Introduction

 

Disorders of the breast are very common and the field of breast surgery is rapidly expanding with new techniques and innovations being developed regularly. Plastic surgeons deal with resection and reconstruction of oncological breast disease as well as aesthetic breast surgery and gynaecomastia surgery in males. With the rising incidence of breast cancer in developed countries the role of the oncoplastic breast surgeon is becoming more and more important. Furthermore, the number of patients having aesthetic breast surgery is increasing, meaning the field of breast surgery is rapidly becoming a specialty in its own right.

 

Oncoplastic Breast Surgery

 

Around 45 000 women, and 300 men, are diagnosed with breast cancer in the UK every year. However, despite its rising incidence, the survival rates for breast cancer are consistently improving, illustrating that effective oncoplastic surgery combined with a multidisciplinary approach is working.

 

Indications for Surgery

 

A number of management options are available to patients with confirmed breast cancer, both surgical and non-surgical, with specific treatments tailored to the individual cases. All patients treated with surgery are subsequently offered adjuvant systemic therapy. Although surgery is the first line treatment for all early and locally advanced breast tumours some patients do not want surgery. Surgeons must weigh up the pros and cons of surgery with the patient as, ultimately, the decision lies with them. Combined discussion with the surgeon, patient and a specialist breast nurse, in particular dealing with any psychological issues relating to surgery, may help to alleviate any concerns.

 

Indications and contraindications for surgery are as listed below [1].

 

Table of indications for breast surgery

Investigation and Surgery in the Axilla

 

The lymphatic drainage of the breast is to the axillary nodal basin and therefore breast tumours can spread to the axillary lymph nodes, often as the first location of spread outside of the breast. Therefore it is vitally important that both axillas are investigated thoroughly in all patients with confirmed breast cancer.

 

Investigation of the Axilla

 

The protocol for axillary investigation depends on the stage of disease and whether there are palpable lymph nodes or not.

 

In patients with DCIS who are having breast conserving surgery and are considered to be low risk for invasive malignant disease with no palpable axillary masses, no further investigation is required. However, patients with DCIS having mastectomy or those considered high risk for developing invasive disease (such as those with palpable breast disease or extensive microcalcifications on mammography) are offered sentinal lymph node biopsy, SLNB (below).

 

All patients with early or locally advanced invasive breast cancer, regardless of the type of surgery, are offered pre-surgery ultrasound of the axilla. If positive/suspicious, patients undergo ultrasound (US) guided biopsy of the abnormal lymph node. If, on the other hand, no abnormalities are detected on US or US guided biopsy, SLNB is still offered to the patients.

 

Surgical Management of the Axilla

 

Axillary basin lymph node dissection is performed with:

 

  • Positive SLNB: micro or macrometastasis.
  • Positive US guided biopsy.
  • Tumour cells isolated only on SLNB - in which case this is regarded as a negative result and axillary dissection is not offered.

 

The axillary lymph nodes act as a barrier to the spread of the tumour around the body. Therefore, if axillary spread is identified pre-operatively axillary dissection can be carried out at the same time as the breast surgery to prevent any further dissemination. However, since axillary spread may not occur until long after the removal of the breast tumour, regular follow-up and examination of the axilla are required.

 

Axillary dissection involves making a small incision in the anterior axillary line and excising all loose connective and fatty tissue from the region to ensure removal of all the lymph nodes.

 

Sentinal Lymph Node Biopsy

 

SLNB is an important tool in the staging of breast cancer, as well as melanoma, which also drains to specific nodal basins depending on its location on the body. Most patients are offered SLNB except for when there are obvious palpable nodes with positive US guided biopsy or the patient has DCIS with low risk of invasive disease. SLNB is performed at the same time as breast surgery.

 

Sentinal node describes the node where lymphatic fluid from the breast drains to first; this node(s) is therefore the first barrier to spread. SLNB involves identification of tumour spread in the sentinal lymph nodes that is not obvious on US or examination.

 

Sentinal nodes identified can either be micrometastatic (<2 mm in diameter) or macrometastatic (>2 mm). A positive SLNB, the number of positive nodes and the size of the nodes all influence the staging of the disease and consequently the prognosis. SLNB is also important in preventing unnecessary axillary dissections as it identifies lymph node negative patients.

 

Patients with a positive sentinal node(s) are always offered axillary dissection which happens at a later date after the initial breast surgery + SLNB. Patients with isolated tumour cells in the lymph nodes identified on SLNB are classed as lymph node negative, as there are only a few cells present and not enough to make an obvious mass.

 

How Sentinal Node Biopsy Performed

     

    • A blue dye (Figure 1) and a radiocolloid isotope are injected directly into the tumour - this is the Dual technique as 2 methods of identification are used for accuracy.

     

    • The blue dye will track along lymphatic vessels before staining the sentinal lymph node(s) blue

     

    • A gamma probe is also used in the axilla to identify gamma rays emmited from the isotopes which have also drained to the sentinal node(s)

     

      • Any nodes identified as sentinal nodes (i.e. those that have stained or are emitting gamma rays) are subsequently removed.

       

        • These are then sent for histology to identify whether there is tumour spread within them - if so, the patient will be called back for a full axillary clearance.

         

        • Remember a node that stains blue/emits gamma rays is not positive for tumour spread, this merely identifies the node as the sentinal node

         

        A video discussing SLNB can be accessed via the following link [2]: http://www.youtube.com/watch?v=Cdl2JhhTfYc 

         

         

        Fig 1: Blue dye being injected into the tumour site

        Types of Breast Surgery

         

        In the past, mastectomy (complete removal of the breast) was the mainstay of treatment for breast cancer. However, recent advances in surgical technique have allowed surgeons to remove smaller areas of the breast which may reduce post-operative morbidity and improve the cosmetic results. This type of surgery is known as breast-conserving surgery and is either lumpectomy or quadrantectomy.

         

        The type of surgery offered is usually down to factors such as the size of the tumour, invasion of muscle or skin, risk of recurrence (affected by lymph node involvement, invasion of surrounding tissues, genetic predisposition, multiple calcifications), and patient preference.

         

        Lumpectomy

         

        Lumpectomy involves excision of the breast tumour and a small amount of surrounding tissue. Patients are treated with radiotherapy to the region of the tumour following surgery. The procedure is usually performed under general anaesthetic but it is a short procedure and can be done as a day case under local anaesthesia if the tumour is small. This technique is now the preferred surgery for DCIS and early invasive tumours. A mammogram showing a small tumour indicated for lumpectomy is shown in Figure 2 [3].

         

        Fig 2: Mammogram showing small breast tumour

        Lumpectomy Surgical Procedure

         

        Initially the tumour is located radiologically so that the surgeon knows where to make the incision. It can be located via a mammogram followed by placement of a guide wire into the location of the tumour (Figure 3 [4]). Alternatively the tumour can be located via ultrasound, which may be more pleasant more the patient.

         

        Following this the surgeon makes a small incision in the breast over the location of the tumour (Figure 4 [5]). They dissect down until the tumour is located, this is then excised along with a small amount of surrounding tissue. Ideally an excision margin of 1cm around the tumour is required to prevent local recurrence and remove all residual tumour cells. However in DCIS an excision margin of only 2mm is required.

         

        The lump removed is sent for urgent histology to check the excision margins are clear; the results of this should be available within 20 minutes or so. If tumour cells are present within 1 mm of the excision margins then a re-excision is required to ensure that the margins are clear. This ensures the risk of local recurrence is extremely low. Once margins are clear the wound is closed, firstly via deep sutures and then via cutaneous sutures to ensure a good closure and minimal scarring.

         

        In Paget’s disease of the nipple the nipple-areolar complex is removed in a similar procedure followed by reconstruction. Wounds generally do not require drains unless simultaneous axillary dissection has been carried out, in which case drains are required to prevent the build up of fluid causing a seroma.

         

        Fig 3: Small tumour with guide wire inserted following lumpectomy Fig 4: Illustration of lumpectomy procedure

        Benefits of Lumpectomy

           

          • Maintains cosmetic appearance and functionality of the breast (Figure 5 [6]).
          • Allows complete removal of small-medium sized tumours without removal of large areas of breast.
          • Quick and simple procedure with shorter hospital stay.
          • Lower risk of post-operative morbidity.
          • Usually no need for reconstruction of the breast.

           

          Fig 5: Cosmetic result following right lumpectomy

          Quadrantectomy

           

          Also known as a partial or segmental mastectomy, it is a form of breast conserving surgery where a quadrant (approximately a quarter) of the breast is removed. This is also followed by radiotherapy.

           

          The surgical procedure for quadrantectomy is similar to lumpectomy as only the tumour and the surrounding tissue is removed rather than the whole breast. However, a larger area of tissue is removed than in lumpectomy. This is suitable for larger tumours not-amenable to lumpectomy but that can still be managed without needing a mastectomy.

           

          It is less commonly performed than lumpectomy as the cosmetic result is poorer and often reconstruction is required. However, excision margins should never be compromised for cosmesis as reduction of local recurrence and survival improvement are always the primary aims. Therefore, quadrantectomy should always be considered if lumpectomy is unlikely to remove all residual tumour.

           

          Contraindications to Breast Conserving Surgery

             

            • Multi-focal disease in the breast (Figure 6 [7]).
            • An especially small breast size.
            • Tumour size >5 cm.
            • Previous radiotherapy to breast.
            • Repeated positive resection margins after attempted breast-conserving surgery.
            • Patient contraindicated for radiotherapy following surgery - certain disorders such as collagen-vascular disorders (e.g. SLE, scleroderma, Sjogrens) are believed to cause more severe adverse reactions to radiotherapy, however this is controversial.

             

            Fig 6: MRI scan showing multi-focal breast disease

            Mastectomy

             

            There are many modifications of a mastectomy but the simple purpose is removal of the entire breast tissue from one side. Mastectomy used to be first line treatment in breast cancer, however, these days it is much less commonly performed as breast-conserving therapy has more benefits (above).

             

            Mastectomy is indicated in patients who are contraindicated for breast-conserving therapy, those with large (Figure 7 [8]) or multi-focal tumours, those undergoing prophylactic breast surgery due to high risk (e.g. BRCA 1 or 2). The procedure is performed under general anaesthetic although the hospital stay is usually only 1-3 days. All patients are offered immediate reconstruction of the breast often performed at the same time as the mastectomy.

             

            Fig 7: Lateral and medial mammograms showing a large tumour with probably involvement of the nipple

            Total mastectomy is the removal of all breast tissue to the clavicle superiorly, the sternum medially, the inframammary crease inferiorly and the anterior axillary line laterally, as well as removal of the nipple and part of the overlying skin (Figure 8 [9]). This can be combined with axillary node dissection (in modified radical mastectomy) or axillary node dissection and pectoralis major resection (in radical mastectomy - Figure 9 [10]). These procedures are very invasive and are only performed when there is evidence of locally advanced tumours with involvement of the axillary nodes and/or chest wall muscle.

             

            More conservative surgery can be performed using a skin-sparing or nipple-sparing techniques which maintain the position of the inframammary fold and the overlying skin and nipple, but still remove all the breast tissue. Although these techniques are not appropriate for tumours near the skin or nipple, they give excellent results as well as a better cosmetic appearance.

             

             

            Fig 8: Post-operative results following total mastectomy with skin preservation Fig 9: Post-operative result following Radical mastectomy with pectoralis major excision

             

             

            Mastectomy versus Breast Conserving Surgery

             

            A huge study (NSABP-B06) which followed patients treated with mastectomy versus breast-conserving surgery with radiotherapy for 20 years following surgery showed that there was no difference in the survival between the two [11]. However, they did find that there was an increase in the rate of local recurrence in the breast in those undergoing breast-conserving surgery, although this did not equate to a difference in survival.

             

            Complications of Surgery

             

            Breast surgery has same risks associated with all major surgery such as DVT/PE, but also some specific risks such as:

             

            • Seroma - collection of serous fluid under the skin (Figure 10 [12]).
            • Wound infection, breakdown and necrosis.
            • Haematoma - collection of blood under the skin.
            • Lymphoedema - is swelling of the arm due to blockage of lymphatic drainage - usually only occurs following axillary dissection (Figure 11 [13]).
            • Local recurrence of tumour.

             

            Fig 10: Seroma of right breast Fig 11: Lymphoedema of right arm following breast surgery

            Breast Reconstruction

             

            Reconstruction is offered to patients who have a significant breast defect following surgery, usually after a mastectomy. It can be performed immediately, at the same time as breast surgery, however it can also be performed at a later date e.g. following adjuvant therapy. The purpose of reconstruction is to restore form and cosmetic appearance of the breast which is often vitally important to patients, as loss of a breast can have significant emotional and psychological consequences. Reconstruction cannot restore functionality of the breast or sensation. Reconstruction isn’t for everyone and some patients may choose to have a prosthesis, an artificial breast, instead.

             

            Although excellent results can be achieved, patients must be realistic about their expectations as it is impossible to reconstruct a breast identical to what was there before. However there are important characteristics of the reconstruction which will ensure a good appearance such as:

             

            • Symmetry with the contralateral breast e.g. size, height, height of nipple, shape.
            • Symmetrical appearance while wearing a bra or clothes - as often female patients feel the most important thing is to have the appearance of 2 normal breasts while wearing clothes which is very achievable.

             

            There are several different reconstructive options available and which one is offered depends on the individual patient and surgeon.

             

            Reconstructive Flaps

             

            Flaps are autologous tissue transfers from one area of the body to another and are commonly used for reconstruction of a huge variety of defects on the body including following breast surgery. Tissue removed for flaps includes skin, fat and sometimes muscle. All flaps require a healthy vascular supply as the tissue transferred to the breast must remain well perfused to stay healthy. The arterial and venous vessels which supply flaps are known as perforators and there needs to be at least 1 good sized arterial perforator and 1 deep venous perforator.

             

            Flaps can either be transferred directly to the area of the breast with the blood supply still intact (local flaps) or the blood supply can be cut and then anastomosed to local vessels in the breast region (free flaps). Detailed descriptions and diagrams of how flaps are raised can be found on: http://www.microsurgeon.org/

             

            Commonly used flaps for breast reconstruction include:

             

            • DIEP (deep inferior epigastric artery perforator) flap - this involves skin and soft tissue (fat) from the lower abdominal wall. Muscle may have to be dissected to locate the artery. This flap has the benefit of giving the patient a simultaneous tummy tuck as the fat from the lower abdomen is removed

             

            • SIEA (superficial inferior epigastric artery) flap - this involves the same tissue as the DIEP flap but requires no dissection of the abdominal muscle and therefore dissection is less extensive and there is less risk of herniation. The flap is supplied by superficial vessels and therefore not everyone has large enough vessels, if this is the case then a DIEP can be performed, this choice is often made intraoperatively.

             

            • TRAM (transverse rectus abdominus muscle) flap - this involves the same tissue as the DIEP and SIEA flaps but rectus muscle is also included. This is less commonly performed.

             

            • TAP (thoracodorsal artery perforator) flap - this artery supplies the skin and flap overlying the latissimus dorsi in the back. The flap provided is not as bulky as the other flaps and so it is ideal in thin people with smaller breasts. This flap can be transferred as either a local or a free flap

             

            • Latissimus dorsi flap - this is also supplied by the thoracodorsal artery. The muscle is very large and a large section can be removed with the overlying skin and transferred as local or free flap to the breast.

             

             

            Flaps are not always used and implants can be used on their own particularly after skin conserving surgery. Once flaps are transferred to the region of the breast they are moulded into the shape and size of the contralateral breast. This is a very difficult skill to master and often subsequent corrections are required following reconstruction to ensure symmetry.

             

            Corrections may include:

             

            • Breast augmentation (using implants) or reduction on the contralateral (healthy) breast to achieve a symmetrical appearance.
            • Mastopexy (breast lift) of reconstructed or healthy breast to achieve symmetrical height.
            • Implants combined with a flap to ensure adequate bulk of the reconstructed breast.
            • Lipoplasty - this involves autologous transfer of fat from one region of the body (usually the abdomen) to the breast to act as a filler or tissue expander. This bulks out the shape of the breast and is useful for small defects such as dips, dimples or asymmetrical curvature of the breast. Lipoplasty is also very useful following breast conserving surgery as this can leave an abnormal dip or dimple in the breast which can be filled out by fat transfer.

             

            Nipple Reconstruction

             

            Following breast reconstruction most patients subsequently require nipple reconstruction (Figure 12 [14]) unless they have undergone nipple conserving surgery. Nipples can either be reconstructed by folding part of the flap used to reconstruct the breast or by transferring part of the healthy nipple from the contralateral side.

             

            These reconstructions can then undergo nipple tattooing which involves injecting semi-permanent dye lasting around 18 months into the nipple area to give the appearance of an areola that is equivalent to the healthy side. Not all patients want nipple reconstruction, in which case a nipple prosthesis can be worn instead.

             

            Fig 12: Final result of left nipple reconstruction

            Gynaecomastia

             

            This is essentially an increase in male breast tissue, leading to the appearance of breasts. It is usually due to a build up of male oestrogen or side effects of drugs. Pseudo-gynaecomastia is a build up of fat in the breast region, with no build up of breast tissue, usually due to obesity and commonly referred to as ‘man boobs’. The appearance of male breasts is relatively common affecting up to 50% of the population and the number of men seeking surgery for this embarrassing condition is dramatically increasing.

             

            Gynaecomastia can cause significant psychological and emotional problems leading to loss of self confidence, reluctance to go out socially and depression. However the NHS only offers surgery for gynaecomastia if the patient can prove they suffer a serious reduction in quality of life due to the condition and therefore surgery is vital for their health or well-being. If a patient requires the surgery purely for cosmetic reasons then this is dealt with privately.

             

            Some common causes of gynaecomastia include:

             

            • Hypogonadism
            • Liver cirrhosis
            • Hyperthyroidism
            • Oestrogen producing tumours e.g. testicular, adrenal
            • HCG producing tumours e.g. testicular, bronchial, pituitary
            • Renal failure patients on dialysis
            • Drugs - Spironolactone, Cimetidine, Digoxin, Finasteride, Anabolic steroids, Cannabis
            • May occur in normal puberty - this often settles on its own

             

            Gynaecomastia Surgery

             

            The surgery offered depends on the size of the breasts and the cause (fat or breast tissue). If breast tissue is the problem then usually a reduction mammoplasty is performed where the excess tissue is excised and the skin tightened. If fat is the problem then often liposuction of the breast is the best option as this involves a smaller incision scar. A combination of the two can also be offered.

             

            Larger cannulas capable of breaking up the denser glandular tissue have recently been developed allowing breast tissue to be removed in the same way as fat in liposuction. The aim of surgery in the give a better cosmetic appearance with a flatter, better-contoured chest but also to improve the emotional well-being and quality of life of the patient. The pre and post-operative results of gynaecomastia can be seen in Figure 13 [15].

             

            Fig 13: Pre and Post Op Gynaecomastia

             

             

            The Future of Breast Surgery

             

            Minimal access surgery using endoscopic techniques is the great technological advancement of all branches of surgery as it allows smaller wounds, less morbidity, shorter hospital stays and equivalent or better results. Endoscopic techniques have been developed for both aesthetic and oncological breast surgery. Endoscopic procedures are extremely attractive to cosmetic surgeons as they reduce scar size therefore enhancing cosmesis.

             

            Breast augmentation, reduction and mastopexy can all be performed endoscopically with incisions typically in the axilla, periareolar and even periumbilical regions. Although these are yet to become common practice in the UK it is likely that minimal access aesthetic breast surgery will become more common in the future. Oncological endoscopic breast surgery is still in its infancy. Early reports have suggested that it is technically feasible to perform and it will provide good disease control results [16]. However, it is yet to become mainstream practice mainly due to a lack of randomised clinical trials proving its efficacy.

             

            As with other areas of plastic surgery, tissue regeneration may also have a huge impact on breast surgery in the future. Stem cell research evaluating whether stem cells can be used to regenerate breast tissue after mastectomy is an exciting prospect. Stem cells, extracted from a patient's fat tissue and concentrated, are already gaining popularity in breast augmentation. An alternative to using pure stem cells is fat grafting, where a section of fat tissue (rich in stem cells) is removed from the abdomen and grafted to the breast. These ideas illustrate the exciting and innovative area of breast surgery where cutting edge technologies are being constantly developed to improve patient care and disease control.

             

            Summary

             

            In summary, breast surgery is directed by two key principles - local control of breast disease and preservation, restoration and enhancement of form and appearance. The former is always the priority in breast disease and control of malignancy must never be compromised by a desire for cosmetic results.

             

            It is the role of the breast surgeon to ensure adequate clearance of a tumour and follow-up to deal with any local recurrence or spread. Only then can the secondary role be fulfilled in the context of breast disease in terms of reconstruction and improving aesthetic appearance. However an important part of any breast surgeons work will always be dealing with patients without breast malignancy but who require some alteration in appearance of their breasts for their own mental or physical benefit.

             

            References

             

            1. http://www.nice.org.uk/Search.do?keywords=Breast%20cancer&searchType=GUIDANCE&parentKeyword=Cancer%20by%20site

            2. http://www.youtube.com/watch?v=Cdl2JhhTfYc

            3. http://www.fas.org/irp/imint/docs/rst/Intro/tn_im7b.jpg

            4. http://www.sciencephoto.com/image/277106/530wm/M5510095Removal_of_breast_tumour_lumpectomy_-SPL.jpg

            5. http://www.surgeryencyclopedia.com/images/gesu_02_img0146.jpg

            6. http://www.breastflap.com/images/photo-mastectomy-2.jpg

            7. http://breast-cancer.ca/images/multifocal-breast-tumor-mri.jpg

            8. http://www.rad.washington.edu/academics/academic-sections/mbi/education/mammoed/teaching-files/case-3

            9. http://www.surgery.com/images/gim/gesu_02_img0153.jpg

            10. http://img.medscape.com/pi/emed/ckb/plastic_surgery/1271089-1276001-944tn.jpg

            11. Fisher B, Anderson S, Bryant J et al. Twenty-Year Follow-up of a randomized trial comparing total mastectomy, lumpectomy and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347:1233-1241

            12. http://drkevinbrenner.com/wp-content/uploads/2011/07/DSC_0012crop.jpg

            13. http://2.bp.blogspot.com/_a0Ho-H5DFLI/SQD_huyNAbI/AAAAAAAAAcE/O3_rYZ2BZTA/s320/jacksonvillelymphclinic.jpg

            14. http://www.thebreastclinic.co.uk/photos.htp

            15. http://www.breastsurgeryuk.com/Resources/images/Gynaecomastia-Case-2.jpg

            16. Park HS, Lee JS, Lee JS et al. The feasibility of endoscopy-assisted breast conservation surgery for patients with early breast cancer. J Breast Cancer. 2011;14:52-57

             

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