Surgical Options

The Team Approach

Women recently diagnosed with breast cancer should be seen by a surgeon with a special interest in breast cancer care soon after the diagnosis is made (ref. 1). The surgeon coordinates care with other members of the team including the oncologist, the radiologist, and the pathologist (ref. 2-4). Additional team members may include a plastic surgeon and a nurse navigator (ref. 5).

Surgical Treatment Options

Lumpectomy (Breast Conserving Surgery)

Lumpectomy is the procedure of choice for most patients with early-stage breast cancer. Women with more advanced cancer who have responded to chemotherapy or endocrine therapy may also be candidates for this procedure.

A successful lumpectomy requires the removal of the entire tumor and a rim of normal tissue. The closest distance between the tumor and the edge of the lumpectomy specimen is referred to as the margin. The pathologist makes this determination. It takes a few days to get the final pathology report. If the margin is judged to be too close, a second surgery is required. Once margins are cleared the patient is sent back to the radiation oncologist. (See link to radiation therapy).


Mastectomy (removal of the entire breast) is the procedure of choice for women who are not candidates for lumpectomy based on the size of the tumor or other factors (ref. 6). A recent study from Sweden concludes there may be a small survival advantage with lumpectomy as compared to mastectomy (ref. 7).


Nipple Sparing Mastectomy (NSM)

Early-stage breast cancers in which there is “safe distance” between the nipple and the tumor are candidates for saving the nipple (ref. 8). The cosmetic results of a NSM are usually excellent and recurrence rates are low (ref. 9).

Reconstruction Options

Newly diagnosed patients should consider consulting with a plastic surgeon soon after the diagnosis is made to discuss reconstruction options (ref. 10).


Tissue expanders

A tissue expander is a device with a silicone shell and an integrated port for saline injection. The expander is used to stretch the skin so that a permanent implant can be placed in the future.

After the breast surgeon completes the mastectomy, the procedure is turned over to the plastic surgeon who places the expander under the skin or the muscle (ref. 11-12). The time it takes to complete the expansion process is variable, but on average it takes 6-8 weeks to complete. Once expansion is completed, the patient returns to the operating room for removal of the expander and placement of a permanent implant.

Patients who were not candidates for nipple sparing mastectomy are given the option of nipple reconstruction or tattooing to complete their breast reconstruction (ref. 13).

Flap Procedures

TRAM/DIEP FLAP: BREAST RECONSTRUCTION: reconstruction can also be performed using the patient’s own tissue (ref. 14). The most common approach is to take skin from the abdomen and transfer it to the mastectomy site. This procedure is referred to as a TRAM or DIEP FLAP (ref. 15). Both are long and complex procedures and are reserved for motivated patients who are in good health.

LATISSIMUS FLAP: Women who are not good candidates for a TRAM or DIEP flap are often candidates for a LATISSIMUS FLAP (ref. 16). In this procedure the flap is mobilized from the back and transferred to the nearby mastectomy incision. A breast implant may be placed below the flap to add volume. This procedure is well tolerated, and patients can usually be discharged in one-or two-days following surgery.


Breast reduction at time of lumpectomy (Oncoplastic Reconstruction)

Large breasted women who choose to have a lumpectomy may consider the option of having a breast reduction at the time of lumpectomy (ref. 17-18). In addition to the cosmetic advantages, breast reduction can make it easier to achieve wide margins at the time of the lumpectomy which can lower the risk of a positive margin.

Delayed Reconstruction

Breast reconstruction can also be performed years after a mastectomy. The procedure is well tolerated, and the cosmetic results are similar to those achieved with immediate reconstruction.

Prophylactic Mastectomy

Bilateral prophylactic mastectomy is the standard procedure performed in women with a high-risk mutation such as a BRCA1/2 mutation. These women are often candidates for a nipple sparing mastectomy (ref. 19).

Women choosing a mastectomy for a cancer in one breast may also consider a contra-lateral mastectomy to reduce the risk of developing a future cancer in the opposite breast.

Lymph Node Surgery

In the past, it was standard policy to remove all the lymph nodes from under the arm which are referred to as the axillary lymph nodes (Ref.20). Removal of multiple axillary nodes may result in obstructing drainage of lymphatic fluids flowing from the arm. This may cause an accumulation of protein rich lymphatic fluid in the fatty tissues resulting in arm swelling referred to as lymphedema (Ref. 21-24).

New techniques are now available to detect the first lymph nodes draining a tumor. If the first nodes are negative, no further surgery is required, and the risk of lymphedema is markedly reduced. This procedure is referred to as a sentinel node biopsy.


Sentinel lymph node biopsy

There are two basic approaches to detecting the sentinel lymph nodes. The first is for the surgeon to inject a blue dye (isosulfan blue) around the tumor or under the nipple after the patient has been placed under general anesthesia. The dye travels from the breast to the sentinel nodes and turns them blue. The surgeon removes the blue nodes and sends them to the pathologist. If the nodes are negative, no further node surgery is required.

The second approach is to use a radionuclide isotope (tc99) to locate the sentinel lymph node (ref. 25). The injection of the tc99 is usually performed in the breast imaging department prior to surgery. The surgeon uses a probe that detects radiation levels. The surgeon identifies the “hot nodes” which are removed and sent to the pathology department for a frozen section.


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