Mastectomy

Alternative names
Breast removal surgery

Definition

A mastectomy is the surgical removal of the entire breast, usually to treat serious breast disease, such as breast cancer.

There are four general types of mastectomy:

  1. A SUBCUTANEOUS MASTECTOMY removes the entire breast, but leaves the nipple and areola (the pigmented circle around the nipple) in place.
  2. TOTAL (OR SIMPLE) MASTECTOMY is the removal of the whole breast, but not the lymph nodes under the arm (axillary nodes).
  3. In a MODIFIED RADICAL MASTECTOMY, the whole breast and most of the lymph nodes under the arm (axillary nodes) are removed. Removal of these lymph nodes is called an axillary dissection.
  4. RADICAL MASTECTOMY involves removal of the chest wall muscles (pectorals) in addition to the breast and axillary lymph nodes. For many years, this operation was considered the standard for women with breast cancer, but it is rarely used today. It is mostly of historical interest.

Description

While the patient is anesthetized (unconscious and pain-free), an incision is made into the breast. The breast tissue is removed from the overlying skin and the underlying muscle. When an axillary dissection is done, it is typically via the same incision.

One or two small plastic drains are usually left in place to prevent fluid from collecting in the space where the breast tissue used to be.

Your surgeon will decide when these drains are removed, typically when the amount of fluid draining decreases to an acceptable volume. This ranges anywhere from a few days to a week or more. Many women go home with their drains and have them removed during an office visit.

It is possible to reconstruct the breast (with artificial implants or native tissue) at the same operation (immediate reconstruction) or at a later date, after other necessary treatments are given (delayed reconstruction).

Reconstruction adds to the complexity of the surgery. Decisions about whether to undergo breast reconstruction, and the best timing are joint decisions between women and their doctors. It involves the consideration of many different individual factors.

Indications

The most common reason for performing a mastectomy is breast cancer.

Breast cancer is usually discovered when a lump, a change in the appearance of the breast (such as dimpling or puckering), or a suspicious mammogram is investigated. There are two main types of breast cancer surgery:

     
  • The first is breast conservation, where only the tumor and a rim of surrounding tissue is removed. Breast conservation surgery, also known as lumpectomy or partial mastectomy, is usually followed by radiation therapy to the breast.  
  • The alternative to breast conservation surgery is removal of the entire breast, or mastectomy, which is the topic of this article.

Which type of surgery is best for which patients is a complex decision, taking many factors into account. If you are diagnosed with breast cancer, discuss with your doctor the relevant issues for your circumstances thoroughly and in as much detail as you need.

Important issues include the size of the tumor in relation to the size of your breast, whether there is more than one tumor in your breast, the side effects of radiation therapy, and your personal preferences.

Another reason for performing a mastectomy is when a breast contains widespread DCIS, or Ductal Carcinoma in Situ.

DCIS is a pre-cancerous condition, and has the potential to become invasive cancer if left in place. It is typically discovered when a suspicious mammogram alerts your doctor to perform a biopsy.

DCIS present in a small area can be removed with a lumpectomy, but when spread throughout the entire breast, might require a mastectomy. When mastectomy is done for DCIS, it usually does not require removal of the lymph nodes under the arm.

Preventive, or prophylactic mastectomy is the surgical removal of one or both breasts that do not contain cancer or DCIS, in an effort to prevent or reduce the risk of breast cancer.

A subcutaneous or a total mastectomy can be done. This surgery is an option to reduce the risk of breast cancer for women at extremely high risk of developing breast cancer.

Prophylactic (preventative) mastectomy is an alternative to intensive screening, and is undertaken only after very careful consideration, often including genetic testing and a psychiatric evaluation.

Women who might consider propylactic mastectomy include those with a strong family history of breast cancer, especially if relatives are diagnosed at a very early age.

Some families have a known genetic mutation that predisposes to breast cancer (BRCA1 or BRCA2), and individuals can be tested for these genes. Inherited mutations in these genes increase the lifetime risk of developing breast cancer. It is important to note that prophylactic mastectomy greatly reduces, but DOES NOT ELIMINATE the risk of breast cancer.

Risks

Mastectomy is very safe surgery, and most patients recover well with no complications. As with any surgery, however, there are risks. Possible complications are listed here, but keep in mind that unless stated otherwise, they usually do not happen.

The risks of any surgery are bleeding, infection, and injury to nearby tissues. Some post-operative pain and soreness is expected, but can be effectively treated with pain medication. There will also be a scar on the chest wall. Scarring occurs with all surgery, and is unavoidable.

General anesthesia risks include potential breathing and heart problems, as well possible reactions to medications. For a woman who is otherwise in good health, the risk of a serious complication due to general anesthesia is less than 1%.

The risks related specifically to the removal of the breast include a compromised blood supply to the skin of the chest wall, which may cause loss of some skin. In extreme circumstances, this complication may require a skin graft, but this is very rare. There is also a risk of bleeding into the space where the breast used to be. Sometimes a second operation is required to control bleeding, but this is also uncommon.

There are risks specifically related to removing the nearby lymph nodes (axillary dissection):

     
  • Many patients experience shoulder stiffness after removal of the lymph nodes in the armpit. This stiffness improves over time, especially with exercise and physical therapy.  
  • A fluid collection, called a seroma, may collect in the armpit. This is relatively common and usually resolves on its own, but may require needle drainage.  
  • Since the axillary (armpit) lymph nodes normally drain excess fluid from the arm, the removal of these can result in postoperative swelling of the arm on the same side as the breast which is removed. This swelling (called lymphedema) is uncommon, but when it occurs, it can be a persistent problem and carries an increased risk of infection.  
  • There are some important nerves in the area of the axillary lymph nodes that are at risk during surgery. Many patients will have a numb patch on the inside of the arm after surgery. Nerves to muscles of the back and chest wall are also at risk, but your surgeon will make every effort to protect these nerves during surgery.

There are also risks related to reconstructive surgery. If reconstructive surgery was done using an implant, there is an increased risk of infection. There is also a risk that the scar around the implant will contract.

This can make the breast feel hard, and can be treated by removing the scar tissue or removing /replacing the implant. Each of these involves another surgery. Surgical scars may fade with time, but they will never disappear entirely.

Reconstruction using native tissue from the abdomen, back, or buttocks carries a higher risk of bleeding, and a small chance that the transferred tissue will lose its blood supply and have to be removed.

Expectations after surgery

The successful treatment of breast cancer and the likelihood of long-term survival for women with breast cancer depends critically on the stage of the disease when diagnosed.

Self-breast examination, regular clinical breast examinations by medical professionals, and annual screening with X-ray mammography are the main tools of early detection of breast cancer.

Of these three, screening mammography combined with clinical breast examination is the most effective detection method. In the United States, yearly screening mammography is recommended for women over the age of 40.

Detected in its earliest stages, appropriate treatment results in a ten-year survival rate of over 90%. New cases of breast cancer have been gradually increasing in recent years, and will likely continue to do so as the population ages.

However, the chance of dying from breast cancer has been steadily falling by about 1-2% a year. This improvement is due to early detection and newer treatments like hormonal therapy and better chemotherapy.

Breast reconstruction at the time of mastectomy or at a later date can help restore a normal appearance, and the techniques for achieving this have advanced greatly. The goal of reconstruction is to restore symmetry of the breasts when a woman is dressed. The difference between the reconstructed breast and the unaffected breast can be seen when the woman is nude. Reconstruction will not restore normal sensation.

Breast reconstruction can often be done at the time of the mastectomy, if the woman chooses it and if her medical oncologist and surgeon agree. There are various techniques for reconstructing the breast. For most patients, the reconstruction will require two to three surgical procedures.

The first surgery is the reconstruction of the shape of the breast. Sometimes additional surgery is necessary to alter the shape or placement of an implant or to modify the opposite breast for better symmetry. An additional minor procedure involves reconstruction of the nipple/areolar area.

Many women choose not to undergo breast reconstruction. For these women, there are a variety of prostheses that can be worn in the bra to give a natural contour and symmetry.

In addition to surgery, other treatments including hormonal therapy, radiation, and chemotherapy may be included to reduce the risk of recurrence and improve the chances of long-term survival. These treatments have their own side effects, which your doctor will discuss with you.

Convalescence

The hospital stay varies from 1 to 3 days, depending on the type of surgery. Longer stays are common if breast reconstruction is included. As discussed earlier, surgical drains are commonly placed to remove any fluid that might collect.

Drains may be left in at the time of discharge from the hospital, and you will be instructed to measure the fluid that drains from them. Stitches are often placed under the skin and dissolve on their own. If non-dissolving stitches or clips are used, they are typically removed 7 to 10 days after surgery. Full recovery may take as long as 3-6 weeks.

It takes time for a woman to adjust to the loss of a breast. Talking to other women who have had mastectomies, to their partners, and family can help deal with these feelings. A health care provider can help locate support groups for the woman and her family. A mental health professional can help a woman and her family adjust.

Johns Hopkins patient information

Last revised: December 7, 2012
by Mamikon Bozoyan, M.D.

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