Breast Surgery

Breast surgeons evaluate patients who have any changes in the breast or are experiencing symptoms, such as change on self-examination, pain or nipple discharge, etc. It is important for patients to know that not all changes or symptoms are indicative of breast cancer. There are many types of benign breast conditions and some of the more common conditions include:

• Breast infections – these can be caused from an abscess, or a secondary infection, such as mastitis from breastfeeding
• Benign masses – Fibroadenomas, breast cysts, just to name a few, are all different types of benign masses that can develop in the breast
• Nipple discharge – is often due to a papilloma, however, it may be associated with cancer especially when it is spontaneous and on one side. Individuals experiencing nipple discharge do need to see a breast surgeon for evaluation.
• Breast pain – Breast surgeons also evaluate patients who are experiencing breast pain
• Surveillance of individuals who are high risk – Breast surgeons are experts in monitoring patients who are at a high risk of breast cancer. They are able to assess risk and recommend mammograms and MRI’s on a regular basis for surveillance. If patients are carriers of the BRCA gene they are often referred to a genetic counselor following the initial screening. These patients may choose to undergo mastectomy as a prophylactic measure if indicated. We generally see about 50% of women who elect to do this.

Sometimes cancer can be painful, but generally it is not. In fact, most times women diagnosed with breast cancer do not have any symptoms at all, which is why it is so important for women to remain current with their mammograms and breast exams.

When a patient is diagnosed with breast cancer, they are set up for an appointment at the breast center, where the doctors at Surgical Specialists of Colorado, will carefully evaluate the circumstances and discuss treatment options. Together we will find the option that is best for the patient. There are up to ten different types of breast cancer and while it all gets treated in a similar way from a surgical standpoint – the biology of the cancer dictates the medical treatment post-surgery. The type, grade and location of the cancer will determine which treatment options may be available or preferred. At Surgical Specialists of Colorado, treating breast cancer is a highly coordinated process where our breast surgeons meet weekly with a multi-disciplinary team. The breast surgeon collaborates with medical oncology, radiation oncology, radiology and plastic surgery. Breast cancer treatment is personalized for each patient. Some patients may need chemotherapy prior to their breast surgery, others may not need chemotherapy at all. Radiation is also needed in some cases but not others, and there are two surgical procedures available for removal of the cancer – a lumpectomy or a mastectomy.

Open excisional breast biopsy -An excisional breast biopsy is surgically removing an abnormality within the breast. If the lesion in the breast is not felt then the area is localized under image guidance, with ultrasound, mammogram or MRI. This is done prior to surgery under the care of the radiologist.

There are two common ways to localize the lesion:

1. Wire localization — a fine wire is placed at the breast lesion the day of surgery in the radiology department to help the surgeon find the area of concern. The surgeon in then able to find and remove the area of concern along with the wire
2. Radiofrequency clip — a small radio frequency clip, SAVI SCOUT, is placed in the area of concern several days prior to the procedure, under the care of radiology. This helps guide the surgeon to find the abnormal area, which is removed along with the radiofrequency clip.

Lumpectomy is preserving the breast and removing the cancer with a rim of healthy tissue. It is also referred as breast conservation surgery or as a partial mastectomy. Very similar to the excisional breast biopsy, if the cancer cannot be felt it will need to be localized prior to surgery. (refer to localization described under excisional biopsy)

Oncoplastic surgery is using reconstructive techniques to help improve the cosmetic outcome after a lumpectomy. This can be done simply through placement of the surgical incision and techniques for closing the surgical defect or more intricately with the combination of a breast lift with a reduction matching the other breast. The latter technique is performed along with a plastic surgeon.

In a mastectomy, the surgeon removes the breast. Some types of cancer will require a mastectomy. Patients with more aggressive cancer, larger masses or recurrent breast cancer would be recommended to undergo a mastectomy. There are three types of mastectomies that can be performed by the breast surgeon.

• Total mastectomy – This is the removal of the breast with no reconstruction. The removal includes the nipple, areola, and skin. This procedure is for a patient who does not want breast reconstruction.
• Skin-sparing mastectomy – In this surgery, the surgeon removes the nipple and areola but keeps as much of the skin as possible to assist the plastic surgeon in the reconstruction process.
• Nipple sparing mastectomy – In this procedure the surgeon removes the breast tissue but preserves the skin, nipple, and areola. There are strict criteria on who qualify for nipple sparing mastectomy. Following the mastectomy, the patient would go on to breast reconstruction surgery performed by the plastic surgeon.

The breast surgeon works with the patient and the plastic surgeon to coordinate the type of reconstructive breast surgery that will be best. The plastic surgeon can offer a variety of options for breast reconstructions. Implants, free flap and autologous reconstruction are all options. The majority of the time the reconstructive surgery can be done at the same time, however sometimes, the plastic surgeon will place expanders that will allow for implants to be placed in a second surgery. Delayed reconstruction is also an option. Patients do not need to make a decision right away. They can always decide later, as the option will always be available.

Sentinel Lymph Node Biopsy

Lymph nodes are your filtration system. The lymphatic system collects fluid from cells and that then re-enters into the blood stream. Sentinel lymph node biopsy is performed at the time of the cancer surgery to determine if the cancer has spread to the lymph nodes. Sentinel lymph node biopsy is removing the primary lymph nodes that drain the breast. This is located under the armpit.

The day of the procedure, a radioisotope is injected in the breast in the pre-operative setting and during surgery, the surgeon typically injects blue dye into the breast as well. Both the radioactive dye and the blue dye will then travel through the lymphatics to the primary lymph node or nodes that drain the breast. By using a special probe and visualizing the blue dye the lymph node(s) is then found and removed.

Axillary Node Dissection

Axillary Node Dissection is removing axillary tissue (under the armpit) that is bordered by the axillary vein, the latissimus muscle and the chest wall. Axillary node dissections are typically performed if a patient presents with positive lymph nodes found at the time of diagnosis or after a sentinel lymph node biopsy.