BREAST SURGERY

Breast Cancer

Breast cancer means some cells in your breast are growing abnormally. Understanding breast cancer will help you to understand the methods for treatment and what to expect. Learning about the disease can give you strength and relieve fears you may have about cancer.

Take an Active Role

This will help to maintain a sense of control. Ways you can take an active role are:

• Learn as much as you can about breast cancer and the treatment options.
• Ask questions and don’t be afraid to get a second opinion.
• Talk to other women who have been treated for breast cancer.
• Stay active and continue to do the things you enjoy.

Find Support

Share your feelings with family, friends, and spiritual advisors. Help them support you by telling them what you need. The decisions you make are personal ones, but you don’t have to make them alone.

Your Healthcare Team

Your team may include:
A general surgeon, a doctor who performs the surgery to diagnose and remove cancer.
A medical oncologist, a doctor who specializes in using medication to treat cancer.
A radiation oncologist, a doctor who specializes in radiation therapy.
A plastic or reconstructive surgeon, a doctor who can reconstruct the breast.

Changes in Your Breast

• Normal breast tissue is made of healthy cells that reproduce and look the same.
• Noninvasive breast cancer (carcinoma in situ) occurs when cancer cells are only in the ducts.
• Invasive breast cancer occurs when abnormal cells move from the ducts or lobules into the surrounding breast tissue.
• Metastasis occurs when cancer cells move into the lymph nodes or bloodstream and travel to other areas of the body.

Stages of Breast Cancer

Using tests to determine the size of a tumor and how far it has spread is called staging. The stage of your cancer helps to determine your treatment. Based on American Cancer Society guidelines, the stage of breast cancer are:

• Stage 0. The cancer is noninvasive. Cancer cells are all contained within the ducts.
• Stage I. The tumor is 2 cm or less in diameter. It has invaded the surrounding breast tissue, but has not spread to the underarm lymph nodes.
• Stage II. The tumor is larger than 2 cm or has spread to the lymph nodes under the arm.
• Stage III. The tumor is larger than 5 cm and/or the tumor has spread to the skin, chest wall, or nearby lymph nodes.
• Stage V. The tumor has spread to the bones, lungs, or lymph nodes far away from the breast.
• Recurrent Breast Cancer. When cancer returns despite treatment. Local recurrence is confined to the breast itself. Distant recurrence is cancer that appears beyond the breast.

Planning Surgery

After discussing your biopsy results your surgeon, surgery may be recommended before or after other types of treatment. If you desire breast reconstruction an appointment will be made for you to see the Plastic Surgeon.

Planning Adjuvant Therapy

Adjuvant therapy kills cancer cells, and helps keep breast cancer from returning.

Types of adjuvant therapy are:

• Chemotherapy
• Radiation therapy
• Hormone therapy

Considering Breast Reconstruction

Breast reconstruction is an option if you are having a mastectomy. Deciding if it right for you depends on how you feel about your appearance. It may also depend on how you feel about having more surgery. Breast reconstruction may:

• Improve your body image.
• Restore your body posture and balance.
• Increase your comfort in clothing.
• Be done at the same time of the mastectomy or later on.
• Your recovery time may depend on when you have the surgery.

Types of Surgery

Lumpectomy

A lumpectomy is a breast-conserving surgery. Only the area with the cancer and some of surrounding normal tissue are removed. The breast remains intact. There may be a change in the contour of the breast depending on the amount of tissue removed. If you are having a lumpectomy, your will likely have radiation therapy as well.

The tissue will be sent to the pathologist for examination. If some of the cancer remains in the margins or very close to the margins of the tissue that was removed, it may be necessary to have a second surgery to remove more tissue.

A lumpectomy is an outpatient surgery. It is done at the hospital and requires anesthesia. You will go home the same day and will need someone to drive you home.

A follow up appointment will be scheduled for you with the surgeon before you are dismissed. At your appointment the surgeon will discuss the pathology results and examine your incision site.

Mastectomy

A mastectomy is surgery to remove the breast. You may have a simple mastectomy or a modified radical mastectomy. During these procedures the chest muscle is not removed.
As a result, arm strength remains. Keeping the chest muscle also makes reconstructive surgery easier.

A simple mastectomy removes only the breast tissue (lobules, ducts, and fatty tissue), skin and nipple. This surgery requires a hospital stay. Based on the results of surgery and follow up tests, further treatment may be needed.

A Modified Radical Mastectomy removes the breast tissue, skin, nipple and some of the axillary lymph nodes. This surgery requires a hospital stay. Based on the results of surgery and follow up tests, further treatment may be needed.

Sentinel Node Biopsy

If your cancer is invasive your surgeon may recommend a sentinel node biopsy at the time of your lumpectomy or mastectomy. During surgery an incision is made under the arm. A blue dye is used to identify the axillary lymph nodes closest to the breast. Usually 1 to 3 lymph nodes are removed and given to the pathologist. The pathologist looks at them under a microscope to see if the sentinel node contains cancer. If the procedure is unsuccessful in identifying a sentinel node, a full axillary lymph node dissection may be done.

There are several advantages to doing a sentinel node biopsy. You may not need to stay overnight in the hospital. There is no need for a drain. Your recuperation from surgery is faster and you can return to normal activities sooner.

Axillary Lymph Node Dissection

An axillary lymph node dissection is done by making an incision under the arm. The bulk of the lymph node tissue that drains from the breast is removed. The tissue is sent to the pathologist to determine if the lymph nodes contain cancer. Usually you will need to stay overnight in the hospital, or longer depending on your surgery and recovery.

The tissue underneath the arm tends to leak some lymph fluid when the lymph nodes are removed. Therefore, a drain is placed during surgery. Your drain may remain for several days or even a few weeks, depending on the amount of drainage. After the fluid has diminished to less than 30 ml for 2 days in a row, the drain can be removed in the office. Most women have some residual numbness under the inside of the arm. You may be more likely to develop lymphedema of the arm.

After surgery

You will be closely monitored in the recovery room until you are awake and stable. You will have an IV for medications and fluids. Once you are awake you will be taken to your room where the nurses will continue to monitor you until you are fully awake. You will be able to visit with family and friends in your room.

If you have had a mastectomy or an axillary lymph node dissection you may have flexible drains in place. The drains will be emptied every few hours and as needed. The nurse will keep measurements of the amount of drainage. If your drainage is low enough one of the drains may be removed before you go home.

You will have a dressing covering your incision site. The nurses with check the dressing to make sure you are not having any bleeding.

You will be up and walking shortly after surgery. Your IV will be removed when you are taking foods orally and no longer need access for IV medications.

At Home

You will go home a few days after surgery. A follow up appointment will be scheduled for you with the surgeon. You will be sent home with instructions on how to care for your drain and your dressing. You will need to write down the measurements from your drain and take them with you to your follow up appointment. This will help the surgeon decide if it is time to remove your drain. Usually the stitches are dissolvable and do not need to be removed. You will be sent home with pain medication to be taken as directed.

If you have had a mastectomy you will be sent home with exercises for your arm. You will need to wait until your drain is removed before you start some of the exercises.

Write down any questions or concerns you have and bring them with you to your follow up appointment to discuss with the surgeon.

When to Call the Surgeon

Call the surgeon if you have any of the following:

• Fever if 101º F (38.3ºC) or higher
• Cough, pain in the chest or calf, or shortness of breath
• Increased pain, warmth, swelling, or redness near the surgical site.
• Bleeding that soaks the bandage
• Seepage or foul smelling drainage from the wound

After your drain is removed you may develop a seroma (a collection of fluid that occurs under the arm or in the incision). A small seroma is normal and will go away by itself in a few weeks. If you have a large seroma, your surgeon may need to drain (aspirate) it using a syringe and needle.

Wearing a Prosthesis

After surgery you may want to get a temporary prosthesis. It is a soft breast form that fits into a bra. After you have healed completely you can get a permanent prosthesis. Talk to your surgeon if you want a prescription for a permanent prosthesis.

For some women wearing a prosthesis helps to balance weight and avoid back strain. Other women wear a prosthesis for appearance. You can wear the prosthesis when your incision feels less tender and swollen.

Lymphedema

Lymphedema (swelling of the arm after surgery) can be a problem for some women if you have had many lymph nodes removed during surgery or are treated with radiation under the arm. It can occur long after surgery. To limit problems:

• Slowly return to normal use of the arm on the side of surgery.
• Protect your hand and arm from infection. Wash your hands often. Wear gloves when cleaning or gardening.
• Keep the fluid moving in your arm. Don’t wear tight sleeves, elastic cuffs or jewelry that might restrict your circulation in that arm.
• Do exercises to help prevent swelling and improve circulation, such as, squeezing a rubber ball with your hand.

Follow up Care

• Continue to see your family doctor on a regular basis. Other members of your healthcare team may also want to see you. Be sure to report any changes in your breasts or problems with your general health.
• Continue to have mammograms. Your doctor will tell you how often to have.
• Continue to perform regular breast self-exams.

Glossary

Lobules (mammary glands) produce milk during pregnancy and breastfeeding.

Ducts carry milk from the lobules during breastfeeding.

The nipple is the outlet for milk during breastfeeding.

The areola is the dark circle of skin that surrounds the nipple.

Fatty tissue fills the spaces around the ducts and lobules.