From Diagnosis to Recovery: Navigating Breast Cancer Surgery in Singapore.

1. Breast Surgery Therapy (BCT): Breast Conserving Surgery (BCS) and Oncoplastic Breast Conserving Surgery (oBCS), with Radiotherapy (RT)

Often referred to as a lumpectomy or wide local excision, Breast conserving surgery (BCS) removes the tumour along with a margin of surrounding tissue while preserving most of the breast. It is suitable for early-stage breast cancer with favourable tumour-to-breast ratios. Absolute contraindications to BCS and oBCS include:

• The tumour-to-breast ratio does not allow negative margins with a cosmetically acceptable outcome.
• Inflammatory breast cancer;
• Diffuse suspicious or malignant microcalcifications;
• Absolute contraindications to radiotherapy.
  
  

Oncoplastic breast conserving surgery (oBCS) combines tumour removal with reconstructive methods to maintain natural shape and symmetry. Standard BCS can sometimes lead to breast distortion, volume loss, and asymmetry, especially with larger cancers. Oncoplastic techniques allow larger and more complex tumours to be treated conservatively with better cosmetic outcomes. The surgeon may also be able to achieve wider resection margins, better maintain or even improve breast shape. These techniques may involve breast remodelling, lifts, reductions, or tissue flaps.

• Strategic incision placement (e.g. hidden or aesthetic scars)
• Volume displacement (reshaping remaining breast tissue)
• Volume replacement (using local tissue flaps to replace lost tissue)
• Symmetrisation: Symmetry procedures on the opposite breast when appropriate
  
  

Breast conserving therapy (BCT) refers to the combination therapy of Breast conserving surgery (BCS) followed by radiotherapy (RT). 

Why is radiotherapy essential?

• Treats microscopic residual cancer cells in the breast;

• Reduces local recurrence by ~50–70%;

• Converts breast conserving surgery into at least a curative equivalent of mastectomy in appropriately selected patients.
  
  

Outcomes for BCT are favourable in well-selected cases:

• At least equivalent long-term survival to mastectomy when combined with radiotherapy (i.e. BCT). More recent population studies indicate a possibility of superior survival outcomes.
  Preservation of body image and breast sensation (to varying degrees)
  
  
• Generally, a less extensive surgery than a mastectomy with quicker overall physical recovery and long-term form preservation.

2. Mastectomy

A mastectomy is a surgical removal of the whole breast. The surgical removal of one breast is termed a single or unilateral mastectomy; the removal of both breasts is termed a double or bilateral mastectomy. Mastectomies are performed to treat breast cancers and very large non-cancerous tumours (therapeutic) or recommended as an option for lowering the risk of breast cancer for individuals at high risk for the disease (prophylactic).  Your surgeon evaluates your cancer biology, location, breast morphology (shape and size), and your overall body proportions in order to decide on the most suitable surgical option. 

A mastectomy may be recommended for several reasons:

• Extent of disease: Mastectomies are strongly recommended when a patient’s disease is large or widespread, such that a sizable extent of resection is required, when it is determined that breast-conserving surgery (BCS) or oncoplastic breast-conserving surgery (oBCS) is not feasible because all techniques have been considered and exhausted, and they will not provide a satisfactory cosmetic outcome. Mastectomies are also recommended for inflammatory breast cancer. These recommendations are not made lightly. All factors are carefully considered before our patients are advised that their best oncological and aesthetic option will be a mastectomy. 
  
  
• Contraindications to radiotherapy (RT): Mastectomies are at times the best recommendation for patients who cannot undergo radiotherapy (RT), which is often required alongside BCS. RT is contraindicated when there has been previous moderate- to high-dose radiotherapy to the breast or chest wall (including mantle radiation for Hodgkin’s disease), at the time of pregnancy, and in patients with active connective tissue disease such as scleroderma or systemic lupus erythematosus.
  
  
• Increased risk of developing cancer: Bilateral mastectomy is an effective risk-reduction strategy for individuals recognised to have an elevated lifetime risk of breast cancer. This includes carriers of high-risk familial cancer genes.
  
  
• Personal choice: For personal reasons, some patients who are eligible for BCS or oBCS still choose mastectomy as their preferred surgical treatment.
  
  

Types of approaches that may be considered include: 

• Nipple-sparing mastectomy: Preserves the nipple–areola complex and breast skin, and the breast tissue beneath the nipple is removed.
  
  
• Areolar-sparing mastectomy: Preserves the areola and breast skin, breast tissue and the affected nipple are removed.
  
  
• Skin-sparing mastectomy: Removes breast tissue and affected nipple–areola complex but preserves most of the breast skin.
  
  
• Simple mastectomy (also known as Total mastectomy or Modified Radical Mastectomy): Removal of all breast tissue, including nipple and areola.

Nipple-sparing Mastectomy

Minimally invasive nipple-sparing mastectomy (NSM) is a “keyhole” surgical technique that allows an aesthetic placement of smaller, less conspicuous incisions, with the intention of close-to-ideal breast restoration. Minimally invasive NSM involves discrete “off the breast” incisions in the underarm (axilla) or bra line (inframammary fold). These incisions are usually small (2 to 4 cm in length). Incisions are planned to be smaller or longer, depending on the size of the opening required for mastectomy specimen extraction. The mastectomy specimen is deliberately kept intact and whole, as opposed to sliced up, shredded, or morcellated, for accurate specimen assessment and to avoid dissemination of cancer cells. 

They are typically planned for an “aesthetically scarless” result with immediate breast reconstruction. The breast resection is performed as a single-incision, single-port, minimally invasive procedure. In an endoscopic mastectomy, your surgeon utilises a digital endoscope which has a long fibre optic cable system with a video camera and light attached. It functions within the air-insufflated surgical space alongside fine surgical instruments to display the operative field with optimal clarity, enabling your surgeon to precisely visualise remove breast and cancerous tissue during surgery. In addition to the aesthetic benefit of concealing surgical scars, smaller ‘off-the-breast’ incisions also result in less pain, minimal operative scarring and decreased nipple, skin, and wound complications. 

Patients with minimal breast tissue can opt for this when they have no intention to undergo breast reconstruction; however, it is more commonly performed alongside breast reconstruction via specialised minimal-access techniques. With a specialised surgical team, your choice of reconstruction should not be limited, and all viable options remain as long as the decision is medically sound. 

3. Reconstruction Options – Partial or Whole Breast

Patients undergoing mastectomy most often have the option to undergo immediate or delayed full breast reconstruction. Some patients choose to omit breast reconstruction for personal reasons. Surgical strategies include implant-based options and autologous options that utilise one’s own body’s skin, fat, and blood vessels to recreate the breasts as a pedicled or free-flap procedure.

Lymph Node Surgery: Understanding Its Importance

Lymph nodes are small bean-shaped glands that are found throughout the body, including the axilla within the underarm/armpit axillary fat pad. Lymph nodes filter substances that travel through the lymphatic fluid, and they contain lymphocytes (white blood cells) that help the body fight infection and disease. This also means they can filter and trap debris such as cancer cells. In the event of breast cancer spread, the most typical and earliest site of involvement is lymph nodes in the axilla (underarm), around the clavicular (collarbone), or internal mammary region (behind the breastbone at the front centre of the chest). Identifying cancer involvement within the lymph nodes will assist in determining one’s breast cancer stage, which also allows us to estimate the risk of future cancer recurrence. 

Sentinel Lymph Node Biopsy (SLNB)

A sentinel lymph node biopsy is a minor surgical procedure involving the identification of the first few draining axillary lymph nodes of the breasts, termed ‘sentinel nodes’. As the first few lymph nodes are most likely to be affected by cancer, if any, if results are clear, further removal may not be necessary. During surgery, sentinel lymph nodes are identified,  excised and sent for immediate intraoperative microscopic examination (frozen section) by a pathologist while patients remain under general anaesthesia, to see if cancer cells are present in the lymph nodes. If cancer cells are found in the sentinel lymph node, a complete Axillary Lymph Node Dissection (ALND) may be required. When required, the ALND is most often performed immediately during the same surgery.

Targeted axillary dissection (TAD)

Among patients shown to be node positive prior to preoperative systemic therapy, SLNB alone has a reported >10% false-negative rate when performed after preoperative systemic therapy. This false negative rate can be improved by marking and removing the most suspicious or biopsied positive nodes, using dual tracers, and by obtaining ≥3 sentinel nodes. This process describes a targeted axillary dissection (TAD), which is recommended in patients with node-positive breast cancer who clinically and radiologically responded to preoperative (neoadjuvant) chemotherapy. 

The prior proven metastatic axillary lymph node should have ideally been marked with a clip or localiser prior to neoadjuvant chemotherapy to ensure accurate detection. During surgery, the aim is to resect any proven metastatic axillary lymph node together with a sentinel lymph node dissection (SLNB). Targeted lymph nodes and sentinel lymph nodes are sent for immediate microscopic examination (frozen section) by a pathologist while you remain under general anaesthesia. 

If cancer cells are found in the targeted or sentinel lymph node(s), a complete ALND is immediately performed. If your surgeon is unable to conclusively locate all suspicious lymph nodes from a TAD/SLNB, a complete ALND is instead performed for oncological safety. You may be recommended further adjuvant therapy, such as radiotherapy.

Axillary Lymph Node Dissection (ALND) / Axillary Clearance (AC)

Recommended for patients with extensive lymph node involvement. While more extensive, it is crucial for accurate staging and treatment planning.

An axillary lymph node dissection (ALND), also known as axillary clearance (AC), describes the removal of all the lymph nodes and soft (fatty) tissue within the boundaries of the axilla, with preservation of large vessels and important nerves when they are not directly affected by cancer. In an ALND, your surgeon will perform a level I and level II dissection, which is a lymph node dissection that includes tissue inferior to the axillary vein, from the latissimus dorsi muscle laterally to the medial border of the pectoralis minor muscle. Level III dissection to the thoracic inlet is performed only in cases with gross disease in level II and/or III. After the operation, the lymph nodes contained within this fat will be identified and checked under a microscope for cancer cells by a pathologist.

What to Expect on the Day of Breast Cancer Surgery

Surgery involves several coordinated steps to ensure patient comfort and optimal outcomes:

Before Surgery

• Pre-operative evaluation
  
  
• Imaging review
  
  
• Anaesthesia planning
  
  
• Marking of surgical sites
  
  

During Surgery

• Removal of the tumour or breast tissue
  
  
• Lymph node evaluation
  
  
• Reconstruction if applicable
  
  

After Surgery

• Wound care
  
  
• Drain management (if used)
  
  
• Pain management
  
  
• Follow-up for pathology results
  
  

Patients are encouraged to move their arms early to minimise stiffness and support recovery.

Recovery After Breast Cancer Surgery

Recovery varies depending on the type of procedure performed. Generally, patients can expect:

• A gradual return to daily activities
  
  
• Minor discomfort or tightness for several days
  
  
• Restrictions on heavy lifting temporarily
  
  
• Follow-up visits to monitor healing and review histopathological results.
  
  

If additional treatment such as chemotherapy, radiation, or hormone therapy is required, the care team will coordinate timing to ensure safe progression.

Emotional and Practical Support

A breast cancer diagnosis affects more than physical health. Having a clear care pathway, a supportive medical team, and access to counselling or support groups can ease emotional strain. Many patients find reassurance in:

• Clear explanations from their care provider
  
  
• Understanding treatment options
  
  
• Thorough physical and emotional preparation for surgery and recovery
  
  
• Connecting with others who have similar experiences
  
  

Practical guidance on wound care, exercise, and lifestyle adjustments also plays an important role in long-term well-being.

Why an Experienced Breast Surgeon Matters

Choosing a surgeon with specialised training is essential, especially when dealing with complex diagnoses such as breast cancer with tumours requiring precise excision. An experienced breast surgeon helps ensure:

• Accurate diagnosis
  
  
• You are presented with the full range of options
  
  
• Safe and effective surgical planning
  
  
• Minimal disruption to healthy tissue
  
  
• Preservation of breast appearance whenever possible
  
  
• Integration of reconstructive options
  
  
• Compassionate, patient-centred care that puts you at ease
  
  

A specialist also provides continuity throughout treatment, from initial evaluation to long-term follow-up.

Screening Remains the First Line of Defence