Breast health

What is mastectomy?

Mastectomy refers to the surgical removal of the breast. This type of surgery is the most common treatment for breast cancer. In years past, a radical mastectomy was the only treatment available for women with breast cancer. Early diagnosis of breast cancer didn't afford women the benefit of a less radical, more cosmetically appealing treatment option. Fortunately, however, mastectomy doesn't have to be extensive, scarring, or disfiguring. Today, there are many types of mastectomy and in many cases, immediate or delayed breast reconstruction is possible following mastectomy.¹

Types of mastectomy

Depending on the location—and on the surgeon performing the procedure—mastectomy can be of several different types. Following are some of the surgical procedures for breast cancer:²

Lumpectomy	Quadrantectomy refers to the removal of one quarter of the breast, including the skin and connective tissues (fascia). In some cases, the surgeon may also perform either an axillary node dissection or a sentinel node biopsy to remove some or all of the axillary lymph nodes. (See Breast Biopsy for more information on each of these procedures.)
Lumpectomy	Excisional biopsy also involves the removal of the breast cancer tumor and a surrounding margin of normal tissue. If this type of biopsy successfully removes the entire breast cancer tumor, additional surgery may not be necessary. This is likely if the tumor is very small. As explained in further detail in Breast Biopsy, an excisional biopsy may be performed either through needle or wire localization.
Radical Mastectomy	Rarely performed today (because modified radical mastectomy has proven to be just as effective and less disfiguring), radical mastectomy refers to the removal of the entire breast, the nipple, and/or the areolar region, the pectoral major and minor muscles, and the lymph nodes. This procedure is performed only when the cancer has spread to the chest muscles under the breast.
Modified Radical Mastectomy	The most common type of mastectomy, modified radical mastectomy refers to removal of the entire breast, the nipple, and/or the areolar region, and quite often, the axillary lymph nodes.
Simple (Total) Mastectomy	Simple or total mastectomy refers to removal of the breast, including the skin and nipple, but excluding the lymph nodes. In some instances, a sentinel node biopsy is performed to remove the first one to three axillary lymph nodes. (See Breast Biopsy for more information on sentinel node biopsy.) These procedures are appropriate for women with ductal carcinoma in situ.
Partial (Segmental) Mastectomy	Partial or segmental mastectomy refers to the removal of a portion of breast tissue and a margin of surrounding normal tissue. This procedure usually involves the removal of less tissue than in a quadrantectomy but more than in a lumpectomy or wide excision.
Lumpectomy	Lumpectomy or wide excision refers to the removal of the breast cancer tumor and a surrounding margin of normal breast tissue.
Images by illustrator Susan Spangler appear with the artist's permission and courtesy National Cancer Institute, U.S. National Institutes of Health.

Radical mastectomy, modified radical mastectomy, or lumpectomy operation often includes axillary node dissection—the surgical removal of the axillary lymph nodes. Following surgery, the axillary lymph nodes are examined by a pathologist to determine whether the cancer has metastasized beyond the breast and to determine the best course of treatment.

The most common side effect of axillary node dissection is a condition called lymphedema, a chronic swelling of the arm. Where axillary node dissection is combined with radiation therapy, between 10 and 20 percent of patients experience lymphedema. Should you experience any tightness or swelling of your arm, be sure to report these symptoms to your doctor as soon as possible in order to prevent possible long-term suffering.³

Common side effects of axillary node dissection may also include:

• temporary to permanent limitations of arm and shoulder movement
• numbness in skin of the upper arm
• lymphedema

Who is a candidate for mastectomy?

Mastectomy is a viable treatment option for women who:⁴

• have cancer in more than one part of the breast
• have small breasts or whose breasts are shaped so that a lumpectomy would be very disfiguring, leaving them with very little breast or a very deformed breast
• because of previous radiation to the chest and/or breast may not undergo further radiation therapy
• because they are pregnant or may become pregnant near the time of surgery, may not undergo radiation therapy (because of the risk it poses to the fetus)

Some patients are clear candidates for mastectomy, while others may choose between mastectomy and lumpectomy (usually followed by radiation therapy). Although there is no statistically significant difference in survival rates among women who undergo mastectomy and those who opt for lumpectomy, patients should educate themselves and carefully discuss the pros and cons of each with their surgeon. While lumpectomy preserves the physical appearance of the breast (hence its sometimes being called breast conserving therapy), it usually requires five to eight weeks of radiation therapy. On the other hand, mastectomy, while it may reduce local recurrence of breast cancer, also means that patients must make additional decisions about breast reconstruction.⁵

While radiation therapy is more common following lumpectomy, it may be recommended after mastectomy if:⁶

• the tumor is larger than 2 inches (5 cm)
• the removed tissue has a positive margin—see lumpectomy for more information
• four or more lymph nodes were involved
• the cancer occurred in a number of locations within the breast

Before surgery

You should expect to meet with your surgeon a few days before your surgery. This is the time to ask questions about the procedure and to discuss risks, advantages, and disadvantages with your doctor. Also be sure to discuss with your doctor any medications you are currently taking that may interfere with surgery. Depending on the type of procedure your surgeon has chosen, you may be required to donate some of your own blood for a possible blood transfusion during surgery. You will likely be given an informed consent form at this time. Be sure to review it carefully before signing it. Policies differ from hospital to hospital; if you aren't given a consent form during this pre-operative visit, it will be given to you to sign the day of your surgery.

You will more than likely be under general anesthesia. You will be instructed not to eat or drink anything for at least 8 hours before your operation. When you arrive at the hospital, you will be asked to sign an informed consent form, and you doctor will answer any last-minute questions you might have and will also explain any risks associated with your operation. You will then receive anesthesia and any necessary medications. A nurse will begin an intravenous line to administer fluids and medication you may need during your surgery. You may also receive a sedative. The anesthesiologist will then perform a brief medical examination, take your medical history, and ask about any medications you are currently taking, any allergies you have, and any adverse reactions to anesthesia. The information you provide will help assess any problems or conditions that may affect the choice of anesthesia, and it will also help the surgical team determine whether any special precautions need to be taken. You will also be connected to an electrocardiogram, or EKG monitor, a device designed to monitor your heart rate throughout the operation. Your blood pressure and vital signs will also be monitored.

During a simple mastectomy, the surgeon will make an incision along the perimeter of the breast closest to the tumor area. Most of the skin will be left intact. The nipple is not normally removed during this type of procedure, although the milk ducts leading to the nipple are cut, meaning that following the operation, breastfeeding from the affected breast will no longer be possible. Tissue underlying the nipple is gently cut free and removed. Quite often, a rubber drainage tube is inserted into the affected area. This tube is intended to remove blood and lymph accumulated during the healing process. Once the tube is in place either in the breast or under the arm, the skin is then carefully closed with stitches. Stitches are usually removed within 7 to 10 days following surgery, and a sterile dressing is applied to the site. Your surgeon will instruct you to drain the tube into a collection container at regular intervals (usually every 8 hours) and to measure and record the drainage. The drainage tube is removed once drainage is reduced to less than 1 fluid ounce (30 ccs) per day—usually within two weeks following surgery.⁷

After surgery

You may feel cold following surgery. This is a normal part of recovery from anesthesia.

Once you leave the recovery room and return to your hospital room, your nurse will likely want to you to get out of bed within a few hours of surgery to move around. This is because medical evidence supports that women recover more quickly and more effectively the sooner they get moving after surgery. Your doctor and/or nurse(s) will recommend that you begin arm exercises the morning after surgery. They will also likely tell you that you can safely resume your normal activities within a few weeks following your mastectomy.⁸

You may feel apprehensive about looking at your scar for the first time, or you may be eager to look at it, wanting to do so the first time your doctor or nurse comes to change your dressing at the hospital. Be sure to discuss your feelings with your doctor and nursing team. They will be able to talk to you in a compassionate and caring way about your feelings and anxieties.

Although most mastectomy patients do not experience soreness after surgery, some do experience soreness for two to three days. A linear scar at the mastectomy site is likely, as is a pulling or tugging sensation near or under the arm.

Following surgery, you will be required to stay in hospital two to three days, although some patients, namely those who have had breast reconstruction surgery in addition to mastectomy, may stay in hospital up to one week before being discharged. Before you are discharged from hospital, you will be given instructions on:

• how to care for your wound and dressing
• what type of pain and/or new sensations to expect
• proper use of pain medications
• how to monitor the drainage tube
• how to look for signs of wound infection
• which activities to limit or avoid
• what you can expect to feel and how to deal with these emotions
• proper diet
• when to begin arm and hand exercises
• when to wear a bra
• when and how to wear a breast prosthesis, if you've chosen to get one

Once you're home, you're very likely to feel exhausted from the stress of your experience. Listen to your body, and be sure to get the rest and nutrition you need to ensure your recovery. You may wish to withdraw from others for a time, but remember that others have good intentions and want to support you. Be sure to encourage this while still setting appropriate limits to ensure you get the rest you need. Interacting with others may help take your mind off waiting for your pathology results.

Waiting for the results of your pathology report may be hard—even excruciating. The best way to deal with this waiting period is to discuss with your doctor, preferably before your surgery, when and how you will receive the results. Some doctors will phone you with the results while others will require that you make an appointment. Bear in mind that the pathology report may come back only in stages—you may not have complete answers at first. While it may be hard to avoid, try not to make any judgment about your situation until all information about your pathology report is available. Once all the results are back, your doctor will discuss your pathology report and your need for additional therapy such as chemotherapy or radiation therapy.⁹

Sponge baths can refresh you until showers or baths are approved by your doctor. Unless you have a waterproof dressing, you should avoid taking baths until after your wound has healed. You can take a shower after your drainage tube(s) and stitches have been removed.¹⁰

Following mastectomy, it's not uncommon for women to experience phantom breast pain, a type of pain similar to that experienced by patients who have undergone limb amputations. During mastectomy, small nerves between the breast tissue and the skin are cut, causing the neural connections in the brain to undergo a reorganization known as neural plasticity. Phantom sensations result from this neural plasticity and the spontaneous firing of electrical signals from the ends of cut or injured nerves. Regardless of whether you've had breast reconstruction, phantom breast pain is usually characterized by:¹¹

• unpleasant itching or extra sensitivity to touch within the area of surgery
• "pins and needles" or numbness of the skin along the incision site and mild to moderate tenderness of the adjacent area
• pressure
• throbbing

If, after surgery, you experience phantom sensations in the breast, be sure to report any symptoms to your doctor right away to ensure that the pain can be properly managed. Your doctor may recommend breast massage or exercise to help alleviate symptoms. In severe cases, medications may be prescribed to help manage phantom breast pain. Phantom breast pain, as explained above, is the result of neural plasticity and the spontaneous firing of electrical signals from the ends of cut or injured nerves; it does not indicate that cancer cells are still present or that cancer may return. Regular breast self-examination, clinical breast exams and mammograms are the best ways to screen for breast cancer and are encouraged for women who have undergone mastectomy.¹²

Following full recovery from mastectomy, there are certain precautions that should be taken when performing exercise. Be sure to ask your doctor when it is safe to begin exercising and using your surgery-side arm again.

Lymph nodes' function is to filter harmful substances from the lymph fluid. If you had your lymph nodes removed along with mastectomy, your doctor will explain to you that the lymphatics have been disrupted, leaving the arm and skin on the side of the mastectomy more prone to infection by invading bacteria and organisms.¹³

In addition, because lymph nodes are located near blood vessels and because scarring occurs at or near the axillary vein as a result of surgery, there may be a higher chance of axillary vein thrombosis in women who have undergone axillary node dissection. Axillary vein thrombosis occurs when there is a clot in a deep vein in the armpit. It has also been associated with strenuous upper body exercise, since overdeveloped muscles can affect nearby nerves, veins and arteries. For this reason, your doctor may suggest tempering upper body exercise after surgery with periods of rest. He or she may also recommend keeping the arm elevated above the level of the heart for a few hours to avoid undue swelling. To avoid preventable injury, you should be careful not to exercise too strenuously.¹⁴

Are there complications associated with mastectomy?

In addition to phantom breast pain and axillary vein thrombosis, mastectomy carries with it the following risks:¹⁵

• Seroma (serum or fluid collection under the scar) and hematoma (an accumulation of blood in the wound) usually respond readily to treatment such as needle aspiration.
• Delayed wound healing may result because blood vessels are cut during mastectomy. This can occasionally present problems when the body tries to heal the incision site. If blood flow to the incision site is insufficient, small areas of skin may wither or scab, requiring that your surgeon trim them. This is neither a serious nor a common complication.
• Fever and excessive bleeding are all symptoms requiring immediate medical attention.
• Increased risk of infection in the surgical site is usually discovered early and can be readily treated.

How effective is mastectomy?

Breast cancer can recur following mastectomy or other treatment of breast cancer, and this recurrence may be local, regional, or distant. With local recurrence, malignant tumor cells remain in the original site and over time, grow back. Because it indicates that the cancer has spread past the breast and axillary lymph nodes, a regional recurrence of breast cancer is more serious. The most dangerous type of recurrence, a distant breast cancer recurrence is also known as metastasis and indicates that the cancer has spread to distant regions of the body such as bone, the lungs, the liver, or the brain. Treatment will invariably depend on the type and severity of the breast cancer recurrence and may include additional surgery, chemotherapy, radiation therapy, or drug therapy.¹⁶

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1. Mastectomy. breastcancer.org (2004)
2. Mastectomy. Imaginis Corporation. (1997–2004)
   Mastectomy. breastcancer.org (2004))
3. Mastectomy. Imaginis Corporation. (1997–2004))
4. Mastectomy. breastcancer.org (2004))
5. Mastectomy. Imaginis Corporation. (1997–2004))
6. Mastectomy. breastcancer.org (2004))
7. Mastectomy. Imaginis Corporation. (1997–2004))
8. Mastectomy: What to Expect. breastcancer.org (2004))
9. Waiting for Results. breastcancer.org (2004))
10. Drains, Sutures, and Staples. breastcancer.org (2004))
11. Mastectomy. Imaginis Corporation. (1997–2004)
    Mastectomy: What to Expect. breastcancer.org (2004))
12. Mastectomy. Imaginis Corporation. (1997–2004))
13. Mastectomy. Imaginis Corporation. (1997–2004)
14. Mastectomy. Imaginis Corporation. (1997–2004))
15. Mastectomy: What to Expect. breastcancer.org (2004))
16. Mastectomy. Imaginis Corporation. (1997–2004))