Breast Cancer Surgery

There are several types of surgery that remove cancerous tissue from the breast. Depending on your diagnosis, your surgeon may recommend a lumpectomy (partial mastectomy), mastectomy, axillary node dissection and/or lymph node removal. You may also choose to have reconstructive surgery at the time of your cancer surgery or at a later time.

• Sentinel Lymph Node Biopsy
• Axillary Lymph Node Dissection
• Lumpectomy or Partial Mastectomy
• Mastectomy
• Reconstructive Surgery
• Post Operative Exercises

Sentinel Lymph Node Biopsy

If you have invasive ductal or lobular cancer, or a large amount of ductal carcinoma in situ, the surgeon will need to biopsy the lymph nodes under your arm to see whether the cancer has spread from the breast to the lymph nodes nearby. This information is needed to plan further therapy for the breast cancer.

Lymph nodes are part of the lymphatic system of the body. The lymphatic system is a series of vessels or tubes and lymph nodes. Lymph nodes are small bean-shaped structures, which run close to your vascular system (arteries and veins). The lymphatic system is part of your immune system and works to fight infection as well as clean up waste products that your body produces. Lymph vessels and nodes are found throughout the body. The breast lymph vessels drain into the lymph nodes under the arm (called the axilla). If cancer cells are found in these lymph nodes, additional treatments may be recommended.

To do a sentinel lymph nodes biopsy, blue dye and/or a radioactive tracer will be injected into the breast at the time of your breast surgery to help the surgeon locate the lymph nodes. The surgeon will make a small cut in your armpit and find the lymph nodes that the breast tissue first drains to. Usually between one and four lymph nodes are removed. A pathologist, who may be in the operating room at the time of the surgery, will look at the lymph nodes. If no cancer cells are found, no further lymph nodes need to be removed. If cancer cells are found, then an axillary lymph node dissection may be performed.

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Axillary Lymph Node Dissection

If you have invasive ductal or lobular cancer, or a large amount of ductal carcinoma in situ, the surgeon will need to biopsy the lymph nodes under your arm to see whether the cancer has spread from the breast to the lymph nodes nearby. This information is needed to plan further therapy for the breast cancer.

The lymphatic system is a series of vessels or tubes and lymph nodes. Lymph nodes are small bean-shaped structures, which run close to your vascular system (arteries and veins). The breast lymph vessels drain into the lymph nodes under the arm (called the axilla). If cancer cells are found in these lymph nodes, additional treatments may be recommended.

If you have a sentinel lymph node biopsy which shows cancer cells in the lymph node, or if you have enlarged lymph nodes that are known to contain cancer cells, an axillary lymph node dissection may be recommended.

An axillary lymph node dissection removes lymph nodes from under the arm (called the axilla). These lymph nodes are located next to the breast and behind the chest wall muscles. Usually the surgeon removes 10-15 lymph nodes to check for cancer cells, to help decide about further treatments. If there are additional enlarged lymph nodes, they will be removed at the same time.

After an axillary lymph node dissection is performed, a drain is usually placed in that area to drain any fluid that might collect after the surgery. You will usually go home with that drain and it will be removed in the surgeon’s office.

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Lumpectomy or Partial Mastectomy

A lumpectomy or partial mastectomy is surgery that removes the cancer and a small amount of normal tissue around it. A surgeon will make a cut (incision) in the skin of the breast to remove the cancerous tissue and some normal tissue around the cancer. The amount of tissue removed depends on the size of the cancer. At the same time as the lumpectomy, a sentinel lymph node biopsy and/or an axillary node dissection is performed. This surgery is usually done as an outpatient. After you have healed from the lumpectomy surgery, radiation therapy to the breast will be recommended to reduce the chance that the cancer will come back in the breast.

After a lumpectomy your breast may look a little smaller or have less fullness than your other breast. If a larger amount of tissue is removed, women occasionally need a partial breast prosthesis or form to fill in the area.

The tissue removed during the lumpectomy will be sent to the pathology lab after your surgery. The pathologist will make a detailed description of what the cancerous cells look like and how they are behaving. In addition, the pathologist will determine if there are cancer cells at or very near the edge of the tissue removed (this is called the margin). If cancer cells are found at or near the edge, the surgeon may recommend that a second, larger lumpectomy is done or a mastectomy may be the best option.

A lumpectomy is recommended for women who:

• Have small cancers
• Have cancer in only one area of their breast
• Are comfortable having radiation therapy after the lumpectomy
• Wish to preserve their breast

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Mastectomy

A mastectomy is surgery that removes the entire breast. A surgeon makes a cut (incision) and removes all of the tissue of the breast including the nipple. The muscle behind the breast tissue is not removed. At the same time as the mastectomy, a sentinel lymph node biopsy will usually be performed. Once the tissue is removed, the incision is closed. The tissue removed during the mastectomy will be sent to the pathology lab after your surgery. The pathologist will make a detailed description of what the cancerous cells look like and how they are behaving.

After a mastectomy, you will have a scar across your chest and the area will be flat. Rarely, your ribs may look like small bumps underneath your skin. Following a mastectomy, you may choose to wear an artificial breast form (prosthesis) in a bra or attached to your skin. Another option is to have the breast reconstructed or rebuilt using artificial breast implants or your own body tissue. Reconstructive surgery can be done at the time of the mastectomy or you can wait and have it done at a later time.

A mastectomy may be the recommended surgery to remove the cancer when:

• The cancer is large
• Cancer is in multiple areas of the breast
• You cannot or do not wish to have radiation therapy after a lumpectomy
• You feel that a mastectomy is the best option for you

Skin-Sparing Mastectomy
This procedure removes a minimal amount of skin but all the breast tissue. The nipple is still removed as well as any recent incisions. This is done only with immediate reconstructive surgery, and when healed, has a very good cosmetic result.

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Reconstructive Surgery

The goal of reconstructive surgery is to restore the appearance and feel of the absent breast. A plastic surgeon can create a satisfactory breast mound and nipple complex in almost all women. This can be of great benefit by eliminating the inconvenience of an external prosthesis and altering your body image. This is an area of personal choice and preference.

Deciding on Breast Reconstruction
Your plastic surgeon can give you detailed information about specific procedures. You must evaluate your own attitudes and lifestyle to make the decision. Factors that you and your plastic surgeon will consider:

• Your general health
• Anticipated or previous radiation and/or chemotherapy
• The size of the opposite breast
• Your activities, especially sports you enjoy
• The number of procedures that you are willing to have

Delayed or Immediate Reconstruction
There are advantages and disadvantages to both approaches. The need for radiation therapy is an important factor.

Delayed reconstruction can be performed at any time after mastectomy. Advantages:

• More time to consider your options after you know if any additional radiation and/or chemotherapy will be needed
• Less operative time since the reconstruction is not added to the mastectomy

Immediate reconstruction is performed at the time of the mastectomy. Advantages:

• Psychological advantages have been demonstrated.
• Fewer anesthetics are used since the reconstruction procedure is started immediately.

Recovery
The rate of healing and pain tolerance varies among individuals. The type of reconstruction, as well as your general health and activity level, are the main factors which will determine your speed of recovery. Breast reconstruction is less painful than intra-abdominal surgery, and some patients feel fine a few days after surgery. However, most patients need four to eight weeks to return to full normal function.

Types of Reconstruction

1. Implants are round or tear drop shaped pouches that are inserted under the skin to create the form of a breast. Sometimes a full sized implant can be paced at the time of mastectomy. This option is not generally available for delayed reconstruction.
2. A Tissue Expander is shaped like a breast implant, but it is put into the mastectomy space only partially filled with a salt water solution (saline). After the wound heals, the expander is inflated every one to two weeks during an office visit. When the desired volume is reached, the expander is inflated a little more to overstretch the pocket. Finally, the expander is removed and replaced with a permanent implant.
3. Regional Flaps are a combination of muscle, fat, and skin moved from your back (latissmus dorsi flap) or abdomen (TRAM flap) to the chest. The choice depends on your body type, your previous surgical scars and your activity requirements.
4. Free Flaps are composed of skin and fat and taken from your abdomen or buttocks, detached and microscopically attached to blood vessels on your chest.

Possible Complications
Serious complications such as major bleeding, life-threatening infections and blood clots are rare. Though infrequent, minor problems such as fluid collection, tissue loss, excessive scarring and unsatisfactory cosmetic results may require additional surgery. All reconstructive breast surgery results in some aysmmetry of scarring.

Additional Procedures
Surgery to reduce, lift and sometimes enlarge the opposite breast is often required to obtain good symmetry. Reconstruction of the nipple-areolar complex greatly enhances the final result.

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Post Operative Exercises

Getting your flexibility and strength back after breast surgery can be accomplished by performing the exercises that are linked below. These exercises are intended to be done gently. By doing them, you can prevent contraction of scar tissue and decreased range of motion. Check with your surgeon to see when you should begin these exercises and the recommended exercise frequency.

Post Operative Exercises are available at www.thebreastclinic.com .


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