Consultant Oncoplastic Breast Surgeon
Aberdeen Royal Infirmary, Scotland
Yazan Masannat, Consultant Oncoplastic Breast Surgeon, Aberdeen Royal Infirmary
Gemma Card, Speciality Trainee in General Surgery, Aberdeen Royal Infirmary
Major Duct Excision
There are approximately 12-15 ducts in the breast which open onto the surface of the nipple. Where excision of a single duct is called microdochectomy, the more common procedure of Major duct excision (also known as total duct excision or Hadfield’s procedure) is the surgical removal of all lactiferous ducts under the nipple.
Indications for Major Duct Excision
Major duct excision is performed in patients who have pathological nipple discharge which originates from multiple ducts, or which cannot be traced back to a single duct, or if there is nipple discharge in women beyond childbearing age. In the majority of cases, the cause of nipple discharge is related to either duct ectasia (more commonly in smokers), or a benign intraductal papilloma. In approximately 10% (4%-20%) of cases, DCIS or invasive disease may be found upon histological analysis of the specimen, and in this situation it is likely that further treatment would be recommended.
Major duct excision may also be indicated in patients with recurrent mastitis or breast abscesses especially in cases of recurrent periductal mastitis, in selected sub cohort of patients that have stopped smoking.
Contraindications to Major Duct Excision
If a patient wishes to preserve breast feeding ability, then microdochectomy should be offered to excise only the pathological duct or group of ducts and preserve the rest. Even when microdochectomy is performed the ability to breast feed in the future cannot be guaranteed as sometimes the scarring from surgery is suffiecient to obliterate the ducts.
Risks and Complications of Major Duct Excision
Bleeding – Approximately 1 in every 100 patients requires to return to theatre within the first 12 hours after surgery with post-operative haematoma.
Infection – Wound infection occurs in less than 5 in 100 women, but is more common in women who have had recurrent breast duct infections and smokers.
Loss or reduction in nipple sensation – There is complete or partial loss of sensation in about 1 in 3 patients after a major duct excision.
Complete loss of nipple – Rarely, the blood supply to the skin of the nipple can be affected by the operation, and this can lead to complete or partial loss of the nipple. This is very rare and usually occurs in heavy smokers.
In cases of pathological discharge cannulation of the discharging duct is done using a lacrimal probe while some will inject Methylene blue for duct identification. This is not done in the video below as the patient had multi-duct discharge and the surgery was performed mainly for symptom control.
The surgical approach is through an inferior periareolar incision. The skin flap is raised behind the nipple preserving the blood supply to the nipple. Once the ducts are identified they are encircled using blunt dissection with an artery clip or scissors from both sides. The Ducts are disconnected the the tissue is coned down to 4 or 5 cm using diathermy. The defect behind the nipple is closed using Vicryl and if the nipple was inverted prior to surgery and everted during surgery then a figure of 8 suture at the base of the nipple will prevent it everting again. Local Anaesthetic without adrenaline is used and the wound is closed in 2 layers with Monocryl.
S. Abdalla, L. Savag, Y. Masannat, S.E. Pinder, I.S. Fentiman and H. Hamed (2014). Pathological Nipple Discharge. OAJ Sci Tech. Volume 2, Article ID 101037
M.F. Dillon, S.R. Mohd Nazri, S. Nasir, E.W. McDermott, D. Evoy, T.B. Crotty, N. O'Higgins, and A.D. Hill (2006), The role of major duct excision and microdochectomy in the detection of breast carcinoma, BMC Cancer, 6, p. 164
M. Gioffré Florio, T. Manganaro, A. Pollicino, P. Scarfo, and B. Micali (1999) Surgical approach to nipple discharge: a ten-year experience, Journal of Surgical Oncology, 71, no. 4, 235–238.
C. D. Haagensen (1971), Diseases of the breasts, 253–254, WB Saunders, Philadelphia, 2nd ed.
S. Lau, I. Küchenmeister, A. Stachs, B. Gerber, A. Krause, and T. Reimer (2005), Pathologic nipple discharge: surgery is imperative in postmenopausal women, Annals of Surgical Oncology, 12, no. 7, 546–551.
MBBS, MRCSI, MRCSEd, DBRM, FEBS, FRCSEd, MD
Consultant Oncoplastic Breast Surgeon
Aberdeen Royal Infirmary
Honorary Senior Clinical Lecturer and
Co-Lead of the Medical Law and Ethics Course
University of Aberdeen, Scotland
Tutor MS Oncoplastic Breast Surgery
University of East Anglia, England
Education and Training Committee Member at the Association of Breast Surgery (ABSGBI)
Education and Training Committee Member at the European Society of Surgical Oncology (ESSO)