What is the management for a breast wound in a woman?

Management of Breast Wounds in Women

For breast wounds in women, management depends critically on the wound etiology: surgical wounds require meticulous hemostasis with subcuticular skin closure and avoidance of breast tissue drains, while complex or infected wounds may benefit from negative pressure wound therapy, and all wounds require careful monitoring for infection which presents as cellulitis in 22% of cases even without purulent drainage. 1, 2

Surgical Wound Management (Post-Biopsy or Excision)

Intraoperative Technique

• Achieve meticulous hemostasis during the procedure as hematoma formation creates changes difficult to interpret on physical examination and mammography, potentially leading to unnecessary repeat biopsies 1, 3
• Avoid placing drains directly in breast tissue as this compromises cosmetic outcomes; allow the cavity to fill with serum naturally 1, 3
• Close skin incisions with subcuticular technique to optimize cosmetic results 1, 3
• Do not reapproximate breast parenchyma for lesions within the breast substance, as this often causes distortion when the patient is upright despite appearing adequate when supine 1

Immediate Postoperative Care

• Initiate early shoulder exercises immediately to prevent frozen shoulder, even though this may prolong drainage if axillary dissection was performed 3
• Avoid arm slings and shoulder immobilization as these lead to limited range of motion 3
• Provide multimodal analgesia including paracetamol and NSAIDs (unless contraindicated) started pre-operatively or intra-operatively 1

Wound Monitoring and Infection Detection

• Monitor for cellulitis as the primary manifestation of infection rather than waiting for purulent drainage, as 22% of patients exhibit signs of infection and 11% require antibiotics for cellulitis without meeting conventional infection criteria 2
• Use wound scoring systems rather than relying solely on presence of pus, as 27% of patients with significant wound scores have cellulitis without meeting conventional infection criteria 2
• Instruct patients to seek immediate attention for persistent or worsening pain not controlled by over-the-counter medications, or any new concerning breast symptoms 3

Complex or Infected Wound Management

For Established Infections or Wound Complications

• Obtain wound cultures and initiate appropriate antibiotic therapy based on sensitivities 4
• Consider vacuum-assisted closure (VAC) therapy for complex breast wounds, which is effective in 83% (15/18) of cases 5
• For peri-prosthetic infections with implants, use negative pressure wound therapy with instillation and dwell time (NPWTi-d) combined with implant removal and antibiotics, which significantly decreases bacterial burden and inflammatory markers 6

Salvage Procedures for Exposed Implants

When implant exposure occurs (rather than routine removal and delayed replacement):

• Perform wound cultures with targeted antibiotic therapy 4
• Execute excisional debridement of the skin wound 4
• Perform open capsulotomy to relieve tension 4
• Irrigate with neomycin-polymyxin or povidone-iodine 4
• Place closed catheter drainage 4
• Replace with sterile prosthesis and achieve secondary closure (successful in 100% of 11 patients with 9/11 maintaining good results at 2 years) 4

Follow-Up Imaging Protocol

Post-Biopsy Surveillance

• Obtain follow-up mammography every 6-12 months for 1-2 years after benign biopsy with concordant pathology/imaging before returning to routine screening 3
• Perform post-biopsy mammogram after microcalcification removal to ensure complete excision 3
• Include special mammographic views of the surgical site beyond routine mediolateral oblique and craniocaudal views 3
• Use magnification and spot compression techniques for detailed visualization of the biopsy site 3
• Compare current images with all preceding studies to assess direction of change, as post-surgical changes are most marked in the first 6 months and stabilize within 2 years 3
• Use ultrasound to characterize postoperative masses such as seromas as fluid-filled rather than solid 3

Critical Pitfalls to Avoid

• Do not excise skin segments unnecessarily as this alters nipple position or inframammary crease 1
• Do not use periareolar incisions for peripheral lesions as these are cosmetically inappropriate 1
• Do not section specimens before pathologist evaluation as this compromises margin assessment 1
• Do not delay breast lesion evaluation while managing other incidental findings, as breast lesions have highest malignancy suspicion 7
• Ensure pathology-imaging concordance after any biopsy; if discordant, surgical excision is necessary 7