Types of Mastectomy
Several surgical procedures are used to treat breast cancer: simple (total) mastectomy, modified radical mastectomy, radical mastectomy, skin-sparing mastectomy, subcutaneous mastectomy, partial mastectomy, and lumpectomy.
• Simple or total mastectomy—In this procedure, the entire breast is removed, but the lymph nodes and surrounding muscle are left intact.
• Modified radical mastectomy—This is the most common surgical procedure performed for breast cancer. The entire breast, the lymph nodes under the arm, and the lining over the chest muscles are removed. The muscles remain intact.
• Radical mastectomy—The breast, lymph nodes, muscles under the breast, and some of the surrounding fatty tissue are removed. This procedure is rarely performed. Radical mastectomy is used in cases of extensive tumors and in cases where cancer cells have invaded the chest wall.
• Skin-sparing mastectomy—A relatively new surgical technique called skin-sparing mastectomy may be an option for some patients. During this procedure, the surgeon makes a much smaller incision, sometimes called a "keyhole" incision, circling the areola. Even though the opening is smaller, the same amount of breast tissue is removed. Scarring is negligible and 90% of the skin is preserved. Reconstruction is performed at the same time as the procedure by a plastic surgeon, using tissue from the patient's abdomen or latissimus dorsi, a muscle in the back.
• Subcutaneous mastectomy—The tumor and breast tissue are removed, but the nipple and the overlying skin are left intact. Reconstruction surgery is easier, but some cancer cells may remain.
• Partial mastectomy—In a partial mastectomy, a larger amount of breast tissue and some skin are removed with the tumor. A partial mastectomy also includes removal of the lining over chest muscles below the tumor and, usually, some lymph nodes. This surgery is usually performed for Stage 1 and 2 tumors.
• Lumpectomy—In a lumpectomy, the tumor and a small amount of surrounding tissue are removed. Several lymph nodes may also be removed.
Gynecomastia: Treatment
Author: Jay M Pensler, MD, Aesthetic Plastic and Reconstructive Surgery, Private Practice; Clinical Associate Professor, Department of Surgery, Division of Plastic Surgery, Northwestern University Medical School
Coauthor(s): Merle J Yost, BA, MA, LMFT, Licensed Marriage and Family Therapist
Contributor Information and Disclosures
Updated: Jul 1, 2009
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• Overview
• Workup
• Treatment
• Follow-up
• Multimedia
• References
• Keywords
Treatment
Medical Therapy
Medical management is most successful when the gynecomastia is of recent onset and is caused by testosterone deficiency. Testosterone administration has inconsistent effects in persons with Klinefelter syndrome, but it can cause dramatic improvement in those with other forms of testicular failure (eg, anorchia, viral orchitis). Testosterone therapy involves an element of uncertainty because testosterone can serve as substrate for extraglandular estrogen formation. Under some circumstances (eg, patient with liver disease), androgen therapy can cause a disproportionate increase in plasma estrogen levels.

Various drug regimens have been tried for the treatment of gynecomastia. These drugs include the antiestrogens tamoxifen7 and clomiphene, the aromatase inhibitor testolactone, and danazol (a weak androgen that inhibits gonadotropin secretion and causes a decrease in plasma testosterone). Treatment with dihydrotestosterone, which cannot be aromatized to estrogen, has also been reported to cause significant symptomatic improvement in uncontrolled studies of persons with gynecomastia. However, to the authors' knowledge, no controlled studies have been conducted to test the clinical effectiveness of any of these regimens and, in the authors’ hands, none of the aforementioned treatments have been even minimally successful in patients with idiopathic gynecomastia.

Without an increase in receptor number or binding capacity of the receptors, exogenous medical treatment is not likely to be effective; therefore, medical treatment is not likely to be effective for patients with idiopathic gynecomastia, since they do not exhibit an altered number of such receptors.

Radiation

Several studies have shown that prophylactic breast irradiation reduces the risk of gynecomastia in patients with prostate cancer who are undergoing long-term estrogen or anti-androgen therapy. The risks of long-term malignancies, however, have not been clearly defined.
Surgical Therapy
The objectives of surgical management for breast gynecomastia are (1) to restore the normal male breast contour and (2) to correct deformity of the breast, nipple, or areola. The surgical options for the patient with gynecomastia are mastectomy, liposuction-assisted mastectomy, or a combination of the 2 approaches. Most patients receive maximal benefit from a combined approach.

Surgical resection (subcutaneous mastectomy)

The choice of surgical technique depends on the likelihood of skin redundancy after surgery. Generally, skin shrinkage is greater in younger individuals than in older individuals. Many different incisions have been described for the excision of male breasts. The most common approach is the intra-areolar incision, or Webster incision. The Webster incision extends along the circumference of the areola in the pigmented portion. The length of the incision varies according to the specific anatomy of the patient.

The Webster intra-areolar incision is placed in the inferior hemisphere.


The Webster intra-areolar incision is placed in the inferior hemisphere.

This incision may be enlarged by lateral and medial extensions, though this is rarely required.


The Webster intra-areolar incision may be enlarged by lateral and medial extensions.

The transverse nipple-areola incision may be used, but it may often be associated with limited exposure.


The transverse nipple-areola incision.

The triple-V incision is an additional approach that has been advocated.


The triple-V incision offers increased exposure. This approach is rarely used today.

The transaxillary incision has been recommended because of its advantage of scars on the chest wall; however, its disadvantage is that it causes glandular resection to be more difficult and incomplete. Obtaining adequate hemostasis is also very difficult through this approach.

In severe gynecomastia, skin resection and nipple transposition techniques may occasionally be necessary. The most common type is the Letterman technique. After the skin is resected, the nipple-areola complex is rotated superiorly and medially based on a single dermal pedicle.


The most common technique for skin resection and nipple transposition is the Letterman technique.

Sometimes, in massive gynecomastia, an en bloc resection of excessive skin and breast tissue and free nipple grafting can be performed, but such cases are extremely unusual.


In massive gynecomastia, an en bloc resection of excessive skin and breast tissue and free nipple grafting can be performed using an elliptical incision with a nipple-areola graft.

Preoperatively, the surgeon should outline the incision and estimate the thickness and depth of fat and breast tissue to be removed. Liposuction is performed after the infiltration of tumescent solution. The authors presently use a combination of ultrasonic-assisted liposuction (UAL), power-assisted liposuction (PAL), and traditional liposuction. The surgical dissection, which proceeds after the liposuction, entails a dissection that is extended to the pectoralis major fascia. The fat and breast tissue are excised en bloc from the pectoralis fascia. Hemostasis is achieved with a Bovie electrocautery instrument. A catheter may need to be inserted to prevent postoperative hematoma; however, with the use of tumescent solution that contains epinephrine, this is rarely required.

Liposuction-assisted mastectomy

Teimourian and Pearlman, first introduced liposuction with surgical resection in the 1980s.13 Recently, the advent of ultrasonic liposuction has improved the results of gynecomastia correction. In liposuction-assisted mastectomy, less compromise of the blood supply, nipple distortion, saucer deformity, and areola slough occur. In addition, the postoperative complications (eg, hemorrhage, infection, hematoma, seroma, necrosis) are fewer with this technique than with open surgical resection. However, liposuction-assisted mastectomy is not effective for correcting glandular gynecomastia. Therefore, the fatty and glandular components of the breast must be assessed prior to any surgical intervention. Few patients can be sufficiently treated with liposuction only.
Preoperative Details
A standard preoperative workup that is age-appropriate should be performed. Longstanding cases of idiopathic gynecomastia that are stable do not require routine endocrine evaluation.
Intraoperative Details
Surgical resection

The technique used depends on the degree of gynecomastia. If the gynecomastia requires surgical resection, the Webster intra-areolar incision is the typically the most appropriate. Prior to surgical resection, the breast is infiltrated with tumescent solution and liposuction is performed. For massive breast gynecomastia, more skin removal and deeper excision are necessary. With an accurate estimation of the extent of the hypertrophied tissue and the thickness of the fat on the chest wall, the dissection should reach the pectoralis major muscle fascia very near to the preoperatively estimated breast limits. The hypertrophied tissue is then excised from pectoralis major fascia. Hemostasis is secured, and a surgical drain may, rarely, be placed. Subcutaneous tissues are reapproximated, and the skin is closed subcuticularly. The authors use a compression vest postoperatively, which has made drains unnecessary in the overwhelming majority of patients.

Liposuction-assisted mastectomy

Liposuction-assisted mastectomy is the most popular method used for pseudogynecomastia. The liposuction cannulas are inserted through a 3-mm areolar incision or an incision in the anterior axilla along the pectoralis major tendon. The surgeon the removes fatty and minimal glandular tissues. For small and moderate gynecomastia, suction lipectomy is extended to the clavicle, to the sternum, to 2 cm below the inframammary crease, and to the axilla. For moderate to large gynecomastia, suction lipectomy is extended to the postaxillary fold in conjunction with excision.
Postoperative Details
Compression garments are applied for at least 4 weeks. A small amount of blood, injection fluid, and liquified fat may leak from the incision sites for approximately 24 hours. The patient may resume his physical activities within few days. Exercise is resumed a few days after surgery and is gradually increased over time. Patients return to work typically after 1-2 days.
Follow-up
Patients are usually seen 1 week postoperatively and once a month for the first 6 months. The final results are not fully appreciated for up to a year.


Postoperative view of patient after surgical glandular excision and combined ultrasonic-assisted liposuction (UAL) and power-assisted liposuction (PAL).



Postoperative view of above patient. Note that while the glandular and fatty tissue have been removed, the nipples remain in the preoperative position relative to each other. Also note the significant skin retraction postoperatively.
Complications
Complications of mastectomy for gynecomastia include the following:
• Hematoma (most common)
• Breast asymmetry
• Nipple or areola necrosis
• Nipple or areola inversion
• Infection
• Sensory changes
• Painful scar
• Contour deformity
• Conspicuous scar
• Skin redundancy

Stewart

Pilonidal sinus: Limberg flap, a better option for pilonidal sinus

Dr. Mohammad Nadeem Aslam, Dr. Sidra Shoaib, Dr. Majeed Chaudhary
Department of Surgery, Mayo Hospital, Lahore, Pakistan

Abstract
Pilonidal sinus disease has been treated for a long time with conventional open excision technique. The rhomboid flap of Limberg is a transposition flap that has been pleaded for treatment of this condition. We present our experience with the Limberg technique for both primary and recurrent pilonidal sinuses. 110 patients, with pilonidal sinus disease were treated with rhombic excision and Limberg transposition flaps. Under general anesthesia, all sinus tracts were resected en bloc, and the Fasciocutaneous Limberg flap was prepared from the gluteal region and closed it with a suction drain. Full primary healing was obtained in 110 patients, 1 patient had minimal necrosis of flap and 2 had gaping of flap. Minor infection occurred in 3 patients. But all these complications healed uneventfully. The average hospital stay was 3 days. Follow up period was 1 year and 1 recurrence occurred. So it was concluded that limberg flap may be a useful technique to treat pilonidal sinus
Keywords: Pilonidal sinus, Limberg, rhomboid transposition flap

INTRODUCTION

Intergluteal pilonidal disease is a commonly encountered condition in adult primary care, and it causes significant morbidity. A calculated incidence of the disease of 26 per 100000 inhabitants was found [1]. Pilonidal disease generally presents as a cyst, abscess, or one or more sinus tracts with or without discharge in the upper part of the natal cleft.
Men are affected three to four times more commonly than women [1,2] and the condition is most frequent in the third decade of life. It is infrequently encountered in patients older than 45 years [4].
The etiology of pilonidal cysts has been a matter of debate. The condition was probably first described by Mayo in1833, and it was felt to result from the congenital disposition but with time the view shifted towards acquired theory [3]. A widely acceptable view is that they are caused by local trauma, poor hygiene, excessive hairiness, and presence of deep natal cleft. [5, 6]
The management of pilonidal sinus disease is frequently unsatisfactory. Many surgical and non- surgical treatment modalities have been suggested, but the ideal and widely accepted treatment has still not yet been established [7]. In this regard, low recurrence rate, shorter hospital stay, less cost, minimal inconvenience and time off work are important considerations. Surgical techniques include laying the track open, wide excision with open wound, wide excision with marsupialization, excision with primary midline or asymmetric closure and techniques involving various flaps procedures. All the surgical procedures have their pros and cons.
The rhomboid flap of Limberg is a transposition flap that has been advocated for treatment of this condition [8]. In 1946, Limberg first described a technique for closing a 600 rhombus shaped defect with a transposition flap [9]. It is easiest to construct. It is a series of communicating equilateral triangles, with all angles meeting at 600. The advantage of this reconstruction is that it is very easy to perform and design. It flattens the natal cleft with a large, well-vascularized pedicle that can be sutured without tension. That eventually helps in maintaining local hygiene, avoids hair insertion by reducing the friction between buttocks, reducing humidity, maceration, erosions and scar formation at the natal cleft [10].
In this study we present our experience with this technique.


Materials and methods
Study was conducted in the Department of South surgical ward, Mayo hospital, Lahore and Sir Gangaram Hospital from 1st Jan 2007 to 31st December 2007. 110 patients with pilonidal sinus disease were included in the study. All the patients who presented with primary or recurrent pilonidal sinus disease were included, while the patients, who came with an acute pilonidal abscess, and patients having diabetes mellitus, uncontrolled hypertension, bleeding diathesis, steroid intake, recent myocardial infarction and smoking were excluded to control the confounding factors.

INCLUSION CRITERIA EXCLUSION CRITERIA
Primary pilonidal sinus Acute pilonidal abscess
Recurrent pilonidal sinus Co-morbid factors

All the patients were admitted to the hospital, one day prior to the operation. These patients were advised to return to normal activities after removal of stitches, after about 10 days, but to avoid excessive physical strain and strenuous sports for following 3 to 4 weeks. Follow up of all patients was performed on an outpatient basis, every month for 6 months. It included the detailed history and clinical examination by trained personnel. The outcome measures recorded were wound infection, healing time, time off work, gaping, necrosis and recurrence rate.
OUTCOME MEASURES % age
Wound infection 2.7 %
Time Off Work 10 days
Gaping 1.81%
Necrosis 0.9 %
Recurrence 0.9%

Wound infection was defined as the systemic signs associated with purulent discharge from the wound, necessitating open drainage or debridement. Recurrence was defined as, the reappearance of symptoms and sinus after complete healing of the wound. Data was analyzed by using SPSS software (version 11).

Surgical Technique
All the patients were admitted to the hospital, one day prior to operation. The hair around the natal cleft was shaved before operation. Under general anesthesia, the patients were positioned prone (Jack Knife) and the buttocks were strapped apart by using the adhesive tapes. Area to be excised and flap lines are marked prior to operation and a rhomboid incision including the sinus and its extensions is made down to the presacral fascia.



The flap is constructed by extending the incision laterally and down to the fascia of the gluteus maximus muscle. Flap should be exactly of the same angles and length of the defect made by the excision. The subcutaneous fat was undermined and lifted as a flap from the gluteal fascia extending down to the level of post sacral fascia to close the wound in a tension free manner.



Suction drain was placed in the wound cavity, through a separate stab incision. Subcutaneous tissue was approximated with interrupted 2/0 vicryl. Skin was closed with mattress interrupted stitches with prolene 4/0. Drain removed on 2nd day. Sutures were removed on 10th post operative day.


Results
110 patients were included in the study which included 102 males and 8 female patients. All were between 17- 30 years of age. Of these sinuses 103 were primary and 7 were recurrent. Full primary healing was obtained in all 110 patients, 1 patient had minimal necrosis of flap and 2 had gaping of flap which healed secondarily. Minor infection occurred in 3 patients. But all these complications healed uneventfully. Average drain removal is 2 days. The average hospital stay was 3 days. There was 1 recurrence, at one of lower corner, after 6 months of follow up.






COMPLICATIONS NO. %age
Flap Necrosis 1 0.9
Gaping 2 1.81
Wound Infection 3 2.7
Recurrence 1 0.9








Discussion
Pilonidal sinus is characteristically a blind epithelial tract (the sinus) situated in the skin of the natal cleft, a short distance behind the anus and generally containing hair [17]. The incidence is highest in males. The etiology and pathogenesis of pilonidal sinus is still a matter of debate. According to present view it is basically caused by excessive hairiness, poor hygiene, and humidity [18]. Other factors affecting the incidence are increased sweating associated with sitting and buttock friction, poor personal hygiene, obesity, and local trauma, Increase depth, narrowness of the natal cleft and the friction movements of the buttocks paves the way for loose hair to collect and insert in deep cleft [19]. The cleft is further prone to the collection of loose hairs, by increased sweating associated with sitting and buttock friction, poor personal hygiene, obesity, and local trauma. The hair is perceived as a foreign body, initiates an inflammatory response and can then lead to a pocket of infection leading to abscess or sinus formation [20].
The surgical treatment should intend towards removing all the sinus tracts as well as the predisposing factors that contribute in the formation of pilonidal sinus. The goals of the ideal procedure for the treatment of this disease should be reliable wound healing with a low risk of recurrence, a short period of hospitalization, minimal inconvenience to the patient, and low morbidity with few wound-management problems [21]. Also, treatment should allow the patient to resume normal daily activities as quickly as possible. The advantage of this reconstruction is that it is very easy to perform and design. It flattens the natal cleft with a large, well-vascularized pedicle that can be sutured without tension. That eventually helps in maintaining local hygiene, avoids hair insertion by reducing the friction between buttocks, reducing humidity, maceration, erosions and scar formation at the natal cleft. Any midline dead space is eliminated and a midline scar is avoided. It is a particularly useful technique for complex sinuses with multiple pits and extended tracts where radical excision leaves a large defect [22]. The alternative of healing with secondary intention would require prolonged supervised wound care. This operation is also suitable for cases where simpler operations have failed. The use of local flap accelerates healing.
In our study overall complication rate was around 5%. 2.7% had minor wound infection that healed with antibiotics. 1.81% had gaping wound which healed with secondary intention and 0.9% had minor skin flap necrosis which also healed but with scarring. There was 0.9% recurrence in 6 month period.
Our results with the Limberg flap are therefore comparable with other series that have shown wound complication and recurrence rates of 0-16% and 0-5% respectively [10-16, 19, 21, 23-24]. Interestingly, 75% of the complications in our series occurred in patients with primary pilonidal sinuses. This may reflect the fact that in those cases the Limberg flap was applied in complex primary pilonidal sinuses necessitating extensive tissue dissection.
We also feel that preoperative antibiotic prophylaxis is important for prevention of wound infection, although there is no published convincing evidence for this practice.
The importance of the post-operative wound care should also be stressed. Exercise or sitting down on the wound should be avoided for two weeks and the patient has to return slowly to normal activities. Hair removal either by shaving the edges of the wound is mandatory (4, 5, 8). This has to be continued at least until complete healing of the wound, but preferably on a long-term basis.
The aim of all surgery should be to minimize both the financial burden to the community and the cost to the patient in terms of time off work, number of dressings and post-operative visits, complications and recurrences. We have experienced that the transposed rhomboid flap for closure of the wound after pilonidal sinus excision meets these criteria and its advantages outweigh the need for a few days hospital stay. However, it is important to discuss with patients when offering them the various surgical options, as the procedure is not without complications and can result in prolonged morbidity and/or a second procedure in a few cases.
Comparison of various studies
Name of author Year Study carried out at No. of patients
Hospital Stay complication Recurrence
Katsoulis IE et al [19] 2006 Colorectal Unit, Surgical Department,
Guy's and St Thomas' Hospitals,
London, UK 25 4
16%
Urhan MK et al [23] 2002 Department of Surgery, Ankara Training and Research Hospital, Ankara, Turkey 102 3.7 7% 4.9 percent
Mentes BB [24] 2004 Colorectal Surgery Division, Department of Surgery, Gazi University Medical School, Ankara, Turkey. 238 2.10 +/- 0.20 days (range 1-3 days) 2% 1.26%
Akin M et al [21] 2007 Department of General Surgery, Gazi University School of Medicine, Besevler, Ankara, Turkey 411 3.2 15.75% 2.91%
Dr.Mohammad
Nadeem Aslam 2007 Department of Surgery, Mayo Hospital, Lahore, Pakistan 110 3 5% 1%


Conclusion
Limberg rotation flap can be recommended as a preferred procedure in the management of chronic pilonidal sinuses. It has the advantages of short hospital stay, early wound healing, rapid return to work and very low recurrence rate with excision and the open wound.


References
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