Alternatives to subcutaneous mastectomy.

It is our belief that subcutaneous mastectomy often leads to complications, with poor results. In addition, because a considerable amount of breast tissue may be left behind, its value as a prophylactic operation must be questioned. Two alternatives are presented. In our experience, these lead to fewer complications with a more thorough removal of the mammary gland, and achieve a better appearance. The alternatives are (1) simple mastectomy with secondary reconstruction; (2) the type of mastectomy described by Spira--with primary reconstruction using a subpectoral silicone prosthesis covered by muscle and an inferiorly-based dermal flap.     

An improved technique for immediate retropectoral reconstruction after subcutaneous mastectomy

Subcutaneous mastectomy is becoming an operation of choice in certain cases of premalignant and other breast pathology. We describe a technique for simultaneous subcutaneous mastectomy and retropectoral implantation of a silicone prosthesis. Gentle blunt prepectoral, retromammary dissection is performed through an axillary incision as far inferiorly as the inframammary fold, where a fibrous bridge between the anterior surface of the pectoralis major muscle and the skin prevents dissection any lower. Through the same incision, the retropectoral space is dissected to about 5 cm below the inframammary fold. A second incision is made in the inframammary fold to join the retromammary plane of the first dissection. The gland is then dissected subcutaneously and removed through the inframammary incision. A silicone implant is introduced retropectorally through the axillary incision, thus avoiding splitting the pectoralis major. Satisfactory results have been obtained in 23 bilateral and 14 unilateral cases; it is important that the dissection be performed carefully in order to prevent the implant from riding up too high in its musculoaponeurotic sling.     

Apple coring the nipple in subcutaneous mastectomy

A simple technique is described for removing the ductal tissue from the nipple in a subcutaneous mastectomy. We believe that complete removal of all the ductal tissue is desirable in this operation, and that it will also decrease the incidence of subsequent infection. The operative technique, the problems, the advantages, and the disadvantages of the procedure are described.     

Biological basis for management of benign disease of the breast. The case against subcutaneous mastectomy.

The biology of breast disease abnormalities which are primarily the result of hormonal imbalance, and the action of hormones upon breast tissue are discussed. An understanding of the basic biological principles makes it possible to manage these patients more accurately. An accurate diagnosis is necessary to predict what changes will occur with the progression of time. Our reservations about subcutaneous mastectomy are stated.     

Conservative management in full-thickness nipple-areolar necrosis after subcutaneous mastectomy

Nipple-areolar necrosis is a known and expected complication in a small percentage of patients undergoing subcutaneous mastectomy, especially with concomitant mastopexy or in smokers. Impending ischemia or congestion of the areola can often be ameliorated by simple maneuvers such as suture release. When full-thickness necrosis occurs, conservative management with essential debridement, dressings, and careful wound hygiene alone will often yield a surprisingly good result, requiring little or no revisional surgery.     

The incidence of obscure carcinoma in subcutaneous mastectomy. Results of a national survey.

A national survey of plastic surgeons has been conducted to determinr the incidence of occult breat carcinoma in patients having a subcutaneous mastectomy. The results are reported herein. We believe subcutaneous mastectomy is the most effective prophylactic procedure presently available that is acceptable to women who have a high risk of developing breast cancer.     

Consent for mastectomy.

The value of a system for reducing the number of women with breast lumps who consent unnecessarily to mastectomy was assessed. Sixty-one patients with breast lumps were divided preoperatively into three groups with benign, doubtful, and malignant lumps according to clinical, mammographic and ultrasound criteria. On the basis of these criteria written consent was requested from 29 patients for mastectomy and from 32 for only excision of the lump. Fourteen of the 29 patients who gave consent for mastectomy had carcinomas, and none of the 32 patients consenting to only lump excision. In an attempt to improve further on these results the same 61 patients were analysed retrospectively. Criteria based on age and the results of clinical examination and mammography were devised. By using these criteria only 19 women would have had to give consent for mastectomy. This new policy, which was devised to spare many women the stress of consenting unnecessarily to mastectomy, requires to be tested further in a much larger series of patients.