Breast Surgery

Our practice handles an extensive list of breast problems ranging from abnormalities on the breast skin to the most complex breast cancers. We are the specialists when it comes to breast masses, abnormalities on mammograms, breast ultrasounds, breast MRIs and many other conditions such as fibrocystic breast disease.

Nearly every person or family has been touched in some way by breast cancer. It is our goal to deliver you compassionate, patient-friendly care that is tailored to your needs. We are the physicians that coordinate the treatment for all breast cancers, from diagnosis to treatment plan and survivorship follow-up. Whether you feel a palpable mass during a breast self-exam or have an abnormality found by your primary care physician or gynecologist, we have the expertise to diagnose and treat all causes of breast masses.

Fibrocystic breast disease is a very common problem that is often difficult to distinguish from more serious breast conditions such as cancer. Often, at the time of the office visit, we are able to distinguish between benign and malignant conditions of the breast. Needle aspirations of cysts and core biopsies of solid lesions are often done on the same day as the office visit. We coordinate surgical treatment of even the most complicated breast cancers, using a multidisciplinary approach that involves medical oncologists, radiation oncologist, breast radiologists and plastic surgeons.

Our surgical services include:

  • Punch Biopsy
  • Fine-Needle Aspiration Biopsy
  • Core Needle Biopsy
  • EnCor Enspire® Vacuum-Assisted Breast Biopsy System
  • Incisional Biopsy
  • Excisional Biopsy
  • Partial Mastectomy (Lumpectomy)
  • Mastectomy
  • Breast Reconstruction Surgery
  • Sentinel Lymph Node Biopsy
  • Genetics Nurse Navigator Services

Causes, Risks & Prevention

Breast Cancer

Family History

The cause of breast cancer is multifactorial but there is one myth that needs to be dispensed immediately. Many patients believe that if there is no history of breast cancer in immediate family members, their risk of developing breast cancer is minimal. In fact, only about 10 to 15% of breast cancers have a primarily genetic etiology (cause). Over 85% of breast cancers occur in patients with no family history.

Genes

Most of the time, there are multiple factors that contribute to breast cancer. The most popular topic at present is the role of genes in breast cancer. The most common two genes are BRCA 1 and BRCA 2, both of which increase the risk of breast and ovarian cancers. The lifetime risk of breast cancer if a patient has one of these mutations can approach 85%. However, there are many other genes that also increase the risk of breast cancer, including PALB2, CHEK2, NF (for neurofibromatosis) and many others. When a patient meets criteria for genetic testing, the most common genes that increase the risk for breast cancer are routinely included in the screening.

Hormones

The next risk factor is hormonal. Estrogen definitively increases the risk of developing breast cancer, which is why men are not diagnosed with breast cancer as often as women. The topic of hormone replacement therapy in peri- and post-menopausal women is a discussion that is far too broad and complex to be addressed. Having extended years of uninterrupted menstrual cycles increases the risk of breast cancer. An example would be a patient who never has children and takes oral contraception for many years. This doesn’t cause cancer but can increase the risk.

Аge

Age plays a role in breast cancer, with the risk increasing as women age. However, breast cancer diagnosed during late teens and early twenties is fairly common, so any solid or suspicious lump in any age group should be biopsied.

Other Factors

Obesity is also an indirect risk factor, as it can lead to a higher level of circulating estrogen in the body. Radiation treatment to the chest for other conditions such as lymphoma, especially during the teen years, leads to a very high risk of breast cancer. The onset of menstrual cycles at an early age can slightly increase the risk of cancer. Smoking and regular alcohol consumption probably increase the risk slightly, as well.

There is no absolute way to prevent breast cancer, but there are ways to lower your risk:

  • Maintain a healthy weight with diet and exercise
  • Avoid smoking and daily alcohol consumption
  • Limit the period of time on hormone replacement therapy and use the lowest dose possible to alleviate menopausal symptoms
  • Get regular screening mammograms and annual physical exams by your physician

Despite the governmental task force recommendations, monthly self breast exams are very helpful in the early diagnosis of breast cancer. There are multiple other factors that play a role and multiple reliable websites and links will be provided on this site for more information.

Fibrocystic Breast Disease

For fibrocystic breast disease, there likely is a genetic component as it tends to happen to multiple generations of women in the same family. We do not have a specific cause and don’t yet have a good solution on how to prevent this problem. The symptoms of fibrocystic breast disease can range from pain only to cysts only, with every possible combination in between.

The biggest issue is differentiating cysts from serious masses such as cancer. Never assume that a breast mass is a cyst unless an ultrasound is completed to confirm the diagnosis. Many patients have a delay in diagnosis of their breasts cancers as they are confused with fibrocystic disease. Fibrocystic disease does not increase your risk of breast cancer but is most commonly confused with breast cancer. It is true that breast cancers are usually not painful and cysts are associated with pain, but this not always the case. Some cancers are painful and tender, and some cysts are not. Again, the importance of distinguishing between these two problems is paramount in the treatment of breast disease.

Detection, Tests & Imaging

Mammogram

Probably the most important lesson about breast evaluation is that imaging such as mammograms without a clinical breast exam by your physician is not a complete breast evaluation. There are cancers that only show up on mammography and some that only can be diagnosed by symptoms or on a breast exam by an experienced physician. Mammograms are the most important imaging technique for the breast. Most women have their first mammogram at age 40 and then annually. Some patients start their mammograms at an earlier age if they are at high risk of developing breast cancer. Most facilities now offer 3D mammograms or tomograms for their patients. Most insurances, including Medicare, cover the cost of a screening 3D mammograms but even if you insurance plan does not cover it, the additional $100 or so is money well spent. This imaging technique is more sensitive especially in patients that are younger with dense breast tissue.

Breast Ultrasound

A breast ultrasound is used for the evaluation of abnormalities found on mammograms and for palpable masses in the breast. It can be done at the imaging center where you had your mammogram but also can be done in our office.

Dr. Martin is the first and only physician in the Middle Georgia area who is accredited by the American Society of Breast Surgeons to perform breast ultrasound and breast ultrasound-guided biopsies.

Dr. Martin is the first and only physician in the Middle Georgia area who is accredited by the American Society of Breast Surgeons to perform breast ultrasound and ultrasound-guided breast biopsies. We have state-of-the-art ultrasound equipment from GE. One of our units is also portable, so it can be transported to the hospital or the operating room (OR) if it is needed for procedures at locations other than the office. Very often, physicians refer their patients to our practice knowing that they can have the ultrasound performed at the same time as the office visit, saving time and money.

Breast MRI

A breast MRI is also offered for the evaluation of breast lesions. Most commonly, an MRI is used in screening patients who are at a higher risk for breast cancer. We also use an MRI to evaluate patients who have been diagnosed with breast cancer in order to give a complete evaluation of both breasts and associated lymph nodes prior to a breast cancer operation.

Biopsy

If a needle biopsy is required for abnormalities seen only on mammograms, such as suspicious calcifications or a density that does not have a corresponding ultrasound abnormality, a stereotactic core needle biopsy can be done. This is done under local anesthesia by one of the breast radiologists, using a table, prone positioning and computer-guided needle biopsy system.

For most biopsies, the pathology report takes about two working days to complete. Ultrasound-guided needle biopsies are most commonly done in the office on the same day as your initial consultation if the approach is necessary for a diagnosis of a breast mass.

We also have extensive experience with the needle biopsy of lymph nodes and performing biopsies in the proximity of breast implants. We also routinely use clips for marking the site or mass in the breast, at the time of the biopsy. These clips are not felt during an exam, do not trigger metal detectors but can be seen in future mammograms and ultrasounds.

Physical Exam

All of these imaging modalities are great techniques but the physical exam of the breast is often the first and most important way to detect a breast mass. You should become adept at performing a breast self exam; there are many online resources that demonstrate proper techniques for a self examination.

The most important thing is to actually perform the exam, at least monthly. Many women think they are not capable of performing a good self exam, but don’t let that belief stop you. If you are menstruating, then the best time of the month to do your exam is the week after menstrual bleeding has stopped. If you have had a hysterectomy or are post menopausal, pick any day of the month and don’t miss your self exam on that day.

There is no blood test to detect breast cancer. PET scans and CT scans are not used as screening tools for breast cancer.

Treatment

In our practice we offer state-of-the-art, comprehensive and often multidisciplinary approaches to treat all breast diseases. We will begin with the most simple and least invasive, to the most complicated.

Punch Biopsy

For skin conditions, rashes and inflammation, a punch biopsy of the skin done under local anesthesia may be necessary to obtain a diagnosis so that effective treatment can be rendered. This procedure uses an injection of local anesthetic followed by a circular device, either 3 or 5 mm in size, that allows for a full-thickness biopsy of the skin and adjacent tissue.

Fine-Needle Aspiration Biopsy

For all types of cysts, enlarged breast ducts and small solid nodules, a procedure called a fine-needle aspiration can be performed with ultrasound guidance. This involves a small gauge needle that is introduced into the cyst or the area of concern after the injection of local anesthesia. Ultrasound allows for the precise placement of the needle tip in a cyst (for drainage) or directly into a small mass so that cells can be withdrawn for study by our pathologists. We can then determine if a mass or a complex cyst is suspicious or benign. This procedure is relatively painless and is usually done at the time of your office visit. This will expedite your treatment and often save you from a repeat visit to the office.

Core Needle Biopsy

For solid masses, whether they are benign or noncancerous in appearance or suspicious for cancer, we offer core needle biopsies done with ultrasound guidance. Using an injection of local anesthetic, a guide needle is inserted to the mass of concern and then an automated biopsy needle is inserted through the guide needle to perform the biopsy. When the biopsy needle is fired, it very rapidly punctures the mass and takes a core of tissue that is approximately the diameter of a small spaghetti noodle and about 2 cm in length. A slight pinch is felt during the biopsy but it is well tolerated by most patients.

We often take multiple cores, and you will notice the physician saving ultrasound images during the procedure to document the lesion of concern, the needle in the lesion and the appearance of the lesion after the biopsy. A clip is often placed in the area of the biopsy at the conclusion of the procedure, which indicates the area has been biopsied. It also allows for the identification of the site on a mammogram, if needed, and also allows for localization of the site should the area need to be removed surgically. This type of biopsy is also usually done on the day of your office visit, which means you can receive a pathology report within 2 to 3 days of the office visit.

EnCor Enspire® Vacuum-Assisted Breast Biopsy System

If your solid mass is the most common type of a benign lesion, called a fibroadenoma, we offer a technique to remove the mass with a vacuum- type needle and ultrasound guidance. This technology is offered by Bard and is called the EnCor Enspire vacuum-assisted breast biopsy system. We have performed more than 75 of these procedures in the last three years.

This system allows a benign mass to be completed removed through a needle hole in the skin rather than by a surgical incision. It is usually performed under local anesthesia in the office. The procedure takes only about 30 minutes. The masses are completely removed with the technique, and all of the tissue is collected in a specimen container to be evaluated by the pathologist. This ensures that the mass is truly benign and that the small amount of tissue around the mass that is removed is also benign. There is minimal damage to normal breast tissue and the cosmetic result is excellent.

We follow up on the site with ultrasounds and exams at 6 months and a year at no charge, to ensure no recurrence of the mass. You can actually observe the mass being removed on the ultrasound screen during the procedure, if you desire.

After the procedure, you can return to normal activities the next day. Bruising of the breast is common after the procedure but quickly heals with essentially no scarring. Please note that the only contraindication to this procedure is if the mass is in close proximity to the undersurface of the skin. There must be at least 3 to 4 mm of separation to allow for this approach.

Incisional and Excisional Biopsies

There are two types of breast biopsies done surgically in the operating room. One type is an incisional biopsy, where a portion of a mass or suspicious area is removed and submitted to our pathologists for a diagnosis. This technique is done in the operating room and can be done either under local anesthesia, sedation with local anesthesia or under general anesthesia. The area of concern is not completely removed.

An excisional biopsy is the more common approach where the lesion, mass or area of concern is completely removed. The entire mass or area is submitted to the pathology.

With both techniques, the breast tissue is closed so that the original shape and appearance of the breast is maintained after healing. The skin is usually closed with small absorbable sutures that do not need need to be removed. Most patients return to work the following day with no limitations. The pathology report is usually available in 2 to 3 business days.

Partial Mastectomy (Lumpectomy)

A more involved type of biopsy is a partial mastectomy, also called a lumpectomy. With this technique, your surgeon is purposefully removing a mass or area with a rim of normal breast tissue around the mass. This is to achieve a clear margin around the area and is the technique used for small intraductal cancers and invasive cancers.

If the area to be removed is palpable or can be felt by your doctor, then no localization procedure is needed. If the area of concern involves calcifications that are suspicious on a mammogram, then you may need a marking mammogram prior to the surgery. This is done immediately before the procedure in the mammography suite by the breast radiologist using a local anesthetic, mammogram guidance and a wire to mark the area. The wire is inserted through a needle, left in place in the breast and covered with a dressing. You are then taken to the operating room (OR) and the partial mastectomy (lumpectomy) is performed under anesthesia.

A similar technique is used for lesions or masses that can only be seen with an ultrasound. In this situation, immediately prior to the procedure, you will go to our office, where a similar type of needle is placed in the area of concern with the help of ultrasound guidance. Again, the needle is left in place and covered with a dressing and then you are taken to the OR for the surgical removal of the area under anesthesia. Surgical closure of the breast is again done with absorbable sutures to achieve a normal appearance to the breast after healing. Local anesthetic is also injected into the remaining breast tissue so that you will have minimal pain when awake from anesthesia.

Every patient is not a candidate for a partial mastectomy. If the procedure is recommended for cancer, a certain breast shape is required to heal correctly after a partial mastectomy when it is followed by radiation therapy. These techniques combined is what allows a breast conserving technique, such as a partial mastectomy or lumpectomy, to have the same cure rate as when the breast is removed completely (total mastectomy). Patient that have severe ptosis, droopiness of the breast, may be candidates for a combined procedure with a plastic surgeon. We refer to this technique as an oncoplastic technique, combining cancer surgery with plastic surgery. We essentially combine a breast lift/reduction procedure with a partial mastectomy. This allows you to have a more normal breast shape after the surgery and allows the cancer surgeon to be more aggressive when trying to obtain a clear margin.

Once healing occurs, usually in about 4 weeks, radiation can be given to the breast. This helps to prevent a swollen breast that can be reddened and firm after treatment, especially if the breast is very ptotic or droopy. Both sides are operated on, with insurance covering both sides. The side where the cancer is located, and where radiation is to be given, is reconstructed to be slightly larger to accommodate for the breast shrinkage that occurs with radiation therapy. The plastic surgeon is present simultaneously with us as part of our team-based approach. Patients that have opted for this approach are very pleased with their outcome. They keep their breasts and then enjoy a much more appealing shape of their breasts when healed.

Mastectomy

When a mastectomy, or complete removal of the breast, is required for cancer or other problems, breast tissue is removed from underneath the breast skin. The muscle remains in place. The old radical mastectomy, when the breast tissue, skin of the breast and the underlying muscle were all removed, is no longer performed.

We offer all types of mastectomies, including skin and nipple sparing techniques, when appropriate. Not all patients are good candidates for nipple-sparing techniques. The cancerous area must be at least two centimeters from the nipple and not have an extensive component of cancer nearby the breast ducts. Patients with large breasts typically are not good candidates for nipple sparing. However, plastic surgeons can work with patients to save the nipple even in large-breasted patients. This nipple sparing technique is often combined with immediate reconstruction techniques done at the same operation by the plastic surgeon. We will address this approach later in this section.

If the nipple and areolar cannot be spared, then a skin-sparing mastectomy will be performed. If no reconstruction is planned, then the excess breast skin is removed, so the patient will be smooth across the chest wall after closure. If reconstruction is planned, whether delayed or immediate, a majority of the breast skin will be saved for the reconstruction process. There are even certain situations where the breast can be removed through a circular incision around the areola only, and a new nipple is created from the skin of a flap brought from another site on the body, such as the back or abdomen. Most of the time, with mastectomies, radiation therapy can be skipped, unless the chest wall muscle, breast skin or multiple lymph nodes are involved with cancer.

Breast Reconstruction Surgery

Breast reconstruction techniques are numerous and can be fairly straightforward or can be very complex. These will be discussed from the least invasive to the most invasive.

Sometimes, when a partial mastectomy is performed, the patient may have a small breast or the tissue removed leaves a significant defect in the breast. The breast tissue can be rearranged during the closure so the breast maintains its normal shape. This requires the reshaping of the breast tissue and skin only.

When a total mastectomy is performed, one of the most common techniques is to use a tissue expander that is placed under the muscle of the chest wall and remaining breast skin by the plastic surgeon. This expander is then inflated until the pocket where it is located reaches the desired size. This can take from four weeks to 3 to 4 months, depending on the size of the pocket and type of expander used. The plastic surgeon then exchanges the expander for an implant. Most plastic surgeons now prefer silicone implants for their texture and more normal feel. They are often referred to as gummy bear implants because if they are damaged or rupture, the material from which they are constructed retains it shape because of the gel material. This is safer and there is no silicone leakage from a ruptured implant.

Once the implant is in place, you can be as extravagant with nipple reconstruction as you desire. We offer 3D nipple tattoos and even reconstruction of the nipple projection with skin, if desired. More advanced flap techniques can be used to reconstruct the breast. Skin and muscle can be harvested from the back, and brought around to reconstruct the breast. This is called an LD, or latissimus dorsi, flap. It is often combined with an implant to achieve a good breast shape. Skin and muscle can also be harvested from the lower abdomen combining an abdominoplasty or tummy tuck with breast reconstruction. This is called a TRAM flap and leaves the blood vessel to the muscle intact to provide blood to the skin and muscle of the flap. This is a much more involved procedure, requiring hours of surgery and a prolonged recovery, usually 6 to 8 weeks or more. This type of flap can also be done as a free flap, where the blood vessel to the flap is divided and then reattached to a blood vessel under the arm to provide the blood flow to the flap. This is called a DIEP flap, or a deep inferior epigastric perforator flap. These techniques often lead to the best overall result but require longer surgical procedures and longer recoveries. Please refer to our colleagues’ website at Renaissance Plastic Surgery, located here in Macon, for more information on these techniques.

Sentinel Lymph Node Biopsy

Most breast cancer operations require the evaluation of lymph nodes in order to check if cancer has spread to the nodes that drain the breast. Sentinel node biopsy is now the gold standard for the evaluation of lymph nodes in breast cancer surgery. The skin is injected with either a radioactive isotope in a small amount of injectable fluid or a blue dye called lymphazurin blue. This injection is made into the skin and dermis and not into the breast tissue itself. The breast skin lymphatics mirror the lymphatics of the breast tissue, but are much larger and more numerous. After being injected into the skin near the cancer, the dye, or isotope, then travels to the nearby lymph node or nodes where it collects. The surgeon can see the blue dye in the node or can identify the concentration of radioactive fluid in the node with a handheld Geiger counter in the operating room. Most of the time, there are 1 to 4 sentinel nodes, but there may be more. It is very rare for this technique not to identify a sentinel node or nodes. Our surgeons primarily use the radioactive isotope technique. Dr. Martin started this technique at Coliseum Medical Centers back in the 1990s, introducing the technique for use by other surgeons at the hospital. We have performed well over a thousand sentinel lymph node biopsies in our practice. This allows for removal of fewer nodes for evaluation and significantly reduces the risk of lymphedema, or swelling of the arm, after breast surgery.

In almost all cases of cancer, the diagnosis is made with a needle biopsy prior to surgery. This allows for the treatment decisions to be made for each patient tailored to their specific cancer. We are treating more patients with chemotherapy prior to surgery now more than ever. This allows us to evaluate the response of the cancer to the treatment prior to performing any surgery.

Recovery

For most biopsies, whether done with a needle or in the operating room, most patients can return to work and normal activity the following day. For more extensive procedures, such as a partial mastectomy or a sentinel node biopsy, return to work will be around 7 to 10 days postoperatively. For the most extensive procedures such as mastectomies and reconstructive procedures, the recovery can take weeks and even months. Recovery time will vary with each patient.

It is important to know that in most biopsy procedures on the breast where tissue is removed, it is very common to develop a ridge or a mass in the area of the biopsy. This is actually called a healing ridge and usually resolves completely at three months. It is a good idea to bring a comfortable bra with you to the hospital if you are having a breast surgery. You can wear the bra for support and compression, which will help to alleviate postoperative discomfort.

For the more comprehensive procedures such as mastectomies, the nurse navigators will see you prior to discharge and fit you with a post-mastectomy bra that has soft prosthetics to give a shape under your clothing and pockets for your drains, if they are placed at the time of your surgery. The piece of tape or strips that are placed on your breast incisions can be removed 4 or 5 days postoperatively unless you are otherwise instructed by the doctor or the nursing staff. You will also be instructed on care of the drains prior to discharge. If you taking a blood thinning medication that was paused prior to your surgery, this medication can usually be resumed on the day following your surgery. You should receive specific instructions about your medications prior to discharge. You will also be instructed by the physicians, nurse practitioner or nurse navigators as to activity, hygiene, wound care and follow-up visits.

Accreditations and Expertise

National Accreditation Program for Breast Centers

We are accredited by the National Accreditation Program for Breast Centers (NABPC), which is overseen by the American College of Surgeons. This accreditation requires centers to maintain a group of standards that help to deliver the best care to patients with breast diseases. We are held to a high standard and are evaluated in three-year cycles to make sure these standards are met by all of the physicians that participate. We encourage all of our patients to visit the NAPBC website to see how this program elevates the quality of care delivered to our patients.

ACR Breast Ultrasound Accreditation

Dr. Martin is one of only eleven breast surgeons in the state of Georgia who holds the Breast Ultrasound Accreditation obtained from the American College of Radiology (ACR). The ACR sets national quality standards for patient care, and Dr. Martin has earned this prestigious award for ensuring clinical image quality and patient safety.

Our Breast Care Team

Treatment of breast cancer is very complicated and is continuously changing. Our surgeons and breast care team work diligently to stay up-to-date with all treatments available. We also are routinely assisted by nurse navigators at our Coliseum Breast Health Center at Coliseum Medical Centers. These nurses deliver patient education and counseling in one-on-one sessions with the patient and their families. Many patients feel that this relationship with the nurse navigators is critical to their journey through their treatment for breast cancer. The nurses are there for every step of the treatment process, participate in the multidisciplinary conferences where we discuss patient care, and communicate regularly with the treating physicians regarding their patients’ care. They are a vital part of the care team.

Another critical piece of the treatment team is the genetics nurse navigator who, in our program, is a nurse practitioner with years of oncology nursing experience. She also meets with patients one-on-one and with family members to take extensive family histories, review pathology reports and understand personal history in order to determine if genetic testing is necessary. Our genetics nurse navigator can also tabulate a risk assessment to determine your lifetime risk of breast cancer. If that risk is over 20% lifetime risk of developing breast cancer, you will be entered into our high-risk breast cancer screening program. This includes visits with our surgeons twice a year for physical exams as well as alternating 3D mammograms with a breast MRI, annually. These imaging techniques are staggered so that they are done six months apart. If your risk is high enough, you may also see a medical oncologist for risk-reduction strategies. This approach allows us to, in most cases, detect a breast cancer in a very early stage, should it develop. The risk-reduction strategies may even help to prevent the development of breast cancer. The genetics nurse navigator will also educate patients that have a gene mutation that might increase their risk for cancer. We screen every patient that has a mammogram at our center with a questionnaire about their family history, which could trigger the need for genetic testing.

Lastly, the cases of all of our patients who are diagnosed with cancer are presented at our multidisciplinary breast conference that is held every other Tuesday. This meeting is attended by cancer surgeons, plastic surgeons, radiologists, pathologists, medical oncologists, radiation oncologist, nurse navigators, the genetics nurse practitioner and others that participate in our breast care team. Each patient’s case is presented and then a consensus opinion is developed regarding the patient’s care plan. This allows a team approach to your care, offered at no cost to you. It is likely that all of your treating physicians will be present at this conference.