Mastectomy

Mastectomy is an operation in which the entire breast, usually 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 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).

A woman may decide to have a mastectomy versus a lumpectomy based on the following:

• If the tumor is big 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

Several types of mastectomy are available. The surgeon may choose one of the following types of mastectomies:

• Subcutaneous mastectomy: The surgeon removes all of the breast tissue except the nipple and the areola. No lymph nodes in the armpit (axillary lymph nodes) are removed. Subcutaneous mastectomy can be used when a woman desires a prophylactic (preventive) mastectomy. Breast implants (saline or silicone) are usually placed during the mastectomy to reconstruct the breast. Subcutaneous mastectomy is not usually recommended for women who are known to have breast cancer already.



• Simple or total mastectomy: The surgeon removes the entire breast tissue but does not remove the muscle tissue under the breast and the lymph nodes in the armpit. Simple or total mastectomy is often performed prophylactically (preventively), or it is performed for a woman who has ductal carcinoma in situ (cancer cells just in the milk ducts of the breast) where sampling of the axillary nodes is not recommended.



• Skin-sparing mastectomy: The surgeon removes the entire breast, including the nipple and the areola, using an incision around the perimeter of the areola. If a sample is needed of the lymph nodes in the armpit (either sentinel node biopsy or axillary node dissection), the sample can be taken through a separate incision in the armpit. Skin-sparing mastectomy saves the skin envelope of the breast to allow immediate reconstruction.



• Modified radical mastectomy: The surgeon removes the entire breast tissue, including the nipple and the areola, and most of the lymph nodes in the armpit 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.

• 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.

• An intravenous (IV) line administers 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 along the perimeter of the breast or the areola, depending on the planned procedure.



• The surgeon removes most of the underlying breast tissue. This breast tissue is removed and sent to a laboratory for analysis. Cells are examined under a microscope to determine if they are benign (noncancerous) or malignant (cancerous).



• The skin is closed with stitches or staples.



• Drainage tubes are usually inserted into the operated area to drain out blood and fluid that may continue to ooze out of the operated tissues after the skin is closed.



• A pressure dressing is placed over the operated site to minimize the oozing after the surgery.



• The duration of the operation depends on the type of mastectomy being performed. A modified radical mastectomy takes 2-3 hours.

• 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 2-7 days, depending on the type of mastectomy and the type of reconstruction, if any.

• The first follow-up visit occurs about 1 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 2 weeks) when the amount of fluid draining from the operation site decreases to an acceptable volume.

Most women recover with no complications; however, as with any surgery, risks are involved.

The risks of any surgery include infection, bleeding, those associated with general anesthesia (for example, heart and lung problems), and reaction to medications.

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.

• If breast cancer is detected in its earliest stage, treatment results in a 10-year survival rate (that is, percent of women still living) of more than 90%.
  
  
  • 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.

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



• Stitches come out

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.

Y-ME National Breast Cancer Organization
212 W Van Buren, Suite 1000
Chicago, IL 60607-3908
(312) 986-8338

Susan G. Komen Breast Cancer Foundation
5005 LBJ Freeway, Suite 250
Dallas, TX 75244
(972) 855-1600

|Web Links|

American Cancer Society, All About Breast Cancer

National Cancer Institute, What You Need To Know About Breast Cancer

MedlinePlus, Breast Cancer

Centers for Disease Control and Prevention, Cancer Prevention and Control, National Breast and Cervical Cancer Early Detection Program

MayoClinic.com, Breast Cancer

MedlinePlus, Mastectomy

breastcancer.org, Mastectomy

Media file 1: Anatomy of the breast.

Media type:  Illustration

Media file 2: Types of mastectomy.

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Media file 3: The blue highlighted area indicates breast tissue removed during total (simple) mastectomy.

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Media file 4: The blue highlighted area indicates breast and lymphatic tissue removed during modified radical mastectomy.

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Media file 5: The blue highlighted area indicates breast and lymphatic tissue and the red highlighted area indicates muscle removed during radical mastectomy.

Media type:  Illustration

Media file 6: 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.

Media type:  Photo

Media file 7: Postoperative appearance of the woman from Multimedia File 6 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.

Media type:  Photo

Media file 8: 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.

Media type:  Photo

Media file 9: The woman in Multimedia File 8, 2 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 2 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.

Media type:  Photo

mastectomy, removal of the breast, breast removal, breast cancer, breast cancer tumor, lumpectomy, simple mastectomy, total mastectomy, modified radical mastectomy, radical mastectomy, mammogram, mammography, breast self-exam, breast self-examination

Author: Leigh A Neumayer, MD, MS, FACS, Professor of Surgery, Department of General Surgery/Critical Care, University of Utah School of Medicine; Consulting Surgeon, Salt Lake City Veteran's Affairs Medical Center.

Coauthor(s): Marga Massey, MD, Assistant Professor, Department of General Surgery, Division of Plastic and Reconstructive Surgery, University of Utah School of Medicine; Shehnaz Shaikh, MD, Medical Writer, .com, Inc.

Editors: Bryan D Cowan, MD, Director, Division of Reproductive Endocrinology, Professor, Department of Obstetrics and Gynecology, University of Mississippi College of Medicine; Mary L Windle, Pharm D, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, .com, Inc; Lee P Shulman, MD, Professor of Obstetrics and Gynecology, Head, Section of Reproductive Genetics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.