Mastectomy

Mastectomy is surgery to remove all breast tissue from a breast as a way to treat or prevent breast cancer. Many women with early-stage breast cancer can choose breast-conserving surgery (lumpectomy), in which only the tumor is removed from the breast. Deciding between mastectomy and lumpectomy can be difficult. Both procedures are equally effective. But lumpectomy isn't an option for some women with breast cancer, and others prefer to undergo a mastectomy. 

Newer mastectomy techniques can preserve breast skin and allow for a more natural breast appearance following the procedure. Surgery to restore shape to your breast — called breast reconstruction — may be done at the same time as your mastectomy or during a second operation at a later date

Why it's done
The goal of mastectomy is to remove all breast tissue if you have breast cancer or are at especially high risk of developing it. You may have a mastectomy in one or both breasts. 

Physically removing the tumor is the single most effective treatment for breast cancer. Removal and examination of breast tissue and nearby lymph nodes also provides important information to help guide future treatment decisions. 
Mastectomy may be a treatment option for many types of breast cancer, including: 

  • Ductal carcinoma in situ (DCIS).
  • Stages 1 and 2 (early-stage) breast cancer
  • Stage 3 (locally advanced) breast cancer
  • Inflammatory breast cancer (after therapy to reduce skin swelling and inflammation)
  • Paget's disease of the breast
  • Locally recurrent breast cancer
  • Phyllodes tumor
Your doctor may recommend mastectomy instead of lumpectomy plus radiation if:
  • You have two or more tumors in separate areas of the breast.
  • You have widespread or malignant-appearing calcium deposits(microcalcifications) throughout the breast.
  • You've previously had radiation treatment to the breast region.
  • You're pregnant, when radiation creates an unacceptable risk to your unborn child.
  • You've had lumpectomy, but cancer is still present.
  • You carry a gene mutation that gives you a high risk of developing a second cancer in your breast.

You might also choose mastectomy over lumpectomy if:
  • You have a large tumor relative to the overall size of your breast. You may not have enough healthy tissue left after lumpectomy to achieve an acceptable cosmetic result.
  • You have a connective tissue disease, such as scleroderma or lupus, and may not tolerate the side effects of radiation to the skin.
  • You have a skin condition called xerodoma pigmentosa.
  • You live a long distance from a radiation facility and it would be very difficult to be there for treatment over an extended period of time.

You might also consider mastectomy if you don't have breast cancer, but are at high risk of developing the disease. Preventive (prophylactic) or risk-reducing mastectomy removes one or both of your breasts in hopes of preventing or reducing your risk of developing breast cancer in the future. 

If your cancer is very large or aggressive or you have inflammatory breast cancer, your doctor may recommend that you have chemotherapy before surgery (neoadjuvant therapy) to shrink the tumor. 

Risks
Bleeding and infection at the surgical site are potential risks of mastectomy, as with any surgery. Between 20 and 60 percent of women experience chronic pain following mastectomy, called post-mastectomy pain syndrome. Symptoms include chest wall pain and tingling down your arm. You may also experience pain or itching in your shoulder, armpit or surgical scar. 

Other possible risks of mastectomy include: 
  • Swelling (lymphedema) in your arm
  • Formation of hard scar tissue at the surgical site
  • Shoulder pain and stiffness
  • Numbness, particularly under your arm, from lymph node removal
  • Buildup of blood in the surgical site (hematoma)

In addition to the physical risks, losing a breast or adjusting to a different breast shape, feel and appearance can be difficult psychologically. The changes can affect how you feel about yourself and your sexuality, at least for a time. 

How you prepare
 
Before your surgery, you'll meet with a surgeon, and perhaps an anesthesiologist, to discuss your operation, review your medical history and determine the plan for your anesthesia. This is a good time to ask questions and to make sure you understand the procedure, including the reasons for and risks of the surgery. One important issue to discuss is whether you'll have breast reconstruction and when. One option may be to have the reconstruction done immediately after your mastectomy, while you're still anesthetized. Breast reconstruction may involve: 
  • Using breast expanders or gel or silicone implants
  • Using your body's own tissue (autologous tissue reconstruction)
  • Using a combination of tissue reconstruction and implants
Breast reconstruction is a complex procedure performed by a plastic surgeon, also called a reconstructive surgeon. If you're planning breast reconstruction at the same time as mastectomy, you'll meet with the plastic surgeon before the surgery. Some doctors, called oncoplastic surgeons, are trained to do both mastectomy and reconstruction. 

You'll be given instructions about any restrictions before surgery and other things you need to know, including:
  • Tell your doctor about any medications, vitamins or supplements you're taking.Some substances could interfere with the surgery.
  • Stop taking aspirin or other blood-thinning medication. A week or longer before your surgery, avoid medications that can increase your risk of excessive bleeding. These include aspirin, ibuprofen and other nonsteroidal anti-inflammatory drugs (NSAIDs), and blood-thinning medications (anticoagulants) such as warfarin (Coumadin).
  • Don't eat or drink eight to 12 hours before surgery.
What you can expect 
Mastectomy" is an umbrella term used for several different procedures. Mastectomy also includes removing lymph nodes to determine whether the cancer has spread. For an axillary node dissection, the surgeon removes a number of nodes from your armpit on the side of the tumor. In a sentinel lymph node biopsy, your surgeon removes only the first one or two nodes into which a tumor drains (sentinel nodes). These are then tested for cancer. If no cancer is present, no further lymph nodes need be removed. If cancer is present, the surgeon will remove more lymph nodes in the armpit. 

The different types of mastectomy are: 

  • Modified radical mastectomy -- Removal of the entire breast, including the breast tissue, skin, areola and nipple. The lining over the chest muscles and sometimes part of the chest wall is also removed, as well as most of the underarm lymph nodes (complete axillary node dissection). This procedure may be recommended for large tumors or if the cancer has spread to the lymph nodes.
  • Simple (total) mastectomy-- Removal of the entire breast, including the breast tissue, skin, areola and nipple, but not the underlying chest tissue. A sentinel lymph node biopsy may be done at the time of a simple mastectomy.
  • Skin-sparing mastectomy-- Removal of all the breast tissue, nipple and areola, but not the breast skin. Breast reconstruction is performed immediately following the mastectomy. Skin-sparing mastectomy may not be suitable for larger tumors.
  • Nipple-sparing (subcutaneous) mastectomy -- removal of only breast tissue, sparing the skin, nipple, areola, chest wall muscles and lymph nodes. Breast reconstruction is performed immediately afterward.
Before the procedure 
Your doctor or nurse will tell you when to arrive at the hospital. Mastectomy without reconstruction usually takes one to three hours. It usually requires a one- to two-day hospital stay, although more and more people are going home on the same day as the operation. If you're having both breasts removed (double mastectomy), expect to spend more time in surgery and possibly more time in the hospital. If you're having breast reconstruction following mastectomy, the procedure also takes longer. 

If you're having sentinel node biopsy, several hours before your surgery a radioactive substance or blue dye or both will be injected into the area around the tumor or the skin above the tumor. In the hours before your surgery, the dye will travel to the sentinel node or nodes, allowing your doctor to see where they are and remove them during surgery. 
Just before your surgery you will:
  • Undress and put on a hospital gown
  • Meet with your surgeon to go over any last-minute concerns
  • Meet with an anesthesiologist or nurse anesthetist to go over the type of anesthesia you'll be given and ask any questions you have
  • Have an intravenous (IV) line placed, usually into a vein in your arm, so that your medical team can give you medication during surgery
  • Possibly be given a sedative
  • Be transported on a wheeled bed (gurney) to the operating room

During the procedure 
Mastectomy is usually performed under general anesthesia, so you're unconscious during the surgery. Your surgeon starts by making an elliptical incision around your breast. If you're having a simple mastectomy, the surgeon removes all your breast tissue — the lobules, ducts, fatty tissue and a strip of skin with the nipple and areola. If you're having a modified radical mastectomy, the surgeon also removes the lymph nodes under your arm. For a skin-sparing mastectomy, the surgeon makes a smaller incision that allows breast tissue to be removed but leaves the breast skin intact. Regardless of the type of mastectomy you have, some breast tissue and lymph nodes will be sent to the pathology lab for analysis. 
If you're having breast reconstruction at the same time as mastectomy, the implants will be placed or the new breast mound will be built immediately after your breast tissue is removed. Some women who have skin-sparing mastectomy will have a temporary tissue expander placed. The expander holds the breast skin in place so you can delay having breast reconstruction until after radiation therapy. 

As the surgery is completed, the incision is closed with sutures (stitches), which either dissolve or are removed later. Your surgeon may place thin adhesive strips across the incision to help hold it together while the incision heals. The strips normally loosen and come off on their own within a few weeks. You might also have one or two small plastic tubes placed where your breast was removed. The tubes will drain any fluids that accumulate after surgery. The tubes are sewn into place, and the ends are attached to a small drainage bag. 

After the procedure 
After your surgery, you can expect to:
  • Be taken to a recovery room. A nurse will monitor your blood pressure, pulse and breathing.
  • Have a dressing (bandage) over the surgery site
  • Feel some pain, numbness and a pinching sensation in your underarm area
  • Receive instructions on how to care for yourself at home, including taking care of your incision and drains, recognizing signs of infection and understanding activity restrictions
  • Talk with a nurse about when to resume wearing a bra or wearing a breast prosthesis
  • Be given prescriptions for pain medication and possibly an antibiotic

Most people meet with their doctor a week or two after surgery. Your drainage tubes will likely be removed at that time. 

Results

The results of your pathology report should be available within a week after your mastectomy. At your follow-up visit, your doctor will explain the report. If you need more treatment, your doctor may refer you to: 
  • A radiation oncologist to discuss radiation treatments, which may be recommended if you had a large tumor, many lymph nodes that tested positive for cancer, cancer that had spread into the skin or nipple, or cancer remaining after mastectomy
  • A medical oncologist to discuss other forms of treatment after the operation, such as hormone therapy, if your cancer is sensitive to hormones, or chemotherapy, or both
  • A plastic surgeon, if you're considering breast reconstruction
  • A counselor or support group to help you cope with having breast cancer
Mastectomy offers a cure for many women with breast cancer. Advances in mastectomy and breast reconstruction techniques have led to less invasive and more cosmetically satisfying procedures. Most women recover well after mastectomy, both physically and emotionally.

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