total mastectomy

The breast is made up of glands, fat and fibrous tissue. The mammary gland is derived from the epidermis and is located in the reticular fascia. The nipple is the local hyperplasia of the spinous process of the epidermis. The physiological activities of the mammary gland are restricted by various hormones such as anterior pituitary hormone, adrenocortical hormone and sex hormones, and the corresponding structural changes are produced. The adult female breast is located in the sac of the superficial fascia, with 4 to 5 intercostal spaces between the upper and lower sides, and the upper boundary is generally at the second rib level. The outside world reaches the middle line. The outer upper part of the gland protrudes into the axillary fossa as the mammary gland. The center of the breast is the nipple, surrounded by a ring-shaped areola. The cyst of the breast is a superficial thoracic fascia that extends deep into the breast, dividing the mammary gland into about 20 radially arranged leaflets of the breast, with a honeycomb-like adipose tissue between the leaves. Each mammary lobules has a corresponding lactiferous duct that opens to the nipple. The enlargement of the milk duct near the nipple is called the ductal sinus. A fiber bundle (Cooper) ligament is attached to the skin and the pectoralis major fascia around each lactiferous duct. The lymphatic vessels of the breast are very rich, and the main reflux pathways are axillary lymph nodes and internal mammary lymph nodes. Axillary lymph nodes can be divided into 5 groups: external, anterior, posterior, internal and central. The lateral group is located around the sacral and venous; the anterior group is located in the superficial anterior serratus, the lower edge of the pectoralis minor muscle, and the lateral thoracic artery. The breast cancer metastasis first invades the lymph nodes; the posterior group is located in the posterior wall of the armpit, along the subscapular vessels. Distribution; the central group is in the center of the axillary basal, in the loose fat connective tissue deep in the fascia, where the lymph nodes of each group meet; the medial group is located deep above the pectoralis minor muscle, and the output tube is assembled as the subclavian trunk and the lateral neck. The lymph nodes are connected, the subclavian lymphatic trunk is filled, the thoracic duct is injected into the left side, and the right lymphatic duct is injected into the right side. The parasternal lymph nodes are arranged along the blood vessels in the thoracic cavity. The superficial and deep lymphatic vessels in the medial part of the breast and the anterior thoracic wall merge into the lymph nodes of this group, and then merge into the mediastinum or supraclavicular lymph nodes via the intercostal lymphatic vessels. The lymphatic vessels on the underside of the breast pass through the anterior wall of the abdomen and merge into the lymphatic vessels in the subgingival space. Deep lymphatic vessels of the breast are injected through the pectoral muscle into the subclavian lymph nodes. The shallow lymphatics of the breast are extensively associated with the lymphatic vessels of the skin. The cancer can thus be transferred to the contralateral breast and armpits. The blood supply to the breast is mainly from the lateral thoracic artery, the intercostal perforator of the internal thoracic artery, and the lateral branch of the intercostal artery. The superficial vein of the breast is the subcutaneous vein, and the deep vein is accompanied by the artery of the same name, and merges into the internal thoracic vein, the iliac vein, the azygous vein or the semi-sham vein, and finally flows into the pulmonary vascular network. The innervation of the breast is mainly the lateral branch and anterior branch of the 2nd to 6th intercostal nerve and the supraclavicular and thoracic nerves. Treatment of diseases: breast sarcoma, breast tuberculosis, intraductal papilloma Indication Total mastectomy applies to: 1. Larger intraductal papilloma or associated with bleeding, and older patients. 2. Chronic cystic breast disease, a wide range of lesions, suspected of precancerous lesions, there is a relative indication of total breast resection of the disease side. 3. Breast tuberculosis, due to chronic inflammation, extensive scars, sinus, lesions destroy most of the breast tissue, long-term anti-spasm or non-surgical treatment of unhealed. 4. Breast sarcoma, advanced breast cancer as a palliative surgery. 5. Breast in situ or small cancer, eczema-like cancer lesions mainly in the nipple site. 6. Male breast hyperplasia, one side of the breast is significantly larger than the contralateral non-surgical treatment. Preoperative preparation The scope of surgical field preparation is the ipsilateral chest and supraclavicular region and armpit. Shave the mane. For tuberculous lesions, anti-tuberculosis treatment should be performed before surgery. Surgical procedure 1. The upper limb is abducted by 90°, and the incision is designed according to the size of the breast. If the chest is wide and the breast is full, a longitudinal fusiform incision can be made between the 2nd to 6th ribs. Patients with thin chests may have a horizontal fusiform incision as appropriate, such as carcinoma in situ or early cancer, and the margin should be 5 cm from the tumor. 2. Incision of the cortex and subcutaneous tissue, sharply dissecting the two sides of the flap in the fat layer, from the inside to the sternal border, to the lateral edge of the pectoralis major. Note that the accessory breast in the anterior aspect of the ankle should be included within the resection range. 3. Separate the breast tissue along the surface of the pectoralis major fascia. The breast tissue can be removed from the upper to the outer anterior line as appropriate. 4. The blood vessels of the chest wall should be carefully stopped. The intercostal and thoracic internal arteries should be sutured to stop bleeding, and the wounds with more oozing blood are covered with damp hot gauze to facilitate hemostasis. If the suture tension is large in the middle of the incision, it can be suitable for sneak separation. 5. After the breast tissue is removed, clean the wound, remove residual blood clots, shed fat and connective tissue, and place a drainage tube or rubber roller with a side hole at the lowest position of the incision or the outside of the incision, and fix it properly on the skin. Fix it on the drain with a safety needle to avoid dislocation. The negative pressure drainage tube should be used in the large residual cavity, and the drainage effect is better. 6. Sewing the subcutaneous tissue and skin according to the layer. If the patient is a scar, the incision may be slightly Z-shaped and the healing is better. The incision is properly pressure wrapped with a gauze pad. The drainage tube was taken out after 24 to 48 hours. complication 1. Incision flap necrosis is one of the common complications. Often due to excessive skin removal, there is tension in the skin edge when suturing, or the suture is not properly angled, the local blood circulation disorder, affecting the healing of the incision. 2. When the wound surface is large and the flap edge is difficult to match, the adipose tissue under the free flap should be sneaked as appropriate until the skin tension in the middle of the incision is not large. The slit edge of the incision should not be too tight to avoid ischemia and infection at the foot. 3. The blood or effusion under the skin of the wound is mostly due to the large wound surface. The operation can not completely stop the bleeding. Under the skin flap, there is a wide lymphatic exudate from the cut capillary lymphatics. Improper placement of the drainage tube during surgery or proper compression of the wound after suturing of the wound may also result in such complications. The method of treatment is to check the wound 24 hours after surgery, and those with blood should improve drainage. After 48 hours, hemorrhage and effusion should still be performed. Local puncture should be performed. The serum stored in the reservoir should be absorbed or placed in a small incision next to the incision to be placed in a silicone tube for negative pressure suction. In a few cases, 1 or 2 needle sutures can be removed through the original incision to drain the blood, and the fluid is pressurized and bandaged.

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