Most breast diagnoses are established through image-guided core biopsy — a minimally invasive outpatient procedure performed under local anaesthetic that provides a tissue sample without the need for a formal surgical operation. However, there are situations where surgical excision of breast tissue is required either to reach a definitive diagnosis or to treat a condition that cannot be adequately managed by other means.

This page covers two related areas: open surgical biopsy performed to establish a diagnosis when other methods have been insufficient, and surgical procedures for the management of pathological nipple discharge.

Surgical (Open) Biopsy for Diagnosis

When Is Surgical Biopsy Needed?

Image-guided core biopsy is the preferred and most commonly used method for diagnosing breast abnormalities, and it establishes a definitive diagnosis in the vast majority of cases. Open surgical biopsy is now required only in selected situations where core biopsy has not provided a sufficient answer.

Surgical biopsy is recommended in the following circumstances.

High-risk or borderline lesions on core biopsy — certain pathological findings on core biopsy are classified as B3 lesions (lesions of uncertain malignant potential) and require complete surgical excision for full pathological assessment, because the small sample obtained by core biopsy may not be representative of the entire lesion. These include atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), classical lobular carcinoma in situ (LCIS), flat epithelial atypia (FEA), radial scars, and papillary lesions with atypia. For these lesions, surgical excision provides the pathologist with the complete tissue needed to exclude an associated cancer or higher-grade lesion adjacent to the biopsy site.

Discordant triple assessment — when the results of clinical examination, imaging, and core biopsy do not all point in the same direction, the discordance itself is a clinical concern. A benign core biopsy result that does not adequately explain a suspicious clinical or imaging finding should not be accepted without further investigation. Surgical excision resolves the discordance by providing complete tissue for analysis.

Technically inadequate biopsy — occasionally a core biopsy does not yield sufficient representative tissue for a definitive pathological interpretation, due to the nature or location of the lesion. In these cases, surgical excision may be required to obtain an adequate specimen.

Patient preference — some patients prefer definitive surgical removal of a lesion over ongoing surveillance, even when the biopsy result is benign. This is a reasonable choice and is supported where clinically appropriate.

The Procedure

Open surgical biopsy is performed under general anaesthetic as a day procedure. For palpable lesions, the lump is directly excised through a carefully placed incision. For impalpable lesions detected only on imaging, pre-operative localisation is required to guide the surgeon to the correct area.

Hook-wire localisation involves insertion of a fine wire into the lesion under mammographic or ultrasound guidance on the morning of surgery, which acts as a guide for the surgeon during the operation.

ROLL (Radio-isotope Occult Lesion Localisation) uses a radioactive tracer injected into the lesion under imaging guidance, detected intraoperatively with a gamma probe. This is our preferred localisation technique in many cases, as it can be performed the day before surgery and avoids the need for a wire protruding from the breast on the day of the procedure.

Incisions are placed in inconspicuous positions wherever possible, wounds are closed with dissolving sutures, and all excised tissue is sent for complete pathological analysis. Results are typically available within five to seven days and are reviewed at the post-operative appointment.

Surgery for Nipple Discharge

Pathological nipple discharge — discharge that is spontaneous, from a single duct opening, blood-stained, or clear — requires specialist assessment and in many cases surgical treatment. The two surgical procedures used for nipple discharge are microdochectomy and total duct excision.

When Is Surgery for Nipple Discharge Recommended?

Surgery is recommended when nipple discharge is confirmed to be pathological and one of the following applies.

Imaging and assessment have identified a lesion within the duct system — most commonly an intraductal papilloma — that requires removal for both diagnosis and treatment. Discharge is persistent, spontaneous, and serous (clear yellow) or blood-stained despite a thorough workup that has not identified a specific lesion on imaging, where surgical exploration of the duct is required to exclude a small papilloma or early intraductal carcinoma that is below the resolution of standard imaging. Discharge is caused by benign ductal disease (such as duct ectasia) and is persistent, bothersome, or associated with nipple discomfort and retraction that has not responded to conservative management.

Microdochectomy

Microdochectomy is the selective surgical removal of a single milk duct. It is the preferred procedure when discharge is clearly coming from one specific duct opening and a localised lesion such as an intraductal papilloma is suspected or confirmed.

The procedure is performed under general anaesthetic as a day procedure. The specific discharging duct is identified by inserting a fine probe through the nipple opening, which the surgeon uses as a guide to locate and precisely excise that duct alone while preserving all surrounding ducts. This targeted approach means the remaining ducts are undisturbed, and the ability to breastfeed from the other ducts is preserved. The incision is placed around the edge of the areola and heals with minimal visible scarring.

The excised duct and any associated lesion are sent for pathological analysis, which confirms the diagnosis and excludes malignancy. Results are typically available within five to seven days.

Microdochectomy is particularly well-suited to younger women who have not yet completed their family and wish to preserve breastfeeding capacity from the operated breast.

Total Duct Excision

Total duct excision (also called subareolar or central duct excision or Hadfield's procedure) removes all of the major milk ducts from behind the nipple-areola complex. It is recommended when discharge is coming from multiple duct openings rather than a single one, when the specific discharging duct cannot be identified and isolated, when duct ectasia causing persistent symptoms involves the duct system broadly, or in the management of recurrent periductal mastitis or subareolar abscess where chronic ductal inflammation has not been controlled by other means.

The procedure is performed under general anaesthetic as a day procedure. An incision is made at the border of the areola, and all of the major ducts behind the nipple are carefully excised while the nipple itself and its overlying skin are preserved. The nipple appearance is maintained, though some change in nipple sensation can occur. Breastfeeding from the operated breast is not possible after total duct excision, as the ducts connecting the glandular tissue to the nipple have been removed.

For women with recurrent non-lactational mastitis or chronic periductal infection, total duct excision removes the source of the recurring infection and provides lasting resolution in most cases. Perioperative antibiotics are used to reduce the risk of infection in the post-operative period.

All ductal tissue excised is sent for pathological analysis, which confirms the nature of the ductal disease and excludes any unexpected malignancy. In the rare instance where an incidental finding of significance is identified, further management will be discussed at the post-operative appointment.

Recovery

Recovery from both surgical biopsy and duct surgery is straightforward for the majority of patients. Most patients are discharged the same day. Some bruising, swelling, and tenderness at the wound site is expected for one to two weeks. Wounds are closed with dissolving sutures under a waterproof dressing that can be showered with until removed at the first post-operative appointment.

Most patients can return to desk work and light activities within a few days, and to strenuous exercise within three to four weeks. Specific recovery guidance will be provided at your pre-operative appointment and reviewed at post-operative follow-up.

Booking an Appointment

If you have been referred for surgical biopsy, have a high-risk lesion on core biopsy, or have pathological nipple discharge requiring surgical management, we welcome a prompt appointment.

This page is intended as a general guide only and does not replace personalised medical advice. The most appropriate surgical approach for your situation should always be discussed with your specialist.