Surgery

Breast cancer surgery

Surgery is one of the most widely used treatments for breast cancer. The type of surgery performed will depend on a number of parameters, including tumour size, location, cancer spread and overall health.

Surgery may be performed for the following reasons:

• to remove only the tumour (lumpectomy or partial mastectomy). Whenever possible, surgeons try to preserve the breast, opting for a lumpectomy (removal of abnormal tissue) whenever possible.
• to remove the entire breast (total mastectomy). After a mastectomy, women may experience certain side effects, such as lymphedema (swelling), pain or numbness in the arm or shoulder, as well as changes in self-esteem and body image. Don’t hesitate to discuss these issues with your healthcare team.
• to inspect and, if necessary, remove any invaded lymph nodes (axillary lymph node dissection and sentinel lymph node technique).

Surgery is sometimes performed after an initial treatment, known as neoadjuvant therapy, aimed at reducing the size of a large breast tumour.

Axillary lymph node dissection

Surgeons check to see if the disease has spread to the lymph nodes using a sentinel lymph node biopsy (the first few lymph nodes in the lymph node chain). Depending on the result and whether or not the lymph nodes have been invaded, they may be removed (axillary lymph node dissection).

Axillary lymph node dissection (also called axillary dissection) involves removing the lymph nodes in the armpit to:

• assess the presence of cancer cells in the axillary lymph nodes (number of lymph nodes affected, number of cells per lymph node) to determine the extent of the cancer;
• remove the lymph nodes containing cancer cells;
• remove the lymph nodes if the risk of spread is high; and
• reduce the risk of recurrence.

The surgeon makes an incision under the arm and removes between10 and 40 lymph nodes for analysis by the pathologist. A small drain and a drainage bag are installed after the excision to collect any fluid that may leak from the operated area and promote healing. The drain stays in place for a few weeks or until the discharge decreases. The patient returns home one to two days after surgery.

Possible side effects include infection, fluid build-up under the skin near the incision, swelling, stiffness, difficulty moving the arm or shoulder, numbness or pain. A build-up of lymph in the soft tissues can cause lymphedema.

Breast reconstruction

Breasts are an important body part for many women. Breast loss or deformity after surgery is often difficult to accept.

There are several options available to you to reclaim your body image.

External breast prostheses or breast reconstruction are two options, depending on your needs, desires and lifestyle.

You may also choose not to undergo breast reconstruction. The goal is for you to feel comfortable and at ease with your decision. The choice is yours. Don’t hesitate to discuss the advantages, disadvantages and your fears about breast reconstruction with your healthcare team, as well as with your loved ones. Consider all the options and choose the one that’s best for you.

The right to have a flat or asymmetrical chest

After mastectomy, some women don’t want to have traditional breast reconstruction or wear external breast prostheses; they prefer to have a flat or asymmetrical chest. This is how they want to redefine their bodies after breast cancer and their choice is just as valid.

If you plan to have a flat chest after surgery, tell your surgeon and make sure it is part of your operative request.

Several equivalent terms are used to designate a flat closure of the chest wall: esthetic flat closure, nonreconstructive mastectomy or optimal flat closure. These operations involve reconstructing the chest wall in an esthetic way by removing excess skin, fat and breast tissue following a total mastectomy. The remaining tissues are then tightened and smoothed so that the chest wall appears flat.

Wearing external breast prostheses

There are two types of external breast prostheses:

Temporary non-adhesive textile breast form: these are inserted into a pocketed bra. They are comfortable and can be used immediately after the operation.

Silicone breast form: these are similar in weight and appearance to natural breasts, giving a natural shape to the figure. They can be stuck to the breast or inserted into a bra.

Tips for choosing your external prosthesis:

• Consider asking someone close to you to help you choose, since they know your body shape and can give you their opinion.
• Compare different models and prices.
• Take your time when weighing your options.
• Let an expert guide you in making the right choice.

Breast reconstruction

What you need to know

Breast reconstruction is a surgery to make the breast look more natural following a mastectomy.

The timing of breast reconstruction depends on the treatments you’ve received and when you feel ready to have the surgery. It can be done at the same time as the mastectomy if it doesn’t interfere with treatment, or later, usually three or four weeks after chemotherapy and four to six weeks after radiation to give the breast time to heal. It can also be done months or years later if you want.

It is important to remember, however, that a reconstructed breast will not be exactly the same as a natural breast. Sensations may be different and the surgery may leave scars. These differences will lessen with time.

Breast reconstruction following breast cancer is covered by the Régie de l’assurance maladie du Québec (RAMQ).

The different types of breast reconstruction

Reconstruction using breast implants

Breast implants are a round or teardrop-shaped sac made of rubberized silicone and filled with sterile salt water or silicone gel. The implant is inserted into a cavity under the chest muscles. Two techniques may be used to form this pocket: tissue expansion or direct-to-implant reconstruction.

Tissue expansion

If the skin and chest tissue are too tight or too flat, the surgeon may perform a tissue expansion. This procedure involves inserting an empty sac under the chest muscles and gradually filling it with saline solution. The solution is added at the doctor’s office once or twice a week for up to three months. When the pocket is large enough, a second surgery is performed to remove the expansion prosthesis and replace it with the permanent implant.

Direct-to-implant reconstruction

The pocket for the implant may be made of special skin tissue from a human donor called an acellular dermal graft (AlloDerm, DermMatrix) from which the cells have been removed. Strips of tissue are stitched to the breast tissue to create a pocket for the implant.

Breast implant safety issues

There have been concerns about the safety of silicone implants, but years of monitoring have proven that they are safe and don’t cause health problems. Very rare cases of non-Hodgkin’s lymphoma called breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) have been reported with textured implants, and Health Canada has suspended approvals for Allergan’s Biocell (macro-textured) breast implants. These implants are no longer used in Canada, but some people may still have them. If you are among them, you can find information here. 

Autologous breast reconstruction

In addition to prostheses, another option is autologous breast reconstruction. With this technique, muscle and fat tissue is taken from other parts of your body and grafted onto your chest. This option results in a more natural look. Different techniques are used to perform autologous breast reconstruction: the free flap and the pedicle flap.

Pedicle flap technique

In the pedicle flap technique, the tissue removed from the abdomen (muscle, skin and fat) remains attached to the muscles and blood vessels; it’s not completely removed. The flap is moved under the skin to the breast area. This technique is used when the patient has not received radiation.

Reconstruction of the areola and nipple

The areola and nipple can also be reconstructed if necessary. This procedure is usually performed after the reconstructed breast has reached its final shape, i.e, three to six months after reconstruction. A reconstructed nipple is generally less sensitive than a natural one and the colour of the nipple and areola may be different from that of the other breast.

Artistic tattoos

After a mastectomy, you may also choose to get an artistic tattoo. To find out more, read the Canadian Breast Cancer Network’s blog post titled Considering a Mastectomy Tattoo? Here’s What You Need to Know.

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References

• Office québécois de la langue française. (2020). Mastectomie à fini plat. http://gdt.oqlf.gouv.qc.ca/ficheOqlf.aspx?Id_Fiche=26558216 
• Réseau canadien du cancer du sein 
• Pour en apprendre davantage sur les différentes options de reconstruction et de non-reconstruction, vous pouvez participer à la Soirée Bravoure, organisée par la Fondation du Centre hospitalier de l’Université de Montréal (CHUM)