eMentorSurgery

Dear students, This is only for your revision and NOT A FULL TEXT.

Breast

•       Secondary sexual feature

•      Nutritionfor the neonate

Anatomy

•       Areola

•       Nipple

•       Adipose tissue

•       Fibrous connective tissue

•       Epithelial secretory tissue

•       15 – 20  lobules

•       Lactiferous  ducts

Within the superficialfascia

Anterior to the upper thorax

Extent

n  2nd to 6th ribs vertically

n  Sternal Edge to

                    mid axillary line

Nipple

n Covered by hairless skin

n 4th intercostal space

n Colour varies

n Lactiferous ducts open (15 – 20)

Areola

n Around the nipple

n  Colour varies

n  Tubercles of Montgomery

Post Natal Development

At Puberty – Phase

 I           :    Elevation of the nipple

 II          :     Glandular subareolar tissue

                     Nipple & breast projecting from                   chest wall as a single mass     

III         Pigmentation of areola

               breast  tissue increases

IV   :Areola & Nipple form a

         secondary mass

V           :Smooth contour of the breast

n Mammary line

       Axilla to inguinal region

n Accessory breast tissue (polythelia)

       Thoracic region       90

  Axilla                      05

  Abdomen               05

Arteries

Axillary

n Internal Thoracic

n Thoraco acromial

       (Pectoral branches)

n Lateral Thoracic

n Posterior intercoastal artery

Venous drainage

Follows the arteries

Internal Thoracic and  axillary veins

Lymphatic drainage

•       Axillary nodes 75%

•       Internal mammary

Lateral-axillary vein

Anterior-lateral thoracic

Posterior-subscapular

Central-fat

Interpectoral- betweenpectoralis

Apical

Produces Milk

n Volume       : 1100ml/day

                             (double for twins)      

n Water          :88%

n Lactose : 7%

n Fat        :4%

n Protein : 1%

Investigations

•       Mammography

•       Ultrasound

Biopsy

Cytology

Nipple Discharge

1. Serous         : Simple cyst

2. Greenish     : Fibroadenosis

3. Yellowish    : Abscess

4.Bloody            : Duct papilloma

                                  : Duct Ca.

5.Milky              : Galactocoele

6.Paste like : Duct ectasia

Benign lesions

Ø Cystic

Ø   Solid

Cystic

Ø  Inflammatory

             Abscess/Antibioma

Ø   Non inflammatory

        * Neoplastic

              Cystosarcoma

        * Non neoplastic

            Galactocele

            Firbro adenosis

Solid

Ø Fat necrosis

Ø  Fibro adenoma

Breast Abscess:

•     Lactating mother

•      Staph. aureus

•      Breast lump

•      Painful / tender

•      Inflammed

•      Incision & drainage

Galactocele

Ø Retention cyst

Ø  During lactation

Ø    ? Calcification

Ø    Excision

Fibroadenosis

Ø Defect in normal       development and involution(ANDI-Aberrationin Normal Development and Involution )

Ø Fibrosis, adenosi and cystformation 

Ø Pain-cyclical

Ø  Diffuse nodularity

keep change its location in breast

Ø  F N A C in elders

Ø  Breast support

Ø  ? Surgery

Benign Cyst/s

Ø Lobular involution

       (Including microcysts,

        apocrine changes,

        fibrosis and adenosis)

Ø    Pain

Ø    Discrete lumps

Ø    Excision

Fat Necrosis

§      Older Women

§         H/O trauma   

§         Breast Mass

§         Non tender, localised

§         Skin Retraction

§      X-ray Abnormality

§         Exision of mass

Fibro adenoma..(nowincluded in ANDI)

Mouse in the Breast

§         From a single lobale

               (Not a single cell)

§        Hormonal dependency

§        Lactate during pregnancy

§        Involute in

          perimenopausal period

Types

q                      Common

q                         Giant > 5cms

q                         Juvenile

q                         Phylloides

q                         Fine needle aspiration

q                        Ultrasonography

q                        Mammography

Observation

Removal

Excisional Biopsy:

Ø 4 cms size

Ø  Doubtful

        diagnosis

Cystosarcoma Phylloides

v                      Phyllus– Leaf like

v                      Tumourcells –  Branching

v                      Nota sarcoma –

        Intracanalicular 

                 fibroadenoma

•     Rapid growth

•      Varying consistancy

•      Moble mass

•      Inflammatory signs

•      No palpable nodes

Ø Excision

Ø   Simple

        mastectomy

Papilloma:

Ø Nipple discharge,

      blood stained

Ø   Breast Lump

Ø   Aspiration Cytology

Ø   Excision of the mass(Mirodochecectomy)

Duct Ectasia:

Ø      Ductal involution

Ø   Dilatation with age

Ø   Nipple discharge

Ø   Nipple retraction

Ø   No Inflammation

Ø   Breast Lump

 -------------------------------------------------------------------------------------------------------------------

SURGERY ON BREAST

Operations on Breast

Drainage of Abscess

Excision of Lump

Surgery for Ca. Breast

            Modified Radical Mastectomy

            Simple Mastectomy -commonly practised now

Drainage of Abscess

Indication :

            AcutePyogenic Abscess

Anaesthesia 

            GeneralAnaesthesia

Incision 

            AlongLanger’s Lines

                  -Curvedin a Circular Shape

                  - MostDependent Area

 Deepen the Incision

Drain the Pus

Break the Loculi

Keep a Drain

Post Operative

            Antibiotics

            Analgesics

Excision of Lump

Indications

            Fibroadenoma

           Fibroadenosis ?    If patient requires

            Cyst in the Breast ?    Reccurent cyst after multiple aspirations and cytology

            ChronicAbscess         (Antibioma)

            Early Carcinoma Breast ?   Clinicaly vague in diagnosis

 Anaesthesia

            General  or Local

            Incisions

                        Circum-Areolar

                        Circular Incision         (Langer’sLines)

                        Submammary            (Gaillard– Thomas )

 Excision of Lump

Excise the Lump Compltely

With a Margin of Healthy Tissue

Cavity - Drain Kept

Skin Sutured

Gynaecomastia

Treatment

            Excision

Anaesthesia

            General or Local Anaesthesia

Incision   (Depends on size )

            Circumareolar

            Submammary

Carcinoma Breast

Modified Radical Mastectomy

Simple Mastectomy

Radical Mastectomy  First Described By-William Halstead-(John Hopskins Medical School)

 WLE-Wide Local Excision

Radical Mastectomy -No longer done

Structures Removed

Breast along with Nipple & Areola

Tumour in the Breast

Pectoralis Major & Minor Muscles

Axillary Fat, Fascia & Lymph Nodes

May Require Skin Grafting

Disadvantages

            Loss of Anterior Axillary Fold

            Skin grafting doesn’t take well

            RadiationDamage was More

            Cosmetically NOT acceptable

            Psychologically Damaging

Why Muscles removed?

            Facilitate Axillary Dissection

Modified Radical Mastectomy

Advantages 

Preserving Pectoralis Major

            Preserves Ant Axillary Fold

            Skin Graft takes up Better

            Radiation Damage is less

Now-a-days Standard Operation for Carcinoma Breast

Radical mastectomy NO LONGER DONE

Modified Radical Mastectomy

Incision

            Stewart’sIncision

            HorizontalElliptical Incision

            IncludePrevios Biopsy Site

Structures Preserved

Perctoralis Major Muscle

Long Thoracic Nerve of Bell

Thoracodorsal Nerve

Axillary Vein

Complications

Flap Necrosis

Haematoma under the flaps

Lymphoedema of Arm

Simple Mastectomy

Structures Removed

            Breastwith Nipple & Areola

            Tumourin the Breast

            PectoralFascia

Anaesthesia , Position &

Incision  all sameas in Patey’s Mastectomy

Simple Mastectomy

Indications

            AdvancedCarcinoma Breast -Palliative

            RecurrentPhyllodes Tumour