How Mammillary Fistulas Should Be Managed

Abstract

Mammillary fistulas are uncommon, but when they occur they cause prolonged morbidity. The etiology and management strategies are less well established. The purpose of this study is to evaluate the etiologic factors and assess the results of surgical treatment. It is a retrospective study of all patients treated for mammillary fistula from 1990 to 2001. The clinical data, including complications of surgical treatment, were collected from medical records. Fistulas were segregated into simple and complex fistulas before analyzing the results of surgical treatment. Thirty-five patients were treated during this period. A history of either drainage of a subareolar abscess or spontaneous rupture of an inflammatory mass preceded the development of mammillary fistula in the majority of patients. Previous Hadfield's procedure for duct ectasia contributed to the development of fistula in seven patients. Seventeen patients presented with simple fistula. A large proportion of them were treated by total duct excision in recent years, with a higher rate of recurrence (4/6). Eighteen patients presented with complex fistulas; two of them had recurrences following surgical treatment. The overall recurrence rate was 23%. The majority of the patients showed features of periductal mastitis on histologic examination. Postoperative wound infection was positively associated with fistula recurrence. The best management of mammillary fistula remains a problem. Simple fistulas should be treated by fistulectomy and primary closure. Total duct excision should be reserved for complex fistulas. Postoperative wound infection is also a major factor in fistula recurrence. All patients should receive antibiotics. Surgery for duct ectasia has caused fistulas in 20% of cases in our study, raising the issue of restricting total duct excision to more severe forms of the disease. Mammillary fistulas should be treated more appropriately in a specialized breast unit with particular interest in benign breast disease.

Male Zuska's disease

“…Gollapalli et al 5 found that smokers are six times more likely to develop primary abscess when compared to non-smokers (OR of 6.15, 95% CI 2.65–14.29). Spontaneous drainage onto the border of the areola signifies the development of a fistulous tract 2 3 6. Other authors have demonstrated inconsistency with this theory.…”

“…Other authors have demonstrated inconsistency with this theory. Hanavadi et al 6 concluded that periductal mastitis is more commonly the culprit, as they were unable to consistently identify a keratin plug or duct ectasia. Likewise, in a study of 52 fistulas, Lambert et al 7 drew similar conclusions.…”

Surgical treatment of recurring subareolar abscess using oncoplastic techniques

“…Moreover, few authors have focused on the multiply recurrent form of this disease; these patients who have already undergone multiple surgeries with failure are a highly selected group. The need to excised dilated lactiferous terminals is no longer debated nowadays but the techniques vary [10][11][12][13]. In a series of 204 periareolar abscesses, Lesanka Versluijs-Ossewaarde reported a 79% recurrence rate if surgical excision did not included the lactiferous ducts versus 28% when the terminal lactiferous ducts were excised [14].…”

Duct Ectasia and Periductal Mastitis in Indian Women

“…Because of the lack of awareness of the treating physicians, these patients are subjected to undue stress and radical procedures which are unnecessary most of the times. Till date, the only definitive treatment for this condition is only surgical (microdochectomy, fistulectomy, and major mammary duct excision) [7][8][9]. Hence, it becomes surgically relevant to study the disease process, in order to gain a good knowledge of these benign breast diseases, which is in turn necessary to alleviate the fear of cancer and appropriately treat the disease.…”