Female Breast Surgery

Excisional Breast Biopsy (Lumpectomy)

Description

Excisional biopsy may be performed with general anesthesia or under local anesthesia

with or without IV sedation. Excisional breast biopsy is removal of an abnormality

in the breast typically for diagnosis. The aim of the surgery is to determine

the nature of the mass and to rule out carcinoma. The lump may be small or large;

however, the nature and breast size are important factors in determining risk of

complications. A non-palpable mass will usually require a form of localization (see

next case). Preoperative workup includes mammogram (especially in women aged

>30–40 years as tumor may be obscured by the density of younger breast tissue) and

ultrasound (for assessing solid, cystic, or malignant characteristics). A diagnostic

fi ne- or core-needle biopsy is usually performed prior to excisional biopsy, under

MMG or U/S guidance if required. Incisional biopsy for diagnosis may be included

under this risk profi le; however, excisional biopsy aims to remove the entire lesion,

often with a “cuff” of normal tissue. The incision chosen may be peri-areolar,

horizontal, or even radial according to the location and desired cosmesis. Dissection

usually aims to excise a margin of normal tissue around the lesion, often including

pectoral fascia. Electrocautery, and deep, absorbable suture closure, is used

for hemostasis, often avoiding wound drains. Marking sutures are usually used to

orientate the specimen to defi ne pathological margins.

Anatomical Points

The anatomical base of the breast extends from the inferior clavicle to the inframammary

fold and from the lateral sternum into the axilla. Occasionally, islands

of breast tissue exist in the axilla, isolated from the axillary tail. The nipple-areolar

complex and main breast mass may vary considerably between individuals, with

age and posture. A breast mass can be located anywhere within the breast. The size

and nature of the mass and breast essentially determines the placement and type of

incision, surgical result, and cosmesis. The possibility of mastectomy or further surgery

is often a consideration in preoperative placement of incision. Care should be

taken to avoid downward repositioning of the nipple with large excisions of lower

pole breast tissue. This deformity may be avoided by mobilizing nearby normal

breast tissue into the area of the defect.

Perspective

See Table 2.1 . Hematoma is an uncommon, but signifi cant, complication. Rarely,

operative drainage is required. The risk of infection after an excisional breast biopsy

is minimal and preoperative antibiotics are rarely used. Poor cosmesis, dimpling,

scarring, and skin necrosis can occur after excisional biopsy. Removing as little

tissue as possible (especially subcutaneous fat, where possible) improves cosmetic

outcome. Often after surgery the patient perceives that the mass is still present. This

is related to healing scar or seroma formation. This postoperative mass may be palpable

for up to 6 months postoperatively while the scar is remodeling. There is often

some temporary paresthesia over the incision. Many patients describe it as burning

or shooting pain. Acute postoperative pain is usually managed well with oral pain

medication and resolves after a couple of days. Chronic pain is rare.

Major Complications

The major risk of excisional biopsy is development of a large postoperative hematoma.

This complication can be avoided by meticulous control of bleeding during surgery.

Most hematomas can be managed nonoperatively. Large hematomas require surgical

evacuation and, if left untreated, may become infected or spontaneously drain. Draining

of infected hematomas can lead to open wounds that persist for months.

Failure to diagnose due to inadequately sampling a palpable lesion, biopsying

the wrong area, or incomplete excision are uncommon with an excisional biopsy,

but may necessitate further surgery. Preoperative verifi cation of the position of the

mass in the awake patient is wise, as some lesions are best felt in one position. It is

important to be sure that the mass can be identifi ed and marked once the patient is

supine and anesthetized. If there is any question preoperatively regarding the palpability

or location of the lesion, an image-guided procedure should be performed

prior to surgery to ensure removal of the suspicious lesion (see below). Dense

fi brous breast tissue can obscure the mass. In most situations the mass should be

removed entirely.

If skin fl aps are raised to remove a superfi cial mass, care should be taken not

to make the fl aps too thin, causing reduced blood supply to the skin, resulting in

necrosis, tissue loss, or skin dimpling. If skin necrosis occurs, the necrotic skin

must be excised if the area is extensive or it may be treated with local wound care

if it is small.

Consent and Risk Reduction

Main Points to Explain

• GA risk

• Wound infection

• Bleeding/hematoma

• Abscess formation

• Cosmetic deformity

• Further surgery