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

I. Diagnostic Approach to Benign Breast Disease

General Concept

Benign breast diseases = non-malignant lesions of breast epithelium, stroma, ducts or inflammatory tissue
Most breast lumps are benign, but malignancy must be excluded
Use triple assessment:

History and physical examination
Imaging
Biopsy / cytology when indicated

History

Age and menopausal status
Pregnancy/lactation
Cyclic vs non-cyclic pain
Duration and growth of lump
Nipple discharge:

Physiologic: bilateral, multiduct, milky/green/yellow
Suspicious: spontaneous, unilateral, single-duct, bloody/serous

Fever/redness/pain → mastitis or abscess
Family history and previous breast biopsy
Medication: hormones, antipsychotics, spironolactone, antiandrogens

Physical Examination

Inspect both breasts:

Asymmetry, skin changes, erythema
Nipple inversion, eczema, discharge
Surgical scars

Palpate both breasts and axillae
Describe mass:

Site/quadrant, size, consistency
Mobile or fixed
Tender or painless
Well circumscribed or irregular

Imaging Choice

Age <30 with palpable mass → ultrasound first
Age 30-39 → ultrasound and/or diagnostic mammography/tomosynthesis depending on clinical setting
Age >=40 → diagnostic mammography/tomosynthesis first, ultrasound complementary
Suspicious imaging or discordant clinical finding → image-guided core needle biopsy
BI-RADS 3 probably benign lesion → short interval imaging follow-up

Biopsy / Aspiration

Core needle biopsy = preferred for solid or suspicious lesions
FNAB/cyst aspiration:

Useful for painful/simple cyst aspiration
Fluid should usually be non-bloody and lesion should resolve
Bloody aspirate, residual mass or recurrent cyst → cytology/biopsy and further workup

Excisional biopsy if imaging-pathology discordance, atypia/high-risk lesion, or persistent suspicious lesion

II. Common Benign Breast Diseases

Fibrocystic Changes

Very common hormone-related breast changes
Most common in reproductive-age/premenopausal women
Pathomechanism:

Estrogen/progesterone stimulation → ductal/lobular changes → cyst formation + stromal fibrosis

Risk/association: hormonal therapy, family history; caffeine may worsen mastalgia in some patients

Classification

Non-proliferative changes

Simple cysts
Fibrosis
Apocrine/papillary metaplasia
Minimal or no increased cancer risk

Proliferative disease without atypia

Usual ductal hyperplasia, sclerosing adenosis, papilloma
Slightly increased cancer risk

Atypical hyperplasia

Atypical ductal hyperplasia / atypical lobular hyperplasia
Higher future breast cancer risk
Usually needs excision or specialist risk management depending on biopsy result

Clinical Features

Cyclic breast pain, worse before menstruation
Breast swelling and lumpiness
Often multiple and bilateral
May have nodularity without dominant suspicious mass

Diagnosis and Treatment

Clinical examination + age-appropriate imaging
Ultrasound for cystic/solid distinction
Mammography in older women or suspicious setting
Core biopsy if suspicious, dominant mass, atypical imaging or discordant findings
Treatment mostly conservative:

Reassurance after malignancy excluded
Supportive bra
NSAIDs/analgesia
Cycle-related mastalgia: hormonal manipulation only in selected severe cases
Cyst aspiration if large/painful
Surgical excision if cancer suspicion, atypia/high-risk lesion or persistent symptomatic lesion

Breast Cysts

Fluid-filled sacs in breast tissue
May be solitary or multiple
Often tender and fluctuate with menstrual cycle
US confirms cystic nature:

Simple cyst → anechoic, thin wall, posterior enhancement
Complicated/complex cyst → debris, septa, solid component; may need aspiration/biopsy

Treatment:

Observation if asymptomatic simple cyst
Aspiration if painful, large or patient anxious
Bloody fluid/residual mass/recurrent cyst → further investigation

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 and regress after menopause
Malignant transformation is very rare

Clinical Features

Well-circumscribed, firm, rubbery, mobile mass
Usually painless
"Breast mouse" = moves easily under fingers
Can be multiple or bilateral
Rapid growth raises concern for phyllodes tumor

Diagnosis and Treatment

Physical examination
US: oval, well-circumscribed, hypoechoic solid lesion
Mammography less sensitive in young dense breasts; used by age/risk
Core needle biopsy if uncertain, enlarging, atypical imaging or older patient
Treatment:

Small, typical, asymptomatic → observation/follow-up
Excision or vacuum-assisted removal if large, growing, symptomatic, cosmetic concern, patient preference or cancer/phyllodes suspicion
Large/rapidly growing lesion >3-4 cm → excision often preferred

Intraductal Papilloma

Benign epithelial tumor growing within lactiferous duct
Ductal epithelial and myoepithelial proliferation around fibrovascular core
Central solitary papilloma often near nipple
Multiple/peripheral papillomas carry higher association with atypia/cancer risk

Clinical Features

Spontaneous unilateral nipple discharge
Often bloody or serous
Palpable subareolar mass if large
May be screen-detected

Diagnosis and Treatment

US: intraductal mass with duct dilatation
Mammography may show mass or calcifications
Ductography/galactography may show intraluminal filling defect, now less commonly used
Core needle biopsy if lesion visible/large enough
Treatment:

Excision if symptomatic, bloody discharge, atypia, discordant biopsy, multiple/peripheral papillomas or patient preference
Observation may be acceptable for asymptomatic concordant papilloma without atypia after MDT/radiology-pathology agreement

III. Inflammatory, Male and Other Benign Breast Conditions

Mastitis

Inflammation/infection of breast tissue
Usually lactational in breastfeeding women
Common pathogen: Staphylococcus aureus
Clinical features:

Painful red swollen breast
Fever, malaise
Localized tenderness/warmth
May progress to abscess

Treatment:

Continue breastfeeding or pumping if possible
Analgesia, hydration, milk drainage
Antibiotics covering staphylococci, e.g. flucloxacillin/cephalexin depending on local practice and allergy
If no improvement or mass/fluctuation → ultrasound for abscess
Non-lactational mastitis or persistent erythema → exclude inflammatory breast cancer

Breast Abscess

Localized pus collection in breast
Usually complication of mastitis
Clinical: fluctuant tender mass, fever, erythema
Diagnosis: ultrasound confirms collection and guides drainage
Treatment:

Antibiotics + drainage
US-guided needle aspiration preferred when feasible, may need repetition
Incision and drainage if large, multiloculated, skin necrosis or failed aspiration
Culture pus
In non-lactating women, biopsy/imaging follow-up if atypical or non-resolving

Gynecomastia

Benign enlargement of male glandular breast tissue
Due to estrogen-androgen imbalance
Physiologic:

Neonatal
Pubertal
Older age

Pathologic/secondary causes:

Medications: spironolactone, antiandrogens, anabolic steroids, some psychotropics
Liver disease, renal failure
Hypogonadism
Testicular/adrenal tumors rarely
Idiopathic

Clinical: 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
Medication in early painful persistent cases selected by specialist
Surgery if persistent, distressing or fibrotic: subcutaneous mastectomy, liposuction-assisted contouring

Other High-Yield Benign / Borderline Lesions

Lesion	Key points	Treatment logic
Phyllodes tumor	Fibroepithelial tumor, can mimic rapidly growing fibroadenoma; benign/borderline/malignant	Wide local excision with clear margins; no routine axillary surgery
Fat necrosis	After trauma/surgery/radiotherapy; can mimic cancer clinically/imaging	Biopsy if suspicious; observe if concordantly benign
Duct ectasia	Dilated subareolar ducts, sticky colored discharge, periductal inflammation	Conservative; duct excision if persistent troublesome discharge or suspicion
Periductal mastitis	Smoking association; recurrent periareolar inflammation/fistula	Antibiotics, drainage if abscess, duct/fistula excision if recurrent

IV. Types of Breast-Reconstruction Surgeries

Timing and Goals

Goal: restore breast mound shape, symmetry and body image after mastectomy or large breast-conserving excision
Timing:

Immediate reconstruction → same operation as mastectomy
Delayed reconstruction → after cancer treatment/radiotherapy
Delayed-immediate reconstruction → temporary expander first, definitive reconstruction after pathology/radiotherapy decision

Choice depends on cancer stage, radiotherapy need, body habitus, comorbidities, smoking, patient preference and plastic surgery expertise

1. Implant-Based Reconstruction

Uses silicone or saline implant
Can be one-stage direct-to-implant or two-stage expander-to-implant
Two-stage method:

Tissue expander placed at mastectomy
Gradual expansion stretches skin/soft tissue
Exchange for permanent implant later

Implant position:

Prepectoral: above pectoralis muscle, often with mesh/ADM support
Subpectoral: under pectoralis muscle, sometimes with ADM lower pole support

Pros: shorter operation, no donor-site scar, faster initial recovery
Cons/risks: infection, implant loss, capsular contracture, rupture, malposition, rippling, less natural feel, worse outcomes after radiotherapy

2. Autologous / Flap-Based Reconstruction

Uses patient's own skin/fat +/- muscle
Can be pedicled or free flap with microvascular anastomosis
More natural look/feel and ages with patient
Longer surgery, donor-site morbidity and microsurgical risk

Abdominal Flaps

TRAM flap = transverse rectus abdominis myocutaneous flap

Uses lower abdominal skin/fat and rectus muscle
Pedicled or free flap
More abdominal wall weakness/hernia risk than perforator flaps

DIEP flap = deep inferior epigastric perforator flap

Uses lower abdominal skin/fat supplied by perforators
Preserves rectus muscle
Less donor-site morbidity than TRAM
Requires microsurgery

SIEA flap: superficial inferior epigastric artery flap; less common, anatomy-dependent

Back, Gluteal and Thigh Flaps

Latissimus dorsi flap:

Pedicled flap from upper back
Often combined with implant or expander for volume
Useful after radiotherapy or when chest wall soft tissue is poor

Gluteal flaps: SGAP/IGAP from buttock, free flap, less common
Thigh flaps: PAP/TUG and related flaps; alternative when abdomen not usable

3. Oncoplastic and Partial Breast Reconstruction

Used after breast-conserving surgery when volume loss/deformity risk is significant
Combines wide tumor excision with plastic surgical reshaping
Methods:

Local glandular rearrangement
Therapeutic mammoplasty/reduction pattern
Local perforator flaps, e.g. LICAP/AICAP, for lateral defects
Contralateral symmetrization if needed

4. Fat Grafting / Lipofilling

Autologous fat harvested by liposuction and injected to improve contour
Used as adjunct after implant or flap reconstruction
Can correct rippling, contour defects and radiation fibrosis
May require repeated sessions

5. Nipple-Areola Complex (NAC) Reconstruction

Usually final stage after breast mound reconstruction settles
Options:

Local skin flaps for nipple projection
Skin grafts for areola
3D tattooing/pigmentation
Nipple-sparing mastectomy when oncologically safe avoids later NAC reconstruction

Complications of Reconstruction

General: bleeding, infection, seroma, wound dehiscence, skin/nipple necrosis
Implant: capsular contracture, rupture, malposition, rippling, implant loss
Flap: partial/total flap loss, fat necrosis, donor-site hernia/weakness, contour deformity
Radiotherapy increases fibrosis, contracture and wound-healing complications, especially with implants

Exam focus: Benign breast disease still needs triple assessment when a dominant lump is present. Fibroadenoma is a mobile solid tumor in young women; fibrocystic change causes cyclic bilateral pain/lumpiness; papilloma causes spontaneous bloody nipple discharge; abscess needs antibiotics plus drainage. Reconstruction is immediate or delayed, implant-based or autologous, with nipple-areola reconstruction/fat grafting as common final refinements.