Early diagnosis methods, the level of awareness about the breast cancer in women, learning and using the breast self-examination techniques, catching the disease in the early stages and the approach of doctors that care about the quality of life of the patients allow for the implementation of the breast conserving surgery. 

As a result of the developments in radiotherapy and chemotherapy methods, extensive surgeries (mastectomy) previously performed have been replaced by the surgeries aimed at preserving more breast skin (breast skin conserving) and breast tissue (breast conserving). 

In addition, in the approach to the cancer treatment, physicians focus on the methods that aim not only to control the cancer but also to protect and increase the patient’s quality of life. 

As in the surgical treatment of all cancers, the main purpose of the breast cancer is to clean the tumor tissue and save the patient’s life. Unlike other organ cancers, the problem of the breast cancer patients is not only the problems caused by the diagnosis of cancer. 

Since the body integrity is impaired as a result of the surgical removal of the breast (mastectomy), severe negative psychological effects are seen in most women as a result of the change in body image. A series of psychosocial problems are observed in women after the breast loss, such as depression and other affective disorders, loss of sexual desire, deterioration in body perception, fear of losing feminine characteristics, concerns about recurrence of the disease, difficulty in finding suitable clothes and problems caused by externally applied breast prostheses in the form of a bra. 

When one is diagnosed with cancer, the feeling that one’s life is so close to the breaking point, coping with multiple problems and trying to “make life worth living” often make women more emotional and more vulnerable. 

In this respect, instead of the hasty approach of the patients diagnosed with the breast cancer and their relatives, treatment should be started in a way that the treatment options are talked over and discussed in detail and positive support is received. 

How is the breast conserving surgery performed? 

he breast conserving surgery in the breast is a surgical process in which only the cancerous area is removed together with the intact breast tissue and the breast is preserved. It is a breast surgery process that has very good oncological safety, good cosmetic results, and positively affects the patient’s quality of life, if it is performed with the right techniques to the appropriate patient.

In the breast conserving surgery, the cancerous mass, which is removed with the intact breast tissue during the operation while the patient is asleep, is first radiologically examined (specimen mammography is taken). It is then sent for pathological examination. An experienced pathologist freezes the removed tissue with the frozen section method, makes thin sections around the mass and examines the boundaries of the mass, which we call SURGICAL LIMIT, within 30-45 minutes. This part of the surgical process is very important. If there are no cancer cells at the surgical margin as a result of the pathological examination, the surgical process for the breast is completed. If there are cancer cells at the surgical margin, the margin is slightly expanded. If the tumor cells are still present at the end, the shape of the surgery is changed and the breast tissue is completely removed. In cases where the surgical margin is clean, millimeter-sized hooks, which we call thin metallic clips, are placed in the space where the mass is removed for more intense irradiation during radiotherapy in the future (in order to reduce the risk of recurrence of the disease in the breast). The task of these clips is for the radiation therapy to more intensely irradiate the area where the tumor was removed. If a serious deformity (deformity) will occur in the breast after the mass is removed, the space can be filled with the slip (intraglandular flap) process using the breast’s own tissue, which is one of the oncoplastic surgical processes. Today, the breast-conserving surgery is one of the surgeries with very good patient satisfaction. 
The breast conserving surgery cannot be applied to every patient. For the breast conserving surgery, the factors such as the fact that the tumor tissue is unifocal within the breast, the appropriate tumor-breast ratio (since the volume of the remaining breast tissue will not be sufficient when a small-sized in-breast is a large-diameter tumor) and the patient’s preference are evaluated. In addition, it cannot be applied in the patients who have received radiotherapy, diagnosed with connective tissue disease, the breast cancer diagnosed during early pregnancy and inflammatory breast cancer. Sometimes we call neoadjuvant treatment by applying drug treatment before the surgery and by shrinking the large tumors; it can be applied to the patient who is suitable for breast-conserving surgery. 

The patient diagnosed with the breast cancer should definitely evaluate the breast surgeon and breast conserving surgery option together. 

 

MASTECTOMY 

Mastectomy is the process of removing the entire breast along with the breast nipple. Mastectomy can be grouped as simple mastectomy in which only the breast tissue is removed and modified radical mastectomy, in which the breast tissue and axillary lymph nodes are removed. After mastectomies, the surgical field is flat and there is usually an incision in the form of a horizontal line. Mastectomy in cases where the tumor is scattered in the breast, in cases where the tumor tissue has penetrated the breast skin (there are cancer cells in the breast skin), in inflammatory breast cancer (locally advanced breast cancer. The breast skin appears to be inflamed), the breast shielding is applied for the breast cancer, but the cancer is inside the breast. It is recommended in patients who have relapsed and in cases where radiotherapy cannot be applied. 

Mastectomies are classical surgeries that have been widely practiced in the past. Today, by means of the developments in oncological treatments, the surgical methods are applied where the quality of life of the patient is considered more minimal. In women who will have a mastectomy, skin-conserving mastectomy is applied in the breast-conserving mastectomies where the skin of the breast and the breast nipple are protected under very special conditions. Any case without inflammatory breast cancer and the tumor has not spread to the skin and nipple of the breast is a candidate for skin conserving mastectomy. In the patients who have undergone skin conserving mastectomy, the breast repair is performed with the patient’s own tissues (preferably with tissues taken from the abdomen or back) or with implants, after the breast is emptied simultaneously with the plastic surgery team during the operation. This group of surgeries is as oncologically safe as classical mastectomies. 

 

SKIN CONSERVING MASTECTOMY 

It is a surgical method that has become popular in the breast cancer surgery in recent years. In some patients, in cases where the tumor does not cover the breast skin, a large part of the breast skin is preserved and the breast is emptied and the breast repair is completed simultaneously with the patient’s own tissues (from the abdomen or back) or with the prostheses we call implants. With this method, the patient gets a breast shape that satisfies the patient instead of the breast tissue in a single session. Thus, we prevent the negative effects seen in some patients that may be due to breast removal. The patients have less scarring at the surgical site and a good aesthetic result. 

 

BREAST NIPPLE CONSERVING MASTECTOMY 

It is a type of surgery in which the breast nipple and breast skin are conserved together, which has been applied in recent years, and the breast repair is performed by plastic surgery methods by emptying the breast. The nipple conserving mastectomies are generally preferred in the breast cancer diagnosed at an early stage, in cases where the tumor is small and located far from the breast nipple. During the operation, a thin tissue sample from under the breast nipple is sent for rapid pathological examination called frozen section. If cancer cells are not seen at the breast nipple, the breast nipple is preserved. If there is a disease, the breast nipple is sacrificed. In breast conserving mastectomies, the blood supply and neural stimulation of the breast nipple can sometimes change. Depending on this, deformity, discoloration, loss of sensation and decreased sensitivity of the breast nipple can sometimes develop. Before the breast conserving mastectomy process, the position of the cancer in the breast should be evaluated in detail with the radiologist and it is recommended that the repair be evaluated together with the plastic surgeon.  

 

CONSERVING RISK REDUCING MASTECTOMY (PROPHYLACTIC RISK REDUCING MASTECTOMY) 

In recent years, as a result of the developments in genetics and the knowledge that family history is important in the breast cancer, preventive risk reducing mastectomies are performed simultaneously with the breast repair methods, which is one of the plastic surgery process, to a group of women with a high risk profile without being diagnosed with the breast cancer. In order to apply prophylactic mastectomy, the person should have genetic tests related to the breast cancer, receive genetic counseling and then discuss all possible options (including aesthetic expectations) with the breast surgeon and decide accordingly. 

ONCOPLASTIC SURGERY

The definition of oncoplastic breast surgery means the planning of a surgical intervention for the breast cancer and a cosmetic intervention that will create a better aesthetic result in breast. 

Breast reconstruction processes in the breast conserving surgery; 

» With classical breast conserving surgery: If the remaining serious deformity (deformity) occurs in the breast after the tumor is removed from the breast, the deformities can be corrected with tissue turning-shifting methods from within the breast. 

» In large breasts (macromastia), it can be performed together with the cancer surgery and breast reduction method. With this method, the patients undergo cancer surgery and get rid of the problems (breast pain, back pain, shoulder pain, limitation of movement, rash that does not go away under the breast, risk of spinal curvature, etc.) due to their large breasts. 

» Risk reducing surgery (prophylactic protective mastectomy and repair) 

» Repair with skin-conserving mastectomy 

» Repair after mastectomy     

It has been shown in many studies that the breast reconstruction (breast reconstruction) has positive effects on the post-operative psychological state of women and that patients can be followed easily without causing serious difficulties. It has no adverse effects on the recurrence of the disease or the success of cancer treatment. It is one of the surgeries with high oncological safety. 

When talking to the patient about the treatment plan, the person’s oncological and cosmetic needs should be considered. A balanced decision should be made by taking into account the patient’s age, medical and psychosocial status and the wishes and expectations of the woman. 

The breast repair can be performed in the same session (simultaneous repair) with the surgery performed for the breast cancer or it can be performed in a separate session (late repair) after the cancer treatments (drug and radiation) are finished. Today, the more preferred technique is simultaneous breast repair due to better psychological results. This method does not require a second surgical process. 

The breast repair should be a safe process for the patient. There should be no significant functional impairment, minimal complication rates and no delay in initiating the cancer treatments after concomitant repair. Different methods can be used in breast repair: 

1. Only synthetic implants (silicone prostheses, those whose outer wall is filled with saline (saline), etc.)
2. Process in which the implant and the patient’s own tissues are used together (Combined)
3. Interventions in which only the patient’s own tissues are used

 

REPAIR WITH SYNTHETIC IMPLANTS ONLY 

Two types of prostheses are used for this purpose: 

• Tissue expanders placed temporarily
• Permanent breast implants

 

The tissue expanders are used to give elasticity to the breast skin before the permanent implant is placed. They are gradually inflated by injecting increasing amounts of saline into the chamber inside. After the patient completes oncological treatments, it is removed when the time comes and a permanent implant is placed into the loosened breast skin or it is possible to leave some special types of tissue expanders in place as permanent implants. 

The permanent implants are silicone prostheses that are frequently used in the breast aesthetic surgery. The studies conducted in recent years have shown that the use of silicone for this purpose is safe. 

The use of only synthetic implants for the breast repair is preferred by the patients who do not want surgery on their back or abdomen or it is recommended for the patients whose anatomical structure is not suitable. 

The women with other small and medium breasts also provide a better cosmetic result. 

In repair process with either tissue expander or permanent implant, the prosthesis is placed under the anterior chest wall muscles. 

 

IMPLANT AND PROCESSES WHERE THE PATIENT’S OWN TISSUES ARE USED TOGETHER (COMBINE) 

The most commonly used muscle-skin tissue (flap) for this purpose is the latissimus dorsi muscle on the back. The permanent implant is placed over the anterior chest wall muscles and under the latissimus dorsi muscular-skin flap, which is displaced from the back. 

Especially in cases where there is a significant defect in the breast skin flap after mastectomy, repair with a muscular-skin flap will be required, as the process using only the implant will not be sufficient and will not leave a good cosmetic result. 

A good cosmetic result can be obtained in medium and large diameter breasts. Care is taken to keep the incision mark on the back below the bra line. 

 

INTERVENTIONS WHERE ONLY THE PATIENT’S OWN TISSUE IS USED 

When considering the use of the patient’s own tissues, latissimus dorsi muscle-skin flap (LD flap – back muscle) and transversus rectus abdominis flap (TRAM flap – anterior abdominal wall muscle and adipose tissue) are used. 

Latissimus dorsi muscle-skin flap (LD flap – back muscle) 

In the patients with medium-sized breasts, the latissimus dorsi muscular-skin flap is an appropriate choice for repair. Appropriate symmetry and appearance can be achieved by placing prosthesis under the flap when necessary (without the need for any surgical process on the other breast). Repair with this process is a technique that should be preferred primarily because of its robustness, potential tissue volume (± prosthesis) and low complication rates in many patients. 

Transversus rectus abdominis flap (TRAM flap – anterior abdominal wall muscle and adipose tissue) 

It is preferred in the patients who need more tissue to achieve an appropriate symmetry with the opposite breast. There are two types: 

• Pedicle (transferring the flap while preserving the veins)
• Free (after cutting the veins feeding the flap and reconnecting them with the veins appropriately after tissue transfer)

Free TRAM flap has better cosmetic results, but it takes longer and requires more experience. Microsurgical techniques are needed during the operation. 

After repair with TRAM flap, it can be necessary to put a synthetic-patch on the abdominal wall to prevent hernia in the anterior abdominal wall. It is not an appropriate choice for the patients who have had previous abdominal surgery. 

 

SURGERY MADE INTENDED TO AXILLARY FOSSA 

The cancer cells that have the potential to spread in the breast cancer can spread to the axilla lymph nodes, where the lymphatic flow of the breast is most intense. In this respect, the examination of lymph nodes with the cancer in the axillary fossa is important in terms of the pathological stage of the disease, the determination of the treatment and the results of the treatment. If the cancer cells are found in the axillary fossa lymph nodes, it indicates that the disease is more likely to spread to other parts of the body. In this respect, processes for the axillary lymph nodes are gaining importance in the treatment of the breast cancer. 

 

AXILLARY FOSSA LYMPH GLAND DISSECTION (REMOVE) 

It is a classical surgical method in the breast cancer. It is usually done with an incision applied to the breast. The breast conserving surgery is performed with a separate incision made under the axillary fossa. It is a delicate process. It is the process of cleaning the lymph nodes under the axillary fossa. The removed lymph nodes are sent for pathological examination. A vacuum absorbent drain (hemovac) is placed to drain the fluid accumulated in the axillary fossa after the surgery. 
 

GUARD LYMPH NODE BIOPSY (SENTINEL LYMPH NODE BIOPSY-SLNB)

Among the breast cancer surgical applications, it is perhaps one of the most important surgical developments in terms of giving importance to the patient’s quality of life. As a result of many years of studies, it has been shown that removal (dissection) of the axillary lymph nodes in the breast cancer is not very effective in the survival of the disease, it provides information about the course of the disease and local control is achieved by removing the cancerous gland in the axilla. It is also a scientific fact that in the early stage of the breast cancer; approximately 70% of the patients do not have cancer cells in their axillary fossa. Here, the guard lymph node biopsy prevents conditions such as swelling in the arm (lymphedema) that negatively affect the quality of life of this group of patients. With the guard lymph node biopsy performed in the breast cancer surgery in the last 20-25 years, we can have information about the condition of the disease in the axillary fossa without removing excess lymph nodes, usually with the process performed during the operation. 

 

BREAST SURGERY BEFORE AND AFTER 

After the diagnosis of the breast cancer is given to our patients by biopsy methods, it is important to know the stage of the disease. The staging is done with the staging methods. If the patient is going to undergo a surgical process, I first give detailed information about the breast cancer surgery. Then, together with all the examinations of the patient, I offer my recommendations about the most appropriate surgical method for the patient in accordance with the scope of the disease and I evaluate my patient together with the plastic surgeon when necessary. After the patient is informed about the surgical options, we start the process for the appropriate surgical method with his participation in the decision of treatment. 

Before the surgery, the blood tests are done as preparation for the surgery and the anesthesiologist evaluates them for the surgery. On the day of the operation, the patient is seen again in the room by the breast surgeon and drawings about the surgery are made on the breast. If the patient will be subjected to pathological examination during the operation, the pathologist is informed. The breast surgeries are usually performed under the general anesthesia depending on the type of surgery and the process takes an average of 2 to 4 hours depending on the type of surgery. After the patient wakes up after the surgery, she is taken to her room (she rarely needs intensive care). Liquid food is started to the patient 6 hours after the operation. Normal food is recommended the next day. If a vacuum drain (hemovac) is used to drain the fluid accumulated in the operation area, the drains are drained and followed daily. 

After the breast surgery, the patients are usually hosted in the hospital for 2-3 days. For our patients coming from outside of Antalya, this period can be extended if desired. 

The surgical treatment is completed with daily dressings. After the pathology results come within 5 to 7 days after the surgery, the patient is informed about the results and possible treatments and is directed to the relevant specialist (usually a medical oncology specialist). The patient is then called for follow-up at appropriate intervals.