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, technique,
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 dissection
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
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 benefi ts
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 consequences
from breast surgery might be achieved
by:
• Good explanation of the risks, aims,
benefi ts, 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 signifi cantly reduce risk of
complications or aid early detection, prompt intervention, and
cost.
2 Breast Surgery
With these factors and
facts in mind, the information given in this chapter must
be appropriately and
discernibly interpreted and used.
Important Note
It should be emphasized
that the risks and frequencies that are given here
represent derived fi
gures . These fi gures are best estimates of relative frequencies
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 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.
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