Breast Surgery

Breast changes are common.  From the time breasts begin to develop through menstruation and menopause, women may experience various kinds of breast pain and other breast changes such as breast lumps and tenderness.  Lumps within breast tissue are usually found unexpectedly during test procedures or during a routine monthly self-examination.  Most lumps are not cancerous but represent changes within the breast tissue.

Your breast is composed of several glands and ducts that lead to the nipple and the surrounding colored area called the areola. The milk-carrying ducts extend from the nipple into the underlying breast tissue like the spokes of a wheel. Under the areola are lactiferous ducts which fill with milk during lactation after a woman has a baby. When reaching puberty, changing levels of hormones cause the ducts to grow and cause fat deposits in the breast tissue.  The glands that produce milk (mammary glands) may extend to the armpit area (axilla).

There are no muscles in the breasts, but muscles lie under each breast and cover the ribs. These normal structures inside the breasts can sometimes make them feel lumpy. Such lumpiness may be especially noticeable in women who are thin or who have small breasts.

Breast pain is a common breast problem mostly in younger women who are still having their periods and happens less often in older women. About two-thirds of women with breast pain have a problem called cyclic mastalgia. This pain typically is worse before your menstrual cycle and usually is relieved at the time your period begins. The pain may also happen in varying degrees throughout the cycle. Because of its relationship to the menstrual cycle, it is believed to be caused by hormonal changes. This type of breast pain usually happens in younger women, although the condition has been reported in postmenopausal women who take hormone replacement therapy. Breast pain that is not associated with the menstrual cycle is called noncyclic mastalgia. It occurs less often than the cyclic form. It typically occurs in women older than 40 years and is sometimes linked to a fibrous mass (fibroadenoma) or a cyst.  Although breast pain is a concern, it is rarely the only symptom of breast cancer.  Most breast cancers involve a mass or lump.

Breast pain or tenderness may also occur in teenage boys. The condition- called gynecomastia – is enlargement of the male breast which may occur as a normal part of development, often during puberty when there are changes in hormone levels. In adult men, 1 in 4 men between the ages of 50-89 will develop gynecomastia caused by natural hormone changes or as a result of certain medications (such as anti-androgens, anabolic steroids, heart, ulcer, antidepressants) or other health conditions. One should see a physician if experiencing swelling, pain, tenderness or nipple discharge on one or both breasts.

Lumps or abnormalities in the breast are often detected by physical examination, mammography, or other imaging studies. However, it is not always possible to tell from these imaging tests whether a growth is benign or cancerous.

If an abnormality is not felt during examination, there are signs that indicate the need for medical attention. These include:

• severe breast pain
• changes in the size of a breast or the nipple
• changes in the shape of both breast or nipple
• pitting, dumpling or redness of the breast skin
• nipple redness, irritation, or inversion
• changes in the pattern of veins visible on the surface of the breast/li>
• some types of nipple discharge

To determine the condition of the mass, a breast biopsy may be required.  The biopsy is removal of breast tissue for examination by a pathologist. This can be accomplished surgically, or by withdrawing tissue through a needle. Image-guided needle biopsy is not designed to remove the entire lesion, but most of a very small lesion may be removed in the process of biopsy.

Fine needle aspiration (FNA), which uses a very small needle to extract fluid or cells from the abnormal area.

Core needle (CN) which uses a large hollow needle to remove one sample of breast tissue per insertion.

Vacuum-assisted device (VAD) which uses a vacuum powered instrument to collect multiple tissue samples during one needle insertion.

Wire localization in which a guide wire is placed into the suspicious area to help the surgeon locate the lesion for surgical biopsy.

The type of biopsy will depend on whether the area can be felt, how well it can be seen on mammogram or ultrasound and how suspicious it feels or appears. Specialized equipment is needed for different types of biopsy. Generally, needle biopsy is less invasive than surgical biopsy. It is appropriate for some but not all situations and some surgeons feel it is far less accurate.

If the abnormality is not felt, a needle localization must be done before the actual surgery. After local anesthetic is administered, a fine wire is placed in the area of concern. Either x-ray or ultrasound guidance is used. The patient is awake and usually sitting up.

There are two types of surgical breast biopsies considered here, excisional and incisional. An excisional biopsy is a procedure where the entire area of concern and some surrounding tissue is removed. It is usually done as an outpatient procedure- in a hospital or surgery center. The patient may be given a light anaesthesia which will speed recovery time in comparison to a general anaesthesia.

If a mass is very large, an incisional biopsy may be performed. In this case only a portion of the area is removed and sent for analysis. The procedure is the same as an excisional biopsy in other respects.