4.3.4 Main Points of Surgery
（1）The design of surgical incision：under normal circumstances，breast incisions may be made with radioactive incisions or curved incisions.Generally when the tumor is located above the breast，the lump is usually removed by arc incision，and the armpit lymph node biopsy or cleaning can make another incision in the armpit，which is more hidden，so that the appearance is better and beautiful.Of course，sometimes when the lump is located at the end or above the breast armpit，it can also be made with a radial incision and extended to the armpit so that the armpit lymph nodes can be removed.The lesions located under the breast are made with a radial incision.With the use of tumor profile technology，the current breast cancer breast preservation surgery incision selection is not limited to radiation or arc incision，located in different quadrants of the block can use double-ring incision，diamond incision，racket-shaped incision，reverse T-type incision，similar to the reduction of breast forming incision，as well as a variety of individual surgical incision.Through tumor profile technology can be more convenient to remove more tumors around the breast tissue，and by transferring adjacent fat and breast tissue to fill，appropriate adjustment of the nipple position，so as to ensure the appearance of the case to improve the negative rate of cut edge，reduce the risk of re-surgery due to positive cut edge.It is generally believed that in the removal of breast tissue more than 20%of the one-sided breast can be used tumor profile technology forincision design and implementation of breast preservation treatment，after surgery the patient's breast will be relatively full and strong，if necessary，can also be at the same time to carry out the health breast profile.
（2）Skin removal：in order to maintain a better appearance of the local，it is not recommended to do extensive skin removal.If the tumor is not adhesion to the skin，the skin on the surface of the tumor can generally be retained，or only a small piece of skin on the surface of the tumor to be removed，the subcutaneous may retain some fat.In order to be beautiful，it is sometimes possible to remove the skin corresponding to the amount of de-removal glands，to ensure that the shape of the breast after stitching is relatively full，there is no obvious residual cavity.
（3）Separation of breast tissue：in the skin and subcutaneous tissue separation，and then to the depth of the breast tissue separation，pay attention to ensure a certain cut edge and normal tissue.Surgery as far as possible to expose adequate，from one direction to cut the tissue into the breast after the gap，and then with a finger into the breast after the gap，so that the entire specimen in the hands，can be relatively simple to grasp the width of the cut edge.
（4）The procedure marks the cut edge：in the operation，the removal of the breast specimen must be timely cut edge marking，timely send pathology test，clear edge，substrate whether there is cancer.Usually surgeons can use stitches to identify different cut edges and send them for pathological examinations.When frozen pathological slices or postoperative paraffin pathology examinations indicate positive cut edge，it is usually recommended that the procedure is widely removed；
（5）Wounded treatment：the wound surface should carefully stop the bleeding，place titanium clip mark at the cutting edge，guide the follow-up radiotherapy.If the removal of breast tissue is less，it is recommended to stitch the residual cavity to ensure the full appearance of the breast，but also can play a certain amount of hemorrhage，reduce the risk of postoperative fluid infection.If there is more breast tissue removed，no stitches are required without breast reconstruction.Because the seam can cause postoperative breast surface wrinkle and affect aesthetics，also due to too much consideration of the seam insufficient cut edge will be caused.When there are more breast tissue removed，you can use adjacent flap transfer to fill.After the wound surface completely stops the bleeding，usually place the drainage tube，very important is the postoperative pressure bandage and a certain brake.
（6）The definition of cut-off negative：Since the start of self-preservation of breast surgery，the definition of safe negative cut edge in clinical practice continues to develop and improve.The cut width of the tumor refers to the distance from the tumor boundary from the surface of the removed tissue.How much tumor cut width is considered safe negative cut？Early studies have reported that in breast-preserving cases，if the normal tissue around the tumor is removed from 0.5 to 1.0cm，then 95%of the cases are surgical cut circomatics test satology negative.Therefore，in order to obtain a negative cut，it is generally recommended to remove at least 1cm of normal breast tissue around the tumor.Subsequent literature indicates that although cutting-edge positively means higher local recurrence rate，there was no significant correlation between the size of the cut-edge width and the local recurrence rate in patients with cut-edge negativeness.As a result，subsequent clinical studies continue to attempt to reduce the width of the safety cut edge from 1cm to 1mm or less of feasibility and safety.More and more recentdata recommend the use of ink staining to evaluate the cut edge，and the rule of cut edge tumor-free（no ink on any cancer cell）can be recognized as immersion cancer cut negative.
（7）Common breast tumor shaping techniques：patients whose tumors are located in the lower quadrant，breasts are larger，breasts are obviously sagging，can use upper tweed，pour T breast forming（Superior-Pedicle，Inverted-Mammaplasty）.The procedure steps are shown in the figure below.
a.Preoperative incision design b.Decapitated c.Under wrinkle incision to cut the breast d.Retain nipple mastullbelicoccal complex to remove the glands beneath the breast e.tissue closing to breast re-stitching f.Extensive excision of tumors and surrounding tissue g.Stitching mouth Richard M Rainsbury.Nat.Clin.Prac.oncol.2007
Case Analysis 3.1
The patient's tumor is located in the right breast quadrant at 6 o'clock direction，and the right breast cancer prosthesis is performed with left breast mastectomy.
Preoperative design
postoperative
When the tumor is located inside of the breast，it can also be designed with inverted T-breast forming and racket-type surgery.
Clough，K.B.Ann Surg Oncol，2010
Case Analysis 3.2
The patient's tumor is located in the lower quadrant of the left breast.Operate left breast cancer breast preservation surgery and right breast reduction surgery.
Preoperative
Preoperative design
Postoperative position
postoperative side position
When the tumor is located in the upper quadrant，a double-ring incision can be used.(https://www.daowen.com)
Case Analysis 3.3
The patient's tumor is located in the right breast quadrant，operate the right breast cancer prosthesis plus the left breast shrink.
When the tumor is located in the outer quadrant，a racket-type incision can also be used.
Clough，K.B.Ann Surg Oncol，2010
Case Analysis 3.4
Patients's tumors are located on the outside of the left breast，operate left breast cancer preservation and breast reduction.
Preoperative design
Postoperative position
Postoperative Side
Adjacent fat lobe transfer can also be taken when tissue defects are large.
Case Analysis 3.5
Patient's tumor sits in the lower quadrant of the left breast，operate the left breast cancer prosthesis and near-fat flap transfer breast mammaplasty.
Preoperative
Postoperative
Case Analysis 3.6
Patient's tumor located in the lower quadrant of the outside of the breast，operate right breast cancer preservation surgery and near-fat flap transfer breast mammaplaty.
Preoperative design
postoperative