Surgery
Surgical techniques used by SCCA breast surgeons include:
- Lumpectomy
- Sentinel node biopsy
- Mastectomy
- Alternative surgeries
- Lymph node surgery
- Breast reconstruction
- Nipple reconstruction
- Restoring breast symmetry
Lumpectomy
Nearly all women with breast cancer will have some type of surgery, typically either a mastectomy, in which the entire breast is removed, or a lumpectomy, in which only the cancer and a margin of surrounding tissue is removed. The goal of a lumpectomy is to remove the cancer without leaving residual cancer cells in the breast. It is usually followed by radiation to destroy any remaining cancer cells. Breast surgery for SCCA patients is performed at University of Washington Medical Center by surgeons who see patients at both locations.
Sentinel Node Biopsy
If your breast cancer requires surgery—either a mastectomy or a lumpectomy—your surgeon will also want to remove some of the lymph nodes under your arm to see if the cancer has spread to these glands. Cancer in the lymph nodes increases the likelihood that cancer cells have spread to other parts of your body.
Until recently, surgeons would remove most of the lymph nodes in the armpit, usually between 10 and 20, in a procedure called an axillary lymph node dissection. However, the long-term side effects of removing these lymph nodes—including lymphedema (swelling of the arm), nerve injury, and reduced range of motion in the arm—can be uncomfortable and even debilitating. To avoid these problems, SCCA offers a simpler procedure called sentinel lymph node mapping, or sentinel node biopsy, in which as few as one to three lymph nodes are removed.
In this new procedure, the surgeon locates and removes the "sentinel node," which is the first lymph node to which a breast tumor is likely to spread, if your cancer has spread beyond the breast. If the biopsy results are negative, no more surgery is necessary. If the results are positive, your surgeon will perform a completion axillary lymph node dissection and remove most of the remaining lymph nodes.
Sentinel node biopsy has few serious side effects, but it is not appropriate for all women. If this procedure is right for you, SCCA has a team of experienced surgeons led by Dr. David Byrd, who pioneered sentinel node biopsy in the Pacific Northwest.
Mastectomy
Not every woman is a candidate for a lumpectomy, also known as breast preservation therapy. The key is getting completely around the cancer with a margin of healthy tissue and still leaving a "cosmetically acceptable breast," which is very subjective. Some women are happy if their surgeon can spare their nipple, even if most of the breast tissue has to be removed, while other women who could have a lumpectomy opt for a mastectomy—or even a double mastectomy—for personal reasons.
Women who are diagnosed with DCIS (ductal carcinoma in situ) Facts/Types], often can have a lumpectomy, depending on the size of the cancer and also whether the surgeon can get good negative margins. (The margins are important in ensuring that no cancer tissue is left behind.) In some instances, however, mastectomy may still be required for DCIS.
Women who have invasive breast cancer (a tumor) may also be able to have a lumpectomy. The decision depends in part on the size of the tumor relative to the size of the woman’s breast, as well as if the cancer involves more than one segment of the breast.
For women who are good candidates for lumpectomy, the procedure has the same long-term overall survival rate as a mastectomy, as long as surgery is followed with radiation therapy to the breast -- the two treatments go hand-in-hand.
Not your grandmother’s mastectomy
For some women, mastectomy is their only choice. These include women with certain types of breast cancer, including inflammatory breast cancer, cancers that have advanced and are quite large by the time of diagnosis, and cancers that have spread to more than one-quarter of the breast.
Some women who could have a lumpectomy opt for a mastectomy instead, for “peace of mind.” However, even if a woman’s only option is a mastectomy, she still has a number of choices about how the surgery can be done, and these newer procedures are much less disfiguring than the mastectomies of 30 years ago.
Until the 1970s, the most common surgery for breast cancer was the radical mastectomy, which was very disfiguring in that it removed the breast, lymph nodes, skin, and pectoralis muscle.
Then surgery advanced to the modified radical mastectomy, which leaves the muscle and only takes the breast tissue, an ellipse of skin, and the lymph nodes. This procedure is still done for inflammatory breast cancer, as well as for large, locally advanced tumors with known axillary lymph node involvement.
The most common procedure done today is called a "total mastectomy,” in which all the breast tissue is removed. At the same time, a sentinel lymph node biopsy is performed to see if the cancer has metastasized to the axillary nodes. One or two sentinel lymph nodes are removed during the mastectomy and checked immediately for evidence of spread. If these nodes are positive, then the surgeon will go ahead and remove most of the lymph nodes under the arm as part of an axillary dissection. With this surgery, the woman is left with a scar across the width of the breast and the nipple is removed.
Alternative surgeries
There are alternatives to a total mastectomy, however, including the skin-sparing mastectomy, nipple-sparing mastectomy, and the donut mastoplexy, which leave the patient with smaller scars.
A woman with a small cancer who plans to have immediate breast reconstruction may want to discuss whether she is a candidate for the skin-sparing procedure with both her oncologic and plastic surgeons. In this surgery, an incision is made around the nipple and areola, often with a small cut toward the side. The breast tissue is all removed through this small incision.
The nipple-sparing surgery also uses a small incision, one that leaves the nipple intact. This surgery is typically done for women who are having a prophylactic mastectomy because they are at high risk for breast cancer because of a family history, and generally not for woman with known cancers.
The donut mastopexy is not often performed for breast cancer in the United States, but is offered by SCCA surgeons under the direction of Dr. Benjamin Anderson.
Lymph node surgery
Traditionally, a woman who had surgery for breast cancer would have most of the lymph nodes under her arm removed in order to determine whether or not the cancer had spread beyond the breast. The long-term side effects of removing these lymph nodes—which include lymphedema (swelling of the arm), nerve injury, and reduced range of motion in the arm—can be uncomfortable and even debilitating. To avoid these problems, SCCA offers a simpler staging procedure called sentinel lymph node mapping, in which as few as one to three lymph nodes are removed. If the nodes show no evidence of cancer, no more lymph nodes will be removed. Our doctors pioneered this procedure in the Pacific Northwest.
Surgical Techniques
SCCA offers new surgical alternatives to traditional mastectomy that give better cosmetic results. One of these procedures, the donut mastopexy, is not often performed for breast cancer in the United States, but is offered by SCCA surgeons under the direction of Dr. Benjamin Anderson.
Women who choose to have a mastectomy may want to discuss a skin-sparing or nipple-sparing mastectomy with Dr. Kristine Calhoun.
Breast Reconstruction
Timing
In some cases, breast reconstruction can be done immediately after your mastectomy, so that you wake up from surgery with a breast mound already in place. This is often possible for women whose cancer has been detected early.
For other women, the medical team may advise delaying reconstruction. The women who may be advised to wait include women whose cancer is more advanced and will require additional treatment, such as radiation and chemotherapy, and women who have high blood pressure, are obese, or who smoke. These issues can complicate breast reconstruction.
DIEP
If you are considering breast reconstruction after a mastectomy, you may want to ask your surgeon about a reconstructive surgical procedure called the DIEP (deep inferior epigastric perforator) flap. In this procedure, the surgeon takes skin and fat from the abdomen to recreate a breast mound, but not muscle, as in older procedures.
Our surgeons prefer the DIEP flap (Deep Inferior Epigastric Perforator Flap) to other types of tissue reconstruction of the breast. The reason is that only skin and fat from the lower abdomen are used to recreate the breast; the abdominal muscles are left intact.
Although the surgery is more complex and takes more time than other types of breast reconstruction, the advantages include faster recovery and less pain after surgery. With the older TRAM flap surgery, during which abdominal muscles were cut, many women experienced loss of strength in the abdomen and abdominal hernias.
Nonetheless, the DIEP flap is major surgery, involving a long and complex operation. It may not be suitable for women who are very overweight, who are heavy smokers, or who have had previous abdominal surgery.
Advantages of the DIEP flap
The advantages of the DIEP flap over other types of reconstruction include quicker recovery time, because the abdominal muscles are not cut; long lasting results, because an implant is not used; and less pain. There is also less risk of a hernia after surgery (0.5 percent) than with the TRAM flap (4 to 9 percent).
Disadvantages of the DIEP flap
The DIEP flap is major surgery, and requires about five hours to reconstruct one breast, and up to eight hours if you are having reconstruction on both breasts. Most women stay in the hospital for three to four days after surgery and require four to six weeks at home for full recovery.
In addition, you will be left with permanent scars on your lower abdomen and around your belly button. There is a small risk (less than 2 percent) of “flap loss” if a clot develops in the blood vessels in the tissue being used to reconstruct your breast. Also, hard lumps of fat may develop in the reconstructed breast that will need to be removed at the time the nipple is reconstructed.
You may also need an additional surgery to restore symmetry with your other breast. This surgery is usually done three months after your initial surgery.
If you have had radiation therapy This method of reconstruction is preferred for women who have had radiation therapy to the chest wall to treat their breast cancer.
Donut Mastopexy
The donut mastopexy is a type of lumpectomy. The procedure allows surgeons to remove an entire segment of the breast through an incision at the edge of the areola. The final scar circles the areola and is virtually hidden.
The term "donut" refers to the way the procedure is done. A circular incision is made around the areola, and the surgeon then separates breast tissue from both the overlying skin and the underlying chest muscles. The cancerous segment of breast tissue is removed, and the surgeon shifts the remaining healthy breast tissue on the chest wall to remold the breast inside the skin.
The ring of skin around the nipple is pulled together with a purse-string suture and tightened up like a drawstring, leaving a circular scar that is hidden around the nipple.
SCCA physicians have performed this new procedure on more than 40 women thus far, with cosmetically excellent results. The operation causes some degree of lifting of the breast, which some women find they like better than the appearance of their breast before surgery. If necessary, you can have a breast reduction on the other side to restore symmetry.
The surgery is considered a good alternative to a mastectomy or traditional lumpectomy for some women. Ask your surgeon if this procedure is right for you.
Latissimus Dorsi Flap
The major advantage of the latissimus dorsi flap is that it creates a more natural looking breast mound than an implant alone.
In this procedure, a smaller implant is used, along with back muscle, skin, and fat tissue, which camouflage the implant. The muscle that is used, the latissimus muscle, is tunneled under the armpit and transferred along with some skin to the chest wall. Your arm will be weaker after surgery.
Advantages of the latissimus dorsi flap
This procedure gives an aesthetically more pleasing result and improved breast contour than the implant alone.
In addition, it is a durable reconstruction, and there is less capsular contracture (hardening of the tissue around the implant).
Disadvantages of the latissimus dorsi flap
The disadvantages of this procedure are that it requires an implant, and some of the complications associated with implants, including infection and leakage, may occur.
Other disadvantages are the length of the surgery (typically three hours), longer recovery time (two to three days in the hospital and several weeks at home before returning to work), and the loss of back muscle. This loss of back muscle may weaken your arm and may also worsen any lymphedema that you have in your arm. In addition, you will have a scar on your back.
If you have had radiation therapy
Women who have had radiation therapy to the chest wall to treat their breast cancer can have this type of breast reconstruction. The non-radiated back tissues replace the firmer radiated chest wall skin.
TRAM Flap
In the past, the most common method of tissue reconstruction of the breast was the TRAM flap, so called because it uses the transverse rectus abdominis muscle, the large muscle that runs from below the ribs to the groin, to create a breast mound.
However, because the TRAM flap sacrifices the abdominal muscles, it increases pain as well as the risk of a hernia, and results in a weaker abdomen. As a result, our surgeons very rarely offer this procedure.
Instead, women who prefer tissue reconstruction should ask their surgeon about a newer procedure, the DIEP flap, which uses only skin and fat from the abdomen to create the new breast mound and does not transfer the rectus muscle.
Tissue Expander and Implant
Most women who have breast reconstruction surgery choose saline implants. This procedure involves expanding the skin with a tissue expander to make room for the implant.
In most cases, this surgery cannot be done immediately following a mastectomy. However, the tissue expander can be put in place at the time of your mastectomy, or it can be placed weeks, months, or even years later.
The tissue expander is placed behind the pectoralis major muscle. It has a valve that is used to gradually fill the expander with sterile saline during visits to the clinic over several weeks.
Once the skin has stretched sufficiently, the expander is removed and a permanent soft saline implant is inserted during an outpatient surgery.
Advantages of the implant
This procedure is done as an outpatient surgery. The recovery time is relatively quick: Most women take off only one week from work.
In addition, there are no donor-site scars. Your surgeon will follow your mastectomy scar so that no new scars are created, as there are with tissue reconstruction.
Disadvantages of the implant
The disadvantages of this procedure include infection, leakage, and capsular contracture (hardening of the tissue around the implant). With any of these problems, the implant may need to be removed and replaced.
If you have had radiation therapy
Women who have had radiation therapy to the chest wall to treat their breast cancer generally are not good candidates for implant reconstruction. They are usually better candidates for tissue reconstruction.
Nipple Reconstruction
No matter which method of breast reconstruction you choose, the second step will be to reconstruct a nipple.
The nipple and areola can be reconstructed once the breast mound has “settled,” usually about three months after your reconstructive surgery. This does not require tissue grafts from other parts of your body.
This reconstructed nipple will be colorless. The final step is to tattoo the nipple and areola so that it matches the color of your other breast. This final step is usually done six weeks to three months after the nipple has been reconstructed.
Restoring Breast Symmetry
After your breast reconstruction, you may find that your breasts are not the same size or shape. If you choose, symmetry can be restored with one of several types of surgery. This additional surgery is typically done at least three months after your initial reconstruction, regardless of what type of surgery you had.
The options for restoring symmetry include breast reduction, a breast lift, or breast enlargement.
Breast reduction
A breast reduction, or reduction mammoplasty, removes fat, glandular tissue, and skin from the larger breast. It also reduces the size of the areola and provides a lift.
The technique that we use, vertical reduction mammoplasty, minimizes scars and provides a natural, youthful breast shape. It is an outpatient surgery, and you will go home the same day.
You will need to have a mammogram before surgery. This surgery is not appropriate for women who smoke or are obese because of higher rates of complications. You may need to quit smoking and lose weight before your surgeon will agree to this procedure.
Breast lift
After breast reconstruction, your other breast may require a breast lift, or mastopexy, to restore symmetry.
The breast lift is done as an outpatient surgery and takes one to two hours. It is usually done about three months after your initial breast reconstruction surgery.
Though a breast lift is usually not covered by health insurance when it is done for cosmetic reasons, your insurance may pay for the procedure to equalize the size of your breasts after breast reconstruction.
Breast enlargement
Breast enlargement, or augmentation mammoplasty, is done with a saline implant. Though a breast enlargement is usually not covered by health insurance when it is done for cosmetic reasons, your insurance may pay for the procedure to equalize the size of your breasts after breast reconstruction