 90 days.

All mastectomy options listed above, with the exception of the modified one, allow for simultaneous reconstructive surgery (both operations, breast removal and reconstruction, are performed simultaneously).

Possible complications of breast removal surgery

Like any surgical intervention, mastectomy has its own unique complications. Here are some of them:

• Temporary tissue swelling.
• Pain in the area of ​​the postoperative wound.
• Hardening in the area of ​​the scar that forms at the site of the incision.
• Infection of a postoperative wound.
• Bleeding.
• Swelling of the arm on the side of the operation if lymph node dissection (removal of axillary lymph nodes) was performed. This may be preceded by earlier signs of this complication, such as a feeling of numbness in the hand, soreness of the skin to any touch, and redness.
• Symptoms of phantom pain, which are manifested by itching, tingling, pulsation in the area of ​​the removed breast. These sensations can be managed with medication, exercise, or massage. Phantom pain is not a sign of the presence of cancer cells in the area where the breast was removed and does not mean that the cancer is likely to return.
• Seroma is a fairly common complication after mastectomy, the result of the accumulation of tissue fluid in the cavity formed after the operation (clear fluid trapped in the wound). The surgeon treats large seromas (all kinds of manipulations that help remove fluid) on an outpatient basis.
• "Ugly" scar. Although scarring cannot be avoided, it is usually not noticeable unless the mastectomy is performed by highly trained professionals. Quite often, especially in the first year after surgery, many patients experience discomfort under the arm if lymph node dissection has been performed.
• Depression and feelings of loss of gender identity.

There are also other complications, the occurrence of which largely depends on the general health of the patient. Therefore, you should definitely discuss all possible risks of the procedure with your surgeon before surgery.

The woman's condition after surgery

After the operation is completed, the patient is sent to the recovery room for observation. The type of mastectomy and type of anesthesia largely determine how long your stay in this room will last. After the patient's blood pressure, pulse, and breathing have stabilized and she has regained consciousness, she is transferred to a regular ward.

After a mastectomy, patients usually stay in the hospital from 1 to 3 days, sometimes longer, depending on the type of surgery and whether there was breast reconstruction.

In most cases, the soreness may last several days, although many patients experience no pain after surgery. It is recommended to take pain medication to relieve symptoms as recommended by your doctor. Aspirin and some other painkillers can cause bleeding. Therefore, before taking any medication, you should consult your doctor.

Recovery at home

From the moment a woman finds herself at home after being discharged from the hospital, she needs to ensure that the post-operative area is dry and clean. To do this, the doctor will give certain instructions, and he can also give recommendations on how to change it yourself.

If breast removal was performed with lymph node dissection, the surgeon may recommend exercises to help develop the arm on the surgical side. Pain after lymph node dissection in the axillary region often forces a woman to hold her arm in a forced position, which leads to shoulder stiffness. That is why it is necessary to start exercises to prevent this pathology as early as possible. Like any physical activity, these exercises can cause injury, so you should consult your surgeon before attempting them. They are useful to perform even if lymph node dissection has not been performed.

Women usually return to their normal routine within 4 weeks after a mastectomy. Recovery time may be longer if breast reconstruction is performed at the same time, which can take several months.

Therefore, the recovery period largely depends on the individual case. The timing of your rehabilitation should be discussed in advance with the surgeon.

You should also tell your doctor if the following symptoms occur:

• a sharp increase in body temperature, accompanied by chills;
• there is fluid leakage from the wound (blood, etc.), there is redness and swelling;
• increase in pain intensity;
• sudden numbness and tingling in the hand from the side of the operation.

Depending on your specific situation, your surgeon may provide additional postoperative instructions.

Many patients have concerns about the appearance of their breasts after a mastectomy. Fortunately, recent versions of this operation allow breast reconstruction to be performed in most women. An alternative solution to restoring breast shape after surgery is to wear a prosthesis or a special bra.

The main treatment strategy for breast cancer is its surgical removal (mastectomy), either alone or in combination with radiation, hormonal and chemotherapy. The surgical strategy of modern treatment is aimed at solving two main problems - reliable cure for a dangerous disease and creating conditions that allow breast reconstruction after mastectomy and improve the patient’s quality of life.

Radical methods of surgical treatment

Among all cancers in women, breast cancer (BC) ranks first and second place after heart and vascular diseases among the causes of mortality. The number of breast cancer patients increases every year by an average of 1-2%. This indicates the need to prefer the most radical methods of treatment.

At the same time, in the initial stages, the proportion of which has increased in the last 10 years, it is possible to perform organ-preserving operations with reconstructive plastic elements or even without them, and advances in the field of endoprosthetics can significantly improve the quality of life of those who have undergone such operations, even in later stages of the disease.

Halstead-Meyer mastectomy

Classic radical surgery. It is based on the principle of staged spread of cancer cells from the primary tumor to regional lymph nodes through vessels and collectors of the same name.

Therefore, the essence of the operation is to remove the mammary gland with the skin and subcutaneous tissue as a single complex with the pectoral muscles (minor and major), as well as with the lymph nodes and subcutaneous fat located in the subclavian, axillary and subscapular areas.

The nature of the skin incision during surgery depends on the location of the tumor. An oval transverse incision is predominantly used, which allows the edges of the wound to be connected with a skin suture at any localization without much tension. This method was used for all stages of breast cancer, but led to the development of serious late complications in most patients, especially in the form of limited mobility in the shoulder joint (60%). Currently, the Halstead-Meyer technique is performed only in the following cases:

1. Tumor growth into the pectoralis major muscle.
2. Involvement in the malignant process of the lymph nodes located along the posterior surface of this muscle.
3. The need for palliative surgery in a high-quality single solution.

Patey-Dyson mastectomy

It is the result of a search for more gentle solutions to surgical intervention, which is a modification of the previous type. The author of the technique was based on the fact that lymphatic capillaries and vessels abundantly penetrate the skin and subcutaneous fat layer, but are almost absent in the fascia of the pectoral muscles. Therefore, D. Patey proposed preserving the pectoralis major muscle along with wide excision of the skin and subcutaneous tissue around the cancerous tumor. In order to remove the subclavian and apical axillary lymph nodes, they were asked to limit themselves to removing only the pectoralis minor muscle. This technique made it possible to slightly reduce the percentage and severity of late postoperative complications.

Madden mastectomy

An even more gentle method in which both pectoral muscles are preserved. Removal of the mammary gland is carried out as a single block with the subcutaneous fat layer, subclavian, axillary and subscapular lymph nodes. The operation is characterized by no less radicalism, but is accompanied by significantly less trauma (compared to the previous ones), less blood loss and better and faster wound healing.

But the most important thing is that as a result of applying the Madden modification, muscle preservation allows us to eliminate or significantly reduce the number of patients with the development of limited functional mobility of the shoulder joint and obtain a more acceptable cosmetic effect. Due to this, operational modifications of this type are considered functionally sparing.

In recent years, there has been a tendency to reduce the volume of surgical intervention while maintaining radicalism in oncological terms. The possibility of moving away from the aggressive tactics that have persisted for decades is explained by:

• a significant increase (among all breast cancer patients) of women with early stages of the disease;
• improvement of instrumental diagnostic techniques;
• development and use of effective combinations of surgical treatment with targeted, hormonal, chemotherapy and radiation treatments;
• revision of biological and clinical concepts of the development of malignant processes - they take into account not only the stage of cancer, but also the degree of its activity, the rate of tumor growth, the heterogeneity of cells, the hormonal state of the body and its reactivity.

All this allows us to predict the course of the disease, the likelihood of complications and choose treatment tactics.

The listed types of radical mastectomy make it possible to successfully solve therapeutic problems. However, after their implementation, reconstructive possibilities associated with:

1. The need to restore the deficit of soft tissues in the absence of their reserve.
2. Creation of a transitional fold and nipple-areolar complex.
3. Creation and correction of the shape and volume of the gland.
4. Restoring the symmetry of the mammary glands.

Subcutaneous mastectomy

This is a technique that allows you to optimally solve the main treatment problems:

1. Maintaining sufficient radicalism of surgical intervention and oncological safety.
2. Significantly facilitating primary gland reconstruction in order to achieve the best possible aesthetic results.

This technique involves almost complete separation from the skin and removal of the glandular and fatty tissue of the mammary gland. At the same time, the nipple-areolar complex is also removed, which significantly worsens the expected aesthetic results of the operation. Therefore, many oncologist surgeons strive to preserve it, for which various modifications are used.

Unfortunately, this is not always possible. Preservation of the nipple and areola depends on:

• dimensions of the primary node;
• localization of the tumor and its distance to the nipple-areolar apparatus;
• severity of intraductal components;
• cell type of the tumor and the nature of its growth;
• the degree of involvement of the nipple-areolar apparatus in the cancer process (according to various sources, it ranges from 5.6 to 31%).
• condition of regional lymph nodes.

Subcutaneous mastectomy uses a variety of incisions to provide wide visual access. Depending on the conditions, an extended subcutaneous mastectomy may be used, which involves an incision under the gland from the parasternal line to the mid-axillary line. It allows you to remove gland tissue along with the muscular fascia at the base, expose the excretory ducts of the nipple, and in the armpit - easily isolate and remove the processes of the mammary gland along with the lymph nodes.

Subcutaneous mastectomy makes it possible to simultaneously perform reconstructive surgery of the breast by moving your own tissues or create a pocket under the pectoralis major muscle to place an implant.

The choice of any of the listed methods largely depends on the stage of the tumor process.



Complications after mastectomy

Despite the constant improvement of surgical treatment methods, the number of complications remains quite high - from 20 to 87%. Complications in the immediate postoperative period contribute to the intensive development of connective tissue in the surgical area and the occurrence of late complications. Risk factors are:

1. Old age (after 60 years).
2. Obesity and even just overweight.
3. Significant volume of mammary glands (from size 4).
4. Concomitant diseases, especially diabetes mellitus, chronic lung and heart diseases, arterial hypertension.
5. Additional radiation and/or hormonal therapy performed before surgery.

Major early complications

• lymphorrhea (leakage of lymph) that occurs after radical mastectomy in all patients;
• marginal necrosis with subsequent divergence of tissue flaps at their junctions; this occurs mainly due to excessive tension of soft tissues when they are deficient;
• infection and wound suppuration.

The causes of lymphorrhea, regardless of the extent of the operation, are the removal of lymph nodes and the inevitable intersection of the lymphatic vessels connecting them. Ligation of all vessels during the operation is impossible, since most of them remain invisible. The duration of profuse lymphorrhea can be 1 month or more, which creates conditions for infection and the development of marginal necrosis, delaying the timing of additional anticancer therapy, and the formation of a seroma (lymphocele) in the axillary zone, which is a cavity surrounded by a capsule and filled with lymph. Its formation requires repeated surgical intervention.

Late complications after mastectomy

They occur in all patients and with any method, but they are especially pronounced when using the Halsted-Meyer method. The complex of most typical complications, called postmastectomy syndrome, includes:

1. Impaired drainage of lymph from the tissues of the limb (lymphostasis).
2. Narrowing or complete closure of the lumen of the subclavian and/or axillary veins, as a result of which the outflow of venous blood is disrupted.
3. Development of rough postoperative scars involving the axillary nerves.

These complications cause prolonged or even permanent severe swelling of the limb, the development of adductor contracture of the shoulder (in 60%), limiting mobility in the shoulder joint and accompanied by frequent pain and permanent disability.

Gymnastics

Gymnastics after mastectomy, recommended by the Association for Breast Cancer and Mastectomy in the USA, has a certain positive result. Gymnastics includes exercises such as combing your hair, squeezing a rubber ball with your hand, rotating and swinging your arms, putting them behind your back with a towel and like fastening a bra.




Breast reconstruction



Breast reconstruction after mastectomy is carried out simultaneously with the main operation or, if this is not possible, approximately six months after it. Many different reconstructive techniques have been developed, which are conventionally divided into 3 groups:

1. Reconstruction with the patient’s own tissue, which is the movement of a tissue flap with preserved blood flow - iliofemoral flap, greater omentum flap, rectus abdominis flap with skin (TRAM flap) pedicled or free, and others.
2. Use of expanders and silicone implants.
3. Combined techniques - the use of methods of the first and second groups. For example, tissue deficiency is filled with a flap from the back surface of the back, and silicone implants are used for additional volume, shape correction and symmetry.

Reconstructive methods, in terms of their capabilities and effectiveness, are arranged in the following sequence:

1. It is possible to make maximum use of organ-preserving techniques with subsequent volume replacement by moving local tissues. This option in most cases allows you to recreate the volume, shape and even symmetry of the mammary glands.
2. Reconstruction of the gland using endoprostheses after subcutaneous mastectomy with preservation of the nipple-areola complex. It is also possible to combine the same mastectomy method with a muscle (without skin) flap from the back and the addition (if necessary) of an endoprosthesis.
3. TRAM-flap method, which is used when it is impossible to use the above options, since its technical implementation is much more complicated. In addition, it causes significant damage to the donor area.







Treatment of breast cancer is planned by an oncologist surgeon with the participation of other specialists - a morphologist, a chemotherapist and a radiologist, which allows for the optimal choice of surgical method, systemic treatment and postoperative rehabilitation.

A) Indications for mastectomy according to Peyti:
- Absolute readings: multicentric tumors, stage T4 tumors, tumors large in relation to the size of the breast. A combination with axillary lymphadenectomy is mandatory.
- Alternative operations: Quadrantectomy for smaller tumors or in patients in very poor general condition.

b) Preoperative preparation. Preoperative studies: mammography, chest x-ray, ultrasound (axilla, abdominal organs), bone scan.

V) Specific risks, informed consent of the patient. Lymphedema of the arm (in 10% of cases).

G) Anesthesia. General anesthesia (intubation).

d) Patient position. Lying on your back, arm abducted, armpit accessible.

e) Operative access for mammary gland removal according to Peyti. Horizontal elliptical excision of the mammary gland with transition to the axillary region.

and) Stages of mastectomy according to Peity:
- Patient position
- Incision
- Caudal dissection of the breast

- Expansion of the scope of the operation


- Closure of the wound

h) Anatomical features, serious risks, surgical techniques:
- The long thoracic nerve runs along the lateral chest wall (serratus anterior muscle), the thoracodorsal nerve lies dorsal to it (latissimus dorsi muscle).
- Avoid circumferential lymph node dissection around the axillary vein (the cranial edge of the axillary dissection is the intercostobrachial nerve).
- After surgery, apply an elastic bandage.
- The “unfixed” macroscopic specimen must be immediately sent to the pathology department to determine receptors for estrogen and progesterone, as well as for histological examination of the tumor.

And) Measures for specific complications. None.

To) Postoperative care after breast removal for cancer:
- Medical care: Remove active drainage after 2 days.
- Activation: movements of the hand as pain is overcome.
- Physiotherapy: to restore lymphatic drainage.
- Period of incapacity for work: 2 weeks, depending on the type of occupation and further medical measures.

k) Surgical technique of mastectomy according to Patey:
- Patient position
- Incision
- Caudal dissection
- Cranial dissection of the mammary gland
- Expansion of the scope of the operation
- Dissection of the axillary vein
- Resection of the pectoralis minor muscle
- Closure of the wound




1. Patient position. The patient is positioned on the operating table with his arm abducted and the armpit is shaved. The shoulder on the side of surgery can be slightly elevated using a flat pillow placed under the back.

2. Incision. The incision is made transversely and includes the scar from the previous biopsy. For interventions in the armpit, the incision can be extended laterally.




3. Caudal breast dissection. The incision deepens to the fascia of the pectoralis major muscle. The fascia is separated from the muscle and released in a cranial direction. Ventral arteries and intercostal vessels are coagulated or ligated with suturing. Dissection of the breast tissue along with the fascia of the pectoralis major muscle continues into the axilla. Dissection is performed with a scalpel or diathermy.

4. Cranial breast dissection. Dissection from the cranial part of the incision is carried out in the same way, ensuring separation of the fascia of the pectoralis major muscle to the axilla.




5. Expanding the scope of the operation. Dissection should continue along the fat pad of the axilla along the lymphatic collectors into the cavity itself. The most cranial point is the apex of the axilla. When deepening into the axilla, the pectoralis major muscle is retracted medially to expose the pectoralis minor muscle. The fascia of the pectoralis minor muscle and the lymph nodes between the pectoral muscles are removed. Care must be taken not to disrupt the innervation of the pectoralis major muscle. To achieve this, wide intermuscular dissection should not be performed. After reaching the axilla, its contents are gradually separated from the serratus anterior muscle. During dissection, the long thoracic and thoracodorsal nerves are isolated and protected.

6. Dissection of the axillary vein. The axillary tissue, along with the breast tissue, is transected between the Overholt forceps at their most cranial point at the axillary vein. To avoid damage to the lymphatic vessels, dissection should not be continued more cranial to the vein.




7. Resection of the pectoralis minor muscle. If the tumor is located near the pectoralis minor muscle, the muscle can be divided at its insertion and removed. To do this, it is isolated from under the pectoralis major muscle and cut off using diathermy. We usually do not remove this muscle.

8. Closing the wound. The operation is completed by two active drainages, subcutaneous and skin sutures. In some situations, it is possible to perform a one-stage reconstructive operation.