Mastectomy

Mastectomy

Also called: Bilateral Mastectomy, Double Mastectomy, Single Mastectomy

Reviewed By:
Mark Oren, M.D., FACP
Joanne Poje Tomasulo, M.D., ACOG

Summary

A mastectomy is a surgical procedure to remove part or all of one or both breasts. It is usually performed to treat or prevent breast cancer. There are several different types of mastectomies, including:

  • Partial mastectomy. Removal of some of the breast tissue surrounding the tumor and the lining of the chest muscles beneath it. In some cases, lymph nodes under the arm or in the chest may also be removed.

  • Simple mastectomy. Removal of all of the breast tissue, including the lobules, ducts, fatty tissue and a strip of skin with the nipple and areola.

  • Modified radical mastectomy. Removal of the entire breast and some lymph nodes from under the arm or in the chest.

A mastectomy may cure breast cancer and dramatically reduce the likelihood of its return, but there is a chance for the cancer to recur. Breast tissue is widely distributed on the chest wall and can sometimes be found in the armpit and in areas stretching from above the collarbone down to the abdomen. Some of these areas are not within the scope of a mastectomy, and other forms of treatment may be necessary to help ensure that all cancer is treated (e.g., chemotherapy).

Some women may choose to have a prophylactic or preventive mastectomy. This entails surgery to remove one or both breasts to reduce the risk of developing breast cancer. Prophylactic mastectomies may be considered by women who may have had cancer in one breast, have a family history of breast cancer or have a genetic predisposition to the disease.

Mastectomies can be emotionally challenging for women faced with the loss of one or both breasts. For this reason, many women choose to undergo a breast reconstruction that creates an artificial breast closely approximating a natural breast.

About mastectomy

A mastectomy is a surgical procedure to remove some or all of one or both breasts. It is usually performed as a treatment for breast cancer when the disease has spread throughout the breast or into other parts of the body. A mastectomy can be effective at curing a patient’s cancer and preventing it from recurring.

There are several different types of mastectomies. These include:

  • Partial mastectomy. Removal of some of the breast tissue surrounding the tumor and the lining of the chest muscles beneath it. In some cases, lymph nodes under the arm may also be removed. Like a lumpectomy, a partial mastectomy is considered a breast-sparing surgery and leaves the nipple and areola intact. The amount of tissue removed varies widely according to the individual patient’s needs. Tests after the procedure will determine whether the patient will need radiation therapy, chemotherapy or hormone therapy. Other terms for partial mastectomy include segmental mastectomy, wide resection, wide excision and quadrantectomy.
  • Simple mastectomy. Removal of all of the breast tissue, including the lobules, ducts, fatty tissue and a strip of skin with the nipple and areola. Tests after the procedure will determine whether the patient will need radiation therapy, chemotherapy or hormone therapy.
  • Modified radical mastectomy. As with a simple mastectomy, this procedure involves removal of the entire breast. However, it also includes removal of some or most lymph nodes from under the arm. This is the most common mastectomy surgery for women who have their breast removed. Lymph nodes are examined after a modified radical mastectomy to see if the cancer has spread and further treatment is necessary. The modified radical mastectomy has largely replaced the radical mastectomy, which involves removal of the pectoral muscles (chest wall) under the breast and all of the lymph nodes in the axillary area and up to the collarbone. This can result in significant disfigurement, and is rarely performed today.

Women usually do not have mastectomies until after they have been diagnosed with cancer. However, in some cases, a healthy woman may decide to have a preventive mastectomy. Although all women are at risk for breast cancer, family history of the disease places some women at increased risk. Preventive mastectomy can reduce the odds of breast cancer by about 90 percent in women in high-risk and moderate-risk groups, according to the National Cancer Institute.

In addition, women who are treated for breast cancer in one breast may elect to have a preventive mastectomy on the other breast. While a preventive mastectomy (also called prophylactic or risk-reducing mastectomy) dramatically reduces the cancer risk, it does not eliminate it. Breast tissue is widely distributed on the chest wall and can sometimes be found in the armpit and in areas stretching from above the collarbone down to the abdomen. Breast cancer can develop in these tissues even when a mastectomy has been performed.

Factors that place women at a higher risk for breast cancer include:

  • History of cancer in one breast
  • Family history of breast cancer on either the mother’s or the father’s side. Women who have several relatives diagnosed with breast cancer prior to age 50 are at especially high risk.
  • Genetic testing that identifies mutations associated with cancer. Women with the mutated genes associated with breast cancer (BRCA1 and BRCA2) have an 80 percent chance of getting breast cancer during their lifetime, according to the American Cancer Society. Research has also found variations of ATM, CHEK2 and RAD51 genes increase the risk of developing breast cancer.
  • Early signs of cancer in the breast such as precancerous cells

Choosing to have a mastectomy is a difficult decision and should be made in consultation with a physician. A patient’s cancer care team can provide information and recommendations that can help with the decision. Some women may choose to seek a second opinion about surgery and additional treatments for their cancers.

In many cases, women who have mastectomies will also choose to undergo subsequent breast reconstruction. This is a surgical procedure in which the breast is rebuilt to resemble the shape the patient had before the mastectomy.

Mastectomy is also one possible treatment option for the rare cases of male breast cancer.

Before and during the mastectomy

Patients may be asked to donate blood prior to the procedure in case a transfusion becomes necessary later. They should tell their physician about all medications they are taking to ensure that none of them will interact adversely with medications used during surgery. Patients usually are asked not to eat or drink anything for eight to 12 hours prior to surgery.

Patients undergoing a mastectomy usually will be placed under general anesthesia and will be asleep during the procedure. The surgeon will make an incision into the breast, which may extend to the armpit if lymph nodes are to be removed. Breast tissue between the overlying skin and underlying muscle is removed, with the extent of tissue removal varying depending on which type of mastectomy is being performed.

  • Partial mastectomy. Tissue is removed in triangular wedges all the way down to the level of the muscle. The remaining tissue and skin are then sutured (stitched) together.
  • Modified radical mastectomy. The surgeon makes an elliptical incision and removes the nipple and the scar from the breast biopsy. This is known as a skin-sparing incision that tries to limit the amount of skin removed as a means of enhancing a future breast reconstruction. The surgeon then tunnels under the skin up to the collarbone (clavicle) and down to the border of the ribs, and between the middle of the breastbone (sternum) and out to the muscle behind the armpit. The breast is peeled off, leaving the muscle behind.

If lymph nodes are being removed, this will be done as part of either a sentinel node biopsy or axillary dissection. Following the removal of the breast and lymph nodes, the flaps of skin are joined and sewn together.

A mastectomy can take up to two to five hours. Depending on the procedure, a mastectomy may be outpatient surgery, or the patient may be admitted to the hospital. In most cases, women having mastectomies will spend one or two nights in the hospital, or may be placed in a short-stay observation unit with follow-up care provided by a home care nurse.

After the mastectomy

Immediately after the procedure, patients are taken to a recovery room until they are awake and vital signs are stable. Bandages (dressings) cover the surgery site. 

Following the procedure, the breast area will be flat or, in very thin women, slightly concave (indented), There will be a scar that goes across the middle of the chest where the breast used to be. Initially, the skin in the breast and underarm area will not be completely flat, and fluid may accumulate as part of the natural healing process. The surgeon typically inserts one or more drains (plastic or rubber tubes) into the breast or underarm area. The drains remain in place to remove blood and lymph fluid that accumulates during healing.

At home, patients may need to empty the drains that were placed in the breast and underarm area during surgery. They will measure the fluid in them and alert their physician about any potential problems that arise, such as a large swelling of tissue due to excess underlying fluid. This is rare, and can be drawn out with a needle in a procedure known as aspiration. Drains usually remain in place for one or two weeks and are removed when drainage has been decreased to 1 fluid ounce a day.

In some cases, a woman may have her arm placed in a sling to prevent her from moving the arm and tearing the surgical incisions. However, many physicians prefer not to do this because it can cause the patient’s arm to stiffen and the muscles to become tight. If the arm is kept immobile for a long period of time, physical therapy or occupational therapy may be necessary before the patient can properly use it again.

As a result, physicians will often forsake the sling and instead recommend that the patient use the arm normally and move it frequently to prevent problems. Patients should avoid lifting anything heavier than 5 pounds for several days following the surgery. The physician will recommend certain range-of-motion exercises to prevent contractures of the arm and avoid lymphedema, swelling in the arm that can occur if the surgery has removed lymph nodes. In some cases, women may receive physical or occupational therapy to help in these areas.

Patients will see their physician for a follow-up visit within a week to two weeks after surgery. At that point, the physician will explain the results of the pathology report on the removed tissue and will explain any need for additional treatment, if necessary.

Women who have a mastectomy may receive follow-up treatments to ensure that their cancer is completely eradicated and to reduce the odds of it returning. Commonly used treatments include:

  • Chemotherapy. Uses one or more powerful drugs to target dividing cancer cells to keep them from reproducing and spreading throughout the body. It may be used before (to shrink a tumor prior to surgery) or after a mastectomy.
  • Radiation therapy. Uses an energy called ionizing radiation to kill cancer cells and shrink tumors. Radiation therapy may be performed to shrink a tumor before a mastectomy and is sometimes performed after partial and simple mastectomies. It may also be performed after a modified radical mastectomy, depending on the results of laboratory analysis of lymph nodes removed during the procedure.
  • Biological therapy. Repairs, stimulates or enhances the immune system so that it can better recognize and destroy cancer cells. In some cases, biological therapy directly targets the cancer cells for destruction.  This therapy also may be used because it often has fewer of the side effects associated with cancer treatments such as chemotherapy.
  • Hormone therapy. Treatment to reduce the level of, or interfere with, certain hormones that cancers need to grow.
  • Additional surgery. In some cases, the results of analysis of tissues removed during a mastectomy may indicate the need for additional surgery.

Women may still need mammograms after a mastectomy. Some breast tissue can remain after a mastectomy, which should be monitored for cancerous areas. Women should continue to get regular mammograms in the other breast if they have had a unilateral mastectomy.

Potential risks with mastectomies

Mastectomies can be life-saving operations for women who have cancer or who are at high risk for the disease. The procedure, however, comes with several risks, including:

  • Bleeding
  • Infection
  • Accumulation of clear fluid in wound (seroma)
  • Lymphedema
  • Injury to tissue near the breast
  • Scarring
  • “Phantom” symptoms, such as itchiness of a nipple that is no longer there
  • Blood clots
  • Reduced sensitivity and sexual response
  • Psychological and emotional issues

The pain following a mastectomy varies among women and the extent of surgery. Patients who experience significant pain should report it to their physician because this may indicate a serious complication, such as postoperative bleeding. 

Many women experience numbness and a pinching or pulling feeling in the underarm area. Women commonly feel numbness in the area of the breast as a result of the severing of the breast’s nerve supply. In a partial mastectomy, women are more likely to feel partial numbness whereas in a total mastectomy, the numbness may be present throughout the entire breast. Many women report that this resembles the “tingly” feeling that occurs when a foot is asleep and begins to come back again. It is likely to be permanent, although it may fade over time.

In addition, women may experience a tight feeling with arm movement due to damage to the muscles. The reduced movement may be most pronounced with elevating and stretching the arm over the head. Exercises to promote gradual range of motion will be provided for the patient to complete during the recuperation period. Physical or occupational therapy may be prescribed to help with mobility problems or lymphedema.

Patients will likely experience periods of exhaustion following surgery. This is normal, and it often comes and goes quickly and without warning.

Breast reconstruction

Women who have had a breast removed may opt to wear a prosthesis in their bra or to have a breast reconstruction. In this surgery, a plastic surgeon will sculpt a new breast using either a synthetic breast implant or the patient’s own tissue. In some cases, this is performed during the same surgery in which the breast is removed. In other cases, the reconstruction will be scheduled for a later date.

Breast reconstruction will help create an artificial breast that looks similar to a natural breast, particularly under clothing and in silhouette. However, the new breast will not look exactly like a natural breast, and some asymmetry may be evident between a new breast and a remaining natural breast. In addition, women who have breast reconstruction will not experience normal sensation in their breasts.

Questions for your doctor about mastectomy

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctors the following questions about mastectomy:

  1. Why should I consider a mastectomy to treat my cancer?
  2. What are the advantages of a mastectomy over a lumpectomy? What are the disadvantages?
  3. Which type of mastectomy is best for my condition?
  4. What are the risks with this surgery?
  5. Will I have the procedure as an inpatient or outpatient?
  6. What procedure will be used to remove my lymph nodes?
  7. When will I learn my biopsy results from surgery?
  8. What can I expect in terms of recovery?
  9. What can I do to prevent complications following the surgery?
  10. What signs indicate a need for immediate medical attention during recovery?
  11. Will I need additional cancer treatment following the mastectomy?
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