Mastectomy

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Mastectomy Overview

Mastectomy is an operation in which the entire breast, often including the nipple and the areola, is removed. Mastectomy is usually performed as a treatment of breast cancer.

In general, women with breast cancer can decide along with their surgeon whether to be treated with a lumpectomy or a mastectomy.

A lumpectomy is the removal of the cancerous breast tissue as well as a surrounding rim of healthy breast tissue. A lumpectomy is a breast-conserving surgery that is usually followed by radiation therapy (high-dose X-rays or other high-energy rays to kill cancer cells).

Some factors that may influence a woman to choose a mastectomy over a lumpectomy are:

  • If the tumor is large and, after the lumpectomy, very little breast tissue would remain
  • If she does not want to undergo radiation therapy after the surgery
  • If she believes she will have less anxiety about a recurrence of breast cancer with a mastectomy

If the woman has tumors in more than one quadrant of the breast, most cancer doctors recommend a mastectomy.

Historically, a mastectomy for breast cancer included an axillary lymph node dissection (removal of many of the axillary lymph nodes). Over the last decade, the approach has changed slightly in that many women can undergo a sentinel lymph node biopsy (removal of the first few lymph nodes draining the tissue of the breast) rather than an axillary lymph node dissection. The nomenclature is such that a modified radical and a radical mastectomy include an axillary lymph node dissection as part of the overall procedure. With the adoption of sentinel lymph node biopsy in the treatment of early breast cancer, the nomenclature for mastectomy has also changed. Depending on the characteristics of the tumor, the breast, and the patient, the surgeon may choose one of the following types of mastectomies:

  • Simple or total mastectomy: The surgeon removes the entire breast tissue but does not remove the fascia or lining of the muscle or the muscle tissue under the breast. This mastectomy can be combined with a sentinel lymph node biopsy in any case of an early invasive cancer and in some cases of ductal carcinoma in-situ when a mastectomy is chosen as the treatment option. Any of these can also be combined with an axillary lymph node dissection (which by convention turns the total mastectomy into a "modified radical mastectomy"). There are several subtypes of simple or total mastectomy depending on how much skin is removed.
  • Traditional: The surgeon removes an ellipse of skin that includes the skin of the nipple/areolar complex. This is the most commonly performed mastectomy. If the woman doesn't want immediate reconstruction or is not offered immediate reconstruction, the end result is a flat chest with a scar about 5 inches in length, usually oriented transversely.
  • Skin-sparing: In addition to the breast tissue as noted, the only skin removed is that of the nipple and areola, usually through a circular incision around the areola. If the breast is large, the surgeon may have to make a "keyhole" incision (one that includes a straight incision in one direction, generally down) to allow removal of the breast tissue.
  • Nipple-sparing: The surgeon makes an incision around the nipple but leaves the areola intact. Again, in order to remove all of the breast tissue, the incision will need to be bigger than what is achieved with removal of the nipple. This is often an S-shaped incision.
  • Total skin-sparing: The surgeon removes the breast tissue but leaves all the skin (including the skin of the nipple and areola) behind. The incision can be place in the outer part of the breast, in the inframammary fold or around the areola.

In general, if leaving the skin of the areola and or nipple, some surgeons recommend that the woman have a tumor that is less than 2 centimeters in size and that is more than 2 centimeters away from the nipple. The skin-sparing mastectomies are ideal for patients undergoing prophylactic mastectomy. The skin-sparing, nipple-sparing, and total skin-sparing mastectomies are generally done in combination with immediate breast reconstruction. The benefit of these procedures is that more of the breast skin envelope is preserved to make it easier to recreate the breast. No randomized trial has been undertaken to evaluate if there is an increased risk of local (in the breast skin or on the muscle) recurrence with the skin-sparing techniques. Most surgeons estimate that preserving more skin increases the risk of local recurrence of the tumor by 1% or 2 % over 20 years (from 3%-5% for traditional to 5%-7% for skin-sparing).

  • Modified radical mastectomy: This combines a simple or total mastectomy, including the skin of the nipple and the areola, and includes removal of most of the lymph nodes in the armpit (axillary nodes) using a 6- to 8-inch incision. A woman undergoing a modified radical mastectomy can have immediate or delayed breast reconstruction.
  • Radical mastectomy: The surgeon removes the entire breast tissue, all the lymph nodes in the armpit, and the muscles of the chest wall (pectoral muscles) that lie under the affected breast. Radical mastectomy was common in the past; however, it is rarely performed now.

Mastectomy Preparation

  • A few days before the surgery, a health-care provider evaluates the woman's overall health to ensure that she is fit for the surgery.
  • Several tests, such as routine blood workup, urinalysis, and electrocardiogram (ECG), may be performed a few days before the surgery.
  • Before the surgery, the anesthesiologist examines the woman and reviews the test results.
  • If the woman is taking any medication or is allergic to any medication, the surgeon and the anesthesiologist should be informed. The surgeon and the anesthetist should also be informed if the woman is taking any herbal supplements. Some herbal supplements, such as ginkgo, can increase a person's risk of bleeding and, therefore, should be discontinued before surgery.
  • If the surgery is scheduled for early morning, the woman is required to not eat or drink anything after midnight on the night prior to the surgery.
  • Showering with an antibacterial soap the night before the surgery may be required.
  • A woman should follow any other instructions given by the health-care provider.
  • The woman will be asked to sign a consent form stating that she understands the risks involved in the surgery. She should feel free to ask the surgeon and the anesthesiologist any questions prior to signing the consent form.
Breast cancer

Breast Reconstruction

Breast reconstruction is one or more operations performed to restore all components of the breast of women who have undergone mastectomy (removal of the entire breast). Breast reconstruction after mastectomy has evolved over the last century to become an integral component in the therapy for many women with breast cancer.

During the Mastectomy Procedure

  • An intravenous (IV) line is used to administer medicines that may be required during surgery.
  • Heart function is monitored by an ECG machine.
  • A blood-pressure cuff is placed on the woman's arm to monitor her blood pressure during surgery.
  • The operation site is washed and sterilized.
  • Sterile drapes are placed over the woman to guard against infection. Only the operation site is kept uncovered.
  • General anesthesia is administered. The woman may be given a dose of antibiotics to prevent infection.
  • The surgeon makes an incision depending on the planned procedure.
  • The surgeon removes the underlying breast tissue. This breast tissue is removed and sent to a pathology laboratory for analysis. A pathologist examines the tissue under a microscope to determine the extent of the cancer or, in the case of a prophylactic mastectomy, determine if it is benign (noncancerous) or malignant (cancerous).
  • The skin is closed with stitches or staples.
  • Drainage tubes may be inserted into the operation site to drain out blood and fluid that may continue to ooze out of the tissues after the skin is closed.
  • A pressure dressing may be placed over the operation site to minimize the oozing after the surgery.
  • The duration of the operation depends on the type of mastectomy being performed. Most mastectomies take one to two hours, not including the time required for any lymph node procedures (sentinel lymph node biopsy or axillary node dissection) or reconstruction procedures.

After the Mastectomy Procedure

  • After surgery, the woman is taken to a recovery room where her vital signs (blood pressure, pulse, and breathing) are monitored. Once stable, she is moved out of the recovery room.
  • Depending on the severity of her pain, the woman may be given pain medications orally or by intravenous injection. The medication does not eliminate pain, but it does reduce the pain.
  • A woman undergoing a mastectomy generally stays in the hospital for one to seven days, depending on the type of mastectomy and the type of reconstruction, if any. A few women are able to go home the night of their mastectomy.

Next Steps after Mastectomy

The first follow-up visit occurs about one week after the surgery to make sure the incision is healing well and that no postoperative complications are present.

  • During this visit, the surgeon explains the results of the biopsy and, if necessary, discusses any further treatment (chemotherapy [using medications to kill cancer cells], radiation therapy, or both).
  • Stitches that dissolve by themselves are often used to close the incision. If the surgeon used nondissolving stitches or clips, they are removed during the first follow-up visit.
  • Drainage tubes are usually removed (typically within two weeks) when the amount of fluid draining from the operation site decreases to an acceptable volume.

Mastectomy Risks

Most women recover with no complications; however, as with any surgery, risks are involved. The risks of any surgery include infection, bleeding, those risks associated with general anesthesia (for example, heart and lung problems), and reaction to medications.

Risks specifically related to the mastectomy itself are numbness of the breast skin and necrosis (tissue death) of the breast skin. The numbness requires no treatment. Necrosis of the skin may require a return to the operating room for revision of the scar.

Risks specifically related to mastectomy in which the lymph nodes in the armpit (axillary lymph nodes) are removed include swelling of the arm (called lymphedema) and possible injury to the nerves in the armpit area.

Mastectomy Results

If breast cancer is detected in its earliest stage, treatment results in a 10-year survival rate (that is, percent of women still living) was 82 % of 2011. Long-term survival is similar whether the woman chooses lumpectomy or mastectomy. The difference between the treatments is there is an increased risk of a local recurrence (in the breast or on the chest wall) with lumpectomy. Also, lumpectomy is almost always followed by radiation therapy.

  • Self-examination of the breast and an annual mammography help in the early detection of breast cancer.
  • In the United States, yearly mammography screening is recommended for women older than 40 years.
  • In addition to mastectomy, treatments such as hormonal therapy, radiation therapy, and chemotherapy (if required) improve the chances of recurrence-free, long-term survival.

When to Seek Medical Care Following a Mastectomy

A woman should contact a health-care provider if any of the following occur after a mastectomy:

  • fever,
  • signs of an infection (such as excessive redness at the incision site),
  • increased drainage of fluid, or
  • the stitches come out.

Mastectomy Support and Counseling

A woman who undergoes a mastectomy has to deal with not only the stress of coping with the cancer but also the anguish of losing her breast. Interacting with other women who have undergone mastectomies can help in dealing with these feelings. If a woman lives in the United States, she can locate the Reach to Recovery program in her area at the Web site of the American Cancer Society, Support for Survivors and Patients, Reach to Recovery.

Types of Mastectomy Pictures

Anatomy of the breast.
Anatomy of the breast. Click to view larger image.

Types of mastectomy.
Types of mastectomy. Click to view larger image.

The blue highlighted area indicates breast tissue removed during total (simple) mastectomy.
The blue highlighted area indicates breast tissue removed during total (simple) mastectomy. Click to view larger image.

The blue highlighted area indicates breast and lymphatic tissue removed during modified radical mastectomy.
The blue highlighted area indicates breast and lymphatic tissue removed during modified radical mastectomy. Click to view larger image.

The blue highlighted area indicates breast and lymphatic tissue and the red highlighted area indicates muscle removed during radical mastectomy.
The blue highlighted area indicates breast and lymphatic tissue and the red highlighted area indicates muscle removed during radical mastectomy. Click to view larger image.

A 62-year-old woman presents with an infiltrating lobular carcinoma of the right breast (T1N0). These photos represent her appearance after a lumpectomy and staging sentinel lymph node procedure. Her lumpectomy was performed through an incision at the juncture of the areola and steri-strips are still in place. Her lymph node biopsy was completed through a separate small incision in her axilla. Once her tumor size and lymph node status were defined, she was provided information regarding her need for chemotherapy and irradiation therapy before proceeding with complete mastectomy. Additionally, the woman was referred to a plastic surgeon in order to provide her with an opportunity to explore her options for breast reconstruction.
A 62-year-old woman presents with an infiltrating lobular carcinoma of the right breast (T1N0). These photos represent her appearance after a lumpectomy and staging sentinel lymph node procedure. Her lumpectomy was performed through an incision at the juncture of the areola and steri-strips are still in place. Her lymph node biopsy was completed through a separate small incision in her axilla. Once her tumor size and lymph node status were defined, she was provided information regarding her need for chemotherapy and irradiation therapy before proceeding with complete mastectomy. Additionally, the woman was referred to a plastic surgeon in order to provide her with an opportunity to explore her options for breast reconstruction. Click to view larger image.

Postoperative appearance of the woman from the previous photo after bilateral completion mastectomies without any form of immediate reconstruction. A tradition linear incision was performed at which time all of the breast tissue, the overlying skin, the nipple, and the areola were removed. Care was taken to excise excess soft tissue under her arms to avoid a contour irregularity in her clothing and to facilitate the fitting of an external prosthesis. The choice for a left prophylactic mastectomy was made by the woman with support of her surgical oncologist given a strong family history of breast cancer. She elected not to proceed with any form of immediate breast reconstruction as a personal decision after she had completed an evaluation with a plastic surgeon. She was informed that should she change her mind regarding reconstruction, it could be performed at a later date after the completion of her adjuvant therapy.
Postoperative appearance of the woman from the previous photo after bilateral completion mastectomies without any form of immediate reconstruction. A tradition linear incision was performed at which time all of the breast tissue, the overlying skin, the nipple, and the areola were removed. Care was taken to excise excess soft tissue under her arms to avoid a contour irregularity in her clothing and to facilitate the fitting of an external prosthesis. The choice for a left prophylactic mastectomy was made by the woman with support of her surgical oncologist given a strong family history of breast cancer. She elected not to proceed with any form of immediate breast reconstruction as a personal decision after she had completed an evaluation with a plastic surgeon. She was informed that should she change her mind regarding reconstruction, it could be performed at a later date after the completion of her adjuvant therapy. Click to view larger image.

A 54-year-old woman with a history of previous bilateral silicone breast implant placement for elective breast augmentation presents with a right-sided infiltrating ductal carcinoma (T1NO) diagnosed by core biopsy. These photos represent her preoperative appearance prior to mastectomy and immediate reconstruction.
A 54-year-old woman with a history of previous bilateral silicone breast implant placement for elective breast augmentation presents with a right-sided infiltrating ductal carcinoma (T1NO) diagnosed by core biopsy. These photos represent her preoperative appearance prior to mastectomy and immediate reconstruction. Click to view larger image.

The woman in this photo two years postoperative s/p right skin-sparing mastectomy with immediate right breast reconstruction using a contralateral, rotational transverse rectus abdominus myocutaneous (TRAM) flap with staged nipple reconstruction, areolar tattoo, and delayed lower body lift. These photos represent her appearance two years after the initial treatment of her cancer and immediate staged autologous reconstruction. Her right silicone breast implant was removed at the time of the mastectomy with the reconstruction having been made entirely of her adipose tissue from her abdominal donor site. Her left breast implant was not removed. The lower abdominal incision is longer than that which is typically required for a TRAM flap given her additional lower body lift.
The woman in this photo two years postoperative s/p right skin-sparing mastectomy with immediate right breast reconstruction using a contralateral, rotational transverse rectus abdominus myocutaneous (TRAM) flap with staged nipple reconstruction, areolar tattoo, and delayed lower body lift. These photos represent her appearance two years after the initial treatment of her cancer and immediate staged autologous reconstruction. Her right silicone breast implant was removed at the time of the mastectomy with the reconstruction having been made entirely of her adipose tissue from her abdominal donor site. Her left breast implant was not removed. The lower abdominal incision is longer than that which is typically required for a TRAM flap given her additional lower body lift. Click to view larger image.

Medically reviewed by John A. Daller, MD; American Board of Surgery with subspecialty certification in surgical critical care

REFERENCE:

"Mastectomy: Indications, types, and concurrent axillary lymph node management"
UpToDate.com

"Contralateral prophylactic mastectomy"
UpToDate.com

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