The aim of Breast Conserving Surgery (BCS) is to remove a cancer or lump from the breast with a wide margin whilst maintaining the shape and appearance of the breast as much as possible.
It is a very effective procedure and as such it is the best treatment option for the vast majority of women with breast cancer.
Different surgical techniques and scar placements are possible to try and best achieve this. Surgical techniques vary from the basic wide local excision (WLE) or lumpectomy to more complex Oncoplastic surgical techniques. Wide local excision involves the surgical removal of cancer and simple re-approximation of breast tissue. Whereas Oncoplastic Surgery is essentially the fusion of breast cancer surgery with cosmetic plastic surgery to preserve and reconstruct the breast into a normal shape after removal of large breast cancers.
With Oncoplastic Surgery larger cancer resections are feasible using local tissue flaps and/or breast reduction techniques to refashion the breast into a normal shape.
To be suitable for BCS the cancer needs to be small enough relative to the size of the breast to allow a wide margin of normal tissue to be excised around the cancer. BCS is always followed by radiotherapy for cancers and together this provides equivalent results for survival of breast cancer compared to a mastectomy.
Sometimes WLE may not be successful at the first attempt (~15%) as the cancer may be more extensive on microscopic (pathology) evaluation than originally suspected from the breast imaging. Generally the pathology results will take 5-7 days to return and this will be discussed at your first follow-up review. If the WLE is not successful in achieving an adequate clearance then the options are either to remove more breast tissue at the margins of the previous operation or perform a mastectomy.
In some patients, combining WLE with a breast reduction or breast lift surgery (Oncoplastic Surgery) makes it possible to achieve an adequate surgical margin in whom it would otherwise not be. These procedures can allow a wider cancer excision with a greater chance of complete removal at the first operation. An operation that combines a wide local excision with breast reduction or lift is called a Therapeutic Mammaplasty.
Therapeutic Mammaplasty allows for a wider cancer resection at the same time as a cosmetic reduction in the breast volume. In some patients this operation can make preserving the breast possible, when ordinarily a mastectomy would be recommended. The additional benefit in some patients with very large breasts is the reduction in breast volume can reduce the side effects of radiotherapy.
Appearance after Breast Conserving Surgery:
After BCS the affected breast will be smaller. In the most patients it is possible to achieve a very good cosmetic result with minimal scarring and slight contour abnormality or indentation. However this can be varied depending on the position of cancer, extent of surgery, patient factors (smoking) and extent of radiotherapy. The outcome from radiotherapy is unpredictable. Although radiotherapy never enhances the cosmetic outcome, in most patients it will not have any lasting side-effects. Occasionally some patients have obvious signs that radiotherapy has been given.
Preparation for Surgery:
The following includes typical events that may occur prior to surgery; however, since each patient is unique, what will actually occur may be different:
Preoperative preparation includes blood tests, medical evaluation, chest x-ray and an ECG depending on your age, medical condition and anaesthetic recommendation
After Dr Noushi discusses the surgery including the potential risks and benefits of the operation, you will need to provide a written consent.
You should have nothing to eat or drink for 6 hours prior to your procedure. Dr Noushi and the hospital will be more specific about the time to begin fasting depending on the time of day that your procedure is scheduled. However you are allowed to have medications that Dr Noushi or his anaesthetist has told you are permissible to take with a sip of water prior to surgery.
It is recommended that you shower the night before or morning of the operation.
Medication may need to be adjusted or avoided. It is best to inform Dr Noushi and his anaesthetist of ALL your current medications as well as allergies to medications prior to the examination. Most medications can be continued as usual. Medication use such as aspirin, non-steroidal anti-inflammatories (arthritis medication), blood thinners (eg. Warfarin, clopidegral etc), antidiabetic medication (insulin), Vitamin E, St John’s wart and any dietary drugs should be discussed with Dr Noushi and his anaesthetist prior to the procedure. Blood thinners may need to be ceased for your procedure and this may require consultation with your other specialists.
It is also essential that you alert Dr Noushi and his anaesthetist if you require antibiotics prior undergoing dental procedures, since you may also require antibiotics prior to this procedure (eg for patients with artificial heart valves).
If you have any major diseases, such as heart or lung disease that may require special attention during the procedure, discuss this with Dr Noushi and his anaesthetist.
Quit smoking and arrange for any help you may need at home.
Surgery and Aftercare:
You will be admitted on the day of surgery and be required to fast for 6 hours before surgery. On the day you will be re-examined and the site of the scar drawn on the breast. If your cancer was detected by imaging alone and cannot be felt then the radiologists may place a wire close to the cancer to assist with surgical excision.
The length of the operation and duration of hospital stay depends on the extent of breast and lymph node surgery undertaken. For most patients the operation takes 1-3 hours. Patients who have only had a standard WLE can go home on the same day provided they feel well and have someone at home with them. However in most instances one would stay in hospital for 1 – 2 days.
Dissolving stitches are used and there will be a waterproof dressing over your wound. You can shower with the dressing on, however ensure you do not rub or soak it. This dressing can be removed in 1 week. You may be advised to wear a supportive bra day and night for a couple of weeks.
Generally breast-conserving surgeries are not associated with a lot of pain. Most patients have some discomfort after their operation, which is often related to the surgery performed to remove lymph nodes from under the armpit (axilla) or chest region (internal mammary nodes), which usually settles after a few days. Patients are able to perform normal activities within a few days of this operation. Their overall recovery and return to work will depend upon a variety of factors including the extent of surgery and what treatment is necessary after surgery.
As with all surgical procedures breast surgery does have some risk. Serious complications after surgery are rare. It is not usual to outline every possible and rare complication from an operation, however it is important that you have enough information to make an informed decision.
Any operation can be complicated by infection, bleeding, seroma and wound healing problems. Wound healing can be particularly affected by infection and smoking. Any operation can be associated with anaesthetic problems (nausea in particular), venous thrombosis and allergic reaction to drugs or dressings. Every effort is made to avoid these problems.
Some problems from breast surgery include (but not limited to) the following:
Incomplete excision - Incomplete excisionoccurs in about 15% of patients in the first operation as the cancer may be more extensive on microscopic (pathology) evaluation than originally suspected from the breast imaging. Generally the pathology results will take approximately 5 – 7 days to return and this will be discussed at your first follow-up review. If the WLE is not successful in achieving an adequate clearance then the options are either to remove more breast tissue at the surgical margins or perform a mastectomy
Bleeding - All visible bleeding is stopped during the operation, but sometimes blood vessels can reopen and bleeding can restart. A bit of bruising is common and is nothing to worry about. Alot of bleeding causing a lump underneath the wound may require another operation to find and stop the bleeding vessel.
Seroma - This is fluid that collects under the wound. It produces a swelling and sometimes some tightness. Some patients can hear a sloshing sound from the fluid moving around. This is a common problem but easily treated by removing the fluid with a needle and syringe in a relatively painless procedure. Some patients need this drained more than a couple of times, but this is not an important problem and usually settles within a few weeks of surgery.
Infection - Any operation site can become infected. This occurs in less than 0.5% of patients. If it were to occur then it will usually happen in the first week after surgery. The wound becomes red, swollen and tender, and there may be a discharge through the wound. It is usually treated with antibiotics alone, but sometimes the wound has to be re-opened to allow the discharge to drain.
Pain & numbness – The nerves supplying the skin around the wound will have to be cut in this operation and that may leave an area of permanent numbness around the wound. This may get better with time, but may not completely go away. Most patients will have some pain after the operation and this will be treated with pain medication. Only a small number will have persisting pain that needs further treatment.
Wound healing - Occasionally when the breast tissue is rearranged to fill a defect where a cancer has been removed by wide local excision, the blood supply to a part of the breast or skin fails. In the skin and nipple region this may produce some skin loss, altered sensation and scarring. In the breast this may result in a lumpy area, which is called fat necrosis. It gradually resolves over time, although can take up to 2 years to settle. Lesser degrees of lumpiness at the site of surgery are common after radiotherapy and may be permanent.