Understanding Surgery for Breast Cancer
Reviewed by Dr. C.H. Weaver M.D. 10/2020
Nearly all women with breast cancer will undergo some kind of surgery as part of their diagnosis and/or treatment. The extent of surgery for breast cancer may range from removal of only a small piece of breast tissue to removing one or both breasts, including underarm (axillary) lymph nodes. The role of surgery in the management of breast cancer is to:
- Obtain a tissue sample for determining an accurate diagnosis.
- Evaluate the tissue to determine if precision cancer medicines can be used to treat the cancer.
- Determine the stage of the cancer and whether additional treatment is necessary.
- Treat the cancer locally.
- Create a cosmetically acceptable reconstructed breast.
The type of surgery that a patient with breast cancer undergoes depends largely on the size and location of the cancer, the breast size, the feasibility of breast reconstruction, and how important breast preservation is to the patient.
A biopsy is the removal of cells or tissue for further evaluation; it is often performed to determine whether cancer is present. A biopsy may involve surgical removal of all or a part of a breast lump, or use of a needle to remove tissue or fluid. Learn about breast biopsies here...
A simple (total) mastectomy involves the removal of the entire breast, but not the axillary (underarm) lymph nodes. There are also different degrees of mastectomy, including the following:
- Partial (segmental) mastectomy is the removal of one-quarter or more of the breast and the lining over the chest wall. This may include removal of axillary lymph nodes. Reconstruction may be difficult after a partial mastectomy because of the drastic change to the contour and size of the breast after the procedure.
- Radical mastectomy is an aggressive therapy that consists of extensive removal of the entire breast, the lymph nodes under the arm in the axilla and the chest wall muscles under the breast.
- Modified radical mastectomy involves the removal of the entire breast and the lymph nodes in the axilla under the arm.
Removal of the cancer and a portion of surrounding tissue is called a lumpectomy. Because a lumpectomy alone is associated with a higher rate of cancer recurrence than mastectomy, patients who elect to have a lumpectomy are also treated with radiation therapy. This combination of lumpectomy and radiation therapy is called breast-conserving therapy. Among women with early-stage breast cancer, breast-conserving therapy and mastectomy produce similar rates of long-term survival. (1)
Axillary Lymph Node Evaluation
Evaluation of early stage breast cancer typically includes a biopsy and removal of axillary (under arm) lymph nodes in order to help determine the stage of the cancer and whether the cancer has spread outside the breast. This is important because when axillary lymph nodes have cancer, more aggressive treatment is required in order to achieve the best chance for cure. For over 30 years, the standard of practice for evaluating lymph nodes has been a surgical procedure called an axillary lymph node dissection. This procedure involved the removal of approximately 10-25 axillary lymph nodes and was performed during the initial surgery or as a separate procedure. Sentinel lymph node biopsy has largely replaced axillary lymph node dissection. The procedure appears to be just as effective in determining cancer spread to axillary lymph nodes and results in fewer side effects.
As blood circulates through the body and travels into smaller and smaller vessels, excess fluid, protein and other substances are pushed out into the surrounding tissue. This substance is called lymph fluid. Under normal circumstances, lymph fluid is removed from the tissues by the lymph system, which is a series of vessels and organs that moves the fluid back toward the heart and filters it through lymph nodes. Lymph nodes are specialized structures that are composed of white blood cells and serve to “clean” the lymph fluid of bacteria or other contaminants like cancer cells. The sentinel lymph node biopsy involves removing a single lymph node (or a small number of nodes), called the sentinel node, which is the first lymph node to collect excess fluid surrounding the cancer. Prior to surgery, blue dye is injected near the cancer. The dye drains from the area containing the cancer into the nearby lymph nodes, through the sentinel node. The node containing the dye is removed during surgery and evaluated under a microscope to determine whether cancer has spread. If the sentinel node is free of cancer, more extensive lymph node surgery is usually not required.
Breast reconstruction surgery has become increasingly refined and can be successfully accomplished in almost all women treated with mastectomy. The goal of breast reconstruction surgery is to create a breast that matches the opposite breast. This can be accomplished by using a breast implant alone, by actually reconstructing the breast with the patient’s own tissue, or by utilizing a combination of these two techniques. Breast reconstructive surgery can be performed immediately after mastectomy or it can be delayed for some time. If chemotherapy treatment or if radiation is to be given to the chest wall, many doctors prefer delayed reconstruction so that the healing of the reconstructed breast is not impaired.
It is recommended that patient include a plastic surgeon in their team of physicians as early in their treatment as possible so that their chosen method of breast reconstruction can be incorporated into the overall treatment plan.T he two techniques commonly used in breast reconstruction are:
- Synthetic breast implants
- Autologous reconstruction, which utilizes the patient’s own tissue
Synthetic Breast Implants
The simplest method of reconstructing the breast is with the use of synthetic implants. During this procedure, an implant that closely approximates the size and shape of the other breast is inserted through the mastectomy incision, under the pectoralis major (chest muscle). Implant surgery is relatively simple and can be performed at the time of initial surgery or delayed until after all treatment is completed. If performed at the time of mastectomy, implant surgery adds an additional 30 minutes or approximately 1½ hours is required if it is delayed and performed as a separate surgical procedure. Recovery from implant surgery is typically quicker after immediate reconstruction than after delayed reconstruction.
The procedure of implant surgery usually requires the surgeon to insert a temporary tissue expander under the pectoralis muscle in order to stretch the muscle and the skin over the chest wall. The tissue expander contains a valve-like opening or port through which small amounts of saline (salt-water) can be injected. Every week or two, saline is injected into the expander until it is inflated to a size slightly larger than the implant. Because the expansion occurs gradually, there is minimal pain or discomfort associated with the procedure. When the tissue has been expanded to the point where it can accommodate the breast implant, the expander is replaced with the permanent implant.
If there is not enough skin to cover the implant, the muscle over the chest wall has been removed, or the skin has been damaged by radiation and cannot be stretched, the surgeon can remove a fan-shaped section of muscle and skin from the back that remains attached to a portion of skin or pedicle. The pedicle contains the blood supply for the flap and this procedure is referred to as the latissimus dorsi flap. The flap is tunneled under the skin and pulled out through an opening in the chest where it is sutured in place over the mastectomy site. The implant can then be placed under the muscle to complete the reconstruction. The latissimus dorsi flap procedure is more complicated than a simple implant insertion. It leaves a scar on the woman’s back and requires a longer recuperation. There is a potential for shoulder problems because a portion of the muscle required for shoulder motion has been removed. However, this procedure usually creates a better result than an implant, especially in women with large breasts or those who have received previous radiation treatment. The risks and benefits of the various implant procedures should be carefully discussed with your surgeon in order to achieve the best results.
There are currently two types of implants available in the United States for breast reconstruction, silicone gel implants and saline-filled implants.
Silicone gel implants have generated a fair amount of controversy regarding their safety because of the question as to whether they can trigger certain connective tissue and autoimmune diseases. In 1992, the Food and Drug Administration restricted the use of silicone implants in order to evaluate whether they were indeed associated with autoimmune conditions. Patients who desired reconstructive surgery with silicone gel implants after mastectomy were given access to clinical trials. Studies completed thus far have failed to show an increased risk of autoimmune disease among women with silicone implants, although the follow-up is relatively short. It is interesting to note that other countries did not take silicone implants off the market.
Saline-filled implants have not been associated with any risks. If saline implants leak, the saline is absorbed into the body and is harmless. Many women prefer the silicone gel implants to the saline filled implants because the silicone feels more like breast tissue.
Autologous Reconstruction of the Breast
Autologous reconstruction of the breast utilizes the body’s own tissue to build a mound that feels and appears like a natural breast. Autologous breast reconstruction is major surgery compared to breast implants. It requires several hours in the operating room and is associated with the complications of any major surgery. Two major surgical techniques are currently used for autologous reconstruction of the breast. These are the TRAM flap (transverse rectus abdominis myocutaneous) and the free flap. Individuals deciding to undergo breast reconstruction surgery should discuss these options with a qualified plastic surgeon in order to ensure the result they achieve is satisfactory.
The TRAM flap procedure utilizes tissue taken from the woman’s abdomen. Tissue containing a section of the skin, the underlying fat, and a portion of the abdominal muscle is excised except for one or two pedicles of tissue, which remain attached to the abdomen. The remaining attached tissue serves as the blood supply for the flap that will be used to reconstruct the new breast. The flap is tunneled under the abdominal wall to the chest and then rotated to fit the mastectomy wound. The smooth edges are made by attaching the edges of the breast incision to the flap. The TRAM flap procedure thus creates a breast with a natural texture very similar to a normal breast. Side effects associated with the TRAM flap procedure may include abdominal weakness and an increased risk of developing an abdominal hernia, which is a bulging of the internal tissues through an area of weakness in the abdominal wall. Because of these potential problems, modifications of the TRAM flap technique have been developed. These newer techniques limit the amount of muscle which is removed with the flap.
A free flap, or a free TRAM, utilizes an island of fat and skin that is entirely removed from the abdomen. Since the fat and skin are completely excised from the abdomen, a new blood supply to the tissue must be provided. This requires a surgeon who specializes in microsurgery to attach the blood vessel supply in the flap to those in the chest wall. This procedure is technically more difficult to perform than the TRAM flap, but less muscle is removed. An even more complicated technique called a Deep Inferior Epigastric Perforator (DIEP) flap removes no muscle.
Deep Inferior Epigastric Artery Perforator (DIEP) flaps and Superior Inferior Epigastric Artery (SIEA) flaps.
DIEP Microsurgical Breast Reconstruction: In this procedure the DIEP flap is transplanted to the chest for breast reconstruction by microsurgically attaching the circulation of the deep inferior epigastric artery to the blood vessels in the chest. Through the increased tissue circulation, the reconstructed breast remains soft and feels more like a normal breast. Unlike the TRAM flap surgery (which uses the same area from the abdominal wall), the DIEP flap does not include any muscle in the flap. This procedure can only be performed in specialized microsurgery centers, where the surgeon uses an operating microscope. Potential advantages include less postoperative pain and less likelihood of abdominal hernia formation and abdominal muscle weakness when compared with TRAM flaps. Healthy, physically active, non-smoking patients with enough abdominal tissue to create a breast mound are good candidates for this procedure.
SIEA Microsurgical Breast Reconstruction: This flap uses the same tissue as the DIEP flap but harvests the superficial blood supply to the skin and fat of the abdomen. Although SIEA flaps require less surgical dissection than DIEP flaps, only 30% of patients have a SIEA vessel that can be identified during surgery. Although the abdominal tissue used is the same as the DIEP, the SIEA relies on a distinctive blood supply and requires less surgical dissection than the DIEP. However, the majority of patients are not candidates for the SIEA procedure. This is because only about 30% of people have an SIEA vessel that is visible during surgery and that can be used for the procedure. Doppler studies may help in identifying the SIEA prior to surgery. Potential advantages of SIEA flaps over DIEP flaps include a shorter operative time, less post-operative pain, and earlier recovery to full function.
Researchers from the Department of Plastic Surgery at M. D. Anderson Cancer Center surveyed 179 patients over a five-year period: 47 had undergone SIEA flaps, 49 had reconstruction using DIEP flaps, and 136 had muscle-sparing free TRAM flaps. The investigators found that single-side SIEA flap patients had superior outcomes with respect to duration of postoperative pain and ability to lift things after surgery when compared with TRAM flap patients. Furthermore, for those patients who required flaps on both sides to reconstruct double mastectomies, SIEA flaps were superior to both double DIEP flaps and TRAM flaps.
Though the technique of skin-sparing mastectomy is harder for the breast surgeon to perform, the potential for improved cosmetics makes it worthwhile in certain circumstances. In some cases, breast size, tumor size, tumor location, presence of other scars, or other patient factors precludes the use of this technique. The importance of the skin-sparing technique is that it results in a more natural appearance, with less scarring and fewer visible patches of skin from other areas of the body.
A skin-sparing mastectomy removes the entire breast tissue, similar to a mastectomy, but leaves the skin covering the breast intact and capable of housing fat and muscle from other parts of the body. The procedure is more difficult than a traditional mastectomy in that the surgeon must make a small incision in the breast about the size of a half-dollar and then carefully remove all the breast tissue inside the breast. When done correctly, an empty envelope of skin exists that can than be filled with fat and muscle taken from the woman’s back or abdomen. Because the surgery uses fat from the woman’s own body, the newly constructed breast behaves just like the companion breast when weight is gained or lost.
Nipple Sparing Mastectomy
Unlike a standard mastectomy, which removes the whole breast and breast skin including the nipple, nipple-sparing mastectomy (NSM) removes the breast tissue but leaves intact the breast skin, nipple, and areola (the ring of darker skin around the nipple). Often, a woman feels more whole when she keeps her nipple and the breast look more natural after NSM, a woman who still has fully intact breast skin can often choose to have a single-stage breast reconstruction with an implant, rather than needing a tissue expander (an inflatable breast implant) to stretch the skin over several months.
Their recurrence rate with NSM, is comparable to reported rates of disease recurrence after standard mastectomy. Furthermore, the procedure has several advantages over standard mastectomy.
Women with breast cancer are candidates for the NSM procedure unless they have any of the following conditions: clinical or imaging evidence of cancerous involvement of the nipple and areola, which doctors call the nipple-areola complex; locally advanced breast cancer involving the skin; inflammatory breast cancer; or very large or sagging breasts, which would result in an unacceptable location of the nipple.
Because any mastectomy involves cutting nerves in the breast there is a loss of sensation at the nipple. In NSM, a small chance exists that the nipple will wither and the tissue will die, a condition called necrosis. The rate of nipple necrosis is 1 - 2 percent.
No known study has compared NSM with standard mastectomy by randomly assigning women to one or the other operation, however, it appears from the low local recurrence rate in this and other reported studies that breast cancer patients who undergo NSM have no increased risk of their cancer returning because they keep their nipple. (15)
Conclusions The evolution of breast reconstruction reflects a growing concern for women’s health, both physical and emotional. Procedures to reconstruct the breast in both women and men who have undergone treatment for cancer is no longer considered unnecessary, as it was in the first half of the 20 th century. Paralleling the development of refined techniques for transferring tissue, techniques for breast reconstruction have advanced dramatically in the last several years. Some of these procedures are among the most challenging that plastic surgeons perform. Though there will always be people who do not opt for reconstruction or who are not candidates, current techniques ensure that the vast majority of people who desire reconstruction after mastectomy will be able to be reconstructed with the goal of a balanced and aesthetic result.
Answers to Frequently Asked Questions
Q: If a woman has been diagnosed with breast cancer, what questions should she ask her physician to be sure she has the necessary information about reconstruction options at the outset of treatment?
As we’ve learned, women often aren’t being given their options and full information about reconstruction. For this reason it’s important—at the beginning of the treatment process—that women ask their physicians to refer them to a plastic surgeon who can help them understand all their options.
It’s critical that a plastic surgeon be part of the team because he or she is the best qualified to help the patient if a mastectomy or any other type of surgical procedure will lead to any loss or deformity of the breast. A plastic surgeon might be able to restore and reconstruct the affected breast and, in many cases, the other breast as well to ensure that the woman has the best chance for symmetry at the end of treatment.
It’s also important for women to be aware, from the outset, that if their insurance covers management of breast cancer, reconstruction is required to be covered.
And remember, this is not a cosmetic procedure. It’s reconstruction. The difference is that the goal of reconstruction is to take something abnormal and make it more normal, whereas the goal of cosmetic surgery is to take something that looks normal and make it look better.
Q: What should a patient know about the risks and the benefits of reconstructive surgery?
One of the important things that the patient must understand is that if she chooses to have reconstruction at the same time as the surgery to remove the cancer, the reconstruction does not significantly add to the risk of the operation. Reconstructive surgery does not increase risk significantly, and it has no impact on survival percentage—but it does help women get back to social and life events more quickly. Women who have reconstruction typically get back to work and to social situations sooner. Although some women choose to have reconstruction at a later date, doing it at the time of the mastectomy or lumpectomy eliminates the need for additional hospitalization and, most important, gets women on the road to reconstruction and restoration that much sooner.
Q: Are there any recent innovations or advances in breast reconstruction of which women should be aware?
We continue to develop sophisticated techniques that use autologous (the patient’s own) tissue to restore breasts—through microsurgery and without microsurgery—that can accomplish very natural and aesthetically pleasing breast reconstruction. It’s important to note, however, that at the same time we have also made advances with breast implants—in both the types of implants and the surgical procedures we use—and we’re getting even better results with implants in women who have undergone mastectomy.
Q: What should women know about what reconstructed breasts might look and feel like when compared with natural or augmented breasts?
A: It’s variable and depends on many factors, including the woman’s anatomy, how much tissue was removed to treat the cancer, what type of reconstruction she has chosen, how she heals, whether she will undergo radiation, how advanced the cancer is, and whether it’s limited to one spot or multiple spots in that breast. In most cases the expectation is not that the patient will have perfectly normal-looking breasts—there are naturally going to be some visible scars. In most cases, however, we can accomplish breasts that feel and appear natural; and, if the patient is able to have nipple-sparing mastectomy and minimal incisions, in some cases reconstructions can look like augmentations. Again, the best thing to do is to talk to a plastic surgeon, who can give the patient a realistic sense of the range of outcomes.
Q: What points might a woman consider when deciding which type of reconstructive surgery to choose?
One of the issues to be considered is what’s happening with the other breast. Oftentimes cancer might be on both sides, or a woman might have a strong chance of developing cancer in the other breast, so a prophylactic mastectomy might be advisable. Once a woman understands her options, another consideration might be to choose not to do implants or use her own tissue because of the particular requirements of those different surgeries, which could include multiple stages and extensive recovery time.
Q: How can patients go about selecting a qualified surgeon to perform their breast reconstruction?
Women can ask their breast surgeon for a referral and can ask friends or family for recommendations. It’s also a good idea to go to plasticsurgery.org to make sure that the surgeon you’re referred to is a member of the American Society of Plastic Surgeons; this ensures that the surgeon has undergone a rigorous training program, adheres to a code of ethics, and has continuing medical education requirements that are up-to-date in all of the latest techniques.
When you initially meet with your plastic surgeon, be sure that you’re speaking the same language—that you’re on the same page about the desired result and that you understand each other. If you feel that’s not the case, get another opinion. It’s essential that you are comfortable with your doctor because reconstructions are often staged procedures over time, and there’s a lot of communication necessary between doctor and patient. It’s critical that the plastic surgeon listen to you, address any concerns, and be available to you if any issues arise along the road to reconstruction.
Dr. Malcolm Z. Roth, MD, FACS, graduated with his MD degree from New York Medical College in 1982. He then completed his general surgery training at Beth Israel Medical Center and completed a residency in plastic and reconstructive surgery at the New York Hospital–Cornell University Medical Center. Dr. Roth continued his training at the Hospital for Special Surgery, where he completed a hand and microsurgery fellowship. He is currently president of the American Society of Plastic Surgeons and chief of the Division of Plastic Surgery at Albany Medical Center in New York.
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