A Mastectomy is the surgical removal of the breast. The precise type of operation performed is determined after careful assessment and discussion between you and your doctor.
There are three types:
Simple Mastectomy–removal of the entire breast.
Partial or Segmental Mastectomy–removal of a portion of the breast tissue along with the tumor.
Modified Radical Mastectomy–removal of the entire breast and all of the lymph nodes in the underarm region. If axillary nodes (lymph nodes) are removed, your doctor can obtain important information on whether the nodes contain cancer cells or not. This will help to determine the right treatment for you after your surgery.
Breast conserving surgery (BCS) has replaced mastectomy for a majority of breast cancer patients in the developed world, with level I data confirming comparable survival and local control of disease, but many patients still require mastectomy and some prefer it. Current indications for mastectomy are as follows:
a. Any cancer unsuitable for BCS, based on
• Large tumor-to-breast-size ratio
• multicentric tumor
• Insufficient response to neoadjuvant chemotherapy or endocrine therapy
• Persistently positive margins of excision
• Inflammatory breast cancer
• Extensive malignant/indeterminate microcalcifications
• Early pregnancy
• Proven or suspected genetic susceptibility
• Local recurrence following bcs/rt
• Contraindication to rt
b. For prophylaxis in high-risk but unaffected patients
•Proven or suspected genetic susceptibility
•History of prior mantle RT
c. Patient preference
The prerequisites for mastectomy include a histological diagnosis of cancer, preferably by needle biopsy, sufficient breast imaging to define the extent of the lesion, a complete medical history and physical examination, and a fully informed discussion with the patient of all surgical options, including the risks and benefits of each approach. This discussion should include mastectomy vs BCS, the types of mastectomy (conventional, skin-sparing, nipple-sparing), the options for reconstruction (none, straight-to-implant, tissue expander, and autologous tissue [latissimus, TRAM/DIEP]), the timing of reconstruction (immediate, delayed), the approach to the axilla (none, SLN biopsy, ALND), and the role/timing of systemic therapy and RT. Preoperative consultation should include, if appropriate, the plastic surgeon, medical oncologist, and radiation oncologist. Emotional and psychologic support should be offered whenever necessary.
Imaging should always include bilateral mammography, with ultrasound as appropriate for dense breasts and/or younger age. MRI is not mandatory, but may be useful to confirm the need for mastectomy, to monitor the response to neoadjuvant chemotherapy, and to clear the contralateral breast. A metastatic workup is appropriate for patients with clinical stage III disease.
Mastectomy is done under general (or regional) anesthesia, in the supine position, with the patient’s arms abducted at 90 degrees and, depending on the operative plan, with one or both arms sterilely draped into the operative field. Prophylactic antibiotics are given prior to induction.
Mastectomy without reconstruction is typically done through an elliptical incision, encompassing the nipple-areola, sufficient to allow SLN biopsy or ALND, and removing enough skin that the skin flaps will lie flat without redundancy. Mastectomy with reconstruction is typically done through an elliptical “skin-sparing” incision, with the axillary procedure done through a separate counter incision; incision planning is best done collaboratively with the plastic surgeon. Nipple-sparing mastectomy is done through a variety of incisions (inframammary, midlateral, circumareolar, or a combination) and is dependent on patient anatomy and surgeon preference.
Mastectomy requires the elevation of skin flaps sufficiently thin to remove all breast tissue, and extended to the anatomic limits of the breast (the sternal border medially, the clavicle superiorly, the latissimus laterally, and the rectus sheath/inframammary fold inferiorly). This is best done under direct vision and can be quite challenging in very thin patients or through incisions which limit exposure (as is typical for nipple-sparing mastectomy, where able assistants and lighted retractors are particularly helpful).
In nipple-sparing mastectomy it is particularly important to remove all of the breast tissue directly behind the nipple and to send the “nipple margin” to pathology as a separate specimen. The breast is dissected off the underlying pectoralis major, removing all breast tissue and (by surgeon preference) the pectoral fascia.
Tumor adherence to the muscle is encompassed by removing the portion of adherent muscle with the breast specimen, taking additional deep margin specimens and placing clips as needed. The breast specimen is oriented with sutures and submitted fresh to pathology for processing. Any planned reconstructive procedures are carried out, drains are placed, and the incisions are closed conventionally.
What are the benefits?
• To reduce the potential risk of needing another operation: the purpose of a mastectomy is to remove as much of the breast tissue as possible and therefore reduce the risk of further surgery being required.
• To reduce the need for radiotherapy: in some cases, there is no need for radiotherapy (X-ray treatment) after a mastectomy, however this decision can only be made after the results of the tissue analysis are known. The final decision about whether you will need radiotherapy is usually made at your postoperative clinic visit.
What are the risks?
All operations involve risks. You need to be aware of these so that you can make an informed choice about surgery. Your Surgeon will talk to you in more detail if there are any individual risks that might specifically apply to you.
If there is obvious bleeding from your wound site immediately after surgery, a nurse may simply put an extra dressing in place to help it stop. Very rarely another operation may be needed if the bleeding continues.
Sometimes, after surgery, the wound continues to produce fluid under the scar, which cannot escape. The fluid may collect and cause swelling. This collection of fluid is called a seroma. It is quite a common problem after breast surgery and is not harmful in any way. You will notice that the wound becomes swollen under the scar or your armpit. A seroma can be drained by your Nurse Practitioner if it becomes painful, however it is better to allow it to reabsorb naturally when possible.
This operation will leave a permanent scar that will fade over time. The scar from this operation will extend across your chest from the middle near your breastbone to under your arm. This means there will be a ‘flatness’ on your affected side. If you would like to, your Surgeon can talk to you about the possibility of reconstruction and the options available in your individual circumstances.
All surgery carries a risk of developing an infection. This is rare but can be treated with antibiotics
Day of Surgery
Arrive at the hospital to be registered at your scheduled time. After admission and preparation for surgery by the nursing staff, you will go to the Operating Room. The Anaesthetist will administer an anaesthetic. The most common type of anaesthesia for mastectomy surgery is general anaesthesia (puts you to sleep). The length of surgery is approximately one hour.
You will remain in the Recovery room for 1-2 hours while recovery from anaesthesia is monitored. You will be taken to your hospital room or to Day Surgery. Patients often return from surgery with a variety of tubes. Intravenous is given for fluids and medications. A drainage tube may also be present in the operated area
Your doctor will prescribe pain medication either by injection or tablet. It is normal to have discomfort/pain after your surgery. It is very important to keep the pain under control. Please let your nurse know if you are uncomfortable. You may experience some numbness and tingling sensations in your upper arm. This is normal and should decrease in time.
After surgery, you may have nausea and/or vomiting. Anti-nausea medication may be given to control this. You will be able to increase your diet as your condition permits, starting with ice chips and clear fluids to a diet as tolerated.
Deep breathing and coughing is very important to help prevent lung congestion or pneumonia. It is helpful to support your incision with your hand or a pillow when coughing.
After surgery, the wound is covered with a sterile dressing. It is important to keep it clean and dry until it is well healed. You may have a drainage tube in the affected area. The tube is made of soft plastic and attached to a suction bulb coming out of the skin, near the incision. The drain is placed during surgery and removes fluid that accumulates under the incision site after surgery. You will be instructed on its care before going home from the hospital.
The drain should be pinned to your shirt or bra, NEVER pin the drain to your pants. The drain is removed once the amount of fluid is decreased. A Home Care (CCAC) Case Manager may visit you in the hospital to arrange nursing visits at home. The staples or sutures are usually removed in 10-14 days.
Most patients go home the same day as the surgery. Have someone available to stay with you for a few days to help you as needed.
Feelings of anxiety, sadness, fear of looking at the incision area are normal. A Mastectomy means abrupt change in body image. It is normal to mourn the loss of a breast. Sexual intimacy may be affected. It often helps to be able to discuss potential sexual problems with one’s partner, with a counselor or a with a breast cancer support group.
After you have had a mastectomy, you may be emotionally overwhelmed. You may think about the fact that you have been treated for a serious disease. You have had an operation that has changed your appearance, perhaps your self-image. You might wonder how the mastectomy will affect your lifestyle and personal relationships. You may be unsure how to act towards family and friends.
Every woman reacts to a mastectomy differently. You can take steps to ease your emotional adjustment. Express your feelings to your doctor and people close to you. This will help your doctor understand what you need to fully recover and it will help your family and friends to share your difficulties and to help you work through them. Your family and friends can be your strongest supporters, but they may not know how to show their support. You can help them by being open and honest about the way you are feeling.