breast treatment and pronostic

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VSPACE="0"><IMG SRC="14fb4240.gif" border=0 width="180" height="292" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="150b4060.gif" border=0 width="180" height="262" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="151b4080.gif" border=0 width="180" height="264" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="152b4220.gif" border=0 width="180" height="290" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="1539abc0.gif" border=0 width="154" height="188" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="15496b60.gif" border=0 width="150" height="182" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="155988f0.gif" border=0 width="152" height="143" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="15697b90.gif" border=0 width="151" height="185" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="1d1d9960.jpg" border=0 width="217" height="150" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="1d4b5900.gif" border=0 width="181" height="144" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="1d5b6900.gif" border=0 width="182" height="144" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="1002" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP BGCOLOR=#000000 HEIGHT= 365 WIDTH="998"><bR> <bR> <bR> <div> <B>Breast augmentation is usually done to balance a difference in breast size, to improve body contour, or as a reconstructive technique following surgery. </B></div> <bR> <bR> <bR> <div> <B>Incisions are made to keep scars as inconspicuous as possible, in the breast crease, around the nipple, or in the armpit. Breast tissue and skin is lifted to create a pocket for each implant. </B></div> <bR> <bR> <bR> <div> <B>The breast implant may be inserted directly under breast tissue or beneath the chest wall muscle. </B></div> <bR> <bR> <bR> <div> <B>After surgery, breasts appear fuller and more natural in tone and contour. Scars will fade with time. </B></div> </tD> </tR> </TABLE></div> <bR> <bR> <div> ===========================================================================================================================</div> <div> A mastectomy is a surgical procedure that consists of removing a malignant tumor from the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>.</div> <div>  The following are different types of interventions: </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Excisionnal biopsy:</B> This procedure removes a small part of the tumor to confirm the diagnosis. This helps plan future treatments. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Segmentectomy</B> (a partial mastectomy - tumorectomy): This procedure consists of removing a portion of the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>. The tumor with normal tissues around it and part of the axillary lymph nodes are removed. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Modified Radical Mastectomy:</B> The whole <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>, including the nipple, the skin around the nipple, and axillary lymph nodes are removed. </div> <div> <I>What Is Axillary Dissection?</I></div> <div> The surgeon removes some lymph nodes. This helps decide your possible treatment after <FONT SIZE="3" COLOR="#800000" FACE="Arial" >surgery</FONT>.</div> <div> After <FONT SIZE="3" COLOR="#800000" FACE="Arial" >surgery</FONT>, temporary sensations may occur on the inside part of your arm on the operated side. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">You may feel numbness, tickling, burning or weakness. These feelings will disappear within 6 months to one year after the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >surgery</FONT>. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Permanent diminished sensation will be felt near the operated area since nerves were affected during the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >surgery</FONT>. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Presence of edema (or swelling) on the arm of the operated side may occur. This swelling is due to an altered clearance of tissue fluids caused by the removal of the axillary lymph nodes. This swelling usually disappears. If the swelling persists, your physician may recommend that you wear a more elasticized brassiere. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Occasionally, fluid may collect near the incision. This happens about 20% of the time and is easily resolved. Should this become uncomfortable, the physician may remove the liquid at the clinic. </div> <div> Please advise your physician of any redness, heat or swelling of the incision.</div> <div> Special Care</div> <div> Special care should be given to your hand and arm on the operated side after a mastectomy: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Avoid: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">injuries; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">strong detergents; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">tight clothing. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Treat all infections as soon as possible. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Apply a moisturizing cream to the incision. </div> <bR> <div> <TABLE BORDER="2" CELLPADDING="2" CELLSPACING="1" WIDTH="880" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" BGCOLOR=#00FFFF > <tR> <tD VALIGN=TOP HEIGHT= 5134 WIDTH="868"><div> The goal of any <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> cancer treatment is to achieve effective local-regional control of the tumor in order to maximize the chance for cure. With the advent of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> sparing procedures, an equally important goal is to attain a good cosmetic result.</div> <div> <B>LCIS</B> </div> <div> <B>Treatment</B> is close follow-up including routine <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> examination and an annual mammogram. In years past, the treatment was bilateral mastectomies, which we now know is a rather drastic treatment to prevent the development of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> cancer rather than treating the actual cancer. </div> <div> <B>DCIS</B> </div> <div> <B>Treatment</B> of is one of the most controversial subjects in the surgical literature. In the past, mastectomy was considered appropriate treatment for all patients with DCIS. It was often found to be a mass on a mammography. Currently, a mastectomy or removal of the entire <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> may still be indicated for some women with DCIS, in particular those with multicentric disease. However, many women can preserve their <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> by undergoing a limited <FONT SIZE="3" COLOR="#800000" FACE="Arial" >surgery</FONT> known as  <A NAME="lumpect"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>lumpectomy</B><I>.</I> </div> <div> <B>Lumpectomy </B><FONT SIZE="3" COLOR="#800000" FACE="Arial" >surgery</FONT> involves removing the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> tissue which contains the carcinoma in situ and a surrounding margin of normal or uninvolved <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> tissue. This is accomplished through a small surgical incision about two inches in length. The contour of the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> is usually unchanged. Local radiation to the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> is given postoperatively in order to reduce the possibility of disease recurring in the same <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>. This is given for a total of six weeks - 5 days a week. </div> <div> With extremely small cancers, there may be a role for lumpectomy alone. There is not enough data available to support not giving radiation therapy on a routine bases. </div> <div> In DCIS, the axillary lymph nodes are not routinely removed. The reason for this is that less than 1% of patients with DCIS have spread of disease to the lymph nodes at the time of their original diagnosis. </div> <div> <B>Treatment Options for Invasive </B><FONT SIZE="4" COLOR="#800000" FACE="Arial" ><B>Breast</B></FONT><B> Cancer</B></div> <div> Regardless of the specific type of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> cancer, the treatment approach is generally the same. </div> <div> <B>Simple Mastectomy</B></div> <div> The entire <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>, including the nipple and areala is removed.</div> <div> <B>Modified Radical Mastectomy</B></div> <div> This involves removal of the entire <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> and two levels of lymph nodes under the arm. The chest wall muscles remain intact and the arm on the affected side functions normally. </div> <bR> <div> <B>Breast</B><FONT SIZE="3" COLOR="#008080" FACE="Arial" ><B> Reconstruction</B></FONT></div> <div> Reconstruction of the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> either by the use of an implant or the use of one's own muscle and skin known as a myocutaneous flap, can be performed at the time of mastectomy of at a later date. </div> <div> Breast<FONT SIZE="3" COLOR="#000000" FACE="Arial" > Conservation Therapy</FONT></div> <div> The term <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Breast</FONT> Conservation Therapy refers to the three components of treatment </div> <div> <B>Removal of the tumor</B> </div> <div> Tumor removal<B> </B>with a margin of normal <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> tissue. In situ disease, the incision is relatively small, about 2 inches and a normal appearing <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> is maintained. </div> <div> <B>Removal of the auxiliary lymph nodes</B> </div> <div> This can be achieved through a small, separate incision in the crease of the armpit. The purpose of the axially node dissection is to determine whether there are tumor cells in the lymph node. This finding would alter both the staging of the disease and subsequent treatment. </div> <bR> <bR> <div> <B>Radiation Therapy</B> </div> <div> This is an xray treatment to the remaining <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> tissue. It is not painful nor does cause nausea or hair loss. The rationale is to sterilize any remaining microscopic tumor cells. The recurrence rate for <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Breast</FONT> Conservation Therapy (BCT) is known to be somewhat higher than that for mastectomies however, extensive studies have shown that the long term survival rates for these two approaches are equivalent despite differences in local recurrence rates</div> <bR> <div> Treatment of <FONT SIZE="4" COLOR="#800000" FACE="Arial" >breast</FONT> cancer during pregnancy</div> <div> Management of the pregnant patient with <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> cancer is complex but can be accomplished safely using a multidisciplinary team approach. Generally the rule is to treat the cancer and allow the pregnancy to proceed to term, but there are occasional exceptions. Radiation therapy is not feasible because of excessive exposure to the developing fetus; hence the generally accepted treatment is modified radical mastectomy. Staging studies are performed very selectively or deferred until after delivery. The decision to use chemotherapy must be made after weighing all factors.</div> <bR> <div> Pregnancy and lactation after treatment for <FONT SIZE="4" COLOR="#800000" FACE="Arial" >breast</FONT> cancer</div> <div> Patients who are clinically free of disease are not adversely affected by pregnancy. Current recommendations are to allow pregnancy to proceed if a woman becomes pregnant after successful treatment of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> cancer. </div> <bR> <bR> <bR> <bR> <bR> <div>  <A NAME="1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B>BREAST</B></FONT><B> RECONSTRUCTION</B></div> <div> Reconstruction of a <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> that has been removed due to cancer or other disease is one of the most rewarding surgical <FONT SIZE="3" COLOR="#800000" FACE="Arial" >procedures</FONT> available today. New medical techniques and devices have made it possible to create a <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> that can come close and form and appearance to matching a natural <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>. <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Breast</FONT> reconstruction may be performed immediately following <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> removal (mastectomy) or a patient may postpone reconstruction to have a period of emotional readjustment. Ideally, a <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> surgeon and a plastic surgeon can work together to develop a strategy that would be the best option for each individual patient. It is important to begin thinking about reconstruction as soon as the patient is diagnosed with cancer. In many cases, a reconstructed <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> has superior esthetic appearance to some recently developed <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> conserving therapies. Post mastectomy reconstruction can improve your appearance and renew your self- confidence, and in most cases health insurance policies will cover the cost of reconstruction. </div> <div> Breast<FONT SIZE="3" COLOR="#000000" FACE="Arial" > reconstruction usually involves more than one operation. The first stage of reconstruction, creation of the </FONT>breast<FONT SIZE="3" COLOR="#000000" FACE="Arial" > mound, is almost always performed using a general anesthesia. Follow up </FONT>procedures<FONT SIZE="3" COLOR="#000000" FACE="Arial" > may require only a local anesthetic and be performed in our office setting. </FONT></div> <div> There are many options available in post mastectomy reconstruction. </div> <div>  <A NAME="2"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>SKIN EXPANSION</B> </div> <div> The most common technique combines skin expansion and the subsequent insertion of an implant. Following mastectomy, the surgeon will insert a balloon expander beneath the skin and chest muscle. Through a tiny valve mechanism buried beneath the skin, saline solution will be injected to gradually fill the expander over several weeks. After the skin over the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> area has stretched enough, the expander will be removed and a second operation, a more permanent implant, will be inserted. The nipple and areola were reconstructed in a subsequent procedure. Some patients do not require preliminary tissue expansion and an implant may be inserted as the first step. </div> <div>  <A NAME="3"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>FLAP RECONSTRUCTION</B></div> <div> An alternative approach to implant reconstruction involves creation of a skin flap using tissue taken from other parts of the body, such as the back or abdomen. The flap, consisting of skin, fat, and muscle with its blood supply, are transferred to the chest, creating a pocket for an implant or in some cases creating the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> mound itself without the need for an implant. In flap reconstruction, the recovery will take longer and there are additional scars. However, the results are generally more natural and there are no concerns about an implant. In some cases, the patient may have the added benefit of an improved abdominal contour. </div> <div>  <A NAME="4"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>FOLLOW UP </B><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B>PROCEDURES</B></FONT> </div> <div> In addition to follow up <FONT SIZE="3" COLOR="#800000" FACE="Arial" >surgery</FONT> on the reconstructed <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>, including replacement of a tissue expander with an implant, or to reconstruct the nipple and areola, an additional operation may be needed to enlarge, reduce, or lift the opposite <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> to match the reconstructed <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>. </div> <div> For most mastectomy patients, <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> reconstruction dramatically improves their appearance and quality of life following the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >surgery</FONT>. </div> <div>  <A NAME="5"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B>BREAST</B></FONT><B> REDUCTION</B> </div> <div> Breast<FONT SIZE="3" COLOR="#000000" FACE="Arial" > reduction represents one of the clearest examples of the interface between reconstructive and aesthetic plastic </FONT>surgery<FONT SIZE="3" COLOR="#000000" FACE="Arial" >. In time, overlarge sagging </FONT>breast<FONT SIZE="3" COLOR="#000000" FACE="Arial" >s can interfere with normal functioning and physical activity. They often cause back pain, problems with posture, deformities of the back and shoulders, skin rashes and </FONT>breast<FONT SIZE="3" COLOR="#000000" FACE="Arial" > pain. Bra straps may leave indentations in the shoulders. That is why </FONT>breast<FONT SIZE="3" COLOR="#000000" FACE="Arial" > reduction </FONT>surgery<FONT SIZE="3" COLOR="#000000" FACE="Arial" > is normally classified as a reconstructive procedure and may be covered by insurance. </FONT></div> <div> The procedure removes fat, glandular tissue,and skin from the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>s, making them smaller, lighter and firmer. It can also reduce the size of the areola, the darker skin surrounding the nipple. The goal is to give the woman smaller, better shaped <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>s in proportion with of the rest of her body. The scars resulting from <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> reduction extend vertically down the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>, and horizontally along the crease underneath the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>. For the most part the horizontal scar is hidden. Scars usually fade quite well over time and most <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> reduction patients are very pleased with the final outcome. Liposuction may also be used in conjunction with <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> reduction <FONT SIZE="3" COLOR="#800000" FACE="Arial" >surgery</FONT> to achieve refinement in <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> shape or to remove excess fat from the armpit area. </div> <div> Breast<FONT SIZE="3" COLOR="#000000" FACE="Arial" > reduction is performed as an outpatient under general anesthesia. The operation typically lasts two to three hours. Postoperatively the patient wears a special surgical bra over gauze dressings. A small drainage tube is placed in each </FONT>breast<FONT SIZE="3" COLOR="#000000" FACE="Arial" > to drain off fluids for a day or two. The discomfort after </FONT>surgery<FONT SIZE="3" COLOR="#000000" FACE="Arial" > is easily controlled by medications. The dressings are removed after a few days along with the drains. There are no sutures that need to be removed. In general </FONT>breast<FONT SIZE="3" COLOR="#000000" FACE="Arial" > reduction patients can return to normal activities within ten days. Excessive exercise and overhead lifting should be avoided for several weeks. </FONT></div> <div> Of all plastic <FONT SIZE="3" COLOR="#800000" FACE="Arial" >surgery</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >procedures</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> reduction provides one of the quickest changes in body image. The patient will be rid of the physical discomfort of large <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>s; the body will look better proportioned and clothes will fit better. This is one of our happiest groups of patients. </div> <bR> <bR> <bR> <div>  <A NAME="6"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B>BREAST</B></FONT><B> LIFT (MASTOPEXY)</B> </div> <div> Over the years, factors such as pregnancy, nursing and the force of gravity take their toll on a woman's <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>s. As the skin loses its elasticity, the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>s often lose their shape and firmness and begin to sag. A <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> lift, or mastopexy, is a surgical procedure to raise and reshape sagging <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>s. In many cases performing a <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> augmentation using saline filled implants will provide a sufficient amount of uplift, avoiding extra scars from the mastopexy procedure. If your <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>s are small or have lost volume, for example after pregnancy, <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> implants inserted in conjunction with mastopexv can increase both their firmness and their size. </div> <bR> <bR> <div> The <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> lift is performed in an outpatient <FONT SIZE="3" COLOR="#800000" FACE="Arial" >surgery</FONT> center or in our office-based facility. <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Breast</FONT> lifts may be performed under general anesthesia or if a lesser operation is needed the use of local anesthesia combined with a sedative is adequate. The operating time for a mastopexy can vary from 30 minutes to a couple of hours. </div> <div> Another-common procedure involves an anchor-shaped incision following the natural contour of the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>. The incision outlines the area from which <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> skin will be removed and defines the new location for the nipple. When the excess skin has been removed the nipple and areola are moved to the higher position. The skin surrounding the areola is brought down and together to reshape the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>. Because all the incisions made are at or below the nipple area scars will be hidden by swimsuits and low cut clothing. Women who have implants combined with their <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> lift may find their results last longer, defying the effects of gravity, pregnancy, aging and weight fluctuations that will eventually take their toll. </div> <div> Postoperatively the patient wears a special surgical bra over gauze dressings, with no drains or sutures that need to be removed. The <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> will be bruised, swollen and uncomfortable for a day or two but the pain shouldn't be severe and any discomforts can be relieved easily with oral medication. </div> <bR> <div> Mastectomy</div> <div> For a long time, a procedure called a radical mastectomy was the only treatment available to women with breast cancer. No matter what stage of breast cancer you had, mastectomy was your only option. Catching a cancer early didn't give you the benefit of having a less radical, more cosmetically acceptable treatment option. Things have changed a great deal since then. Mastectomy no longer has to be as extensive, scarring, or disfiguring. It can actually be different operations for different people, in different situations.</div> <bR> <div> In a "simple" or "total" mastectomy, the surgeon removes the entire breast but does not take out any axillary lymph nodes (nodes in the underarm area, also called the axilla). No muscles are removed from beneath your breast. Occasionally, lymph nodes may be removed because they are actually located within the breast tissue taken during surgery. A total mastectomy is appropriate for women with ductal carcinoma in situ or DCIS, and for women seeking prophylactic mastectomies—that is, breast removal in order to prevent any possibility of breast cancer occurring.</div> <bR> <bR> <div> Woman with total (simple) mastectomy</div> <bR> <div> A pink highlighted area indicates tissue removed at mastectomy</div> <div> B axillary lymph nodes: levels I</div> <div> C axillary lymph nodes: levels II</div> <div> D axillary lymph nodes: levels III</div> <bR> <div>  </div> <div>  <IMG SRC="18390aa0.gif" border=0 width="400" height="426" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <bR> <bR> <div> A modified radical mastectomy removes the entire breast and includes a procedure called axillary dissection, in which levels I and II (of three levels) of the axillary lymph nodes nodes in the underarm area) are also removed. Most women who have mastectomies today have modified radical mastectomies.</div> <bR> <bR> <div>  Woman with modified radical mastectomy</div> <bR> <div> A pink highlighted area indicates tissue removed at mastectomy</div> <div> B axillary lymph nodes: levels I</div> <div> C axillary lymph nodes: levels II</div> <div> D axillary lymph nodes: levels III</div> <bR> <div>  </div> <div>  <IMG SRC="18490bd0.gif" border=0 width="400" height="445" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <bR> <bR> <div> Radical mastectomy includes removal of the entire breast, all underarm lymph nodes, and chest wall muscles under the breast. Although it was common in the past, radical mastectomy is now rarely performed because modified radical mastectomy has proven to be just as effective and less disfiguring. Today radical mastectomy is recommended only when cancer has spread to the chest muscles under the breast.</div> <bR> <bR> <div>  Woman with radical mastectomy</div> <bR> <div> A pink highlighted area indicates tissue removed at mastectomy</div> <div> B axillary lymph nodes: levels I</div> <div> C axillary lymph nodes: levels II</div> <div> D axillary lymph nodes: levels III</div> <div> E supraclavicular lymph nodes</div> <div> F internal mammary lymph nodes </div> <div>  </div> <div>  </div> <bR> <bR> <bR> <div> <IMG SRC="18490bd0.gif" border=0 width="400" height="445" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><A HREF="http://www.breastcancer.org/tre_surg_mastectomy.html#" TARGET="_top" TITLE="http://www.breastcancer.org/tre_surg_mas"><U><IMG SRC="18690b10.gif" border=0 width="400" height="433" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></U></A></div> </tD> </tR> </TABLE></div> <div> radical mastectomy</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Surgery has many roles in the management of <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> disease. Not only is it the main form of treatment for most malignant <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> conditions, but it also has an important role in the <FONT SIZE="3" COLOR="#0000FF" FACE="Verdana" ><U>investigation of lumps</U></FONT>, <FONT SIZE="3" COLOR="#0000FF" FACE="Verdana" ><U>screening</U></FONT> and in disease <FONT SIZE="3" COLOR="#800000" FACE="Verdana" ><U>staging</U></FONT>. It is often thought that surgery is only a form of treatment.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> However, as a general rule in the investigation and treatment of <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> disease, there is a distinction between diagnosis and treatment. Most of the time, <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> specialists will try to establish the diagnosis before definitive treatment is commenced - obviously it is better to know what you are dealing with before deciding what needs to be done.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Sometimes however, there is an overlap between diagnosis and treatment, and sometimes, even after surgery there is a need for more "diagnostic information" to help with <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >staging</FONT>. </div> <div> With these points in mind, the main roles of surgery are now summarised along with some examples: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">It has a diagnostic role when uncertainty remains following standard investigation of <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> symptoms. For example, suppose a woman presents with a lump. <FONT SIZE="3" COLOR="#0000FF" FACE="Verdana" ><U>Triple assessment and core biopsy</U></FONT> are not diagnostic or raise some suspicion of <FONT SIZE="3" COLOR="#800000" FACE="Verdana" ><U>cancer</U></FONT> but do not absolutely confirm the diagnosis. A <FONT SIZE="3" COLOR="#0000FF" FACE="Verdana" ><U>mastectomy</U></FONT> cannot be performed as a definitive treatment, since the diagnosis is uncertain. On the other hand, the lump cannot be left in the <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> since there is some suspicion that it may be <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >cancer</FONT>. In this case, surgical removal of the lump in the form of <FONT SIZE="3" COLOR="#0000FF" FACE="Verdana" ><U>lumpectomy</U></FONT> would be performed to establish the diagnosis, and to "treat" the lump. If the pathologist reports a <FONT SIZE="3" COLOR="#0000FF" FACE="Verdana" ><U>benign lump</U></FONT>, it is likely that no further treatment is required. On the other hand, if <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >cancer</FONT> is confirmed, further "definitive" surgical treatment (perhaps a mastectomy) may be needed along with <FONT SIZE="3" COLOR="#0000FF" FACE="Verdana" ><U>chemotherapy</U></FONT> etc. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">It has a direct role in the treatment of many conditions. For example, lumpectomy for many <FONT SIZE="3" COLOR="#0000FF" FACE="Verdana" ><U>benign lumps</U></FONT>. Mastectomy is usually indicated in <FONT SIZE="3" COLOR="#800000" FACE="Verdana" ><U>breast</U></FONT><U> </U><FONT SIZE="3" COLOR="#800000" FACE="Verdana" ><U>cancer</U></FONT>, but can also be performed for other conditions such as <FONT SIZE="3" COLOR="#0000FF" FACE="Verdana" ><U>Phyllodes tumour</U></FONT>. In these cases, surgery is the principle method of removing the disease from the body. It may also be necessary to give <FONT SIZE="3" COLOR="#0000FF" FACE="Verdana" ><U>adjuvant therapy</U></FONT> after surgery has been performed, and in these cases radiotherapy, chemotherapy or hormonal therapy are often used. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Surgery is one method of <FONT SIZE="3" COLOR="#800000" FACE="Verdana" ><U>staging</U></FONT> <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >cancer</FONT>. Suppose a woman has a lumpectomy for a lump that turns out to be <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >cancer</FONT> on pathology. It is then necessary to stage the disease. Examination of the axillary nodes by surgical removal at a second operation would be indicated and help with the <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >staging</FONT> process. Other methods of <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >staging</FONT> are also used (such as ultrasound and CT scanning) but for the axilla, nodal pathology is needed. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Surgery can be used to palliate patients with incurable disease. For example, if a patient has a tumour that is beginning to ulcerate through the skin but which has already metastasised (spread) to other parts of the body. Cure is not usually possible in such cases, but palliative surgery may help to stop the problems that would arise if ulceration were to continue (e.g. pain, discharge etc). However, it should be stressed that this is just an example, and in practice every patient is different and many options are available. </div> <div> There are many different types of surgical procedure for <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> conditions, and many specialists will perform them in slightly different ways using various techniques. What follows are some of the main procedures, their indications and uses and complications.<FONT SIZE="3" COLOR="#000000" FACE="verdana" > </FONT></div> <bR> <bR> <bR> <bR> <div> 2.  <A NAME="mastectomy"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Mastectomy</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mastectomy is the main form of treatment for <FONT SIZE="3" COLOR="#800000" FACE="Verdana" ><U>breast</U></FONT><U> </U><FONT SIZE="3" COLOR="#800000" FACE="Verdana" ><U>cancer</U></FONT>. However, not all patients with <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >cancer</FONT> opt to have the whole <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> removed. Some prefer instead to have a <FONT SIZE="3" COLOR="#0000FF" FACE="Verdana" ><U>wide-local excision</U></FONT> of the tumour, followed by <FONT SIZE="3" COLOR="#0000FF" FACE="Verdana" ><U>radiotherapy</U></FONT>. It has been shown that both of these options result in the same long-term survival and therefore are equally safe as "curative" procedures.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Some patients however are not eligible for "<FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> conserving" surgery, and must have a mastectomy. Such patients include women with small <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT>s and large tumours. In these patients, trying to remove only the tumour and leave the <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> will either result in inadequate clearance of the tumour (which raises the possibility of recurrence) or it will leave the <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> so deformed that there would be no cosmetic benefit over a mastectomy. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The other situations where <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> conservation is not encouraged and mastectomy preferred are in women with recurrent tumours, those with tumours close to or underlying the nipple, and in women who have large tumours. In these cases, the problem is that the disease may be more extensive than just the lump, so in order to treat the disease safely mastectomy is preferred. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">There are several different methods of performing mastectomy. Most of these have slightly different incisions, some horizontal across the chest wall, others more vertical. The exact names of each are not so important (except to <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> specialists) but the principles are the same. It should be noted that mastectomy is normally performed along with <FONT SIZE="3" COLOR="#0000FF" FACE="Verdana" ><U>axillary clearance</U></FONT> to remove the axillary nodes. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Basically, an ellipse is incised around the <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT>, through which skin flaps are raised on either side. These are dissected down to the underlying pectoralis major muscle. The <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> is then removed from the chest wall and the dissection continued around to the axilla. The axillary contents are then removed along with the <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> for <FONT SIZE="3" COLOR="#800000" FACE="Verdana" ><U>staging</U></FONT> purposes. After removal of <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> and axillary contents, it is common for two drains to be inserted. These allow for blood to be collected once the would has been closed, preventing it from collecting on the inside. One drain is normally left in the axilla, and the other under the lower <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> skin flap.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">After surgery, the drains will be left in for a variable amount of time depending on the amount of blood that is collected. Typically however, this is no more than 5 days, but can be longer if required.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">It should be stressed that modern mastectomy does not involve the removal of the chest wall muscles, as was performed in the "radical" mastectomy of the past. Removal of some of the muscle is however indicated on occasion when the tumour has invaded the muscle.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The complications of mastectomy are as follows. In the short term there are the usual anaesthetic complications that can occur, which include nausea, vomiting, drug reactions etc. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">More specifically though, post-mastectomy patients can occasionally get wound infections and haematomas (collections of blood in the wound). Haematomas arise for a number of reasons including surgical technique, early removal of drains or in patients on blood-thinning drugs such as aspirin. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pain and numbness on the inside of the upper arm can also occur and is due to division of the intercostobrachial nerve in the axilla during axillary dissection (a common part of the procedure, though not performed by every specialist).</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">After the first couple of weeks, some patients can develop wound collections of serous, inflammatory fluid. These are normally drained by a needle and syringe at the outpatient clinic.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In the longer term, tumour recurrence in the mastectomy wound is possible, though this depends on many factors, and other treatments such as chemotherapy and radiotherapy are often used to prevent this. Another long-term complication is swelling of the arm due to disruption of lymphatics. This is more due to the axillary surgery rather than the mastectomy.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Following mastectomy, some women opt for <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> reconstruction (see below). This can either be done immediately (at the time of the mastectomy during the same operation) or at a later date.</div> <bR> <bR> <bR> <bR> <div> 3.  <A NAME="axiallary_clearance"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Axillary Node Clearance</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Axillary node clearance on its own as an operation is normally done for <FONT SIZE="3" COLOR="#800000" FACE="Verdana" ><U>staging</U></FONT> purposes. The most common clinical setting for a woman to have this operation is when she has had a lump removed that was not confirmed to be <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >cancer</FONT> before her lumpectomy but which was shown to be <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >cancer</FONT> on pathology. A <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >cancer</FONT> diagnosis demands <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >staging</FONT> of the disease to determine what further treatment and adjuvant therapy is required. For this reason the axillary lymph nodes need to be examined.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The operation itself involves an incision in the axilla through which the axillary contents are excised. There are three "levels" to the dissection. Level 1 is up to the level of the inferior border of the pectoralis minor muscle, Level 2 to the upper border of pectoralis minor, and level three is above pectoralis minor, all the way into the apex of the axilla. The intercostobrachial nerve, which supplies sensation to the inner aspect of the upper arm, crosses the axilla, and in Level 3 clearances (the most common type), it is divided. Some surgeons try to preserve it, and if dissection allows, this is possible. Normally (but not always) a drain will be left in to collect blood, and similar complications can occur as those listed above under mastectomy.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Level 3 clearance not only stages the disease, but also treats the axilla. If a level 1 clearance is performed, and reveals positive nodes, there remains the possibility that further positive nodes remain in the axilla at Levels 2 and 3. These have to be dealt with, otherwise tumour would be left behind and cure compromised.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> There would be two options at this point - either remove the remaining nodes in another operation, or give radiotherapy to the axilla. In some centres, it is preferred to deal with the axilla by Level 3 clearance from the start, since this stages the axilla fully, and removes the need for radiotherapy even if the nodes are positive (since all of them have been removed). The down side though is that Level 3 clearance is more likely to result in damage to the intercostobrachial nerve, and to the lymphatics draining the arm. This can then result in a swollen, oedematous arm.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> If the nodes turned out to be positive, this may be acceptable, since radiotherapy can cause this complication as well, but if the nodes are all negative, it could be argued that the Level 3 dissection was unnecessary. The exact decision taken therefore depends upon a number of factors.</div> <bR> <bR> <bR> <bR> <div> 4.  <A NAME="wide_local_excision"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Wide Local Excision</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Wide local excision is the operation that is performed when <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> conserving treatment for <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >cancer</FONT> is chosen. For women with suitable tumours, the lump and a margin of surrounding <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> tissue are excised through an elliptical excision. The dissection is taken down as far as the pectoral muscle to ensure clearance below the tumour.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Axillary clearance is often performed at the same time for <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >staging</FONT> purposes. When this is done, two separate incisions are used, one for the tumour and one for the axilla. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The reason for this is that, at the start of the operation, it is not known whether the tumour has spread to the axilla. The axillary contents are removed first, since these are potentially free from disease. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Once removed and the axillary wound closed, the tumour is removed. In this way, theoretical seeding of tumour into a healthy site, is prevented.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A drain may be required if the wide local excision <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> cavity is large after tumour removal. This would be kept in for a day or two after surgery.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The potential complications are similar to those mentioned above including haematomas, wound infections etc.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Wide local excision alone is not regarded as a sufficient operation to achieve cure for <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >cancer</FONT>. It is usually complemented with radiotherapy to the remainder of the <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT>. The theory is this. If some of the <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >cancer</FONT> cells have begun to spread along the lymphatics in the <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT>, but have not yet reached the axilla, they may be left behind in the <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> lymphatics once the tumour is removed. There they will remain, especially if the axillary glands are removed. To deal with these remaining <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >cancer</FONT> cells, and to reduce the risk of further primary tumours from forming in the <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT>, radiotherapy is used in the post-operative period.</div> <bR> <bR> <bR> <div> 5.  <A NAME="needle_localised_biopsy"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Needle-Localised Biopsy</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Needle-localised biopsy is used when a <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> abnormality cannot be felt. Such situations arise frequently in the context of <FONT SIZE="3" COLOR="#800000" FACE="Verdana" ><U>breast</U></FONT><U> screening</U>, where women are asymptomatic (i.e. when there are no lumps to feel), but have routine mammograms to look for X-ray abnormalities that may suggest <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >cancer</FONT>. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In the vast majority of patients in whom an abnormality is found, there is nothing to feel on palpation of the <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT>.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Obviously, it will be difficult if not impossible to accurately biopsy a <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> abnormality if the surgeon cannot feel it. This procedure is therefore also used on occasion during wide-local excision of small tumours in women with large <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT>s where it is difficult to feel the tumour.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Needle-localised biopsy therefore involves the pre-operative insertion of a guide wire ("needle") into the abnormal area under X-ray control. The surgeon then makes an incision near the wire, finds it in the wound, and follows it to its tip in order to locate the abnormal area. This is then excised and sent to X-ray whilst the patient is still under anaesthetic. An X-ray of the specimen is taken to confirm that the abnormal area has been removed. Once confirmed the surgeon closes the wound and awaits the pathology of the specimen in the normal fashion.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Axillary clearance is not normally done at the same time as needle-localised biopsy, since the procedure is normally diagnostic, and until <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >cancer</FONT> has been confirmed, there is no indication for axillary <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >staging</FONT>. This is a general rule however and it should be stressed that there are certain circumstances where axillary surgery may be performed at the same time.</div> <bR> <bR> <bR> <div> 6.  <A NAME="lumpectomy"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Lumpectomy</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Lumpectomy is the operation that is used to treat benign lumps such as <FONT SIZE="3" COLOR="#0000FF" FACE="Verdana" ><U>fibroadenomas</U></FONT> or to remove lumps that are not diagnosed pre-operatively.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The aim is to remove the abnormal tissue, and do minimal damage to the surrounding <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT>.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> For this reason, these procedures normally require a smaller incision, and the lump is usually enucleated (shelled out) rather than taking a wide cuff of normal tissue as well.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The complications are normally few, but again may include haematomas and infections in the wound.</div> <bR> <bR> <bR> <div> 7.  <A NAME="breast_reconstruction"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><FONT SIZE="3" COLOR="#800000" FACE="Verdana" >Breast</FONT> Reconstruction</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Reconstruction of the <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> is an option following mastectomy. However, not all women are suitable for reconstruction - for example, the elderly, frail patient who may not tolerate the additional surgery well. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">For such patients there are a range of <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> prostheses that can be worn in the bra.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Reconstructive surgery is either performed at the same time as the initial mastectomy, or at a later stage.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> It involves the use of either a <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> implant prostheses or a muscle flap using either the rectus abdominus muscle (TRAM flap - transverse rectus abdominus myocutaneous), or the latissimus dorsi muscle from the back.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000008000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Breast<FONT SIZE="3" COLOR="#000000" FACE="Verdana" > implants such as the silicone implant give a natural feel to the </FONT>breast<FONT SIZE="3" COLOR="#000000" FACE="Verdana" > after surgery, but the </FONT>breast<FONT SIZE="3" COLOR="#000000" FACE="Verdana" > may not sit at the same level as the opposite side.</FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Expandable saline implants are used to overcome this. These can be expanded from a reservoir under the arm using a syringe. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This is done over a period of time, allowing the skin to stretch and grow over the prosthesis. Eventually, some saline is removed with the result that the normal ptosis of the <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> is restored. This expansion process can be uncomfortable, and may not be possible in women who have had radiotherapy due to the scarring that this causes. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The problem with prostheses is that they can cause the formation of a fibrous capsule in the <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> that can result in pain and distortion of the <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT>. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The possibility of infection is also a problem, and when it occurs, the prosthesis normally has to be removed. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Using muscle flaps requires a bigger operation with a longer recovery period is the most obvious problem. More worryingly though is the possibility of flap necrosis when the blood supply of the donor muscle cannot supply it adequately. This is more likely in women who smoke. Wound infections can also occur with flaps and in the case of the TRAM flap, the potential for abdominal wall hernias after the surgery also exists. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A number of techniques exist for dealing with the nipple.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Skin from the thigh can be used, or there are a number of prosthetic nipples available.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sometimes reconstructing a <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> cannot achieve the same size as the opposite, normal <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT>. This is especially true in women with large <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT>s who undergo mastectomy. In these cases, it may be necessary to reduce the size of the normal <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> to match that of the reconstructed side. This operation is known as a reduction mammoplasty. The converse is sometimes true for women with small <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT>s. The reconstructed side may end up larger than the normal side, which in turn may need to be augmented in order to achieve symmetry.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Overall however, excellent results can be obtained by <FONT SIZE="3" COLOR="#800000" FACE="Verdana" >breast</FONT> reconstruction, and this is very important especially in younger patients.</div> <bR> <bR> <bR> <bR> <div> =====================================================================================================================</div> <div> <B><U>surgery and stages</U></B></div> <bR> <bR> <div> Stage I and II</div> <div> Surgery</div> <div> i.<B> Tylectomy</B></div> <div> Indicated when acceptable cosmetic result obtainable, tumor is localized, tylectomy margins are negative, no suspicious microcalcifications remain, and when there is no contraindication to radiation therapy (pregnancy, lupus). Tylectomy followed by radiation therapy is preferred method treatment according to NIH Consensus Conference (1991).</div> <div> ii<B>. Modified radical mastectomy</B></div> <div> Indicated when breast conservation not possible or not desired, and when radiation is contraindicated.</div> <div> iii.<B> Axillary node dissection (Level I and II nodes)</B></div> <div> Performed with either procedure if lymphadenopathy evident or if clinically relevant for postoperative adjuvant therapy. Removal of clinically negative nodes has no therapeutic benefit.</div> <div> iv.<B> Breast reconstruction</B></div> <div> Performed electively at time of mastectomy if no radiation is planned or at later date after planned radiation is completed.</div> <div> <B>Radiation</B></div> <div> Radiation is administered following tylectomy or after mastectomy in high risk patients. RT reduces local recurrence risk from 39% to 10%, but does not improve overall survival. Dose to breast usually 45-50 Gy, using tangential fields, with a tumor bed boost to 60 Gy. Axilla is not radiated unless tumor present.</div> <div> Survival</div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="502" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP BGCOLOR=#00FFFF HEIGHT= 19 WIDTH="420"><div> Stage I </div> </tD> <tD VALIGN=TOP BGCOLOR=#00FFFF WIDTH="75"><div> 90%</div> </tD> </tR> <tR> <tD VALIGN=TOP BGCOLOR=#00FFFF HEIGHT= 19 WIDTH="420"><div> Stage I I A </div> </tD> <tD VALIGN=TOP BGCOLOR=#00FFFF WIDTH="75"><div> 70-80%</div> </tD> </tR> <tR> <tD VALIGN=TOP BGCOLOR=#00FFFF HEIGHT= 19 WIDTH="420"><div> Node positive, receptor positive </div> </tD> <tD VALIGN=TOP BGCOLOR=#00FFFF WIDTH="75"><div> 61-75%</div> </tD> </tR> <tR> <tD VALIGN=TOP BGCOLOR=#00FFFF HEIGHT= 19 WIDTH="420"><div> Node positive, receptor negative </div> </tD> <tD VALIGN=TOP BGCOLOR=#00FFFF WIDTH="75"><div> 25-50%</div> </tD> </tR> </TABLE></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Treatment of breast cancer can take a variety of forms, depending upon the grade and stage of the cancer as well as the overall health of the patient and the wishes of the patient. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Therapy needs to be appropriate for each individual woman.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">At a minimum, a localized carcinoma can be removed completely with local excision (lumpectomy) with margins free of tumor. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This is termed "breast conserving surgery" (BCS). At the same time sampling of axillary lymph nodes can be done to determine if lymph node metastases are present.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> A total mastectomy with removal of the breast can be performed. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The survival following BCS is generally as good as for total mastectomy, other factors being equal.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Surgical procedures may be combined with radiation therapy and or chemotherapy, depending upon the type of cancer present and hormone receptor status.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Radiation, coupled with BCS, may help to reduce the incidence of a second cancer in the breast when intraductal carcinoma is diagnosed. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">More extensive cancers may be treated with a modified radical mastectomy with removal of the entire breast and axillary lymph nodes. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Some breast carcinomas that have a higher stage may be amenable to more aggressive chemotherapy which can be coupled with total body radiation and bone marrow transplantation.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Prognosis cannot be completely predicted.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> There are some general guidelines as to the potential biologic behavior of a breast carcinoma.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> In general, a better prognosis will accompany cancers:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Less than 2 cm in size</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Without axillary lymph node involvement</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">That are non-invasive ductal carcinoma and LCIS</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">With ER and PR positivity</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Which lack of aneuploidy</div> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div> <B><U>Lumpectomy</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><U> </U></FONT></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b701180000ff00.gif" HEIGHT="19" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">T</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" >his procedure removes the cancerous tumor, while preserving the breast tissue.</FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> This type of surgery removes only the breast lump and the surrounding marginal tissues.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Additional tissues will be removed if the marginal tissues removed from lumpectomy were found to be abnormal. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Usually lumpectomy is<B><U> followed by six weeks of radiation therapy. </U></B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Side effects of this treatment including temporary swelling and tenderness and hardness of the breast due to scar tissue that formed at the surgical site.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Partial or segmental mastectomy or quadrantectomy removes more breast tissue than a lumpectomy (up to one-quarter or more of the breast).</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Then six to seven weeks of external beam radiation therapy is usually given following this surgery.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">For most women with early stage breast cancer, breast conservation therapy (lumpectomy and radiation therapy) is as effective as mastectomy. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">There is no difference in survival rates of women treated with these two approaches. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">However, breast conservation therapy is not an option of all women with breast cancer and is usually not recommended for:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Women who have already had radiation therapy to the affected breast </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Women with two or more areas of cancer in the same breast that are too far apart to be removed through one surgical incision </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Women whose initial lumpectomy or when needed, their reexcision, has not completely removed the cancer. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Women with certain connective tissue diseases such as scleroderma, that make them especially sensitive to the side effects of radiation therapy. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pregnant women who would require radiation while still pregnant, risking harm to the fetus. </div> <bR> <bR> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div> <B><U>Mastectomy</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><U> </U></FONT></div> <bR> <div> <B><U>Simple or Total Mastectomy</U></B><B><U> </U></B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b701180000ff00.gif" HEIGHT="19" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">D</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" >uring a simple (sometimes called a total) mastectomy, the entire breast is removed, </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">while the lymph nodes or muscle tissue from beneath the breast stay in tact.</div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> This procedure is used to treat ductal carcinoma </B><I><B>in situ</B></I><B> (DCIS) that is not suitable for breast conserving </B>surgery. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Some stage 0 breast cancers are treated via mastectomy. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Like the lumpectomy, all mastectomies are performed at local hospitals. </div> <bR> <div> <B><U>Modified radical mastectomy </U></B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b701180000ff00.gif" HEIGHT="19" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">T</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" >he most widely used surgical treatment for breast cancer, and has proven to be an effective local treatment for cancers in all stages. </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This form of mastectomy removes the breast and the underarm lymph nodes. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">It is the most common form of surgery for individuals with breast cancer who have the breast removed and post-operative radiation therapy is usually not necessary.</div> <bR> <div> <B><U>After a Modified Radical Mastectomy</U></B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b701180000ff00.gif" HEIGHT="19" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">T</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" >he surgery is performed using a general anesthetic.</FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> After the mastectomy patient may experience some discomfort around the chest and under the arm. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pain medication can help to control the discomfort. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Usually two drainage tubes will be in place to drain fluids that may collect in the operative areas.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> One tube is used to drain the chest area and the other is used to drain the location, where the auxiliary lymph nodes were removed.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Patient will be encouraged to get out of bed the same day as surgery, as soon as the anesthetic has worn off, and at that time patient should be able to eat regular food.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Expect to stay in the hospital for a few days, but the trend is for shorter hospital stays after a mastectomy. </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Right after mastectomy, patient should receive a temporary prosthesis. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The prosthesis (breast form) provides symmetry without putting pressure on the surgical area. </div> <bR> <div> <B><U>Radical mastectomy </U></B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b701180000ff00.gif" HEIGHT="19" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">T</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" >his rarely-performed surgery removes the entire breast, the underarm lymph nodes and the pectoral muscles beneath the breast. </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This type of surgery was once very common. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The disfigurement and side effects it causes, and modified radical mastectomy has been proven to be as effective as radical mastectomy, so now it is rarely performed. </div> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div> <U>Axillary Lymph Node Dissection</U></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b701180000ff00.gif" HEIGHT="19" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" >xillary dissection is performed along with radical or modified radical mastectomy procedure. </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Its purpose is to determine whether breast cancer has spread to axillary (underarm) lymph nodes, and examined under the microscope. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Whether or not cancer cells are present in the lymph nodes under the arm is an important factor in selecting adjuvant therapy.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> It was once believed that removing as many lymph nodes as possible would reduce the risk of spreading cancer cells to other part of the body and improves the chance of curing the cancer. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">It is now known that systemic therapy would be a better approach in treating cancer cells that have spread beyond the breast and axillary lymph nodes. Thus the purpose of axillary dissection would be a good indicator for further treatment decisions. </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">There is an increased chance of swelling of the arm (lymphedema) with axillary dissection. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The physician or nurse coordinator would know how to perform simple measures to reduce the chance of swelling. [Side Effect]</div> <bR> <bR> <div> <B><U>After the Lumpectomy with Axillary Node Dissection</U></B></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">General anesthetic is performed for lumpectomies with axillary node dissection.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Patients are usually sent home the same or next day afteryour surgery, once the effects of the anesthetic have worn off.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Most of the time a tube will be in place under patient's arm on the operated side to drain away any fluid that collects there following axillary </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">lymph node dissection. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Simple instructions on how to care for the drainage tube at home will be given to patient and patient's family member or friend before leaving the clinic or hospital. </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> 7 to 10 days to remove the stitches and the drainage tube under your arm. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">appropriate arm and shoulder exercises. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Exercise usually begins after the drain is removed to reduce the chance of lymphedema, a swelling of the arm.</div> <bR> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div> <B><U>Side Effects of Mastectomy and Lumpectomy</U></B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b701180000ff00.gif" HEIGHT="19" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">T</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" >he side effects for every women can be very unique and different. </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Common side effects of Mastectomy and Lumpectomy may include:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">arm may be stiff and numb on the surgery side. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">pins and needles sensations in the incision and arm </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">may have a drain in the incision for about one week </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">lymphedema. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">may experience emotional ups and downs (grief, fear, shock, anger, resentment) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">physical changes to the breast area. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">wound infection, such as hematoma (accumulation of blood in the wound), and seroma (accumulatioin of clear fluid in the wound). If axillary lymph nodes are also removed then additional side effects may occur. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The main side effect of removing axillary lymph nodes is lymphedema (swelling of the arm) that had happened about 10% to 20% of breast </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">cancer patients.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Also after the surgery, women may experience numbness of the upper inner arm skin and temporary or permanent limitations in arm and shoulder movement. </div> <div> <B><U><IMG SRC="12178aa0.gif" border=0 width="120" height="170" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></U></B></div> <DIV ALIGN="LEFT"></DIV> <div> <B>Radiation Therapy</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b701180000ff00.gif" HEIGHT="19" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">R</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" >adiation therapy is an integral part of breast conserving treatment </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">using high-energy rays or particles that destroy cancer cells. This </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">treatment may be used to reduce the size of a tumor before surgery or </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">to destroy cancer cells remaining in the breast, chest wall, or </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">underarm area after surgery. This therapy aimed solely at decreasing </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">the likelihood of breast cancer recurring in the operated breast or </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">chest wall region. It is rarely used when mastectomy has been performed. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">When given after surgery, radiation therapy is usually not started until </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">the tissues have been able to heal for about a month.</div> <bR> <div> <B><U>External beam radiation</U></B></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">is the usual type of radiation therapy for women with breast cancer.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The radiation is focused from a source outside the body on the area affected by the cancer.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> It is much like getting a diagnostic x-ray, but for a longer time. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Before treatments start, the radiation team will make careful measurements to determine the correct angles for aiming the radiation beams and the proper dose of radiation. </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">They will make some ink marks on your skin that they will use later as a guide for focusing the radiation in the right area.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Patients are usually treated five days per week in an outpatient center over a period of about six weeks, with each treatment lasting a few minutes. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The procedure itself is painless.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Antiperspirants can interfere with external beam radiation therapy of the underarm area, and should be avoided until treatments are complete. </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The main side effects of external beam radiation therapy are swelling and heaviness in the breast, sunburn-like skin changes in the treated area, and fatigue. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sun exposure of the treated skin should be avoided because it can make the skin changes worse.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> These changes to the breast tissue and skin usually go away in 6 to12 months. In some women, the breast becomes smaller and firmer after  radiation therapy. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Radiation therapy of axillary lymph nodes also can cause lymphedema . Radiation therapy is usually not used during pregnancy because it can be harmful to a fetus.</div> <bR> <bR> <div> <B><U>Brachytherapy</U></B></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">also known as internal radiation, is another way of delivering radiation therapy.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Instead of aiming radiation beams from outside the body, radioactive substances are placed directly into the breast tissue next to the cancer. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This method, currently considered to be experimental.</div> <bR> <div> <B><U>and finally chemotherapy</U></B></div> <div> <B>.</B></div> <bR> <div> <B> What is tamoxifen?</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> Tamoxifen is a medication in pill form that interferes with the activity of estrogen (a female hormone). Tamoxifen has been used for more than 20 years to treat patients with advanced breast cancer. It has also been used as adjuvant, or additional, therapy following surgery or radiation therapy for early stage breast cancer. Tamoxifen has recently been found to reduce the incidence of breast cancer in women at high risk of developing this disease. Tamoxifen continues to be studied for the prevention of breast cancer. It is also being studied in the treatment of several other types of cancer. </div> <bR> <div> <B>2. How does tamoxifen work on breast cancer?</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> Estrogen promotes the growth of breast cancer cells. Tamoxifen works against the effects of estrogen on these cells. It is often called an "anti-estrogen." As a treatment for breast cancer, the drug slows or stops the growth of cancer cells that are already present in the body. As adjuvant therapy, tamoxifen has been shown to help prevent the original breast cancer from returning and also prevent the development of new cancers in the opposite breast. </div> <bR> <div> <B>3. Are there other beneficial effects of tamoxifen?</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> While tamoxifen acts against the effects of estrogen in breast tissue, it acts like estrogen in other body systems. This means that women who take tamoxifen may derive many of the beneficial effects of menopausal estrogen replacement therapy, such as a lowering of blood cholesterol and a slowing of bone loss (osteoporosis). </div> <bR> <div> <B>4. Can tamoxifen prevent breast cancer?</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> Research has shown that when tamoxifen is used as adjuvant therapy for early stage breast cancer, it not only prevents the recurrence of the original cancer but also prevents the development of new cancers in the opposite breast. Based on these findings, the National Cancer Institute (NCI) funded a large research study, the </div> <div> Breast Cancer Prevention Trial (BCPT) conducted by the National Surgical Adjuvant Breast and Bowel Project (NSABP), to determine the usefulness of tamoxifen in preventing breast cancer in women who have an increased risk of developing the disease. Results from this study showed a 49 percent reduction in diagnoses of invasive breast cancer among women who took tamoxifen. Women who took tamoxifen also had 50 percent fewer diagnoses of noninvasive breast tumors, such as ductal or lobular carcinoma in situ. However, there are some risks associated with tamoxifen, some even life threatening. The decision to take tamoxifen is an individual one in which the woman and her doctor must carefully consider the benefits and risks of therapy. </div> <div> Women with an increased risk of developing breast cancer have the option to consider taking tamoxifen to reduce their chance of developing this disease. They may also consider participating in the upcoming Study of Tamoxifen and Raloxifene that will compare tamoxifen with the osteoporosis prevention drug raloxifene, which could have similar breast cancer risk reduction properties, but might be associated with fewer adverse effects. </div> <div> At this time, there is no evidence that tamoxifen is beneficial for women who do not have an increased risk of breast cancer. </div> <bR> <div> <B>5. What is the Study of Tamoxifen and Raloxifene (STAR), and how can a woman learn more about it?</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> The National Surgical Adjuvant Breast and Bowel Project (NSABP), a component of NCI's Clinical Trials Cooperative Group Program, has launched a new breast cancer study. The new trial, known as STAR, began recruiting participants in June 1999. It will involve about 22,000 postmenopausal women who are at least 35 years old and are at increased risk for developing breast cancer. The study is designed to determine whether raloxifene, a drug similar to tamoxifen, is also effective in reducing the chance of developing breast cancer in women who have not had the disease, and whether the drug has benefits over tamoxifen, such as fewer side effects. </div> <div> Women can learn more about the STAR trial in several ways. They can call NCI's Cancer Information Service at <FONT SIZE="3" COLOR="#000080" FACE="Arial" ><B>1-800-4-CANCER</B></FONT> (1-800-422-6237). The number for deaf and hard of hearing callers with TTY equipment is 1-800-332-8615. Information is also available on NSABP'S Web site at http://www.nsabp.pitt.edu or NCI's clinical trials Web site at http://cancertrials.nci.nih.gov on the Internet. </div> <bR> <div> <B>6. Does tamoxifen cause blood clots?</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> Data from large treatment studies suggest that there is a small increase in the number of blood clots in women taking tamoxifen, particularly in women who are receiving anticancer drugs (chemotherapy) along with tamoxifen. The total number of women who have experienced this side effect is small. Women in the BCPT who took tamoxifen also had an increased chance of developing blood clots. The risk of having a blood clot due to tamoxifen is similar to the risk of blood clots for women on single-agent estrogen replacement therapy. </div> <bR> <div> <B>7. Does tamoxifen cause uterine cancer?</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> The BCPT found that women taking tamoxifen had more than twice the chance of developing uterine cancer compared with women on placebo (an inactive substance that looks the same as, and is administered in the same way as, tamoxifen). The risk of uterine cancer in women taking tamoxifen was in the same range as (or less than) the risk in postmenopausal women taking single-agent estrogen replacement therapy. Additional studies are under way to define more clearly the role of other risk factors for uterine cancer, such as prior hormone use, in women receiving tamoxifen. </div> <div> Like many cancers, uterine cancer is potentially life threatening. Most of the uterine cancers that have occurred during studies of women taking tamoxifen have been found in the early stages, and treatment was usually effective. However, breast cancer patients who developed uterine cancer while taking tamoxifen have died from the disease. Abnormal vaginal bleeding and lower abdominal (pelvic) pain are two symptoms of the disease. Women on tamoxifen should see their doctor if they experience these symptoms. </div> <bR> <div> <B>8. Does tamoxifen cause eye problems?</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> As women age, they are more likely to develop cataracts (a clouding of the lens inside the eye). Women taking tamoxifen appear to be at increased risk for developing cataracts. Other eye problems, such as corneal scarring or retinal changes, have been reported in a few patients. </div> <bR> <div> <B>9. Does tamoxifen cause other types of cancer?</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> There have been a few reports of liver cancer and reports of other liver toxicities that have occurred in women taking tamoxifen. Although tamoxifen can cause liver cancer in particular strains of rats, it is not known to cause liver cancer in humans. Tamoxifen did not cause liver cancer in the BCPT. It is clear that tamoxifen can sometimes cause other liver toxicities in women, which rarely can be severe or life threatening. Doctors may order blood tests from time to time to check liver function. </div> <div> Although one study suggested a possible increase in cancers of the digestive tract among women receiving tamoxifen for breast cancer, other trials, including the BCPT, have not shown an association between tamoxifen and these cancers. </div> <div> Studies such as the BCPT show no increase in cancers other than uterine cancer. This potential risk is being evaluated. </div> <bR> <div> <B>10. Should women taking tamoxifen avoid pregnancy?</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> Yes. Tamoxifen may make premenopausal women more fertile, but doctors advise women on tamoxifen to avoid pregnancy because animal studies have suggested that the use of tamoxifen in pregnancy can cause fetal harm. Women who have questions about fertility, birth control, or pregnancy should discuss their concerns with their doctor. </div> <bR> <div> <B>11. What are some of the more common side effects of taking tamoxifen?</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> In general, the side effects of tamoxifen are similar to some of the symptoms of menopause. The most common side effects are hot flashes and vaginal discharge. Some women experience irregular menstrual periods, dizziness, headaches, fatigue, loss of appetite, nausea and/or vomiting, vaginal dryness or bleeding, and irritation of the skin around the vagina. As is the case with menopause, not all women who take tamoxifen have these symptoms. </div> <bR> <div> <B>12. Does tamoxifen cause a woman to begin menopause?</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> Tamoxifen does not cause a woman to begin menopause, although it can cause some symptoms that are similar to those that may occur during menopause. In most premenopausal women taking tamoxifen, the ovaries continue to act normally and produce female hormones (estrogens) in the same or slightly increased amounts. </div> <bR> <div> <B>13. Do the benefits of tamoxifen in treating breast cancer outweigh its risks?</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> The benefits of tamoxifen as a treatment for breast cancer are firmly established and far outweigh the potential risks. Women concerned about the risks and benefits of medications they are taking are encouraged to discuss these concerns with their doctor. </div> <bR> <div> <B>14. How long should a woman take tamoxifen for the treatment of breast cancer?</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Women with advanced breast cancer may take tamoxifen for varying lengths of time depending on their response to prior treatment and other factors. When used as adjuvant therapy for early stage breast cancer, tamoxifen is generally prescribed for 5 years. However, the ideal length of treatment with tamoxifen is not known. </div> <div> Two studies have confirmed the benefit of taking tamoxifen daily for 5 years. These studies compared 5 years of treatment with tamoxifen with 10 years of treatment. When taken for 5 years, the drug prevents the recurrence of the original breast cancer and also prevents the development of a second primary cancer in the opposite breast. Taking tamoxifen for longer than 5 years is not more effective than 5 years of therapy. </div> <bR> <bR> <div> <B><U>complication</U></B></div> <div> Lymphedema </div> <bR> <div> <B>WHAT EVERY WOMAN FACING BREAST CANCER SHOULD KNOW ABOUT LYMPHEDEMA:Hand and Arm Care Following Surgery or Radiation Therapy for Breast Cancer</B> </div> <bR> <bR> <div> Women who have been treated for breast cancer may be at risk for lymphedema, or arm swelling. Most women who have had breast cancer will not develop this side effect, but many will. This booklet describes what lymphedema is, the steps you can take to lower your risk, and what signs to look for. It is not possible to predict who will get lymphedema, but recognizing it early and treating it promptly is the best way to manage it. </div> <bR> <bR> <bR> <div> <B>WHAT IS LYMPHEDEMA?</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Our bodies have a network of lymph nodes and lymph vessels that carry and remove lymph fluid, similar to the way blood vessels circulate blood to all parts of the body. The lymph fluid contains white blood cells, which help us fight infections. During surgery for breast cancer, the doctor usually removes some of the lymph nodes from the underarm area to see if the cancer has spread. Some lymph vessels that carry fluid from the arm to the rest of the body are removed also, because they are intertwined with the nodes. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The removal of lymph nodes and vessels changes the way the lymph fluid flows within that side of your upper body, making it more difficult for fluid in the arm to circulate to other parts of the body. If the remaining lymph vessels cannot remove enough of the fluid in the breast and underarm area, the excess fluid builds up and causes swelling, or lymphedema. Radiation treatment can affect the flow of lymph fluid in the arm and breast area in the same way, putting the patient at increased risk for lymphedema. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Lymphedema usually develops slowly over time. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The swelling can range from mild to severe, and it can develop soon after surgery or radiation treatment or many months or even years later. Women who have many lymph nodes removed and radiation therapy may have a higher risk of developing lymphedema, but doctors do not fully understand why some patients are more likely to have problems with fluid build-up than others. As breast surgery and treatment continue to become more conservative (that is, as more women are treated with lumpectomy) and as research advances are made with procedures such as the sentinel lymph node biopsy (a new procedure which allows the surgeon to remove only one or two lymph nodes), </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">doctors expect that fewer women will develop lymphedema. Although much remains to be learned about this condition, there are ways that you can care for the arm and breast area to reduce your chances of having future problems.</div> <bR> <bR> <div> <B>HOW TO REDUCE SWELLING AFTER SURGERY OR RADIATION</B> </div> <div> Immediately after surgery, some swelling may occur in the affected arm or breast area. This swelling is usually temporary and will gradually disappear over the next six to twelve weeks. The following suggestions may help relieve the swelling: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Use your affected arm as you normally do when combing your hair, bathing, dressing, and eating. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Elevate your affected arm above the level of your heart for 45 minutes, two or three times a day, while lying down. Position your arm on pillows so that your hand is higher than your wrist and your elbow is slightly higher than your shoulder. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Exercise your affected arm while it is elevated above the level of the heart by opening and closing your hand 15 to 25 times. Repeat this three to four times a day. This exercise helps to reduce swelling by pumping lymph fluid out of the arm through the undamaged lymph vessels. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">To regain your normal range of shoulder and arm movement, begin exercising your affected arm about a week after your surgery as directed by your doctor, nurse, or physical therapist. Generally, normal range of motion returns within four to six weeks. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If you have radiation therapy after surgery, it may cause or prolong the swelling in the arm or cause some swelling in the breast toward the end of the treatment. This swelling is temporary and will gradually disappear. During treatment and up to 18 months afterward, you should do simple stretching exercises daily to maintain your shoulder range of motion. </div> <bR> <bR> <div> <B>HOW TO HELP PREVENT AND CONTROL LYMPHEDEMA</B> </div> <div> Although there are no scientific studies to show that women can prevent lymphedema, most experts recommend following these basic guidelines, which may lower your risk of developing lymphedema or delay its onset: </div> <bR> <bR> <div> <B>Try to Avoid Infection</B> </div> <div> Your body responds to infection by making extra fluid to fight the infection. Removal of or damage to lymph nodes and vessels makes it more difficult to transport this extra fluid, and this can trigger lymphedema. Good hygiene and careful skin care may reduce the risk of lymphedema by helping you to avoid infections. Follow these suggestions to help you care for your hand and arm on the side of your surgery: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Whenever possible, have your blood drawn, and IVs and injections given in your unaffected arm. Also have flu shots and vaccinations in your unaffected arm or somewhere else, such as the hip. Let your health care provider know that you are at risk for lymphedema. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Keep your hands and cuticles soft and moist by regularly applying moisturizing lotion or cream. Push cuticles back with a cuticle stick rather than cutting them with scissors. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Keep your arm clean. Clean and protect any skin openings caused by cuts, abrasions, insect bites, hangnails or torn cuticles. Use an over- the-counter antibacterial cream on any openings once they are cleaned, and then cover with a bandage. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Wear protective gloves when doing household chores involving chemical cleansers or steel wool, gardening or yard work, and perhaps while washing dishes. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Wear a thimble when sewing to avoid needle and pin pricks to your finger. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Use an electric shaver for removing underarm hair; these may be less likely to cut or break the skin than straight razors or hair removal creams. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If necessary, use an insect repellent when outdoors to avoid bug bites. If you get stung by a bee in the affected arm, clean and elevate the arm, apply ice, and contact your health care provider if it becomes infected.</div> <bR> <bR> <div> <B>Try to Avoid Burns</B> </div> <div> Like infections, burns can lead the body to make extra fluid that may build up and cause swelling in women whose lymph nodes have been removed or damaged. Suggestions for avoiding burns include: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Protect your arm from sunburn. Use sunscreen that is labeled "SPF15" or higher and try to stay out of the sun during the hottest part of the day. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Use oven mitts. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Avoid oil splash burns from frying and steam burns from microwaved foods or boiling liquids. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Avoid excessive heat, such as from hot tubs and saunas, since heat can increase fluid build-up.</div> <bR> <bR> <div> <B>Try to Avoid Constriction</B> </div> <div> Constriction or squeezing of the arm may increase the pressure in nearby blood vessels, which may lead to increased fluid and swelling. Some women have associated this with the onset of lymphedema. Lymphedema onset has also been associated with air travel, possibly because of the low cabin pressure. Suggested precautions include: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Wear jewelry, clothing, and gloves that are not too tight. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Avoid shoulder straps when carrying brief cases and purses. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Wear a loose-fitting bra so that the straps do not dig into your shoulder. Following mastectomy, use a light weight prosthesis. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Have your blood pressure routinely taken on the unaffected arm or, if both arms are affected, on your thigh. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Wear a compression sleeve when traveling by air if you fly frequently or for long flights. If possible, try to keep the arm elevated above the level of your heart and flex it frequently during the trip. A well-fitted compression sleeve may help prevent swelling. Talk to your doctor or physical therapist about whether you should be fitted for a sleeve to wear during air travel.</div> <bR> <bR> <div> <B>Try to Avoid Muscle Strain</B> </div> <div> It is important to use your affected arm for normal everyday activities, such as brushing your hair and bathing, for you to heal properly and regain strength. However, overuse has been associated with the onset of lymphedema in some women. It's a good idea to follow these suggestions whenever possible: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Use your affected arm as normally as possible. Continue to do the activities you did before your surgery once you are fully healed, about four to six weeks after surgery or radiation treatment. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Exercise regularly but try not to over-tire your arm. Before doing any strenuous exercise, such as weightlifting or tennis, talk with your doctor, nurse, or physical therapist about your specific goals and limitations so that you can decide what level of activity is right for you. Ask your doctor or physical therapist if you should be fitted for a sleeve to wear during strenuous activities. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Use your unaffected arm or both arms as much as possible to carry heavy packages such as groceries or handbags, or children.</div> <bR> <bR> <div> <B>HOW TO CARE FOR CUTS, SCRATCHES, OR BURNS</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Wash the area with soap and water. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Apply an antibiotic cream or ointment to the area. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cover with a clean, dry gauze or bandage. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">For burns, apply a cold pack or cold water for 15 minutes, then wash with soap and water and apply a clean, dry dressing. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Watch for early signs of infection: rash, red blotches, swelling, increased heat, tenderness, fever. Call your doctor right away if you develop an infection.</div> <bR> <bR> <div> <B>SIGNS OF LYMPHEDEMA</B> </div> <div> The signs of lymphedema may include: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Arm feels full or heavy </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Skin feels tight </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Less movement or flexibility in the hand or wrist </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Difficulty fitting the arm into jacket or shirt sleeves </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ring, watch, and/or bracelet feels tight but you have not gained weight</div> <div> If you have had lymph nodes removed or radiation treatment, you may want to examine your upper body in front of a mirror. If you notice any of the signs listed above, and if they last for one to two weeks, call your doctor or health care provider. </div> <bR> <bR> <div> <B>WHEN TO CALL YOUR HEALTH CARE PROVIDER</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If you notice any swelling, with or without pain, that lasts for one to two weeks. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If any part of your affected arm or underarm area (axilla) feels hot, is red, or has sudden swelling. These symptoms could signal an infection and may require antibiotics. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If you develop a temperature over 100.5°F that is not related to a cold or flu.</div> <bR> <bR> <div> <B>LYMPHEDEMA TREATMENT</B> </div> <div> If you are diagnosed with lymphedema, there is effective treatment to reduce the swelling, prevent it from getting worse, and limit the risk of infection. Typically, the therapy is prescribed by your doctor and should be given by an experienced therapist. Mild lymphedema should be treated by a physical therapist or other health care professional who has gone through special training. Moderate or severe lymphedema is most often treated by a therapist with specialized training and expertise who will provide skin care, massage, special bandaging, exercise, and fitting for a compression sleeve. Seeking and getting treatment early should lead to a shorter course of treatment to get your lymphedema under control. </div> <bR> <bR> <bR> <div> <B><U>Cosmetic </U></B><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B><U>Breast</U></B></FONT><B><U> </U></B><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B><U>Surgery</U></B></FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In our society, the female <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> is considered one of the most important symbols of femininity. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The extraordinary emphasis placed upon this explains the frequency with which women seek consultation with cosmetic surgeons. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The size, shape and firmness of the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>s as well as the appearance of the areola and nipple may all contribute to aesthetic concerns. </div> <bR> <div> <B><U>Breast</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B><U> Augmentation (Implants)</U></B></FONT></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000008000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Breast<FONT SIZE="3" COLOR="#000000" FACE="Arial" > augmentation is an evolving special procedure. </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Over the last century women throughout the world have attempted to augment their <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>s using various substances and techniques, most often with less than satisfactory results and often with dangerous consequences. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Today, techniques are available which are both safe and aesthetically satisfying. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Most commonly the implants that are used today are saline containing implants which are known to be completely safe even if a rupture or leak should occur. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Saline solution is a substance which is completely physiologic with the human body.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Basically it is an isotonic salt solution similar to tears and blood plasma.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Pure saline solution is always used and contains no preservatives or other chemicals. In addition, the saline implants are inserted into the specially created <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> pocket in the deflated state which signifies that the incision site necessary to permit placement of the implant can be much smaller than was previously necessary for pre-filled gel implants. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The implants are filled with the saline solution through tiny fill tubes using a sterile introduction system. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The implants can be placed either under the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> gland itself or under the pectoral muscle. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">They are often placed under the pectoral muscle for patients with small <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>s or for those whose <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>s have not sagged.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The site of entry is located in the underarm region (transaxillary approach) and this can be camouflaged by the normal folds of the underarm area. The scar is usually less than one to two inches in length.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The most modern technique performed today uses an endoscopic instrument in order to visualize the pocket that is being created in the sub-glandular or sub-pectoral space. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This better assures the ability to control bleeding during the procedure and assures optimal post-operative recovery. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This procedure can be done in the office surgi-center with intravenous sedation (twilight anesthesia)</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The patient is discharged home later in the day following recovery in the surgi-center .</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> In most cases, patients can return to work within the week following <FONT SIZE="3" COLOR="#800000" FACE="Arial" >surgery</FONT>. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The patient is advised to wear a surgical support bra 24 hours a day for about one month. </div> <bR> <div> <B><U>Mastopexy (</U></B><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B><U>Breast</U></B></FONT><B><U> Lift)</U></B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This operative procedure is done to lift the sagging <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Three structures hold the youthful <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> firmly in its location-the muscle,the gland and the skin.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> One or more of these structures may be weakened due to pregnancy, <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> feeding, lack of support, weight loss or heredity. <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Breast</FONT> lifting procedures are more common in middle-aged women as well as for women who are satisfied with the size and volume of their <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>s but wish to have higher and firmer <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>s.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Correction of <I>saggy</I> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>s can be achieved with several different treatment modalities. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">For patients with a mild excess of skin, (mild sag), the lift can be done by removing a ring (or donut) shaped segment of skin from around the areola. This results in a periareolar incision which heals with a faint scar around the areola</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">. For patients who have a more significant degree of sag, another technique is used which requires an inverted T incision. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This permits optimal skin reduction and results in an aesthetically pleasing <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> contour. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">As with all cosmetic <FONT SIZE="3" COLOR="#800000" FACE="Arial" >surgery</FONT> procedures, special attention is placed on minimizing the appearance of the post-operative scar. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Another approach that is frequently requested combines a lift procedure with a simultaneous augmentation</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">. In most cases, patients who have undergone any of these procedures preserve normal <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> function which includes lactation following future pregnancies.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Although nipple sensitivity may occasionally change following <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >surgery</FONT>, it usually returns to normal within a few weeks. </div> <bR> <div> <B><U>Breast</U></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B><U> Reduction</U></B></FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Large, pendulous <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>s are both physically and emotionally distressing for many women. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The excessive weight on the chest often causes chronic back and neck pain.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> In addition these patients complain of unaesthetic depressions that have appeared on their shoulders due to the constant weight of the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>s pulling down on the bra straps. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Occasionally, heavy <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>ed women develop carpal tunnel syndrome which affects their fingers. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This is due to compression of nerves between the pectoral muscle and bones of the shoulder girdle which suffer a change in alignment due to postural changes that compensate for the heavy weight of the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>s.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Additionally, the constant warmth and moisture in the crease under large <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>s frequently causes a fungal overgrowth with chronic irritation of the inframammary skin.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Heavy <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>s also interfere with a woman's ability to participate in sports such as aerobics and jogging. Finding fashionable clothes is also more challenging and difficult for large <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>ed women. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">These factors often lead to loss of self-confidence and increased self-consciousness. <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Breast</FONT> reduction <FONT SIZE="3" COLOR="#800000" FACE="Arial" >surgery</FONT> is the most therapeutic way to treat this condition. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This is performed in a hospital operating room environment. General anesthesia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> An inverted T incision is made through which maximal sculpting of the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >breast</FONT>s is possible. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The patient is required to remain for a 23-hour overnight stay for optimal post-operative observation. She is then re-evaluated by the surgeon in the morning on the first post-operative day, at which time the bulky dressing will be removed and the incisions will be checked.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> A more light-weight dressing and a support surgi-bra is then applied and the patient my be discharged home with relatives. </div> <div> <U><IMG SRC="1372c9f0.gif" border=0 width="300" height="159" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="138c3960.gif" border=0 width="195" height="150" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="139c3960.gif" border=0 width="195" height="150" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">breast lift<IMG SRC="13ac2010.gif" border=0 width="194" height="257" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="13bc3010.gif" border=0 width="195" height="257" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">breast augmentation<IMG SRC="13c735d0.gif" border=0 width="115" height="93" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="13d79610.gif" border=0 width="121" height="97" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="13e827d0.gif" border=0 width="130" height="125" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="13f827d0.gif" border=0 width="130" height="125" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></U></div> <DIV ALIGN="LEFT"></DIV> <div> S<FONT SIZE="6" COLOR="#FF0000" FACE="TIMES" >UBCUTANEOUS </FONT>M<FONT SIZE="6" COLOR="#FF0000" FACE="TIMES" >ASTECTOMY </FONT></div> <div> This operation may be indicated for some forms of <FONT SIZE="4" COLOR="#800000" FACE="TIMES NEW ROMAN" >breast</FONT> cancer, in women who have a high genetic risk of <FONT SIZE="4" COLOR="#800000" FACE="TIMES NEW ROMAN" >breast</FONT> cancer, and occasionally in those suffering from severe long-standing <FONT SIZE="4" COLOR="#800000" FACE="TIMES NEW ROMAN" >breast</FONT> pain. </div> <bR> <div> The operation involves the reconstruction at the same time as the removal of the <FONT SIZE="4" COLOR="#800000" FACE="TIMES NEW ROMAN" >breast</FONT> tissue. The procedure is not suitable for all women, and in cancer there is an element of risk incurred by leaving the skin and nipple intact.</div> <bR> <div> The <FONT SIZE="4" COLOR="#800000" FACE="TIMES NEW ROMAN" >breast</FONT> tissue is removed through an incision in the <FONT SIZE="4" COLOR="#800000" FACE="TIMES NEW ROMAN" >breast</FONT>, leaving the nipple, skin and a layer of fat intact. An <FONT SIZE="4" COLOR="#0000FF" FACE="TIMES NEW ROMAN" ><U>implant</U></FONT> is then inserted under the layer of fat or under the muscle on the chest wall.</div> <bR> <div> The procedure is performed under general anaesthetic and involves a hospital stay of around a week. Women are generally advised to wear a supportive bra for a period of time after the operation.</div> <bR> <div> The <FONT SIZE="4" COLOR="#800000" FACE="TIMES NEW ROMAN" >surgery</FONT> is associated with changes in skin and nipple sensation, and the presence of <FONT SIZE="4" COLOR="#0000FF" FACE="TIMES NEW ROMAN" ><U>scarring</U></FONT>. It may be necessary to perform <FONT SIZE="4" COLOR="#800000" FACE="TIMES NEW ROMAN" >surgery</FONT> on the opposite <FONT SIZE="4" COLOR="#800000" FACE="TIMES NEW ROMAN" >breast</FONT> in order to regain <FONT SIZE="4" COLOR="#800000" FACE="TIMES NEW ROMAN" >breast</FONT> symmetry.</div> <bR> <div> <FONT SIZE="4" COLOR="#0000FF" FACE="TIMES NEW ROMAN" ><U>Complications</U></FONT> include bleeding and infection, as with any surgical procedure. The implant can protrude through the wound, or can bulge through the fibrous sheath which the body forms around the <FONT SIZE="4" COLOR="#800000" FACE="TIMES NEW ROMAN" >breast</FONT>, or through a gap in the muscle</div> <bR> <bR> <bR> <div> <B>Tummy Tuck</B></div> <bR> <bR> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">T<B>ummy tuck is the surgical procedure to remove excess skin and fat from the middle and lower abdomen and to tighten the muscles of the abdominal wall. It is also known as "abdominoplasty".</B> </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The best candidates for "tummy tuck" are women or men who are in relatively good shape who have large fat deposits or loose abdominal skin that did not respond to diet , exercise or both. Women who had multiple pregnancies and stretched their abdominal muscles and skin will specially benefit from such a procedure. Older patients who are obese and lost the elasticity of their skin can also benefit form this procedure. Tummy tuck can be partial (mini tuck) or complete. Either procedures can be used alone or in combination with liposuction to achieve the results you are looking for. Ask your surgeon.</B> </div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Partial and complete abdominoplasties are usually performed as an outpatient procedures, in an outpatient surgical center, an office-based facility or a hospital.</B> </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This procedure can be done under general or local anaesthesia. Complete abdominoplasty usually takes two to five hours while partial abdominoplasty may take an hour or two.</B> </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Because any surgical procedure carry certain risks and possible complications, you should discuss the procedure in detail with your board certified plastic surgeon. See our page </B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B><U>"How to choose a plastic surgeon?"</U></B></FONT><B>.</B> </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">After </B><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B>surgery</B></FONT><B>, some people return to their jobs in two weeks while some others take three or four weeks before going back. The results of tummy tuck are usually long lasting if you keep your weight and exercise regularly.</B> </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"><IMG SRC="157960e0.gif" border=0 width="150" height="270" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="158dcfd0.gif" border=0 width="220" height="253" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="159e8fd0.gif" border=0 width="232" height="253" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="15a2dfd0.gif" border=0 width="301" height="253" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="15bf2e00.gif" border=0 width="242" height="224" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="15ce7c90.gif" border=0 width="231" height="201" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="15d2adf0.gif" border=0 width="298" height="223" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <U><IMG SRC="15ec7aa0.gif" border=0 width="199" height="170" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="15fb6aa0.gif" border=0 width="182" height="170" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="160f2aa0.gif" border=0 width="242" height="170" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="161cfaa0.gif" border=0 width="207" height="170" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="162fab00.gif" border=0 width="250" height="176" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="163fac50.gif" border=0 width="250" height="197" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="164e9aa0.gif" border=0 width="233" height="170" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="165f4aa0.gif" border=0 width="244" height="170" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="166c6b40.gif" border=0 width="198" height="180" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="167d8a00.gif" border=0 width="216" height="160" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="168c3970.gif" border=0 width="195" height="151" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="169aaaa0.gif" border=0 width="170" height="170" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="16aaeaa0.gif" border=0 width="174" height="170" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="16bd5aa0.gif" border=0 width="213" height="170" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="16cbfaa0.gif" border=0 width="191" height="170" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="16de5aa0.gif" border=0 width="229" height="170" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="16ec2aa0.gif" border=0 width="194" height="170" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="16fc4aa0.gif" border=0 width="196" height="170" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="16de5aa0.gif" border=0 width="229" height="170" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="171d0aa0.gif" border=0 width="208" height="170" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">one week evolution surgery</U></div> <div> <U><IMG SRC="172dcac0.gif" border=0 width="220" height="172" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="173dcae0.gif" border=0 width="220" height="174" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="174dab40.gif" border=0 width="218" height="180" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="175feb40.gif" border=0 width="254" height="180" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="176ffb40.gif" border=0 width="255" height="180" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="177e6ad0.gif" border=0 width="230" height="173" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">after 4 months</U></div> <div> <U><IMG SRC="178c5ad0.jpg" border=0 width="197" height="173" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="179c5b90.jpg" border=0 width="197" height="185" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="17ac69a0.jpg" border=0 width="198" height="154" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="17bc79a0.jpg" border=0 width="199" height="154" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="17cd29d0.gif" border=0 width="210" height="157" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="17dd29d0.jpg" border=0 width="210" height="157" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="17ed29d0.gif" border=0 width="210" height="157" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="17fdca70.gif" border=0 width="220" height="167" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="19d06660.jpg" border=0 width="262" height="358" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="19f06660.jpg" border=0 width="262" height="358" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="1a006660.jpg" border=0 width="262" height="358" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="1a106c70.jpg" border=0 width="262" height="199" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="1a106c70.jpg" border=0 width="262" height="199" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></U></div> <bR> </td> </tr></table></body>