When there is a history of unilateral nipple discharge, localization is not possible, and no mass is palpable, the patient should be reexamined every week for 1 month. When unilateral discharge persists, even without definite localization or tumor, surgical exploration should be considered. The alternative is careful follow-up at intervals of 1 to 3 months. Mammography should be performed. Purulent discharge may originate in a subareolar abscess and requires excision of the related lactiferous sinus (186).
Erosive adenomatosis is a rare benign condition of the nipple that mimics Paget’s disease (187). Patients seek treatment for pruritus, burning, and pain. On clinical examination, the nipple can appear ulcerated, crusting, scaling, indurated, and erythematous. The nipple can be enlarged and more prominent during menstrual cycles (188). The differential diagnosis includes squamous cell carcinoma, psoriasis, contact dermatitis, seborrheic keratosis, adenocarcinoma metastatic to the skin, and unusual primary tumors of the nipple (187). Biopsy should be performed to diagnose the lesion. Local excision is curative (187).
10 days. If the lesion progresses to a localized mass with local and systemic signs of infection, an abscess is present. It should be drained, and breastfeeding should be discontinued.
Nonlactational Abscess Rarely, infections or abscesses may develop in young or middle-aged women who are not lactating (193). The approach to nonlactational abscess is conservative (194,195). A suspected abscess should be evaluated with preliminary ultrasonography to detect the presence of an inﬂammatory mass, frank pus, solitary cavity, or a multiloculated abscess (196). Aspiration of pus, if present, and antibiotic therapy is instituted with reaspiration, if necessary (196). When the ﬂuid collection is greater than 3 mL, percutaneous drain placement is an option (194). A single aspiration is sufficient in about one-half of patients (194). Recurrent abscess formation is low (10%) (194). Bacteriologic analysis of 190 abscesses in nonlactating and lactating women showed a preponderance of gram-positive cocci. S. aureus was the most common organism isolated (51.3%). Of these, 8.6% were methicillin-resistant S. aureus. Other common organisms included mixed anaerobes (13.7%) and anaerobic cocci (6.3%) (196). If these infections recur after multiple aspirations, incision and drainage followed by excision of the involved lactiferous duct or ducts at the base of the nipple may be necessary during a quiescent interval. In virtually all cases, mammillary sinus (lactiferous duct fistula) can be confirmed as the cause of reinfection or persistent infection (197). Inﬂammatory carcinoma is a consideration when erythema of the breast is present. Patients should not undergo prolonged treatment for an apparent infection unless biopsy eliminated the possibility of inﬂammatory carcinoma.
Disorders of Breast Augmentation
Estimates indicate that nearly 4 million women in the United States have undergone augmentation mammoplasty. Breast implants are usually placed under the pectoralis muscle or, less desirably, in the subcutaneous tissue of the breast. Most implants are made of an outer silicone shell filled with a silicone gel or saline.