Procedures

The type and complexity of the procedures ordered by Dr. Cross will vary greatly from person to person depending on each individual’s needs. Listed below are some of the more common procedures we perform.

Procedures Performed In-Office

Diagnostic Ultrasound
Diagnostic Ultrasound is recommended to assist in clarification of a questionable area found in the breast on mammogram, ultrasound or physical exam. If resolution can be obtained by further radiographic evaluation then no further surgery, views or work up is indicated. If placed into a 6 month follow up category, then this is considered standard of care and a follow up ultrasound will be recommended by your PCP, radiologist, or surgeon to ensure stability of the area. If an area is considered stable for 2 years this confers 98% chance of the area of concern being benign.

Core Needle Biopsy
If a lump has been found through examination, mammography, or ultrasound, a core needle biopsy may be used to diagnose the abnormality. The needle has a large center that removes a core of tissue from the lump. Core biopsies may be used with ultrasound or stereotactic equipment to guide the physician to the suspicious area. The procedure is performed in a breast center or clinic. The skin where the needle will be inserted is cleansed with an antiseptic to destroy bacteria. The area is then numbed by injecting a very small needle containing an anesthetic agent. Since the needle is large, you will feel pressure as the physician inserts the instrument. The needle removes a core of tissue that is sent to the pathology lab for evaluation. The pathologist informs your physician of the results of the biopsy, whether it is benign (not cancerous) or malignant (cancerous). The procedure should take less than 30 minutes. A small radiographic clip is placed in the biopsy cavity to identify the spot for future procedures. When completed, a small bandage will be placed on your breast and you can return to your normal activities. You may shower the same day as your biopsy. If a hematoma (accumulation of fresh blood appearing as a lump under the skin) forms from the rupture of a small vessel during the biopsy, inform your physician. This area may later show up on mammography as a change in your breast tissue. Infection is a rare occurrence with core biopsy.

Surgical Procedures (performed in the operating room)

Excisional Breast Biopsy
Is recommended to remove an area of breast tissue because it is considered abnormal or unusual in some way. Depending on the location in the breast there may be a visible scar, deformity or other complication post-operatively. This procedure has a low complication rate, but risks include bleeding, infection, wound dehiscence, and seroma formation. It may or may not require the use of ultrasound in-operatively to assist us in the removal of the area or finding the area before an incision is made.

Lumpectomy
Is a procedure when breast conserving surgery is being recommended. A wide excision will be performed to get completely around the tumor/lesion to ensure that none is remaining. The success rate for this operation is around 80-85% meaning that safe surgical margins have been obtained and that the tumor/lesion has been completely removed. There are times that one must go back for a second operation for additional margins or removal of additional tissue because of unknown tumor/lesion margins, clip migration, or other unlisted conditions that are rare. The risks from this procedure are bleeding, infection, seroma formation, wound dehiscence, or the need for a second procedure. Sometimes clear margins can never be obtained because the tumor/lesion is very complex and, in the case of malignancy, a mastectomy would be suggested to be performed at another time.

Biozorb

BioZorb is a three-dimensional marker that is placed into the surgical cavity when tissue is removed from an area of the body. It is made of a commonly used, bioabsorbable material. Its open spiral design enables the surgeon to secure the device within the surrounding soft tissue.

BioZorb contains six titanium clips that help define the treatment target site 3-dimensionally. Once implanted, the BioZorb marker can be viewed with clinical imaging such as ultrasound, mammography, MRI and CT.

Sentinel Lymph Node Biopsy
Is a procedure where an injection of radioactive Technetium sulfur colloid will be injected in a four point site around the Nipple Areolar Complex either the evening before surgery or the morning of surgery. You will be asked to massage the breast every 15 minutes to stimulate flow of the technetium throughout the breast and into the axillary region. With a special instrument called a gamma counter we will be able to find the sentinel node (1-3 Nodes) 95% of the time. This is the main draining lymph node of the tumor and if it is negative no further node dissection will be performed. There are times when a frozen section will be performed to determine if the LN has tumor present and if visualized under the microscope by a Pathologist then additional lymph nodes will be dissected from the axilla. There is little risk of lymphedema with a sentinel dissection but increased risk if a full dissection is necessary. If the sentinel node cannot be identified for technical reasons or anatomic reasons, then a full dissection will be performed. The risk of this surgery is bleeding, infection, pain, numbness, and seroma formation.

Axillary Dissection
An axillary dissection will be performed if there is evidence of cancer in the lymph nodes in the axilla (armpit). An axillary node dissection is a surgical procedure in which an incision is made under the arm and several lymph nodes from under the arm are removed and sent to the pathology lab for official diagnosis.

Total Mastectomy
This operation can be performed by removing as much as 90% of the breast tissue leaving only 10% to ensure survival of the skin with adequate blood flow. Our goal is to remove the tumor with greater than 2 mm margins. Sometimes it may be less than 1 mm and still be adequate. Every once in while the tumor may approximate an anterior (skin) or posterior (chest wall) margin, when this happens radiation therapy maybe needed but this will be determined by a Radiation Oncologist, Hemotology Oncologist and your surgeon. Most of the time there is no tumor on the opposite side but sometimes there is. When the nipple and areolar complex is removed then the result will be a small straight transverse incision. The reconstructive process is tedious using tissue expanders, dermal matrix, or other tissue flaps to rebuild the breast tissue. This process usually takes several operations and several months to complete. A new nipple can be rebuilt at a later time if desired. The complications from this procedure may include tissue loss, bleeding, infection, implant infection, implant failure, and possible dehiscence.

Modified Radical Mastectomy
Is recommended because breast conservation is not an option or the patient requests this operation. This operation can be performed by removing as much as 98% of the breast tissue. Our goal is to remove the tumor with adequate surgical margins with at least 1-2 mm margins, sometimes it may be less than 1 mm margin and still be adequate. Every once in while the tumor may approximate an anterior (skin) or posterior (chest wall) margin, when this happens radiation therapy maybe needed but this will be determined by a Radiation Oncologist, Hemotology Oncologist and your surgeon. The nodes may or may not be positive but we usually obtain about 15-20 lymph nodes sometimes it may be less. We remove the nipple, the areola, and a significant amount of skin and breast tissue plus some tissue behind the axilla to ensure complete tumor excision, clean margins and reduce excessive fatty tissue in the axilla. There could be prolonged drainage (seroma formation), wound dehiscence, wound infection, bleeding, cellulitis, and a significant large scar from the axilla to the sternum. Usually two drains will be placed at the time of surgery and there will be numbness on the chest wall, back side of the arm and sometimes down the arm. We see lymphedema occur rarely with this operation but the chance will increase if there are needle sticks, blood pressures, and any trauma to the arm. If radiation is required to help with your survival rate, the chance of complications increases. This is the standard operation for extensive cancers, high grade cancers, inflammatory cancers or unusual cancers, and especially those with many positive lymph nodes under the arm. Most people do well but sometimes fluid collections form when the drains are removed, when this happens this requires multiple aspirations to remove the fluid. The fluid is usually harmless and seldom is infected but there are times we will request antibiotics to be taken on and off as needed. Typically it takes 4-6 weeks to recover and return to normal activities. Sometimes exercise regimes are required for strengthening of the shoulder to help with range of motion.

Skin-Sparing Mastectomy

Skin-Sparing Mastectomy with reconstruction (NIPPLE-SPARING): This operation can be performed by removing as much as 90% of the breast tissue leaving 10% to ensure survival of the skin with adequate blood flow. Our goal is to remove the tumor with greater than 2 mm margins. Sometimes it may be less than 1 mm and still be adequate. Every once in while the tumor may approximate an anterior (skin) or posterior(chest wall) margin, when this happens radiation therapy maybe needed but this will be determined by a Radiation Oncologist, Hemotology Oncologist and your surgeon. The reconstructive process is tedious using tissue expanders, dermal matrix, or other tissue flaps to rebuild the breast tissue. This process usually takes several operations and several months to complete. Most of the time there is no tumor on the opposite side but sometimes there is. The more skin that is left in place the more difficult the procedure, but the best reconstructive results are obtained in this manner. Leaving the whole nipple areolar complex in place can be done but it may have a higher risk of recurrence, loss of sensation to the nipple, full loss of the nipple, discoloration. This may be recommended at times when the tumor is far away from the nipple or the tumor is small. A request can be made to save the nipples and if deemed safe and with minimal chance of recurrence it can be performed. It is more technical, but once again it is a chance for a superior reconstructive result. The complications from this procedure may include tissue loss, bleeding, infection, implant infection, implant failure, and possible dehiscience.

Breast Reduction 
Reduction for macromastia is being recommended because of neck pain, breast pain, inframammary rashes, indentations in your shoulder region from bra straps and just generalized heaviness of the breasts. This operation will reduce the size of the breast by about 1/3 the previous size. There will be multiple incisions such as vertical incisions and a large inframammary fold incision that could result in excessive scarring around the nipple areolar complex region. Usually a drain will be placed for 1-2 days. It could take as long as 2-3 months for the breast to heal and may be sore for up 6 months. Loss of sensation around the nipple and sometimes even complete loss of the nipple areolar complex has been known to happen, along with bleeding, infection, and inability to produce milk or properly breast feed in the future. There will also be scarring on the mammogram in the future which could lead to further diagnostic testing, or even future biopsies because of excessive scarring on the inside of the breast tissue.

Oncoplastic Breast Surgery
Oncoplastic surgery combines the plastic surgery techniques with breast surgical oncology. If a large lumpectomy is required that will leave the breast distorted, the remaining tissue will be rearranged to give the breast a more appealing cosmetic appearance. The contralateral breast can be modified to create symmetry.

Stereotactic Breast Biopsy
A stereotactic breast biopsy is a safe and minimally invasive form of breast biopsy used to obtain samples of abnormal breast tissue that are seen on your mammogram that cannot be seen by using an ultrasound machine. The abnormality in your breast is precisely located with a computer-guided imaging system and removed with a vacuum-assisted needle. Stereotactic biopsies are most commonly done if you have been diagnosed with microcalcifications, and occasionally for breast lumps that cannot be seen using ultrasound machine. Stereotactic biopsies are done on an outpatient basis and require only a very small incision which helps minimize the amount of pain experienced.

 




Dr. Cross Reports Positive Findings from Use of 3D Marker in Breast Cancer Treatment

FAYETTEVILLE, Ark. – A research study by local surgical oncologist Michael Cross, M.D., F.A.C.S., concluded that use of the BioZorb® surgical marker appears to provide better cosmetic outcomes and may be associated with an increased use of breast-conserving surgery in his practice. The study found that more than 90% of patients who received the implant […]

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