Mastectomy

Partial or Radical, that is the question?

There are four types of mastectomies: partial mastectomy, or lumpectomy, in which the tumor and surrounding tissue is removed; simple mastectomy, where the entire breast and some axillary lymph nodes are removed; modified radical mastectomy, in which the entire breast and all axillary lymph nodes are removed; and the radical mastectomy, where the entire breast, axillary lymph nodes, and chest muscles are removed.

A mastectomy is the surgical removal of a breast.

The vast majority of mastectomies are performed on women as a axillary lymph nodes are removed; and the radical mastectomy, although men may develop breast cancer and require the procedure, too. In some cases, a lumpectomy may be another surgical treatment option for these patients. Those with more extensive breast cancer may require a bilateral mastectomy, which is the removal of some or all of the tissue in both breasts.

Some men with a condition called gynecomastia, in which the breast tissue becomes overdeveloped, opt for a mastectomy for cosmetic purposes.

There are several types of mastectomies. The decision of what type of mastectomy should be done should be made with the assistance of the surgeon performing the mastectomy, the oncologist and the plastic surgeon performing the reconstruction. Some techniques may not be able to be considered, depending upon the location and severity of the cancer. The emotional needs of the patient must also be weighed.

The decision to have breast reconstruction surgery should be made before the mastectomy surgery is done. The reconstruction may be able to be done right after the mastectomy or at a later date.

The surgery is done under general anesthesia and typically lasts 2 to 3 hours, although it may take longer if a procedure to remove the lymph nodes is planned or reconstructive surgery is being performed immediately after the mastectomy.

Types of Mastectomy

There are four different kinds of mastectomies that are available to breast cancer sufferers. Your health care provider may recommend one type of mastectomy over the other depending upon your health, age, and the stage of your breast cancer.

Partial (Segmented) Mastectomy

Partial mastectomy is the least invasive type of mastectomy. It is frequently performed if you are in the early stages of breast cancer or if you have a small tumor. Partial mastectomy involves removing only a small portion of your breast. Generally, about one-quarter of your breast is removed.

Total (Simple) Mastectomy

With a total mastectomy, your entire breast is removed, including your breast skin and nipple. No axillary (armpit) lymph nodes are removed.

Modified Radical Mastectomy

If you have a modified radical mastectomy, your entire breast, breast skin, and nipple are removed. Some axillary lymph nodes are also removed. This is the most commonly-performed mastectomy procedure.

Radical Mastectomy

The radical mastectomy involves removing your entire breast, breast skin, and nipple, along with your axillary lymph nodes. The muscles in your chest wall are also removed. This procedure is now rarely performed because of the disfigurement that it causes.

Axillary Lymph Node Dissection

Some mastectomy procedures involve the removal of your axillary lymph nodes. These are the lymph nodes found beneath your armpit and just above your breast. Lymph nodes help our bodies to drain fluids and fight infection properly. When you develop breast cancer, cancer cells can sometimes spread to your lymph nodes, indicating a more aggressive form of cancer.

It is sometimes necessary to remove these nodes in order to analyze them for cancer cells. During some mastectomy procedures, between 10 and 40 of your axillary lymph nodes will be removed. These lymph nodes will then be examined under a microscope for cancer cells. The information gained from this analysis can then be used in order to guide future treatment.

Side effects of axillary lymph node dissection include:

Lymphedema, or swelling of the armpit

Limited arm movement

Numbness in the upper arm

Conditions

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 history of connective tissue disease, such as systemic lupus erythematosus, and may not tolerate the side effects of radiation, particularly to the skin.

The tumor is located beneath the nipple and may involve the nipple, making it more difficult to preserve the nipple and areola.

You live a long distance from a radiation facility and being there every day for five to six weeks would be too large a hardship.

You may also consider mastectomy may if you don’t have breast cancer but are at high risk of developing the disease. This procedure, called 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.

Introduction

Nipple and skin sparing techniques can be used in combination with most mastectomy surgeries to retain more skin than is done in a traditional mastectomy. A general guideline for retaining the nipple, areola and additional skin is this: The area of cancer should be a minimum of two centimeters away from the tissue that is to be saved. Therefore, a patient whose cancer is affecting the skin or nipple would not be a candidate for having those tissues retained after surgery.

Skin Sparing Mastectomy This technique preserves the skin of the breast, but not the nipple and areola, which are removed. The breast tissue is then removed through that area. For women with large breasts, an additional incision may be made to allow the breast tissue to be removed, but the vast majority of skin is left behind after surgery.

Nipple Sparing Mastectomy The incision to remove the breast tissue is made around the areola, thus preserving both the nipple and areola. This procedure, like the skin sparing procedure, may result in a larger incision than is necessary in the traditional procedure, especially if the breast is large in size. It’s important to note, however, that the nipple contains breast tissue that is still at risk for forming breast cancer. Therefore, it must be screen for cancer on an annual basis.Total Skin Sparing Mastectomy

This procedure, also known as a subcutaneous mastectomy, not only preserves the skin of the breast, but the nipple and areola, too. The incision to remove the breast tissue can be placed in the fold under the breast where it cannot be easily seen once healed, or the incision may be made around the areola.

Preparing for your operationYou will be able to see a specialist breast care nurse before you are admitted to hospital. Your nurse will provide advice and support on the practical and emotional aspects of having a mastectomy, and offer information on bras and prostheses (bra inserts).Your surgeon will discuss how to prepare for your operation. For example, if you smoke you will be asked to stop, as smoking increases your risk of getting a wound infection and slows your recovery.

You will need to stay in hospital for up to 10 days depending on the type of surgery you have.

A mastectomy is done under general anaesthesia. This means you will be asleep during the operation.

You will be asked to follow fasting instructions. Typically, you must not eat or drink for about six hours before a general anaesthetic. However, some anaesthetists allow occasional sips of water until two hours beforehand.

At the hospital your nurse will explain how you will be cared for during your stay. Your nurse may check your heart rate and blood pressure, and test your urine.

Your surgeon will usually ask you to sign a consent form. This confirms that you understand the risks, benefits and possible alternatives to the procedure and have given your permission for it to go ahead.

You may be asked to wear compression stockings to help prevent blood clots forming in the veins in your legs. You may need to have an injection of an anti-clotting medicine called heparin as well as, or instead of, stockings.

Procedure of Operation

Mastectomy usually takes between one and two hours.

The technique your surgeon will use will depend on the type of mastectomy you are having.

In a simple mastectomy, once the anaesthetic has taken effect, your surgeon will make a diagonal or horizontal cut across the skin of your breast. He or she will then remove breast tissue and, usually, some of your lymph nodes. Your skin is then reshaped and the cut is closed up with fine stitches.

Breast reconstructionIt’s often possible to restore the shape of your breast with a breast reconstruction. This can be done at the same time as the mastectomy or at a later date. Your surgeon will advise you which type of reconstruction is best for you.

Activity After SurgeryAvoid strenuous activity, heavy lifting and vigorous exercise until the stitches are removed. Tell your caregiver what you do and he or she will help you make a personal plan for “what you can do when” after surgery.Walking is a normal activity that can be restarted right away.

You cannot do housework or driving until the drain is out. You may restart driving when you are no longer on narcotics and you feel safe turning the wheel and stopping quickly.

Following a lymph node dissection, don’t avoid using your arm, but don’t exercise it until your first post-operative visit.

You will be given exercises to regain movement and flexibility. You may be referred to physical therapy for additional rehabilitation if it is needed.

Most people return to work within three to six weeks. Return to work varies with your type of work, your overall health and personal preferences. Discuss returning to work with us.

ComplicationsThis is when problems occur during or after the operation. Most women aren’t affected. The possible complications of any operation include an unexpected reaction to the anaesthetic, excessive bleeding or developing a blood clot, usually in a vein in the leg (deep vein thrombosis, DVT).Specific complications of mastectomy are rare but can include:

Pain from your armpit to your hand (cording). It can be treated with physiotherapy and antibiotics, but may last months and may re-occur

A build up of fluid (lymphoedema) in your arm making it swollen and painful – it can occur months or years after surgery

Pain and sensations (such as numbness or “pins and needles”) around the operation site, which can last for years after surgery (post-mastectomy pain syndrome)

Risks
Mastectomy is commonly performed and generally safe. However, in order to make an informed decision and give your consent, you need to be aware of the possible side-effects and the risk of complications of this procedure.

Side-effects

These are the unwanted, but mostly temporary effects of a successful treatment, for example feeling sick as a result of the general anaesthetic and swelling around your wound.

Side-effects of a mastectomy include: Pain or tightness in your breast area and in your arm and shoulder, especially if you have had all your lymph glands removedNumbness and tingling in your upper arm – this usually goes away within a few months of your operation, but you should contact your breast care nurse if it doesn’t

A scar – the appearance will depend on the type of surgery. Ask your surgeon what to expect

Fluid collection (seroma) around your operation site – this is usually absorbed within a few weeks but may need to be drained if it’s large or uncomfortable

Infection of the operation site – you may need antibiotics to treat an infection.

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