Scandinavian Journal of Surgery 100: 147152, 2011

A CLINICAL STUDY ON THE RESECTION OF BREAST FIBROADENOMA USING TWO TYPES OF INCISION
X.-F. Liu1, J.-X. Zhang2, Q. Zhou1, F. Chen1, Z.-M. Shao2, C. Lu1
Department of Breast, Nanjing Maternity and Child Health Hospital of Nanjing Medical University, Nanjing, China 2 Department of Breast Surgery, Cancer Hospital/Cancer Institute, Department of Oncology, Fudan University, Shanghai, China
1

ABSTRACT

Background and Aims: Breast broadenoma (FA) is traditionally managed by FA excision through an overlying incision (FETOI). FA excision through a periareolar incision (FETPI) has been developed, paying special attention to incision location to preserve cosmesis. The purpose of this article is to discuss the FETPI technique. Methods: The clinical data of 76 patients who underwent FETPI (98 FAs, group A) and 82 patients who underwent FETOI (122 FAs, group B) were retrospectively analyzed in this non-randomized study. Early postoperative complications, nipple sensation loss, and cosmetic results were compared between the two groups. The techniques, indications, and special considerations of the FETPI technique were described and identied. Results: The FETPI technique was associated with more early postoperative complications (7/76 vs. 2/82, p=0.067) and more nipple sensation losses (15/76 vs. 7/82, p=0.042) than those of the FETOI technique. Cosmetic assessment at 6 months demonstrated statistically more excellent/good results in group A than in group B (62/76 vs. 50/82, p=0.004). Conclusion: The FETPI technique yields superior cosmetic results with minor postoperative complications.
Key words: Areola; incision; breast; broadenoma; excision; periareolar incision; overlying incision; nonrandomized study; surgical techniques; surgical indications INTRODUCTION Fibroadenomas (FAs) are benign solid tumors composed of stromal and epithelial elements. After carcinoma, FA is the second most common tumor in the breast and is the most common tumor in women younger than 30 years. Conservative therapy has been attempted medically with progesterone and daCorrespondence: Zhi-Ming Shao, M.D. Department of Breast Surgery Cancer Hospital/Cancer Institute Department of Oncology, Fudan University 270 Dongan Road Shanghai 200032 Peoples Republic of China Email: zhimingshao@yahoo.com

nazol, since the most prevalent theory on the etiology of FAs attributes them to excessive estrogen inuence or response. Unfortunately, FAs fail to respond to these antiestrogen medications (1). In the era of modern radiology and nonsurgical tissue biopsies, conservative treatment of FA is often considered safe and acceptable after adequate triple testing (clinical examination, radiology, and biopsy) (2, 3, 4, 5, 6). Patients who choose conservative management need to be informed of the limitation of triple testing and must be assessed promptly if there is symptomatic or clinical change (4). The authors have noted that, in clinical practice, approximately 1/3 of FAs that have undergone longterm periodic monitoring ultimately cause anxiety and discomfort for patients and difculty for physicians. These masses will be excised, and only surgical resection is curative.

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The criteria for surgical treatment in this study included the following: 1. Patients older than 35 years of age (7). 2. Mean change in tumor dimension for a 6-month interval is greater than 20% for all ages (8). 3. Patients with FAs that are symptomatic (surgery in this case is a traditional option, and patients prefer it). 4. Patients younger than 20 years who have a likelihood of juvenile FAs (9). 5. Patients with psychological/nervous disorder caused by long-term regular follow-up or who are unavailable for regular follow-up. Surgical removal is curative, and the most obvious approach to surgical excision is through an incision overlying the mass. That is why breast FA has been traditionally managed by FETOI, which often results in marked scarring. Patients feel uncomfortable about the unsightly scar, especially adolescent patients who are sensitive about their body appearance. The FETPI technique offers the advantage of an incision in an aesthetically acceptable area. The scar can be camouaged by the dark color of the areolar skin and the roughness of the areolar glands (10). The periareolar scar is esthetically superior to the overlying scar (11). However, FETPI is not possible if the lesion is far away from the areolar border or if the areola is small and the lesion is not underneath the areola. In addition, if a lesion is 25 cm away from the areolar border, a subcutaneous tunnel, which may cause skin injury, is necessary to expose the lesion in the FETPI technique. Therefore, FETPI should be selectively and carefully performed. Unfortunately, few publications have dealt in detail with the technical considerations necessary for successful execution of the FETPI procedure. In this paper, some important aspects of the FETPI procedure indications, contraindications, surgical technique, procedural limitations, benets, complications, and surgical outcomes are analyzed by comparing FETPI and FETOI through a review of patients medical records. METHODS
STUDY DESIGN

small areola, distance from the outer margin of the mass to the nearest areolas edge >6.0 cm, suspicion of malignancy, nonpalpable lesions, and age >35 years. From June 2008 to February 2009, 260 consecutive female patients underwent FA excision at Nanjing Maternity and Child Health Hospital of Nanjing Medical University and at Shanghai Cancer Hospital of Fudan University. Among them, 92 patients with 106 breast FAs were excluded from analysis for the following reasons: age >35 years, suspicion of malignancy, inframammary incision, impalpable tumors, or tumors greater than 5 cm. The study included a total of 158 patients with a mean age of 27.4 years (range, 1235 years) and a median followup period of 12 months (8 to 16 months). Fifty-one patients had multiple tumors, including 36 patients with bilateral lesions, and 6 patients were young adolescents (younger than 20 years and older than 12 years). Histopathologic examination was consistent with FA in each tumor, and average tumor diameter was 2.5 cm. Among these 158 patients, 76 patients (with 98 FAs) fullling the FETPI indications were entered into group A. Patients who underwent FETOI (n = 82, 122 FAs, group B) by the surgeon teams in the same period included 22 patients suitable for FETPI who chose FETOI after informed consent.
EXCISIONAL PROCEDURES OF THE FETPI TECHNIQUE

Informed consent was obtained from the patients, and approval was obtained from the designated review board of the institution involved. This study was performed with a retrospective, comparative, historical design. Before the study, for the purpose of selecting suitable patients, the authors had already determined the well-dened criteria of indications and contraindications for the FETPI technique based on their previous clinical experience. The FETPI technique was indicated for patients with the following characteristics: an areola diameter greater than 3.5~5.0 centimeters (cm), a distance from the outer margin of the mass to the nearest areolas edge 5.0 cm, the largest diameter of clinically diagnosed palpable FAs3.0 cm, and age 35 years. The contraindications of FETPI included the following: the largest diameter of the mass >5.0 cm and a

The incision marking was outlined preoperatively, with the patient in a supine position and arms abducted 90 degrees on arm boards. The procedure generally was performed under a local anesthetic or intravenous anesthesia. A circumareolar skin incision was made on the marking at the areolar border after the anesthesia had been administered. The subcutaneous tissue was dissected off by electrocautery, pulling the edges of the incision upward with skin hooks. Dissection was continued in the plane between subcutaneous fat and breast tissue, and downward toward the mass. The position of the mass was determined again by palpation. A radial incision within breast tissue was made outward and downward to the palpable mass to an appropriate depth. After mass exposure, the skin ap was raised, and the thin tissue around the FA was grasped with forceps to facilitate exposure of the mass. A thin excision of the tumor with a 23 mm circumferential margin of macroscopically normal tissue was necessary. After the FA was removed, meticulous hemostasis was needed before closure. Breast tissue approximation was not considered necessary but was preferred if such closure would not result in deformity. The dermis of the skin was approximated using interrupted 4-0 absorbable sutures (Ethicon Vicryl) to decrease skin tension. A running subcuticular stitch with 4-0 absorbable sutures was used without burying the starting and nishing knots in order to take stitches out in an appropriate time to avoid skin irritation. A soft cotton pressure dressing was then placed inside, and the outside was bandaged postoperatively. Compression with a sandbag for 6 hours was preferred in the case of subcutaneous tunnel or when the operative site was located in front of the chest. Both methods played a critical role in hemostasis.
EXCISIONAL PROCEDURES OF THE FETOI TECHNIQUE

The main difference between the FETOI and FETPI procedures was the incision location. Most commonly, a curve incision was located on the lesion in FETOI. Dissection was continued down through the subcutaneous tissue at the edges of the mass by electrocautery after the skin overlying the mass was dissected.

A clinical study on the resection of breast broadenoma using two types of incision TABLE 1 Scored by assessment (from 1 to 4) of three scar parameters, namely, scar width, area of pigment loss in the scar, and height of scar swelling. Score* 1 2 3 4 Scar width 1 mm >1 mm and 2 mm >2 mm and 3 mm >3 mm Area of pigment loss in scar 20 mm >20 mm2 and 40 mm2 >40 mm2 and 80 mm2 >80 mm2
2

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Height of scar swelling 1 mm >1 mm and 2 mm >2 mm and 3 mm >3 mm

* These parameters were quantied using the following scale: 1=minimal, 2=discreet, 3=moderate, and 4=marked.

THE EVALUATION CRITERIA

TABLE 2 Difference between group A and group B in areola diameter, tumor sizes, distance between the areolar border and the mass (DBABM), operation time, bleeding volume, scar length, early complications, and nipple sensation loss. Group A Group B p-value 0.004 0.000 0.000 0.003 0.000 0.034 0.067 0.042

The scar clinical grading scale was determined using 3 parameters: scar width, area of pigment loss in the scar, and height of scar swelling. These parameters were quantied using a score from 1 to 4 (1=minimal; 2=discreet; 3=moderate; and 4=marked; Table 1). The signicance of the scar was assessed on a scale from grade 1 (best scar) to grade 4 (poor scar), according to the sum of the scores of the three parameters at 6 months after treatment (3 or 4=grade 1; 5, 6 or 7=grade 2; 8, 9 or 10=grade 3; and 11 or 12=grade 4). Patients rated their subjective feelings about cosmetic outcomes themselves. They were asked to assess the scar on a scale of 1 to 4 (1=excellent; 2= good; 3=fair; and 4=poor) at 6 months after treatment. The nipple sensation loss was investigated after a 6-month follow-up period. The patients told the doctors whether their nipple sensation was lost or not. Nipple sensation was rated as 1 (good) or 2 (sensation loss).
STATISTICAL ANALYSIS

Areolas diameter 4.40.5cm Tumor diameter 2.40.5cm DBABM 2.60.9cm Operation time 445 minutes Bleeding volume 345ml Scar length 4.80.6cm The early complications* 7 Nipple sensation loss 15

4.20.4cm 2.90.4cm 4.00.8cm 424 minutes 246ml 4.60.6cm 2 7

* Early complications included (comparing group A to group B): hematoma formation (4 vs. 2), pain on the rst postoperative night (1 vs. 0), and skin ap bruises (2 vs. 0).

The areola diameter, tumor diameter, distance between the areola border and the mass, bleeding volume, and operation time in the two groups were expressed as the mean standard error of the mean (SEM, see Table 2). Differences between the 2 groups were compared by Students t-test. Early complications, nipple sensation loss, and cosmetic results in the 2 groups were compared using the chi-square test, and p < 0.05 was considered to be signicant. All the statistics analysis was performed in SAS ZealAnyDay Version 1.7 (Copyright 199798 HaiLi, Zeal SoftStudio).

RESULTS
SURGICAL COMPLICATIONS

There was no surgical mortality. All patients tolerated the procedure well without acute complications, and no major complications were noted. The early complications (pain on the rst postoperative night, skin ap bruises, hematoma formation) of group A were not signicantly higher than that of group B (7/76,

Fig. 1. One patient had a broadenoma in the left breast. The broadenoma is circled with ink, and the skin-areola junction is drawn with ink.

Fig. 2. A line is drawn along the skin-areola junction, the outer edge of the lesion is located 5 cm away from the areolar border.

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Fig. 3. The skin-fat ap is raised upward by a skin hook. The resected edges are grasped with Allis clamps. The broadenoma is revealed by applying rm tension to pull breast tissue. The procedures allow removal of the broadenoma.

Fig. 5. The scar is camouaged by the skin-areolar junction with nearly invisible scarring at the incision line along the junction of areola and skin.

2/82; p=0.067). Four patients in group A presented hematoma in the subcutaneous tunnel area, which resolved between 1 and 6 months after surgery. Two patients in group B developed a small postoperative hematoma, which resolved within 3 months of observation. No patients in either group developed mastitis or incisional complications.
OPERATION TIME, BLEEDING VOLUME, AND NIPPLE SENSATION

Fig. 4. The mass is resected through the incision at the junction of the areola and breast skin.

The operation time of group A was longer than that of group B (445 minutes vs. 424 minutes, p= 0.003). The bleeding volume of group A was greater than that of group B (345ml vs. 246 ml, p=0.000). A signicantly higher proportion of female patients lacked normal nipple-areola sensation in group A than group B (15/76 vs. 7/82, p=0.042, Table 2).

TABLE 3 Number (percentage) of patients with various scar grades. Scars were graded from 1(best scar) to 4 (poor scar) Group A Group B Sum Grade 1* 12 (15.8%) 20 (24.4%) 37 (23.98) Grade 2 34 (44.7%) 29 (35.4%) 53 (62.0%) Grade 3 26 (34.2%) 23 (28.0%) 25 (15.8%) Grade 4 4 (5.3%) 10 (12.2%) 14 (8.9%) Total 76 82 158

* Scars were graded according to the total scores of the 3 parameters (scar width, area of pigment loss in scar, and height of scar swelling) at 6 months after treatment. (3 or 4=grade 1; 5, 6 or 7=grade 2; 8, 9 or 10=grade 3; and 11 or 12=grade 4).

TABLE 4 Patients rated their subjective feelings of cosmetic outcomes using the scale of excellent, good, fair, or poor at 6 months after treatment Group A Group B Total Excellent 18 (23.7%) 14 (17.1%) 32 (20.3%) Good 44 (57.9%) 36 (43.9%) 75 (47.5%) Fair 10 (13.2%) 10 (12.2%) 20 (12.7%) Poor 4 (5.3%) 22 (26.8%) 31 (19.6%) Total 076 082 158

A clinical study on the resection of breast broadenoma using two types of incision AESTHETIC OUTCOME NIPPLE SENSATION LOSS

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No scars were surgically revised in either group. The mean scar length was 4.80.6 cm in group A and 3.70.6 cm in group B (p=0.034), 5.3% of patients in group A had marked scarring (grade 4), compared with 12.2% in group B (p=0.126, Table 3). A signicantly higher proportion of female patients complained of poor scarring in group B than in group A (4/76 vs. 22/82, p=0.001, Table 4). The cosmetic results were positive (excellent, good, and fair) in 72 (94.7%) of the 76 patients in group A, in contrast to 60 (73.2%, p=0.001) out of 82 in group B. Sixty-two of the 76 (81.6%) patients in group A and 50 of the 82 (61.0%) patients in group B judged their cosmetic results to be excellent or good during the 6-month follow-up period (p=0.004).

The only factor found to inuence the sensitivity of the nipple in the study was the lateral location of the incision. There are other ndings that support the same point (17). Schlenz et al. found that the nipple and areola were always innervated by the lateral and anterior cutaneous branches of the 3rd, 4th, and 5th intercostal nerves (18). These cutaneous branches took supercial courses within the subcutaneous fat and reached the nipple from the lateral side, terminating at the medial areolar border. These ndings suggest that the nerves innervating the nipple and areola are best protected if skin incisions at the lateral areolar border are avoided (18).
DISRUPTION OF LACTATION

DISCUSSION
HISTORY AND ADVANTAGE OF THE PERIAREOLAR INCISION

The periareolar incision was introduced rst by Dufourmentel in 1928. Subsequently, the incision was widely used in gynecomastia (12, 13) and in breast augmentation (14, 15) for a long time because of its cosmetic advantage. Some surgeons considered the periareolar incision as the gateway to the breast (11). Cosmetic results were satisfactory for pediatric patients with palpable breast FAs who had undergone operation through a circumareolar incision (16). At present, the majority of surgical textbooks suggest a hemi-circumareolar or periareolar incision if possible.
DISADVANTAGES OF FETPI

The FETPI technique involves extensive undermining and may interrupt milk ducts. It is not possible to assess problems in lactation in the context of the present study. However, in order to avoid damage to lactiferous ducts due to extensive undermining when using FETPI, the dissection plane between subcutaneous fat and breast tissue should be identied and followed by pulling the edges of the incision upward.
PATIENT SELECTION FOR FETPI

The formulated criteria are generally practicable in the light of the present study, with no need to change them thus far. However, in certain cases the criteria maybe inapplicable. For example, if a patient with a supercially located mass greater than 5 cm in diameter (which violates the indications of FETPI) also had a large areola, FETPI would be technical feasible.
THE LIMITATIONS OF THE STUDY

In the FEPTI group, the operation time was longer (by 2 min), and the volume of intraoperative blood loss was larger (by 10 ml) when compared with the FETOI group. Although statistically signicant, both differences, the longer duration and the excess blood loss, are meaningless in clinical practice. Renement of surgical techniques (such as exposure, hemostasis, and closure) is required for surgeons. Dissection parallel to the skin in the vascular plane between subcutaneous fat and breast tissue will minimize bleeding. Meticulous hemostasis should be achieved before closure to minimize hemorrhage and to prevent the formation of hematomas. A common reason for skin ap bruises is excessive traction during surgery, and these may resolve without treatment. A consistently dark spot may be a sign of dysfunction of venous drainage or arterial supply; therefore, relieving the compression is necessary. A thick ap that includes skin and all subcutaneous fat is a good option to prevent skin ap necrosis and skin ap bruises. The majority of these complications occurred early in the learning curve. Most of the complications were minor and preventable. They did not interfere with the esthetic outcome.

This was not a randomized study. Tumor locations were more peripheral among the FETOI patients, which may bias the results. Thus, a prospective, randomized study appears to be warranted. CONCLUSION To summarize, the results show that if criteria for patient selection are carefully respected, the FETPI procedure can provide both oncological safety and cosmesis. A circumareolar incision should be performed when feasible. ACKNOWLEDGEMENTS This work was supported by a grant from Nanjing Health Bureau Clinic Research Foundation [Project No.YKK09080].

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X.-F. Liu, J.-X. Zhang, Q. Zhou, F. Chen, Z.-M. Shao, C. Lu 10. Song RY: Augmentation mammoplasty and an improved method of silastic gel breast prosthesis implantation through an areolar incision. Zhonghua Zheng Xing Shao Shang Wai Ke Za Zhi 1990; 6(1):7274 11. Shrotria S: The peri-areolar incision--gateway to the breast! Eur J Surg Oncol 2001;27(6):601603 12. Saad MN, Kay S: The circumareolar incision: a useful incision for gynaecomastia. Ann R Coll Surg Engl 1984;66(2):121122 13. Pitanguy I: Transareolar incision for gynecomastia. Plast Reconstr Surg 1966;38(5):414419 14. Becker H: The intra-areolar incision for breast augmentation. Ann Plast Surg 1999;42(1):103106 15. Jones FR, Tauras AP: A periareolar incision for augmentation mammaplasty. Plast Reconstr Surg 1973;51(6):641644 16. Tiryaki T, Senel E, Hucumenoglu S, et al: Breast broadenoma in female adolescents. Saudi Med J 2007;28(1):137138 17. Benediktsson KP, Perbeck L, Geigant E, et al: Touch sensibility in the breast after subcutaneous mastectomy and immediate reconstruction with a prosthesis. Br J Plast Surg 1997;50(6):443 449 18. Schlenz I, Kuzbari R, Gruber H, et al: The sensitivity of the nipple-areola complex: an anatomic study. Plast Reconstr Surg 2000;105(3):905909

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Received: June 22, 2010 Accepted: December 8, 2010