Special Surgery 33. Benign Diseases of the Breast. Types of Breast-Reconstruction Surgeries

I. Diagnostic Approach to Benign Breast Disease

General Rule

• Benign breast diseases: non-malignant lesions of breast epithelium, stroma, ducts or inflammatory tissue
• Most breast lumps are benign, but breast cancer must be excluded
• Triple assessment:

1. History + physical examination
2. Imaging: ultrasound / mammography
3. FNAB or core needle biopsy if suspicious or uncertain

High-Yield Diagnostic Points

• Physical examination: lump site, size, mobility, tenderness, skin/nipple changes, axillary nodes
• Ultrasound: first-line in young women and cyst/solid distinction
• Mammography: older women, suspicious lesion, screening context
• Core needle biopsy: suspicious solid lesion, atypical imaging, discordant findings
• Cyst aspiration: painful/large cyst; bloody fluid or residual mass → further workup

II. Common Benign Breast Diseases

Fibrocystic Changes

• Very common hormone-related breast change
• Most common in premenopausal/reproductive-age women
• Pathomechanism: estrogen + progesterone stimulation → ductal/lobular hyperplasia → cyst formation + stromal fibrosis
• Risk/association: hormone replacement therapy, caffeine sensitivity, family history

1. Non-proliferative

• Simple cyst, fibrosis, papillary/apocrine metaplasia
• Minimal/no increased cancer risk

2. Proliferative without atypia

• Ductal/lobular hyperplasia without atypia
• Slightly increased cancer risk

3. Atypical hyperplasia

• Atypical ductal/lobular hyperplasia
• Higher future breast cancer risk

• Clinical features: cyclic breast pain worse before menstruation, bilateral/multiple lumps, swelling/lumpiness
• Diagnosis: physical examination, ultrasound, mammography if age/risk appropriate, FNAB/core biopsy if cancer suspicion
• Treatment: reassurance, supportive bra, NSAIDs/analgesia, oral contraceptives in selected cyclic mastalgia
• Intervention: cyst aspiration if large/painful; surgical excision if cancer suspicion or atypia/high-risk lesion

Breast Cysts

• Fluid-filled sacs; solitary or multiple
• Usually tender and may fluctuate with menstrual cycle
• Diagnosis: ultrasound confirms cystic lesion
• Observation if asymptomatic simple cyst
• Aspiration if painful, large or enlarging
• Bloody aspirate, residual mass or recurrence → cytology/biopsy and further workup

Fibroadenoma

• Most common benign breast tumor in young women
• Composed of fibrous and glandular tissue
• Hormone-sensitive: estrogen influence
• Typical age: 15-35 years
• May enlarge in pregnancy or hormone therapy; may regress with age
• Malignant transformation is very rare
• Clinical features: firm, well-circumscribed, mobile, usually non-tender mass
• "Breast mouse": moves easily under fingers
• Diagnosis: physical examination, ultrasound hypoechoic solid lesion, mammography by age/risk, core biopsy if uncertain
• Treatment: observation/follow-up if small and asymptomatic
• Surgical excision: rapid growth, large size >3-4 cm, symptoms, patient preference or cancer/phyllodes suspicion

Intraductal Papilloma

• Benign epithelial tumor growing within lactiferous ducts
• Ductal epithelial + myoepithelial proliferation around fibrovascular core
• Common in premenopausal women
• Clinical features: spontaneous unilateral bloody/serous nipple discharge
• Palpable subareolar mass if large
• Diagnosis: ultrasound intraductal mass + duct dilatation; mammography may show mass/calcification
• Galactography/ductogram: intraluminal filling defect, now less commonly used
• Core needle biopsy if lesion is visible/large enough
• Treatment: surgical excision if symptomatic, atypia, multiple/peripheral papillomas or discordant biopsy
• Asymptomatic concordant papilloma without atypia → observation may be acceptable after specialist agreement

III. Inflammatory and Male Breast Conditions

Mastitis and Breast Abscess

• Mastitis: inflammation/infection of breast tissue
• Usually lactational in breastfeeding women
• Most common pathogen: Staphylococcus aureus
• Clinical features: painful red swollen breast, warmth, fever/malaise
• Treatment: antibiotics covering staphylococci, analgesia, hydration, continue breastfeeding or pumping
• No improvement or fluctuant mass → ultrasound for abscess
• Breast abscess: localized pus collection
• Treatment of abscess: antibiotics + drainage
• Drainage: ultrasound-guided needle aspiration or incision and drainage if large/multiloculated/failed aspiration
• Non-lactational or non-resolving inflammation → exclude inflammatory breast cancer

Gynecomastia

• Benign enlargement of male glandular breast tissue
• Mechanism: estrogen-androgen imbalance
• Causes: physiologic puberty/aging, medications, liver disease, renal failure, hypogonadism, idiopathic
• Clinical features: subareolar rubbery glandular disc, tenderness possible
• Red flags for male breast cancer: hard eccentric mass, nipple retraction/discharge, skin change, axillary nodes
• Treatment: reassurance if physiologic, stop/treat underlying cause
• Surgery if persistent/distressing: subcutaneous mastectomy or liposuction-assisted contouring

IV. Types of Breast-Reconstruction Surgeries

Timing

• Immediate reconstruction: during mastectomy
• Delayed reconstruction: after cancer treatment/radiotherapy
• Choice depends on cancer stage, radiotherapy, body habitus, comorbidities, smoking, patient preference and expertise

1. Implant-Based Reconstruction

• Uses saline or silicone implant
• Often two-stage: tissue expander first → later permanent implant replacement
• Pros: shorter operation, no donor site
• Cons: infection, implant loss, capsular contracture, less natural feel, worse after radiotherapy

2. Autologous / Flap-Based Reconstruction

• Uses patient's own tissue: skin, fat, sometimes muscle
• Can be pedicled or free flap with microvascular anastomosis
• Pros: more natural look/feel
• Cons: longer surgery, donor-site morbidity, flap loss risk

• TRAM flap: transverse rectus abdominis myocutaneous flap

• Lower abdominal skin/fat + rectus muscle
• Pedicled or free flap
• Higher abdominal wall weakness/hernia risk

• DIEP flap: deep inferior epigastric perforator flap

• Lower abdominal skin/fat supplied by perforators
• Preserves rectus muscle → less donor-site morbidity than TRAM
• Requires microsurgery

• Latissimus dorsi flap: pedicled upper-back flap, often combined with implant
• Gluteal/thigh flaps: alternatives when abdomen is not usable

3. Nipple-Areola Complex Reconstruction

• Usually final stage after breast mound reconstruction
• Options: local flaps for nipple projection, skin grafts, tattooing/pigmentation
• Nipple-sparing mastectomy avoids later reconstruction if oncologically safe