Hoag Breast Care Center

Breast Cancer Surgery Overview

Surgery is the most common treatment for breast cancer. In the past, almost all breast cancer cases were treated with mastectomies. Today however, that number is closer to 25-30 percent. The rest (70-75 percent) are treated with various types of lumpectomies (removal of the cancerous lump with some surrounding normal breast tissue) and preservation of the remainder of the breast.

• Multi-centric cancers, which are located in multiple areas of the breast;
• Certain cancers that are large or extensive in size relative to the size of the breast;
• Other cases, including those that may have resulted from a genetic predisposition
• And of course, patient preference is always of paramount importance.

Additionally, at Hoag Breast Care Center, the latest breast-saving oncoplastic surgical techniques are provided by a team of fellowship-trained breast surgeons.

Types of Surgeries

Back to Top

Lumpectomy

Lumpectomy, also referred to as wide excision or breast conserving surgery, is the surgical removal of a cancerous tumor along with a margin of normal appearing adjacent breast tissue. This procedure is often performed on patients with small or localized breast cancers and allows patients to maintain most of their breast after surgery.

During the procedure, the patient receives a local anesthetic along with sedation or general anesthesia. The surgeon then makes an incision over or near the breast tumor and removes the entire abnormality along with a small margin of normal appearing adjacent breast tissue.

Oncoplastic Surgery

At Hoag Breast Care Center, an advanced surgical technique known as oncoplastic surgery may be employed by Hoag’s expert team of fellowship-trained breast surgeons. Oncoplastic surgery combines the techniques of both oncologic (cancer) surgery with plastic surgery. A large variety of incisions are available when performing oncoplastic breast surgery. Some involve reshaping the opposite breast at the same time. Some of these techniques enable the surgeon to completely hide the incision behind or under the breast, leading to a pleasing cosmetic result as well as a definitive surgical excision of the cancer. For more information about oncoplastic surgical techniques, click here.

Axillary (underarm) Lymph Node Surgery

When a diagnosis of breast cancer is made, patients are naturally fearful that it might have spread. The most important place to look for the spread of breast cancer are the lymph nodes in the armpit (axilla).

Before 1995, in virtually every case of breast cancer, all of the axillary lymph nodes were removed (usually 15 – 40 nodes) so that they could be checked for the spread of breast cancer. Complete axillary lymph node dissection occasionally resulted in persistent arm pain and occasional arm swelling (lymphedema). Fortunately, a new technology called sentinel lymph node biopsy has replaced the need for routine axillary lymph node dissection.

In addition to the lumpectomy, a separate incision may be required to include a sampling or removal of a few of the axillary (underarm) lymph nodes. Called sentinel lymph node biopsy, this procedure is performed to determine whether the cancer has begun to spread outside of the breast itself.

Post-lumpectomy Care

After lumpectomy, patients are usually able to go home the same day. Recovery from a lumpectomy generally consists of one to two days for the effects of the anesthesia to subside and the incision to heal. During this time patients may also experience mild to moderate pain at the incision sight, as well as general breast tenderness and swelling. They may also notice slight bruising and scarring around the area of the incision. Full recovery is generally complete in one to two weeks; however, if pain persists or becomes severe, or if unusual swelling or redness is noted at any point after surgery, of if there is an elevated temperature above 100 degrees, the breast surgeon should be contacted.

Lumpectomy for invasive cancer is almost always followed by radiation therapy to destroy any remaining cancer cells that may still be present in the breast tissue. Standard radiation therapy is delivered to the whole breast during a 6-7 week period. When appropriate, Hoag offers breast cancer patients an innovative partial breast irradiation treatment, called MammoSite®.

Other types of adjuvant (additional) therapy may also be given including chemotherapy, and/or a combination of hormonal or drug therapies.

Back to Top

Mastectomy

Mastectomy is the surgical removal of virtually all of the glandular and ductal tissue of the breast including the tumor. Radiation therapy is then done only if the tumor is extensive (more than five centimeters), or if the skin, muscle or multiple lymph nodes are involved.

While some patients will be obvious candidates for mastectomy, others are faced with the choice between mastectomy and breast conserving therapy (lumpectomy, followed by radiation therapy). Although both mastectomy and lumpectomy generally have equal survival rates, there are distinct advantages and disadvantages to both procedures. Hoag encourages patients to educate themselves on all possible options and to thoroughly discuss breast cancer treatment and reconstruction with their surgeon and other members of their cancer treatment team before deciding on a treatment plan.

• Total Mastectomy has now become the most common procedure for removing the entire breast. With total mastectomy, the surgeon makes incisions that encompass the nipple and some adjacent skin. The breast tissue, including the nipple, is then removed.
• Modified Radical Mastectomy removes the whole breast, most of the lymph nodes under the arm and often the lining over the chest muscles. But no muscles are removed.
• Skin-Sparing Mastectomy with Reconstruction preserves most of the normal skin (with the exception of the nipple). An implant or tissue flap is then used to fill the space where the breast tissue was removed.
• Nipple-Sparing Mastectomy with Reconstruction preserves virtually all of the breast skin as well as the nipple areola complex and is appropriate for selected patients with tumors that do not involve the nipple areola area.

Oncoplastic Surgery

At Hoag Breast Care Center, an advanced surgical technique known as oncoplastic surgery may be employed by Hoag’s expert team of fellowship-trained breast surgeons. Oncoplastic surgery combines the techniques of both oncologic (cancer) surgery with plastic surgery. For more information about oncoplastic surgical techniques, click here.

Mastectomy Procedure

During a mastectomy, the patient receives general anesthesia. Blood pressure and vital signs are monitored throughout the surgery. Typically, a drainage tube is inserted into the surgery site and the incision is closed with dissolvable sutures. The area is then carefully bandaged. The drainage tube is usually removed within one week of surgery.

If lymph nodes are to be removed during a mastectomy, they are generally removed through the same incision.

After mastectomy, patients are usually able to go home within one to three days, although some patients will occasionally go home the same day. During the recovery process, patients may experience moderate pain at the incision sight, as well as general breast soreness and swelling. A patient may also notice slight bruising while healing. In addition, a surgical scar will be visible at the mastectomy site. Full recovery is generally complete in two weeks; however, if pain persists or becomes severe, or if unusual swelling, fever, or redness occurs at any point after surgery, patients should contact their physician.

Back to Top

Oncoplastic Surgical Techniques

Back to Top

Sentinel Lymph Node Biopsy

Each breast contains vessels that carry lymph. Lymph is a fluid that can transport cancer cells. The lymph vessels lead to small bean shaped organs called lymph nodes. Clusters of lymph nodes are found throughout the body, including underneath the arm, above the collarbone and in the chest. If cancer has spread outside the breast, it is often first found in the lymph nodes in the armpit. That’s why lymph nodes under the arm (axillary nodes) are often examined during breast cancer surgery.

Mapping the drainage of the lymphatic fluid from the breast allows a surgeon to identify which lymph nodes are at greatest risk for involvement by breast cancer. Those at risk are called sentinel lymph nodes and are removed and evaluated. It has been found that the status of these sentinel lymph nodes is typically a very accurate reflection of the status of the remaining lymph nodes.

Just prior to breast cancer surgery, a radioactive tracer and/or blue dye is injected into the breast at, or near, the tumor site. The dye migrates through the lymphatic channels to the lymph nodes. The dye itself does not identify cancer cells; it does however, accumulate in one or more lymph nodes that are termed the “sentinel lymph nodes.” These nodes can then be removed and examined to determine whether cancer is present. If there is no breast cancer involvement, further lymph node surgery can be avoided.

Sentinel lymph node biopsy has proved to be a highly accurate means of identifying breast cancer lymph node involvement. This allows for more accurate and tailored treatment plans for breast cancer patients. Occasionally, only tiny clusters of breast cancer cells are identified in the sentinel node (called micrometastases). Such tiny clusters may only be apparent with special tissue preparations , which can take as long as 48-72 hours after surgery to prepare and interpret.

Back to Top

Lymphedema

Some breast cancer surgery patients develop chronic arm swelling as a consequence of having underarm lymph nodes removed. This swelling is called “lymphedema.” However, using current surgical techniques, the risk of this occurring is greatly reduced.

The arm swelling is caused by an accumulation of fluid that is unable to return to general circulation. In breast cancer surgery patients, removal of a large number of underarm lymph nodes (axillary node dissection) can disrupt the lymphatic channels and result in fluid accumulation in the arm.

Sentinel node biopsy procedures allow removal of many fewer lymph nodes than the standard lymph node dissections routinely performed in the past. Patients who undergo only a sentinel lymph node sampling very rarely develop lymphedema.

Those patients with axillary lymph nodes found to be involved by cancer, generally require that more lymph nodes are removed through a procedure known as axillary node dissection. There can be some risk for the development of lymphedema for these patients. Additional lymphedema risk factors include obesity, age and radiation to the lymph nodes.

In high-risk patients, lymphedema cannot always be avoided. Precautions that may help include the avoidance of infection or injury to the arm and avoidance of constriction of the arm (tight clothing, blood pressure cuffs, wearing a heavy purse, etc.).

The risks from IVs and blood draws occur only if there is injury from those procedures. Blood draws or IVs themselves generally do not cause lymphedema in the absence of some complication. Be sure to check with your physician for any additional precautions.

If lymphedema develops or seems to be developing, evaluation can be arranged with a lymphedema specialist. An appropriate physical therapy program can minimize the degree of swelling and in some early cases, reverse the process. For more information, please call 949/764-5645.

Back to Top

Immediate Breast Reconstruction

It’s important for women to realize that breast reconstruction is possible for the majority of breast cancer patients at the same time as mastectomy. Your body type, age and cancer treatment program will determine which reconstruction method will give you the best result.

It’s also important for women to know that if you undergo a mastectomy, California law requires that group health insurers pay for breast reconstruction and for surgery to the other breast for symmetry.

Breast reconstruction is done either using implants or tissue flaps in order to rebuild the contour of the breast, along with the nipple and areola, if desired. Breast implants have a silicone shell that is filled with silicone or saline (salt water). Often a temporary implant, called a tissue expander, is initially placed to create a pocket for the implant. The expander is placed behind the skin and chest muscle. It is later exchanged with a permanent implant during a separate procedure.

Tissue flaps made from muscle, fat and skin from another area of the body, can be moved to the chest area where they are then shaped to form a breast. This tissue is most often taken from the lower abdomen, back or buttocks.

Skin-sparing mastectomies, including those utilizing oncoplastic surgical techniques, preserve the breast skin, minimize the size of the surgical incisions and allowing for a more natural appearing breast after reconstruction.

Although some women may not be interested in breast reconstruction, many breast specialists support reconstructive surgery as an important option for patients to consider. Hoag encourages all mastectomy patients to discuss each of the options for breast reconstruction with their physicians in order to determine the best possible plan for their individual situation.

Back to Top

Surgical Discharge Instructions

Leave the elastic binder or Ace wrap in place until the day following the procedure. If it is uncomfortable or if you feel any difficulty breathing, you may remove it sooner. In some cases, your doctor may advise you to leave the binder on until you are seen in the office.

When you remove the outer bandage, leave the steri-strips (skin tapes) in place. You may shower and get the incisions wet 24 hours after surgery.

Take Tylenol, ibuprofen or the prescribed medication for pain per the instructions on the label. Call the Breast Care Center at 949/764-8281 for an appointment one to two weeks after surgery unless your surgeon instructs otherwise.

What you can expect

It is normal to see a small amount of blood on the skin or bandage and you will likely feel soreness after the local anesthesia wears off in six to 12 hours. Purplish or black and blue discoloration of the skin sometimes appears a day or two after surgery. You may also experience a low grade temperature of less than 101 degrees Fahrenheit in the first 24 hours.

When to call your surgeon

Back to Top