Types of Breast Surgery
Various types of breast surgery
Excisional Breast Biopsy
This is the simplest of all the procedures and is done for a palpable or easily identified breast mass with ultrasound. The purpose of this is simple—to remove the entire mass to make sure that is not cancer and to prevent growth of the mass in the future. Surgery may involve local or general anesthesia depending on how deep the mass is and patient preference. The incision will be a small straight line directly over the mass and will be sealed with glue. Risks of this procedure are small and usually are limited to bruising. The need for further intervention or treatment will depend on the biopsy result. If benign, often a surveillance image (ultrasound or mammogram) will be recommended in 6 months.
Major Duct Excision
This procedure is done for patients experiencing nipple discharge or if there is some concern for papilloma (growths) within the milk ducts leading to the nipple. This procedure is always done under general anesthesia. After the patient is asleep, a small tube is placed into the nipple and blue dye is injected into the tube to mark the duct. Then a small incision is placed at the areola (the junction of the darker part of the nipple and the breast). The nipple is lifted, and the portion of breast tissue underneath the nipple marked with the blue dye and the tube is removed. The incision is then closed with dissolving stitches and glue. Sometimes the blue dye causes a temporary staining of the skin. Temporary numbness or stinging sensation of the nipple is normal.
Needle Localized Breast Biopsy
This operation is done in the situation that a breast abnormality is detected by mammogram but cannot be readily felt or seen. The patient will start the day with the breast radiology group (Solis) to identify the mass with the mammogram machine and then place a small caliber wire (not really a needle) from the skin into the breast. An x-ray will be done at the completion of this to ensure that the wire is in the correct position. The wire is then secured to the skin with tape. The patient will then drive over to the Surgery Center and then the operation will proceed similarly to an excisional breast biopsy. The wire, the breast mass, and any breast metallic markers placed initially by radiology will be removed all together.
This operation means removal of the entire breast and nipple but without removal of any lymph nodes. A patient may choose to have this procedure done for ductal carcinoma in situ (noninvasive breast cancer) or in cases of prophylactic removal of the breast to prevent cancer from forming. The patient will be under general anesthesia. An elliptical incision is made around the nipple and all breast tissue from the clavicle to sternum to the crease underneath the breast to the axilla is removed from the pectoralis chest wall muscle. After the tissue is removed, a small plastic drainage tube is placed in the area where the breast used to be, and the skin closed in a straight line over it. The tube will exit from a separate area near the axilla and be attached to a suction bulb. The patient will be shown how to empty the bulb when it is full, and it will be important for the patient to record the output. The drainage will first be bloody and then clear over time to a light red or yellow color. When the surgeon judges that the amount of fluid coming from the drain is small enough to show proper healing inside, the drain will be removed in the office. Initial numbness to the skin is common. It is important to continue to move the arm on the side of surgery to prevent scar tissue from impeding range of motion.
Partial Mastectomy and Sentinel Lymph Node Biopsy
Partial mastectomy is when just the portion containing the breast abnormality is removed. Depending on the patient, this may be done with or without needle localization. In cases of ductal carcinoma in situ (noninvasive cancer), this is done as a stand-alone procedure. In cases of invasive breast cancer, it is paired with an axillary lymph node biopsy which is done at the same time but through a second incision. As invasive cancer has the potential to spread, a lymph node from underneath the axilla is removed during the surgery to screen it for cancer. This is called a sentinel lymph node biopsy. The lymph node is identified by the surgeon injecting blue dye around the nipple of the breast after the patient has gone under general anesthesia. The body’s lymphatic vessels pick up the dye and carry it through the breast into the axilla where the dye will stain the first lymph node that it encounters. This is a way to map how a cancer cell might similarly be carried. If the first lymph node does not have cancer, the chance for subsequent further lymph nodes to be affected is small. This prevents lymph nodes from unnecessarily being removed. If the first lymph node does have cancer, it is then necessary to remove the entire packet of lymph nodes from the axilla to properly stage the cancer. As the dye will just stain the first lymph node, the rest of the lymph nodes are removed as a mass together. The major blood vessels and nerves in the axilla will stay will all remaining fatty tissue and lymph nodes removed. If a single lymph node is removed, it is often no necessary for a drain tube to be used to promote healing. However, if all the lymph nodes are removed, a drain will be used to help the area underneath the axilla heal. The drain will also alert to any leaking lymphatic fluid as the color of the fluid will look more like milk rather than blood tinged. The amount of time that the drain is necessary depends on the output. As there are many sensory nerves in the axilla, it can be very normal to have numbness underneath the arm from the shoulder to the elbow. It can be normal for a patient to favor that arm after surgery in the axilla, but range of motion exercises are vital to protect against scar tissue formation.
Modified Radical Mastectomy
This operation sounds scarier than it is. The reason it is called “modified” is because surgeons used to remove a women’s chest wall muscle as well during a mastectomy. That was found to be unnecessary and caused significant deformity, so it was abandoned. This operation involves removal of the entire breast with biopsy of the axillary sentinel lymph node again using blue dye. Instead of two incisions of the partial mastectomy, the operation is done through one larger incision. An elliptical incision is made around the nipple (identical to a simple mastectomy) and the axillary potion is done though the same cut. The decision to remove one or all the axillary lymph nodes is based on pathology exam during the operation. As there is a large space resulting after the surgery, a drain is always left. Drain care and range of motion exercises remain important just as other surgeries. In some cases, physical therapy might be helpful. The patient’s chest is usually flat on this side after surgery unless decision has been made ahead of time for future plastic surgery in which case skin might be persevered.
A mediport is recommended to patients who expect to have intravenous chemotherapy following surgery. The medications can be quite irritating to the veins and repeated IV sticks can be bothersome to the patient. This especially true for patients who have had axillary lymph nodes removed in which case the recommendation is not to ever have an IV stick on that arm to prevent further damage to the lymphatic vessels. A mediport is essentially an implanted IV through which blood can be drawn or medication infused. Placement requires general anesthesia. After asleep, a small incision is made on the upper chest and a pocket underneath the skin is created. A needle is then placed in a large blood vessel (either the internal jugular in the neck or subclavian underneath the clavicle). Once inside the vessel, a wire is placed through the needle to serve as a guide into the superior vena cava, which is the large vein leading to the heart. Imagine taking the side roads to lead to the interstate. Once the wire is in place, a small hollow rubber tube is placed over the wire and then the wire is removed. The part of the tubing that is outside of the patient is then tunneled under the skin to attach to a special reservoir that will be placed into the created skin pocket. The reservoir has a special center that will allow needles to go into and out of it without leaking. A form of real time x-ray called fluoroscopy will be used to trace the pathway of the tubing from the reservoir on the chest wall as it leads to the vena cava to ensure there are no kinks or twists. The port pocket is then sealed with dissolving stitches and can be used immediately. A bump will be visible and palpable on the chest wall so that the nurses will know where the port is and be able to access it. A chest x-ray is performed following the procedure. Sometimes an inadvertent puncture of the lung can happen as the needle is finding the correct blood vessel. This can cause the lung to deflate and because the air is trapped within the chest, the lung cannot reinflate. A special tube is needed to remove the trapped air and allow the lung to reinflate. This is very rare but important to rule out for all patients who have had this procedure. Fortunately, removal of the port is very easy as there are no needles to insert and no tubing to guide. The removal of the port can be done in the office.
Insertion of a SAVI device
In cases where radiation is deemed necessary, sometimes a SAVI might be indicated. The SAVI is an inplanted device that is placed following partial mastectomy to deliver radiation directly into the cavity where the cancer used to be. It is beneficial in that it drastically reduces the number of days of radiation therapy and minimize the potential for radiation damage to other structures near the breast (lungs and heart). It is most useful in early-stage small breast cancers. If a patient is a candidate, the procedure is done in the office under local anesthesia. After a cancer is removed from the breast, there is a small cavity that remains that fills with fluid. Under usual circumstances, the fluid is reabsorbed by the body and the space heals. For insertion of the device, this fluid filled area can be seen with ultrasound. A small incision is made near the cavity and a specialized needle is introduced into the cavity. The fluid is removed, and the area is stretched with a balloon. The SAVI looks a little like an umbrella. The SAVI is slid into the cavity and then the spokes of the umbrella are opened. The idea is to have each spoke of the device touch each wall of the cavity. When completely opened, the device is taped into place and the part that is external to the patient is tucked into the bra. The radiation is then able to be attached to that outside part. When done, the radiation team can close the umbrella and slide the device out. Usually, a patient might have 1-2 stiches or just steri strips to close the incision.