This document discusses strategies for preventing complications from modified radical mastectomy (MRM) procedures. It emphasizes the importance of thorough planning, execution with contingency adjustments, and strict adherence to aseptic technique. Key steps include carefully planning the incision to ensure adequate margins and avoid dog ears, creating a flap of appropriate thickness, performing a total mastectomy while controlling hemorrhage, and completing a thorough axillary dissection with hemostasis before closure. Drains should be placed laterally and medially as needed to reduce seroma formation post-operatively. With meticulous attention to each stage of the procedure, surgical complications and unwanted outcomes from MRM can be minimized.
Call Girl Bangalore Nandini 7001305949 Independent Escort Service Bangalore
Preventing Surgical Complications of Modified Radical Mastectomy
1. Back to Basics
Preventing Complications – Improving Outcomes
Preventing Complications of Breast Surgery
Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg
September 5, 2013
2. Back to Basics
Preventing Complications – Improving Outcomes
Preventing Surgical Complications of Modified
Radical Mastectomy – Improving Outcomes
How I Usually Do it
Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg
September 5, 2013
3. Preventing Surgical Complications of Modified
Radical Mastectomy – Improving Outcomes
How I Usually Do it
Preventing Surgical Complications to
Improve Outcomes of MRM?
4. Preventing Surgical Complications of Modified
Radical Mastectomy – Improving Outcomes
How I Usually Do it
MRM
Procedure
To remove the whole breast and the ipsilateral
axillary lymph nodes that contain or may contain
cancer
5. Preventing Surgical Complications of Modified
Radical Mastectomy – Improving Outcomes
How I Usually Do it
MRM
Procedure
To remove the whole breast and the ipsilateral
axillary lymph nodes that contain or may contain
cancer
GOOD-EXCELLENT POSTOPERATIVE OUTCOMES
6. Preventing Surgical Complications of Modified
Radical Mastectomy – Improving Outcomes
How I Usually Do it
MRM
Procedure
To remove the whole breast and the ipsilateral
axillary lymph nodes that contain or may contain
cancer
GOOD-EXCELLENT POSTOPERATIVE OUTCOMES?
7. Preventing Surgical Complications of Modified
Radical Mastectomy – Improving Outcomes
How I Usually Do it
MRM
Procedure
To remove the whole breast and the ipsilateral axillary
lymph nodes that contain or may contain cancer
GOOD-EXCELLENT POSTOPERATIVE OUTCOMES?
Complete extirpation
NO surgical complications and unwanted side-effects
(or lowest acceptable rate)
8. Preventing Surgical Complications of Modified
Radical Mastectomy – Improving Outcomes
How I Usually Do it
Good-Excellent Postoperative Outcomes
NO local recurrence
NO surgical complications
(dehiscence, flap necrosis, hematoma, infection,
major axillary vascular and nerve injury)
NO unwanted side-effects
(seroma, dog-ear, ugly scar)
9. Preventing Surgical Complications of Modified
Radical Mastectomy – Improving Outcomes
How I Usually Do it
Good-Excellent Postoperative Outcomes
NO local recurrence
NO surgical complications
(dehiscence, flap necrosis, hematoma, infection,
major axillary vascular and nerve injuries)
NO unwanted side-effects
(seroma, dog-ear, ugly scar)
How do we prevent
these?
10. Preventing Surgical Complications of Modified Radical
Mastectomy – Improving Outcomes
How I Usually Do it
For every intraoperative move made,
there is a risk for surgical complications and
unwanted side effects!
Intraoperative Risk Management
11. Preventing Surgical Complications of Modified
Radical Mastectomy – Improving Outcomes
How I Usually Do it
Good-Excellent Postoperative Outcomes
NO local recurrence
NO surgical complications
(dehiscence, flap necrosis, hematoma, infection,
major axillary vascular and nerve injuries)
NO unwanted side-effects
(seroma, dog-ear, ugly scar)
How do we prevent
these?
Intraoperative Risk
Management
12. Preventing Surgical Complications of Modified
Radical Mastectomy – Improving Outcomes
How I Usually Do it
Good-Excellent Postoperative Outcomes
NO local recurrence
NO surgical complications
(dehiscence, flap necrosis, hematoma, infection,
major axillary vascular and nerve injuries)
NO unwanted side-effects
(seroma, dog-ear, ugly scar)
Intraoperative Risk
Management
Good Planning
Good Execution
Good Contingency
Adjustment during
Execution
13. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Asepsis
Incision
Flap Creation
Total Mastectomy
Axillary Dissection
Drain
Incision Repair
Risks
Local
recurrence
Surgical
complications
Unwanted
side-effects
14. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Asepsis
Incision
Flap Creation
Total Mastectomy
Axillary Dissection
Drain
Incision Repair
Infection
Dehiscence
Local Recurrence
Flap Necrosis
Hematoma
Seroma
Major Axillary Vascular / Nerve Injury
Avoidance
of
Others
Dog-ear Deformity
Ugly Scar
15. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Asepsis Infection
16. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Asepsis Infection
Procedures to eliminate / reduce
microorganisms in operative field
Sterilize an operative field
with a wide boundary
(at least 3 in)
17. Sterilize an operative field with a wide boundary
(at least 3 in)
Supraclavicular
area Subcostal
area
Upper arm
Contralateral
mid-clavicular
line
Posterior
axillary line
18. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Asepsis Infection
Procedures to eliminate / reduce
microorganisms in operative field
Suture drapes
along the posterior axillary line
to avoid contamination of the lateral field
(close to operating table) and
during axillary dissection
19. Suturing of the Drape along the Posterior Axillary Line to
Prevent Contamination in the Lateral Field
20. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Asepsis Infection
Procedures to eliminate / reduce
microorganisms in operative field
Maintain sterility of the operative field
during the entire operation
Avoid contamination of operative field
by unsterilized instruments,
gloves, dirty specimen, etc.
21. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Incision
Tension-Dehiscence
Local Recurrence
Dog-ear Deformity
22. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Incision
Tension-Dehiscence
Local Recurrence
Planning and accurate planning
BEFORE operation / incision! Dog-ear Deformity
23. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Incision Local Recurrence
Adequate margin
At least 2 cm around palpable tumor on the surface
24. Planning an Incision to Get an Adequate Margin
Outline the border of
the mass
Allot at least 2-cm margin around the palpable border
of the mass.
May be more if possible and if needed to have a taut
(but no tension) mastectomy flap closure to avoid
seroma and unsightly bulges.
Not too large to cause tension and dehiscence though.
25. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Incision
Determine the axis/ direction of the elliptical incision that
will best promote primary closure without tension.
Tension-Dehiscence
26. Planning an Incision to Determine Direction of Elliptical Incision
1° Objective: Primary closure without tension
27. Planning an Incision to Determine Direction of Elliptical Incision
1° Objective: Primary closure without tension
28. Planning an Incision to Determine Direction of Elliptical Incision
1° Objective: Primary closure without tension
29. Planning an Incision to Determine Direction of Elliptical Incision
1° Objective: Primary closure without tension
30. Planning an Incision to Determine Direction of Elliptical Incision
1° Objective: Primary closure without tension
4
5
31. Avoid a scar that can be seen when
patient wears a bra!
Planning the Incision
32. Planning an Incision
Avoid placement of the scar
at the upper and mid-sternal
areas (areas known to be
keloid prone).
Place at the lower part.
33. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Incision
Plan out incision to avoid dog-ear deformities!
Dog-ear Deformity
Frequent, particularly in patients with large
body habitus and large breast
Unsightly and source of long-term discomfort!
34. Sliding-suturing
(Devalia Technique)
Devalia H, Chaudhry A, Rainsbury RM, Minakaran N, Banerjee D. An oncoplastic
technique to reduce the formation of lateral 'dog-ears' after mastectomy. Int Semin
Surg Oncol. 2007 Dec 17; 4:29.
Planning an Incision to Avoid Lateral Dog-ear Deformity
35. D-incision with Triangular Advancement
IC Bennett and MA Biggar . A triangular advancement technique to avoid
the dog-ear deformity following mastectomy in large breasted women
Ann R Coll Surg Engl. 2011 October; 93(7): 554–555.
Planning an Incision to Avoid Lateral Dog-ear Deformity
36. Tear-drop shaped incision
Mirza M, S. K., Fortes-Mayer K. and W. M. H. (2003). "Tear-drop incision for
mastectomy to avoid dog-ear deformity." Ann R Coll Surg Engl. 85(2):131.
Planning an Incision to Avoid Lateral Dog-ear Deformity
37. Planning an Incision to Avoid Lateral Dog-ear Deformity
Waisted Teardrop
Rebecca Thomas, Christine Mouat and Burton King. Mastectomy flap design: the
‘waisted teardrop’ and a method to reduce the lateral fold. ANZ J Surg 82 (2012)
329–333.
Initial drawing of
elliptical incision
Retract laterally
medial side and
redraw to make a
teardrop incision
Retract medially lateral
side and redraw to
make a teardrop
incision(broader base)
38. Waisted Teardrop
Rebecca Thomas, Christine Mouat and Burton King. Mastectomy flap
design: the ‘waisted teardrop’ and a method to reduce the lateral fold.
ANZ J Surg 82 (2012) 329–333.
Planning an Incision to Avoid Lateral Dog-ear Deformity
Resultant waisted” teardrop incision
40. Techniques to Avoid Lateral Dog-ear Deformity
Tear-drop / Waisted Teardrop
Y-incision / Fish-tail
Sliding-suturing
Planning preoperatively (standing, lying down, with arms on the side
and extended) and before the incision is the strategy to avoid a dog-
ear deformity!
41. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Incision
Plan out incision to avoid dog-ear deformities!
Dog-ear Deformity
42. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Not TOO thick to include breast tissue
Not TOO thin to cause flap necrosis
Flap Creation Flap Necrosis
Local Recurrence
43. Flap Creation – How I Usually Do It
1-cm of subcutaneous tissue
(subcutaneous tissues only –
pink-whitish tissues stay away)
44. Flap Creation – How I Usually Do It
Control thickness / thinness of flap
45. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Local RecurrenceTotal Mastectomy
Hematoma
Ensure TOTAL mastectomy!
Ensure adequate and secure hemostasis!
46. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Flap not TOO thick to include breast tissue
Be guided by the usual boundaries
of the breast (clavicle, latissimus dorsi,
parasternal, rectus sheath)
Remove part of the pect major if too near
Local RecurrenceTotal Mastectomy
48. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Ligate transected blood vessels ≥ 2 mm
In diameter
Cauterize fully – transected vessels not to be
ligated
Ligate and cauterize blood vessels
right away
Check hemostasis prior to wound closure
Total Mastectomy Hematoma
49. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Promote a taut flap over the chest wall
Ensure ever-functional tube drain
Total Mastectomy Hematoma
50. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Local Recurrence
Hematoma
Axillary Dissection
Major Axillary
Vascular / Nerve
Injury
51. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Remove ALL grossly palpable
masses / nodes
guided by the usual boundaries
of the axilla
Local RecurrenceAxillary Dissection
52. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Avoid injury
Careful dissection when near the areas
Axillary Dissection Major Axillary
Vascular / Nerve
Injury
53. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Adequate and secure hemostasis.
Axillary Dissection Hematoma
54. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Axillary Dissection Hematoma
Ligate transected blood vessels ≥ 2 mm
In diameter
Cauterize fully – transected vessels not to be
ligated
Ligate and cauterize blood vessels
right away
Check hemostasis prior to wound closure
55. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Axillary Dissection Hematoma
Checking hemostasis prior to wound closure
56. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Axillary Dissection Hematoma
Promote a taut flap over the chest wall
Ensure ever-functional tube drain
57. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Drain lateral
Medial as indicated
SeromaDrain
58. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Closed tube suction drain at axillary space
Medial drain indicated
if there is a significant cavity
after laying down of flaps prior to wound repair
Drain removed if output is less than 50 cc
past 24 hours (assumption: tube functional)
SeromaDrain
59. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Incision Repair
Ugly Scar
Dog-ear Deformity
Dehiscence
60. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Incision Repair Dehiscence
Avoid tension
Secure knots
61. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Avoid excessive stitch marks
Railroad tracks
Avoid dog-ear deformity
Incision Repair Ugly Scar
Dog-ear Deformity
65. Preventing Surgical Complications of Modified Radical
Mastectomy – Improving Outcomes
How I Usually Do it
For every intraoperative move made,
there is a risk for surgical complications and
unwanted side effects!
Intraoperative Risk Management
66. Preventing Surgical Complications of Modified Radical Mastectomy –
Improving Outcomes
How I Usually Do it
Procedure
MRM
Outcomes
Evaluation
Planning
Execution with contingency
adjustment
Asepsis
Incision
Flap Creation
Total Mastectomy
Axillary Dissection
Drain
Incision Repair
Infection
Dehiscence
Local Recurrence
Flap Necrosis
Hematoma
Seroma
Major Axillary Vascular / Nerve Injury
Avoidance
of
Others
Dog-ear Deformity
Ugly Scar
67. Preventing Surgical Complications of Modified
Radical Mastectomy – Improving Outcomes
How I Usually Do it
Good-Excellent Postoperative Outcomes
NO local recurrence
NO surgical complications
(dehiscence, flap necrosis, hematoma, infection,
major axillary vascular and nerve injury)
NO unwanted side-effects
(seroma, dog-ear, ugly scar)
68. Preventing Surgical Complications of Modified Radical
Mastectomy – Improving Outcomes
How I Usually Do it
Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg
September 5, 2013
For further reading and copies of my slides:
http://www.slideshare.net/rjoson/mastectomy-morbidities-pghrj08sept11
http://www.slideshare.net/rjoson/preventing-mrm-complications-pghrj13sept5
For feedback and queries:
rjoson2001@yahoo.com
0918-804-03-04 (text me if you like my lecture now)
Facebook / rjoson2001
Notas do Editor
I was assigned this topic for my lecture: Preventing Complications of Breast Surgery. With the extent of breast surgery being very broad, which can range from excision to classical radical mastectomy and with the time alloted to me, if you don’t mind, I will limit my lecture to modified radical mastectomy as this is still the most common operation being done in the Philippines.
Thus, I change the title of my lecture to “Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes. How I Usually Do It.” In my lecture, following the theme of this postgraduate course, I will share with you how I usually do my MRM nowadays with emphasis on preventing complications and therefore, improving outcomes.
Preventing surgical complications to improve outcomes of MRM? What does this statement mean? How do you do it? Or how do I usually do it?
We all know that modified radical mastectomy is a surgical procedure that removes the whole breast and the ipsilateral axillary lymph nodes that contain or may contain cancer.
When we do the MRM procedure, our goal is good-excellent postoperative outcomes.
What are considered good-excellent postoperative outcomes after an MRM?
Good-excellent postoperative outcomes means complete or adequate removal of the whole breast and the ipsilateral axillary lymph nodes that contain or may contain cancer with NO surgical complications and unwanted side-effects as much as possible, if not, with the lowest acceptable frequency such as 1-2%.
More specifically, we are talking of NO local recurrence; NO surgical complications; and NO unwanted side-effects. Examples of surgical complications to avoid are dehiscence; flap necrosis; hematoma; infection; major axillary vascular and nerve injury. Examples of unwanted side-effects are seroma, dog ear deformity, and ugly scar. There are others. For today, I will focus on the items listed.
So how to prevent these complications?
Let me start by saying that for every intraoperative move made by a surgeon, there is always a risk for surgical complications and unwanted side effects. Thus, every surgeon has to do an intraoperative risk management.
What does this intraoperative risk management consist of?
It consists of good planning; good execution and good contingency adjustments during the execution.
There must be good planning on asepsis; incision; flap creation; total mastectomy; axillary dissection; use of drain; and incision repair with good execution and contingency adjustments during execution to avoid the risks of local recurrence; surgical complications; and unwanted side-effects.
As I said, we will focus on these nine risks today.
Let’s start with asepsis. There must be good planning and execution of the plan with contingency adjustment to reduce the risk of postoperative wound infection.
There must be planning and execution with contingency adjustments on procedures to eliminate / reduce microorganisms in the operative field, one of which is to sterilize an operative field with a wide boundary, at least 3 inches.
Assuming this is the planned incision, the areas of prepping should be up to posterior axillary line; upper arm; supraclavicular area; contralateral mid-clavicular line on the contralateral breast; and subcostal area.
Another recommended procedure is to suture drapes along the posterior axillary line to avoid contamination of the lateral field, which is close to the operating table, and during axillary dissection.
Like so.
The other key strategies are to maintain sterility of the operative field during the entire operation and to avoid its contamination from whatever source, such as unsterilized instruments, gloves, dirty specimens, etc.
For the incision, there must be good planning and execution of the plan with contingency adjustment to reduce the risk of local recurrence; tension during closure which may lead to dehiscence; and dog-ear deformity, particularly, on the axillary area.
There must be planning of the incision and accurate planning before the operation and before the incision.
The first thing to do to lessen the risk of local recurrence is to have an adequate margin with at least 2 cm around the palpable tumor on the surface.
This is how I usually do it. I outline the border of the mass through inspection and palpation. Then, I allot at least 2-cm margin around the palpable border of the mass. Later on, I can adjust my margin – it can be more than 2 cm if possible and if needed, to have a taut (but no tension) mastectomy flap closure to avoid seroma and unsightly bulges.
The strategy that I usually use is to determine the long axis or direction of the elliptical incision that will best promote primary closure of the resultant mastectomy wound without tension.
I usually do these simple maneuvers to determine whether the two edges of the flap of an elliptical incision will reach each other during wound closure without undue tension – press and push firmly the assumed resulting edges of the flaps toward each other with an assistant’s finger marking an imaginary point or line where the flaps will reach and meet . These manuevers are done for all possible directions of the long axis of the elliptical incision, namely, transverse, oblique, and vertical. The maneuvers are being done to determine the direction of the elliptical incision that can facilitate primary closure without tension. In this slide, the manuevers are being done to see whether a transverse incision can facilitate primary closure without tension. Note the nipple-areola complex is considered in the planning.
In this slide, the manuevers are being done to see whether a vertical elliptical incision can facilitate primary closure without tension. In this slide, the vertical direction of the elliptical incision cannot be done as the nipple-areola complex is far away.
After the maneuvers, this particular elliptical incision was decided upon as this direction of the long axis will facilitate primary closure without undue tension.
In this slide, the manuevers are being done again to see whether the decided elliptical incision can really facilitate primary closure without tension. With such maneuvers, one can be confident there will be no problem of primary closure and no tension and therefore, prevent or minimize risk of dehiscence related to tension.
If there are several directions that can be used to promote primary closure, factor in cosmetic goal to make the final choice. The final elliptical incision does not have to be completely transverse, oblique, or vertical in a straight line. There may be curvings at both ends of the elliptical incision, as illustrated in No. 3 planned incision here. The lateral curving is done for cosmetic reasons, such as avoiding a scar that can be seen when patient wears a bra; to avoid risk of keloid in the sternal area; and to avoid lateral dog-ear deformity.
such as avoiding a scar that can be seen when patient wears a bra (put the incision-line in the lower part of the sternum).
to avoid risk of keloid in the sternal area (avoid placement of the scar at the upper and mid-sternal areas as these ae areas known to be keloid prone). Place at the lower part.
The other consideration in the incision planning is to avoid lateral dog-ear deformity. This is frequently seen in obese patients and those with large breasts. This is not only unsightly but a source of long-term discomfort.
There are several techniques that are being proposed to avoid a lateral dog-ear deformity. Shown here is the sliding-suturing technique in which the upper flap is divided into 2 parts and lower flap into 3 parts. The distal 1/3 of the lower flap is slided and sutured to to upper ½ of the upper flap.
Another technique is the D-incision with triangular advancement meaning initially draw a D-incision as shown and then make a triangular extension of the incision and then suture the outer upper flap to the outlined triangular area.
Another technique is a so-called tear-drop shaped incision with the broader bottom of the tear-drop at the lateral side.
Still another technique is the so-called waisted teardrop incision. The first step is to draw an initial elliptical incision that ensure adequate margin. Then, retract laterally the medial side and redraw to make a teardrop incision (pointed tip at the medial side). Then retract medially the lateral side and redraw to place the broader base of the teardrop incision.
The modifications will result in a waisted teardrop incision or a teardrop with a waist. Then wound repair without lateral dog-ear deformity.
Still another technique is an incision which entails trimming of skin that results in a Y-incision or fish-tail incision.
Thus, there are various techniques that one can choose from to avoid a lateral dog-ear deformity. I have tried all of them. At the moment, my stand is that there is no so-called one and only one-best technique. It will depend on the patient’s body stature, the location and size of the breast cancer; etc. What I can say is planning preoperatively (in standing, lying down, with arms on the side and extended) and before the incision at the operating table is the strategy to avoid a lateral dog-ear deformity. Choose from whichever technique that are being proposed with some adjustment if needed to avoid the dog-ear deformity as much as possible.
Always have in mind this target - no or minimal lateral dog-ear deformity – like those seen in this slide.
Let us now go to flap creation. There must be planning and execution with contingency adjustments on flap creation to prevent flap necrosis and local recurrence. The principle to follow is NOT too thick to include breast tissue to lessen the risk for local recurrence and NOT too thin to cause flap necrosis.
What I usually do are the following: I make sure there is about 1-cm layer of subcutaneous tissue in the flap and I stay only at the layer of the yellow subcutaneous tissue – I stay away from pinkish and whitish tissues which I consider are breast tissues.
I usually use my fingers, not clamps, when I establish the flaps, as I have better control of the thickness or thinness of the flap.
Let us now go to total mastectomy. There must be planning and execution with contingency adjustments on total mastectomy to prevent local recurrence and hematoma. The strategies to follow are to ensure total removal of the breast to minimize the risk of local recurrence and adequate and secure hemostasis to minimize the risk of bleeding and hematoma.
To minimize the risk of local recurrence during mastectomy, I am guided by these principles: 1) I ensure my flap is not too thick to include breast tissue (I am guided by the color of the tissue I am cutting when I am establishing the flap – I stay only the layer of the yellow subcutaneous tissue – I stay away from pinkish and whitish tissues which I consider are breast tissues); 2) I am guided by the usual boundaries of the breast (clavicle; latissimus dorsi; parasternal line; and rectus sheath); and 3) I remove part of the pectoralis muscle or other underlying tissue if the breast cancer mass is too near it.
Like so.
To minimize the risk of postoperative bleeding and hematoma, I am guided by these principles: 1 ) Ligate transected blood vessels ≥ 2mm in diameter; 2) Cauterize fully transected vessels which will not be ligated; 3) Ligate and cauterize transected blood vessels right away; 4) Checking of hemostasis prior to wound closure;
Promoting a taut flap over the chest wall and ensuring ever-functional tube drain or drains.
In the axillary dissection, there must be planning and execution with contingency adjustments to prevent local recurrence, hematoma, and injury to major axillary vascular and nerve.
The strategy to minimize the risk of local recurrence is to remove all palpable masses or nodes in the axilla guided by the usual boundaries of the axilla.
The strategy to minimize the risk of injury to the major axillary vessels and nerves is careful dissection when near the usual location of these structures.
The strategy to minimize the risk of bleeding and hematoma is adequate and secure hemostasis.
To minimize the risk of postoperative bleeding and hematoma, I am guided by these principles: 1 ) Ligate transected blood vessels ≥ 2mm in diameter; 2) Cauterize fully transected vessels which will not be ligated; 3) Ligate and cauterize transected blood vessels right away; 4) Checking of hemostasis prior to wound closure.
Procedures that I usually use in checking hemostasis prior to wound closure consist of directly looking for bleeding in the whole operative field and using a maneuver of pouring sterile water into the axillary space to facilitate detection of bleeding, if present. There will be red staining of the water if there is bleeding.
Promoting a taut flap over the chest wall and axilla; and also ensuring an ever-functional tube drain or drains.
As to the use of drain, consider its use to prevent seroma formation. I usually use drain on the axilla. I use a drain in the parasternal area only there is a big dead space that I cannot obliterate.
Thus, the principles that I follow are: 1) closed tube suction drain at the axillary space; 2) medial drain is indicated if there is a significant cavity after laying down the flaps prior to wound repair; and 3) drain/s are removed if the output is less than 50 cc during the past 24 hours.
As to the repair of the mastectomy wound, there must be planning and execution with contingency adjustments to minimize risk of a dehiscence, an ugly scar and dog-ear deformity.
Avoiding tension and providing well-secured knots are the two key strategies in avoiding dehiscence. Tension-avoidance is considered early on in the phase of incision planning.
To prevent ugly scar, avoid excessive stitch marks which may resemble railroad tracks. Avoid dog-ear deformity.
A close-up of an ugly scar with plenty of stitch marks and dog-ear deformity. Avoid this kind of an outcome.
What I usually do, I usually use embedded absorbable sutures. I put attention in avoiding dog-ears like this.
Always end with a wound repair that is appreciated as beautiful, not ugly, such as this, taut, no dog-ears, with minimal stitch mark.
I am done with sharing with you what I usually do to prevent surgical complications of MRM thereby improving outcomes. In closing, if I may, my general take-home messages for you will be, one, for every intraoperative move made by a surgeon, by us, by you, always remember there is always a risk for surgical complications and unwanted side effects. Thus, all of us have to do an intraoperative risk management.
As I said, we will focus on these nine risks today.
If you follow such an approach, I assure you (based on my experience), you will produce good-excellent postoperative outcomes in your modified radical mastectomy in terms NO or minimal local recurrence; NO or minimal surgical complications; and NO or minimal unwanted side-effects.
On that note, I end my presentation. I hope I have shared things that you like. For further reading and copies of my slides, you may visit these sites which contain the lecture that I made in 2008 with focus on seroma, bleeding, and infection. For queries and feedback, you may email me; you can text me; or interact with me in Facebook. Thank you.