43 Care of the breast surgical patient

Breast cancer, the most common cancer in women,¹ is a malignant tumor that develops from cells of the breast. Although breast cancer in men is rare, it does occur. With the newer forms of treatment of cancer of the breast, including improved forms of diagnosis, surgical procedures on the breast have increased. However, with earlier breast cancer diagnosis and with the advent of enhanced radiation and chemotherapy protocols, surgical procedures performed on the breast might not be as extensive as in years past. All women are at risk for breast cancer. The two most significant risk factors are female gender and older age.² Ninety-five percent of new cases and 97% of breast cancer deaths occurred in women older than 40 years.² Risk of breast cancer also increases if the woman’s mother, sister, or daughter has had the disease. Breast surgery is most commonly performed on women; however, procedures are occasionally performed on men and children. In addition, nondisease breast procedures may be performed for cosmetic purposes. Breast cancer is the second leading cause of death for women after lung cancer.¹ The chances of a woman having breast cancer are one in eight. Chances of dying from breast cancer are approximately 1 in 33. Breast cancer is the most common cause of cancer in African American women and the second leading cause of death in African American women, exceeded only by lung cancer. Approximately 1 in 100 men is expected to develop breast cancer in a lifetime. As the patient’s advocate, the perianesthesia nurse must be supportive, caring, and reassuring to the patient having breast surgery. Positive support is the start of the patient’s rehabilitation process. Early detections, self examination, mammography, and an increased public awareness are all important factors in decreasing annual breast cancer mortality.² Breast cancer treatment today involves a combination of therapies, including surgical excision of the tumor, radiation therapy alone, or a combination of surgery, radiation and chemotherapy. New studies and treatment protocols are continuously being developed and subjected to trials, but early detection remains the best hope for cure.

Surgical interventions and perianesthesia nursing care

Breast biopsy

Breast cancer is often first suspected when a lump is felt or an abnormal area is found on mammogram results. Lumps in the breast often are discovered during monthly self examination or with routine mammograms, breast ultrasound scans, or magnetic resonance imaging. A biopsy is done when the results of these other tests suggest breast cancer. The biopsy is the only way to know for certain. The lumps or masses are aspirated or excised and sent for definitive diagnoses.

For many of the female patients who undergo a biopsy, the diagnosis is fibrocystic disease. Fibrocystic disease describes a variety of benign and localized tumors or swelling within the breast tissues, including cysts, masses, and intraductal papillomas. Other nonfibrocystic conditions also may cause breast lumps. Inflammatory conditions, such as breast abscesses, fat necrosis, and lipomas of the skin (e.g., sebaceous cysts), can cause breast lumps.

A breast biopsy can be a one-step (biopsy and mastectomy, if needed) or two-step procedure. Two-step procedures are the most common practice. The two-step procedure allows the patient to be educated about the choices and given the opportunity to make an informed decision regarding the type of surgery to be performed in the event of a positive biopsy finding. The short delay between the biopsy and further treatment has not been shown to affect survival rates. If more extensive surgery is planned in the event of a positive biopsy result, the patient must have given preoperative informed consent for the definitive surgical procedure.

The patient is usually admitted as a same-day surgery patient. The patient may undergo needle biopsy, incisional biopsy, or excisional biopsy. A needle biopsy includes the introduction of a disposable cutting-type needle through the mass to entrap a core of tissue. The needle is withdrawn, and the specimen is sent to the pathology laboratory. In an incisional biopsy, a portion of the mass is surgically excised along a curved incision line. An excisional biopsy may be needed to remove the entire mass and some of the adjacent tissue around it for examination. A stereotactic procedure may be performed in which the patient lies face down on a special table. The breast protrudes through a hole in the table and is lightly compressed while the computer provides detailed diagnostic images. The biopsy area is located and a probe is inserted to remove the tissue specimens (Fig. 43-1).

FIG. 43-1 A, In stereotactic procedures, patients lie facedown on a special table. The woman’s breast protrudes through a hole in the table’s surface, where it is lightly compressed and immobilized while a computer produces detailed images of the abnormality. B, When the biopsy area has been located and mapped, the Mammotome probe is inserted through a ¼-inch incision in the breast, where it gently vacuums, cuts, and removes breast tissue samples. C, The incision is then closed with a small adhesive bandage.

(From Rothrock J: Alexander’s care of the patient in surgery, ed 14, St. Louis, 2011, Mosby.)

Because of the patient’s natural apprehension, the patient may receive intravenous moderate sedation along with local anesthesia. Monitored anesthesia care may also be indicated. If the patient meets phase I discharge criteria while still in the operating suite, the patient may bypass the phase I postanesthesia care unit (PACU). Otherwise, the patient is usually awake on arrival in the PACU but drowsy because of the sedation. Routine admission procedures are accomplished. The head of the bed may be elevated 45 degrees.

The dressing is usually a 4 × 4 sponge held in place with the patient’s bra. It should be inspected for excessive drainage, which occurs only rarely. The patient can resume fluid and food intake as soon as the cough and gag reflexes have fully returned and nausea has subsided. Pain should be minimal, if any, and easily controlled with minor analgesics.

If midazolam has been administered, the patient may repeatedly ask the same questions. The perianesthesia nurse must patiently repeat the answers and also ensure that the person who accompanies the patient at discharge understands the home care instructions.

Surgical choices for the treatment of cancer

Most women need some type of surgery to treat the breast tumor and remove as much of the cancer as possible. Surgical treatment choice depends on the stage of the disease, the size and site of the mass, and the patient’s individual choice. Advances in early diagnosis and modifications in surgical techniques have increased the number of surgical choices in the treatment of breast cancer (Fig. 43-2). Surgical treatment may range from breast-conserving techniques (lumpectomy) to modified radical mastectomy that involves the breast and the axillary nodes.

FIG. 43-2 Surgical choices for treatment of breast cancer.

(Redrawn from Ignatavicius DD, Workman ML: Medical-surgical nursing: critical thinking for collaborative care, ed 6, Philadelphia, 2010, Saunders.)

Lumpectomy

Lumpectomy, also called breast-conserving therapy, is the surgical treatment of choice when the breast tumor is well defined and less than 5 cm in diameter. In landmark clinical trials reported in 1988, the National Surgical Adjuvant Breast Cancer Project reported that lumpectomy followed by radiation therapy produced 8-year disease-free survival rates equal to those of modified radical mastectomy.³

Lumpectomy is usually performed with general anesthesia. Only the breast tumor and a margin of 1 to 1.5mm of surrounding normal tissue are removed. Surgery may also be done to determine whether the cancer has spread to the lymph nodes. Lumpectomy with subsequent radiation therapy is frequently the treatment of choice for small tumors.

Sentinel lymph node biopsy

A sentinel lymph node biopsy may be done to visually examine the lymph nodes without having to remove them first. Sentinel node biopsy was developed to reduce the morbidity associated with surgical staging of the axilla in patients with no palpable axillary nodes.³ A blue dye alone or in combination with a radiolabeled colloid dye is injected near the tumor and is carried by the lymph system to the first (sentinel) node to receive lymph from the tumor. This lymph node is most likely to contain cancer cells if the cancer has spread. The sentinel node is not located in the same site in every patient. When this node is found, it is removed and examined. If it is free of cancer, further surgery may not be needed. If there is evidence of positive nodes and axillary node dissection and adjunct therapy may be required. It is done through a separate incision and involves a sample of 10 to 15 lymph nodes lateral and inferior to the pectoralis minor muscles for pathology. Removal and examination of the nodes allows for staging of the cancer and helps the patient and provider to choose adjuvant therapy and treatment options. A possible side effect from the removal of the lymph nodes is lymphedema or swelling of the arm (seen in 1 to 3 of 10 women; Box 43-1).

BOX 43-1 Lymphedema

Lymphedema may occur after breast surgery because of a build-up of fluid. This swelling often worsens the physical and emotional strain for patients as they deal with their diagnosis of breast cancer. Women who have multiple lymph nodes removed are more likely to develop lymphedema. Symptoms include swelling of the affected arm or upper chest, a heavy sensation in the arm, discomfort in the arm, difficulty moving the arm, stiffness, weakness, and numbness. Women with lymphedema should be instructed to avoid trauma or injury to the affected arm; avoid blood draws, intravenous catheters, and blood pressure monitoring in the affected arm; practice careful skin and nail hygiene to prevent infection; avoid heavy lifting; and avoid extreme temperature changes. Elevation of the arm and compression garments can help to promote lymph drainage. There is no cure for lymphedema, and the goal is to control the swelling and relieve the symptoms.

Clinical trials are underway to study the effectiveness of new treatments and therapies to reduce the incidence of lymphedema after breast cancer surgery. One current trial (CA:GB 70305) is investigating whether a combination of education, use of light arm weights with exercise, a light compression sleeve with vigorous activity, and regular breathing exercises can reduce the risk or severity of lymphedema after axillary lymph node dissection (www.cancer.gov/clinicaltrials/CALGB-70305).

Modified from Mohler III ER, Mondry TE: Patient information: lymphedema after breast cancer surgery, available at http://www.uptodate.com/contents/patient-information-lymphedema-after-breast-cancer-surgery?source=search_ result&search=lymphedema&selectedTitle=5∼109. Accessed December 11, 2011.

Patient complications from sentinel lymph node biopsy may include allergic reactions to the dye. Use of the dye in patients with known sensitivity is contraindicated and perianesthesia nurses should be alert for any signs of anaphylaxis.

When the patient is admitted to the PACU, all the initial assessment measures should be performed. The blood pressure cuff should be placed on the arm opposite the operative side. The arm on the operative side should be elevated on a pillow because the removal of lymph nodes increases the risk of lymphedema. The operative-side arm should be assessed frequently for circulatory adequacy with monitoring of color, temperature, capillary refill, and the presence and strength of the radial pulse. Venipunctures and injections should not be performed on the operative-side arm. Sentinel node biopsy is usually an outpatient procedure that allows rapid return to full mobility and permits return to work weeks sooner than after axillary dissection.³ Dressings should be small, and bleeding or drainage should be minimal. A Hemovac or Jackson-Pratt closed-drainage system may be connected to drains placed at the incision site, but with a sentinel node biopsy are seldom required.

Nursing personnel should be aware that although this procedure allows the patient to keep the breast, it does not eliminate fear of the cancer diagnosis or concerns about whether the procedure was successful; therefore the nurse must provide factual reassurance and support.

Mastectomy

Partial (segmental) mastectomy

The partial mastectomy involves the removal of more of the breast tissue than in the lumpectomy and is usually followed by radiation therapy. Some surgeons refer now to lumpectomy or partial mastectomy as a wide local excision.³

Simple mastectomy

The simple mastectomy is the removal of the entire breast, but not the lymph nodes under the arm. Both breasts may be removed if the patient is at an increased risk for breast cancer. Most patients go home the next day.

Modified radical mastectomy

The modified radical mastectomy is the most commonly performed surgery for elimination of breast cancer. The entire involved breast and axillary, pectoral, and superior apical nodes are removed. The underlying pectoral muscles are not removed. The modified radical mastectomy is performed with hopes of decreasing the chance of the malignancy spreading.

Radical mastectomy

The radical mastectomy is rarely performed in the United States, because the modified radical mastectomy has been found to be just as effective for the patient and less disfiguring, with fewer side effects. The radical mastectomy involves the extensive removal of the entire breast, lymph nodes, and chest wall muscles under the breast. Refined techniques for diagnosis and surgery, radiation therapy, and chemotherapy have made it unnecessary in most instances.

Mastectomy is performed with general anesthesia. The patient is admitted to the Phase I PACU, with the head of the bed elevated 30 to 45 degrees. Admission assessments are performed per PACU protocol. Dressings may be bulky and should be checked frequently for excessive serosanguineous drainage and for constriction. Patients should be observed closely for signs of postoperative hematoma below the skin flaps. Attention to the drains and the maintenance of free drainage within the vacuum system prevent this potential complication. Drains are usually placed under the skin flaps to remove excess blood and serum that ordinarily collect under the wound site, thus causing edema, infection, and sloughing of the skin graft (Fig. 43-3).⁴ The drains may be connected to Hemovac or Jackson-Pratt devices or some other closed suction device. Generally, additional vacuum is needed the first 8 postoperative hours, and the Hemovac is connected to vacuum pressure of 20 to 30 mm Hg. These drains should be monitored for excessive bleeding, which must be reported to the surgeon. Dressings are necessarily snug, but should not impair respiration or circulation to the upper extremity. The arm on the operative side should be supported and elevated on a pillow; it must be checked frequently for cyanosis or pallor, and the pulse must be palpated for intensity. If signs of respiratory distress or impaired circulation arise, the surgeon should be notified to rearrange the dressing.

FIG. 43-3 Closed incision with closed wound drainage system in place.

Patients usually need intravenous fluid augmentation for the first 24 postoperative hours. Oral feeding is allowed after cough and gag reflexes have returned and if nausea is not present. Small sips of fluids may be offered and taken as desired, and diet resumed as tolerated. Postoperative pain can be moderate to severe and can usually be controlled with opioids such as meperidine and morphine. The incidence of persistent postsurgical pain in patients who received breast surgery has been identified as much as 65%.⁵ With the increased preoperative use of paravertebral nerve blocks for breast surgery patients, pain management has been greatly enhanced, resulting in less need for opioids and improved patient satisfaction.⁶ Hypothermia may be a problem because of prolonged exposure in the operating room, and rewarming should be accomplished with additional warmed blankets or a forced warm air device. Postoperative instructions for patients who have axillary node dissections should include hand and arm care instructions. Consistent education and support are necessary. Emotional support may be sought through support groups such as the Reach to Recovery program (American Cancer Society: web site, www.cancer.org/; or telephone, 800-ACS-2345).

Evidence-Based Practice

Thoracic paravertebral block (PVB) in breast surgery can provide regional anesthesia during and after surgery with the potential advantage of decreasing postoperative pain. In this study Boughey and colleagues report their institutional experience with PVB over the initial 8 months of use in their ambulatory care center. They reviewed 213 patients undergoing breast operations. Comparison was performed between a group of 178 patients who received PVB and the control group of 135 patients who did not. Pain scores were assessed immediately postoperatively, 4 hours postoperatively, 8 hours postoperatively, and again the morning after surgery. Immediately after surgery there was a statistically significant difference in the number of patients reporting pain between PVB patients and those without PVB. At all time points up until the morning after surgery, PVB patients were significantly less likely to report pain than controls. PVB in breast surgical patients provided improved postoperative pain control. Pain relief was improved immediately postoperatively, and this effect continued to the next day after surgery. PVB significantly decreased the proportion of patients who required overnight hospitalization after major breast operations and therefore may decrease cost associated with breast surgery.

Implications for practice

Paravertebral block greatly improves the quality of recovery and pain relief after breast cancer surgery. Most patients receiving a PVB have less postoperative pain, nausea, and vomiting. Perianesthesia nurses should be aware that these patients will have reduced opioid requirements and tolerate early ambulation or mobilization. Patients should be monitored for hypotension and signs and symptoms of pneumothorax.

Source: Boughey JC, et al: Improved postoperative pain control using thoracic paravertebral block for breast operations, Breast J 15(5):483-488, 2009.

Breast reconstruction

The loss of a breast from cancer can be devastating to women, and the changes in body image may be difficult to manage. One of the advances made in breast surgery during recent years is the availability of effective means of reconstructing the breast after removal for cancer. Breast reconstruction can be accomplished in conjunction with mastectomy or at a later time, depending on each patient’s individual decision and preference and the need for chemotherapy or radiation.

Breast reconstruction may be performed in a variety of methods in which the surgeon, in collaboration with a plastic surgeon, tailors the operation to the patient’s individual irregularity. Reconstructive options can be divided into two main types: those that use autogenous tissue and those that require alloplastic material.³ Breast reconstruction can be performed with three different techniques: available tissue with an implant, the use of tissue expanders, and the use of flaps. Use of the available tissue is the simplest procedure, but often sufficient tissue is not available after mastectomy. If enough tissue is available, an appropriately sized implant is placed under the remaining skin flap or muscle. The other breast may have its size adjusted with either a reduction mammoplasty or a mastopexy to achieve symmetry if necessary and the patient desires to do so. Autogenous methods of reconstruction give the best symmetry.³

Mastectomy can leave a shortage of enough skin tissue to create a breast mound. For these patients, a breast reconstruction technique with available tissue and implants is used to stretch the normal tissue to create extra tissue. A pocket is made under the remaining tissues into which a soft silicone bag is made to simulate the natural contour. The pocket can be made at the time of surgery or before the surgery with an inflatable tissue expander. The expander method requires the administration of several injections of gradually increasing volumes of saline solution over a period of weeks. When the desired amount of stretch has been reached, the temporary tissue expander is removed and replaced with a permanent breast implant.

Myocutaneous flap reconstruction (Figs. 43-4 and 43-5) involves moving nearby muscle and skin into the area of the mastectomy to replace the significant tissue deficiency after mastectomy. Commonly used muscle and skin flaps include the latissimus dorsi and rectus abdominis muscles with attached skin. Nipple-areola reconstruction can be accomplished with small portions of the labia and grafting to the selected location or areola reconstruction with tattooed pigment.³ Postoperative care is generally the same as for the patient who undergoes other types of breast surgery, with attention to graft and flap donor sites (see Chapter 44).

FIG. 43-4 Appearance of patient after healing from bilateral mastectomies for cancer.

FIG. 43-5 Appearance of same patient in Fig. 43-4 after muscle-skin flap (latissimus) and nipple reconstructions. Patient has gained considerable weight, and later she delivered a healthy baby. She is free of disease 6 years after the mastectomy.

These operations have provided a measure of comfort to patients whose body image has been significantly disrupted by mastectomy. Patients report return of a sense of femininity and confidence. Many women do not choose to undergo additional surgery after mastectomy, but knowledge that the operation is available is reassuring.

Mastopexy (breast lift)

Breast ptosis (sagging) is defined by the position of the nipple areolar complex related to the inframammary crease. The reshaping process differs from reduction mammoplasty in the amount of tissue removed. There is usually minimal to no removal of breast tissue with use of a breast implant when needed.⁷ Generally less than 300 g of tissue removed is considered a mastopexy procedure (Figs. 43-6 and 43-7).

FIG. 43-6 Mastopexy (breast lift). Before surgery, this patient had sagging (ptosis) of the breasts.

FIG. 43-7 Mastopexy, showing same patient in Fig. 43-6 several weeks after surgery. Scars are beginning to fade.

Mastopexy is commonly performed as a same-day procedure, and postoperative care after mastopexy is generally not demanding. General anesthesia is most commonly used, and only minor adjustments in breast tissue are made.

The patient is positioned on the back after surgery and may assume a semi-Fowler to high-Fowler position for comfort as soon as she awakens. The motion of the arms is restricted to below shoulder level.

Postoperative dressings are minimal, and drains are rarely necessary because the entire procedure, with the exception of nipple release, is at the level of the dermis. Drainage should be minimal, and if frank bleeding occurs, the surgeon should be notified. Pain is usually not a problem, and discomfort can be controlled with mild analgesics. Food and fluids may be resumed as tolerated after nausea has disappeared.

Augmentation mammoplasty

Breast augmentation is done for hypomastia, to correct breast asymmetry, to recreate the breast after mastectomy, or for the patient’s desired enhancement of breast size (Figs. 43-8 and 43-9).⁷ Incisions may be inframammary, axillary, or semicircular around the lower half of the areolar outline. The inframammary approach is the simplest, but the axillary incision provides the least visible scar after surgery. Breast implants can be placed beneath the mammary tissue or under the muscle layer of the chest. Many surgeons believe that positioning the implants beneath the muscle provides the patient with the most natural appearance. Breast augmentation can also be accomplished endoscopically with transluminal breast augmentation in which a small incision is made inside the navel. These patients have self-adhesive wound strips over the umbilical incision and are fitted with an elastic bandage.

FIG. 43-8 Appearance of patient before breast augmentation.

FIG. 43-9 Postoperative appearance of patient after breast augmentation with silicone bag prostheses.

Breast augmentation patients usually receive general anesthesia, but local anesthesia with sedation is a viable consideration. The patients may have compression dressings in place on admission to the PACU, but some physicians have a brassiere placed on the patient immediately after surgery. The patients usually go home the same day and see the physician in the office the following day to change the dressing. Incisional drains are rarely used with breast augmentation. Patients may need aggressive pain management in the initial phase I PACU, but generally can be comfortable with the use of oral analgesics. Patients should be encouraged to gently move their arms to prevent stiffness and discomfort.

Reduction mammoplasty

Reduction mammoplasty is the surgical method to correct gigantomastia or macromastia in which patients have back pain, breast pain, postural changes, or shoulder strap discomfort from the weight of the breasts.⁷ These women may also have an inability to participate in physical activities such as jogging, aerobics, and horseback riding. Breast reduction is performed with general anesthesia. Breast tissue and skin are excised; the nipple areolar complex is elevated superiorly on the new breast mound. Reduction mammoplasty is a lengthy procedure in which significant fluid and blood loss is anticipated. Because of the prolonged anesthesia and surgery time, some providers use a team approach to reduce the surgical time. Some patients donate autologous blood before this surgery, but all patients should have a blood type and screen before surgery. Frequently, intravenous crystalloids are all that is necessary for fluid replacement.

A newer method in reduction mammoplasty is the laser deepithelialization technique. When the carbon dioxide laser is used to remove the epidermis from the inferior pedicle, reduction mammoplasty can be performed with little blood loss. The inferior pedicle technique is a commonly used approach to reduction mammoplasty. When the inferior pedicle technique is used, the laser simplifies skin removal. The laser is preferred for pedicle deepithelialization in all patients, especially patients who have large ptotic breasts, because rigid stabilization is not necessary.

On admission to the PACU, the patient is positioned on the back; as soon as the condition warrants, the patient is placed in a low Fowler position. Dressings may be of any variety, but most often wide strips of Elastoplast, which readily conforms to the patient’s new skin contours, are used. A Velpeau bandage should be in place to restrain the patient from raising the arms, and the patient should be advised of this. Drains are rarely necessary, and drainage should be minimal. If drains are present, they should be connected to a vacuum source, such as the Hemovac. Because of the length of the surgery and the fluid volume loss, special attention should be paid to urine output, pulse rate, and blood pressure. Rewarming may be necessary to prevent or reduce hypothermia. Initially, parenteral opioids may be needed after surgery, followed by oral analgesics. Light ice packs may be used to relieve discomfort and minimize tissue swelling. Most patients spend one night in the hospital after surgery. As after mastectomy, the patient should be advised to not do anything that puts strain on the pectoral girdle.

Surgery in gynecomastia

Gynecomastia, or benign hypertrophy of one or both breasts in boys and men, is relatively common (Fig. 43-10). The condition may be bilateral or unilateral. The causes may be hormonal, systemic disease-oriented, drug-related, or idiopathic.

FIG. 43-10 A, Preoperative view of gynecomastia. B, Postoperative view after excision of gynecomastia.

(From Rothrock J: Alexander’s care of the patient in surgery, ed 14, St. Louis, 2011, Mosby.)

In extreme instances or in cases in which gynecomastia causes problems in psychological adjustment, this excess tissue can be excised or removed with suction lipectomy. Suction lipectomy is useful when the gynecomastia is caused primarily by fat. Optimal cosmetic results can be obtained. The surgical procedure is similar to that of breast reduction in women. A periareolar incision is made, and tissue is removed. Suction drainage of the incision site is usually necessary and may be conveniently accomplished with a Hemovac or other closed drain system.

Postoperative care is essentially the same as that for women who undergo breast surgery. If no drains are necessary, the patient can be discharged the day of surgery after reflexes have returned, nausea has subsided, and food and fluids can be taken.