The question of excision or observation was mentioned in the CCTV feature, but in fact the question is: Is there a mass? Benign or malignant? Can a benign mass become malignant? The presence of a lump is simple, as long as it can be felt or detected by ultrasonography. However, could it be a breast enlargement? If it is a mastopexy, should it be removed? It is advisable not to guess whether it is benign or malignant, but to look at the pathology results! Can benign become malignant? You seem to be able to say only that it can, or at least very likely. Therefore, our current attitude is that we recommend surgical excisional biopsy whenever there is a lump that can be removed.
Localization of the mass
Localization of the mass is very important in breast surgery, especially for multiple and exceptionally small masses. No one has to worry about a large lump, but whoever sees a small lump has to worry about it!
How to precisely localize the lump?
Many surgeons now use preoperative ultrasound positioning to mark the skin and make the incision according to this mark. Some people analyze that it is because the body position during ultrasound is different from the body position during surgery, but the problem is not that simple.
I recommend two positioning methods, which I hope will be helpful.
1.Ultrasound precise positioning
Nowadays, many hospital ultrasound departments have performed the nine-zone positioning method for the breast, such as the internal upper, external, and areolar zones. But these are far from enough, because these can be judged by hand. We need ultrasound descriptions: the thickness of the breast in the lump area, whether the lump is located on the surface of the gland or on the deep side or in the middle, and how far the lump is from the surface of the breast.
2.In vitro precise localization
I usually treat the breast as a table (watch), with the nipple as the center and the line between the lump and the nipple as the radial axis, and note the points at which it points. Then I measure the distance between the center of the lump and the nipple on the radial axis and the distance from the edge of the breast gland. If the lump is too small, this should also be done with ultrasound. The position of the breast may move with changes in position, but it does not rotate.
Thus, a mass located in the outer upper quadrant is: left breast mass 8*6 mm, centered on the back of the gland, 10 mm according to the surface, 15 mm thick gland, positioned at 2 points, 3 cm inside and 2 cm outside.
Incision selection
Let’s talk about two issues.
1. Do not affect the design of the incision for possible radical breast cancer surgery.
2. If there are multiple lumps of different sizes on the same side of the breast, in a similar area, would you make one lump with one incision, or would you make one large incision with one pot?
Although I like small incisions, I still recommend designing an appropriate large opening to take care of mainly small lumps. The actual excision should also be small first and then large, otherwise it will be difficult to find again after disrupting the anatomical relationship!
Anesthesia
Epidural or intravenous complex anesthesia. Only doctors with special talents will choose local anesthesia!
Finding the mass
Although we have made a lot of preparations in advance, but after the actual skin incision, we often encounter this situation, obviously on the localization point, how come we can’t feel it where? Maybe your fingers are not sensitive enough, maybe you still lack enough experience, maybe your positioning is off, but what’s the use of saying that now, you need to find it right away!
Step 1
Find the lump before you find the breast.
Step 2
Swim along the surface of the breast. If the lump is located on the surface of the breast, lift the breast and observe it with the naked eye. If it is not visible, when probing with your fingers, press first and then probe, without sliding your fingers lightly over the surface of the breast. Second, it should be done from the outside in. This is because the lateral edge of the breast lump is most clearly defined. The two lateral margins are easily disturbed by the interval of each glandular lobe, and the mammary peritoneum tends to form tension when the medial margin is probed.
Step 3
If the lump cannot be explored via the surface of the breast, or if the lump is located deep within the gland, an incision of the gland is required. Be careful not to incise at the intended lump location; many lumps have decreased tension after incision of the peritoneum and may be similar to or even lower than the surrounding breast tissue in terms of softness and stiffness.
The lobe of the breast adjacent to the lump should be incised at intervals that are less damaging, less bleeding, and most importantly, almost no accidental lump injury. The vast majority of benign masses do not cross the interlobular septum, and if the mass breaches the septum, it is likely to be malignant.
It is important to incise the interlobular septum all the way to the pectoralis major muscle space of the breast and not halfway through.
Step 4
Extend one finger into the mammary pectoralis muscle space and place one finger on the surface of the breast and double-click. See how far it can fly into the sky.
Step 5
If it still can’t be found, don’t hesitate to locate it with intraoperative ultrasound. Whoever let the ultrasound say where it is, let him find it. Don’t cut the gland to pieces and then be told that the gland structure is confusing and cannot be explored, it must have been there before surgery anyway, so look carefully for it yourself.
Excision of the mass
Once the mass is found, the method of excision should be chosen depending on the size of the mass. If the mass is huge, the adjacent lobe interval should be separated and lobectomy should be performed. If the mass is small, it should be excised in the direction of the radial axis in order to close the breast wound. Trenching excision should be avoided.
Regardless of the size of the mass, it should be excised outside the pseudohypophysis of the mass.
Trauma suturing
1. How is the trabecular cavity formed?
Undoubtedly, it is the result of tissue loss after lump excision.
2. What kind of a trabecular cavity is formed?
How big the mass is, how big the trabecular cavity is. How deep is the mass and how deep is the cavity? What is the shape of the mass, the cavity is at least that big, but not small. Is this really how it should be? Is this really the only way? I don’t think so! We can’t choose the shape of the mass, but we can choose the way to remove it. The right way of excision makes the perfect suture.
3.Treatment of traumatic tissue
(1), the skin needs to be sutured, there is no doubt about it. The best way is continuous subcutaneous plus continuous intracutaneous suture with absorbable thread, which is the strongest, with the least tension and the smallest scar. The specific operation may find that the subcutaneous tissue is not easily revealed, the epidermis remaining after the suture-free strong suture, and the suture is ugly after the intradermal suture. As long as the epidermal cutting edge is cut off one before suturing, the subcutaneous can be revealed.
(2) Subcutaneous tissue
First, excessive excision of subcutaneous tissue is unnecessary and unhelpful for mass removal. If there is no subcutaneous tissue missing, the difference between suture and no suture is not significant. However, if more subcutaneous tissues are removed, then the space left for the buttress to be closed is not possible and only the residual cavity can be preserved. The reason is that the special relationship between the skin, fascia and mammary peritoneum in the breast area cannot be easily moved laterally!
4. Breast tissue
Twenty years ago, breast wounds had to be stopped by skin stitches, and 10 years ago it was popular to stop bleeding with the electric knife carpet.
The discussion focused mainly on the treatment of breast trauma. My opinion is that after careful hemostasis of the breast section, it is best to close it with sutures, provided that attention is paid to the residual breast morphology during excision. Sutures are not required after mammary gland lobe septation. In the case of trench excision, if you are not willing to shape the residual breast, it is better to leave it alone and wait for the fat to fill it in later, but reluctantly suture it, not only is it unsightly, but mainly a lump-shaped scar nodule will be formed.