Mastectomy 
Dayalan Clarke 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
The mastectomy has undergone changes over 
the last 70 years. We have moved from a radical 
mastectomy (Halsted’s Mastectomy) in the 1950’s, 
to a modified radical mastectomy (MRM or Patey’s 
Mastectomy) in the 1960’s and with the introduction 
of the sentinel node biopsy to stage the axilla, to a 
simple mastectomy at the turn of the century. Whilst 
the radical mastectomy and modified radical 
mastectomy include an axillary lymph node 
dissection, the simple mastectomy is usually 
performed with a sentinel node biopsy to stage the 
axilla and if the sentinel node is positive, the axilla is 
then treated with a completion lymph node dissection 
or more recently with axillary radiotherapy to avoid 
a second surgical procedure. Axillary Dissection is 
discussed in a separate chapter.  
The radical mastectomy is an obsolete 
operation, so in this chapter we will discuss the 
ompradical mastectomy or simple mastectomy. The 
modified radical mastectomy is still very common in 
resource-limited settings; it involves a combination 
of mastectomy, as described here, and axillary 
dissection, as described in its own chapter.  
The incisions for these two procedures are the 
same and there are two main incisions that can be 
used. The incisions involve removing an ellipse of 
skin along with the breast tissue, the nipple-areolar 
complex and the amount of skin removed depends on 
the size of the breast. The aim of a good mastectomy 
is to remove enough skin so there is no redundant 
skin on the chest wall at the end of the mastectomy, 
but at the same time not removing too much skin 
making closure of the wound difficult. One should 
also make sure that the entire extent of the breast 
tissue is removed, as leaving behind any breast tissue 
will increase the risk of local recurrence of the breast 
cancer. The steps in this chapter show how to 
properly remove all the breast tissue. 
Informed consent should be obtained. The 
patient should be made aware of the potential 
complications including bleeding, infection, and 
seroma (collection of serous fluid in the immediate 
post 
operative 
period.) 
Complications 
that 
accompany axillary lymph node dissection include 
loss of sensation to the medial aspect of the upper 
arm and lateral aspect of the upper chest wall due to 
the division of the intercostobrachial nerve, shoulder 
stiffness and lymphedema, a long-term complication 
of axillary dissection that occurs months to years 
after the procedure. 
Mastectomy proceeds in the following steps:  
• Measurement of the elliptical incisions, superior 
and inferior 
• Dissection of the superior flap 
• Dissection of the breast tissue off the pectoralis 
major muscle 
• Dissection of the inferior flap and removal of the 
breast tissue 
• Irrigation, hemostasis, closure 
 
Steps: 
There are 2 main incisions that will be 
detailed in this discussion: the horizontal ellipse and 
the oblique ellipse. 
 
 
Mastectomy 
Dayalan Clarke 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Two incisions for simple mastectomy: the horizontal (Top) and 
oblique (Bottom) ellipses. Both incisions allow generous access 
to remove all breast tissue in continuity with the nipple-areola 
complex. The ellipse should be large enough so that after the 
breast tissue is removed, the skin edges can be closed without 
either redundancy or tension. 
 
1. The patient is positioned in the supine position 
with the arm of the mastectomy side being placed 
on an arm board, abducted to 90 degrees. The 
chest wall-arm junction should be at the edge of 
the table, where the surgeon will stand. The 
assistant stands on the same side as the surgeon 
and above the abducted arm. 
2. The breast, axilla and the upper arm are prepared 
and draped. One does not have to prepare and 
drape the upper arm in a way that the arm can be 
mobilized during surgery, though some surgeons 
may prefer to do this. 
3. The ellipse of the skin incision is marked on the 
breast. For the horizontal ellipse mastectomy, 
two points A and B are first marked on the breast 
with a sterile marking pen. Point A is the medial 
extent of the ellipse and is placed at the level of 
the nipple 1 to 2cms lateral to the midline. Point 
B is the lateral extent of the ellipse, and the 
placement of this point will differ depending on 
whether one is planning a horizontal ellipse or an 
oblique ellipse. Point B should not extend too far 
laterally and should not extend beyond the 
midaxillary line. The further lateral one extends 
point B, the more likely one is to end up with a 
“dog ear” at the lateral extent. For a horizontal 
ellipse, Point B is marked at the same horizontal 
level as point A. For an oblique ellipse, Point A 
is marked medially, a few centimeters below the 
level of the nipple and point B is placed close to 
the axilla, on the lateral border of the pectoralis 
major or just lateral to it.  
 
Point A is chosen first, at the level of the nipple about 2cm 
lateral to the midline of the chest. Point B is then chosen 
opposite Point A, creating a horizontal or oblique ellipse.  
 
4. For both the horizontal and oblique ellipse 
mastectomies, the breast is pulled down with one 
hand and the points A and B are connected by a 
gentle convex ellipse which marks the incision 
for the superior flap.  
 
Pull the nipple downwards gently and make a convex line that 
connects the two points.  
 
Mastectomy 
Dayalan Clarke 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
The inferior incision of the ellipse is marked by 
now pulling the breast upwards and connecting 
points A and B by a concave ellipse through point 
C. The level at which the inferior elliptical 
incision is marked (point C) is determined by the 
“parallax” method. For this the surgeon holds a 
marking pen or raised index finger halfway 
between their eyeline and the breast. The breast 
is gently pulled downwards so the upper curve of 
the elliptical incision is in line with the marking 
pen and the surgeon’s eye. With the pen or finger 
held at this level, the breast is now gently pulled 
upwards towards the patient’s head and the point 
where the pen lies on the inferior aspect of the 
breast is now marked on the breast – point C. 
This point is used as the lower level of the 
inferior ellipse, to connect points A and B with a 
gentle concavity downwards. 
 
With an elevated pen or finger (shown,) mark a point at the 
middle of the ellipse.  
 
 
Without moving your head or finger, grasp the nipple and 
gently pull it upwards. The point where your finger shows you 
on the inferior aspect of the breast is Point C, the lowest extent 
of the inferior ellipse.  
 
5. Once the incisions have been marked on the skin, 
the superior incision is made with a scalpel along 
the convex line from points A to B. 
 
An incision is made along the superior ellipse through the skin 
to the subcutaneous tissue. 
 
6. The incision is deepened with the scalpel or 
diathermy to go through the subcutaneous fat 
until the layer of the superficial fascia. The white 
strands of the superficial fascia are easily 
identified. The raising of the mastectomy flaps is 
now carried out in this plane between the 
superficial fascia and the breast parenchyma. 
This is normally a well-defined plane which is 
relatively avascular. Once this plane is reached, 
either skin hooks, cats paw retractors or 
Allis/Littlewoods clamps are used to retract the 
superior skin flap. If using Allis/Littlewoods, 
make sure these are placed only on the dermis or 
deeper. Penetrating towel clips are also 
acceptable. 
Mastectomy 
Dayalan Clarke 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
The assistant provides counter-traction with the instruments. 
The surgeon applies traction with the non-dominant hand and 
opens the plane between the subcutaneous fat and the breast 
tissue.  
 
7. The adequate retraction of this superior skin flap 
by the assistant is crucial to an easy and blood 
free dissection. Like all surgical dissections, the 
success of raising the flaps in a mastectomy 
depends on adequate traction applied by the 
assistant and counter traction applied by the 
surgeon. The assistant should retract the skin flap 
upwards towards the operating room ceiling 
rather than towards the head of the patient. While 
the assistant is retracting the skin flap towards the 
ceiling, the surgeon retracts the breast with his 
left hand inferiorly towards the patient’s feet. 
This traction and counter traction should open the 
plane between the superficial fascia and the 
breast parenchyma, to allow an easy and 
avascular plane to carry out this dissection. 
 
Illustration of the plane followed during mastectomy. The skin 
and subcutaneous tissue are retracted away from the breast 
tissue and preserved. Contrary to this illustration, the color of 
breast tissue is very similar to that of subcutaneous fat. Careful 
retraction and meticulous technique is needed to find this plane. 
Source: Andrewmeyerson, CC BY-SA 3.0 via Wikimedia 
Commons 
 
8. The dissection of the superior flap is continued 
superiorly till the dissection reaches the fibers of 
the pectorals major above and beyond the breast 
parenchyma.  
 
The endpoint of the superior flap dissection is the pectoralis 
major muscle. As seen here, the assistant’s retraction of the skin 
is countered by the surgeon’s non-dominant hand pulling the 
breast tissue downwards.  
 
9. Once the pectoralis major fibers are reached 
superiorly, the breast parenchyma is dissected off 
the pectoralis major from medial to lateral. This 
is a well-defined avascular plane. If the surgeon 
retracts the breast adequately, it should dissect 
away from the pectoralis muscle with minimal 
bleeding. 
Mastectomy 
Dayalan Clarke 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
With proper retraction, the breast tissue can be dissected off the 
anterior surface of the pectoralis major muscle.  
 
10. The breast is dissected off the pectoralis major 
muscle as far as the level of the inframammary 
crease if possible. Once this is done, the surgeon 
may prefer to swap places with the assistant for 
the dissection of the inferior flap.  
11. The skin incision for the inferior flap is now 
made as marked previously. Before making the 
inferior flap incision, check that the edge of the 
superior flap will meet the inferior incision 
without any tension. If this appears difficult, the 
skin incision of the inferior flap can be revised to 
reduce the tension of the closure.  
 
The inferior flap dissection is done in the same way that the 
superior one was, with the assistant providing counter-traction 
on the skin and the surgeon’s non-dominant hand pulling the 
breast tissue in a cranial direction.  
 
12. The inferior flap skin incision is deepened 
through the subcutaneous fat and superficial 
fascia. Again, with traction and counter traction 
this plane is developed and dissected till one 
reaches the inframammary crease. As with the 
superior flap dissection reaches the pectoralis 
major muscle, this dissection reaches the 
chest/anterior abdominal wall. 
 
As before, the dissection of the inferior flap is complete when 
the muscle fibers of the pectoralis major muscle are reached.  
 
13. The dissection for the inferior aspect is again 
carried out at this level from point A to point B.  
14. Starting from point A, the breast is now removed 
from the chest wall starting medially and 
finishing laterally to include the axillary tail for a 
simple mastectomy. 
15. For an axillary dissection the dissection carries 
on en-bloc into the axilla. You may extend the 
incision from the lateral tip of the ellipse, Point 
B, to the anterior border of the latissimus dorsi 
for better access to the axilla.  
16. Once the breast is removed, its orientation is 
marked with sutures for the pathologist to 
accurately assess the margins. 
17. The cavity is washed out with Normal Saline and 
adequate hemostasis is achieved with diathermy. 
Mastectomy 
Dayalan Clarke 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Appearance of the cavity after removal of the breast and 
achievement of hemostasis.  
 
18. Once adequate hemostasis is achieved a low 
suction drain size 10 or 14 is placed in the cavity 
and sutured to the skin. 
 
A drain is passed through a separate incision in the skin, in this 
case with a provided trocar.  
 
19. The administration of a local anesthetic agent is 
strongly recommended for post operative 
analgesia, according to standard dosing. 10mls of 
this is administered as an interpectoral block 
administered between the pectoralis major and 
pectoralis minor, and 10mls as a serratus block 
injected at the superior border of the serratus 
muscle before closure, under direct vision. The 
remaining 20mls is injected into the drain after 
closure of the wound. If local anesthetic is 
injected into the drain, do not connect the drain 
to suction for 30 minutes to allow for the local 
anesthesia to be absorbed by the tissues. 
 
 
 
Injection of local anesthetic into the anterior border of the 
serratus anterior muscle. If axillary dissection was not 
performed, this structure will not be visible.  
 
20. The mastectomy wound is closed in 2 layers. The 
first layer is 3-0 interrupted absorbable dermal 
stitches (such as Vicryl or PDS) followed by a 
Mastectomy 
Dayalan Clarke 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
continuous subcuticular suture of 3-0 or 4-0 
absorbable monofilament suture.  
 
The appearance of the wound after the first layer of closure, 
with interrupted absorbable dermal sutures. 
  
Appearance of the wound after subcuticular closure.  
 
21. This is followed by Steri-Strips and a sterile 
occlusive dressing. 
 
Pitfalls 
• A seroma is a common complication of this 
operation, whether a drain is left or not. It is 
easily dealt with in the clinic by serial aspiration 
until the seroma does not recur. Follow strict 
sterile technique when aspirating the seroma, to 
prevent a secondary infection.  
• Failure to close the wound: miscalculation on the 
surgeon’s part can result in two wound edges that 
cannot be brought together at the end of the 
operation. This complication is better prevented 
than treated, by following the steps outlined 
above. If the tumor is mobile, grasp it, elevate it 
away from the chest wall, and visualize where the 
elliptical skin incisions must be made in order for 
the skin to come together. If you find that the skin 
cannot 
be 
closed 
after 
mastectomy, 
try 
undermining the tissue farther in a cranial and 
caudal direction. If this still does not work, an 
inelegant but effective solution to this problem is 
a split-thickness skin graft to close the wound, 
either immediate or delayed.  
• Wound infection: this is unusual, but may require 
opening the wound widely, as there is a cavity 
underneath.  
 
 
Dayalan Clarke MS, MD, FRCS(Ed)  
South Warwickshire NHS Foundation Trust 
Warwick, United Kingdom 
 
June 2023 
