Local Anaesthesia for Fibroadenoma Excision

Agent/Drug of Choice

Technique: Field Block (NOT direct infiltration over the mass)

• Distorts the tissue making palpation impossible
• Spreads into the tumour potentially causing rupture
• Makes orientation and excision harder

Step-by-Step Injection Technique

• With the patient awake, palpate and mark the mass borders and planned incision with a surgical marking pen before giving LA (which can distort landmarks).

• Raise an intradermal wheal at the planned incision site using a fine 25-27G needle. This is the most painful injection - go slowly.

• Inject along the full length of the planned incision subcutaneously.

• Using a 22G spinal or long needle, insert through the wheal and advance in the subcutaneous plane along each side of the mass border.
• Inject while withdrawing the needle (not while advancing - reduces intravascular injection risk).
• Cover all 4 sides of the mass (superior, inferior, medial, lateral), staying 1-2 cm peripheral to the mass edge.

• Infiltrate into the deeper breast parenchyma along the expected dissection plane, at the level just below the mass. This anaesthetises deeper sensory branches.

• Allow 3-5 minutes for the LA to take full effect before incising. Epinephrine takes 7-10 minutes for full vasoconstriction - waiting improves haemostasis.

• Additional LA can be injected into deeper layers as needed during dissection, especially as the dissection plane goes deeper around the mass.

Injection Technique Tips

• Aspirate before injecting each time - the breast has a rich vascular supply; intravascular injection of LA is dangerous.
• Warm the solution slightly to body temperature - reduces stinging.
• Use the sodium bicarbonate buffer (10 mL lidocaine : 1 mL 8.4% NaHCO₃) - significantly reduces pain.
• Inject slowly and use the smallest gauge needle tolerated.
• For periareolar incisions: also infiltrate the subareolar plane as the areola has distinct innervation.

Incision Placement (affects where you anaesthetise)

When to Upgrade Anaesthesia

• Mass >4-5 cm (giant fibroadenoma / phyllodes)
• Deep-seated lesion near chest wall
• Patient anxiety is high
• Non-palpable lesion requiring wire/seed localisation
• Multiple lesions being excised

• Pfenninger & Fowler's Procedures for Primary Care, 3e, p. 926-928
• Mulholland & Greenfield's Surgery, 7e, p. 3886-3887 (Excisional Biopsy technique)
• S Das, A Manual on Clinical Surgery, 13e, p. 434

Step-by-Step Surgical Technique for Fibroadenoma Excision

Indications for Surgery

• Size >3 cm (most agree) or >5 cm (Bailey & Love)
• Rapid growth (>20% increase in 6 months)
• Patient age >30 years
• Suspicious features on imaging (microlobulation)
• Atypia on core biopsy
• Family history of breast cancer
• Patient preference / significant anxiety

For elderly patients, always excise with a rim of normal tissue - the mass may contain malignancy or be a phyllodes tumour. In young women with a typical fibroadenoma, simple enucleation is acceptable.

Preoperative Preparation

• Mammogram for all women >30 years before the procedure (to rule out occult synchronous lesions)
• Ultrasound to confirm the mass is solid, well-marginated, benign-appearing
• Core needle biopsy (ideally done before surgery) to confirm histology
• Mark the mass with indelible ink before sedation/LA is given, with the patient awake and in the operative position
• Obtain written informed consent

Patient Positioning

• Supine, arm on the ipsilateral side abducted to 90 degrees and padded at the elbow and wrist
• Appropriate padding of all pressure points
• Breast prepped with antiseptic and draped in sterile fashion

Step 1: Incision Planning

Step 2: Local Anaesthesia (Field Block)

• 1% Lidocaine + epinephrine 1:100,000, buffered 10:1 with 8.5% NaHCO₃
• Raise a dermal wheal at the planned incision site
• Infiltrate along the incision line subcutaneously
• Perform a circumferential field block around the mass borders - do NOT inject directly over the mass (distorts it, makes palpation impossible)
• Wait 5-7 minutes before incising

Step 3: Skin Incision

• Incise skin with a No. 15 blade, holding it at right angles to the skin edges (avoids bevelling, which creates uneven wound edges)
• Carry the incision down vertically to the subcutaneous layer

Step 4: Dissection Down to the Mass

• Use tissue scissors or electrocautery to dissect down through the subcutaneous fat to the level of the mass
• Develop thick flaps - as thick as possible while still being able to remove the lesion anteriorly
• Cauterise bleeders with electrocautery at each layer as you go
• Inject additional LA into deeper layers if the patient feels discomfort

Step 5: Enucleation / Excision of the Mass

• Grasp the mass with an Allis clamp to provide countertraction - this lifts the mass and puts its capsule under tension, making dissection easier
• Using curved tissue scissors, a No. 15 blade, or electrocautery, dissect circumferentially along the plane just outside the capsule
• The fibroadenoma will "pop out" from its capsule when correctly dissected - this is the classic enucleation technique
• Keep dissection close to the capsule to minimise dead space and preserve breast parenchyma
• Do not morcellate the mass (do not cut it into pieces - it must come out intact for proper pathological orientation)
• Benign fibroadenomas: enucleation alone is sufficient
• Elderly patient / suspicious features: excise with a small rim of normal breast tissue (wide local excision margin)

Step 6: Specimen Orientation

• Orient the specimen with marking sutures before sending to pathology:
  • Short suture = Superior margin
  • Long suture = Lateral margin
• This is essential - if the lesion is found to be malignant on final histology, the pathologist can identify which margin is involved and guide re-excision
• Send all specimens for histopathological evaluation - frozen section is optional (hormone receptor analysis is done on paraffin-embedded tissue)

Step 7: Haemostasis

• Achieve meticulous haemostasis with electrocautery before closure
• Inspect the entire cavity - even small bleeders must be controlled
• Hematoma is the most common complication and can mimic recurrence

Step 8: Wound Closure

• Breast distortion and deformity
• Mammographic scarring (difficult future surveillance)
• Dimpling of overlying skin

• No drains - they are not required for a simple fibroadenoma excision
• Apply a firm supportive dressing and a well-fitting bra postoperatively

Special Case: Giant Fibroadenoma (>5 cm)

• Approach via a submammary (inframammary) incision (Gaillard Thomas incision) for large lesions
• Enucleation is still possible through this hidden incision
• Consider sedation or general anaesthesia for giant fibroadenomas
• Overlying skin may be thin and stretched - check vascularity before closure

Complications to Watch For

• Pfenninger & Fowler's Procedures for Primary Care, 3e, pp. 926-928
• Mulholland & Greenfield's Surgery, 7e, pp. 3886-3887
• Bailey & Love's Short Practice of Surgery, 28e, pp. 408-424
• Current Surgical Therapy, 14e, pp. 893-895