Surgery risks, complications and consequences

Surgery: Complications, Risks and Consequences
Breast,
Endocrine and
Surgical
Oncology
Brendon J. Coventry Editor

Surgery: Complications, Risks and Consequences
Series Editor
Brendon J. Coventry
For further volumes:
http://www.springer.com/series/11761

Brendon J. Coventry
Editor
Breast, Endocrine
and Surgical Oncology

ISBN 978-1-4471-5420-4 ISBN 978-1-4471-5421-1 (eBook)
DOI 10.1007/978-1-4471-5421-1
Springer London Heidelberg New York Dordrecht
Library of Congress Control Number: 2013957871
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Editor
Brendon J. Coventry, BMBS, PhD,
FRACS, FACS, FRSM
Discipline of Surgery
Breast, Endocrine and Surgical
Oncology Unit
Royal Adelaide Hospital
University of Adelaide
Adelaide, SA
Australia

This book is dedicated to my wonderful wife
Christine and children Charles, Cameron,
Alexander and Eloise who make me so
proud, having supported me through this
mammoth project; my patients, past, present
and future; my numerous mentors, teachers,
colleagues, friends and students, who know
who they are; my parents Beryl and
Lawrence; and my parents-in-law Barbara
and George, all of whom have taught me and
encouraged me to achieve
“Without love and understanding we have
but nothing”
Brendon J. Coventry

vii
This comprehensive treatise is remarkable for its breadth and scope and its author-
ship by global experts. Indeed, knowledge of its content is essential if we are to
achieve optimal and safe outcomes for our patients. The content embodies the
details of our surgical discipline and how to incorporate facts and evidence into our
surgical judgment as well as recommendations to our patients.
While acknowledging that the technical aspects of surgery are its distinguishing
framework of our profession, the art and judgment of surgery requires an in depth
knowledge of biology, anatomy, pathophysiology, clinical science, surgical out-
comes and complications that distinguishes the theme of this book. This knowledge
is essential to assure us that we are we doing the right operation, at the right time,
and in the right patient. In turn, that knowledge is essential to take into account how
surgical treatment interfaces with the correct sequence and combination with other
treatment modalities. It is also essential to assess the extent of scientific evidence
from clinical trials and surgical expertise that is the underpinning of our final treat-
ment recommendation to our patient.
Each time I sit across from a patient to make a recommendation for a surgical
treatment, I am basing my recommendation on a “benefit/risk ratio” that integrates
scientific evidence, and my intuition gained through experience. That is, do the
potential benefits outweigh the potential risks and complications as applied to an
individual patient setting? The elements of that benefit/ risk ratio that are taken into
account include: the natural history of the disease, the stage/extent of disease, sci-
entific and empirical evidence of treatment outcomes, quality of life issues (as per-
ceived by the patient), co-morbidity that might influence surgical outcome, risks
and complications inherent to the operation (errors of commission) and the risk(s)
of not proceeding with an operation (errors of omission).
Thus, if we truly want to improve our surgical outcomes, then we must under-
stand and be able to either avoid, or execute sound management of, any complica-
tions that occur (regardless of whether they are due to co-morbidity or iatrogenic
causes), to get our patent safely through the operation and its post-operative course.
These subjects are nicely incorporated into the content of this book.
Foreword I

viii
I highly recommend this book as a practical yet comprehensive treatise for the
practicing surgeon and the surgical trainee. It is well organized, written with
great clarity and nicely referenced when circumstances require further
information.
Charles M. Balch, MD, FACS
Professor of Surgery
University of Texas, Southwestern Medical Center,
Dallas, TX, USA
Formerly, Professor of Surgery, Johns Hopkins Hospital,
Baltimore, MD, USA
Formerly, Executive Vice President and CEO,
American Society of Clinical Oncology (ASCO)
Past-President, Society of Surgical Oncology (USA)
Foreword I

ix
Foreword II
Throughout my clinical academic career I have aspired to improve the quality and
safety of my surgical and clinical practice. It is very clear, while reading this impres-
sive collection and synthesis of high-impact clinical evidence and international
expert consensus, that in this new textbook, Brendon Coventry has the ambition to
innovate and advance the quality and safety of surgical discipline.
In these modern times, where we find an abundance of information that is avail-
able through the internet, and of often doubtful authenticity, it is vital that we retain
a professional responsibility for the collection, analysis and dissemination of evi-
denced-based and accurate knowledge and guidance to benefit both clinicians and
our patients.
This practical and broad-scoped compendium, which contains over 250 proce-
dures and their related complications and associated risks, will undoubtedly become
a benchmark to raise the safety and quality of surgical practice for all that read it. It
also manages to succeed in providing a portal for all surgeons, at any stage of their
careers, to reflect on the authors’ own combined experiences and the collective
insights of a strong and influential network of peers.
This text emphasizes the need to understand and appreciate our patients and the
intimate relationship that their physiology, co-morbidities and underlying diagnosis
can have upon their unique surgical risk with special regard to complications and
adverse events.
I recognize that universally across clinical practice and our profession, the evi-
dence base and guidance to justify our decision-making is growing, but there is also
a widening gap between what we know and what we do. The variation that we see
in the quality of practice throughout the world should not be tolerated.
This text makes an assertive contribution to promote quality by outlining the
prerequisite foundational knowledge of surgery, science and anatomy and their
complex interactions with clinical outcome that is needed for all in the field of
surgery.

x
I thoroughly recommend this expertly constructed collection. Its breadth and
quality is a testament to its authors and editor.
Lord Ara Darzi, PC, KBE, FRCS, FRS
Paul Hamlyn Chair of Surgery
Imperial College London, London, UK
Formerly Undersecretary of State for Health,
Her Majesty’s Government, UK
Foreword II

xi
Information is provided for improved medical education and potential improvement
in clinical practice only. The information is based on composite material from
research studies and professional personal opinion and does not guarantee accuracy
for any specific clinical situation or procedure. There is also no express or implied
guarantee to accuracy or that surgical complications will be prevented, minimized,
or reduced in any way. The advice is intended for use by individuals with suitable
professional qualifications and education in medical practice and the ability to
apply the knowledge in a suitable manner for a specific condition or disease, and in
an appropriate clinical context. The data is complex by nature and open to some
interpretation. The purpose is to assist medical practitioners to improve awareness
of possible complications, risks or consequences associated with surgical proce-
dures for the benefit of those practitioners in the improved care of their patients. The
application of the information contained herein for a specific patient or problem
must be performed with care to ensure that the situation and advice is appropriate
and correct for that patient and situation. The material is expressly not for medico-
legal purposes.
The information contained in Surgery: Complications, Risks and Consequences
is provided for the purpose of improving consent processes in healthcare and in no
way guarantees prevention, early detection, risk reduction, economic benefit or
improved practice of surgical treatment of any disease or condition.
The information provided in Surgery: Complications, Risks and Consequences is
of a general nature and is not a substitute for independent medical advice or research
in the management of particular diseases or patient situations by health care profes-
sionals. It should not be taken as replacing or overriding medical advice.
The Publisher or Copyright holder does not accept any liability for any injury,
loss, delay or damage incurred arising from use, misuse, interpretation, omissions
or reliance on the information provided in Surgery: Complications, Risks and
Consequences directly or indirectly.
Conditions of Use and Disclaimer

xii
Currency and Accuracy of Information
The user should always check that any information acted upon is up-to-date and
accurate. Information is provided in good faith and is subject to change and alter-
ation without notice. Every effort is made with Surgery: Complications, Risks and
Consequences to provide current information, but no warranty, guarantee or legal
responsibility is given that information provided or referred to has not changed
without the knowledge of the publisher, editor or authors. Always check the quality
of information provided or referred to for accuracy for the situation where it is
intended to be used, or applied. We do, however, attempt to provide useful and valid
information. Because of the broad nature of the information provided incomplete-
ness or omissions of specific or general complications may have occured and users
must take this into account when using the text. No responsibility is taken for
delayed, missed or inaccurate diagnosis of any illness, disease or health state at any
time.
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The decisions about the accuracy, currency, reliability and correctness of informa-
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Errors or Suggested Changes
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Conditions of Use and Disclaimer

xiii
This book provides a resource for better understanding of surgical procedures and
potential complications in general terms. The application of this material will
depend on the individual patient and clinical context. It is not intended to be abso-
lutely comprehensive for all situations or for all patients, but act as a ‘guide’ for
understanding and prediction of complications, to assist in risk management and
improvement of patient outcomes.
The design of the book is aimed at:
• Reducing Risk and better Managing Risks associated with surgery
• Providing information about ‘general complications’ associated with surgery
• Providing information about ‘speciﬁc complications’ associated with surgery
• Providing comprehensive information in one location, to assist surgeons in their
explanation to the patient during the consent process
For each speciﬁc surgical procedure the text provides:
• Description and some background of the surgical procedure
• Anatomical points and possible variations
• Estimated Frequencies
• Perspective
• Major Complications
From this, a better understanding of the risks, complications and consequences
associated with surgical procedures can hopefully be gained by the clinician for
explanation of relevant and appropriate aspects to the patient.
The Estimated frequency lists are not mean’t to be totally comprehensive or to
contain all of the information that needs to be explained in obtaining informed con-
sent from the patient for a surgical procedure. Indeed, most of the information is for
the surgeon or reader only, not designed for the patient, however, parts should be
selected by the surgeon at their discretion for appropriate explanation to the indi-
vidual patient in the consent process.
How to Use This Book

xiv
Many patients would not understand or would be confused by the number of
potential complications that may be associated with a speciﬁc surgical procedure, so
some degree of selective discussion of the risks, complications and consequences
would be necessary and advisable, as would usually occur in clinical practice. This
judgement should necessarily be left to the surgeon, surgeon-in-training or other
practitioner.
How to Use This Book

xv
Over the last decade or so we have witnessed a rapid change in the consumer
demand for information by patients preparing for a surgical procedure. This is
fuelled by multiple factors including the ‘internet revolution’, altered public con-
sumer attitudes, professional patient advocacy, freedom of information laws, insur-
ance issues, risk management, and medicolegal claims made through the legal
system throughout the western world, so that the need has arisen for a higher, fairer
and clearer standard of ‘informed consent’.
One of the my main difficulties encountered as a young intern, and later as a
surgical resident, registrar and consultant surgeon, was obtaining information for
use for the pre-operative consenting of patients, and for managing patients on the
ward after surgical operations. I watched others struggle with the same problem too.
The literature contained many useful facts and clinical studies, but it was unwieldy
and very time-consuming to access, and the information that was obtained seemed
specific to well-defined studies of highly specific groups of patients. These patient
studies, while useful, often did not address my particular patient under treatment in
the clinic, operating theatre or ward. Often the studies came from centres with vast
experience of a particular condition treated with one type of surgical procedure,
constituting a series or trial.
What I wanted to know was:
• The main complications associated with a surgical procedure;
• Information that could be provided during the consent process, and
• How to reduce the relative risks of a complication, where possible
This information was difficult to find in one place!
As a young surgeon, on a very long flight from Adelaide to London, with much
time to think and fuelled by some very pleasant champagne, I started making some
notes about how I might tackle this problem. My first draft was idle scribble, as I
listed the ways surgical complications could be classified. After finding over 10 dif-
ferent classification systems for listing complications, the task became much larger
and more complex. I then realized why someone had not taken on this job before!
Preface

xvi
After a brief in-flight sleep and another glass, the task became far less daunting
and suddenly much clearer – the champagne was very good, and there was little else
to do in any case!
It was then that I decided to speak with as many of my respected colleagues as I
could from around the globe, to get their opinions and advice. The perspectives that
emerged were remarkable, as many of them had faced the same dilemmas in their
own practices and hospitals, also without a satisfactory solution.
What developed was a composite documentation of information (i) from the
published literature and (ii) from the opinions of many experienced surgical practi-
tioners in the field – to provide a text to supply information on Complications,
Risks and Consequences of Surgery for surgical and other clinical practitioners to
use at the bedside and in the clinic.
This work represents the culmination of more than 10 years work with the sup-
port and help of colleagues from around the world, for the benefit of their students,
junior surgical colleagues, peers, and patients. To them, I owe much gratitude for
their cooperation, advice, intellect, experience, wise counsel, friendship and help,
for their time, and for their continued encouragement in this rather long-term and
complex project. I have already used the text material myself with good effect and
it has helped me enormously in my surgical practice.
The text aims to provide health professionals with useful information, which can
be selectively used to better inform patients of the potential surgical complications,
risks and consequences. I sincerely hope it fulfils this role.
Adelaide, SA, Australia Brendon J. Coventry, BMBS, PhD,
FRACS, FACS, FRSM
Preface

xvii
I wish to thank:
The many learned friends and experienced colleagues who have contributed in
innumerable ways along the way in the writing of this text.
Professor Sir Peter Morris, formerly Professor of Surgery at Oxford University,
and also Past-President of the College of Surgeons of England, for allowing me to
base my initial work at the Nufﬁeld Department of Surgery (NDS) and John
Radcliffe Hospital in the University of Oxford, for the UK sector of the studies. He
and his colleagues have provided encouragement and valuable discussion time over
the course of the project.
The (late) Professor John Farndon, Professor of Surgery at the University of
Bristol, Bristol Royal Inﬁrmary, UK; and Professor Robert Mansel, Professor of
Surgery at the University of Wales, Cardiff, UK for discussions and valued advice.
Professor Charles Balch, then Professor of Surgery at the Johns Hopkins
University, Baltimore, Maryland, USA, and Professor Clifford Ko, from UCLA and
American College of Surgeons NSQIP Program, USA, for helpful discussions.
Professor Armando Guiliano, formerly of the John Wayne Cancer Institute,
Santa Monica, California, USA for his contributions and valuable discussions.
Professor Jonathan Meakins, then Professor of Surgery at McGill University,
Quebec, Canada, who provided helpful discussions and encouragement, during our
respective sabbatical periods, which coincided in Oxford; and later as Professor of
Surgery at Oxford University.
Over the last decade, numerous clinicians have discussed and generously con-
tributed their experience to the validation of the range and relative frequency of
complications associated with the wide spectrum of surgical procedures. These cli-
nicians include:
Los Angeles, USA: Professor Carmack Holmes, Cardiothoracic Surgeon, Los
Angeles (UCLA); Professor Donald Morton, Melanoma Surgeon, Los Angeles;
Dr R Essner, Melanoma Surgeon, Los Angeles.
Acknowledgements

xviii
New York, USA: Professor Murray Brennan; Dr David Jacques; Prof L Blumgart; Dr
Dan Coit; Dr Mary Sue Brady (Surgeons, Department of Surgery, Memorial
Sloan-Kettering Cancer Centre, New York);
Oxford, UK: Dr Linda Hands, Vascular Surgeon; Dr Jack Collin, Vascular Surgeon;
Professor Peter Friend, Transplant and Vascular Surgeon; Dr Nick Maynard,
Upper Gastrointestinal Surgeon; Dr Mike Greenall, Breast Surgeon; Dr Jane
Clark, Breast Surgeon; Professor Derek Gray, Vascular/Pancreatic Surgeon;
Dr Julian Britton, Hepato-Biliary Surgeon; Dr Greg Sadler, Endocrine Surgeon;
Dr Christopher Cunningham, Colorectal Surgeon; Professor Neil Mortensen,
Colorectal Surgeon; Dr Bruce George, Colorectal Surgeon; Dr Chris Glynn,
Anaesthetist (National Health Service (NHS), Oxford, UK).
Bristol, UK: Professor Derek Alderson.
Adelaide, Australia: Professor Guy Ludbrook, Anesthetist; Dr Elizabeth Tam,
Anesthetist.
A number of senior medical students at the University of Adelaide, including
Hwee Sim Tan, Adelaine S Lam, Ramon Pathi, Mohd Azizan Ghzali, William Cheng,
Sue Min Ooi, Teena Silakong, and Balaji Rajacopalin, who assisted during their stu-
dent projects in the preliminary feasibility studies and research, and their participa-
tion is much appreciated. Thanks also to numerous sixth year students, residents and
surgeons at Hospitals in Adelaide who participated in questionnaires and surveys.
The support of the University of Adelaide, especially the Department of Surgery,
and Royal Adelaide Hospital has been invaluable in allowing the sabbatical time to
engineer the collaborations necessary for this project to progress. I thank Professors
Glyn Jamieson and Guy Maddern for their support in this regard.
I especially thank the Royal Australasian College of Surgeons for part-support
through the Marjorie Hooper Fellowship.
I thank my clinical colleagues on the Breast, Endocrine and Surgical Oncology
Unit at the Royal Adelaide Hospital, especially Grantley Gill, James Kollias and
Melissa Bochner, for caring for my patients and assuming greater clinical load when
I have been away.
Professor Bill Runciman, Australian Patient Safety Foundation, for all of his
advice and support; Professors Cliff Hughes and Bruce Barraclough, from the Royal
Australasian College of Surgeons, the Clinical Excellence Commission, New South
Wales,andtheAustralianCommission(Council)onSafetyandQualityinHealthcare.
Thanks too to Kai Holt, Anne-Marie Bennett and Carrie Cooper who assisted
and helped to organise my work. I also acknowledge my collaborator Martin
Ashdown for being so patient during distractions from our scientiﬁc research work.
Also to Graeme Cogdell, Imagart Design Ltd, Adelaide, for his expertise and help-
ful discussions.
I particularly thank Melissa Morton and her global team at Springer-Verlag for
their work in preparing the manuscript for publication.
Importantly, I truly appreciate and thank my wife Christine, my four children and
our parents/ wider family for their support in every way towards seeing this project
through to its completion, and in believing so much in me, and in my work.
Adelaide, SA, Australia Brendon J. Coventry, BMBS, PhD,
FRACS, FACS, FRSM
Acknowledgements

xix
Contents
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Brendon J. Coventry
2 Breast Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Richard Rainsbury, Brendon J. Coventry, Armando Giuliano,
Robert Mansel, Jim Katsaros, Richard Rahdon, Venkat Ramakrishnan,
Krishna Clough, Nora Hansen, and Helen Mabry
3 Thyroid and Parathyroid Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Armando Giuliano, Samuel Wells Jr., Thomas Reeve,
Hisham Abdullah, and Brendon J. Coventry
4 Adrenal Gland Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Sarah Thompson, David Walsh, and Brendon J. Coventry
5 Lymphatic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
John Thompson, Armando Giuliano, Guy Rees, Douglas Tyler,
Brendon J. Coventry, Nora Hansen, and Helen Mabry
6 Splenic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Brendon J. Coventry and David Watson
7 Specialized Cancer Procedures and Surgery. . . . . . . . . . . . . . . . . . . . . 201
John Thompson, Brendon J. Coventry, Douglas Tyler,
and Hidde M. Kroon
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219

xxi
Contributors
Hisham Abdullah, MD Putrajaya Hospital, Putrajaya, Malaysia
Krishna Clough, MD Department of General and Breast Surgery,
Institut Curie, Paris, France
Brendon J. Coventry, BMBS, PhD, FRACS, FACS, FRSM Discipline of
Surgery, Breast, Endocrine and Surgical Oncology Unit, Royal Adelaide Hospital,
University of Adelaide, Adelaide, Australia
Armando Giuliano, MD, FACS, FRCSEd Department of Surgery,
Cedars-Sinai Medical Center, Los Angeles, CA, USA
Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center,
Los Angeles, CA, USA
Saul and Joyce Brandman Breast Center – A Project of Women’s Guild, Cedars-
Sinai Medical Center, Los Angeles, CA, USA
Nora Hansen, MD Departments of Surgical Oncology and General Surgery,
Northwestern Memorial Hospital, Chicago, IL, USA
James Katsaros, MBBS, FRACS James Katsaros Clinic,
North Adelaide, Australia
Hidde M. Kroon, MD, PhD Sydney Melanoma Unit, Sydney Cancer Center,
Royal Prince Alfred Hospital, Sydney, NSW, Australia
Helen Mabry, MD Center for Breast Care, The University of Toledo
Medical Center, Toledo, OH, USA
Robert Mansel, MD Institute of Cancer and Genetics,
Cardiff University School of Medicine, Cardiff, Wales
Richard Rahdon, MBBS, Bmed Sci, FRACS Body Recon Plastic Surgery,
Geelong, VIC, Australia

xxii
Richard Rainsbury, MBBS, BSc, MS, FRCS BMI Sarum Road Hospital,
Winchester, United Kingdom
Venkat Ramakrishnan, MS, FRACS, FRCS St. Andrews Centre for Plastic
Surgery and Burns, Chelmsford, Essex, United Kingdom
Guy Rees, MBBS, FRCS, FRACS Discipline of Surgery, Otolaryngology,
Head and Neck Surgery, The Queen Elizabeth Hospital, Royal Adelaide Hospital,
and Lyell McEwin Hospital, The University of Adelaide, Adelaide, Australia
Thomas Reeve, MBBS Endocrine Surgical Unit, University of Sydney,
Sydney, NSW, Australia
John Thompson, MD Department of Surgery, Royal Prince Alfred Hospital,
Melanoma Institute, The University of Sydney, Sydney, Australia
Sarah Thompson, MD, PhD, FRACS Oesophagogastric and Upper GI Unit,
Discipline of Surgery, University of Adelaide, Royal Adelaide Hospital,
Adelaide, Australia
Douglas Tyler, MD Division of Surgical Oncology, Department of Surgery,
Duke University Medical Center, Durham, NC, USA
David Walsh, MBBS, FRACS Discipline of Surgery, The Queen Elizabeth
Hospital, The University of Adelaide, Adelaide, Australia
David Watson, MBBS, MD, FRACS Department of Surgery,
Flinders Medical Centre, Adelaide, Australia
Samuel Wells Jr., MD Medical Oncology Branch and Afﬁliates,
National Cancer Institute at the National Institutes of Health, Bethesda, MD, USA
Contributors

1B.J. Coventry (ed.), Breast, Endocrine and Surgical Oncology,
Surgery: Complications, Risks and Consequences,
DOI 10.1007/978-1-4471-5421-1_1, © Springer-Verlag London 2014
This volume deals with complications, risks, and consequences related to a range of
procedures under the broad headings of breast surgery including reconstructive
breast surgery, thyroid and parathyroid surgery, adrenal surgery, lymphatic surgery,
in particular nodal resection from biopsy to radical lymphadenectomy, splenectomy,
and more specialized surgical oncology procedures including isolated limb infusion
and perfusion and retroperitoneal dissections, for resection of lymph nodes,
sarcomas, lymphomas, and testicular cancers.
Chapter 1
Introduction
Brendon J. Coventry
B.J. Coventry, BMBS, PhD, FRACS, FACS, FRSM
Discipline of Surgery, Breast, Endocrine and Surgical Oncology Unit,
Royal Adelaide Hospital, University of Adelaide,
L5 Eleanor Harrald Building, North Terrace,
5000 Adelaide, SA, Australia
e-mail: brendon.coventry@adelaide.edu.au
Important Note
It should be emphasized that the risks and frequencies that are given here
represent derived ﬁgures. These ﬁgures are the best estimates of relative fre-
quencies across most institutions, not merely the highest-performing ones,
and as such are often representative of a number of studies, which include
different patients with differing comorbidities and different surgeons. In addi-
tion, the risks of complications in lower- or higher-risk patients may lie out-
side these estimated ranges, and individual clinical judgement is required as
to the expected risks communicated to the patient, staff, or for other purposes.
The range of risks is also derived from experience and the literature; while
risks outside this range may exist, certain risks may be reduced or absent due
to variations of procedures or surgical approaches. It is recognized that differ-
ent patients, practitioners, institutions, regions, and countries may vary in
their requirements and recommendations.

2
Individual clinical judgement should always be exercised, of course, when
applying the general information contained in these documents to individual
patients in a clinical setting.
The authors would like to thank and acknowledge the following experienced
clinicians who discussed the chapters and acted as advisors: John Farndon (late),
Bristol, England, UK; Michael Greenall, Oxford, England, UK; Jane Clarke,
Oxford, England, UK; Gregory Sadler, Oxford, UK; Peter Malycha, Adelaide,
Australia; Charles M Balch, Texas, USA; Rick Essner, Los Angeles, USA; Murray
Brennan, New York, USA; Christopher O’Brien, Sydney, Australia; and Donald L
Morton, Los Angeles, USA.
B.J. Coventry

3B.J. Coventry (ed.), Breast, Endocrine and Surgical Oncology,
Surgery: Complications, Risks and Consequences,
DOI 10.1007/978-1-4471-5421-1_2, © Springer-Verlag London 2014
Chapter 2
Breast Surgery
Richard Rainsbury, Brendon J. Coventry, Armando Giuliano, Robert Mansel,
Jim Katsaros, Richard Rahdon, Venkat Ramakrishnan, Krishna Clough,
Nora Hansen, and Helen Mabry
Armando Giuliano MD, FACS, FRCSEd
Department of Surgery, Surgical Oncology, Los Angeles, CA, USA
Samuel Oschin Comprehensive Cancer Institute, Surgical Oncology, Los Angeles, CA, USA
Saul and Joyce Brandman Breast Center – A Project of Women’s Guild,
Los Angeles, CA, USA
Cedars-Sinai Medical Center, Los Angeles, CA, USA
R. Rainsbury, MBBS, BSc, MS, FRCS
BMI Sarum Road Hospital, Winchester, UK
B.J. Coventry, BMBS, PhD, FRACS, FACS, FRSM (*)
Discipline of Surgery, Breast, Endocrine and Surgical Oncology Unit,
Royal Adelaide Hospital, University of Adelaide, L5 Eleanor Harrald Building,
North Terrace, 5000 Adelaide, SA, Australia
e-mail: brendon.coventry@adelaide.edu.au
R. Mansel, MD
Institute of Cancer and Genetics, Cardiff University School of Medicine, Cardiff, Wales
J. Katsaros, MBBS, FRACS
James Katsaros Clinic, North Adelaide, Australia
R. Rahdon, MBBS, Bmed Sci, FRACS
Body Recon Plastic Surgery, Geelong, VIC, Australia
V. Ramakrishnan, MS, FRACS, FRCS
St. Andrews Centre for Plastic Surgery and Burns, Chelmsford, Essex, United Kingdom
K. Clough, MD
Department of General and Breast Surgery, Institut Curie, Paris, France
N. Hansen, MD
Departments of Surgical Oncology and General Surgery, Northwestern Memorial Hospital,
Chicago, IL, USA
H. Mabry, MD
Center for Breast Care, The University of Toledo Medical Center, Toledo, OH, USA

4
General Perspective and Overview
The relative risks and complications increase proportionately according to the
type of surgery, site of a breast lesion, extent of procedure performed, tech-
nique, the complexity of the problem, and the breast and lesion size. Extensive
or complex surgery usually carries higher risks of bleeding and infection than
smaller procedures, in general terms. Similarly, risk is relatively higher for
recurrent and complex breast problems, for associated axillary lymph node
dissections and especially for those closer to neural structures (e.g., brachial
plexus, axillary, long thoracic, or thoracodorsal). Axillary lymph node dissec-
tion procedures are typically associated with a higher frequency and greater
range of complications compared to procedures involving the breast alone.
This is principally related to the surgical accessibility, risk of tissue/nerve
injury, seroma formation, and interruption of lymphatic channels and outflow
from the upper limb and chest.
Reconstructive procedures carry a further range of potential complications also
related to the donor site for autogenous tissue (e.g., back or abdomen) or the use of
foreign material as an implant (e.g., breast prosthesis or abdominal mesh). This, in
broad terms, increases the extent of tissue injury and risk of infection, bleeding, and
nerve injury. The type and extent of any reconstructive procedure is associated with
complications related to “technical and anatomic” issues.
In general, for many breast operations, the complications are similar in type
and frequency. Knowledge of the anatomy and the variations commonly seen
are helpful in minimizing nerve and vessel injury. Surgeons argue the benefits
of one approach over the other, but there is somewhat little tangible data to
demonstrate differences in terms of the observed or reported complications.
Other surgeons will argue that the use of drains adds to the complication rates,
but this needs to be balanced with the extent and risks of bleeding and lymphatic
leakage.
Possible reduction in the risk of misunderstandings over complications or conse-
quences from breast surgery might be achieved by:
• Good explanation of the risks, aims, benefits, and limitations of the procedure(s)
• Useful planning considering the anatomy, approach, alternatives, and method
• Avoiding likely associated vessels and nerves
• Adequate clinical follow-up
Multisystem failure, systemic sepsis, and death are rare after breast surgery,
even with extensive reconstruction, but are reported and remain a risk.
Positioning on the operating table has been associated with increased
risk of deep venous thrombosis and nerve palsies, especially in prolonged
procedures.
The use of specialized units with standardized preoperative assessment,
multidisciplinary input, and high-quality postoperative care is essential to
the success of complex breast surgery overall and can significantly reduce risk of
complications or aid early detection, prompt intervention, and cost.
R. Rainsbury et al.

5
With these factors and facts in mind, the information given in this chapter must
be appropriately and discernibly interpreted and used.
For diagnostic fine- or core-needle biopsy complications, see volume 1 or lymph
node surgery (Chap. 5), or for other procedures, see the relevant chapter.
Female Breast Surgery
Excisional Breast Biopsy (Lumpectomy)
Description
Excisional biopsy may be performed with general anesthesia or under local anes-
thesia with or without IV sedation. Excisional breast biopsy is removal of an abnor-
mality in the breast typically for diagnosis. The aim of the surgery is to determine
the nature of the mass and to rule out carcinoma. The lump may be small or large;
however, the nature and breast size are important factors in determining risk of
complications. A non-palpable mass will usually require a form of localization (see
next case). Preoperative workup includes mammogram (especially in women aged
>30–40 years as tumor may be obscured by the density of younger breast tissue) and
ultrasound (for assessing solid, cystic, or malignant characteristics). A diagnostic
fine- or core-needle biopsy is usually performed prior to excisional biopsy, under
MMG or U/S guidance if required. Incisional biopsy for diagnosis may be included
under this risk profile; however, excisional biopsy aims to remove the entire lesion,
often with a “cuff” of normal tissue. The incision chosen may be peri-areolar,
Important Note
It should be emphasized that the risks and frequencies that are given here
represent derived figures. These figures are best estimates of relative frequen-
cies across most institutions, not merely the highest-performing ones, and as
such are often representative of a number of studies, which include differ-
ent patients with differing comorbidities and different surgeons. In addition,
the risks of complications in lower- or higher-risk patients may lie outside
these estimated ranges, and individual clinical judgment is required as to the
expected risks communicated to the patient, staff, or for other purposes. The
range of risks is also derived from experience and the literature; while risks
outside this range may exist, certain risks may be reduced or absent due to
variations of procedures or surgical approaches. It is recognized that different
patients, practitioners, institutions, regions, and countries may vary in their
requirements and recommendations.
2 Breast Surgery

6
horizontal, or even radial according to the location and desired cosmesis. Dissection
usually aims to excise a margin of normal tissue around the lesion, often includ-
ing pectoral fascia. Electrocautery, and deep, absorbable suture closure, is used
for hemostasis, often avoiding wound drains. Marking sutures are usually used to
orientate the specimen to deﬁne pathological margins.
Anatomical Points
The anatomical base of the breast extends from the inferior clavicle to the infra-
mammary fold and from the lateral sternum into the axilla. Occasionally, islands
of breast tissue exist in the axilla, isolated from the axillary tail. The nipple-areolar
complex and main breast mass may vary considerably between individuals, with
age and posture. A breast mass can be located anywhere within the breast. The size
and nature of the mass and breast essentially determines the placement and type of
incision, surgical result, and cosmesis. The possibility of mastectomy or further sur-
gery is often a consideration in preoperative placement of incision. Care should be
taken to avoid downward repositioning of the nipple with large excisions of lower
pole breast tissue. This deformity may be avoided by mobilizing nearby normal
breast tissue into the area of the defect.
Perspective
See Table 2.1. Hematoma is an uncommon, but signiﬁcant, complication. Rarely,
operative drainage is required. The risk of infection after an excisional breast biopsy
is minimal and preoperative antibiotics are rarely used. Poor cosmesis, dimpling,
scarring, and skin necrosis can occur after excisional biopsy. Removing as little
tissue as possible (especially subcutaneous fat, where possible) improves cosmetic
outcome. Often after surgery the patient perceives that the mass is still present. This
is related to healing scar or seroma formation. This postoperative mass may be pal-
pable for up to 6 months postoperatively while the scar is remodeling. There is often
some temporary paresthesia over the incision. Many patients describe it as burning
or shooting pain. Acute postoperative pain is usually managed well with oral pain
medication and resolves after a couple of days. Chronic pain is rare.
Major Complications
The major risk of excisional biopsy is development of a large postoperative hematoma.
This complication can be avoided by meticulous control of bleeding during surgery.
Most hematomas can be managed nonoperatively. Large hematomas require surgical
evacuation and, if left untreated, may become infected or spontaneously drain. Draining
of infected hematomas can lead to open wounds that persist for months.
R. Rainsbury et al.

7
Failure to diagnose due to inadequately sampling a palpable lesion, biopsying
the wrong area, or incomplete excision are uncommon with an excisional biopsy,
but may necessitate further surgery. Preoperative verification of the position of the
mass in the awake patient is wise, as some lesions are best felt in one position. It is
important to be sure that the mass can be identified and marked once the patient is
supine and anesthetized. If there is any question preoperatively regarding the pal-
pability or location of the lesion, an image-guided procedure should be performed
prior to surgery to ensure removal of the suspicious lesion (see below). Dense
fibrous breast tissue can obscure the mass. In most situations the mass should be
removed entirely.
If skin flaps are raised to remove a superficial mass, care should be taken not
to make the flaps too thin, causing reduced blood supply to the skin, resulting in
necrosis, tissue loss, or skin dimpling. If skin necrosis occurs, the necrotic skin
must be excised if the area is extensive or it may be treated with local wound care
if it is small.
Table 2.1 Excisional breast biopsy (lumpectomy) estimated frequency of complications, risks,
and consequences
Complications, risks, and consequences Estimated frequency
Most significant/serious complications
Infection 1–5 %
Bleeding 1–5 %
Bruising 50–80 %
Hematoma formation
Small 5–20 %
Large (reoperative evacuation) <0.1 %
Incomplete excision of lesion (procedure dependenta
1–5 %
Necessity for further surgerya
5–20 %
(Re-excision/completion mastectomy/axillary clearance)
Rare significant/serious problems
Fat necrosis 0.1–1 %
Failed biopsy of lesiona
0.1–1 %
Less serious complications
Pain/tenderness
Acute (<4 weeks) 5–20 %
Chronic (>12 weeks) <0.1 %
Paresthesia (sensory nerve injury) 0.1–1 %
Skin flap problems 0.1–1 %
Wound Scarring
Skin scarring (poor cosmesis, dimpling/deformation of the skin) 1–5 %
Deep scar formation (residual breast lump) 5–20 %
Drain tube(s)a
1–5 %
Note: The pathology of the lesion and breast size will largely determine the likelihood of complete
clearance and necessity for further procedures or treatment
a
Depends on the underlying pathology, surgical technique preferences, and location in the breast
2 Breast Surgery

8
Localization Biopsy of Mammographically Detected Lesions
(Hookwire or Carbon-Track Localization)
Description
General anesthesia is usually used, but local anesthesia and IV sedation may be
used. A mammographic or ultrasound image-guided localization and excisional
breast biopsy is indicated for a non-palpable mammographically detected lesions,
architectural distortion, or suspicious microcalciﬁcations. The localization can be
achieved by a hookwire or using a carbon track, both being placed using a needle
and MMG or U/S, to locate and mark the lesion (Fig. 2.1).
Fine-needle or core-needle biopsy should be obtained prior to operation, if pos-
sible, to permit better operative planning and margin consideration. Often a cancer
operation rather than a diagnostic procedure can be performed, perhaps sparing the
patient two operations. Rarely, two wires or carbon markings are used to deﬁne
large lesions.
Consent and Risk Reduction
Main Points to Explain
• GA risk
• Wound infection
• Bleeding/hematoma
• Abscess formation
• Cosmetic deformity
• Further surgery
Fig. 2.1 Scar following
carbon black marking and
carbon-localised breast
biopsy showing residual
sequestered carbon at the
scar several years later
R. Rainsbury et al.

9
The incision chosen may be peri-areolar, curvilinear, horizontal, or even radial
according to the lesion location, marker, and desired cosmesis. Dissection usually
aims to excise a margin of normal tissue around the lesion and hookwire/carbon
marker, often including pectoral fascia. Radioactive seed implantation under mam-
mographic control has also been used. Electrocautery and deep, absorbable suture
closure is used for hemostasis, often avoiding wound drains. Marking sutures
are usually used to orientate the specimen to define pathological margins. Once
the specimen is removed, a specimen radiograph is performed to compare to the
original film and determine completeness of excision and radiological margins.
Anatomical Points
taken to avoid downward repositioning of the nipple with large excisions of lower
pole breast tissue. This deformity may be avoided by mobilizing nearby normal
breast tissue into the area of the defect.
Perspective
See Table 2.2. Complications overall are not very common. Development of a large
postoperative hematoma is a significant complication (Figs. 2.2 and 2.3). Infection
and prolonged drainage can be significant and may result in cosmetic problems.
Failure to diagnose the abnormality can also occur. Cosmetic defects are rarely
troublesome. However, all may require further surgery and this can be significant,
resulting in further hospitalization.
Often, after surgery a mass may be palpable due to scarring and seroma forma-
tion and may persist for up to 6 months postoperatively while the scar is remodel-
ing. There is often some temporary paresthesia over the incision. Many patients
describe it as burning or shooting pain. Acute postoperative pain is usually man-
aged well with oral pain medication and resolves after a couple of days. Chronic
pain is rare.
Major Complications
The major risks are development of a large postoperative hematoma or infection.
These complications are rare and can be avoided with careful hemostasis. Large
2 Breast Surgery

10
hematomas may require surgical evacuation, otherwise infection and spontaneous
drainage may occur. Draining of infected hematomas can lead to open wounds that
last for months. Dense fibrous breast tissue can make localization and excision dif-
ficult. Occasionally, the localization hookwire or carbon mark is inaccurate or dis-
placed, leading to failed biopsy. Failure to diagnose due to inadequately sampling a
non-palpable lesion, biopsying the wrong area, or incomplete excision, is not very
common with a localization biopsy, but may necessitate another localizing proce-
dure and further surgery. Removal of the lesion may be confirmed using a specimen
MMG or U/S.
If skin flaps are raised to remove a superficial mass, care should be taken not to
make the flaps too thin, causing reduced blood supply to the skin, resulting in necro-
sis, tissue loss, or skin dimpling. Extensive skin necrosis may require dressings and/
or excision and skin flap repair.
Table 2.2 Localization biopsy of mammographically detected lesion—hookwire or carbon,
estimated frequency of complications, risks, and consequences
Infection 1–5 %
Bleeding 1–5 %
Bruising 50–80 %
Hematoma formation
Small 5–20 %
Displacement of hookwire/carbon mistrackinga
1–5 %
) 1–5 %
1–5 %
20–50 %
(Re-excision/completion mastectomy/axillary clearance)
Pain/tenderness
Paresthesia (sensory nerve injury; breast, nipple) 0.1–1 %
Skin flap problems 0.1–1 %
Wound scarring
Skin scarringa
1–5 %
(poor cosmesis, dimpling/deformation of the skin)
Drain tube(s)a
1–5 %
clearance and necessity for further procedures or treatment. Technical issues may determine accu-
racy of localization and biopsy
a
R. Rainsbury et al.

11
Fig. 2.2 Breast hematoma after partial mastectomy and sentinel node biopsy
Fig. 2.3 Breast hematoma
after core biopsy of left breast
2 Breast Surgery

12
Subcutaneous Mastectomy (Complete Mastectomy)
Description
General anesthesia is usually used, but local anesthesia and IV sedation may be
used. Subcutaneous mastectomy is removal of breast tissue only, usually used for
in situ carcinoma, where axillary dissection is not required, or for mastectomy for
benign conditions (e.g., prophylactic mastectomy, reconstruction, severe breast
pain, equalization after contralateral mastectomy). Some may regard it as a lesser
type of mastectomy, but it should include >99 % of breast tissue. Mammography is
done to exclude or deﬁne pathology. An inframammary peri-areolar incision is often
used and can be extended laterally. The nipple-areolar complex may be preserved
without devascularizing the nipple, especially if later reconstruction is desired.
Cosmesis is achieved by tapering the edges and/or liposuction. Reconstruction is
sometimes performed, either immediate or delayed. Hemostasis and suction drain-
age can reduce hematoma formation. Absorbable interrupted sutures and a running
subcuticular skin suture are often used for closure.
Anatomical Points
The breast tissue is excised including the full anatomic extent of the breast, superiorly
extending to below the clavicle, medially to the sternal edge, laterally into the axilla,
and inferiorly to the inframammary fold. The breast and the chest wall shape vary con-
siderably between individuals and with age, dictating the extent of surgery required.
Perspective
See Table 2.3. Postoperative hematoma is best avoidable by careful hemostasis.
Infection is rare. Seroma formation may occur and it can be aspirated if it is large
• GA risk
• Wound infection
• Further surgery
R. Rainsbury et al.

13
Table 2.3 Subcutaneous mastectomy estimated frequency of complications, risks, and
consequences
Infection 1–5 %
Bleeding/hematoma formation
Small 5–20 %
Large (reoperative evacuation) 0.1–1 %
Bruising >80 %
Aspiration (postoperative)a
1–5 %
Incomplete excision of lesion (procedure dependentb
) 1–5 %
Failed biopsy of lesionb
1–5 %
Nerve injury (shorter term <12 weeks)a
50–80 %
Nerve injury (longer term)a
Arm/chest wall paresthesia (intercostobrachial nerve injury) 1–5 %
Necessity for further surgeryb
20–50 %
(Re-excision/completion mastectomy/axillary clearanceb
)
Possibility of further treatment (surgery, radiotherapy, chemotherapy,
endocrine therapy)b
5–20 %
Asymmetry >80 %
Volume loss (size disparity)b
>80 %
Skin ﬂap necrosisb
0.1–1 %
Dehiscence 0.1–1 %
Edema of chest [+/− arm/hand]b
0.1–1 %
Nipple necrosisb
0.1–1 %
Pneumothorax <0.1 %
Pain/tenderness
Phantom breast painb
5–20 %
Lymphocele lymphatic leak 5–20 %
Seroma formation 5–20 %
Fat necrosis 5–20 %
Arm/breast/chest swellinga
1–5 %
Blood transfusion 0.1–1 %
Wound scarringb
Skin scarring (poor cosmesis; dimpling/deformation) 1–5 %
Deep scar formation (residual breast/chest wall lump) 0.1–1 %
Drain tube(s)b
20–50 %
a
Complications of axillary surgery must be included if this is performed synchronously with breast
surgery
b
2 Breast Surgery

14
or left to resolve if small. Recurrent seromas can be unpredictable, tedious, and last
for >1 month. The scars may be unequal in position or size when the patient has
recovered fully from surgery. There may be excess skin that is unsatisfying to the
patient. Both of these conditions may require another operation. Acute postopera-
tive pain is common and is easily managed with oral analgesics. Chronic pain is
rare. Some patients may temporarily experience heightened sensation of the nipple,
if retained, but this usually resolves. Numbness or paresthesias of the nipple are also
possible. If immediate reconstruction is done, these complications need discussion
and consideration (see various forms of reconstruction). The axilla complications
are not present as axillary surgery is not typically included. Infection is uncommon.
Major Complications
A large hematoma may require evacuation and control of the bleeding with further
surgery. If a large hematoma is not drained, it may drain spontaneously or rarely
dissipate. Large hematomas also increase risk of infection. Although sometimes
unpredictable, poor cosmesis because of unequal scar position/size, excessive skin,
dimpling, excess scarring, or persistence of a subareolar mass, then additional oper-
ations may be indicated to improve the outcome. However, most women do not
complain of deformity. Chronic pain or paresthesia are not common, but can be
signiﬁcant problems.
Partial Mastectomy (Segmental Breast Resection;
Segmentectomy)
Description
General anesthesia is usually used, but local anesthesia may be used +/− IV seda-
tion. Partial mastectomy (PM) or lumpectomy is indicated for breast conservation
• GA risk
• Wound infection
• Skin necrosis
• Further surgery
R. Rainsbury et al.

15
for excision of invasive breast usually cancer or ductal carcinoma in situ (DCIS).
The aim is to remove the carcinoma with surrounding normal tissue to achieve
margins of 1–2 cm. Preoperative mammogram and ultrasound (and occasionally
MRI) are used to determine the nature and extent of the lesion and identify other
lesions in either breast.
PM may follow an excisional, incomplete, or localization biopsy. A specimen
MMG or U/S is often used to assess margins and may be used to guide resection
of more tissue intraoperatively. Separate samples may be used to assess the biopsy
margins. Marker sutures or clips are used to orientate the specimen for the patholo-
gist. Marker clips may be used for guiding the radiation therapy.
The incision chosen may be peri-areolar, curvilinear, horizontal, or even
radial according to the location and desired cosmesis. Dissection usually aims to
excise a wide margin of normal tissue around the lesion, often including pectoral
fascia. Mobilization of remaining breast tissue may be necessary to reapproxi-
mate the breast parenchyma, especially in the medial and lower breast, to reduce
shape deformity. Electrocautery and deep, absorbable suture closure is used for
hemostasis, often avoiding wound drains, with a subcuticular skin suture. A sep-
arate axillary incision is often used for axillary lymph node surgery (described
separately).
Anatomical Points
taken to avoid downward repositioning of the nipple with large excisions, notably
the lower breast tissue. This deformity may be avoided by mobilizing nearby nor-
mal breast tissue into the area of the defect. Cancer specimens involving the nipple
by direct extension require removal of the nipple as part of the segmental resection.
Invasive cancer may invade any of the structures surrounding the breast includ-
ing the skin, the pectoralis muscle, the ribs, and the chest wall. Usually very large
cancers that invade one of these structures will be initially treated with neoadjuvant
chemotherapy prior to operation.
Perspective
See Table 2.4. The most signiﬁcant, but infrequent, complications are develop-
ment of a large hematoma, infection, abscess formation, incomplete excision
with close or involved margins, and the requirement for further surgery due to
2 Breast Surgery

16
these. Favorable cosmetic outcome and optimal margins can be competing goals.
Surgical judgment is important to maximize both goals. Poor cosmesis, dimpling,
skin necrosis, and hypertrophic scarring are usually less severe, but more frequent
complications. There may be some temporary paresthesia surrounding the inci-
sion. Patients often describe it as burning or shooting pain. Acute postoperative
pain is usually controlled with oral pain medication. Chronic pain is rare. The risk
of infection after a partial mastectomy is minimal and prophylactic antibiotics are
rarely indicated.
Table 2.4 Partial mastectomy (segmental breast resection; segmentectomy) estimated frequency
of complications, risks, and consequences
Infection 1–5 %
Small 5–20 %
Bruising >80 %
Lymphocele lymphatic leak 5–20 %
Seroma formation 5–20 %
Fat necrosis 5–20 %
Wound scarring
Skin scarringa
(poor cosmesis; dimpling/deformation of the skin) 1–5 %
) 1–5 %
1–5 %
20–50 %
(Re-excision/completion mastectomy/axillary clearancea
)
Asymmetry >80 %
Volume loss (size disparity)a
>80 %
Nipple necrosisa
0.1–1 %
Pneumothorax <0.1 %
Pain/tenderness
Arm/breast/chest swellingb
1–5 %
Skin ﬂap problemsa
0.1–1 %
Drain tube(s)a
1–5 %
a
b
Complications of axillary surgery must be included if this is performed synchronously with breast
surgery
R. Rainsbury et al.

17
Major Complications/Consequences
A major consequence of conservative breast surgery is incomplete carcinoma exci-
sion, often necessitating further surgery. Occasionally, a 3rd resection or a total mas-
tectomy may be advisable, if excision is still incomplete. The cosmetic outcome may
be reduced after more than one re-excision such that mastectomy becomes a more
appealing alternative. Mastectomy may be followed by immediate reconstruction.
Hematoma formation can be avoided by meticulous control of bleeding dur-
ing surgery. Most hematomas can be managed nonoperatively. Large hematomas
require surgical evacuation. Infection and abscess formation may complicate
large hematomas if left untreated and can spontaneously drain. Draining of infected
hematomas can lead to open wounds that last for months. Recurrent large seromas
or lymphatic sinuses are rare, but also significant complications.
If skin flaps are raised to remove a superficial mass, care should be taken not
to make the flaps too thin, causing reduced blood supply to the skin, resulting in
skin necrosis, tissue loss, or skin dimpling. Extensive skin necrosis may require
dressings and/or excision and skin flap repair.
Modified Radical Mastectomy (Usually Including
Axillary Clearance)
Description
General anesthesia is required. The main indication is breast cancer that is not
amenable to breast conservation due to size, location, contraindication to radia-
tion therapy, local ulceration/extension, the presence of multiple cancers in different
quadrants of one breast, or patient preference. Some patients prefer mastectomy
with or without delayed reconstruction. The advantages to mastectomy include a
lower incidence of local recurrence and a new breast cancer, avoidance of radiation
therapy for selected patients, and possibly better cosmetic result with immediate
reconstruction especially for patients with large tumors, small breasts, or tumors
• GA risk
• Wound infection
• Further surgery
2 Breast Surgery

18
in the lower breast. Axillary lymph node surgery, either sentinel node biopsy or
definitive level I/II axillary dissection, is usually included at the same operation as
the mastectomy (Fig. 2.4). The arm is typically “free draped” to the elbow allowing
good access to the axilla. A transverse or oblique elliptical incision is usually used,
including the nipple-areolar complex, any involved skin, and any recent biopsy inci-
sions. Subcutaneous saline, vasoconstrictive agent, and/or local anesthetic is used
by some surgeons for defining the subcutaneous plane for dissection and hemosta-
sis. Superior and inferior skin flaps are raised to expose the breast for resection.
The borders of the dissection are the lateral edge of the sternum, the clavicle supe-
riorly, the latissimus dorsi laterally, and the rectus sheath inferiorly. Then the breast
is dissected off the pectoralis muscle (the pectoral fascia is preferably left intact if
immediate reconstruction with implants or expanders is anticipated) with care taken
to control perforating vessels. The lateral attachments of the breast are left intact until
the axillary dissection is completed. The breast is retracted laterally and the lateral
border of the pectoralis major is identified. Axillary dissection (see separately) is infe-
rior to the axillary vessels. Suction drains are used to drain the chest wall and axilla by
most surgeons, but some do not. The skin flaps are trimmed, if necessary, to achieve
a flat chest wall and a straight scar. An absorbable interrupted deep dermal suture is
usually used followed by a monofilament absorbable subcuticular skin suture.
Anatomical Points
The anatomical base of the breast extends from the inferior clavicle to the
inframammary fold and from the lateral sternum into the axilla. Occasionally, islands
Fig. 2.4 Patent blue dye marking and radioisotope lymphatic mapping for breast cancer, showing
tumour site in right breast (circle) and lymph node sites (right axilla and internal mammary)
R. Rainsbury et al.

19
taken to avoid downward repositioning of the nipple with large excisions, notably
the lower breast tissue. This deformity may be avoided by mobilizing nearby nor-
mal breast tissue into the area of the defect. Cancer specimens involving the nipple
by direct extension require removal of the nipple as part of the segmental resection.
Invasive cancer may invade any of the structures surrounding the breast includ-
ing the skin, the pectoralis muscle, the ribs, and the chest wall. Usually very large
cancers that invade one of these structures will be initially treated with neoadjuvant
chemotherapy prior to operation. Occasionally a duplicated axillary vein is present.
Variations in the vascular structures of the axilla are uncommon, but care should
be taken to identify the important neurovascular structures during axillary surgery.
There are reports of aberrant slips of muscle that span the axilla. They may be low-
lying deltoid fibers or, more commonly, a slip of latissimus extending anterior to
the axillary vein.
Perspective
See Table 2.5. Despite the extent of surgery, major complications are usually not
severe or frequent and are mostly related to the axillary surgery. The most significant
complications are hemorrhage, development of a large hematoma, infection, abscess
formation, and the requirement for further surgery due to these. Hemorrhage after
mastectomy is usually caused by perforating vessels that retract into the pectoralis
muscle and then bleed when the patient coughs or moves postoperatively. Seroma
is fairly common and usually occurs after the drains are removed. If the seroma is
small, it can be allowed to resolve on its own. If it is larger, it may be aspirated or a
drain may be replaced. Drains are often removed when their output is <50 ml/day.
Lymphedema of the arm is a complication of axillary clearance that occurs in
3–80 % of patients who undergo axillary dissection. Severe lymphedema is rare,
but often unpredictable. Intercostobrachial nerve injury is common and results in
sensory changes to the upper inner arm and axilla. Patients complain of numbness
and tingling as well as changes in sweating. The affected area usually decreases
in size over time, but never fully resolves. Pain may occasionally be very severe,
especially during recovery.
Injury to the thoracodorsal nerve leads to paralysis of the latissimus dorsi muscle.
The motor deficits include slight weakness in arm adduction and internal rotation of
the shoulder. It is not a very disabling injury, and most patients adapt to it well with-
out changes in lifestyle. Injury to the long thoracic nerve leads to paralysis of the
serratus anterior muscle. This results in winging of the scapula and shoulder pain.
Wound infection is not very common, but it may occur and should be treated
promptly with antibiotics. Skin flap necrosis can occur and is usually caused by
making the flaps too thin, trauma to the skin edges, or the stretching of expanders
2 Breast Surgery

20
Table 2.5 Modified radical mastectomy (including axillary clearance) estimated frequency
of complications, risks, and consequences (female)
Complications, risks, and consequences
Estimated frequency(including axillary lymph node surgery)
Paresthesia of chest wall, inner arm (intercostal due interruption) 50–80 %
Infection 1–5 %
Seroma formation/large lymphocelea
1–5 %
Need for Aspiration (postoperative)a
1–5 %
Nerve Injury (shorter term <12 weeks)a
50–80 %
Injury to nerve to lat. dorsi/nerve to serratus anterior 0.1–1 %
Lateral cutaneous nerve of arm or forearm 0.1–1 %
Brachial plexus injury <0.1 %
Edema (swelling) of arm/handa
Minor 20–50 %
Severe 1–5 %
Skin flap necrosis 1–5 %
Small 0.1–1 %
Axillary vein injury/thrombosis 0.1–1 %
Axillary artery injury (+/− spasm) 0.1–1 %
Neuropraxia/dysesthesia—permanent paina
0.1–1 %
Edema of chest [+/− arm/hand]b
0.1–1 %
Wound dehiscence 0.1–1 %
Lymphatic fluid leak/sinusa
<0.1 %
Rib osteomyelitisb
<0.1 %
Pneumothoraxb
<0.1 %
Incomplete excision of lesion (procedure dependant)b
0.1–1 %
Mortality (operative)b
<0.1 %
Pain/tenderness
Excess axillary skinb
50–80 %
Bruising >80 %
Shoulder problems 5–20 %
Possibility of further treatment (surgery, radiotherapy,
chemotherapy, endocrine therapy)b
50–80 %
5–20 %
Arm stiffness 1–5 %
Axillary fibrous band/cord adhesionsa
1–5 %
R. Rainsbury et al.

21
in patients undergoing immediate reconstruction. Pneumothorax is a very rare, but
serious, complication. It must be recognized promptly. It can happen during injec-
tion of the tumescent solution or during dissection in a frail, thin patient. Incomplete
carcinoma excision and further surgery are extremely rare.
Poor cosmesis, dimpling, skin necrosis, and hypertrophic scarring are usually
less severe, but more frequent complications. There may be some temporary par-
esthesia surrounding the incision. Patients often describe it as burning or shoot-
ing pain. Acute postoperative pain is usually controlled with oral pain medication.
Chronic pain is rare. The risk of infection after a partial mastectomy is minimal and
prophylactic antibiotics are rarely indicated. Mastectomy may be followed by the
immediate reconstruction and associated complications of this.
The major complications of modified radical mastectomy include hemorrhage, arm
lymphedema, thrombosis, or injury to axillary vein, damage to the brachial plexus,
and injury of the long thoracic nerve. Hemorrhage may be intra- or postoperative.
The latter is recognized by swelling or discoloration of the skin flaps, large volumes
of blood in the drains, or changes in the patient’s vital signs. Hemorrhage requires
a return to the operating room with evacuation of the hematoma and control of
the bleeding vessel. Transfusion is rare, and there are usually no long-term conse-
quences of postoperative hemorrhage. Large hematomas require surgical evacu-
ation. Infection and abscess formation may complicate large hematomas if left
untreated and can spontaneously drain. Draining of infected hematomas can lead to
open wounds that last for months. Recurrent large seromas or lymphatic sinuses
are rare, but also significant complications. Extensive skin flap necrosis from isch-
emia as a result of very thin flaps may require dressings and/or excision and rotation
Complications, risks, and consequences
Estimated frequency(including axillary lymph node surgery)
Small lymphocelea
20–50 %
Wound scarringb
Skin scarring (poor cosmesis, dimpling/deformation) 1–5 %
Wound drain tube(s)b
50–80 %
a
Complications of axillary surgery are included since this is almost always performed as part of
modified radical mastectomy
b
Table 2.5 (continued)
2 Breast Surgery

22
skin flap repair. Arm lymphedema can be temporary or permanent varying widely
in the literature from 3 % to 80 %. The incidence, as well as the severity, usually
increases with the number of lymph nodes removed. Other risk factors for lymph-
edema include older age, obesity, postoperative infection, and axillary radiation. If
lymphedema is recognized early and treated promptly, the development of chronic,
severe lymphedema may be prevented. Early treatment involves good skin care,
nighttime elevation, fitted compression garments, avoiding procedures on the arm,
and manual lymph evacuation.
Axillary vein thrombosis may occur at the time of surgery or postoperatively.
It may contribute to arm swelling and discomfort. Acute thrombectomy may be
useful. Axillary vein or artery injury should be repaired using standard vascu-
lar surgery techniques. Proximal and distal control of the injured vessel must be
obtained. Vein narrowing of >50 % should be relieved with a vein patch. The bra-
chial plexus injury may result from stretch and positional retraction overhead for
a prolonged period or from high dissection above the axillary vein. Microsurgical
nerve repair may be required. Stretch and strain injuries usually resolve with time
and physical therapy. Long-term brachial plexus injuries are rare, but devastating.
Injury to the long thoracic nerve to serratus anterior muscle results in a winged
scapula and shoulder pain. Physical therapy can improve the condition somewhat.
Pneumothorax is very rare, but potentially fatal.
Angiosarcoma of the upper extremity, known as Stewart-Treves syndrome and
usually associated with postoperative radiation, is very rare, but may develop many
years after modified radical mastectomy. It is fatal if not recognized and treated early.
Duct and Nipple Surgery (Microdochectomy and Central Duct
Excision [Hadfields Procedure])
Description
General anesthesia is often used, but local anesthesia with IV sedation is some-
times preferred. The aims are to diagnose or exclude malignancy or control
• GA risk
• Wound infection
• Further surgery
R. Rainsbury et al.

23
discharge. Microdochectomy is used for a discharging duct that can be identi-
fied, cannulated, and excised. If available, ductoscopy can be used to visualize the
lumen of the duct. The aim is to remove a localized duct system, leaving the oth-
ers intact, to obtain a pathological diagnosis. Central duct excision is indicated
for patients with unilateral bloody nipple discharge, particularly from multiple
ducts, or when identification of the discharging duct or cannulation is not feasible.
Most bilateral and non-bloody nipple discharges are caused by pregnancy, lacta-
tion, pituitary tumors, or most commonly benign ectasia/fibrocystic changes. The
majority of bloody nipple discharge represents either a papilloma or duct ectasia.
Most are benign, but malignancy must be ruled out for bloody or copious unilateral
discharge. Radial or peri-areolar incisions can be used for microdochectomy or
central duct excisions. Preoperative mammogram and ultrasound should be per-
formed to detect abnormalities that may require separate consideration. The lesion
in question is usually within 1–3 cm of the nipple, in the infundibular subareolar
part of the duct. Hemostasis is achieved with electrocautery. The incision should
then be closed using absorbable deep dermal interrupted sutures and a subcuticular
skin suture.
Anatomical Points
The ductal system of the breast has complex arborization. Some 10–12 individual
ducts open onto the nipple. Occasionally, a duct may open at the side or base of the
nipple or even within the areola. The ducts do not travel only in a radial direction,
but often branch and overlap adjacent ducts. If possible, it is important to properly
identify the duct in question and ensure that it is excised. A ductoscope or a lacrimal
probe can often help identify the abnormal discharging duct at the time of surgery.
The nipple may be inverted and require eversion, increasing the difficulty of can-
nulation or resection.
Perspective
See Table 2.6. Complications are not usually severe or frequent, however, some
can occur. Most cases of bloody nipple discharge are caused by benign intraductal
papillomas. Carcinoma is the cause of bloody nipple discharge in approximately
5–10 % of cases. Accurate identification of the discharging duct is important for
microdochectomy. The discharging duct should be checked, noted, and marked pre-
operatively by the operating surgeon. Occasionally the duct may not produce any
blood on the day of the operation. Blind resection should not be attempted, rather
the operation should be delayed until the blood can be expressed. Central duct exci-
sion is also a possible alternative to microdochectomy in this situation. Adverse
scarring is not a common problem because the incision is often made at the edge of
the nipple-areolar complex.
Postoperative pain is usually easily controlled with oral analgesics. Chronic pain
is a rare complication. Some patients develop nipple pain and sensitivity that can
2 Breast Surgery

24
last for several months. Loss of nipple sensation can occur as a consequence of this
operation. The sensory nerves to the nipple may be transected or stretched. The
nipple may retract postoperatively in some cases. Nipple retraction may be avoided
by placing a purse-string suture posterior to the nipple to reconstruct normal projec-
tion. Even with only a full-thickness flap and no tissue posterior to the nipple, devas-
cularization is rare, but it can result in nipple necrosis (Fig. 2.5). The patient may
need reconstructive surgery to recreate a nipple. If the majority of ducts are removed
in the central duct excision, breastfeeding may be impeded; however, this is rare if
only one or two ducts are removed. Hematoma formation can usually be avoided
with meticulous hemostasis. Rarely will a hematoma require operative drainage.
Table 2.6 Microdochectomy or central subareolar duct excision (Hadfields procedure) estimated
frequency of complications, risks, and consequences
Infection 1–5 %
Small 5–20 %
Inability to cannulate/locate the discharging ducta
1–5 %
Wound scarringa
Skin scarring (poor cosmesis, dimpling/deformation of the skin) 1–5 %
Deep scar formation (palpable breast lump) 5–20 %
Failed/incomplete excision of lesion (procedure dependenta
) 1–5 %
20–50 %
)
Paresthesia (sensory nerve injury, breast, nipple) 0.1–1 %
Skin flap problems (nipple necrosis/areolar)a
0.1–1 %
Nipple pain 0.1–1 %
Nipple retraction/flatteninga
0.1–1 %
Sexual problems 0.1–1 %
Mammary fistula 0.1–1 %
Discharging sinus/persistent dischargea
0.1–1 %
Inability to breastfeed from the operated breasta, b
Microdochectomy 0.1–1 %
Central duct excision 100 %
Pain/tenderness
Chronic (>12 weeks) 0.1–1 %
Bruising 50–80 %
Drain tube(s)a
1–5 %
Note: The pathology of the lesion will largely determine the likelihood of complete clearance and
necessity for further procedures or treatment. Technical issues may determine accuracy of localiza-
tion and biopsy
a
b
Breastfeeding from the unaffected breast if normal prior to surgery will usually remain normal
R. Rainsbury et al.

25
Most resolve without further intervention. Prophylactic antibiotics are sometimes
used. Infection may infrequently occur, but abscess formation is very rare.
Major Complications
Although relatively rare, serious complications can occur and patients should be
advised of these. These include nipple necrosis which may be partial or complete,
particularly with central duct excision where devascularization of the nipple-areolar
complex results, sometimes compounded by infection. Reconstructive surgery may
be required. Failure to diagnose and remove the underlying abnormality can occur,
as can subsequent close follow-up. Persistent nipple discharge may result or
recurrent discharge may occur. A repeat ductogram and/or further surgery may be
required. Loss of ability to breastfeed from the operated breast is uncommon with
microdochectomy, but usual with central duct excision. Loss of nipple sensation
and chronic breast pain are potential important long-term major consequences.
Adverse cosmetic results, including nipple retraction and nipple-areolar distor-
tion, may be considered major sequelae by some patients.
Fig. 2.5 Partial nipple
necrosis after breast implant
insertion
• GA risk
• Wound infection
• Nipple necrosis
• Further surgery
2 Breast Surgery

26
Breast Abscess Drainage
Description
General or local anesthetic +/− IV sedation is used. The aim is to drain the pus
from the breast abscess cavity. Most small abscesses can be managed with percu-
taneous aspiration and antibiotics. If symptoms have been present for weeks, the
patient is systemically ill, the abscess is very large, or drainage is incomplete, the
patient is probably best served by formal incision, and drainage. When the patient
is systemically unwell or considerable surrounding cellulitis is present, IV antibi-
otics may be required. If lactating, the breast should be regularly expressed of milk
with a breast pump. The patient can usually still breastfeed using the contralateral
breast.
An incision is made directly over the abscess and drained of pus, irrigated and
a small drain placed, or left open, and the cavity packed if the abscess is large.
Healing often takes 1–2 months and cosmetic deformity is not uncommon.
Anatomical Points
Breast abscesses can occur in any area of the breast. If the abscess occurs at the
circumareolar edge, this condition may represent a periductal fistula especially if
the patient is a smoker. The fistula must be unroofed and curetted to allow heal-
ing. Occasionally, infected sebaceous (epidermoid) cysts or areolar gland (of
Montgomery) cysts may be large and present as abscesses.
Perspective
See Table 2.7. The complications of breast abscess drainage include a chronic
healing wound, recurrent abscess, milk fistula, periductal fistula, systemic
infection, disfiguring scar, and breast deformity. If the wound is closed
over a drain or the skin closes too quickly in an open cavity, it is possible that
the abscess may recur. If it does repeat, incision and drainage are required. If
the abscess is large, the skin may need to be left open. Systemic infection is
rare, except in the immunocompromised host. Appropriate antibiotics should
be selected to cover the most common organisms. Staphylococcus aureus and
streptococcal species are the most common organisms. Non-puerperal abscesses
are most likely to contain anaerobes. Antibiotics of choice include flucloxacil-
lin, cepahalosporins, clindamycin, or vancomycin. Vancomycin is the preferred
antibiotic for penicillin-allergic pregnant women. Milk fistula may occur in a
lactating patient. As long as the patient continues to breastfeed, the fistula may
be slow to heal.
R. Rainsbury et al.

27
Major Complications
Systemic infection is the most serious complication of breast abscess. Fortunately,
it is very rare. When the abscess is evacuated, the pus should be sent for culture and
sensitivity. Antibiotic therapy should be tailored to treat the offending organism.
Scarring and skin dimpling with cosmetic deformity are common complications
that can be minimized by keeping the skin incisions as small as possible and closing
the skin when possible.
Table 2.7 Breast abscess drainage estimated frequency of complications, risks, and consequences
Persistent infection 20–50 %
Systemic infection 1–5 %
Recurrent abscess/failed drainagea
5–20 %
Bruising 5–20 %
Small 5–20 %
) 20–50 %
Tumor underlying (all ages)a
1–5 %
Inability to breastfeed
Temporarily 50–80 %
Permanently 0.1–1 %
Nipple pain 0.1–1 %
Nipple or areolar necrosis 0.1–1 %
Nipple deformity/retraction/ﬂatteninga
0.1–1 %
Sexual problems 0.1–1 %
Mammary ﬁstula 0.1–1 %
Discharging sinus persistent dischargea
0.1–1 %
Pain/tenderness
Chronic (>12 weeks) 0.1–1 %
Wound scarringa
Skin scarring (poor cosmesis; dimpling/deformation of the skin) 50–80 %
Drain tube(s)a
1–5 %
Note: The pathology of the lesion will largely determine the likelihood of complete clearance/
drainage and necessity for further procedures or treatment
a
2 Breast Surgery

28
Nipple Biopsy (Paget’s or Other Disease)
Description
Nipple biopsy is usually performed under local anesthesia, but sedation or general
anesthesia is occasionally used. The aim of the nipple biopsy is to exclude carci-
noma. Paget’s disease is in situ carcinoma of the nipple characterized by erythema,
scaling, or ulceration of the nipple, which is often associated with an underlying
breast carcinoma (95 %). The usual differential diagnosis is eczema. The diagno-
sis is often delayed due to trial of eczema treatments. A full-thickness incisional
or punch biopsy is used. A preoperative mammogram and ultrasound are used to
investigate underlying breast parenchymal pathology. There is division of opinion
over the origin of Paget’s clear cells varying from a direct extension of an underly-
ing in situ or invasive carcinoma to a physically separate focus of in situ carcinoma
arising in the nipple isolated from any underlying carcinoma. It may represent wide
ductal system “field” change. In the majority of cases, the carcinoma, if present, is
located within a few centimeters of the nipple-areolar complex. It can be difficult to
identify the location of the carcinoma and it may be only an in situ carcinoma. An
alternative approach is to take a small amount of underlying breast tissue at the time
of nipple biopsy. If the workup does not demonstrate any radiographic abnormality
and the nipple biopsy demonstrates Paget’s disease, then an MRI can be obtained to
further evaluate the breast parenchyma. If no other lesion can be identified, then the
patient has the option of proceeding with a central lumpectomy in order to attempt
to capture the carcinoma or the patient may want to proceed with a mastectomy
with or without immediate reconstruction. An underlying breast carcinoma may not
be present, so some surgeons adopt an expectant management plan, with regular
imaging, often using several modalities.
• GA risk
• Wound infection
• Chronic discharge
• Abscess Reformation
• Breastfeeding problems
• Further surgery
R. Rainsbury et al.

29
Anatomical Points
Nipple shape can vary considerably dictating the ease and cosmetic results. Some
10–12 individual ducts open onto the nipple. Occasionally, a duct may open at the
side or base of the nipple or even within the areola. The nipple may be inverted and
require eversion, increasing the difficulty of biopsy. Anatomic studies have identi-
fied branches of the lateral cutaneous branch of the fourth intercostal nerve entering
the peri-areolar area most consistently at the lower lateral position (4 o’clock on left
and the 8 o’clock on right breast). Care should be taken to avoid incisions in those
areas, if possible.
Perspective
See Table 2.8. First described in 1874 by Sir James Paget as a “disease of the mam-
mary areola preceding cancer in the mammary gland,” we now understand the Paget
cells to be cancerous cells, even if they are in situ. If a significant part of the nipple
is removed, nipple deformity may result. Rarely, if lactation or discharge occurs,
ductal leakage can occur from ducts misdirected in the postoperative scar tissue. It
is often difficult to make a diagnosis of Paget’s disease and adequate tissue must be
Table 2.8 Nipple biopsy (Paget’s disease) estimated frequency of complications, risks, and
consequences
Dimpling/deformation of the nipple skin 5–20 %
Infection 1–5 %
Bruising 5–20 %
Missed/incomplete excision of lesion (procedure dependent)a
1–5 %
Necessity for further surgery (pathology dependant, re-excision/
completion mastectomy/axillary clearance)a
1–5 %
Paresthesia (sensory nerve injury) 1–5 %
Skin ischemia/necrosisa
1–5 %
Bleeding/hematoma formation 0.1–1 %
Pain/tenderness
Wound scarring 5–20 %
Note: The pathology of the lesion and ability to identify the discharging duct will largely determine
the likelihood of complete clearance and necessity for further procedures or treatment. Technical
issues may determine accuracy of biopsy
a
2 Breast Surgery

30
obtained. Full-thickness biopsy is required. Biopsy of the underlying breast tissue
as well as the suspicious nipple skin is often helpful. If a diagnosis is not secured,
but Paget’s is still suspected, the patient should be followed closely and re-biopsied
if required.
Major Complications
The major complications of nipple biopsy are nipple deformity and infection. The
nature of Paget’s disease makes failure to diagnose not uncommon.
Open nipple biopsy is indicated to rule out Paget’s disease. Paget’s disease, if
identiﬁed, represents a form of nipple involvement by pagetoid cells and an effort
should be made to identify whether an underlying breast carcinoma is present and
the location. Hematoma formation, infection, and paresthesia of the nipple are
uncommon with the nipple biopsy.
Male Breast Surgery
Mastectomy (Modiﬁed Radical Mastectomy)
Description
General anesthesia is usually used; occasionally local anesthesia and IV seda-
tion can be used. Male breast cancer accounts for <0.1 % of all cancers in males
and 1 % of all breast cancers. Risk factors include testicular disease, gynecomas-
tia, increasing age, Jewish ancestry, family history, Klinefelter’s syndrome, and
BRCA-2 genetic mutation. About 4–16 % of all men with breast cancer have the
BRCA-2 mutation. Cancer in the male breast usually presents as a painless sub-
areolar mass, often with skin involvement, nipple retraction, and/or axillary node
involvement. Mammography and U/S can be helpful in distinguishing cancer from
• GA risk
• Wound infection
• Further surgery
R. Rainsbury et al.

31
gynecomastia. Once a diagnosis of cancer has been made, most men undergo modi-
fied radical mastectomy. Sentinel node biopsy may be considered in selected clini-
cally node negative men. An elliptical around the nipple-areolar complex and tumor
mass, with in-continuity axillary dissection, is usually performed (described sepa-
rately). Inferior and superior flaps are raised; neurovascular structures including
the axillary vein, the thoracodorsal vessels and nerve, the long thoracic nerve, and
often, where possible, the intercostobrachial nerve are preserved. Careful hemosta-
sis and suction drains are placed to the chest wall and axilla. Absorbable interrupted
deep dermal sutures followed by a running absorbable monofilament subcuticular
skin suture are used.
Anatomical Points
Breast tissue in males is located in the subareolar area predominantly, being much
more confined than in females. The majority of male breast cancer therefore
occurs close to the areola. Spread to the overlying skin, chest wall, and axillary
nodes is a common feature. Occasionally, a duplicated axillary vein is present.
Variations in the vascular structures of the axilla are uncommon, but care should
be taken to identify the important neurovascular structures during axillary sur-
gery. There are reports of aberrant slips of muscle that span the axilla. They may
be low-lying deltoid fibers or, more commonly, a slip of latissimus extending
anterior to the axillary vein.
Perspective
See Table 2.9. Despite the extent of surgery, major complications are usually not
severe or frequent, and are mostly related to the axillary surgery. Hemorrhage after
mastectomy is usually caused from perforating vessels that retract into the pecto-
ralis muscle and then rebleed when the patient coughs or moves. Seroma is fairly
common and usually occurs within the first postoperative week, after the drains
are removed. Small seromas may resolve, but larger seromas may need aspiration
or the drain replaced. Lymphedema of the arm is a complication of axillary clear-
ance that occurs in 3–80 % of patients who undergo axillary dissection. Injury to
the intercostobrachial nerve is common and results in sensory changes to the upper
inner arm and axilla. Patients complain of numbness and tingling as well as changes
in sweating. The affected area usually decreases in size over time, but never fully
resolves. Injury to the thoracodorsal nerve leads to paralysis of the latissimus dorsi
muscle. The motor deficits include slight weakness in arm adduction and internal
rotation of the shoulder. It is not usually a very disabling injury and most patients
adapt to it well without changes in lifestyle. Injury to the long thoracic nerve leads
to paralysis of the serratus anterior muscle, causing “winging” of the scapula and
shoulder pain. The risk of infection after a mastectomy is minimal and prophylactic
antibiotics are rarely indicated. Wound infection is not very common, but it may
2 Breast Surgery

32
Table 2.9 Modified radical mastectomy (including axillary clearance) estimated frequency of
complications, risks, and consequences (male)
Infection 1–5 %
Seroma formation/large lymphocelea
1–5 %
Need for aspiration (postoperative)a
1–5 %
Nerve injury (shorter term <12 weeks)a
50–80 %
Injury to nerve to lat. dorsi/nerve to serratus anterior 0.1–1 %
Lateral cutaneous nerve of arm or forearm 0.1–1 %
Brachial plexus injury <0.1 %
Neuropraxia/dysesthesia—permanent paina
0.1–1 %
Edema (swelling) of arm/handa
Minor 20–50 %
Severe 1–5 %
Skin flap necrosisb
1–5 %
Arm stiffness 1–5 %
Shoulder problems 5–20 %
Possibility of further treatment (surgery, radiotherapy,
chemotherapy, endocrine therapy)b
50–80 %
Small 0.1–1 %
Axillary vein injury/thrombosis 0.1–1 %
Axillary artery injury (+/− spasm) 0.1–1 %
Dehiscence 0.1–1 %
Edema of chestb
0.1–1 %
Lymphatic fluid leak/sinusa
<0.1 %
Rib osteomyelitisb
<0.1 %
Pneumothoraxb
<0.1 %
Incomplete excision of lesion (procedure dependantb
) 0.1–1 %
Mortality (operative)b
<0.1 %
Pain/tenderness
5–20 %
Small lymphocelea
20–50 %
Bruising >80 %
Axillary fibrous band/cord adhesionsa
1–5 %
Excess axillary skin 50–80 %
Wound scarringb
Skin scarring (poor cosmesis, dimpling/deformation) 1–5 %
R. Rainsbury et al.

33
occur and should be treated promptly with antibiotics. Skin flap necrosis can occur
and is usually caused by making the flaps too thin, diathermy, or trauma to the
skin edges. Pneumothorax is an extremely rare, but serious complication, requir-
ing prompt recognition, arising from needle puncture or dissection in a frail, thin
person. Poor cosmesis, dimpling, skin necrosis, and hypertrophic scarring are usu-
ally less severe, but more frequent complications. There may be some temporary
paresthesia surrounding the incision. Patients often describe it as burning or shoot-
ing pain. Acute postoperative pain is usually controlled with oral pain medication.
Chronic pain is rare.
The major complications of modified radical mastectomy include hemorrhage,
arm lymphedema, thrombosis or injury to axillary vessels, damage to the brachial
plexus, and injury of the long thoracic nerve. Hemorrhage may be intra- or postop-
erative. The latter is recognized by swelling or discoloration of the skin flaps, large
volumes of blood in the drains, or changes in the patient’s vital signs. Hemorrhage
requires a return to the operating room with evacuation of the hematoma and con-
trol of the bleeding vessel. Transfusion is rare, and there are usually no long-term
consequences of postoperative hemorrhage. Large hematomas require surgical
evacuation. Infection and abscess formation may complicate large hematomas,
if left untreated, and can spontaneously drain. Draining of infected hematomas can
lead to open wounds that last for months. Recurrent large seromas or lymphatic
sinuses are rare, but also significant complications. Extensive skin flap necrosis
from ischemia as a result of very thin flaps may require dressings and/or excision
and rotation skin flap repair. Arm lymphedema can be temporary or permanent
varying widely in the literature from 3 % to 80 %. The incidence, as well as
the severity, usually increases with the number of lymph nodes removed. Other
risk factors for lymphedema include older age, obesity, postoperative infection,
and axillary radiation. If lymphedema is recognized early and treated promptly,
the development of chronic, severe lymphedema may be prevented. Early treat-
ment involves good skin care, nighttime elevation, fitted compression garments,
avoiding procedures on the arm, and manual lymph evacuation. Axillary vein
Drain tube(s)b
20–50 %
Note: The pathology of the lesion and chest wall tissue will largely determine the likelihood of
complete clearance and necessity for further procedures or treatment
a
Complications of axillary surgery are included as this is usually performed as part of the
procedure
b
Table 2.9 (continued)
2 Breast Surgery

Surgery risks, complications and consequences

Surgery risks, complications and consequences

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