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Surgery

The main goal of surgery is to prevent the cancer from coming back to the area where it originated in your body.

Breast-conserving therapy is done by removing the cancer, with clear margins, and necessary lymph nodes, then letting radiation destroy any remaining cells.This method does not remove the breast itself. (Less formally, it’s called lumpectomy, wide excision, or even partial mastectomy—they all mean the same thing).

The cancer can also be removed by a mastectomy and excision of necessary lymph nodes. In small tumors with little-to-no lymph node involvement, the surgeon can typically take out enough tissue to prevent a local recurrence and eliminate the need for radiation.

With very large tumors or significant lymph node involvement, both mastectomy and axillary dissection are needed to remove as much of the tumor as possible, and radiation therapy is usually recommended to take care of any leftover cells.

Your best choice will probably be dictated not only by the biology of your tumor but also by what make sense to you.

Most women conclude the more drastic treatment will be better, believing the mastectomy will remove not only the breast, but any possibility the cancer will return. But that isn’t always the case. Breast cancer can come back in the scar, chest wall, or axilla (armpits) after a mastectomy, just as it can after a lumpectomy. In 2002, researchers published a 20-year follow-up of women enrolled in a randomized study that compared breast conserving surgery to mastectomy in women with early-stage breast cancer. The study found that long-term survival rates were the same in both groups. This study confirmed the conclusion issued in June 1990 at the National Cancer Institute Consensus Conference: “Breast conservation treatment is an appropriate method of primary therapy for the majority of women with stage I and II breast cancer and is preferable because it provides survival equivalent to total mastectomy while preserving the breast.”

Still it seems that more and more women are choosing mastectomy or even bilateral mastectomy. Part of this might be because, as breast conservation surgery became more common, surgeons began removing larger pieces of tissue to achieve clean margins, often at the expense of cosmetic results. But the reconstructive techniques used for mastectomy can also be used for a lumpectomy, allowing for an excellent aesthetic result and the ability to still have sensation in your breast.

Axillary Surgery: checking the lymph nodes

Along with getting rid of the cancer, the surgeon needs to determine if there are affected lymph nodes in the armpit area (axilla). Aside from preventing recurrence in the armpit, axillary surgery helps to determine the stage of the breast cancer. If a woman has palpable (you can feel them) lymph nodes in her axilla, an ultrasound-directed fine needle aspirate or core biopsy should be done to help determine whether those nodes represent cancer. If this does not show cancer, surgery should still be done, as small areas of cancer within a lymph node may be missed by the needle biopsies.

Only women with large tumors (T3/T4), inflammatory breast cancer, or known lymph node involvement need to have a full dissection of their axilla. Most women can undergo a sentinel node biopsy with less surgery and fewer complications. The concept of sentinel node biopsy is pretty straight­forward. It is based on the theory that there are one or more nodes to which breast cancer is most likely to spread. During or just before surgery, the surgeon injects a small amount of blue dye and radioactive tracer into the breast and follows it as it travels to the lowest draining lymph node or nodes. These nodes are then removed for examination, with the idea that they would be the first stop in the lymph nodes on the cancer’s way out of the breast and into the body. If these nodes are found not to have any cancer, the rest of the axilla is left alone.

A woman with up to two positive sentinel nodes who plans to undergo breast conservation and systemic therapy can also avoid further axillary surgery.

Oncoplastic lumpectomy/partial mastectomy

Recent years have seen an increase in the use of oncoplastic surgery, a combination of cancer surgery and plastic surgery. The oncoplastic approach applies plastic surgery techniques to the whole cancer operation including, if needed, a reduction of the other breast to match the first. Oncoplastic surgery is best done at the time of the lumpectomy, but it can still be performed a week or so later after the pathology has been reviewed. It may also be used if dirty margins require further surgery or at a later time to improve the appearance of your treated breast, but doing it around the time of surgery usually provides the best results. If you cannot find a breast surgeon trained in oncoplastic techniques, the best alternative is to involve a plastic surgeon in assisting the cancer surgeon. Then the plastic surgeon can go on to balance the other breast to match.

Reconstruction

Reconstructive surgery is done in a number of ways. It has at least two components: reconstruction of the breast mound and reconstruction of the nipple areolar complex. The reconstruction of the breast mound can be done with either artificial substances, your own body tissues, or both.

Implants and Expanders

Current options for implant-based reconstruction include:

  • immediate or delayed reconstruction with a standard or adjustable implant.
  • two-stage reconstruction with a tissue expander followed by an implant.
  • or reconstruction with the combination of an implant and your own tissue.

The two-stage technique of expander-implant reconstruction has become the most common approach to implant-based reconstruction. The final implant is either saline or silicone and is placed behind the pectoralis muscle.

One caution: implants don’t last forever. Replacing them can be devastating—like losing the breast all over again, and it may require the flap reconstruction described below. Having problems with the implant suggests the likelihood of having more problems later on. You need to weigh the comparative ease of the implant surgery against the inconvenience and emotional consequences of possible later surgeries.

Flap Procedures

The breast mound can be reconstructed using your own tissue. In the myocutaneous flap, a flap of skin, muscle, and fat is taken from another part of your body and moved. It’s your own tissue, and because you’ve got extra skin, it can make a bigger and more natural breast. You may feel more normal since it’s real tissue, skin, and fat, though it has little sensation. These flaps can come from the abdomen (transverse rectus abdominis muscle, or TRAM flap), back (latissimus dorsi flap), or buttock (gluteus maximus flap).

There are two different techniques for the myocutaneous flap. One is the pedicle, or attached flap. In this procedure, the tissue is removed except for its feeding artery and vein, which remain attached, almost like a leash. The pedicle flap can only be done from tissue close enough to reach to the breast and so is limited to the abdomen (TRAM) or back (Latissimus). The advantage of the pedicle flap is that it’s easier, so more plastic surgeons can do it. It still involves at least three procedures (reconstruction, nipple, and tattoo) and four if you need something done to the second breast to match.

The other option is the “free flap.” In this procedure, the tissue is removed and the feeding artery and vein are cut. The tissue is moved to a new location and the artery and vein are sewn to an artery or vein in the chest or armpit; the surgeons use a microscope to help them reconnect the tiny blood vessels. While the free flap is not as limited as to where the tissue can come from, the most common free flaps are from the abdomen. They can be based either on the lower blood vessels that feed the skin (inferior epigastric) or from the blood vessels that pass through the muscle into the fat and skin (DIEP or deep inferior epigastric perforator flap). Other free flaps include those from the infraumbilical area (SIEA, or superficial inferior epigastric artery flap) and the buttocks (SGAP or IGAP depending on whether it’s based on the superior gluteal artery perforator or the inferior one).

Perforator flaps use the same tissue that is transferred in the muscle/fat/skin flaps, except they dissect blood vessels through the muscle so it can be left behind. These surgeries preserve muscle function instead of taking the muscle with the tissue flap. More recently the superior gluteal artery perforator flap (SGAP) and the inferior gluteal artery perforator flap (IGAP) have been added to the options.

Another procedure gaining some popularity is the TUG flap, or transverse upper gracilis flap. This flap takes one of the muscles in the medial thigh (gracilis) with tissue from the upper inner thigh. Sacrificing this muscle usually has no effect on leg function, and the flap can usually supply enough tissue for an A or B cup reconstruction.

Both versions of the flap procedure require not only highly trained plastic surgeons but specialized teams. You want to go to a center where they do this a lot and the whole staff is comfortable with the procedure and with its potential risks and complications. Researching and talking to people who have had the procedure you are considering is important to help find the right place and the right doctor. It may be necessary to travel to find the surgeon and team that best fits your needs.

Nipple and Areola

There’s a lot of swelling after reconstructive surgery, and that needs to go down before the doctor can construct the nipple and areola. The nipple can be created using skin from the breast or flap, but it won’t be the same color as your original nipple. That can be tattooed later. The areola can be reconstructed with a skin graft or a tattoo. Sometimes the skin from your inner thigh is used, since it’s darker than breast skin. If the skin graft is not dark enough, it can also be tattooed. Skin grafts tend to have more texture and are thus more realistic, but taking the skin graft will put one more scar on your body, unless you take it from someplace where there is already a scar.

Whether or not you want to take the extra step to do your nipple depends on why you want the reconstruction. If your goal is to look symmetrical under clothes, without having to manage a prosthesis, you may decide against it. If you want your new breast to look as real as possible, you’ll probably want to have your nipple completed. This is your choice; you’re the one who’ll go through the surgery, and you’re the one who’ll live with the results.

Making a Decision

To decide what’s best for you, you should discuss it with both your breast surgeon and your plastic surgeon. Make sure you have thought about your goals for reconstruction and share them with both. Get a second or even third opinion. Look at websites that discuss reconstruction and talk to other women who have gone through it. Some doctors will only share the best results, but this is comparable to false advertising. And, it’s important for you to know the limits of what the procedure can do for you and your risk of having less than ideal results.

Prostheses

Many women choose not to have reconstruction because they are comfortable with a prosthesis. It isn’t invasive and can be removed at will. The option of wearing a prosthesis will probably be offered to you in the hospital after your surgery (unless you’ve had immediate reconstruction and obviously won’t need one). In most areas of the country, the hospital arranges for someone to visit you to talk about prostheses while you’re still there. The prosthesis fits into a pocket in a postmastectomy bra. You can shop for them in person or online, from catalogs, in medical supply houses, or in fancy lingerie stores.

Frequently Asked Questions

What is a sentinel node biopsy?

During most breast cancer surgeries, the lymph nodes under the arm are examined to determine if the cancer has spread beyond the breast. Only if the chance of finding cancer in the lymph nodes is extremely low — for example, when a woman has ductal carcinoma in situ (DCIS) or an invasive tumor less than five millimeters in size—will a surgeon suggest that evaluation of the lymph nodes may not be necessary.

A sentinel node biopsy is the procedure that is now the standard of care for evaluating lymph nodes. A sentinel node biopsy is appropriate if:

  • the tumor is in only one location.
  • the tumor is less than five cm in size.
  • you have not had previous chemotherapy or radiation therapy.
  • there is no large resection in the upper outer quadrant (more than six cm), and
  • there are no palpable lymph nodes.

If you have had a breast reduction or silicone implants, the surgeon will not be able to perform a sentinel node biopsy. The procedure will also not work if you have two lumps in different places in your breast, as this means the sentinel nodes will be in two parts of the breast. If your doctor thinks that the lymph nodes are worrisome, she will probably have you undergo an ultrasound to help determine if they are abnormal. If they are, then you will need to have either a fine needle aspiration or a core biopsy. If the node is positive, then you will have an axillary lymph node dissection. If not, you will have a sentinel node biopsy.

The sentinel node biopsy is done at the time of your breast surgery. To identify the sentinel node, surgeons use blue dye either alone or with a radioactive tracer. The tracer is usually injected two hours before surgery or up to the afternoon before for early morning surgery. Make sure you ask for EMLA (an anesthetic cream) to apply to your breast an hour before the injection to reduce the pain. You also can request Ativan (a drug used for anxiety) ahead of time if you think you will be queasy or are very sensitive to pain. The radiation is very low dose so you don't have to worry about being radioactive thereafter or exposing others to harmful effects from your injection.

The blue dye is usually injected in the operating room once you are asleep, followed by a five-minute breast massage prior to operating. There are several different blue dyes that are commonly used. Both dyes that are regularly used can turn your breast blue, and it can take several weeks to months for the color to fade completely. There will also be a transient change in the color of your urine (blue) and stool to a greenish hue.

The radioactive tracer allows the surgeon to wave a hand-held gamma detection probe in concentric circles over the breast to trace the lymph vessels and identify where the sentinel node is most likely to be. Usually, the drainage is to the armpit and a short incision is made just below the hairline over the area with the strongest signal. Next, the tissue is carefully dissected. The surgeon looks for the blue dye in the lymphatic vessel, which will lead to the blue sentinel node or nodes. Although we call this a sentinel node biopsy it is really more than a biopsy and often involves more than one node, since all the nodes that are radioactive and/or blue (usually two to four) are then removed and sent to pathology for examination.

In some centers, the nodes are evaluated during the surgery with either a "frozen section" or a molecular study. This is done first, before your surgeon begins to work on your breast. This gives the pathologist time to examine the sentinel nodes that have been removed while the lumpectomy or mastectomy is taking place. These tests generally take about 30 minutes to perform, and are about 90% accurate. If the nodes are negative the incision is sewn closed without a drain. If the sentinel lymph nodes are found to be "positive" — to contain cancer cells — then a full axillary dissection can be done at the end of the surgery.

In other centers, the nodes are not evaluated at the time of surgery. If this is the case and a positive sentinel node is found, you may be advised to have additional nodes removed in full axillary node dissection. Very rarely, even if the frozen section shows a negative node, the final pathology report might show some cancer cells. Often, this situation will require a discussion with your surgeon or oncologist to determine whether additional lymph nodes need to be removed.

If cancer is found in the nodes, it will help guide decisions related to adjuvant chemotherapy. Also, removing nodes that contain cancer can help prevent a recurrence in the armpit. There is no evidence, however, that removing and examining lymph nodes affects survival.

What is a full axillary lymph node dissection?

A full axillary dissection is done either because there are palpable nodes that have been shown to contain cancer or a positive node was found during the sentinel node biopsy that was done at the beginning of your breast cancer surgery.

If a sentinel node was done at the beginning of the surgery, the surgeon will go through the fresh incision and extend the dissection. If you are having a mastectomy, the axilla is approached through the mastectomy incision.

If you are having an axillary node dissection because you learned after your breast cancer surgery was completed that you had a positive sentinel node, the surgeon will make an incision about two inches across the armpit and then remove the wad of fat in the hollow of the armpit, which should contain most of the lymph nodes. This lump of fat is defined by certain anatomical boundaries and usually contains approximately 10 to 15 lymph nodes. Studies have shown that the chance of missing a positive lymph node if we remove the tissue in the lower two levels of the armpit is less than two percent.

The tissue is sent to the pathologist, who examines the fat and tries to find as many of the lymph nodes as possible. The pathologist then cuts each node in half, makes slides, and examines each of them for cancer.

Some women have more nodes than others. So, you might be told that there were 17 nodes examined. Or, you might be told that there were seven or even 40. However, the total number of nodes is less important than the number that are positive.

Some surgeons put a drain in the axillary incision afterward, and some do not. The operation takes from one to three hours. When you go home you'll have a small dressing on your incision. Depending on the practice of the surgeon there may or may not be sutures to remove, but most surgeons like to see their patients 10 days to two weeks after the surgery to monitor their progress. An earlier visit can be scheduled to discuss pathology results.

Axillary pain, numbness, paresthesias (abnormal sensations), and arm swelling (lymphedema) are a few of the problems that can develop after an axillary node dissection.

Another problem is fluid under the armpit (seroma). Most women have some swelling, but sometimes a woman will get so much that it looks like she has an orange in her armpit. The fluid usually is aspirated by the doctor in the office.

More long lasting is the possibility of damage to a sensory nerve or nerves that pass through the middle of the removed fat. This nerve gives you sensation in the back part of your armpit, though it doesn't affect the way your arm works. If that nerve is cut, you'll have a patch of numbness in the back part of your arm. Most breast surgeons and many general surgeons try to save the nerve. Even if the surgeon does save it, it may get stretched and cause decreased sensation either temporarily or permanently. If you have no sensation for more than a few months, the loss is probably permanent. This problem is less common after sentinel node biopsy but is certainly not eliminated. (If this happens to you, you may want to give up shaving your armpits, or use an electric shaver rather than a razor, which is more likely to cut the skin and cause bleeding.)

Another early problem can be phlebitis in an arm vein. This usually shows up three or four days after surgery. You'll know you might have it if you develop a tight feeling under your arm that goes down to your elbow and sometimes even to your wrist. This has more recently been called axillary web syndrome and is very common, but is also temporary, typically resolving within six to eight weeks. It's not serious but it's bothersome. The best treatment is ice and aspirin or an NSAID (nonsteroidal anti-inflammatory drug) such as ibuprofen. It will go away within several days to a week. Again, it's important to move your arm and keep it from stiffening.

Lymphedema is another concern. The risk of developing this painful arm swelling is about 15-20% after a full axillary dissection.

I was recently diagnosed with DCIS and my surgeon told me that, in addition to removing the duct, he needs to remove my nipple. Is this really necessary?

The answer is a resounding "maybe."

It makes sense that you would want to keep your nipple, but, unfortunately, sometimes this just can't be done. The clinical trials that looked at the effectiveness of nipple preservation when women have tumors located directly under the nipple found an unacceptably high rate of cancer recurrence in the nipple — and this is something you just don't want to risk. The problem is that there is a lot of ductal tissue that comes up into the nipple, and that ductal tissue may contain cancer cells. This is why when the tumor is right under the nipple, it is safer to remove the nipple and reconstruct it. If the ductal carcinoma in situ (DCIS) is not located right under the nipple, then the nipple often can be preserved.

You should get a second or third opinion from another surgeon as to the location of the DCIS and the need for nipple removal before scheduling your surgery.

My reconstruction wasn't what I had expected. What should I do?

Sometimes reconstruction isn't entirely successful. It may not give you the look you want or it may be a source of pain or medical problems. However, there is no need to live with the consequences for the rest of your life. They are often reversible.

The reconstruction can be a source of unpleasant sensations ranging from pins and needles, to burning, to sharp pain. You may also find it hard to adapt to the sensation of having an implant. An implant may seem solid, even rocklike, to the touch. This hardness isn't due to the saline implant but to the scar tissue that has formed around it, encasing it in a tough capsule.

Sometimes plastic surgeons may focus on crafting a perfect breast, not on replicating the patient's natural breast. Even when an implant matches the breast, the new breast is often heavier, because the implant and scar tissue weigh more than the breast tissue. The result is often a breast that is too big, or feels too big.

Because surgeons see women lying on an operating table, they see breasts from a different perspective than does the woman, who usually sees herself standing before a mirror. As a result, they may misjudge the way a breast will fall when the woman is on her feet. If it is a good match for her other breast, which appears flatter when she is lying on her back, it will probably be smaller when the woman stands up.

Occasionally, the new nipple (which is not a true nipple but tissue taken from another part of the body or tissue that has been tattooed to resemble a nipple) is higher or lower than the nipple on the other breast. Sometimes, if the nipple is applied when the reconstructed tissue is still swollen from the surgery it may no longer match when the swelling goes down.

You don't have to accept any of these problems. A plastic surgeon can cut away hard scar tissue and replace implants, exchange an implant for a flap, reduce or enlarge a breast, or lift and reorient nipples.

If you are unhappy with your breasts, get a referral to a plastic surgeon from a friend or your breast surgeon, explain your problem, and have the plastic surgeon outline a plan for correcting it. If possible, get a second opinion. Ask for pictures, so that you can see the plastic surgeon's best and worst outcomes. If you don't like what you see, get a different plastic surgeon.

How many re-excisions can you have after a lumpectomy? I do not want to have a mastectomy, but one area still doesn’t have a clear margin.

You can have as many re-excisions as necessary. The limiting factor is usually the size of the breast and the cosmetic end result. But it should be the patient who decides if the cosmetic end result is something she can live with — not the surgeon. The other limiting factor can be the patient or the surgeon's patience. Some women may not want to face another re-excision while others will want to do anything possible to save their breast.

I had a lumpectomy a year ago. My breast is still a bit swollen and I sometimes have mild pain by the scars. Is this normal?

It is quite normal for the breast to be swollen for some time after surgery and radiation. It's also fairly common for women to have some mild pain by their scars. This is just how some women's bodies respond to the whole experience of surgery and radiation. It appears that your breast has gotten a bit inflamed. It will most likely calm down over time. However, many women do find that their breast remains slightly swollen forever.