Why Breast Cancer Surgery?

The first step and most common form of treatment for breast cancer is Surgery. The type of surgery you have will depend on the stage of the cancer. Our surgeon can give you specific information about your surgery.

Surgery involves removing the tumor and adequate clearance of axillary lymph nodes. These are sent for histopathology which give an accurate report to the extent of the disease, whether it is confined only to the breast or has spread beyond it (to the axillary nodes.) This staging is necessary to decide further adjuvant treatment and even a PET Scan may not be 100 % accurate to do so.

Some people with Stage 2 or Stage 3 cancer may receive chemotherapy first, which is known as “preoperative “ or “neoadjuvant” chemotherapy. The goal is to shrink the tumor. By making it smaller first, you may have the option of a breast-conserving instead of a mastectomy.


Which Surgery Is Right For Me?

Achieving the correct diagnosis is the most vital part of Breast disorders. Once that is done Surgery depends on whether the lump is benign or malignant .

For most benign lumps, a lumpectomy alone is sufficient.

In case of cancer patients, whether a patient is a candidate for surgery or not, depends on factors such as the type, size, location, grade and stage of the tumor, as well as general health factors such as age, physical fitness and other coexisting medical conditions the patient may have.

For many patients, surgery will be combined with other cancer treatments, such as chemotherapy, radiation therapy or hormone therapy. These nonsurgical treatments may be administered before surgery (neoadjuvant therapy) or after surgery (adjuvant therapy) to help prevent cancer growth, spread or recurrence.

In case of malignant lesions the question is should the patient opt for Mastectomy (complete removal of breast) or Breast Conservative Surgery.

The most important criteria to decide that is accessiblity to Radiation facilities. These are not so easily available in smaller towns and hence the decision has to be based on the ability of the patient to take Radiation after surgery.


Types Of Breast Cancer Surgeries


Lumpectomy

Most benign lumps are:

  • Cysts – a sac filled with fluid – these are usually drained in the clinic and rarely need to be removed
  • Fibroadenomas – fibrous and glandular tissue
  • Chronic infections

PREPARING FOR A BREAST LUMP REMOVAL

Lumpectomy is usually done under general anaesthesia. This means you will be asleep during the operation. You may have the operation and go home the same day, or you may need to stay in hospital for a few days.

Sometimes breast lumps are removed under local anaesthesia. The injection of anaesthetic completely blocks feeling in the area around your breast lump and you will stay awake during the operation. You may be given a sedative with a local anaesthetic. This relieves anxiety and helps you to relax.

If you're having general anaesthesia, you will be asked to follow fasting instructions. This means not eating or drinking, typically for about six hours beforehand. However, it’s important to follow your surgeon’s advice.

WHAT HAPPENS DURING A BREAST LUMP REMOVAL

Your surgeon will make a small cut in your skin over or near the lump, or in an area where the scar won’t be obvious (for example close to your nipple or in the crease under your breast). She will cut the lump away along with a section of healthy tissue around it. This is called wide local excision and is done to try and make sure that all the affected cells are removed.

Your surgeon will close the cut with fine stitches that usually disapear by themselves.She will usually place a waterproof dressing over the wound so you can have a bath from the next day after surgery. The lump (and healthy tissue) is sent to a laboratory for testing.

If the lump is large, your surgeon may also reconstruct your breast during the operation. This is done by using local oncoplasty techniques or moving fatty and muscular into the space the lump has been removed from.

Mastectomy

The commonly practiced mastectomy is called MODIFIED RADICAL MASTECTOMY (MRM) in which your entire breast tissue is removed along with lymph nodes in the axilla through the same incision

Rarely if tumour involves the muscle Radical Mastectomy – your breast tissue and the underlying muscle in the chest is removed ‘

Your surgeon will advise you about the type of mastectomy you need.

PREPARING FOR YOUR OPERATION

You may be advised to have chemotherapy or hormone therapy (medicines to stop the hormones in your body that encourage breast cancer) before your mastectomy. These can help to reduce the size of the cancer, which makes it easier to remove.

Mastectomy usually requires a hospital stay of one to two days. The length of your stay will depend on the extent of your surgery and how you feel afterwards.

Mastectomy is done under general anaesthesia. You will be asked to follow fasting instructions. Typically, you must not eat or drink for about six hours before a general anaesthetic.

WHAT HAPPENS DURING MASTECTOMY

Depending on the type of mastectomy you have, your operation may take up to two to three hours.
A diagonal or horizontal cut is made across the breast, and the breast tissue and axillary nodes are removed.

A breast reconstruction may be done at the same time as the mastectomy or at a later date, or not at all.

When the operation is complete, the cuts are closed with staples or stitches (which may be dissolvable).

Fine plastic tubes may be left in your breast area for up to 7-10 days afterwards. These allow blood and fluids to drain into a bag.

WHAT TO EXPECT AFTERWARDS

You will need to rest until the effects of the anaesthetic have passed. You may need pain relief to help with any discomfort as the anaesthetic wears off. You may have a drip in your arm to keep you hydrated and give you painkillers and antibiotics.

When you feel ready, you can begin to drink and eat, starting with clear fluids.

The same evening you will be mobilized to to get out of bed and walk around and use the toilet by yourself.

Your nurse will give you advice about getting out of bed, bathing, diet and gentle exercises. A physiotherapist (a specialist in movement and mobility) will visit you to discuss a programme of exercises for you. These will help restore strength and movement in your arm and speed up your recovery.

Side-effects of a mastectomy include:

  • soreness, swelling, bruising and tightness in your breast area and in your arm and shoulder
  • scarring – you will have a permanent scar, this usually fades over time
  • numbness and tingling in your upper arm

COMPLICATIONS

This is when problems occur during or after the operation. Most women aren't affected. The possible complications of any operation include an unexpected reaction to the anaesthetic, excessive bleeding or developing a blood clot, usually in a vein in the leg (deep vein thrombosis, DVT).

Complications of mastectomy are uncommon, but can include:

  • Infection – antibiotics may be needed
  • Build up of fluid around the healing wound (seroma) – this may require further surgery
  • Change in sensation in the operated area – this can be permanent
  • Unusual red or raised scars (keloids) – these can take years to improve

If you have lymph nodes removed from under your arm in the same procedure, there is a risk of having a build up of fluid in your arm (lymphoedema). This causes swelling, pain and tenderness in your arm and hand and may require further treatment.

The exact risks are specific to you and will differ for every person, so we have not included statistics here. Ask your surgeon to explain how these risks apply to you.

Breast Reconstruction

Deciding factors

Here are some things you might want to consider while you're making a decision about breast reconstruction:

Is it important to you to have a permanent breast shape?
Some women prefer to use a prosthesis (a wearable artificial breast shape) instead of having reconstruction. Other women feel that a reconstructed breast is more convenient than wearing, removing, and taking care of a prosthetic breast.

If in your unique situation, will breast reconstruction involve several surgeries over a long period of time?
For many women, the answer is yes. Talk to your plastic surgeon about what needs to be done, both immediately and later, as you consider your options. For example, if you have very large breasts, the reconstruction might create a smaller breast. In this case, you might have the affected breast reconstructed, followed by reduction surgery on the other breast. Some time later, you'd have the opportunity to get nipple reconstruction on the rebuilt breast.

How important is it that you be able to resume your normal activities as soon as possible?
In most cases, women who choose no reconstruction are able to resume their daily activities more quickly than women who choose reconstruction.

Is the cost of reconstruction surgery a concern for you?
Generally, cost will only be an issue if you do not have health insurance or if your plan does not cover mastectomy.Some insurance companies requires that insurers who cover mastectomy also cover breast reconstruction, including any procedures needed to achieve a balanced appearance between the two breasts.

Did you have a lumpectomy that gave your breast a very different shape than it originally had?
Many women who have lumpectomies are happy with their breast's appearance and don't choose reconstruction. However, if you had a large portion of tissue removed during a lumpectomy, you might want reconstruction to restore a more balanced look. Also, many women find that within a couple of years after lumpectomy, the breast can look disfigured, especially if they’ve had radiation therapy. The treated breast is often smaller than the other breast or obviously distorted by comparison. Reconstruction may be the best option, sometimes with surgery on the opposite breast — such as a reduction or breast lift — to bring them back into balance. (This is a situation in which health insurance coverage may become an issue, since technically no mastectomy has been performed.)
It's also important to know that while breast reconstruction rebuilds the shape of the breast, it doesn't restore sensation to the breast or the nipple. Over time, the skin over the reconstructed breast can become more sensitive to touch, but it won't be exactly the same as it was before surgery.


Types of Breast Reconstruction

There are many different reconstruction techniques available. Your surgeon and her healthcare team can talk to you about the options that may be right for you.

There are two main techniques for reconstructing your breast:

Implant reconstruction: Inserting an implant that's filled with salt water (saline), silicone gel, or a combination of the two.

Autologous or "flap" reconstruction: Using tissue transplanted from another part of your body (such as your belly, thigh, or back). Autologous reconstruction also may include an implant.


Autologous or "Flap" Reconstruction

Autologous reconstruction (sometimes called autogenous reconstruction) uses tissue -- skin, fat, and sometimes muscle -- from another place on your body to form a breast shape. The tissue (called a "flap") usually comes from the belly, the back, buttocks, or inner thighs to create the reconstructed breast.

The tissue can be completely separated from its original blood vessels and picked up and moved to its new place in your chest. This is frequently referred to as a “free flap.” Or the tissue can remain attached to its original blood vessels and moved under your skin to your chest. This is often referred to as a “pedicled flap.” In both types, the tissue is formed into the shape of a breast and stitched into place.

You may have flap reconstruction at the same time as mastectomy (immediate reconstruction), after mastectomy and other treatments (delayed reconstruction), or you might have the staged approach, which involves some reconstructive surgery being done at the same time as mastectomy and some being done after (delayed-immediate reconstruction).

Flap reconstruction using tissue from your abdomen (belly, tummy):

  • SIEA Flap: Many women are pleased with breast reconstruction using belly tissue because it's like having a tummy tuck to rebuild a breast.
    Flap reconstruction using tissue from your back:
  • Latissimus Dorsi Flap: This approach almost always requires an implant, too, so it is not purely a flap reconstruction.

    The latissimus flap can be combined with an implant.

    Breast size: If your breasts are large, you may have to use the donor site that has the most available extra tissue. The stacked or “hybrid” techniques may be used to supply more volume when necessary. Or, a flap reconstruction could be combined with an implant.

  • Whether you plan on getting pregnant: If you plan to get pregnant after your breast reconstruction, you may not be able to have a TRAM flap because the stretching of the belly during pregnancy may put too much strain on the abdominal wall and the incision made to remove the flap tissue. The TRAM flap surgery does use part of the lower abdominal muscle. The DIEP or SIEA flap using belly tissue only (no muscle) may provide a more favorable abdominal wall for pregnancy after reconstruction. Many women have gone on to have healthy, uneventful pregnancies after these surgeries. You also could use tissue from another donor site such as the buttocks or thighs.
  • Hospitals and plastic surgeons in your area: Flap reconstruction requires special surgical techniques, including microsurgery to reattach the flap’s blood vessels after it is placed in the chest, and not all surgeons have experience with them. If you feel strongly about having flap reconstruction, you may have to do some research to find the surgeons and facilities that offer what you want. Your doctor may be able to refer you to plastic surgeons who specialize in certain types of reconstruction. If you need to travel a distance for this surgery, talk to your insurance provider to make sure you’re covered.

Things to know about flap reconstruction: The physical effects of each type of autologous reconstruction are highly individual to your body, your range of motion, your physical strength, and your normal day-to-day activities.

  • Remember that while you’re healing from surgery, there will be at least two and perhaps four areas of the body that are healing at the same time -- your reconstructed breast(s) and the donor tissue site(s), depending on whether one or both breasts are being reconstructed at the same time. Some women may also have a sentinel node biopsy or axillary node dissection at the same time, which means an additional incision.
  • With all types of reconstruction (implant and flap), there is no “one and done” option: There is nearly always a later surgery to make adjustments, sometimes called “finishing work.” Examples include nipple reconstruction, reshaping a flap, removing extra fat from a donor site, or repositioning of an implant. Usually, none of these adjustments is absolutely required, so talk to your surgeon about your preferences.
  • If you gain or lose weight, the size of a flap reconstruction can change along with the rest of your body. The breast(s) will get larger or smaller as your body changes.
  • Flap reconstructions tolerate radiation therapy better than implants alone do. If radiation is part of your treatment plan, make sure to discuss this with your surgeon.

Breast Conservation

Breast-conserving surgery (BCS, also known as breast conservation surgery and segmental mastectomy) is a less radical cancer surgery than mastectomy. Breast-conserving surgery, as in a lumpectomy removes part of the breast tissue during surgery, as opposed to the entire breast and all the axillary nodes using the same or separate incision depending on location of tumour.

The goals of BCS are to provide the survival equivalent of mastectomy, a cosmetically acceptable breast, and a low rate of recurrence in the treated breast.

Radiation therapy is often given after breast-conserving surgery to destroy cancer cells that may not have been removed during surgery. In some cases, chemotherapy and radiation are both given after breast-conserving surgery.

Reasons for the procedure

Breast-conserving surgery is a treatment option for some women with small, localized breast cancers.

Contraindications:

In some cases, breast-conserving surgery may not be recommended as the treatment of choice. Reasons for not undergoing breast-conserving surgery may include, but are not limited to, the following:

  • Non Availability of radiation facilities or unable to go for radiation
  • Previous radiation therapy in the breast or chest area
  • Two or more cancerous areas present within the same breast
  • Tumor that is large relative to a smaller-sized breast
  • Connective tissue disease(s) that are sensitive to radiation therapy
  • Pregnancy at the time of radiation following surgery
  • Tumor size larger than 2 inches that does not decrease in size following chemotherapy
  • Residual tumor left over from previous breast-conserving surgery

During the procedure

  • A small incision (cut) will be made over or near the breast tumor. The doctor will remove the lump or abnormality along with a portion of the surrounding breast tissue. In planning the incision, the surgeon had to take into consideration the location of the lump, type of incision, depth of mass from the skin, and the incision had to be close to the lump to avoid tunneling.
    • An improved adequate surgical margin is crucial and the lump that is removed is sent for intraoperative Frozen Section to confirm that margins are negative
    • If margin is postitive additional tissue has to be removed
    • The surgical technique must ensure adequate excision. Obtaining a tumor-free surgical margin decreases the incidence of a local recurrence (LR) of the primary tumor.[18]
  • If the lymph nodes under the armpit are to be removed, a separate surgical incision may be made in or near the axilla (armpit).
  • Breast tissue and any other tissues that are removed will be sent to the lab for examination.
  • A drainage tube may be inserted into the affected area.
  • The skin will be closed with sutures or adhesive strips.
  • A sterile bandage or dressing will be placed over the site.

After the procedure

After the procedure, you will be taken to the recovery room for observation. Your recovery process will vary depending on the type of procedure performed and the type of anesthesia that is given. Once your blood pressure, pulse, and breathing are stable and you are alert, you will be taken to your hospital room.

Generally, patients are able to go home within 2 days following breast-conserving surgery.