A lumpectomy usually removes the least amount of breast tissue needed to get the tumor out and a margin of healthy tissue around it. The surgeon removes the cancer and a small portion or margin of the surrounding tissue, but not the breast itself. Even though the lumpectomy is the least invasive breast cancer surgery, it can still be very effective, and further surgery may not be needed.

What happens when more tissue needs to be taken?

If more tissue needs to be taken, the surgeon may perform a partial mastectomy. This procedure requires the surgeon to remove a larger portion of the breast than in the lumpectomy — perhaps a whole segment or quadrant of tissue — in order to eliminate the cancer. Occasionally, the surgeon will remove some of the lining over the chest muscles as well.

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In the past, breast cancer surgery often required removing the entire breast, chest wall, and all axillary lymph nodes in a procedure called a total radical mastectomy. Now, less severe surgery options exist and are common.

If the cancer is detected early enough, there are usually options that will remove the cancer while preserving breast tissue. The common options are a lumpectomy (most often followed by breast radiation treatments), a partial mastectomy, and a simple mastectomy.

The More Common Mastectomy Procedures Today Are:

Total Simple Mastectomy

A total simple mastectomy involves removal of the entire breast, nipple, areola, and sentinel lymph node(s). This type of mastectomy removes the breast skin as well, which is what makes it different than a skin-sparing mastectomy.

Skin-Sparing Mastectomy

This procedure requires removal of the breast tissue, nipple, areola, and sentinel lymph node (or nodes) but not the breast skin. Many women who intend to have breast reconstruction will opt for this procedure. In a skin-sparing mastectomy, the breast is hollowed out, allowing for it to then be filled with an implant or fatty tissue from elsewhere in the body, such as fat from the stomach, buttocks, or inner thigh.

Skin-Sparing, Nipple and Areola Sparing Mastectomy

This type of mastectomy is like the skin-sparing mastectomy but also preserves the nipple and areola. In order to preserve the nipple and areola, the breast cancer tumor must be at least 2 centimeters away from these anatomic structures. Commonly the incision is made underneath the breast in the area known as the mammary fold.

Modified Radical Mastectomy

This procedure requires removal of the entire breast, nipple, areola, and axillary lymph nodes but often leaves the chest wall intact.

It is important to know that doing a mastectomy does not result in longer survival than doing a lumpectomy. Both accomplish the same goal which is surgical removal of the primary breast cancer tumor.

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How Does The Lymph System Relate To Breast Cancer?

Although breast cancer is not easily controlled, the spread of breast cancer is sometimes predictable. The cancer cells spread through a customary path, out from the tumor and into the surrounding lymph nodes, before they progress throughout the body.

What is the sentinel node?

The sentinel lymph node (and in some cases there are several grouped together) is the first node “downstream” from the cancer in the lymph circulatory system. If the cancer were to travel away from the breast tumor and into the lymphatic system, this node would be the first one to show evidence of breast cancer.

What Is A Sentinel Node Biopsy?

A sentinel lymph node biopsy is a procedure to examine the lymph node closest to the tumor because this is where the cancer cells have most likely spread. First, the surgeon will want to identify the “sentinel lymph node,” the lymph node (or nodes) closest to the tumor. To be able to identify the sentinel lymph node, the surgeon will inject dye or radioactive substances into the tissue near the tumor. The lymph nodes that are the most susceptible to the cancer’s spread will be marked by the dye or radioactive substance. During surgery, the nearest lymph nodes will be removed and checked for the presence of cancer cells.

A biopsy is nearly always taken of the sentinel node, and the breast surgeon typically removes the sentinel node as well for dissection.

What Is An Axillary Node Dissection?

This procedure is a method for determining if the cancer has spread to more than one of your lymph nodes. Axillary node dissection removes some of the the axillary lymph nodes, which are the lymph nodes located in the underarm. Once removed, they are dissected and examined by the pathologist, looking at all of the tissue and individual nodes very closely under a microscope.

Do The Lymph Nodes Always Need To Be Removed?

Not always, especially when there is no evidence of any cancer in the lymph system. A mastectomy or lumpectomy operation will most often include either a sentinel node biopsy or an axillary node dissection. Both procedures involve a separate incision for lumpectomy patients. Following surgery, the pathologist will test the lymph nodes to determine whether the cancer has spread past the breast. When some evidence of cancer is found in the lymph system, recents standards are as follows:

For patients who are having a lumpectomy and the sentinel node is positive for cancer:

Effective in mid-2012, the standard of care was changed to no longer require women with early-stage breast cancers to have a full dissection and removal of the lymph nodes under the arm when the sentinel node is found to contain cancer. Radiation to the underarm area and upper chest wall is also part of treatment. The exception is for postmenopausal patients who are over age 70 and whose cancer is estrogen receptor-positive. These patients may not need radiation and may undergo hormone therapy instead.

For patients who are having a mastectomy surgery and have a positive sentinel node:

For these women, the standard of care remains the same, calling for the node removal and dissection of the axillary (or underarm) nodes. The additional nodes removed at the time of the breast cancer surgery will be examined by the pathologist in the following days to determine if others beyond the sentinel node contained cancer or not. If cancer cells are found in those lymph nodes, other cancer treatments will be considered.

What Is Lymphedema?

Lymphedema is a chronic condition that is caused by a disruption or damage to the normal drainage pattern in the lymph nodes.  It most often causes swelling of the arm, but it can also affect the breast, chest, and sometimes even the legs. The swelling, caused by an abnormal collection of too much fluid, is called lymphedema.  Removing the axillary lymph nodes increases your risk for developing lymphedema.

The risk of developing lymphedema continues for the rest of your life, so it is imperative that you are aware of these risks.  Often it is best to learn about preventative measures for lymphedema before surgery so you will know the signs and symptoms to look for and can discuss treatment options with your physician.

Some ways to reduce the risk of developing lymphedema following a lymph node surgical removal or radiation to the lymph node area under the arm are:

• Avoid wearing tight rings, watches, or other jewelry on the affected arm
• No needle sticks or blood pressures should be taken on the affected arm
• Whenever a minor injury such as a small cut of the finger or arm occurs, immediately wash the area, apply antibiotic ointment, and cover with a bandage.

After lymph node surgery, if you experience unusual and painful swelling, you should immediately notify your doctor to monitor it. There is no cure for lymphedema, but your doctor can take steps to reduce swelling and maintain that reduction. With proper health care, good nutrition, and exercise, it may be possible for you to reduce the effects of lymphedema.

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Breast Reconstruction Options

There are a few options for breast reconstruction, and which one you use will depend on your age, body type, and treatment plan.

• Breast Implants: The breasts are filled with sacs of saline or silicone gel, or a combination of both. 
• Skin Grafts and Transplant (TRAM Flap, Latissimus Dorsi Flap, Gluteal Flap, or TUG): An alternative solution is to use tissue the surgeon removes from another part of your body. The TRAM flap, which uses tissue and muscle from the belly area, can have lifting restrictions for patients in the future. The Latissimus Dorsi flap takes the muscles from under the shoulder blade. The Gluteal flap takes no muscles, just tissue from the buttocks. A procedure called TUG takes the inner thigh fat and no muscle. Procedures that take no muscle require the expertise of a plastic surgeon who does microvascular surgery.
• DIEP Flap (Deep Inferior Epigastric Perforator Flap): This solution uses the abdominal fat (no muscle) to sculpt the tissue into the shape of your breast, resulting in a full tummy tuck and no lifting restrictions later.
• Additional Cosmetic Details: In addition to reconstructing the breast, the surgeon can add a nipple, change the shape or size of the reconstructed breast, and operate on the opposite breast as well for a better match. Areola and nipple tattooing are also options. The plastic surgeon will be able to discuss with you the benefits and risks of each procedure and help you decide what will make you feel the most natural.

Are There Any Alternatives To Breast Reconstruction Surgery?

One alternative to breast reconstruction is a removable prosthetic breast that is worn in a mastectomy bra equipped with a pocket to keep the prosthesis in place. This will preserve the shape and look of the breast without the surgical procedures. Some women opt for a prosthesis to help balance out their weight and posture, too. Full or partial breast prosthetic forms and mastectomy bras are often times covered by health insurance.

There are also clinical situations in which due to the size of the tumor or other medical diseases and disorders you may not be a candidate for getting reconstruction done at the time of mastectomy. 

If you decide not to undergo a breast reconstruction procedure or are not able to, there are still options to improve the appearance of your chest wall.

Aesthetic flat closure is a surgical procedure that removes or rearranges excess breast skin and fat after a mastectomy to produce a smooth, flat chest wall contour. If needed, revision procedures such as fat grafting can further help with creating the best possible outcome.

With aesthetic flat closure, you can choose to have other forms of reconstruction later (as long as you’re medically cleared).

Coping With Change, Making Your Plan

After a mastectomy, you have several choices that can help you become comfortable with the changes in your body. They are all options with benefits to each approach. What is best for you and your body may not be what is best for another woman.

If you think you will opt for a breast reconstruction, you should speak with your medical team before you have the lumpectomy or mastectomy, even if you plan to wait until later to have your breast reconstruction.

Whether you undergo breast reconstruction, wear a prosthetic breast, or choose to simply embrace the changes you have experienced by allowing the breast removal to remain obvious, you should feel free to make whatever decision is right for you. The goal is to prevent the discomfort of unwanted change, while enabling you to accept what has occurred and continue on with your life.

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