European Journal of Cardiovascular Medicine

Breast cancer remains the most common malignancy among women worldwide and constitutes a major public health burden, particularly in developing countries where patients often present at advanced stages of disease [1,2]. Modified radical mastectomy (MRM) continues to be one of the most frequently performed surgical procedures for operable breast cancer, especially in settings where breast-conserving surgery and radiotherapy facilities are limited or not universally accessible [3]. Although MRM is considered a safe and standardized procedure, it is associated with a spectrum of early postoperative complications and short-term morbidities that can significantly affect patient recovery, hospital stay, quality of life, and overall treatment outcomes [4].Common early postoperative complications following MRM include seroma formation, surgical site infection, flap necrosis, hematoma, wound dehiscence, and upper limb morbidities such as pain, restricted shoulder movement, and lymphedema [5,6]. These complications may delay adjuvant therapies and increase healthcare costs, thereby adversely impacting oncological outcomes [7]. Over the years, several modifications in surgical techniques have been introduced with the aim of minimizing postoperative complications without compromising oncological safety. These include variations in flap thickness, preservation of nerves, modified axillary dissection techniques, use of suction drains, quilting sutures, and meticulous hemostasis [8].Despite the availability of literature addressing individual complications, there remains variability in reported incidence rates, and consensus regarding the most effective surgical modifications is lacking [9]. Furthermore, data from developing regions are limited, where patient characteristics, nutritional status, and healthcare infrastructure may influence postoperative outcomes [10]. Therefore, a systematic evaluation of early postoperative complications and short-term morbidities following MRM, with special emphasis on the impact of modifications in surgical technique, is essential. Such studies can help identify modifiable risk factors, refine surgical practices, and ultimately improve postoperative recovery and quality of care for breast cancer patients.

Modified radical mastectomy remains a commonly performed procedure for breast cancer, especially in resource-limited settings. This study evaluated early postoperative complications and short-term morbidities following modified radical mastectomy, with special emphasis on surgical technique modifications. The results indicate that these modifications can be safely implemented without increasing early postoperative complications, leading to improved postoperative recovery.

Study design: Institution based non-randomized prospective observational study. Place of study: Department of General Surgery, Medical College and Hospitals, Kolkata. Period of study: January 2020 to June 2021 Study Population: The study was conducted among the patients admitted in the indoor under the Department of General Surgery, Medical College and Hospitals, Kolkata with the diagnosis of carcinoma of breast. Inclusion Criteria: • All patients of Breast Carcinoma aged 20-59 years, who have been diagnosed by trucut biopsy and admitted under our unit at MCH, for MRM. • Patients of CA Breast Stage Tis, T1, T2, T3 and selected T4 (minor skin involvement that is amenable for upfront resection) will be included. • Patients with N0, N1 and N2 axilla will be included. • Patients willing to give written informed consent and to follow study procedure. Exclusion criteria: • Patients who have history of any skin diseases. • Patients who have significant medical co morbidities like heart disease, uncontrolled diabetes mellitus, chronic kidney disease, bleeding diathesis. • Pregnant patients. • Patients who have collagen vascular diseases. • Patients who have peripheral vascular diseases. • Metastatic CA Breast, diagnosed by clinical and radiological examinations (HRCT Chest, CECT Abdomen and Pelvis, and Bone Scan). • Patients who do not give consent. Study Variable: • History • Clinical examination • Imaging (usg of both breast with axilla and BIRADS scoring &/or mammography ofboth breast) • Histopathology reports • Immunohistochemistry reports • Visual analogue scale (VAS) • Inj. Bupivacaine- 0.5%, 10 ml • Inj. Tranexamic Acid- 1gm METHODOLOGY Patients were selected based on predefined inclusion and exclusion criteria. Detailed clinical evaluation and relevant investigations, including laboratory tests, imaging, histopathology, and immunohistochemistry, were recorded. All patients underwent modified radical mastectomy (MRM) and were arbitrarily divided into two groups of 30 each. Group A underwent MRM with modifications, including double incision with elective skin margin excision, intraoperative and postoperative tranexamic acid administration, infiltration of thoracodorsal, long thoracic, and medial pectoral nerves with bupivacaine, and postoperative hyperabduction with early shoulder mobilization. Group B underwent conventional MRM without modifications. Patients were followed up until discharge and at 15, 30, and 90 days postoperatively for assessment of complications and short-term morbidities. Postoperative flap care was standardized in both groups. Statistical Analysis: For statistical analysis, data were initially entered into a Microsoft Excel spreadsheet and then analyzed using SPSS (version 27.0; SPSS Inc., Chicago, IL, USA) and GraphPad Prism (version 5). Numerical variables were summarized using means and standard deviations, while Data were entered into Excel and analyzed using SPSS and GraphPad Prism. Numerical variables were summarized using means and standard deviations, while categorical variables were described with counts and percentages. Two-sample t-tests were used to compare independent groups, while paired t-tests accounted for correlations in paired data. Chi-square tests (including Fisher’s exact test for small sample sizes) were used for categorical data comparisons. P-values ≤ 0.05 were considered statistically significant.

Table 1: Distribution of mean Age

Table 2: Association between Clinical tumor (T) status: Modification

Table 4: Association between Seroma formation15th, 30th, 90th post op day discharge: Modification

Table 5 : Association between Wound Infection 30th Post Op Day Discharge: Modification

Table 6 : Association of Mastectomy Skin Flap Necrosis with Modification at Different Post-Operative Time Points (n, %)

Table 7 : Distribution of mean Post op pain (vas score) till discharge, Post op pain (vas score) till discharge, Post op pain (vas score) 15th day post discharge, Post op pain (vas score) 30th day post discharge, Post op pain (vas score) 90th day post discharge: Modification

Figure 1: Association between Clinical tumor (T) status: Modification

In our study included 60 patients with a mean age of 49.82 ± 6.25 years.

Tumour status distribution did not differ significantly between the two groups (p = 0.5621). Among patients without modification, T2, T3, and T4 tumours were observed in 13 (43.3%), 13 (43.3%), and 4 (13.4%) patients, respectively. In the modification group, T2 tumours were present in 9 (30.0%), T3 in 14 (46.7%), and T4 in 7 (23.3%) patients. Overall, T3 tumours were the most common, accounting for 27 (45.0%) cases, followed by T2 in 22 (36.7%) and T4 in 11 (18.3%) cases.

Seroma formation till discharge and at subsequent follow-up intervals was lower in the modification group; however, the differences were not statistically significant. Till discharge, seroma occurred in 4 (13.3%) patients in the modification group compared to 9 (30.0%) in the non-modification group (p = 0.1171). At the 15th post-operative day, seroma rates remained similar (p = 0.0528). At the 30th post-operative day, seroma was observed in 3 (10.0%) patients in the modification group and 6 (20.0%) patients in the non-modification group (p = 0.278). No seroma was observed in either group at the 90th post-operative day.

Wound infection rates were low and comparable between the modification and non-modification groups. Till discharge, wound infection occurred in 2 (6.7%) patients in each group (p = 1.000). At the 15th post-operative day, wound infection was observed in 2 (6.7%) patients without modification and 1 (3.3%) patient with modification, with no statistically significant association (p = 0.5536). No wound infection was reported in either group at the 30th or 90th post-operative day.

Mastectomy skin flap necrosis till discharge was significantly lower in the modification group compared to the non-modification group (p = 0.0443). Only 1 (3.3%) patient in the modification group developed flap necrosis till discharge, compared to 6 (20.0%) patients in the non-modification group. At the 15th and 30th post-operative days, necrosis was observed exclusively in the non-modification group; however, the association was not statistically significant (p = 0.0755). No cases of mastectomy skin flap necrosis were observed in either group at the 90th post-operative day.

Post op pain (vas score) till discharge In Modification, the mean Post op pain (vas score) till discharge (mean± s.d.) of patients was 1.9667± .6149. Distribution of mean Post op pain (vas score) till discharge with Modification was statistically significant (p<0.0001). Post op pain (vas score) 15th day post discharge In Modification, the mean Post op pain (vas score) 15th day post discharge (mean± s.d.) of patients was .4667± .5074. Distribution of mean Post op pain (vas score) 15th day post discharge (vas score) till discharge with Modification was statistically significant (p<0.0001). Post op pain (vas score) 30th day post discharge In Modification, the mean Post op pain (vas score) 30th day post discharge (mean± s.d.) of patients was .1000± .3051. Distribution of mean Post op pain (vas score) 30th day post discharge (vas score) till discharge with Modification was statistically significant (p=0.0407). Post op pain (vas score) 90th day post discharge In Modification, the mean Post op pain (vas score) 90th day post discharge (mean± s.d.) of patients was .0333± .1826. Distribution of mean Post op pain (vas score) 90th day post discharge (vas score) till discharge with Modification was not statistically significant (p=0.2496).

In the present study, 60 patients with a mean age of 49.82 ± 6.25 years were included, which is comparable to Indian studies reporting breast cancer presentation predominantly in the fifth decade of life. Chatterjee et al. [15] (2015) reported that more than 45% of patients from eastern India presented with T3 disease, similar to our finding where T3 tumours constituted 45.0% of cases, followed by T2 (36.7%) and T4 (18.3%) tumours. Tumour status distribution between the modification and non-modification groups in our study did not differ significantly (p = 0.5621), ensuring comparability between groups.

Seroma formation is a well-documented postoperative complication following mastectomy. Woodworth et al. [4] (2000) reported seroma formation in 15–30% of patients after breast cancer surgery, while Gonzalez et al. [5] (2003) observed seroma in 25% of mastectomy patients. Porter et al. [8] (1998) demonstrated a higher seroma rate with extensive electrocautery use (28%) compared to sharp dissection (14%). Kuroi et al. [9] (2006) reported a wide incidence range of 10–50%, emphasizing surgical technique and dead space as key risk factors. In contrast, our study showed a lower incidence of seroma in the modification group (13.3%) compared to the non-modification group (30.0%) till discharge, though the difference was not statistically significant (p = 0.1171). By the 90th postoperative day, no seroma was observed in either group, suggesting transient and self-limiting nature of seroma formation.

Wound infection rates in our study were low and comparable between groups, with 6.7% infection till discharge in both arms. This is consistent with Gupta et al. [11] (2016), who reported wound infection rates of 5–8%, and Rao et al. [14] (2014), who documented wound infection in 6.5% of patients following modified radical mastectomy. Verma et al. [13] (2017) also reported a wound infection rate of 6%, closely mirroring our findings.

Mastectomy skin flap necrosis remains a significant cause of postoperative morbidity. Verma et al. [13] (2017) observed flap necrosis in 12% of patients, while Banerjee et al. [19] (2015) reported a higher incidence of 18%, particularly in patients with locally advanced disease. Singh et al. [16] (2018) demonstrated flap necrosis in 16% of patients with T3–T4 tumours, compared to 6% in early-stage disease. In the present study, mastectomy skin flap necrosis till discharge was significantly lower in the modification group (3.3%) compared to the non-modification group (20.0%), with a statistically significant association (p = 0.0443), suggesting a protective role of the surgical modification in reducing early flap-related complications. Our findings are largely consistent with existing literature and suggest that while surgical modification may not significantly reduce seroma or wound infection rates, it appears to significantly decrease early mastectomy skin flap necrosis, especially in patients with locally advanced breast cancer. Post-operative pain significantly influences recovery following breast surgery. In the present study, patients who underwent surgery with modification experienced significantly lower post-operative pain scores till discharge (p < 0.0001). Similar reductions in early post-operative pain have been attributed to meticulous surgical techniques that minimize tissue trauma, as reported by Woodworth et al. [4] and Gonzalez et al. [5].

Pain reduction in the Modification group remained significant on the 15th post-discharge day (p < 0.0001), indicating sustained early benefit. Comparable findings were observed by Deo et al. [6] and Verma et al. [13], who reported improved post-operative comfort with refined surgical approaches. Although pain scores were low in both groups by the 30th day, the Modification group continued to demonstrate a statistically significant advantage (p = 0.0407), consistent with observations by Banerjee et al. [19].

By the 90th post-discharge day, pain levels were minimal and comparable between groups, with no statistically significant difference (p = 0.2496). This aligns with reports by Petrek and Heelan [7] and Rao et al. [14], suggesting that long-term post-operative pain outcomes are largely independent of surgical modification. Overall, surgical modification primarily contributes to improved early and intermediate post-operative pain control without influencing long-term pain outcomes.

This study assessed early postoperative complications and short-term morbidities following modified radical mastectomy with special emphasis on surgical technique modifications. The patient population was comparable between the modification and non-modification groups with respect to age and tumour stage distribution. Seroma formation was observed less frequently in patients undergoing modified surgical techniques throughout the postoperative period, although this difference was not statistically significant. Wound infection rates were low and similar in both groups, indicating that surgical modification did not adversely affect wound healing or infection risk. In contrast, mastectomy skin flap necrosis was notably reduced in the modification group during the early postoperative period, highlighting the beneficial impact of surgical technique modification on flap viability. Overall, the study suggests that appropriate modifications in surgical technique during modified radical mastectomy can reduce early postoperative morbidity, particularly skin flap necrosis, without increasing other complications.

1.      Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics: GLOBOCAN estimates of incidence and mortality worldwide. CA Cancer J Clin. 2018;68(6):394–424.

2.      Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide. CA Cancer J Clin. 2021;71(3):209–249.

3.      Veronesi U, Boyle P, Goldhirsch A, Orecchia R, Viale G. Breast cancer. Lancet. 2005;365(9472):1727–1741.

4.      Woodworth PA, McBoyle MF, Helmer SD, Beamer RL. Seroma formation after breast cancer surgery: incidence and predicting factors. Am Surg. 2000;66(5):444–450.

5.      Gonzalez EA, Saltzstein EC, Riedner CS, Nelson BK. Seroma formation following breast cancer surgery. Breast J. 2003;9(5):385–388.

6.      Deo SV, Shukla NK, Asthana S, Raina V. A comparative study of modified radical mastectomy and breast conserving surgery in early breast cancer. Indian J Cancer. 2003;40(1):11–15.

7.      Petrek JA, Heelan MC. Incidence of breast carcinoma-related lymphedema. Cancer. 1998;83(12 Suppl):2776–2781.

8.      Porter KA, O’Connor S, Rimm E, Lopez M. Electrocautery as a factor in seroma formation following mastectomy. Am J Surg. 1998;176(1):8–11.

9.      Kuroi K, Shimozuma K, Taguchi T, Imai H, Yamashiro H, Ohsumi S, et al. Evidence-based risk factors for seroma formation in breast surgery. Jpn J Clin Oncol. 2006;36(4):197–206.

10.   Agarwal G, Ramakant P. Breast cancer care in India: the current scenario and challenges for the future. Breast Care (Basel). 2008;3(1):21–27.

11.   Gupta P, Sharma R, Verma S, Gupta S. Clinicopathological profile of breast cancer patients undergoing modified radical mastectomy in a tertiary care center. Indian J Surg Oncol. 2016;7(3):287–292.

12.   Sharma K, Costas A, Shulman LN, Meara JG. A systematic review of barriers to breast cancer care in developing countries resulting in delayed patient presentation. J Oncol. 2012;2012:121873.

13.   Verma R, Bains L, Lal P, Singh S. Evaluation of postoperative complications following modified radical mastectomy. Int J Surg. 2017;4(6):1921–1925.

14.   Rao C, Shetty J, Prasad K. Clinical profile of breast cancer patients and outcomes of modified radical mastectomy in a developing country. J Cancer Res Ther. 2014;10(3):575–579.

15.   Chatterjee S, Ghosh S, Sarkar S, Biswas PK. Presentation and management of locally advanced breast cancer in eastern India. Indian J Cancer. 2015;52(3):387–390.

16.   Singh R, Gupta G, Jain A. Impact of tumor stage on postoperative morbidity following modified radical mastectomy. South Asian J Cancer. 2018;7(2):89–92.

17.   Das S, Sen S, Mukhopadhyay M. Pattern of lymph node involvement in breast cancer patients undergoing modified radical mastectomy. J Indian Med Assoc. 2013;111(8):530–533.

18.   Mukherjee A, Saha S, Ghosh J. Nodal status and its correlation with clinicopathological parameters in breast carcinoma. Indian J Surg. 2016;78(2):129–133.

19.   Banerjee A, Basu S, Roy D. Early postoperative complications of modified radical mastectomy and their predictors. Int J Sci Stud. 2015;3(6):38–42.

20.   Patel M, Shah K, Desai C. Role of neoadjuvant chemotherapy in locally advanced breast cancer: A clinicopathological study. Indian J Cancer. 2017;54(2):344–348.