Breast cancer surgery has evolved enormously over the past two decades. The era of radical, disfiguring surgery as the default approach is long behind us. Today, most patients can choose from a range of surgical options — and the goal is always to remove the cancer completely while preserving as much normal tissue, function, and appearance as possible.

At Breast & Surgical Oncology at The Poche Centre, our surgeons perform the full spectrum of breast cancer surgical procedures — from minimally invasive in-room biopsies through to complex oncoplastic reconstructions. Every procedure we offer is performed by specialist breast surgeons with dedicated subspecialty training, supported by a full multidisciplinary team. No two patients or tumours are the same, and every surgical plan is personalised accordingly.

This page describes each of the procedures our team performs, from initial assessment procedures to definitive surgical treatment.

How Surgical Treatment Is Decided

Surgery is almost always the central component of breast cancer treatment, but the type of surgery that is right for you depends on a number of factors: the size and location of the tumour relative to the breast, whether there is more than one area of disease, whether the lymph nodes are involved, the tumour's molecular characteristics, your personal preferences, and your body's anatomy.

For some patients, neoadjuvant therapy — chemotherapy, targeted therapy, or hormonal therapy given before surgery — is recommended first. This may be to shrink a larger tumour to make breast-conserving surgery possible, to treat disease in the lymph nodes before surgery, or to assess how the tumour responds to systemic treatment. Your surgeon and medical oncologist will advise if this approach is recommended for your situation.
For most patients, surgery comes first, followed by adjuvant (post-operative) radiotherapy, chemotherapy, or systemic therapy as indicated. Your individual treatment sequence is decided at the multidisciplinary team meeting and discussed with you in detail before any decision is made.

All decisions are made with you — not for you. You will always have time to consider your options, ask questions, and, if needed, seek a second opinion before proceeding.

In-Room Procedures

These procedures are performed in our consulting rooms without the need for a hospital admission or general anaesthetic.

Bedside Ultrasound

Bedside ultrasound is used as a real-time adjunct to clinical breast examination. A targeted ultrasound of the area of interest can reveal additional information about the underlying tissue — whether a lump is solid or fluid-filled, whether its margins are well-defined or irregular, and its relationship to surrounding structures — that clinical examination alone cannot provide. Bedside ultrasound does not replace a formal diagnostic ultrasound performed by a specialist breast sonographer and interpreted by a radiologist, but it allows us to target in-room biopsies with precision and provide immediate additional clinical information during your consultation.

Fine Needle Aspiration (FNA)

Fine needle aspiration involves inserting a thin needle into a breast lump or lymph node — either directly if it is palpable, or under ultrasound guidance for impalpable lesions — to collect a sample of cells for cytological examination by a specialist pathologist. Local anaesthetic is not usually required. Results are typically available within 24 hours.

FNA is a useful rapid assessment tool, particularly for evaluating axillary lymph nodes and for aspirating cysts. However, because it provides individual cells rather than intact tissue, it gives less information about the cancer's characteristics than core biopsy. For breast lumps, core biopsy is always preferred as the primary diagnostic procedure.

Core Biopsy

Core biopsy is the gold standard for definitively diagnosing a breast lesion. Under local anaesthetic, a small hollow needle is used to remove several cylindrical cores of tissue from the area of concern, guided by ultrasound or mammographic imaging. The tissue is sent to a specialist pathologist who can confirm whether cancer is present and, if so, determine its type, grade, and receptor status — information that is essential for planning treatment.

Some minor bruising and tenderness at the biopsy site is expected for a few days. Results are typically available within 48 hours. A small titanium clip is often placed at the biopsy site at the time of the procedure to mark the location — this is particularly important if neoadjuvant treatment is planned before surgery, as the clip allows the original biopsy site to be precisely located at the time of the operation even if the tumour has responded significantly to treatment.

Aspiration of Breast Cysts

Most simple breast cysts do not require aspiration — they are harmless and can be monitored. However, cysts that are causing significant discomfort can be aspirated for symptom relief, and complex cysts that have features raising concern on ultrasound may be aspirated to obtain fluid for cytopathological examination to exclude malignancy. Palpable cysts are aspirated directly without ultrasound guidance; impalpable or complex cysts are aspirated under bedside ultrasound. Local anaesthetic is used as required. Results are available within 24 hours.

Operating Theatre Procedures

Breast-Conserving Surgery (Lumpectomy / Wide Local Excision)

Breast-conserving surgery — also called lumpectomy or wide local excision — removes the tumour together with a margin of surrounding normal breast tissue, while preserving the remainder of the breast. For the majority of patients with early-stage breast cancer, breast-conserving surgery followed by radiotherapy to the remaining breast tissue achieves equivalent long-term cancer outcomes to mastectomy, while preserving the breast.

The extent of tissue removed depends on the size and location of the tumour. Our surgeons use a range of oncoplastic techniques — combining cancer surgery with plastic surgical principles — to optimise the cosmetic result after breast-conserving procedures, reshaping and remodelling the remaining breast tissue to minimise contour irregularity and achieve the best possible aesthetic outcome. Where the opposite breast requires a balancing procedure (reduction, lift, or augmentation) to achieve symmetry, this can be performed at the same time or as a subsequent procedure and attracts Medicare and private health insurance rebates.

Occasionally, a second surgical procedure is required if the initial margins of excision are not clear — meaning cancer cells are found close to the edge of the removed tissue. A margin re-excision removes a further layer of tissue from around the cavity to ensure the cancer has been fully cleared. This is a common and expected part of breast-conserving surgery in some cases and does not indicate a failure of the initial operation.

Radiotherapy to the remaining breast is usually recommended following breast-conserving surgery to reduce the risk of local recurrence.

Mastectomy

Mastectomy — removal of all breast tissue on the affected side — remains the most appropriate surgical option for some patients, including those with large tumours relative to breast size, multiple areas of disease within the breast, patients who have previously had radiotherapy to the breast, and those who choose mastectomy for personal reasons including a desire to further minimise the risk of local recurrence or to avoid radiotherapy.

Several types of mastectomy are performed depending on the clinical situation and whether reconstruction is planned:

Total mastectomy removes all breast tissue and the nipple-areola complex through an elliptical incision across the breast.

Skin-sparing mastectomy preserves the majority of the breast skin envelope while removing all underlying breast tissue and the nipple-areola complex. This preserves the natural breast contour for reconstruction and significantly improves aesthetic outcomes compared to conventional mastectomy.

Nipple-sparing mastectomy removes all breast tissue from beneath the intact breast skin and nipple-areola complex, preserving the external appearance of the breast when followed by immediate reconstruction. This approach is suitable for selected patients where the tumour is not immediately beneath the nipple.

Breast reconstruction — either immediate or delayed — is available to most women undergoing mastectomy and is discussed in detail with every patient before surgery.

Breast Reconstruction

For patients undergoing mastectomy, breast reconstruction can be performed at the same time as the mastectomy (immediate reconstruction) or as a separate procedure after other treatments are complete (delayed reconstruction). Reconstruction can use implants, the patient's own tissue (autologous reconstruction), or a combination of both. Each approach has advantages and trade-offs depending on body type, treatment plans, and personal preferences.

Our surgeons have extensive experience in the full range of reconstructive options and will discuss what is most appropriate and achievable for your individual situation.

Sentinel Lymph Node Biopsy

The sentinel lymph node is the first lymph node — or small group of nodes — to which breast cancer cells would travel if they spread beyond the breast via the lymphatic system. Identifying and testing the sentinel node provides critical information about whether cancer has spread to the axillary lymph nodes, which directly influences staging and treatment planning.

Sentinel node biopsy is the standard of care for axillary staging in early breast cancer and has largely replaced the need for full axillary clearance in patients with clinically node-negative disease. Before surgery, a small amount of radioactive tracer and/or blue dye is injected near the tumour to map the lymphatic drainage. During the operation, a gamma probe is used to locate and remove the sentinel node(s), which are sent to pathology for detailed microscopic examination.

Patients whose sentinel nodes contain no cancer cells are safely spared the more extensive procedure of axillary clearance and its associated risks, including lymphoedema. For patients whose sentinel nodes do contain cancer cells, further axillary management is planned based on the extent of nodal involvement and other clinical factors.

Axillary Lymph Node Clearance

When breast cancer has spread to multiple axillary lymph nodes, surgical clearance of the axilla — removal of the lymph node-bearing fatty tissue from the armpit — may be recommended. Axillary clearance provides both treatment (removing disease-bearing nodes) and staging information (the total number of involved nodes influences treatment planning and prognosis).

An average of 15-25 nodes are removed in an axillary clearance. The procedure does not adversely affect immune function. The most significant risk of axillary clearance is lymphoedema — swelling of the arm due to disruption of lymphatic drainage — which affects approximately 15% of patients. Lymphoedema is well managed with lymphatic drainage massage and compression garments, and our team coordinates closely with specialist lymphoedema physiotherapists as part of post-operative care.

Targeted Axillary Dissection (TAD)

For patients who receive neoadjuvant (pre-surgery) systemic therapy, Targeted Axillary Dissection is an advanced technique that allows more precise removal of lymph nodes that were initially involved with cancer and marked with a clip at the time of biopsy. Rather than removing all axillary nodes (full clearance) in patients whose nodes have responded to neoadjuvant treatment, TAD allows selective removal of the marked node alongside the sentinel nodes, enabling accurate pathological assessment of treatment response while minimising the extent of axillary surgery.

Our team has contributed to published research on ROLL (Radio-isotope Occult Lesion Localisation) techniques used to identify the clipped node during TAD, reflecting our commitment to advancing surgical precision in this area.

Hook-Wire Localisation

When a breast abnormality detected on mammogram or ultrasound is impalpable — meaning it cannot be felt during examination — it needs to be precisely located for the surgeon before removal. In hook-wire localisation, a fine flexible wire with a small hook at its tip is inserted into the lesion under mammographic or ultrasound guidance on the day of surgery. The wire remains in place and acts as a guide during the operation, allowing the surgeon to accurately excise only the abnormal tissue while preserving surrounding normal breast tissue.

This technique improves both the accuracy of excision and the cosmetic outcome compared to less targeted approaches.

Radio-isotope Occult Lesion Localisation (ROLL)

ROLL is an alternative to hook-wire localisation that uses a small injection of radioactive tracer — the same material used for sentinel node biopsy — placed directly into the lesion under ultrasound or mammographic guidance before surgery. During the operation, the surgeon uses a gamma probe to detect the radioactive signal and precisely locate and remove the targeted tissue.

ROLL avoids the need for a wire protruding from the breast on the day of surgery and can be performed the day before the operation rather than immediately before. It achieves equivalent or superior precision to hook-wire localisation for excision of impalpable lesions and is the preferred localisation technique for many of the procedures performed in our practice.

SNOLL (sentinel node occult lesion localisation) is when a ROLL localisation is performed in conjunction with sentinel node mapping.

Microdochectomy

Microdochectomy is a targeted surgical procedure in which a single milk duct behind the nipple is selectively removed. It is performed when there is suspicious or blood-stained discharge from a single duct opening, suggesting a localised lesion such as an intraductal papilloma or, less commonly, an early ductal cancer.

Under general anaesthetic, the specific discharging duct is identified and cannulated with a fine probe through the nipple opening, which guides precise removal of that duct alone while preserving the remaining ducts and their function. Microdochectomy is particularly suitable for younger women who wish to preserve the ability to breastfeed from the remaining ducts after surgery. A small incision around the edge of the areola heals with minimal visible scarring.

Total Duct Excision (Subareolar Duct Excision)

When discharge is coming from multiple ducts, or when the specific discharging duct cannot be identified, total duct excision removes all of the major milk ducts from behind the nipple-areola complex. This definitively stops the discharge and provides the pathologist with a comprehensive tissue specimen for examination.

The nipple is preserved in appearance, but breastfeeding from that breast is not possible after total duct excision. In the great majority of cases, the cause is benign ductal disease (such as duct ectasia) requiring no further treatment. If an unexpected malignancy is found in the ductal tissue, further surgery may be required and will be planned accordingly.

Open Surgical Biopsy (Excision Biopsy)

Open surgical biopsy under anaesthetic has largely been replaced by image-guided core biopsy for the majority of diagnostic situations. It remains relevant in selected circumstances — where a lesion is atypical and requires complete removal for full pathological assessment, where previous core biopsy has been technically inadequate or inconclusive, or where a patient chooses to have a benign lesion (such as a fibroadenoma) removed rather than continuing surveillance.
Cosmetic skin-crease incisions, buried dissolving sutures, and waterproof dressings are used to minimise scarring and allow patients to return to normal activities as soon as possible.

What to Expect Around Surgery

Whatever procedure you are having, your surgical team will ensure you are fully prepared and informed. This includes a pre-operative appointment to review your medical history, discuss the procedure in detail, and answer any remaining questions; admission to one of our partner hospitals — The Mater Hospital or North Shore Private Hospital for private patients, or Royal North Shore, Northern Beaches, or Hornsby Ku-ring-gai Hospitals for public patients; and a recovery pathway tailored to the procedure performed.

Your breast care nurse is involved in your care from before surgery through to your follow-up appointments and beyond, providing practical information, emotional support, and a consistent point of contact throughout your treatment journey.

Discussing Your Surgical Options

Every patient's situation is different, and the right surgical approach for you will be determined by your specific diagnosis, your preferences, and a frank discussion with your specialist. We never rush this conversation. You will always leave your consultation with a clear understanding of the options available to you, what each involves, and what we recommend and why.

If you have recently been diagnosed with breast cancer or have been referred for a surgical opinion, we welcome the opportunity to meet with you.