Surgical Options

As part of your treatment, you and your breast surgeon will develop a surgical plan that may include a combination of not only breast surgery but also lymph node surgery.

The two surgeries will be completed at the same time; however
they are referred to as individual surgeries because there are
several possible combinations of the two surgeries.

Lymph Node Evaluation

Breast cancer tumors can shed cancerous cells into the nearby lymph nodes. Your breast surgeon may remove lymph nodes to be examined under the microscope. Identifying the presence or absence of cancer cells in the lymph nodes is an essential part of the staging process and aids in creating a treatment plan.

Sentinel Lymph Node Biopsy

This is a diagnostic procedure to identify if there is cancer in the lymph nodes. Sentinel lymph nodes are the lymph nodes that are closest to the tumor site. They drain lymphatic fluid from the area around the breast which is the reason they are more likely to contain cancer cells. A patient will usually have 1 to 4 sentinel nodes removed for testing.

Axillary Lymph Node Dissection

This procedure is to remove lymph nodes that are known to have cancer. Typically about 10 axillary (underarm) lymph nodes are removed for testing.

Breast Cancer Treatment

Lumpectomy

A lumpectomy is an operation to remove only the lump and some surrounding tissue from the breast. A lumpectomy can be performed as either a diagnostic or treatment tool.

Diagnostic tool — to discover the type of cancer present

If the lumpectomy is being performed as a diagnostic tool, the surgeon will remove part of the tumor and some surrounding tissue. Sometimes, the surgeon will also remove lymph nodes from your axilla (underarm). The lump and the lymph nodes that have been removed will be sent off to the laboratory for testing. This testing process is called staging — meaning that the stage of cancer present will be identified.

Treatment tool — to remove a cancerous tumor

For some types of cancer a lumpectomy is a successful treatment option because it removes the cancerous lump. The size of the lump present will determine the amount of tissue surrounding the lump that needs to be removed.

For patients who have had a lumpectomy, depending on the location of the tumor and size of the breast, partial breast irradiation may be a treatment option. With this technology, breast cancer can be treated in five days instead of six to seven weeks. Candidates for this type of treatment require certain criteria which can be identified by your physician.

Mastectomy

A mastectomy is the removal of the entire breast. One of the benefits of a mastectomy is that it decreases the risk of recurrent breast cancer.

It is possible for women to have breast reconstruction surgery at the same time as the mastectomy. This is called immediate reconstruction, but is not recommended for all women. Women who cannot have immediate breast reconstruction can have delayed reconstruction weeks to years after their mastectomy. Patients typically stay in the hospital one or two nights following a mastectomy, with some additional recovery time once at home.
There are several types of mastectomies, including:

• Simple/Total Mastectomy:Often chosen for prevention, all of the breast tissue, areola and nipple are removed. This procedure is often combined with a sentinel lymph node biopsy.

• Modified Radical Mastectomy:All of the breast tissue and some of the skin of the breast including the nipple and areola, as well as all of the axillary (underarm) lymph nodes are removed.

• Skin-Sparing Mastectomy:All of the breast tissue, areola and nipple are removed. However, nearly all of the breast skin is left in place making simultaneous breast reconstruction ideal.

• Nipple-Sparing Mastectomy:The surgeon works through a small incision to remove the breast tissue while leaving the nipple, the areola, and all of the skin of the breast intact. The results of breast reconstruction are best with this type of mastectomy because the patient retains her nipple and areola.

Breast Reconstruction

Women can choose to have breast reconstruction surgery after a mastectomy to restore the breast. Breast reconstruction can also be done to restore the shape and volume of a breast following a lumpectomy and radiation treatment. Breast reconstruction can be done using the patient's own natural tissue from their belly, buttocks or back or with an implant.

Some types of breast reconstruction include:

[+]Breast Implant

A breast implant can be used to reconstruct a breast. Usually, a specialized type of breast implant called a tissue expander is placed first under the breast skin and chest muscle in order to stretch or expand the muscle and remaining breast skin. Once a satisfactory reconstructed breast volume is achieved, the tissue expander is replaced with a softer and better shaped final implant that is filled with silicone gel or saline (salt water). Breast reconstruction with an implant has the shortest surgery and recovery period, and involves scars only at the breast from the mastectomy (not at the belly, back or buttocks).

[+]DIEP Flap

The DIEP(Deep Inferior Epigastric Artery) flap is a surgical technique in which a flap of excess skin and fat from the lower abdomen (belly) is removed and transplanted to the chest and shaped to reconstruct a breast. This requires specialized microsurgery to connect blood vessels in the flap from the belly to blood vessels at the chest. Many patients like this surgery because removing the flap of tissue from the belly results in a tummy tuck.

[+]TRAM Flap

The TRAM(Transverse Rectus Abdominis Myocutaneous) flap procedure appears identical to the DIEP flap procedure from the outside. The same flap of excess skin and fat from the lower belly is transferred to the chest to reconstruct the breast. The difference is that some or all of the belly muscle is removed with the flap of skin and fat, in order to improve the blood supply and reliability of the flap. Women who smoke, or for other reasons do not have robust blood vessels at the belly are more likely to have a TRAM flap rather than a DIEP flap.

[+]SIEA Flap

The SIEA (Superficial Inferior Epigastric Artery) flap is similar to the DIEP and TRAM flap in that the same flap of skin and fat from the lower abdomen is used to reconstruct the breast, and the patient gets the tummy tuck effect at the belly. The difference and advantage of the SIEA flap is that it uses a blood vessel that does not go through the belly muscles and therefore the belly muscles are not removed (as in a TRAM flap), nor are the belly muscles cut into (as in a DIEP flap). This results in less pain, less weakness, and a shorter hospital stay compared to the TRAM and DIEP flap procedures. However, only a minority of patients have an appropriate blood vessel that is large enough to have a SIEA flap procedure. A previous C-section usually cuts this artery preventing a SIEA flap from being used. Even if a SIEA flap cannot be used, a DIEP or TRAM flap procedure can almost always be performed.

[+]SGAP or IGAP Flap

SGAP or IGAP(Superior or Inferior Gluteal Artery Perforator) flaps are flaps of skin and fat from the upper or lower buttocks that can be used for breast reconstruction. The SGAP and IGAP flap procedures are usually done to reconstruct the breast of a woman who cannot have a flap from the belly (DIEP or TRAM flap) used because there is not enough excess skin and fat at the belly (the patient is too thin), or the patient has had a previous tummy tuck surgery or liposuction of the belly.

Insurance Coverage

Breast reconstruction surgery is not considered cosmetic surgery. Breast reconstruction is performed to restore a breast that has been removed by a mastectomy or distorted following lumpectomy and radiation. Studies have shown that breast reconstruction improves the well being and self esteem of women. Breast reconstruction is considered an integral part of breast cancer treatment. For this reason, The Women's Health and Cancer Rights Act was enacted in 1998. This federal law mandates insurance coverage of breast reconstruction following a mastectomy.

It is best for you to discuss the decision with your surgeon and breast care team. Each procedure has advantages and the decision will depend on your body type and current treatment.