Mastectomy is the partial or complete surgical removal of one or both breasts. It is done to treat breast cancer and rarely in some high-risk breast cancer women and men who choose to have it done prophylactically.

Lumpectomy is a conservative local surgery for breast cancer in which only the breast tumor is removed while mastectomy is more radical in the sense that usually the whole breast including the nipple and the areola is removed.

Sometimes, making a choice between lumpectomy and breast mastectomy is difficult. Nowadays mastectomy is done while preserving the skin of the breast. Breast reconstruction surgery can also be done during breast mastectomy or after it.

Indications for mastectomy | When is mastectomy preferred over lumpectomy?

  • Male patients with breast cancer
  • Big sized breast tumor in a relatively small breast where lumpectomy would leave very little breast tissue
  • Women with a tumor larger than 5 cms
  • Women in whom complete removal of the tumor was not possible with lumpectomy
  • If the patient does not want to undergo radiation, which is required after lumpectomy
  • Nonavailability of the radiation facility
  • Aggressive grade of cancer
  • Where the patient does not want to live with the anxiety of recurrence after lumpectomy
  • Where more than one tumor is present in the same breast
  • Inflammatory breast cancer
  • Paget’s disease of the breast (a rare form of breast cancer involving the nipple and the areola)
  • Local breast cancer recurrence
  • Pregnant women in whom radiation is contraindicated due to pregnancy
  • High-risk women who have tested positively for mutated BRCA genes and opt for prophylactic surgery

Types of Mastectomy

There are six different types of mastectomy.

1) Simple or total mastectomy

In this surgery, the total breast is removed leaving the axillary lymph nodes (lymph nodes in the armpit) and the muscles beneath the breast intact. The sentinel lymph node may or may not be removed.

In this type of mastectomy, the hospital stay is brief but a drainage tube is kept for a few days to drain off blood and fluid from the operated site. It is removed once the amount of draining fluid decreases to about 20 ml per day.

Indications

  • Women who have multiple tumors
  • Women who have larger areas of ductal carcinoma in situ (DCIS)
  • High-risk women who undergo a prophylactic mastectomy to prevent a recurrence. In such cases, both breasts may be removed.

2) Modified radical mastectomy

In this type of mastectomy, the entire breast is removed along with the axillary lymph nodes. The pectoral muscles (muscles of the chest beneath the breast) are left intact.

Indications. This surgery is indicated in people who have invasive breast cancer so the removal of lymph nodes helps to get them examined to detect any spread of cancer.

3) Radical mastectomy

This surgery is the most extensive and causes more disfigurement. It involves the removal of the entire breast, all the axillary lymph nodes, and the pectoral (major and minor) muscles beneath the breast. This surgery is not performed much now as it does show any extra benefit over the modified radical mastectomy.

Indications. This is reserved for people where the malignancy has spread to the chest muscles beneath the breast and in recurrent breast cancer.

4) Partial mastectomy

In this surgery, the cancerous breast tissue is removed along with some normal breast tissue around it. Though this resembles lumpectomy, the normal surrounding breast tissue removed in this surgery is more than that removed in lumpectomy.

5) Nipple-sparing or subcutaneous mastectomy

In this surgery, all of the breast tissue is removed but the nipple is spared. This surgery is not preferred much because of recurrence due to the amount of breast tissue left behind. Neither is it beneficial in breast reconstruction because of the distortion of the breast and numbness over the breast after breast reconstructive surgery.

6) Skin sparing mastectomy

The aim of the skin-sparing mastectomy is to facilitate proper breast reconstruction after mastectomy. This surgery is performed through a small incision around the areola. A total mastectomy or a modified radical mastectomy can be then performed after sparing much of the skin to facilitate breast reconstruction. Most women prefer this surgery but those with cancer of the skin as in inflammatory breast cancer cannot be candidates for this surgery.

What happens before mastectomy?

  • Discuss with the surgeon about the type of mastectomy that is going to be performed.
  • Blood tests are conducted to confirm fitness for surgery.
  • You should inform the surgeon about any prior medication you are taking.
  • If you are going for simultaneous breast reconstruction, the plastic surgeon performing the reconstruction will join in the discussion with you and your surgeon.
  • You will be kept nil by mouth for twelve hours before surgery.
  • You can ask your surgeon any doubt or questions freely.

During mastectomy surgery

Anesthesia: General.

Duration of mastectomy surgery: The mastectomy surgery will take one to two hours without axillary lymph node removal and two to three hours if axillary lymph nodes are removed. Breast reconstruction surgery will take anywhere between 2 to 6 hours depending on the type of breast reconstruction surgery that is done.

Duration of hospital stay: You will be required to stay in hospital for one to seven days depending on the surgery and whether there is accompanying breast reconstruction.

  • On admission to the operation theater, the doctor will order an intravenous drip
  • You will be put on ECG monitoring.
  • They will continuously monitor your blood pressure during the surgery.
  • The doctor cleans and sterilizes the surgery site
  • He places sterile drapes around the operation site.
  • You are given general anesthesia
  • The surgeon then makes an appropriate incision and performs the surgery.
  • Breast tissue that is removed is sent to pathology for the report.
  • If going for reconstruction of the breast, the plastic surgeon takes over and completes the surgery.
  • The incision is closed after the surgery.
  • Pressure bandage is applied to control bleeding.

Recovery after Mastectomy: Recovery

  • Post mastectomy, you are is placed in the recovery room where the vital signs are monitored – pulse, blood pressure, breathing. Once they are stable, you will be shifted to the room.
  • The staff will give medication prescribed by the doctor to reduce pain.
  • The staff will also give you antibiotics to control infection.
  • The doctor will advise light exercises to prevent shoulder and arm stiffness.

Possible complications after mastectomy

Post-mastectomy surgery, you may face certain problems. They include:

  • General risks of surgery such as bleeding, pain, infection, neurological problems, etc
  • Chronic breast pain called post mastectomy pain syndrome accompanied by tingling in the arm of the same side
  • Pain, numbness, and itching in the armpit and shoulder on the side of the surgery.
  • Lymphedema – swelling in the axilla (armpit)
  • Hematoma – a collection of blood at the surgery site
  • Fluid collection around the operation site
  • Stiffness of the shoulder of the same side
  • Psychological effect of losing one or both breasts
  • You may develop mastectomy scarring

Once Home

It will take a few weeks to recover from surgery. Once you are discharged from the hospital, your advice on discharge will include the following:

  • Sponge baths till bandage and sutures are removed.
  • Continue shoulder and arm exercises as advised.
  • Continue medication as advised.
  • “Phantom pain”, itching, and a feeling of crawling may occur due to regrowing of the nerves. You will be advised analgesics for such pain.
  • Mastectomy bras and swimsuits are available that successfully camouflage your missing breast/s. These accessories do help in moving around and socializing without embarrassment.

Results of Pathology

After about one week, the pathology reports should arrive. The following is done once the reports become available.

  • Discussion with the radiotherapist oncologist about the need for post-operative radiation. This becomes necessary when the tumor has been large, axillary lymph nodes tested positive for malignancy, cancer had spread to the skin and nipple and some amount of cancer has been left behind after surgery.
  • Discussion with the oncologist to discuss the merits of hormone therapy and chemotherapy after seeing the reports.
  • Discussion with the plastic surgeon if reconstruction is being contemplated after breast mastectomy.
  • Counseling to help cope with loss of one or both the breasts

There has been a great deal of improvement and advances in mastectomy and breast reconstruction techniques. This has led to less invasive mastectomies and more cosmetically satisfying breast reconstruction surgeries.


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