Numerous studies have validated the use of partial mastectomy (lumpectomy) in the management of breast cancer, demonstrating five and ten-year survival statistics statistically similar to mastectomy. Coupling a desire for breast preservation with minimally-invasive breast biopsy techniques, and including oncoplastic resection and reconstruction principles, many patients are opting to pursue breast conserving surgery with postoperative radiation therapy. Appropriate candidates have smaller tumors and enough potential residual breast tissue to maintain a cosmetically acceptable result, and understand that adjuvant (or postoperative) radiation therapy is required. The use of neoadjuvant, or preoperative, chemotherapy to shrink larger tumors has allowed Dr. Ley to achieve very acceptable cosmetic results in patients motivated to preserve their breasts without compromising their survival odds.

Dr. Ley introduced sentinel lymph node biopsy for breast cancer to Mississippi in 1998 and has performed over two thousand such procedures. By participating in the University of Louisville Breast Sentinel Node Registry, Dr. Ley co-authored eight papers in peer-reviewed surgical journals about the technique (complete bibliography upon request). Using the injection of a radioisotope, Technetium-99 sulphur colloid, with less radiation exposure than a standard chest X-ray, the first lymph node draining the breast, or the one that is theoretically at highest risk for harboring microscopic metastatic disease, is identified through a small incision using the Neoprobe (TM) gamma counter device. This allows removal of only the nodes at risk for disease, and avoids a complete lymph node dissection in patients with negative sentinel nodes. The risk of lymphedema and nerve injury after a sentinel node biopsy is much lower, and the accuracy of the technique has been validated in literally hundreds of published reports. Many patients undergoing breast conserving surgery are able to undergo sentinel node biopsy via a transmammary technique and avoid a second incision in the axilla.

Combining the principles of oncologic breast resection and plastic surgical reconstruction, oncoplastic breast surgery allows for wide resection of breast tissue while maintaining/reconstructing a cosmetically acceptable breast mound in patients with tumors considered marginally appropriate for partial mastectomy by standard techniques. Donut mastopexy, bat-wing mastopexy, reduction mastopexy and crescent mastopexy are among the techniques that Dr. Ley employs.

For patients with symptomatic macromastia (large pendulous breasts causing back and neck pain) diagnosed with early breast cancer, combining a breast-conserving operation with a bilateral breast reduction is often a good choice. These patients must have preoperative breast MRI to rule out multicentric disease and still require postoperative external beam radiation therapy to the affected breast. Dr. Ley has been using this technique since 2001.

In patients with smaller tumors who desire mastectomy and have been biopsied with minimally-invasive techniques or with cosmeticallyacceptable open incisions, techniques to remove the breast and sentinel nodes while preserving the skin of the breast have been shown to be oncologically sound and provide superb cosmetic results. Often combined with the use of autogenous tissue flaps, tissue expanders and a new product called Alloderm, breast reconstruction with results comparable in size, shape and symmetry to the contralateral remaining breast can be obtained. Dr. Ley generally recommends against the use of bilateral latissimus flaps except in selected patients, due to issues with chronic pain and functional limitations. Free TRAM and DIEP flaps can be used, but have a higher incidence of fat necrosis, which produces a palpable mass that can be quite discomfiting to patients who have had breast cancer.

Sometimes a mastectomy cannot be avoided and it is important to perform the operation in such a manner as to prevent redundant skin or provide a satisfactory platform for immediate or delayed breast reconstruction. In patients not desirous of reconstruction, the use of local advancement flaps for skin closure can help avoid redundant tissue. Preservation of the inframammary fold and serratus fascia as well as the dermal perforators (blood vessels arising from the chest wall), is critically important in preparing the mastecomy patient for immediate reconstruction. The use of appropriate postoperative exercises to maintain range of motion of the shoulder, along with preservation of the median pectoral nerve to avoid pectoralis major muscular atrophy is important.In many cases, the most superior intercostobrachial nerves can be preserved to minimize the incidence of numbness and tingling in the upper inner arm, a postoperative problem that can be quite troubling. A rare complication of axillary surgery is post-mastectomy pain syndrome, which can be quite difficult to manage.