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Introduction to the clinical stations
Published in Sukhpreet Singh Dubb, Core Surgical Training Interviews, 2020
In lactational mastitis, entry sites from the surface may inoculate the milk present within the breast due to overproduction or milk stasis. Entry sites can be through breaks in the skin, or fissures, with source organisms arising from the skin surface or an infant's oral cavity. In duct ectasia, the lactiferous ducts undergo squamous metaplasia causing blockage, duct dilation and inflammation. This process predisposes to bacterial infections.
Breast lump assessment
Published in Alexander Trevatt, Richard Boulton, Daren Francis, Nishanthan Mahesan, Take Charge! General Surgery and Urology, 2020
Intraductal papilloma is the most common cause of blood stained nipple discharge, the next being adenocarcinoma. They are benign localised areas of epithelial proliferation within large mammary ducts. They increase the risk of developing invasive breast carcinoma and normally present with unilateral bloody discharge from the nipple. These patients are generally managed with microdochectomy (surgical removal of lactiferous duct and should be followed up by the responsible surgeon for histology results).
Breast
Published in Joseph Kovi, Hung Dinh Duong, Frozen Section In Surgical Pathology: An Atlas, 2019
Joseph Kovi, M.D. Hung Dinh Duong
A 54-year-old woman complained of severe itching and roughness in her left nipple. Examination showed that the surface of the entire nipple and most of the areola was bright red. The upper half of the nipple appeared to be eroded, crusted, and very moist. There was no palpable tumor in the breast. A single, firm lymph node was detected in the left axilla. A biopsy of the nipple was submitted for study. Microscopically, the surface covering epithelium appeared markedly thickened. The upper stratum malpighii was focally eroded. The wide squamous cell layer was extensively invaded by large ovoid cells. These neoplastic cells had ample, clear cytoplasm and possessed prominent, dark, vesicular nuclei. The tumor cells were found either singly or in groups in the epidermis. Although these large, ovoid cells were characteristic so-called Paget cells, some contained melanin pigment granules. In the upper dermis, a heavy lymphocytic reaction was noted. Additionally, one of the deeper lying lactiferous ducts was completely filled by tumor cells. These were morphologically quite similar to the Paget cells found in the epidermis (Figure 71 and 72).
The discovery of the lymphatic system in the 17th century. Part VII: the rise of vascular injection
Published in Acta Chirurgica Belgica, 2021
Raphael Suy, Sarah Thomis, Inge Fourneau
Nuck’s main work, titled Adenographia Curiosa, was published in 1691 [41]. In the dedication he compared himself with a merchant (Mercator) sailing unexplored rivers of bodily fluids in order to discover unknown lands and treasures. It appears from this book that he detected lymph vessels in nearly all organs and tissues, except in the brain in which, however, he suspected their presence. He was the first to describe lymph vessels in the tunics of pulmonary arteries, along the iliac arteries and aorta, in kidneys, and on the heart (Figure 6(a)). He stated that ‘along hidden pathways, unknown to the anatomist, lymph entered the nodes from where it flowed into larger lymph vessels and finally entered into the thoracic duct’. His most remarkable experiment was the injection of ‘his mercury’ via the nipple into avalvular lactiferous ducts, combined with a similar injection into an afferent intrathoracic lymph vessel, and of red-coloured wax in the corresponding internal mammary artery. In this way, he demonstrated that milk was neither lymph nor chyle, as commonly accepted in those days, but a specific liquid separated from arterial blood into the lactiferous ducts within the globules of the mammary glands, a phenomenon which, as he added, was strongly conditioned by the spirit (of the mother) [42,p.12–21]. To the question ‘Why is it that blood does not flow in the form of blood into lymph vessels?’ he answered: ‘all fluids originate from blood, but the smallest arteries admit only clear lymph’ [42,p.53–54].
Correction of inverted nipples with the double-track sun-cross running suture technique
Published in Journal of Plastic Surgery and Hand Surgery, 2018
Jae Hoon Jeong, Iehyon Park, Jihyeon Han, Ji Ung Park
Inverted nipples have remarkable fibrosis and short, severely retracted lactiferous ducts. The bulk of the soft tissue in the nipple is markedly insufficient [9]. Therefore, any surgical procedure in this area must attempt to preserve the lactiferous ducts and nerve system to maintain nipple sensation and to facilitate future breastfeeding. Many previous studies have suggested various surgical techniques for correcting nipple inversion. Various skin or dermoglandular flap reconstructions [4,5,10–12], suture techniques [6,13–15], and even other methods, such as nipple aspiration, micro-knife techniques, and the unique telescope technique (in which a circumferential incision is made, the nipple is pulled, and the base is tightened) [16–19], have been introduced as correction methods. Although previously reported flap methods have shown the presence of sufficient bulk tissue and a low recurrence rate of nipple inversion, several complications have been reported, including visible, undesirable white hypopigmented scars in the areola, the need to remove a portion of the nerve or duct and the requirement for further, complex procedures. In addition, the use of the purse-string suture alone may interrupt the blood supply to the nipple, resulting in circulation problems, necrosis and a high collapse rate, because this suture creates an area of dead space at the centre of the nipple if no core suture is used [12]. Alternative methods include the simple insertion of autologous or heterologous material and the use of a nipple aspirator device. However, these methods have shown inconsistent results and have led to complications such as incomplete correction, granuloma formation and insufficient release of the shortened lactiferous duct.