Mastectomy

The surgical removal of a breast, mostly due to cancer, is called a mastectomy. A mastectomy is performed in variety of ways depending on the size or location of the tumor and the respective surgeon’s decision.

Why Mastectomy?

A mastectomy is generally performed on patients with breast cancer. It is performed as a treatment option for various types of breast cancers; namely, invasive ductal carcinoma, invasive lobular carcinoma, medullary carcinoma, mucinous and tubular carcinomas, inflammatory carcinoma, Paget’s disease, ductal carcinoma in situ (DCIS), and lobular carcinoma in situ (LCIS). However, in this context, it must be noted that mastectomy does not totally eliminate the chance of breast cancer, but it definitely reduces the risk considerably.

Types of Mastectomy

As mastectomy caters to a wide range of cancers, every condition requires a different type of surgery. The most common types of mastectomy for removal of breast cancer are as follows:

Partial mastectomy

This procedure involves the removal of a portion of the breast tissue, the portion that is affected, along with a margin of healthy breast tissue. Though lumpectomy is known to be a type of partial mastectomy, partial mastectomy involves a lot more tissue removal as compared to a lumpectomy.

Total mastectomy

This involves the removal of the entire breast along with the skin, nipple and areola but not the lymph nodes. This procedure is performed on patients with ductal carcinoma in situ. This is done to prevent any possibility of further invasion.

Modified radical mastectomy

In this procedure, the entire breast along with the nipple, areola and axillary lymph nodes (that is the lymph nodes near the armpit) are removed. This procedure is done to inspect the lymph nodes to identify the presence of cancer cells and the extent of metastasis beyond the breast. This is usually performed on patients with invasive breast cancer.

Radical mastectomy

This is similar to modified radical mastectomy, only that in this procedure, the muscles in the chest (both pectoral major and minor) are also removed. This procedure is performed only if the cancer has spread to the chest muscles beneath the breast. In recent times, modified radical mastectomy is preferred over radical mastectomy as the former is known to be less disfiguring than the latter though they are both equally effective.

Mastectomy may also be done as a preventive method to reduce risk of breast cancer. This is known as prophylactic mastectomy. This is performed on patients known to have high risk of breast cancer either with a close family member with breast cancer or having had one at a very early age or if it is proven via genetic tests (like BRCA1/BRCA2). However, this type of mastectomy is done only after thorough discussion with the family, surgeon, genetic counselor and of course the patient herself.

Pre-procedure

On detection of breast cancer, the doctor examines the patient thoroughly to understand the extent of the cancer and the type of mastectomy that would be appropriate for that particular patient. After the doctor decides on the type of procedure and the patient agrees, the date and time of surgery is decided. A few days prior to the surgery, the patient needs to undergo a few tests to check whether the overall condition is favorable for the patient to undergo the surgery. These tests include blood tests, urinalysis, electrocardiogram etc.

The patient should inform the surgeon and also the anesthesiologist regarding the various medications (if any) she is taking for other health issues. She should also keep the surgeon informed in case she is pregnant.

If the surgery is scheduled for early morning, the patient should not eat or drink anything after midnight the previous night.

The patient may be asked to take a shower the previous night, using an antibacterial soap. She should follow all the instructions as given by the surgeon.

The Procedure

As a preparation for the surgery, an intravenous line is placed through which various medications (if required) and anesthesia may be administered. Blood pressure cuffs are placed to monitor the blood pressure. Other vital signs are also checked all throughout the procedure. The heart function is also monitored by the help of an electrocardiogram. The operative site is then washed and sterilized and drapes are placed all around leaving the operative site open. Prevention is taken to avoid any infection that may occur during the surgery.

The procedure then begins with the administration of general anesthesia, which puts the patient to sleep.

This is then followed by making incisions and excising depending on the type of mastectomy done. That is, excision of breast tissues along with skin, nipple and areola in case of total mastectomy; removal of the tumor and a portion of the breast in case of partial mastectomy; removal of breast tissues along with nipple, areola and axillary lymph nodes in case of modified radical mastectomy and excision of breast tissue, skin, nipple and areola along with the chest muscles in case of radical mastectomy.

Finally, the area is closed with sutures or staples.

The excised tissues are sent to pathology to determine whether they are malignant (cancerous) or not.

At the end of the procedure draining tubes are placed to remove blood and fluid from the surgical site. The surgeon may place a pressure dressing to prevent the oozing of excess blood or fluid.

The total duration of a mastectomy takes about 1 to 2 hours; however, this varies depending on the type of mastectomy being performed.

Postprocedure

After the procedure, the patient is transferred to the recovery room where the vital signs are again checked. Once these are stabilized, she is transferred to the floor and depending on the recovery, she is discharged home. The patient is given pain medications either orally or intravenously to reduce the post surgery pain.

The patient is advised to come back for a follow-up visit after about a week to check the incision site and postoperative complications, if any. The draining tubes and sutures/staples are removed during this visit. However, in most cases dissolvable stitches are used, which dissolve by themselves and need not be removed.

The pathological or biopsy results are also discussed during this visit and the surgeon advises on further treatment options (like chemotherapy, radiation therapy and/or hormonal therapy) or surgery that may be required depending upon the results.

Risks and Complications

A mastectomy also involves similar risks and complications involved in any other major surgery; namely, bleeding, infection, blood clots, heart attack or stroke, reaction to medications and/or reaction to anesthesia that can result in heart and lung problems also.

Along with the above, there are other risks involved specifically in a mastectomy. These include numbness and tenderness along the incision site and the adjoining area, sensitivity to touch at the surgical site, hematoma (blood collection) or seroma (fluid collection) under the scar, prolonged wound healing, painful scar tissue formation, swelling of the arm or nerve injury at the armpit area that occurs only in case lymph nodes are removed during the mastectomy procedure.

It should be noted at this point that the mastectomy procedure is an absolutely safe procedure and the above mentioned complications are very rare. Most women recover without any of these complications.

Recovery Process

The recovery period varies from patient to patient; however, the following suggestions will help the patient to hasten the recovery process after a mastectomy:

Rest – Experiencing fatigue is normal after a mastectomy, hence taking plenty of rest relieves the patient to a great extent.

Pain medications – After the surgery, the patient experiences pain and numbness in and around the surgical site for which the doctor prescribes some pain medications.

Surgical drain – The surgical drain is usually left in place after surgery and is only removed on the first postoperative visit. Till such time, the drain needs to be emptied a few times every day. Instructions are also given by the doctor on taking care of the drain.

Exercising – The doctor suggests some arm exercises to prevent stiffness of the arms and shoulders. Certain exercises may be started on the day after the surgery itself while some are given only after the drains are removed. These exercises need to be done on a regular basis to keep the arm flexible.

Taking bath – Taking a full shower is only possible when the patient’s drains and staples or sutures, if any, are removed and the doctor gives permission for the same. Till such time, the patient may take sponge baths which gives a clean and fresh feeling even without a shower.

Prosthesis – Wearing a prosthesis or bra is only possible after the mastectomy site has healed completely. It is best to follow the doctor’s advice in this regard.

‘Phantom sensations’ – It is quite normal for patients who undergo mastectomy to experience crawly or itchy feelings around the surgical area. She may also experience a pressure feeling or sensitivity in that area. This is due to the regrowth of the nerves in this area. These feelings usually go on their own and even if they don’t, the patient gets accustomed to it. However, medications like analgesics, NSAIDs or opioids may also be prescribed for this kind of discomfort.

Seeking Medical Care

Medical advice should be sought in case there is fever, redness or signs of infection, increased drainage of blood or fluid or if the sutures tend to come out on its own.

Patients undergoing a mastectomy not only has to cope with the pains of the surgery but also with the stress of cancer and the fact that her breast has been removed. Thus these patients often undergo a lot of emotional stress. Counseling sessions or a rehab program is often recommended to help these patients come out of such situations.

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