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Diagnostic Breast Surgical Techniques

Core Biopsy

A diagnostic biopsy may be performed with a fine or large needle, depending on the size of the suspected mass.  Ducts or nerves may be severed, depending on the location and direction of the incision.  An incision on the lower, outer quadrant of the breast is more likely to damage the fourth intercostals nerve.  Horizontal incisions are more likely to severe ducts than vertical incisions.  If the suspicious tissue is malignant, a partial or full mastectomy may be necessary.

biopsyCore (needle or Tru-Cut) biopsy is a procedure that uses a larger needle to remove a core of tissue from the center of a cyst.  A small incision is typically made above the cyst and the needle is passed through the incision.  Several tissue samples are withdrawn.  There are several methods of obtaining a core biopsy.

Stereotactic biopsy is a procedure that isolates the precise location of a suspected mass using computer and mammogram imaging taken from multiple angles. One type of this procedure employs an advanced breast biopsy instrument (ABBI), which uses a very large needle that results in a large incision requiring suturing.  A mammotome (MIBB) is another instrument that removes tissue by suction, in greater amounts than standard needle biopsy.  Core biopsies can also be taken with a hand-held device, guided by ultrasound.

The impact upon lactation from core biopsy depends upon the extent, location, and direction of the incision as discussed above.  Scarring or the complication of an infection or hematoma after the biopsy may have an effect upon lactation, depending on the extent.

lumpectomyAblative Surgery

A suspicious mass, such as a fibroma, may need to be removed completely.  Some surgeons will also remove fibroadenomas as large as lemons in order to avoid the remote possibility of malignancy (cystosarcoma phylloides), which is about one percent.(1)   In abscesses that are larger than can be treated with aspiration, an incision and drainage may be required.

As with all breast surgeries, the location, orientation, and extent of the incision will determine the impact upon milk production.    Many surgeons attempt to preserve the cosmetic appearance of the breast by placing incisions in less visible areas, such as on the areola or under the inframammary fold (the fold under the breast).  If an incision on or around the outside of the areola damages the fourth intercostal nerve, nerve response to the nipple and areola will be reduced, negatively impacting milk production.  This cannot always be avoided, however.  When the suspected mass is under the areola or in the nipple, such as in Paget’s disease, incisions on the areola are necessary, although orienting them toward the upper and inner quadrants reduces the likelihood of nerve impairment.(2)  Locating the incision far away from a mass is not always a perfect solution, either, because  the surgeon must cut into the breast to reach the mass, whichgreatly increases the risk of severed ducts and reduced milk production. 

wire localizationWire Localization

When a mass cannot be felt by probing from the outside and core biopsy is not possible, a wire localization biopsy procedure may be performed by inserting a needle into the breast, guided by x-ray, through which a thin wire is passed.  The wire is positioned at the site of the suspected mass and the surgeon uses the wire to locate and remove the mass.  The risk to milk production in this procedure is in the location and direction of the initial incision and the amount of tissue removed around the wire. Most importantly, if the incision is near the lower, outer quadrant of the areola and severs the fourth intercostal nerve, milk production will be impaired.

In some circumstances, mastectomy may be necessary. If such a serious situation occurs to a nursing mother, breastfeeding is usually discontinued due to the toxicity of treatments such as chemotherapy, which can also affect milk production.(3) If it happens prior to a new baby, however, and only one breast is removed and the remaining one has not undergone any other treatments, it is quite possible to produce a full milk supply from the remaining breast. 

sternotomySternotomy

Sternotomy, surgery through the breast to treat heart or lung problems, carries the risk of negatively impacting future milk production. In order to preserve milk production capability and minimize scarring, it is common for the incision to be placed in the inframammary fold.(4), (5), (6) A study in 1992 reported excellent lactation outcomes when the incision for sternotomy is made in the inframammary fold.(7)   This is likely to be true for most mothers, although the extent of the surgery and post-operative healing will be important factors.   Even when the incision is in the inframammary fold, nerve and ducts can be severed.  Post-operative infection can also reduce milk production by causing permanent damage to affected glandular tissue. 

References

(1) Love, S.  Dr. Susan Love's Breast Book. 3rd edition. Cambridge, Mass.: Perseus Publishing, 2000.

(2) Pezzi, C., Kukora, J., Audet, I. et al. Breast conservation surgery using nipple-areolar resection for central breast cancers. Arch Surg 2004 Jan; 139(1):32-7; discussion 38.

(3) Hale, T.  Medications and Mothers’ Milk, 11th edition.  Amarillo, TX: Pharmasoft Publishing, 2004.

(4) Nakamura, K., Irie, H., Inoue, M. et al. Factors affecting hypertrophic scar development in median sternotomy incisions for congenital cardiac surgery. J Am Coll Surg 1997 Sep; 185(3):218-23.

(5) Bedard, P., Keon, W., Brais, M., et al. Submammary skin incision as a cosmetic approach to median sternotomy. Ann Thorac Surg 1986 Mar; 41(3):339-41.

(6) Brutel de la Riviere, A., Brom, G., Brom, A..  Horizontal submammary skin incision for median sternotomy. Ann Thorac Surg 1981 Jul; 32(1):101-4.

(7) Deutinger, M. and Dominag, E. Breast development and areola sensitivity after submammary skin incision for median sternotomy.  Ann Thorac Surg 1992 Jun; 53(6):1023-4.

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