Breast surgery is a form of surgery performed on the breast to remove a lump that may be noncancerous (benign) or cancerous.
There are different kinds of lumps in the breast. Fortunately, 80% of breast lumps are benign and not cancerous. Benign lumps like cysts, fibroadenomas and fibrocystic breast change are harmless and do not increase the risk of breast cancer. However, other lumps, such as intraductal papillomas and Phyllodes tumours, may harbour the risk of cancer, and need to be removed. It is important to distinguish whether a lump is benign or an early stage cancer, as early detection and treatment of breast cancer increase the chance of a prompt and good recovery.
Doing a biopsy and examining the cells from the tumour is the only way to rule out a cancer. With today’s modern techniques, breast biopsy is usually minimally invasive and can be done in less than half an hour under local anaesthesia.
Biopsies of breast lumps
Checking your breasts regularly for lumps or unusual tissue texture is important. If you discover a lump in your breast, visit your doctor as soon as possible to get it checked. Your surgeon may use any of the following day surgery options when taking a biopsy of your breast lump:
Core needle biopsy
This procedure is done under local anaesthesia and takes about 10 – 15 minutes. Your surgeon will insert a needle to draw a sample of the affected tissue to be sent to the lab for analysis. This is usually done with the assistance of imaging technology to provide better accuracy.
Vacuum-assisted needle biopsy
This procedure is performed under local anaesthesia and allows your surgeon to remove the entire lump in one setting. Using a cutting mechanism and assisted imaging technology, your surgeon will cut up the tissue and draw it through the opening of the needle using a vacuum. This procedure usually takes around 20 – 30 minutes. The removed tissue is subsequently examined under the microscope. If the tissue is benign, you don’t need to undergo a second surgery.
If the biopsy tests reveal a cancer, your doctor will evaluate your condition and suggest the most suitable treatment for you.
Surgery for breast cancer
A breast-conserving surgery (BCS) such as lumpectomy removes the cancer and tissue surrounding the tumour, but not the entire breast. With data showing equivalent survival results between BCS and mastectomy, more women with early stage breast cancers can safely opt to preserve their breasts. Achieving complete cancer removal with clear margins is key to this surgery.
Patients taking this option should have tumours that are small in relation to the entire breast size, so that a good breast shape and size can be preserved. Radiotherapy is likely required after BCS. Precise localisation of the tumour during this type of surgery minimises the amount of breast tissue that needs to be removed. If the tumour is detected only with imaging and cannot be felt, a radioisotope marker or thin wire may be inserted prior to surgery to mark and locate the area to be removed.
Breast oncoplastic surgery
Breast oncoplastic surgery combines the techniques of oncologic surgery (to remove the cancer) with plastic surgical techniques to restore the aesthetics of the breast. The use of these techniques in BCS allows removal of larger tumours while achieving better breast cosmesis and symmetry.
These techniques include the use of well-placed incisions and reshaping the remaining breast tissue after tumour removal, in order to minimise scarring and deformities. Breast and nipple symmetry may be restored by doing a simultaneous breast reduction or breast lift. With these myriad of techniques, good oncological clearance is achieved without the need for mastectomy.
The choice of technique used is different for each patient, and is tailored depending on the tumour size and location, and the size and shape of the breasts.
Partial breast reconstruction
Partial breast reconstruction is a tool for women with larger tumour to breast ratio, where the volume of remaining breast tissue may not be adequate following tumour removal, resulting in deformity. In such cases, adjacent tissue from below the breasts or the chest wall may be mobilised to restore the volume of the breast. These tissue flaps survive on blood vessels that are branches from chest wall vessels and are named perforator flaps.
Another form of partial breast reconstruction is the omental flap reconstruction. The omental flap is intra-abdominal fatty tissue that is attached to the stomach and spleen. This tissue is mobilised by minimally invasive abdominal surgery and brought out to fill in the defect in the breast. The omental flap usually has more volume and may be used in patients with larger tumour to breast size ratio.
A mastectomy is usually recommended if the size of the cancer is too large or if the cancer involves multiple locations within the breast. Although most do not require radiotherapy after the surgery, radiation treatment may still be advised after surgery if your tumour is >5cm or if your lymph nodes are affected by cancer.
A simple mastectomy involves removing the entire breast and most of the overlying skin.
If you opt for an immediate breast reconstruction, the overlying skin is preserved as much as possible for a more natural appearance. This is termed skin-sparing mastectomy. If the nipple is also preserved, it is a nipple-sparing mastectomy. This skin preservation is possible only when the tumour is not too close to the skin and nipple.
Full breast reconstructive surgery
Breast reconstruction or the 'rebuilding' of a new breast following lumpectomy or mastectomy aims at improving a patient’s quality of life, including body image perception and other psychosocial aspects of their recovery.
When a mastectomy is required, the options of a full breast reconstruction should be made available to the patient. Full breast reconstruction may be performed with implants, or the patient’s own tissue (skin, fat, muscles) from places like the abdomen, thigh or back, or a combination of both. The type of reconstruction depends on the extent of the tumour, the patient’s health and body habitus, as well as her lifestyle and expectations. A detailed discussion between you and your doctor is necessary before the modality of reconstruction is decided upon.