Chapter 64

Modified radical mastectomy (MRM) involves complete removal of the breast along with the overlying skin and all axillary contents. It has been, and continues to be, a critical component of breast cancer surgery. Although partial mastectomy followed by radiation therapy is an accepted form of therapy, recent studies indicate that the rates of mastectomy in the United States are actually rising.1 It is therefore critical for the practicing surgeon to be familiar with the surgical techniques available for performing mastectomy and reducing postoperative complications.

This chapter describes the performance of total mastectomy using Bovie electrocautery (Bovie Medical Corp; St. Petersburg, Florida), tumescent techniques, and harmonic dissection.

For performance of MRM, patients are placed in a supine position with the ipsilateral arm extended. The patient is shifted to a position as close to the edge of the operating table as safe to facilitate access and visualization. A small roll, typically either a rolled-up operative towel or sheet, can be placed longitudinally just posterior, and medial to, the latissimus muscle. In heavy patients, this can assist in palpating and dissecting the medial aspect of the latissimus muscle. Additional blankets should be placed under the extended arm to ensure the shoulder is at a level, neutral position rather than falling posteriorly. The arm should be prepped circumferentially and draped into the field with either a surgical stockinette or towels, which can be wrapped around the arm. A 6- to 8-cm length of the upper arm and the axillary area remains exposed. This ensures mobility of the arm if needed for access to the axilla and minimizes exposed skin. The surgeon should stand inferior to the extended arm. The assistant can stand either superior to the arm or on the contralateral side.

The incision for an MRM should be oriented in a fashion to remove skin overlying the tumor, and, if reconstruction is not planned, a large enough skin ellipse should be removed to allow for a flat chest wall at closure. The avoidance of skin flap redundancy reduces seroma formation and skin edge necrosis. Longer skin flaps will have more complications related to inadequate blood supply. Generally, an elliptical incision incorporating the nipple areolar complex is appropriate (Fig. 64-1). If a prior needle or surgical biopsy has been performed, the biopsy site should be encompassed within the skin ellipse. The incision should include 1.0- to 2.0-cm margins away from the tumor or the previous biopsy incision. For a very superficial tumor, it is prudent to take a wider skin margin to avoid a positive anterior soft tissue margin. The flaps are elevated superiorly to the clavicle and lateral deltopectoral groove, medially to the sternal border, laterally to the latissimus dorsi muscle, and inferiorly to the upper edge of the rectus sheath (Fig. 64-2). The breast in an MRM should be removed en bloc with the axillary contents. The incision should extend far enough laterally to allow ...

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