Page 416 - Medicine and Surgery

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412 Chapter 10: Breast disorders

local therapies such as radiotherapy to the chest wall. Table 10.4 Aberrations of normal development and
Other factors to be taken into consideration when de- involution
ciding on breast reconstruction include the following: Normal process Aberration of normal
Patient preference. development and

The risk of recurrence. If there is a high risk of recur-
involution
rence reconstruction may be delayed. Breast development Fibroadenoma, juvenile
Previous irradiation does not rule out breast recon- hypertrophy

struction but may affect the choice of surgical tech- Cyclical activity Cyclical mastalgia, cyclical
niques. nodularity
Involution Breast cysts, duct ectasia
Reconstruction of the breast involves either the use of a
breast prosthesis or an autologous myocutaneous flap:
Breast prostheses such as silicone gel implants are usu- under various names (fibroadenosis, fibrocystic change,

ally inserted under the muscles of the chest wall. The mammary dysplasia) these have now been classified
skin may need to be gradually stretched first using as aberrations of normal development and involution
atissue expander. Expansion to form a cavity slightly (ANDI) (see Table 10.4).
largerthantheimplantallowsthereconstructedbreast
to hang naturally (ptosis). Previously irradiated skin Incidence
may be too rigid to allow stretching. Complications Common, affecting most women to some extent.
include capsular contracture, infection and pain.
Myocutaneous flap reconstruction involves taking a
Age
piece of muscle with its overlying skin to create a From puberty onwards, peaks in later reproductive life,
breast mound. A pedicle flap retains its original blood declines after menopause.
supply and is tunnelled under skin to the breast. A
free flap requires its blood vessels to be surgically re- Aetiology
anastomosed such as a latissimus dorsi flap. A TRAM Benign breast disease is thought to occur due to an ab-
(transverse rectus abdominus myocutaneous) flap is normal tissue response to hormones.
an ellipsoid piece of skin, fat and muscle taken from
Clinical features and investigations
across the whole width of the abdomen. It may be used
Some women develop generalised breast nodularity and
as a pedicle or free flap. Complications of myocuta-
others present with more localised nodularity (see also
neous flaps include necrosis of the flap and scarring
section Breast Lumps, page 409). If excised most areas
of the donor site.
of nodularity show either no abnormality or aberrations
Nipple reconstruction may be achieved by shaping of the
of the normal involutional process such as focal areas of
reconstructed breast tissue and tattooing to achieve the
fibrosis or sclerosis. Triple assessment (clinical exam-
correct colour. Nipple prostheses offer an alternative to
ination, imaging and tissue sampling) is required for
further surgical treatment.
any new discrete lump, a new lump within pre-existing
Sufficient counselling on the advantages and disad-
nodularity or asymmetrical nodularity that persists after
vantages, the problems and complications of the tech-
menstruation.
niques must be given to all patients.
Management
For management of specific forms of ANDI see individ-
Benign disorders of the breast ual conditions.
Benign breast disease Fibroadenoma
Definition Definition
Abnormalities that occur during the normal cycle of Previously fibroadenomas were considered to be benign
breast proliferation and involution. Previously known neoplasmsof thebreast.However,astheydonotdevelop