AN OPERATION THAT CAN DECREASE THE RISK
OF BREAST CANCER
DEPENDING ON RISK FACTORS
THIS USED TO BE A VERY CONTROVERSIAL OPERATION
You are reading information regarding the surgical procedure for removal of breast tissue. Sometimes known as subcutaneous mastectomy, more recently known as skin sparing mastectomy.
The surgery involves removal of most (98% plus) of the breast tissue which lies beneath the skin. Incisions are used to try to minimize scars. The skin shell is filled by an implant similar to that used for breast enlargement OR by tissue from other areas of the body.
THIS IS A CONTROVERSIAL ISSUE. . . . BUT WITH THE ADVENT OF GENETIC TESTING – IT IS LESS OF A CONTROVERSIAL ISSUE. . In most cases this surgery is performed on breasts that are FREE of cancer or have MINIMAL OR NONINVASIVE cancer.
Some would wondered why a woman would choose to have her breasts removed if there is no cancer.
I have wondered why a woman, at high to very high risk, is told that she has to wait until cancer actually appears before her breasts or at least most of the internal breast tissue is removed.
Further, why should she be made to wait until there is a significant chance that her disease is no longer confined to the breast(s)?
As a Physician who does advise women about breast removal because of high risk, I attempt to present facts as I see them. It is imperative that there be no ‘pressure’ to go ahead with such surgery.
Each woman must have ample time to reflect and decide, without pressure, as to what should be done. It has been my observation that women who come to see me have thought about removal of their breasts for some time and in some cases for many years.
What is important is that the woman reflect as to how important her current breast configuration is to her. She must consider whether long term survival is more important than the physical and psychological value of the breast configuration.
For most women who consult me, long term survival is of the essence. They want to live to see their children grow, and to see their grandchildren grow.
Whether or not an individual is a candidate for surgery partially depends on risk factors. These risk factors have been statistically analyzed and help give an idea of the probability that cancer will occur.
WHAT DETERMINES ‘AT RISK’ FOR BREAST CANCER
The statistical chances of developing cancer can be calculated. While calculated connotes an exactness, certainly any such calculation is not exact, but it gives a woman enough of a ‘ball park’ figure as to the risk.
The following are associated with increased incidence of breast cancer.
– The presence of ‘pre-malignant’ changes.
– The presence of ‘minimal’ cancer in a breast.
– The presence of invasive cancer in the opposite breast.
– Pre-menopausal breast cancer in one’s mother, maternal grandmother, sisters, or maternal aunts.
– The presence of a genetic marker for breast cancer.
Inability to examine the breast clinically or by mammography.
More than one of the above compounds or increases the risk. IF THE RISK FACTORS ARE NUMEROUS one might reasonably state that the development of cancer approaches inevitability.
Removal of the inner portions of the breast(s) with preservation of the skin and nipple areolar complex if possible and with reconstruction, is THE LOGICAL THING TO DO – TO SAVE LIVES AND TO ATTEMPT TO PRESERVE A SEMBLANCE OF A PLEASING BREAST.
What are considered pre-malignant conditions ?
It is not necessary to feel or see a lump to have pre-cancerous conditions. There may be merely a slight thickening or firmness. If tissue is removed for analysis, it may show precursors to cancer or ‘pre-malignant disease’. Diagnoses such as ductal hyperplasia, intraductal papillomatosis or lobular carcinoma-in-situ are associated with increased chances of cancer. If a woman has had cancer in the opposite breast, there is an increased chance of developing cancer in the remaining breast.
The Genetic Marker There are several markers associated with an increased incidence of cancer. This is not a 100% correlation but indeed the presence of the gene marker does carry an increased risk. The cost of testing originally was two to four thousand dollars. For example, a woman without known additional risk factors, may have about a nine percent chance of cancer (about one in eleven will get cancer of the breast over their lifetime estimated at 80 plus years). As the risk factors compound, this percentage may ‘add up’ over one’s lifetime to a fifty to seventy-five percent chance of cancer.
Besides having a calculated increased chance of breast cancer, another reason for undergoing a reconstruction after subcutaneous mastectomy or skin sparing mastectomy as mentioned, is that doctors may be unable to adequately ‘follow’ breast masses. Cancer, in its early stages may be present, but undetected in the breast.
Other reasons to decide to go ahead with surgery is because of chronic pain, infections, or the need for repeated biopsies associated with deformity of the breast.
While this operation is controversial, only a few physicians would not recommend this operation for a woman whose mother and maternal grandmother had pre-menopausal carcinoma of the breast, and who has had one breast already removed for cancer of the breast or who has lumps in the opposite breast that are difficult to ‘follow’, or whose mammograms shows suspicious microcalcification. If a genetic marker is detected then indications for surgery are great.
Before going ahead with surgery, IT IS THE INDIVIDUAL’S JOB to have it perfectly clear why removal of breast tissue is indicated.
All risks and complications must be considered. This is an operation that has been done many times and successfully so. In most cases this type of surgery is done on breasts that are FREE of cancer or have MINIMAL OR NONINVASIVE cancer.
CIRCUMSTANCES THAT INCREASE THE RISK FOR BREAST CANCER
All percentages are estimates and may be revised from time to time
.Pre-menopausal breast cancer in % increase risk
..genetic cancer marker——————65-95%
..carcinoma in situ————————–25-50%
..cancer in one breast———————-20-25%
..other “pre-cancerous” conditions——-5-15%
IN THE EVENT A DECISION IS MADE TO GO AHEAD WITH SURGERY. . . . .
Information – Consultation
The Doctor will discuss with you the operative procedure, provide written information about the possible risks and complications of the operation, and the results that have been obtained, both good and bad. A physical exam is done. Dr Capuano can evaluate the tissues, previous scars if present, presence of significant masses, and so forth. Your family doctor is usually notified of your situation. If you should decide on surgery then correspondence with your family doctor along with your insurance carrier would be needed to indicate the reasons for surgery and the plans. Pre-certification will be needed in most cases. Many times weeks are needed to clear the procedure with insurance companies. Insurance companies, if presented a clear enough picture of the probability of developing cancer, do pre-certify and payment for the removal of the tissue and the reconstruction is available. If you are under the care of an oncologist or radiation therapist for treatment of prior breast cancer then the assistance of your oncologist or radiation therapist can be helpful.
Preparation for Surgery
Prior to surgery, we ask that you refrain from taking aspirin or products containing aspirin for at least two weeks before your surgery. Do not eat apples, as they contain an aspirin-like substance. Avoid omega fish oils as they have properties similar to aspirin. Avoid eating large amounts of garlic as it too thins the blood. Shower for three evenings including the night before surgery. Use Dial or Safeguard soap. Please do not apply lotions, creams or powders before surgery. Surgery usually requires admission to the hospital, usually on the morning of surgery. Before coming to the hospital, you should again shower with Dial or Safeguard soap (unless you are allergic to such soaps, in which case please ask the Doctor which soap to use). Also brush your teeth and use a mouth wash. Do not eat or drink anything after midnight for anesthesia safety reasons. In certain cases, the surgery can be accomplished as an out-patient surgery or an overnight stay. Usually at least an overnight stay is warranted if not a few days in the hospital.
You will be in the pre-anesthesia area Here you will be seen by the hospital staff, Doctor Capuano and the anesthesiologist. Doctor Capuano may outline the areas of incision. You will have an opportunity to ask questions before surgery. After your chart is checked medication to decrease nervousness is usually given.
The operation involves using incisions beneath the nipple and in the lower portions of the breast. The central part of the nipple which has milk ducts in it will usually be removed.
Blood is rarely if ever needed during the procedure. If there is a history of easy bleeding then donating your own blood prior to surgery may be considered.
The tissue removed is then sent to the pathologist for examination. If cancer should be detected (rare) then a decision has to be made about further surgery but usually nothing further needs be done. You must have confidence in Doctor Capuano that he will use his best judgment if such a rare situation should occur.
Rebuilding the Breast
The methods of rebuilding the breast are many. The current methods are described below.
SALINE OR SILICONE GEL IMPLANT: A saline or silicone gel prosthesis can be used for immediate reconstruction. This method can give a very acceptable final result. Sometimes no other surgery is necessary, however in some cases another operation is indicated to replace the prosthesis for a larger prosthesis. This is done as an out patient procedure.
TISSUE EXPANDER: A tissue expander is like a balloon made of SILICONE and is filled with sterile water. More sterile water may be added after the operation to make the balloon bigger. The expander will be replaced with a PROSTHESIS. This is done as an outpatient procedure.
EXPANDABLE PERMANENT PROSTHESIS: There are hopes that such prostheses will prevent the need for two or more surgery. However as with any prosthesis, leakage can occur and it would be necessary to replace it.
REPLACEMENT WITH SKIN AND FAT: Skin and fat from the abdomen can be used as replacement tissue. This can be carried out in several ways. If you have excessive skin of the abdominal area, you might be interested in such surgery. It is sometimes difficult to fashion both breasts from abdominal tissue however.
Which method will be used ? Doctor Capuano will need to evaluate and discuss the options that seem best. Factors such as previous operations, size requests and your tissue quality, among other factors, are considered. The amount of bleeding, condition of the skin, type of breast disease, presence of infected material, scars, and so forth, will influence decisions during the operation. Thus the final method of reconstruction is determined during the operation.
After surgery a bulky dressing in put in place. Tubes (drains) may or may not be present to drain fluid. They are usually in place for a day or two.
AFTER DISCHARGE FROM THE HOSPITAL OR THE AMBULATORY CENTER
You will be given medications for swelling, discomfort and to prevent infection. All medications should be taken as prescribed. If you have a problem with a medication, please call the office. “Black and blue”, swelling, localized areas of discomfort and temporary numbness are expected and usually take one to two weeks to resolve.
If you experience a sudden onset of discomfort and/or swelling, and/or fever and/or drainage, please call the office promptly. You should rest and relax at home following your surgery. Do not engage in any stressful activities. You should keep your elbows generally at your sides. If you are unsure of any activity, please call the office.
At the time of your first office visit, the dressing will be removed. You will be advised regarding wound care. Showers are usually permitted after a few days.
Sutures are removed during the first two weeks sometimes longer. Secondary surgery is needed in a number of cases. Most commonly such surgery is to replace the prosthesis or expander (balloon) and to adjust the size of the permanent silicone prosthesis. Revision of scars, release of “capsular contracture”, revision of nipples, changing the position of the nipples or other surgery may be beneficial.
COMPLICATIONS. . . . .
As with any surgery, complications can occur. While these complications can be significant they are usually minor. In the approximate order of frequency in which they occur, complications can include, but are not limited to, excessive black and blue, loss of small parts of the nipple or areola (the pigmented part around the nipple), Excessive scarring can occur but scars can be revised. “Rejection” of the prosthesis or tissue, incomplete ‘take’ of flap tissues, persistent pain, more time away from work than originally anticipated, the need for transfusions, problems with heart and or lungs, and so forth. While after surgery a complication free course is anticipated and hoped for, it unfortunately, can not be guaranteed.
SCARS are the most frequent complication (actually a natural consequence of surgery). Usually scars heal well. At first they may be red, spread, thick and even painful. Few remain that way. It does take time (months).
CAPSULAR CONTRACTURE: The breast becomes slightly to very firm around the silicone prosthesis. A capsule forms in each and every case where a prosthesis is implanted. Only time can tell how firm a capsule will be.
CAPSULAR CONTRACTURE – WHAT CAN BE DONE?: As we have noted,a capsule forms around the breast prosthesis. This happens in each and every case In some cases the capsule is thicker and/or firmer than in others. In some it is more bothersome than in others. There are several ways to try to remedy a firm capsule when medications fail. One way is to massage the area and gently squeeze the prosthesis. This causes softening of the capsule in many instances.
CAPSULAR FRACTURE: This is not done anymore. It is presented for historical interest only. Historically it was done by squeezing at the base of the capsule, pushing the prosthesis through the capsule and thus tearing open the capsule. This procedure was associated with problems. Since the capsules torn or burst open (somewhat like a grape being pushed out of its skin), there would be tearing of tissue. Upon tearing, bleeding would occur. Usually it was minimal, however there have been severe cases reported. In these cases the patient had to be taken to the operating room to control bleeding. The prosthesis could usually be put back in place after removal of the blood. END OF HISTORICAL COMMENT
OPEN CAPSULAR SURGERY: Surgery is usually done under a general anesthetic for comfort. Other methods such as sedation (sleepy-like state) can be used. Capsular surgery usually involves the original incisions so that no other scars are produced. The prosthesis is removed. The capsule is then opened surgically. The prosthesis is replaced and the wound closed.
We try to minimize hospital stays. Whenever out patient surgery is possible, it is used.
REMOVAL OF A PROSTHESIS: While this is rare, it has occurred. As a residual, the scars left from the original surgery will be present and permanent.
You should request surgery only if you are confident that the possible benefits of this procedure outweigh potential risks. No one can predict the exact outcome of surgery. While good results have been obtained in the past, no guarantee can be given.
TIME AWAY FROM WORK: The estimated time away from work is usually three weeks to six weeks and depends to a large extent upon the prompt healing of the wounds and the absence of complications.
It also depends on the nature of your job. Three to four weeks is needed before moderate activity can be resumed. Four to six weeks or more may be needed if heavy work must be done. Those individuals with jobs requiring extensive and/or repeated use of the arms may require more time away from work. Please discuss your job activities with the Doctor so you may obtain a better estimate of time away from work.
SUBCUTANEOUS MASTECTOMY requires understanding before surgery. If you have questions, you are encouraged to ask them. Do not request and consent to surgery unless you understand the benefits versus the risks of surgery.
This information is provided for your general information. How such information exactly applies to an individual would depend on a face to face history, examination, perhaps laboratory exams and individual treatment plan. Further, because of the nature of electronic media and information – there is no doctor-patient relationship but merely a general information display – THANK YOU.