“Breast mass” in a toddler is a common indication for referral to a pediatric surgeon. These cause tremendous anxiety for parents but almost always represent breast buds and should never be biopsied. There are women who have severe breast deformities or amastia due to a simple biopsy of a breast bud as a child. Reassurance and serial examinations should be the rule, with ultrasound performed for enlargement of the mass or extreme parental anxiety. Most breast masses in teenagers will turn out to be fibroadenomas, which can be multiple. Unless they are growing, larger than 4 cm in diameter, or causing pain, they should be followed. Many will resolve spontaneously after a few months or years of observation. Sometimes there is increased pressure to perform a biopsy because of an ultrasound report, usually dictated by an adult radiologist, that states that the lesion is “suspicious” and “must be biopsied.” Repeat ultrasound performed by an experienced pediatric radiologist can sometimes provide the reassurance needed to avoid unnecessary surgery. Unless it occurs near the axilla, fibroadenomas should always be removed through a periareolar incision and, because they can usually be separated cleanly from the surrounding breast tissue with blunt dissection, the specimen should include little, if any, normal breast tissue. In addition, except in girls with a history of breast irradiation (Hodgkin’s disease), resection of a breast mass with a margin is rarely necessary.
Fine needle aspiration is useful when dealing with a cyst but is rarely indicated in children. Most pediatric centers lack the expertise in performing the procedure and interpreting the results of cytologic analysis. Likewise, needle-localization biopsy is almost never indicated as this is usually performed in a woman with a nonpalpable lesion detected by screening mammography, which is never indicated in a child. Many adolescents complain of breast pain, for which there is often no effective treatment. When there is pain, many parents think they feel a mass when in fact there is only normal developing breast tissue, which can be very firm and tender to palpation, or simply fibrocystic change, which is not treated surgically.
Mastitis is treated with antibiotics, but an abscess should be aspirated or surgically drained, depending on its size. There is probably a greater risk of injury to the breast anlagen by uncontrolled infection than by incision and drainage performed carefully through a tiny incision at the areolar border. Abscess cavities should never be packed with gauze. Ectopic breast tissue most commonly occurs in the axilla and can be painful. The tissue is usually intimately adherent to the overlying dermis and an acceptable cosmetic result can be difficult to obtain. Gynecomastia can be psychologically distressing but usually resolves after the height of puberty. Many surgeons will refuse to operate (and insurance companies refuse to pay) until the patient has reached 18 years of age and can demonstrate that the breast tissue has failed to begin to diminish in size. The goal of mastectomy in these cases should be to remove only the breast tissue, although removing some fat is often necessary, especially in patients who are also obese. It is often difficult to know how much tissue should be removed from behind the nipple – removing too much can cause necrosis or nipple inversion, and leaving too much can result in recurrence, especially if the child is still young. It is usually best to leave a small amount and to warn the patient that recurrence could occur, albeit rarely.
The inframammary incision can be very useful and cosmetically superior to other thoracotomy incisions; however, when the incision is made while the patient is supine and under general anesthesia it will almost invariably end up being too high (on the breast). If there is any chance that an inframammary incision will need to be made, this site should be marked indelibly prior to the operation, preferably with the patient in an upright position.