Breast Surgery

A total mastectomy is no longer always needed for breast cancer treatment. All patients with benign disease, and the majority of women with breast cancer, can be treated safely with breast conservation surgery. A range of surgical approaches are used to maximize the cosmetic result after breast conserving procedures. Radiotherapy is usually used to reduce the risk of recurrence in the remaining breast tissue after breast conserving surgery. Occasionally a second surgical procedure is necessary if breast conservation is not successful in removing all of the affected breast tissue.

A mastectomy is sometimes the best procedure to manage certain conditions. Breast reconstruction may be performed either simultaneously, or delayed, as the clinical situation requires. Women are encouraged to actively participate in planning the individual procedure that best suits their particular situation. All the breast tissue, and usually the nipple, is removed by mastectomy. Skin preserving (subcutaneous) procedures are used to maximize the cosmetic result if breast reconstruction is planned. The breast care nurse and breast unit psychologist are actively involved in the psychological support of patients considering mastectomy.

Surgically removing all of the lymph nodes situated in the axilla (armpit) is a necessary part of breast cancer surgery if the breast cancer cells have spread to these nodes. An axillary clearance is usually performed if the sentinel node has been found to contain cancer. On average 20 - 30 nodes are removed, but this does not have an adverse effect on the immune system. Some (approximately 15%) patients develop arm swelling which is well managed by lymphatic drainage massage and a compression sleeve.

The sentinel lymph node is the first node breast cancer cells will reach if they spread beyond the breast. Identifying and testing the sentinel node is therefore very helpful for planning subsequent breast cancer treatment after surgery. 

A Microdochectomy is a targeted surgical procedure, whereby a single duct behind the nipple is removed for examination by the breast pathologist. 

The major breast ducts coalesce behind the nipple/areola complex. Suspicious discharge for the nipple may be the first indication of significant disease in the ducts, even in the absence of clinical or imaging findings. Subareolar duct excision removes all of the major ducts from behind the nipple, to stop the discharge, and to provide the pathologist with the duct tissue for examination. The nipple is preserved, but breastfeeding is not possible after a sub-areola duct excision. Usually the cause of the discharge is benign duct disease requiring no further treatment, but if breast cancer is found in the ducts then further surgery may be required.

Early breast disease is often detected on mammogram or ultrasound before a lump can be felt in the breast. Surgical excision of that part of the breast may be needed in order to obtain tissue for examination by the pathologist, pr for definitive treatment. As the lesion in the breast is not palpable, a fine hook wire is inserted into the lesion on the day of surgery using the mammogram or ultrasound to guide accurate placement of the wire. 

Open surgical biopsy under anaesthetic has largely been replaced by fine needle and core biopsies (see above). There remains however the unusual situation where a lesion in the breast is atypical and needs to be fully removed for complete examination by the pathologist.