Approach

• Expose the patient as for breast examination

1. Inspect

   

   • Asymmetrical chest wall with scar
   • Look at surrounding skin into axillar +/- radiotherapy marks
   • Ask patient to press hands into hips - ascertain whether the pectoralis major remains underneath the mastectomy
2. Palpate
   • Likely that you would not have to palpate the breast
   • Palpate the axilla and supraclavicular fossa
3. Percuss
4. Auscultate

Completion

1. Examine abdomen (liver), nieck, lung fields, spine
2. Examine ipsilateral arm for lymphoedema

Indications for mastectomy

1. No survival benefit has ever been demonstrated in performing more radical breast surgery for isolated breast carcinomas
2. Indications
   • Large lumps (defined as >4cm)
   • Involvment of the nipple
   • Mutifocal carcinomas
   • Ductal carcinoma in situ

Types of Mastectomy

1. Simple mastectomy - removal of breast alone
2. Modified radical mastectomy (Patey) - removal of breast, pectoralis minor and axillary structures
3. Radical mastectomy (Halsted) - removal of breast, pectoralis major and minor and axillary contents
4. Extended radical mastectomy - as for radical proceudure but also removing internal mammary nodes (between 2-4th anterior intercostal spaces)

Preparation for mastectomy

1. Physical
   • Mark side prior to anaesthetic
   • Explanation of procedure
   • Intecosto-brachial nerve injury will result in anaesthetised patch of skin in the axilla and upper medial part of the arm
   • CXR to exclude pulmonary metastases
2. Psychological
   • Should see breast care nurse preoperatively
   • Reasons for mastectomy should be discussed
   • Option for reconstructive surgery should be discussed