Surgery

Surgery is often the first treatment offered, however chemotherapy or endocrine therapy is sometimes offered before surgery for some patients. Before your operation, an appointment will be sent to you to be seen by our preoperative assessment nurses. At this appointment, your fitness for surgery will be assessed. This may include blood tests, X-rays and/or an ECG. Consent for the operation may be taken in clinic or on the day of surgery. If your operation is being combined with a sentinel lymph node biopsy, then you will be required to have a scan to identify the lymph nodes that will be removed. This is called a lymphoscintigram. This is either done on the day before surgery at the Royal Devon & Exeter Hospital. You will be sent a letter with a time and date. Please be mindful that parking onsite is limited and expensive so planning in advance would be useful. There are a few park and ride facilities in Exeter.

On the day of the surgery you will have had instructions to go to Petter Ward (Theatre 7), the New Building. There, the surgeon, anaesthetist and ward nurse will see you.

If you are having a localisation wire placement prior to surgery, you will be collected and taken down to the Radiology unit.

If your surgery is a day case procedure, then you will be assessed to ensure that you are fit for discharge. If you are discharged with a drain, our breast care nurses will explain how to look after this and will discuss a time for the drain to be removed in the breast clinic.

When you are discharged home, we would encourage patients to be gently walking during the day rather than lying in bed. This is to reduce the risk of deep vein thrombosis, which can occur after surgery. For patients who have had breast conserving surgery, including a wide local excision or therapeutic mammoplasty, we would encourage them to wear a comfortable non-wired support bra day and night until they are seen in clinic.

Wide Local Excision (Breast Conserving Surgery):

Surgery to remove the area of cancer in the breast is called wide local excision or lumpectomy. The surgeon takes away the cancer and a border of healthy tissue all around it. They leave behind as much healthy breast tissue as possible. You usually have radiotherapy to the breast after this type of surgery.

Therapeutic mammoplasty involves a wide local excision with a breast reduction technique resulting in a smaller, uplifted breast. The nipple and areola are preserved with their intact blood supply and the remaining breast tissue is repositioned to allow reshaping of the breast. The scars are often in the shape of a lollipop or an anchor, but your surgeon will explain this to you as everyone is different. A soft plastic drainage tube may be left within the breast to drain away the tissue fluid (seroma) which will be produced as a result of your surgery. When used, these drains are usually removed within a few days.

Mastectomy:

Mastectomy is the removal of the whole breast.

Your surgeon is most likely to recommend this operation if you have:

  • a large lump (tumour), particularly in a small breast
  • more than one area of cancer in your breast
  • large areas of (pre-cancerous) DCIS in your breast
  • had radiotherapy to the breast before

The surgeon will talk to you before the operation about the options for breast reconstruction. This means the surgeon creates a new breast shape using tissue from another part of your body or an implant, or both.

It is your choice whether you have breast reconstruction or not, but you should be offered one. Some women choose not to have reconstruction.

You might be able to have breast reconstruction at the same time as the mastectomy (immediate reconstruction). Or you might have it some months or years afterwards (delayed reconstruction). Whenever possible you should be able to choose when you have a reconstruction operation. Everyone is different and some women prefer to have it at the same time as the mastectomy while others prefer to delay it.

You might need radiotherapy after a mastectomy if your doctor thinks there is a risk of the cancer coming back in the area of the scar. In this case, your surgeon might discuss delaying breast reconstruction until after treatment.

Axillary Surgery:

Breast cancer cells can sometimes spread to the lymph nodes under the arm. Anyone with invasive breast cancer will have the lymph nodes under the arm assessed. The outcome of this will help the treatment team recommend which treatments are best for you.

Sentinel node biopsy

If your armpit nodes are not involved (on ultrasound scan) then you will most like have sentinel lymph node biopsy. Sentinel lymph node biopsy is usually carried out at the same time as your cancer surgery but may be done before.

A small amount of radioactive material (radioisotope) and a blue dye is injected into the area around the cancer (usually the day before at RD&E hospital) to identify the sentinel lymph node. Once removed, the sentinel node is examined under a microscope to see if it contains any cancer cells.

As the dye leaves your body, you may notice your urine and other secretions turn a bluish-green colour for one or two days after the procedure. The skin around the biopsy site may also be stained a blue-green colour. Some people may have a reaction to the dye, but this is rare and is easily treated if necessary.

If the sentinel node does not contain cancer cells, this means the other nodes are clear too, so no more will need to be removed.

If the results show there are cancer cells in the sentinel node, depending on how much is found you may be recommended to have:

  • further surgery to remove some or all of the remaining lymph nodes (ANC)
  • radiotherapy to the underarm
  • no further treatment to the underarm as long as you are having radiotherapy to the breast and chemotherapy or hormone therapy treatment

If you’re having chemotherapy (called neoadjuvant) before your surgery, your specialist may want you to have a sentinel lymph node biopsy before starting chemotherapy. This can help with planning any further treatment to the underarm after chemotherapy.

If you have DCIS you will only need a sentinel lymph node biopsy if you are having a mastectomy, or if there is a high chance you have some invasive breast cancer.

Axillary node clearance

Axillary Node Clearance is an operation to remove the lymph nodes under the armpit. Breast cancer sometimes spreads to the lymph nodes, and if this has happened it is important to remove the lymph nodes to remove the cancer in your armpit. The results of the operation also give us very important information which helps us to plan further treatment. This operation is sometimes combined with breast surgery or may be done as a separate procedure. Most common potential complications could be bleeding, infection, seroma formation, numbness/pain, stiffness of the shoulder and lymphoedema. You will be offered an appointment to attend our lymphoedema clinic before and after axillary surgery.

Reconstruction and oncoplastic breast surgery

We are now able to offer therapeutic mammoplasties, a form of breast conservation involving plastic surgical techniques such as breast reduction in order to maintain a natural breast shape.  This technique is tailored to each individual patient depending on you’re the location of your tumour (or tumours) and breast size.  It allows the surgeon more flexibility in offering breast conservation where previously a mastectomy would have been advised.

Implant based breast reconstruction can be performed in North Devon.  Upto 40% of patients with breast cancer will require a mastectomy, yet only 20% of those will have a breast reconstruction.  Breast reconstruction can be offered at the same time as a mastectomy in some cases.  In other cases you may be advised to wait until you have completed your treatment.  It is also a very personal choice.  We aim to guide you through the options that are available specifically to you.  In some cases you may be referred to Royal Devon and Exeter where they are able to offer a larger range of options including autologous breast reconstruction (using your own tissue to recreate a breast).  Whichever route you take, we are able to continue your care and follow-up at North Devon.

Nipple reconstruction can also be performed in North Devon.  This is usually a day case procedure and usually done at a later date to the original surgery.  There are alternatives to this including adhesive nipples, tattooing as well as or alone or of course there is always the option of not having this performed.

Lipofilling or ‘fat transfer’ can be offered at North Devon.  This can be used alongside a full reconstruction or even if you have had breast conservation (wide local excision or therapeutic mammoplasty).  It can be used to improve the contour/shape of your breast after any type of breast cancer surgery and can also increase breast volume.

Breast reconstruction:

https://www.breastcancercare.org.uk/information-support/facing-breast-cancer/living-beyond-breast-cancer/breast-reconstruction

Lipofilling Patient Information Leaflet.

Last updated: July 17, 2019