Book Review

Atlas of Breast Surgery

N Engl J Med 1994; 331:61July 7, 1994

Article

Atlas of Breast Surgery
By Samuel A. Wells, Jr., V. Leroy Young, and Dorothy A. Andriole. 387 pp., illustrated. St. Louis, Mosby-Year Book, 1993. $125. ISBN: 0-8151-9216-9

Within the past several years, the surgical management of diseases of the breast has become increasingly a shared enterprise involving both general or oncologic surgeons and reconstructive surgeons. This new atlas exemplifies the benefits of such collaboration, both in advancing surgical technique and in improving the care of patients with benign or malignant breast disorders. The book has great breadth, covering all procedures of therapeutic, reconstructive, and cosmetic breast surgery. These range from simple methods such as fine-needle-aspiration cytology for the diagnosis of cancer to the construction of a gluteus-muscle free flap in complex breast reconstruction.

The authors acknowledge that their book is intended as a practical atlas of surgery. Thus, they do not describe in detail all the operations available to treat a particular problem. Instead, they emphasize procedures that have been used in their own practice with good results. A major attraction of the book is the superb and profuse medical illustrations, all of which are completely original. The book has six sections, all except the first containing several chapters pertaining to specific procedures. Each chapter begins with a brief discussion of the indications and contraindications for the operation, followed by a consideration of its potential complications. The book describes the operative preparation of the patient and postoperative care and lucidly presents the technical details of each operation. Discussion of the pathophysiology of breast diseases and of the empirical basis for each suggested approach is limited, but these entries are consistent with the intended scope of the book. A helpful addition in this regard would have been selected references to key textbooks and papers.

The first section of the book reviews in depth the normal anatomy of the breast and chest wall, including details of the deep muscles and blood vessels that are necessary for planning extensive reconstructions. The second section describes procedures for the diagnosis of cancer, including core needle biopsy, aspiration cytology, and excisional biopsy. This section will interest surgeons and generalists, including those in general medical practice, who may desire to perform these procedures in the office. The third section reviews operations for the treatment of benign disorders of the breast, including breast abscesses, and more unusual conditions such as giant fibroadenoma and intraductal papilloma.

The fourth section of the book discusses the standard operations for the management of breast carcinoma, beginning with lumpectomy and axillary dissection as distinct procedures and ending with radical mastectomy. A separate chapter on brachytherapy for breast cancer is informative and interesting, particularly because such treatments are not often used today.

The fifth and sixth sections constitute the largest part of the book (about two thirds of the total). They deal exhaustively with reconstructive and cosmetic plastic surgery of the breast -- for example, after definitive surgical resection for neoplasia. Purely cosmetic procedures such as reduction mammoplasty and operations for the correction of breast ptosis are also described. Although these sections certainly face competition from extant atlases of plastic surgery, they are very worthwhile. A chapter on the treatment of male gynecomastia in the final section exemplifies the pragmatic and multidisciplinary nature of the book. Operations for this condition are often carried out by general surgeons, and at times the cosmetic outcome is undesirable, particularly if the contour and bulk of the remaining tissue are not taken into consideration. In constrast, the approach delineated here addresses all these issues.

Some topics in breast surgery that might have been desirable to include are not covered in this book. For example, a discussion of chest-wall resection and reconstruction for deeply invasive breast cancer would have enhanced the book's value. Similarly, a section on managing cosmetic complications associated with lumpectomy for neoplasia, a problem that is probably more common than is generally acknowledged, would have been useful. This book is of high quality, however, with the technical descriptions presented at a level appropriate for fellows in training or for practicing surgeons who wish to review procedures. It is unique among the available atlases in its seamless integration of the various perspectives offered by the authors, who are all recognized leaders in surgical oncology and plastic surgery.

Nicholas E. Tawa, Jr., M.D., Ph.D.
Beth Israel Hospital, Boston, MA 02215