Types of Breast cancer surgery

There are several types of surgery for the treatment of breast cancer and your doctor will make a recommendation based on the results of your biopsy.

Lumpectomy

A lumpectomy is often used for smaller tumours. It’s sometimes called a partial mastectomy or a wide local excision. The surgeon removes the cancer and a small amount of surrounding tissue. A pathologist examines the tissue during or after your surgery. 

If there are no cancer cells in the surrounding tissue, you won't require further surgery. 

If cancer, or pre-cancerous, cells are found in the margin around the tissue, you’ll need further surgery to remove more tissue. About 25% of patients who have a lumpectomy need further surgery because tissue examination shows there could still be some cancer left behind. You may also be advised to have a course of radiotherapy.

Lumpectomy with reduction mammoplasty

If you have large breasts, you may want to consider combining your lumpectomy with a reduction mammoplasty. In this procedure, after the cancerous tissue is removed, a surgeon reduces the size of your breast, repositioning it and giving it a smaller, naturally rounded shape. If only one of your breasts has cancer, the other one can be reshaped at the same time so that they match up.

Mastectomy

A mastectomy involves complete removal of your breast tissue. There are several types of mastectomy and the choice will depend on the results of your biopsy. For example:

• Simple or total mastectomy – removal of your entire breast.
• Skin-sparing mastectomy – your nipple and areola (skin around the nipple) are usually removed along with the breast tissue, but the rest of the skin over your breast is kept.
• Nipple-sparing mastectomy – your breast tissue is removed but your breast skin including your nipple and areola are kept. 

Your doctor may do a mastectomy instead of a lumpectomy because:

• the area of cancer is large compared to your breast.
• the cancer has spread to more than one area of your breast.
• you had a lumpectomy but the tissue surrounding the cancer was examined and further surgery is required to make sure all the cancer is removed.
• you’ve had radiotherapy previously and the cancer has recurred (radiotherapy can’t be used twice in the same breast) or you can’t have radiotherapy for medical or practical reasons. 
• you have a strong family history of breast cancer and/or a positive result to a genetic test showing that you have a hereditary breast cancer gene. In this case, you may choose to have a mastectomy to minimise the risk of having cancer in the future.
• it's your preference.

Some patients may require a course of radiotherapy after a mastectomy.

Lymph node surgery

Whether you have a lumpectomy or mastectomy, your surgeon will most likely want to check if the cancer has spread to the lymph nodes under your arm. This can be done by biopsy of the nodes before surgery. It can also be done during surgery by removing most of the nodes, (axillary lymph node dissection), removing a specific node or nodes (targeted axillary dissection) or by looking for the first lymph nodes that the cancer drains into (the sentinel nodes) and just moving those. Targeted axillary dissection and sentinel node biopsy reduces the chance of lymphoedema (a serious side-effect where fluid collects in the arm, breast, or nearby areas) following surgery. 

Targeted axillary dissection involves marking one or more nodes to which cancer is known or suspected to have spread. The marking is performed in the radiology department and may be done with with small markers, hookwires, or a combination of both.

Sentinel lymph node dissection may involve an injection of radioactive liquid into your breast before your surgery, a blue dye injection during surgery, or both. These help identify the lymph nodes nearest to the cancer. Only these nodes are removed. If they’re clear of cancer, no other nodes need to be removed. 

If multiple lymph nodes are already enlarged and appear abnormal, or if sentinel lymph node dissection shows the presence of cancer, your surgeon will most likely do an axillary lymph node dissection or clearance to remove most of the lymph nodes under your arm.    

Breast reconstruction

When you’re planning surgery for breast cancer, you may want to consider your options for breast reconstruction. There are several options to choose from — from no reconstruction at all (going flat), to an implant, or a flap reconstruction using tissue from your back or abdomen.

You may want to consider whether to reconstruct your nipple (if surgery is going to remove it) and whether to have reconstruction done at the same time as your breast cancer surgery or wait until some time later. You can discuss these options, including the timing, with your doctor.

If you’re having a lumpectomy, you’ll most likely not require reconstruction. If there’s a dent in your breast, it can be left as it is, remodelled surgically, or filled with your own fat.

Depending on your circumstances, multiple procedures may be required on one or both breasts to achieve a satisfactory appearance.

As each situation is different, you should discuss your options with a surgeon experienced in breast reconstruction. While breast reconstruction may achieve a good appearance, your breast will not feel the same as before.