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Total duct excision through a linear radial areola incision

Nipple discharge is the third most common presenting complaint of women attending breast clinic. Cytological examination lacks sensitivity, so those with pathological nipple discharge and unremarkable imaging are most commonly managed with complete major duct excision for definitive diagnosis and symptomatic control. Excision of the major duct system of the breast was first described by Adair and Urban, and the operative technique was subsequently reported in detail by Hadfield in 1960. He described a skin incision following the lower half of the edge of the areola, and reflection of the nipple-areola complex from the underlying breast tissue to expose the major ductal system. This incision requires undermining of the nipple and provides limited access to the operative site behind the nipple bud. This has the potential to result in bleeding, nipple-areola complex necrosis, and loss of nipple sensation. An alternative peri-areola approach with an incision over only one third of the areolar circumference has since been described. Furthermore, elliptical radial incisions have been described; Urban reported a radial incision encompassing an ellipse of skin extending from, and sometimes including, the nipple, to beyond the borders of the areola for cases where a sector of abnormal breast tissue is to be removed in continuity with the ducts. An elliptical radial incision for recurrent subareolar abscesses and lactiferous duct fistula has also been reported. We describe a previously unreported linear radial incision within the areola for diagnostic complete major duct excision that is utilized routinely at our institution without complication. The incision should be orientated at the lower outer (5 o’clock in the left breast. 7o’clock on the right) position, and extend from the base of the nipple to the border of the areola, without extending onto the nipple itself, or beyond the areola (Figure 1). The skin is retracted using skin hooks and the major ducts dissected from the surrounding breast tissue using McIndoe scissors. It is advantageous that that the medial end of the incision is sited directly next to the ducts, so they can be dissected under easy vision. The ducts are divided using a blade as they enter the nipple skin, and the tissue containing the major ducts can then be removed as a single conical block of tissue using diathermy. The remaining space may need closure with a single suture to close the parenchyma. The wound is closed with an undyed 4-0 poliglecaprone 25 suture (Monocryl, Ethicon) in two layers. Patients are followed up in nurse led postoperative clinic at 1 week, and with the histology results at 2 weeks. This technique does not require skin flaps to be raised or the areola to be undermined. It provides rapid access to the major duct system (Figure 2) that is sufficient to allow removal of a conical block of tissue. The linear incision facilitates ease of tissue approximation, and the resultant scarring is, in our experience, less visible than that of the peri-areolar incision originally described for this procedure. Because the incision is directly over the operative site, hemostasis is simpler and the operation can be performed under direct vision in good light. Furthermore, the orientation of the