Breast surgery

Anatomy or system affected: Breasts, glands

Definition: Procedures performed on the breast to diagnose or treat benign and malignant breast disease or for reconstructive and cosmetic purposes

Indications and Procedures

The indications for breast surgery can be grouped into benign disease, malignant disease, reconstructive purposes, and cosmetic purposes. Indications for breast surgery in benign disease include persistent breast cysts which are not responsive to aspiration, such as in fibrocystic breast disease. In women who have a solid breast mass, excision of the lump to determine whether it is cancerous would be another indication for breast surgery. In this situation, the breast surgery would be diagnostic as well as potentially curative (for example, if the mass is benign). Another indication for breast surgery would be a breast abscess refractory to drainage; in this situation, excision of the abscess would offer the best chance of a cure. Breast surgery may also be for cosmetic reasons.

Breast cancer is another indication for breast surgery. The surgery is usually performed after a clinical breast examination, mammogram, and biopsy have confirmed the malignancy. The extent of disease and its aggressiveness determine to a large extent the type of breast surgery performed. In early-stage breast cancer, a modified radical mastectomy may be performed. This involves the removal of the entire breast and the axillary lymph nodes. Alternatively, a lumpectomy with axillary node dissection (followed by radiation therapy) may be performed. Which procedure a patient receives also depends on the tumor size, tumor location, and the patient’s breast size.

When a breast is completely removed, the patient may opt for reconstructive surgery. One common type of reconstructive surgery involves fashioning a new breast using a saline implant and a piece of the rectus abdominis muscle (a muscle on the anterior abdominal wall) called a transverse rectus abdominis myocutaneous (TRAM) flap. The areola may be reconstructed using a darker piece of skin taken from another part of the body, and tattooing may also be performed to give the nipple a more natural appearance.

Cosmetic breast surgery is indicated in cases where the patient is not satisfied with the appearance or size of her breasts. Most commonly, this cosmetic surgery takes the form of breast augmentation, breast reduction, or a breast lift. In breast augmentation, implants, usually made of saline, are introduced under or over the pectoralis major muscle that lies underneath the existing breast. This is accomplished through an incision under the armpit, from the underside of the breast, or in the margin around the areola. The procedure may be done under local anesthesia as an outpatient procedure or under general anesthesia. The latter option is generally used when the implants are placed underneath the pectoralis muscle.

Breast reduction surgery, also called reduction mammoplasty, can be indicated when the patient suffers from back, shoulder, or neck pain from large breasts. It is also indicated when the patient is not satisfied with the appearance of her breasts. A patient with large breasts often suffers from ptosis or drooping of the breasts (which can also occur with aging or pregnancy and lactation). Reductive mammoplasty will correct the ptosis as well as reduce the overall size of the breasts. Commonly, tissue is removed from the most dependent (lowest) portion of the breast using vertical incisions, preserving the nipple and the underlying structures (nerves and lactic ducts). After the excess breast tissue is removed, the incision is then closed, with care taken for optimal cosmetic appearance. The breasts are wrapped in bandages to support the tissue while they heal. General anesthesia is almost always used, and blood loss can be greater than for breast augmentation. Drains may be placed temporarily in the breasts to prevent infection and the buildup of fluid. The patient is usually hospitalized for several days. Overnight hospitalization is rarely necessary.

Uses and Complications

The uses of breast surgery include the diagnosis and treatment of benign and malignant breast disease, reconstruction after trauma or mastectomy, and the alteration of breast size and appearance for cosmetic or functional purposes.

Potential complications of all breast surgery include infection, scarring, and bleeding. Infections are infrequent but must be treated aggressively with antibiotics when they occur. If a prosthesis is involved, then it may be removed and reinserted three to six months later. Scarring is of concern because breast surgery is often undertaken for cosmetic or aesthetic reasons. The placement of incisions along skin folds and careful skin closure help to minimize scarring. Restricting immediate postoperative activities, especially those that require stretching, also reduces scarring. As with all surgical procedures, bleeding is a risk of breast surgery. Blood loss from breast surgery can be minimized with careful inspection prior to closing incisions and the cauterization of any bleeding areas.

Although most patients who receive breast augmentation maintain normal breast function and can breastfeed after the surgery, many patients who have undergone breast reduction have difficulty with lactation. In addition, a larger number of women who have undergone breast reduction report loss of sensation than do women who have undergone breast augmentation. Also, scarring in women who have undergone breast reduction tends to be more extensive than in women who have undergone breast augmentation.

When implants are used, complications such as contracture and leakage may occur. Contracture occurs when the tissue immediately surrounding the prosthesis scars and shrinks, leading to an unnatural breast appearance. In rare cases, saline implants may leak. In the past, implants filled with silicone leaked, and a number of patients claimed that these leaks led to a number of medical problems. This issue, called Breast Implant Illness, led women to experience fatigue, joint pain, and mental fogginess. Although the connection between silicone leakage and medical disease remains controversial, the legal climate led to the withdrawal of silicone breast implants in North America until 2006, when the US Food and Drug Administration began approving them for use in women aged twenty-two years or older, though saline remained the overwhelmingly popular choice.

Perspective and Prospects

The number of breast surgeries performed in the United States continues to rise. In particular, cosmetic breast augmentation was the most frequently performed cosmetic surgical procedure between 2006 and 2010. According to the American Society of Plastic Surgeons, 296,203 augmentation mammoplasties were performed in the United States in 2010, and the total number of women with implants in the United States is in the millions. Although in the 2020s, rhinoplasty replaced breast augmentation as the most popular cosmetic procedure, approximately 300,000 women continued to undergo the surgery. As the number of women who have had breast augmentation grows, healthcare providers will probably deal more with the problems particular to breast implants, such as the increased difficulty in detecting breast masses and breast cancers.

Bibliography

American Society of Plastic Surgeons. American Society of Plastic Surgeons Report of the 2010 Plastic Surgery Statistics. [N. p.]: ASPS National Clearinghouse of Plastic Surgery Procedural Statistics, 2011.

Berger, Karen, and John Bostwick III. A Woman’s Decision: Breast Care, Treatment, and Reconstruction. 3th. ed. St. Louis, Mo.: Quality Medical Publishing, 2011.

Bostwick, John, III. Plastic and Reconstructive Breast Surgery. 2d ed. St. Louis, Mo.: Quality Medical Publishing, 2000.

“Breast Implant Illness (BII): What It Is, Symptoms & Treatment.” Cleveland Clinic, 28 June 2022, my.clevelandclinic.org/health/diseases/23366-breast-implant-illness. Accessed 26 July 2023.

“Do Women With Breast Implants Have a Higher Risk of Cancer?” University of Utah Health, 30 May 2019, healthcare.utah.edu/the-scope/health-library/all/2019/05/do-women-breast-implants-have-higher-risk-of-cancer. Accessed 26 July 2023.

Doherty, Gerard M., and Lawrence W. Way, eds. Current Surgical Diagnosis and Treatment. 13th ed. New York: Lange Medical Books/McGraw-Hill, 2010.

Georgiade, Nicholas G., Gregory S. Georgiade, and Ronald Riefkohl, eds. Aesthetic Surgery of the Breast. Philadelphia: W. B. Saunders, 1990.

Guthrie, Randolph, and Doug Podolsky. The Truth About Breast Implants. New York: John Wiley & Sons, 1994.

Health Library. "Mastectomy." Health Library, October 31, 2012.

Stewart, Mary White. Silicone Spills: Breast Implants on Trial. Westport, Conn.: Praeger, 1998.

Tanne, Janice Hopkins. "FDA Approves Silicone Breast Implants 14 Years after Their Withdrawal." British Medical Journal333, no. 7579 (December, 2006): 1139.