Modified techniques versus Hadfield’s procedure in patients with periductal mastitis

Periductal mastitis (PM) is a benign disease affecting a terminal lactiferous duct responsible for 1–2% of all symptomatic breast conditions [1]. Clinically, non-cyclic mastalgia, nipple discharge, nipple-areola complex (NAC) retraction, subareolar breast mass with or without mastitis, periareolar abscess, or often lactiferous duct’s fistula can be seen [1]. The disease was first defined by Birkett [2] as the “morbid condition of the lactiferous duct” in 1850; later, in 1923, Bloodgood [3] reported that lactiferous duct enlargement and periductal inflammation take an important place in the pathogenesis. In 1951, it was defined by Zuska et al. [4] as “mammary fistula” and was referred to as Zuska’s disease in the literature.

The disease’s pathogenesis is complex, but the major pathologic finding is squamous metaplasia that acts on epithelial cells. The disease begins with periductal inflammation that develops due to the obstruction of subareolar lactiferous ducts by keratinous plaques. This inflammation causes duct rupture and periareolar fistula development [4, 5].

In the treatment; fistulotomy, fistulectomy, abscess drainage, and antibiotic therapy are not equally effective. After incision and drainage of abscess or only antibiotic therapy, there is a high probability of recurrence [1]. Therefore, due to the high recurrence rates, the technique of terminal lactiferous duct excision was described by Hadfield’ in the 1960s. However, necrosis and loss of sensation of the areola-nipple complex, nipple retraction, and postoperative infection are potential complications of the Hadfield operation. In addition, the recurrence rate after this procedure is 11% [1]. Several modifications such as a radial incision or periareolar combined radial incision have been introduced to minimize these complications [6‐9].

There are no comparative articles for different surgical techniques in the literature. In our study, we tried to compare the effectiveness of modified strategies techniques, which we performed on PM.

Twenty females who were operated on due to PM at Çukurova University Balcalı Hospital between January 2012 and December 2019 were examined.

All of the 20 patients were female. Their median age was 37.5 ± 6.5 years (ranging from 24 to 49). In fourteen cases, the disease was located in the right breast. Eight patients referred to our clinic had at least one abscess drainage before admission, and two of them were misdiagnosed as idiopathic granulomatous mastitis and received oral corticosteroid therapy. Nine patients were multipara. When possible etiological risk factors for PM are examined, sixteen patients were smokers, one patient has systemic lupus erythematosus (SLE), and two were users of tricyclic antidepressants (Table 1).

Sixty percent of patients (n:12) had type three PM (Table 2). The surgical procedures applied to the patients are given in Table 3. As the surgical procedure, a classic Hadfield operation with periareolar incision was performed on 11 patients, periareolar incision combined radial incision was performed in 7 patients, and round block incision was performed in 2 patients.

Seroma was observed in only one of the patients who underwent the modified technique. In Hadfield’s procedure, NAC retraction (n:2), seroma (n:1), and hematoma (n:1) were seen. None of our patients had complications of NAC necrosis. However, there was no statistical difference in terms of complications (Table 3).

Recurrence occurred in two patients at 12 ± 1.5 months of follow-up, and both had Hadfield’s procedure (Table 3). One of these patients was treated with re-resection and the other with negative pressure wound therapy.

Table 4 presents the evaluation of patients for cosmesis and quality of life at the end of the follow-up period. Patients who underwent round block were more satisfied with their nipple appearance.

Although more than 100 years have passed since the disease’s definition, there are still controversies in diagnosis, classification, and treatment. Some studies investigating the relationship between PM and smoking revealed that the amount of nicotine in the subareolar duct was higher than in plasma [10, 13, 14]. In normal breast tissues, lactiferous ducts are lined by a two-layer cuboidal epithelium, and the orifices on the nipples are lined with squamous epithelium. As a result of the cuboidal epithelium’s metaplasia to squamous epithelium, keratin plugs are formed inside the duct. The keratin plugs cause enlargement and rupture of the ducts leading to periductal inflammation and fistula development. Smoking is a known risk factor accelerating the development of such metaplasia [15]. Most of the PM cases in our study group were smokers (80%), as stated in the literature. Tricyclic antidepressant drugs inhibit dopamine secretion, thus suppressing the inhibitive effect of dopamine on prolactin secretion and might lead to hyperprolactinemia [16]. Hyperprolactinemia causes hyperplasia of the epithelium in the ducts and increases lipid- and protein-rich secretions. These secretions might lead to the terminal mammary duct’s obstruction and could develop PM [17]. Besides lactation and Tricyclic antidepressants, such autoimmune diseases as SLE, Rheumatoid Arthritis, and Sjogren’s syndrome were recorded to might cause hyperprolactinemia [18]. One patient in our series had an SLE diagnosis, and two had a history of tricyclic antidepressant use. But none of our patients had a prolactinoma.

For the first time, Zhang et al. put forward a category [19]. We grouped our patients according to their classification system, and Type 3 PM was the most common in our series. We think that this classification will be useful in determining the extent of surgery is performed.

Abscess drainage and antibiotic therapy without fistulotomy are not sufficient in PM treatment. Versluijs-Ossewaarde et al. reported a recurrence rate of 79% among patients suffering from subareolar abscess treated without excision of the terminal duct [20]. The treatment of PM includes several principles: resection of the ampulla and its abscess, a fistulectomy, reconstruction of the nipple-areola, and correction of the nipple inversion [15, 21, 22]. In 1960, Hadfield described a surgical technique for excision of the major duct system for benign disease of the breast [6]. This procedure is often used in ductal ectasia or intraductal papilloma conditions and includes a periareolar incision to remove the terminal ducts. However, the complete excision of the breast’s terminal ductal system is associated with several complications, such as nipple retraction and necrosis of NAC [7]. Taffurelli et al. presented 18 cases of PM treated with Hadfield’s procedure using a probe to find the fistula’s location. Although they reported good cosmetic results, they found that recurrence developed in 11% of cases [1]. In our series, 11 patients underwent Hadfield’s procedure, and recurrence developed in 2 of them. Moreover, complication rates were higher than other modified techniques.

Various modified surgical treatments have been reported in the literature for the PM to reduce complications and recurrence risk [23]. Menguid et al. has preferred only radial incision, which started from the middle of the NAC to encompass the diseased duct and extended laterally through the areolas and the lateral border. There was no recurrence on the side where the ductus was excised in their 24 patients. However, new fistulas developed in 4 patients in other quadrants, so they performed complete ampulla resection in a seconder surgery [8]. In another article by Komenaka et al., a combined incision of periareolar and radial incision was performed in 15 cases [9]. They found no recurrence at the same localization in the follow-up, but new fistulas developed at another quadrant in two patients. In our series, we preferred the periareolar combined radial incision in 7 patients, and we did not observe recurrence or new fistula development in any of them.

Different treatment methods in PM treatment are not limited to the choice of an incision. Some authors leave the wound to secondary healing. Beechey-Newman performed fistulectomy and saucerization with healing by secondary intention on 53 patients; however, they found an 8% recurrence rate [24]. Some surgeons prefer wide excision. But this may require flap reconstruction for closing the defect. Zhang et al. reported a recurrence rate of 4.3% in their series of 47 patients in which they close the defect after excision with dermo-glandular flap [25]. It is known that NAC retraction or necrosis is feared after such surgeries. Al Masad performed the NAC advancement as a flap into a new bed immediately above the incision across the upper half of the areola-skin junction in 33 patients. He found loss of sensation in 4%, epithelial necrosis of the upper half of the areola in 2%, and recurrence of discharge in 2% [7].

However, as seen, none of the authors stated that they used the round block method in PM’s treatment. This method is often used on oncoplastic breast‐conserving surgery for central tumors [26]. As far as we know, this study is the first article to report that the round block method can be used in the treatment of PM, and we would like to note that there was no recurrence in the two patients we treated with this method. According to our limited experience, round block and periareolar combined radial incision give better results in Types 2b, 3, and 4 PM. Because these patients have a larger abscess space or a longer fistula tract, extensive exposure is required. The classic Hadfield’s operation with a periareolar incision does not provide such extensive exposure. We think these were because we performed large excision when we use these modified procedures, and we could achieve better volume displacement.

Different surgical procedures may be preferred for the removal of the terminal milk duct in PM. The round block method and periareolar combined radial incision make a wider exposure. Therefore, both methods can be alternatives to the classical Hadfield’s procedure.