One of the earliest recorded operative approaches to the treatment of breast cancer dates to the 18th century when Jean Louis Petit advocated removal of the breast, pectoral muscles, and axillary lymph nodes to treat the disease (4). Since then, several operations have been described for the treatment of breast cancer. Most notably, in 1894, William Halsted described what is referred to today as the “Halstedian” radical mastectomy. In his landmark study, Halsted described his surgical attack on breast cancer. He stated, “the suspected tissue should be removed in one piece” (5). This is done by complete en bloc resection of the breast with the pectoralis major muscle and regional lymphatics. With this approach, Halsted achieved a decrease in local recurrence rates of 6% and regional recurrence rates of 22% from rates of 51% to 82% for surgeons of his day (5,6,7). Approximately 10 days after Halsted’s study appeared in print, Willy Meyer published his technique for radical mastectomy (8). Although it was similar to Halsted’s approach, there are some differences that warrant mentioning. In Halsted’s approach, the pectoralis major muscle with the overlying breast tissue was dissected from the underlying sternum and the chest wall prior to removal of the axillary contents. In Meyer’s approach the axilla was dissected prior to the resection of the breast and pectoral muscles. In addition, Halsted simply divided the pectoralis minor muscle and left it in situ, whereas Meyer advocated removal of the pectoralis minor as well. Both Halsted and Meyer used vertical incisions; however, Halsted regularly sacrificed much more skin (taking as much skin as possible on all sides of the tumor) than in Meyer’s approach. A skin graft was often required to cover the chest wall defect with Halsted’s approach. In both Halsted’s and Meyer’s approaches, all three nodal levels from the latissimus dorsi laterally to the thoracic outlet medially were removed (8,9). Both approaches sacrificed the long thoracic nerve and the thoracodorsal neurovascular bundle en bloc with the axillary contents.

These approaches, believed necessary at the time as evidenced by the substantial decrease in recurrence rates with these operations, left women disfigured and with significant disabilities such as “winged scapula,” lymphedema, and shoulder fixation. There have since been several modifications in the surgical treatment of the breast in an effort to decrease the morbidity associated with these operations while preserving the improved disease-free survival that had been noted with Halsted’s approach.

In the 1940s, Patey (10,11) advocated preservation of the pectoralis major muscle. It was noted that this procedure was equivalent in terms of local relapse rate and overall survival to the results for patients treated with the previously described standard radical mastectomy. Haagensen (12), in the early 1970s, advocated preservation of the long thoracic nerve to avoid the “winged
scapula” disability. He stated that it was unnecessary to remove this nerve to achieve adequate surgical treatment of breast cancer. In the 1960s, Auchincloss (13) and Madden (14), in contrast to Patey, advocated preservation of both pectoralis major and minor muscles. With this modification, only level I and level II nodes were easily accessible, and the dissection of level III nodes was restricted. Auchincloss (13) further stated that removal of level III nodes was necessary only if they were clinically involved because of the high recurrence rate if positive nodes were left in place. The Auchincloss modification of the radical mastectomy is most consistent with the modified radical mastectomy of today.

Further modification of the modified radical mastectomy occurred with the development of the total mastectomy. This procedure preserves both pectoralis muscles and the axillary lymph nodes. The rationale for this modification stems from the popularization of the hypothesis that breast cancer is a systemic disease (15). Based on this hypothesis, the regional nodal dissection is unnecessary in the clinically negative axilla because it is unlikely to affect survival.

Several retrospective and prospective studies (16,17,18) sought to prove the hypothesis that breast cancer is a systemic disease early in its course. Most notable of these is the prospective randomized study by Fisher and the National Surgical Adjuvant Breast and Bowel Project (NSABP). In the 1970s, NSABP B-04 (15) compared total mastectomy with and without axillary radiation to standard radical mastectomy. This study, which demonstrated no statistically significant difference in disease-free survival between the study arms, supported the notion that aggressive surgical management does not change survival in a disease that is systemic and heralded the introduction of a more minimal approach to the surgical treatment of breast cancer. Included in this minimalist approach is preservation of muscles, lymph nodes, and even skin. Toth and Lappert first used the term skin-sparing mastectomy (SSM) in 1991 (19). They described preoperative planning of mastectomy incisions in an attempt to maximize skin preservation and facilitate immediate breast reconstruction. Skin-sparing mastectomy (in which the nipple-areola complex and a minimal amount of skin are removed) is commonly used in patients who desire immediate reconstruction. Preservation of the inframammary fold (IMF) and the native skin envelope enhances the aesthetic result of breast reconstruction. Taking the minimalist approach even further is total skin-sparing mastectomy (nipple-sparing mastectomy), which is under investigation in the prophylactic setting as well as for selected patients with breast cancer. Similarly, breast conservation has evolved as part of the trend toward less surgery for breast cancer. A brief discussion is presented here for reference, but details are presented in Chapter 10.

Breast conservation involves removal of the primary tumor with an adequate margin of normal breast parenchyma. It is followed by radiation therapy in order to provide equivalent survival rates to that achieved with mastectomy as demonstrated in the NSABP B-06 (20) and European Organisation for Research and Treatment of Cancer trials (21). Breast-conserving surgery is also referred to as lumpectomy, partial mastectomy, and segmental mastectomy. Any woman is a candidate provided the following criteria are met:

Positive axillary nodes on clinical or pathologic examination are not a contraindication to breast conservation.

Almost all women with breast cancer are candidates for mastectomy. The specific type of mastectomy performed relies on the presentation of the patient and her disease. Differentiation between total mastectomy and skin-sparing mastectomy is a somewhat arbitrary definition, as the defining factor between the two is the amount of skin left intact to accomplish reconstruction. The Halstedian mastectomy is of historic interest today. There are occasions when excision of muscle invaded by tumor is performed en bloc during a mastectomy; however, with the availability of multimodality therapy, radiation therapy and adjuvant chemotherapy are used to improve outcome in those patients with locally advanced disease.

Indications for mastectomy are as follows:

The indications for modified radical mastectomy are similar to those for total mastectomy as it relates to the treatment of disease in the breast. The difference lies in the surgical approach to the axilla. If a patient has biopsy-proven involvement of an axillary lymph node or circumstances that exclude her from undergoing a sentinel node biopsy, then an axillary dissection in conjunction with the mastectomy is performed (i.e., a modified radical mastectomy).

The female breast is an apocrine gland arising from a skin appendage, a so-called “modified sweat gland.” It is enclosed between the superficial and deep layers of the superficial fascia of the anterior abdominal wall. The superficial layer is a very delicate, but definite structure that can be seen in most patients. It is not as well defined in fatty breasts and along the IMF (22). Large vessels lie deep to this plane that send vertical branches to the subdermal plexus (23).