[Does the surgical technique modify the incidence of local recurrence after mastectomy?]

This article discusses operative technique in relation to the prevention of local recurrence following modified radical mastectomy (MM) for carcinoma of the breast. As with any other surgical procedure, a satisfactory outcome requires both a correct indication and attention to the details of operative technique. The indications for MM may be defined from the currently accepted contraindications to breast preservation, while most of the contraindications to MM relate to the presence of a stage IIIb or IV carcinoma. The ideal treatment needs to be defined for the individual case, avoiding both unnecessary overtreatment with its associated morbidity and dangerous undertreatment with consequent reduction of the chance for cure. In our view, confirmation of the diagnosis by an excisional biopsy with frozen section examination should be obtained irrespective of a positive finding in an aspirated specimen. The incision for biopsy must be chosen in such a way that it will be encompassed by a subsequent mastectomy incision. When mastectomy is performed the cavity of the excisional biopsy must not be entered. This includes preservation of the barrier of the pectoralis fascia. When breast preservation is an option, the excisional biopsy must fulfill the criteria of a lumpectomy or tumorectomy, which include a 0.5 to 1 cm macroscopically tumor-free margin, orientation of the specimen by sutures, and immersion of the specimen in india ink. As the extent of intraductal component cannot be reliably determined by frozen section examination, waiting for the definitive pathology report may be better than an immediate decision to perform a mastectomy or breast preservation. The skin incision for mastectomy is transverse or slightly oblique, ending laterally about five cm below the axillary pit. The skin flaps must not include the full thickness of the subcutaneous fatty tissue. The preserved layer of fatty tissue must not be irregular. Axillary dissection of levels I and II is sufficient for staging. Skip metastases to level III occur in less than five percent of cases. Therefore routine dissection of level III with its associated increased risk of lymphedema is not justified.