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An aesthetic approach

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The aesthetic impact of all surgical interventions on the breast should be considered prior to the procedure, whether a needle biopsy or mastectomy (Figures 12.1,12.2,12.3,12.4,12.5,12.6). Incision placement should allow adequate access and the incision should be placed with consideration of the skin crease lines and how obtrusive the scar may be. Resection of skin or large amounts of breast tissue distorts the breast, particularly if followed by radiotherapy, and the effect of this should be considered. While a mastectomy always has a profound impact on body image, a flat scar without a dog ear of tissue at either end is crucial to allow placement of an external prosthesis and psychological adjustment to the procedure. Incision planning and the use of techniques to avoid unsightly wounds such as fishtailing may assist this.

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12.1

Potential incisions for excision of breast lesions. The collagen fibres within the skin of the breast are generally arranged circumferentially (Langer's lines), while the lines of maximum resting skin tension are transverse (lines of Kraissl). Skin incisions in line with both of these heal best.

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12.2A, B

The normal mastectomy incision scar can leave an awkward dog ear in the axilla. Pulling the lateral corner of the wound medially and closing the wound in a Y-shape may help leave a flat scar (fish tail scar). Intraoperative and late results are shown.

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12.3

Another option for trying to abolish the lateral dog ear following mastectomy is to use a Wise-pattern type incision as used for breast reduction.

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12.4

A selection of external breast prostheses worn in the bra following mastectomy. Patients are usually discharged home following mastectomy with a soft fabric-covered generic prosthesis. Once the wound has healed, they are formally fitted for a prosthesis of more natural shape, size, and weight to match the remaining breast.

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12.5

Surgical treatment of a breast cancer using a reduction mammoplasty. This patient presented with a 4 cm breast cancer in the left lower outer quadrant. Wide excision of the cancer would have resulted in marked distortion of the breast and thus mastectomy would be the normal surgical approach. However, the patient has large breasts and an alternative is to use a breast reduction approach. A large volume of breast tissue including the cancer is removed and the breast reformed as in a breast reduction with a similar procedure performed on the normal right side to maintain symmetry. The site of the cancer is shown with a dotted circle with planned incision lines also marked.

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