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mhm. Then if I make you a host, and that should allow you to share your screen. Okay, let's try. I think that's my memory showing that. Brilliant. There we go. Are you sorry? I'm just going to open my presentation. Are you able to see that? Yes. Yeah, I can see that. All right. Um, okay. So, um, I'm usually one of the surgeons specialists, surgeons at the Royal Study County Hospital in the breast unit. Um, I'm just going to talk to, um, you guys about introduction to press surgery. Um, thank you for giving me this opportunity to talk to you guys via this platform. So, um, initially, just a bit of a background about the anatomy of the breast. Um, so we, as we all know, there's a memory line that runs across on both sides, cutting cuts along sort of the midclavicular midaxillary lines and runs pretty much up to the groin and, uh, somewhere around the fourth intercostal spaces. So it's where the nipple area, where complex starts developing and between the second and the sixth intercostal spaces, is usually where the breast tissue lies. Um, it has a regional drainage into lymph nodes. So the first station lymph nodes being in the axilla. Um then, uh, into the internal memory lymph nodes as well as the supraclavicular lymph nodes. So these are all the regional lymph nodes for the breast. If you look at the anatomy of the vascular structures so mainly supplied by branches from the internal thoracic artery immediately and then we have the lateral thoracic artery, which is a part of the axillary, which is a branch of the subclavian. And then you also have some branches coming in from the posterior intercostal arteries. It's quite important to know this anatomy, as it really helps you while you are on the table at the time of the surgery, is so why don't we talk so much about breast disease is, um So, um, uh, you, as you might be knowing breast cancer is a very, very common disease. So in the UK, um, almost one in every 7 to 8 women is diagnosed with breast cancer during her lifetime. Um, and, um, a lot of women do present with not just cancerous, but also non cancerous, uh, conditions like benign, some cysts, nipple discharge, etcetera throughout their lifetime. And unlike other organs. Um, breast is one of the organs which is very, very responsive to the hormonal changes in our body. And, um, it undergoes a lot of change through different life phases. Um, and there are different sort of conditions that could be associated in different stages. Um, and also, breast cancer in itself is a disease, which is, of course, much more common over the age of 60 but can also be seen in quite young women. And it is quite an important, uh, disease just because of the prevailing of it. Um, so in terms of, um, what could be the presentation? So most common symptom usually is, um, a a lump in the breast. Uh, it could be the painless or painful. We always look for. What is the duration? What is the size of the lump? Um, and whether it is associated with any other changes, so you could see other changes. Say, for example, in the skin, there could be some nipple discharge, maybe another lump in the armpit. Um, some other changes, like you might, uh, you know, see patients who present with one breast, which looks seems a bit smaller than the other, uh, so if there are deeper situated lung changes, they might cause a change in the size or shape of the breast. That might be the attraction of the nipple, uh, etcetera. So there are a lot of, um, symptoms that patients can present with, um, also another important symptom that we see quite often it's breast pain, which is not the symptom which is associated with malignancy as much, but it can be quite distressing. So we do see a lot of patients with breast pain as well. So when we see patients with any symptoms in the clinics, how do we go ahead to diagnose what is the root cause? So what it's called us is triple assessment. So one thing is that we take that complete history. So age, menopausal status, any previous breast related problems, any family history of breast or ovarian cancer if they've had any surgeries on their breasts in the past, Um, etcetera, etcetera. So we take all detailed history and, of course, you know, other health conditions, etcetera, Um, after that, a thorough examination by a breast physician, a clinician or a surgeon? Uh, that's one part of the triple assessment The second part is the radiological assessment. So, um, we either do a mammography of if the person who's presenting is age 40 or bowel or we do an ultrasound scan as a first test in radiological investigations. Um, mammography is also complimented by an ultrasound in each over 40. And then we think, you know, if you need to do any other radiological investigations like an MRI, et cetera, that is further if required. Uh, so that is the second component of triple assessment. So thorough radiological evaluation of the breast. One of the new things that is also come up is called tomosynthesis. So, um, it is basically a detailed mammogram in which you get a mammogram in itself is a two D image of the breast. Whereas in tomosynthesis, you get sort of like a, um, sort of a three D image in the sense that you get different sections or slices of the breast as a picture. So you can see certain areas which might be masked because of overlapping of the breast tissue. It can be seen slightly better than tomosynthesis. So different units have different, um, ideological investigations that are used. Um, then the third component of triple assessment is called as guided biopsy is usually done under ultrasound guidance. Uh, sometimes if the lesions are very superficial or very well palpable or sometimes even ulcers, etcetera. The biopsies might be clinical biopsies, but that is the third component of triple assessment. And in the biopsies you would either have an epiphany, which is which is quite sensitive. But you need a really good pathologist to read. The FDA is properly, but the gold standard is usually a core biopsy in which you get a good piece of the tissue to have a look at under the microscope. So this is just an example of a mammogram. You can see that there's a lump close to the pectoral major muscle at the back of the breast. There, um, be usually take two views on the mammogram. One is the CDC view in which you can see whether the lump is in the medial or the lateral aspect of the breast, and one is the love you in which you can see whether the changes are in the upper or the lower part of the breast. Um, and that is the ultrasound picture. So whatever abnormality seen on the mammogram is always corroborated with an ultrasound, and the ultrasound actually helps us to the biopsies as well. Sometimes you can see some changes on mammograms like calcifications, which are probably not seen on ultrasound. And then we need to do. Biopsy is guided by mammogram. So whenever we do anything, whether we do an examination or radiological investigations or even the biopsies, all these are categorized according to What is our level of suspicion? Um, and that is called as bi rads. So that is a short form initially started for the radiology of breast. But now pretty much even an examination and the biopsy reports are reported based on this, um, so it's breast imaging reporting and data system and, um, basically has six categories. So if we are uncertain and we cannot comment on all the examination is incomplete, etcetera. Then it's categorized as zero one is normal. Examination, too, is if you feel something that you feel it's benign. Uh, three is probably benign, but a very, very small chance. So less than 2% chance that it might be something suspicious, so slightly indeterminate. Uh, then four onwards, it starts becoming more suspicious. And six is when you have findings which you have already been proven to be cancer on biopsy. So the important thing to understand here is that if an examination, your biologic category is five. But on radiology, your category is one or two. You would still consider doing a clinical biopsy because the higher category of BIRADS in either of these is considered to be the biologic category for that particular presentation. So you will not discharge a patient if you have suspicious clinical findings despite radiology being normal. Um, so we see a lot of conditions in the breast quite commonly in benign conditions. We see very frequently like we spoke about breast pain. Uh, then we see infections like mastitis, which might be associated with lactation or not, abscesses, cysts, uh, benign lumps like fibroid. Enormous. Um, then we have certain intermediate or indeterminate conditions. Um, these conditions basically are associated with a small risk of developing into cancer in the future, or even having associated cancer within them. Um, and these are categorized as violence category three. Or when we do the biopsy, we categorize them as three as well. Um, and some of them are papillomas. Um, some atypical changes. Radial scars, Uh, some hyperplasia is etcetera. So in these conditions, what we basically do is that we biopsy that area further, or we sample that area further, sir. Surgically, uh, so as to rule out any associated malignancy. So there is a chance that, um, these conditions might be upgraded into being associated with either preinvasive or invasive cancers in about 10 to 15% of the times. Um and then you have malignancies in the breast so you can have one C two or three invasive conditions, which is doctor carcinoma in situ lobular carcinoma in situ. And then you have invasive cancers. Most common cancers in the breast are carcinomas. You can also sometimes see sarcomas, all certain skin malignancies like melanomas. Um, sometimes some very rare tumors, like salivary gland like, you know, gland tumor type, looking lumps, etcetera. But the most common malignancies in the breast are carcinomas. So when we look at carcinomas, um, there is a very typical pathway that the breast cancer cells follow. So if you look at the normal duct, usually in the pathway, the changes that happen at the molecular level, generally start with what is like a ductal hyperplasia. Then it starts becoming a bit atypical, Um, when it increases further to becoming more abnormal, but it's still confined within the milk duct. It's called a ductal carcinoma in situ or D. C. I. S. And then when it invades the wall of the duct, it's called an invasive carcinoma. So this is just some pathological subtypes, most common cancers in the breast, that invasive ductal and invasive lobular cancers, and then in in see to carcinomas as well. You have a doctor and not regular. The management for these pathological types surgically is pretty much the same, but it definitely helps in prognosis and sometimes also helps a certain what the cancer's might be sensitive to, based on the main pathologist and the type. The next thing on pathology that we look at is immunohistochemical tree, so we look at what the cancer cells are sensitive to, so the most common growth factors that we see on breast cancer cells one is the er receptor, or the estrogen receptor and P R. Or the progesterone receptor, which are the female hormones and the other growth factor that we look out for is called us the whole two new receptor, which is quite typically seen in breast cancer and sometimes in some, um, gastric cancers. So these three growth factors are what we mainly look out for. The majority of the breast cancers have the estrogen and progesterone receptors, so estrogen and progesterone in the body is a growth factor for breast cancer. Um, whereas there are maybe around 15% of the cases which have the whole two receptor, around 15% of the cases do not express any of these growth factors. But they have some other growth factors which we don't really have very good targets for yet, and they are called a triple negative. Breast cancers. These are seem to be slightly more aggressive types of breast cancers. Um, then we look at the staging. So based on the size of the tumour number of lymph nodes involved, which regional lymph nodes are involved and whether there is any distant metastasis or not, um, also local involvement of the skin or the chest wall by the tumor, et cetera. We have what is called as the American Joint Society, uh, staging for breast cancer, a JC C staging or the TNM staging. Um, and this is purely based on the anatomical extent of the disease. Uh, there is also a modification to the age a CC staging which income? It operates the immunohistochemical tree because, as we mentioned previously, triple negative cancers are slightly more aggressive. So, um, it has been found that, um say stage two triple negative breast cancer will probably do much worse than a stage two er pr positive breast cancer. So there is a modification in the A. C. C staging system, which accounts for this prognosis based on immunohistochemical tree. Then there is also molecular classification of breast cancer. So that is basically what I wanted to bring all this up is also to highlight that there is a lot of scope for a lot of research right down to molecular level when it comes to breast cancer and all these help in tailoring the treatments, um, for the patients. So when we talk about treatment for breast cancer, I'm mainly focusing on breast cancer because I believe the main aim of the talk is to talk about different types of breast surgeries. Um, and, um, uncle surgery is is probably the most common breast surgery that's done. Of course, I'm not going to cover cosmetic in the sense, um, just for cosmetic type of augmentation, etcetera type of surgeries in this talk. Um, but we are mainly going to concentrate on breast cancer. Um, so in terms of the treatment for breast cancer, the main line of treatment almost 70% of the treatment burden is taken care of by surgery. And surgery is offered to, um, all the patients, um, except those who have metastasis. Um, the main aim of surgery is when we treat with the curative intent. So if there is metastasis and that is spread beyond the breast, then we're probably not going to cure the patient with surgery. And hence why surgery is not the main line. In that case, we do offer surgery for patients with metastasis, mainly for local control, like Valium, domestic, Tommy's and things like that. Then the other modalities of treatment that we use in case of breast cancer are radiotherapy. Chemotherapy, targeted therapy based on the growth factors and endocrine therapy which mainly acts against er and PR. If you look at the history of, uh, surgery for breast cancer, then radical mastectomy. Um, was, uh, you know, first performed by Sir William Halston in 18 82. Um, then there have been a lot of changes as there was advancement in terms of the other local regional systemic treatments with radiotherapy, chemotherapy and endocrine therapy like tamoxifen. Um, also, one important landmark in this development was in 1976. Uh, when, um ser Bernard Fisher proved that a lumpectomy was as effective as a mastectomy because still, then anyone having breast cancer would have a radical mastectomy, and the thought was that if you preserve the breast, that is going to be very detrimental for the patient. Um And then then after we have other advancements mainly in the recent years about immunohistochemical tree, about image guided biopsies about genetic profiling of cancers. And also, um Initially, when treatment for breast cancer started, it was more about how radical you can be in your treatment, whereas now the main aim is to do as little as required. So things like doing a sentinel node biopsy instead of taking out all the regional lymph nodes, etcetera. All these things have developed in the recent past years, so this is just a brief overview about a modified radical mastectomy. So this is quite different compared to a radical mastectomy as it started. Um, so this is called modified radical mastectomy, in which mainly what is done is, um, the exercise Most of the skin on top of the breast with the nipple areola complex. We try and exercise as much breast tissue as possible. Um, and, uh, we excise it from just under the skin as well as excited off the pectoralis facia, and we leave skin enough to give a straight, uh, sort of flat scar across the chest wall. Um, there are various indications for a mastectomy. This is not the most common surgery that we do at the moment. Because at the moment, the most common surgery that we do is preserving the breast. Um, so indications for a mastectomy are, of course, um, related to the disease. If you have multifocal disease involvement of a lot of the breast tissue with cancer, uh, or if the patient chooses to have a mastectomy, then, um, we offer this type of procedure. Um, also, one important thing to remember is that whenever we preserve the breast at the time of surgery for breast cancer. We recommend radiotherapy to the rest of the breast to reduce risk of local recurrence. So if there are any contraindications for radiotherapy, then again, probably mastectomy would be a surgery of choice. Uh, then just a brief overview about what we do for the axilla. So in the mastectomy, we've just spoken about what we do for the breast. What we do for the lymph nodes for under the armpit is, uh, based on what we find in the lymph nodes. So when we do the triple assessment, we check for the lymph nodes under the armpit. If we have any suspicious findings in the breast, if we find any suspicious looking lymph nodes will biopsy them to see whether there is any spread of cancer cells to the lymph nodes or not. And what we do with the rest of the lymph nodes depends on what is the assessment of the lymph nodes at baseline. So if there is spread of cancer cells to the lymph nodes at baseline and surgery is our first line of treatment, then what we do is what is called an auxiliary clearance. So we basically remove the lymph glands from underneath the armpit, and I'll go through the details about that shortly. But if to begin with, the lymph nodes under the armpit are completely clear, and there is no spread to the lymph nodes. They all look normal on the ultrasound, and there's nothing suspicious on examination as well. Then what we do is called a sentinel lymph node biopsy. So, basically, um, there is an injection of a radioisotope in the breast. We also sometimes use blue dye. Um, and what it does is basically help us map out the first station lymph nodes, which are draining anything that is coming out of the breast. And what we do is at the time of surgery, we first sample these lymph nodes. We get them tested intraoperatively. See if there is any spread to the cancer spread of the cancer cells to the lymph nodes, and then take a call. What needs to be done with the rest of the axilla. Um, this is because it has been seen in a lot of studies over thousands of women that there is no benefit with doing over radical procedures when you don't need to. There is no survival benefit of removing normal lymph nodes or normal tissue. Um, even in cancer patients. Hence why we try and have a very systematic and staged approach when it comes to the AXILLA. Then this is a bit about, um, auxiliary clearance. So, as I mentioned, we do an auxiliary clearance for patients who have spread of cancer cells, um, to the axillary lymph into three groups. Level one is, um, the lymph nodes, which are present lateral and inferior to the pectoralis minor muscle. Level two are the lymph nodes, which are present behind the pectoralis minor muscle, and level three are the ones which are medial to the pectoralis minor muscle. So the extent of axillary clearance depends on, um, how many lymph nodes look abnormal and also on the table? What? You know, I feel how how bad the disease feels like, um, we decide the extent of the axillary clearance. Um, there have been some trials which have also recently looked at not doing an axillary clearance. If there are 1 to 2 lymph nodes positive on a sentinel lymph node biopsy, um, they are very strict criteria for that. So very early disease older patient's e er pr positive patients, patients who are definitely going to receive radiotherapy because they they have the best preserved et cetera. But out of those conditions, the standard for any amount of lymph nodes involved in the axilla is an axillary clearance. Um, when um in the area of radical mastectomies, when axillary clearance used to be a part of the surgery, it used to be extremely radical as well. Uh, you know, decision of the minor muscle pick, major muscle axillary vein, LDL particle. Um, all the nerve to say it is in the cost of regulars, etcetera. But now the way we do the procedure is that obviously we preserve all these vital structures and we are as less radical and try and preserve the function as much as possible. Um, then I just put in a slide about reconstruction. So when we discussed mastectomy with any patient, we always also discuss reconstruction to see if that is what they would like to do. And, um, reconstruction can be mainly divided into two types. Um, one is doing reconstruction using the patient's own body tissue called autologous reconstruction, and the other is using implants. Sometimes You've also seen a combination of both being used. Um, so there are pros and cons of using each technique. Um, end of the day it comes down to what is the choice of the patient and what is technically feasible. Um, when we do reconstruction, um, as a primary procedure along with the mastectomy, what we try and do is preserve the skin and develop on the breast. So sometimes we also preserve the nipple area like, um complex, if that is feasible, um, and that skin envelope basically access the pocket in which we place the implant, um, either under the muscle or over the muscle. And we also use certain slings or certain mesh like structures to hold the implant in place. But basically, the breast skin forms the external covering of your reconstruction, uh, in terms of autologous reconstruction. So, um, these are mainly sort of free flaps, which means that, um, tissue from elsewhere is taken up along with its blood vessels, and these blood vessels are then plugged into with microvascular procedures into the intercoastal blood vessel. So the internal memory blood vessels, um and sometimes you also have pedicle flaps. The pedicle flaps are, for example, the lattice most Alzheimer still on the back. The blood supply is preserved to the flap, and we basically swing the muscle from the back to the front to fill in that pocket of um, which is created by the skin over the breast. And if you're using these kinds of reconstructions, then you sometimes also need an implant to give that enough amount of volume. So it might be even combinations that are used. But this is sort of a gist of you know what breast reconstruction involves. Um and um, it's It's sort of goes hand in hand nowadays that whenever we talk about mastectomy, we always always mention reconstruction to the patients and get an idea from them as to what they would like to do, then talking about breast conserving surgery. So if you have, um, you know, majority of the patients that we have for surgeries are for breast conserving surgeries. Um, as we have discussed earlier. Um, it has been proven in a lot of studies and a lot of research that breast conserving surgery has in fact probably better survival outcomes as compared to mastectomies, and it's definitely not inferior in terms of, uh, oncological safety to mastectomy. So breast conserving surgery is also probably the first thing that we discuss with the patients when they come in with a disease which is amenable to breast conservation. Um, So, um, what we mainly do is we excised the area of the cancer or the preinvasive or the D. C. I s changes with a good margin of normal tissue around it. According to our association of re surgery guidelines, we need at least one millimeter clear margins under the microscope. So we exercise in the area, and then what we mainly do is that we move in the surrounding breast tissue to cover the defect. So we basically preserve the breast. Um, we either put the incisions on the lumps based on if the skin is too close or we put them around the nipple areola complex or, you know, under the breast over the lateral skinfold to make it as cosmetic as possible. Um, important with here is that radiotherapy is offered to all the patients who have a breast conserving surgery. Um, for maybe for some of the D. C. I s. If it's it's a very low grade or a very, very early stage of the CS, then probably radiotherapy might not be required. But whenever we talk about breast conserving surgery, we always always talk about radiotherapy. And if there is any chance that the patient does not want radiotherapy or has had radiotherapy in the past etcetera, then we would be a bit cautious about doing breast conserving surgery, of course, again in, um, uh, you know, a lot of studies. It has also been saying that probably, um, elderly patients with early stage might be able to get away with radiotherapy, and it might be safe to avoid radiotherapy. But all those decisions are made based on the postoperative results. And hence, when we discussed the procedure, we always talk about radiotherapy with the patients. Um, and as I was mentioning, um, breast conserving surgery of any form it seemed to be, um, having a much better quality of life outcome is compared to having a mastectomy in patients, Um, and probably also linked to having better survivals. Um, so we have a gray area in between, so some patients are very, very suitable for a simple breast conserving procedure, whereas some need a mastectomy as as an outright procedure that you can see from the beginning where, as there are some patients who lie on the cusp of whether you know we can preserve the breast or not etcetera because it all depends on what is the size of the tumor or what is the volume of the tissue that you need to exercise. Um, compared to what is the amount of breast tissue that we are going to leave the patient with? Uh, so the name of all these procedures is to leave the patient with the breast, which is which has a decent size and shape and fits the body image of the patient. So sometimes, if the size of the tumor is slightly bigger compared to the size of the breast, and you're not able to offer a simple breast conserving surgery, what we do is called is an uncle plastic breast procedure, and this helps avoid a mastectomy. So what we basically do is that, um, we excised the area which is affected, Um, and then we reshape the breast in a slightly different way, so we might have to reposition the nipple, or we might have to reduce the size of the breast as a reduction. Um, sometimes we might also need to do symmetrization on the contralateral side. Um, but all these procedures basically help us try and preserve the breast tissue for the patient because it's been seen that preserving breast tissue definitely gives much better outcome in the long run. Not just quality of life, but emotional well being. Physical wellbeing. Um, and, um, definitely has better outcomes in terms of, you know, when you compare it with the mastectomy and also, if you compare it with mastectomy and reconstruction, then these procedures are slightly less invasive. Um, if if you compared with the auto industry construction and also have slightly less amount of complications when you compare them with implants, etcetera, Uh, so this is sort of, you know, just about incapacity. So when we talk about uncle plastic breast procedures, we, um there are different types of one thing is the simple one that we spoke about, and we just remove the lump, removed the surrounding tissue, cover the defect, and then we close the skin scar. The next bit is slightly complex, so we, uh, there is a greater movement of the breast tissue. Uh, so, uh, if you remember, we saw that slide of blood supply to the breast. And there are 34 main areas where the breast gets its blood supply from and we mainly concentrate on the pedicles with supply the blood supply to the, uh, political complex, Um, and, uh, to try and preserve the nipple areola complex. We then move breast tissue around based on these vascular pedicles that are seen. Um, according to the anatomy of the breast, um, I've just sort of demonstrated some pictures. So in the first one, you can see how we try and move the nipple on the top of it is based on what is called as the inferior pedicle of the breast. So the blood supply is coming from the bottom part of the breast. You're able to remove the lump or the cancer in the lateral part and then move the tissues together. So what happens is the breast becomes small part of the nipple area complex comes a bit higher, but you're able to maintain the shape of the breast. Um, a lot of these patients do require some type of symmetrization on the other side which can either be done at the same time of the cancer surgery or can even be done as a delayed procedure. Uh, then in terms of like a plastic surgery, there are also some volume replacement techniques. So we spoke about the L D. Lab, which comes in from the spring in the muscle from the back to the front. Um, so there are certain flats which are again based on these blood vessels that we were talking about, but they do not, um, involve movement of any muscle, but mainly skin and subcutaneous tissue, which is moved around. So you have issues coming in from the lateral aspect of the chest wall or the back, which is the lateral thoracic. Um uh, flap or you. It's also called one of the fax is called that could also artery perforators flat. Or you have the lateral intercostal artery perforated flap, and you have similar intercostal perforators immediately as well as anteriorly. So these flaps can also be planned for patients who probably are not very suitable even for mammoplasty so possibly small to medium sized breast, but clean on preserving the breast issue and based on the location of the tumor within the breast. We can then see, um, which of these pedicles can be used if you want to avoid mastectomy. So I've just given you just about breast surgeries and breast procedures. Um, no surgery is, you know, not associated with any complications. Uh, we usually talk about certain, See equally that are associated with breast surgery. So one thing is collection of fluid or Ciroma, um, happens with almost all the patients, especially more in the ancillary. If there is an axillary clearance, or if you have had a lot of movement of the breast tissue within the breast, then we see more aromas. You do get numbness because the breast tissue is right under the skin, so that area, or even the nipple areola complex, can feel quite numb. So these are pretty much associated with the surgical procedure rather than being categorized as a complication from the surgery. Um, usual complications that we talk about infections in less than 5% of the cases we talked about, um, hemotomas again. Less than 5% of the cases. Um, in terms of implants, we always, uh, occupations about, you know, loss of implant, uh, infections associated with implants. The implants being rejected can happen in about one in 10 cases. Uh, similarly in flaps, we talk about partial or complete loss of the flap. Um, you know, if the blood supply to the flap is affected in any way, but that is quite rare, as compared to complications with implants. Um, the most important thing is because there are so many options. Uh, it can sometimes be quite difficult for the patient to make a choice for herself or himself. So it is very important to be able to discuss all the pros and cons, um, of the procedures, Um, that can be done, the technical feasible as well as, um, what it means in the long run so that the patient is able to make an informed choice. We also try and show some pictures. We, especially for some reconstructions. We try and get them to maybe see somebody who's had a reconstruction to talk to other patients who have undergone through same procedures, et cetera. Okay, so I was told that, um, through my talk, I should try and, uh, you know, revisit why I chose breast surgery and maybe try and inspire some of you, um, to choose breast surgery as you progress in your career. So, uh, I think the breast surgery is is a good mix of things. So we have very busy clinics, so it's a lot of clinical work. Um, because out of 100 women, probably that we see in the clinic, maybe eight or 10 will have cancer or precancerous changes or something surgical that needs to be done. But if, uh if you're somebody who really likes to clinically interact with patients, then it's It's definitely a very, um, you know, clinically rewarding in that sense. Um, it is a good mix of benign conditions as well as cancerous conditions. Um, uh, So, um, you get to see a good spectrum of changes across the board. Um, it is a very bespoke type of specialty. So, um, one good thing is, it does not, in a way affect function, as in, you know, patients are eating, drinking, following. You know, it's not associated with difficulty in, uh, any main functions of the body in that sense. But at the same time, it definitely has a huge impact on body image. And, um, you know, the emotional state and wellbeing of the patient. So it's a very bespoke specialty. Um, so cosmetic, um, surgery is quite an important part of this procedure, because whatever we do is immediately visible to the patient. So, um, that is that is something that is very important when you think about breast surgery. Um, you have a big team. So, um, you you always get an opportunity to interact with the big team. You have the plastic surgery team. You have radiologists, you have. You know, specialist, you have the medical oncology team radiation oncology team. So it's a big team work, so that makes the work even more interesting. And what makes it, um, uh, you know, really, something very interactive is the availability of a lot of options. Another good thing I that I personally feel about breast cancer is that over the years, the outcomes have improved a lot. So, um, for stage one disease, um, five year survival is more than 90%. So, um, in that sense, as a surgeon, it encourages you to treat the patients. It is not that you're seeing patients with a lot of these small outcomes. Every now and then so you get to see patients with very good outcomes and, you know, having happy fulfill life even after treatment, which is very satisfying. Um, and I haven't really spoken much about screening, but that then helps reinforce benefits of screening. So that is another part of the team that we are closely integrated with is our screening team. Um, one more important bit is a school for clinical research. So because the incidence of breast cancer is so high, the number of cases are so high it is, quite, um, a useful thing in the sense that it really helps you in terms of research in terms of getting numbers to see, um, you know what can be beneficial? What can be so you can sort of have a lot of school for clinical research in in in the sense of outcomes, Long term studies, feasibility studies, patient reported outcomes and things like that. So there's a very good school for clinical research, so it's it's not something that's just doing your work of surgery and seeing patients etcetera. But you can also simultaneously work on a lot of projects and stuff. Um, and we also spoke about I just give you a very brief introduction to molecular subtypes, etcetera. So there is a lot of school for lab research, lab based research, molecular level research as well. Um, and then the last two weeks that I just mentioned here genetics and scope for prevention, which I haven't really touched upon much in my talk. But, um, about 10 to 15% of breast cancers are linked to hereditary or genetic mutations. Um, and there is a lot of scope for preventive surgeries or preventive. Um, say medications, um, or investigation scans et cetera, to reduce or pick up disease early. Uh, in that case. And, um, that, as well is, is sort of a sub group of patients within the blanket of the surgery that you can deal with it, which is also always associated with reconstruction. So I think that surgery in itself is a very, very good combination of, um, a lot of things. Um, you know, a lot of patients, a lot of clinical stuff, a lot of operative stuff. Um, and you don't have a lot of patients on the water all the time. Are turnover is very quick. More than 90% of our procedures are the surgeries. Um, so in that sense, it is not taxing. You don't have Very You don't have a lot of patients really poorly or bad or, you know, things like that. Um, but one thing to remember is that because of all this, you will always have the patients coming back to you, even years after treatment. So, um, you know, if you've not done something quite right, they will keep nagging You, um, in terms of, uh I've just put a question mark of whether it helps us achieve a better work life balance compared to most of the surgeons. So I think definitely in terms of having to attend any emergencies. We don't have that common, um, cause you know, for emergencies when you compare to, say, gee, I or compatibility or etcetera. So, um, most common complications that we need to address in an emergency or infections or hemotomas. Um, but, um, as I mentioned earlier, less than 5% of our cases come down with these. So not very common. Um, but if you look at the amount of clinical work and the admin work that we need to do compared to most of other branches. It is probably quite a bit, um, but on the whole, I really enjoy my work. Um, and I really enjoy interacting with my team and interacting with my patients. Uh, so I hope I have, you know, maybe encouraged you guys to think about breast surgery. And, of course, surgery. Surgical part in itself in breast cancer is very interesting as well. With all these, you know, newer techniques in terms of on capacity and reconstructions and things like that. Thank you so much. If you guys have any questions, please don't email them to me. Thank you very much. That was a really, really interesting lecture. Actually, I really enjoyed that. I did have a couple of questions, if you don't mind me asking them. Absolutely. Um So when we're talking about the the three assessments that you do, so you do the radio radiology part of it as well. Um, is there something specific? So if you do like a mammogram and then an ultrasound by the side, would you say that that's the gold standard? Or it's just getting a biopsy in all situations. The best thing to do? Yes, that's a very good question. So what we usually do. So if if you find, um let's take an example of a lump. So if you find a breast lump, um, it depends on the age of the patient, whether we will do a biopsy or not. It depends on what are the features of that lump on radiology. Uh, so, for example, on the ultrasound it looks completely benign, and the patient is under the age of 25. We will probably not offer a biopsy. We might just, you know, recommend for the patient to keep an eye on things if it increases in size, etcetera, because it's most common to be a benign lump, like a fibroadenoma or something like that. Whereas if you see a new lump in, say, somebody who's over 25 even if it looks benign on imaging, you would still biopsy it. So, um, it is, um, it sort of depends on age and also what investigation we do. Radiology point of view. So we do a mammogram for everybody over the age of 40 and under 40. The first test is an ultrasound, okay, and this is just more of a because I can figure out why when we're going through the picture with the lemons. One of this was a growth of noticeable veins. What's the physiological reason that that changes if you have breast cancer? So all cancers are quite vascular, So there is a lot of neovascularization associated with cancers. Uh, sometimes we see patients especially, you know, when we see young patients who don't really, you know, because there's breast tissue is very dense, probably if they're not able to feel a distinct lump, they might notice these other changes of, uh, prominent veins or one breast is bigger than the other. Or the skin is stretched and shiny or, you know, the redness of the skin, etcetera. Okay, Yeah, that that that makes perfect sense. But I was just I was just unsure. I was like, Let me just double check what I have you. Um, Yeah, there was one more thing I think it was to do with the hyperplasia. So when you have, like, ductal hyperplasia or like, atypical ductal hyperplasia, do you do any active treatment for that? Um, yes. So what we do is, um you know, these things are all, um, sort of incidentally, picked up usually from imaging. Um, the the reason why we need to do something further about this is because about 10 to 15% of these cases can be upgraded to either preinvasive or invasive cancers, So that is why we don't leave them by themselves. But what we do is we sample that area further, so either we do it surgically or we do it radiologically. So the way we do a core biopsy under local anesthesia, we can do slightly bigger biopsies, which are called a vacuum assisted biopsies, So the procedure is pretty much same. Um, it's just that the instrument is bigger and you get more tissue, so you sample that area more. And if it is not associated with, you know, precancerous or cancerous changes, then you would at least follow up that patient with a mammogram every year for five years to keep an eye on how it's evolving or if it does get upgraded, then you will treat based on what you find on the further sampling of that area. Sometimes a radiologist say that you know, say, for example, these changes are very close to the nipple, so we can't do this under local anesthesia. Or sometimes they are in the extreme part of the breast where they can't access with their tools. In that case, that sampling is basically done by surgeries. It's like an excisional biopsy or an incision biopsy based on you know how much what is the extent of change. And then that's done surgically. Okay, that's that's really cool. That's cool. Um, and I did have one more thing. I think I've forgotten now. I'm sorry if I was too too quick. No, no, no, Not at all. Not so I didn't I didn't want to interrupt. It was a really good flow. And I got really into watching it. Um, what was my last question? Uh uh, when you were talking about the reconstruction of the breast, When you take skin from other parts of the body in order to help reconstruct the flaps, Um, do you Do you ever have to do like a complete removal? And you take out everything, including the nipple, And do you ever have to reconstruct the actual nipple onto, like, a plastic kind of procedure where it's a fake nipple, essentially, but just for aesthetic reasons, do you do it like that? Or is that just not feasible? Yes, So we we do it like that as well. So what we do So you know whether you can preserve the nipple at the time of the mastectomy, along with the overlying skin or not. That is the first, most important technical aspect of the ankle surgery, So cancer is very close to the nipple or cancers involving the skin, etcetera. If you need to exercise the skin on the breast from oncological safety point of view, then you would just do probably a simple mastectomy and not preserve the skin or not preserve the nipple area or complex. Um, so that is from the cancer point of view from the technical point of view. Sometimes, um, you know it's based on the size of the breast, So if you have a bigger cup size and the blood supply to the nipple is based on a very long pedicle, then you might not be able to preserve it because of certain technical difficulties, I say, because there is a limit to the size of reconstruction that can be offered, so you might have to reduce the skin envelope to be able to preserve the breath. I mean the skin of the breast. You might not be able to preserve the entire skin envelope, but you might have to reduce it to form a snug pocket around your reconstruction or around the implant. And the other reason when you might have to remove the nipple areola complex and the skin is if you're planning reconstruction as a delayed procedure. So we spoke about radiotherapy in people who have breast conserving surgery. But sometimes we have to offer radiotherapy even after mastectomy, based on what is the stage of the cancer. So if you have Stage three Stage four cancer, um, I'm not stage four cancer, but T three T four tumors or, if you have multiple lymph nodes involved, etcetera. You will offer radiotherapy to the patient for treatment of the cancer at the time of their cancer treatment. Or, you know, just after the cancer surgery. And radiotherapy does have detrimental effects on what reconstruction you do. So, for example, if you give it to somebody who has an implant, it might cause the skin on top of it to really become hard and fibrous, or if you have a flap inside. It might affect the vascularity of the flap, et cetera. So there have been studies done, and they've shown that you can give radiotherapy to reconstructed breast as well. But there is no long term data on this. So in our team, what we prefer to do is if somebody is likely to receive radiotherapy as part of their cancer treatment for even after mastectomy. Then we offer reconstruction as a delayed reconstruction, in which case you would just do a simple mastectomy because you can't really leave a pocket of skin there. So you would just do a simple mastectomy. And then later on, when they come back for a delayed reconstruction, it is basically skin from the area where you take the donut tissue from that forms the skin of the new breast. Okay. And then, as as you were mentioning, we then we talk about, you know, reconstructing the nipple, which can be done with just the skin flap on on top of the reconstructed breast. Um, or we also have, you know, like, three D tattoos. Um, or they can also be some. You know, you get these silicon sort of, uh, Dickens and things like that. So different patients prefer different things that they use, So that's amazing. It is very interesting. The surgical part, you know, the cosmetic part, everything. All bits of the surgery. Um, it's really, you know, you can see how it really needs to be tailored according to each patient. And that is something I really find interesting. It's not a one size fits all kind of thing. Yeah, so definitely that's a That's a definite plus side of it. And it's it's very nice that you have that interaction with your patients as well. And such a place level that you can sit down and discuss these options. And absolutely, but yeah, thank you very much for your time and the absolutely fantastic pleasure. I'm sorry I missed out on, you know, things like genetic screening, whatever. I thought This is mainly about surgical stuff, so yeah. No, no, no. This was This was perfect. Great. All right. Thank you so much. If anybody has any questions, they can just email them to me. Yeah. Yeah. Thank you very much. Thank you. Bye. Good day.