Male Breast Surgery

Mastectomy (Modifi ed Radical Mastectomy)

Description
General anesthesia is usually used; occasionally local anesthesia and IV sedation
can be used. Male breast cancer accounts for <0.1 % of all cancers in males
and 1 % of all breast cancers. Risk factors include testicular disease, gynecomastia,
increasing age, Jewish ancestry, family history, Klinefelter’s syndrome, and
BRCA-2 genetic mutation. About 4–16 % of all men with breast cancer have the
BRCA-2 mutation.
Cancer in the male breast usually presents as a painless subareolar
mass, often with skin involvement, nipple retraction, and/or axillary node
involvement. Mammography and U/S can be helpful in distinguishing cancer from
gynecomastia. Once a diagnosis of cancer has been made, most men undergo modifi
ed radical mastectomy. Sentinel node biopsy may be considered in selected clinically
node negative men. An elliptical around the nipple-areolar complex and tumor
mass, with in-continuity axillary dissection, is usually performed (described separately).
Inferior and superior fl aps are raised; neurovascular structures including
the axillary vein, the thoracodorsal vessels and nerve, the long thoracic nerve, and
often, where possible, the intercostobrachial nerve are preserved. Careful hemostasis
and suction drains are placed to the chest wall and axilla. Absorbable interrupted
deep dermal sutures followed by a running absorbable monofi lament subcuticular
skin suture are used.
Anatomical Points
Breast tissue in males is located in the subareolar area predominantly, being much
more confi ned than in females. The majority of male breast cancer therefore
occurs close to the areola. Spread to the overlying skin, chest wall, and axillary
nodes is a common feature. Occasionally, a duplicated axillary vein is present.
Variations in the vascular structures of the axilla are uncommon, but care should
be taken to identify the important neurovascular structures during axillary surgery.
There are reports of aberrant slips of muscle that span the axilla. They may
be low-lying deltoid fi bers or, more commonly, a slip of latissimus extending
anterior to the axillary vein.
Perspective
Despite the extent of surgery, major complications are usually not
severe or frequent, and are mostly related to the axillary surgery. Hemorrhage after
mastectomy is usually caused from perforating vessels that retract into the pectoralis
muscle and then rebleed when the patient coughs or moves. Seroma is fairly
common and usually occurs within the fi rst postoperative week, after the drains
are removed. Small seromas may resolve, but larger seromas may need aspiration
or the drain replaced. Lymphedema of the arm is a complication of axillary clearance
that occurs in 3–80 % of patients who undergo axillary dissection. Injury to
the intercostobrachial nerve is common and results in sensory changes to the upper
inner arm and axilla. Patients complain of numbness and tingling as well as changes
in sweating. The affected area usually decreases in size over time, but never fully
resolves. Injury to the thoracodorsal nerve leads to paralysis of the latissimus dorsi
muscle. The motor defi cits include slight weakness in arm adduction and internal
rotation of the shoulder. It is not usually a very disabling injury and most patients
adapt to it well without changes in lifestyle. Injury to the long thoracic nerve leads
to paralysis of the serratus anterior muscle, causing “winging” of the scapula and
shoulder pain. The risk of infection after a mastectomy is minimal and prophylactic
antibiotics are rarely indicated. Wound infection is not very common, but it may
occur and should be treated promptly with antibiotics. Skin fl ap necrosis can occur
and is usually caused by making the fl aps too thin, diathermy, or trauma to the
skin edges. Pneumothorax is an extremely rare, but serious complication, requiring
prompt recognition, arising from needle puncture or dissection in a frail, thin
person. Poor cosmesis, dimpling, skin necrosis, and hypertrophic scarring are usually
less severe, but more frequent complications. There may be some temporary
paresthesia surrounding the incision. Patients often describe it as burning or shooting
pain. Acute postoperative pain is usually controlled with oral pain medication.
Chronic pain is rare.
Major Complications/Consequences
The major complications of modifi ed radical mastectomy include hemorrhage,
arm lymphedema, thrombosis or injury to axillary vessels , damage to the brachial
plexus, and injury of the long thoracic nerve. Hemorrhage may be intra- or postoperative.
The latter is recognized by swelling or discoloration of the skin fl aps, large
volumes of blood in the drains, or changes in the patient’s vital signs. Hemorrhage
requires a return to the operating room with evacuation of the hematoma and control
of the bleeding vessel. Transfusion is rare, and there are usually no long-term
consequences of postoperative hemorrhage. Large hematomas require surgical
evacuation . Infection and abscess formation may complicate large hematomas,
if left untreated, and can spontaneously drain. Draining of infected hematomas can
lead to open wounds that last for months. Recurrent large seromas or lymphatic
sinuses are rare, but also signifi cant complications. Extensive skin flap necrosis
from ischemia as a result of very thin fl aps may require dressings and/or excision
and rotation skin fl ap repair. Arm lymphedema can be temporary or permanent
varying widely in the literature from 3 % to 80 %. The incidence, as well as
the severity, usually increases with the number of lymph nodes removed. Other
risk factors for lymphedema include older age, obesity, postoperative infection,
and axillary radiation. If lymphedema is recognized early and treated promptly,
the development of chronic, severe lymphedema may be prevented. Early treatment
involves good skin care, nighttime elevation, fi tted compression garments,
avoiding procedures on the arm, and manual lymph evacuation. Axillary vein
thrombosis may occur at the time of surgery or postoperatively. It may contribute
to arm swelling and discomfort. Acute thrombectomy may be useful. Axillary vein
or artery injury should be repaired using standard vascular surgery techniques.
Vein narrowing of >50 % should be relieved with a vein patch. B rachial plexus
injury may result from stretch and arm retraction overhead for a prolonged period
or from high dissection above the axillary vein. Microsurgical nerve repair may be
required. Stretch and strain injuries usually resolve with time and physical therapy.
Long-term brachial plexus injuries are rare, but devastating. Injury to the long
thoracic nerve to serratus anterior muscle results in a winged scapula and shoulder
pain. Physical therapy can improve the condition somewhat. Pneumothorax
is very rare, but potentially fatal. Angiosarcoma of the upper extremity, known as
Stewart-Treves syndrome usually associated with postoperative radiation, is very
rare, but may develop many years after modifi ed radical mastectomy. It is fatal if
not recognized and treated early.