Mastectomy

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Modified radical mastectomy

Mastectomy is surgery that removes your entire breast.

Types of mastectomy procedures
"Mastectomy" is an umbrella term used for several distinct procedures:

• Radical mastectomy. For many years radical mastectomy was the standard treatment for women with breast cancer. It's now used only in cases of locally advanced cancer that has spread to the chest muscles. Radical mastectomy removes the breast, chest wall (pectoral) muscles, all of the lymph nodes under the arm, and some additional fat and skin. Often, chemotherapy or hormone therapy is given first to shrink the tumor (neoadjuvant therapy).
• Modified radical mastectomy. Operations less extensive than radical mastectomy are just as effective in treating the primary tumor and much less debilitating and disfiguring. In a modified radical mastectomy, your surgeon removes your entire breast and multiple lymph nodes from your armpit (complete axillary node dissection), but the chest wall muscles are left in place. Maintaining the chest wall muscles allows for breast reconstruction, if you choose to have it.
• Simple (total) mastectomy. A simple mastectomy is similar to modified radical mastectomy except that the underarm (axillary) lymph nodes aren't removed. Simple mastectomy is generally used when a sentinel node is examined and shows no sign of cancer. Simple mastectomy is also appropriate when the cancer is in multiple sites within the breast but is confined to the ducts (carcinoma in situ). In this case, the risk of the cancer spreading to the lymph nodes is insignificant.
• Skin-sparing mastectomy. In this surgical technique, breast tissue is removed by making an incision around the areola — the dark circle surrounding your nipple — rather than cutting across the whole breast, as is done in modified radical mastectomy. This technique minimizes scarring and allows more options for immediate or delayed breast reconstruction.
• Subcutaneous (nipple-sparing) mastectomy. In this procedure, a surgeon removes only breast tissue, sparing the skin, nipple, areola, chest wall muscles and lymph nodes. This is one of several surgical procedures plastic surgeons may perform as a preventive measure for people at high risk of breast cancer or a treatment for precancerous breast disease. It's much less commonly used because it leaves more breast tissue than does simple mastectomy. The remaining tissue could potentially develop cancer later on. Surgeons often couple this operation with placement of a breast implant to re-establish breast contour. Subcutaneous mastectomy may not be ideal for someone who is a carrier of the BRCA1 or BRCA2 gene mutation.

How do you prepare for mastectomy?
Before the surgery, your doctor will meet with you to discuss your medical history and any questions or concerns you may have about the operation. Certain circumstances can complicate the procedure, so before the surgery, tell your doctor if:

• You're pregnant — this may preclude treatment with general anesthesia or certain medications
• You're allergic to any medications, including anesthetics
• You or any family members have had adverse reactions to anesthesia in the past
• You're on medication, even aspirin, or you've been taking herbal supplements

To make sure that your stomach is empty, refrain from eating for six to 12 hours before your surgery. You may drink clear liquids, such as water, apple juice, tea or coffee without cream or sugar before coming to the hospital.

Plan on arriving at the hospital on the day of the surgery or the night before. Mastectomy, without reconstruction, takes one to three hours and usually requires a one- to two-day hospital stay. If you choose to have both breasts removed to prevent cancer from developing in your other breast or to ensure identical results in reconstruction, expect to spend more time in surgery and possibly more time in the hospital. Time in the hospital varies depending on individual circumstances.

What happens during a mastectomy?
Mastectomy is usually performed under general anesthesia, which puts you in a temporary state of unconsciousness. The operation begins with your surgeon making a single incision across half your chest. 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 removes those same tissues plus the lymph nodes. In either case, 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 during healing. 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 during surgery. The tubes are sewn into place, and the ends are attached to a small drainage bag. When drainage slows to less than an ounce of fluid a day, usually after one or two weeks, the tubes are removed.

Some women choose to have implants placed immediately after their breast tissue is removed. Others choose to forgo breast reconstruction altogether or opt for implants or a different means of reconstruction at a later time.

After the procedure
Your surgeon or nurse will give you instructions on how to care for yourself at home, including how to care for your incision and drains, how to recognize problems such as an infection, when to resume wearing a bra or start wearing a breast prosthesis, which activities you may need to restrict, and how to take your medications. While you're in the hospital, someone also may talk with you or give you information regarding some of the psychological and emotional factors associated with the surgery.

You'll probably meet with a medical oncologist after surgery to discuss your laboratory results and whether you may benefit from further treatment. You may see your oncologist while you're hospitalized or after you're released from the hospital. If further treatments are recommended, they typically won't begin until three to four weeks after the operation, to allow for healing.

As for side effects of the surgery, most women don't experience excessive pain after a mastectomy. More complain about numbness under the arm. This occurs because nerves are often cut as part of the surgery. Some of the numbness slowly fades as nerve cells regenerate. Some numbness may be permanent.

If you had lymph nodes removed during the mastectomy, the lymphatic channels that drain fluid from your arm to the rest of your body may have been disrupted. The result can be a buildup of fluid in your arm and hand, causing swelling (lymphedema). This swelling may be mild or quite extensive. Some swelling may be permanent.

Radiation therapy follow-up
In most cases of early-stage breast cancer, radiation treatment isn't necessary after mastectomy, as it is after lumpectomy. However, radiation may be recommended if:

• Your tumor is larger than 2 inches (5 centimeters), and you have lymph nodes that test positive for cancer.
• Cancer cells are found in many lymph nodes.
• Your tumor is close to the rib cage or chest wall muscles, which increases the likelihood that cancer cells may have spread to other parts of your body.

Radiation can be administered by X-ray machine (external beam) or through tiny tubes of radioactive material temporarily implanted in your breast.