What is a Mastectomy?
Mastectomy, or surgical removal of the breast, has been used to treat breast cancer for several centuries. The early radical mastectomy, which removed the entire breast, the lymph nodes in the armpit, and one of the major muscles of the chest wall, was based on the mistaken belief that the more tissue removed, the better the chances of curing the cancer. This procedure caused so much deformity, that women feared it as much as the cancer itself. Today it is rarely used, and only for very extensive cancers that spread to the muscles.
In the 1970s and 1980s, research proved that there was no advantage in removing the chest muscles. This led to the modified radical mastectomy that is used today.
This procedure removes as much of the breast tissue as possible, including the nipple and the areola, and a number of axillary lymph nodes, but not the muscles. Patients can choose from a variety of reconstruction techniques that offer pleasing cosmetic results.
0In certain cases, it is possible to perform a procedure called skin-sparing mastectomy. This procedure leaves a natural skin pouch that makes it easier to have an immediate reconstruction, either with implants or with your own tissues, and it yields some of the most realistic and pleasing results.
Skin-sparing mastectomy is not right for you if you have decided against immediate reconstruction, or if the tumor is too close to the skin.
In some cases a nipple-sparing mastectomy can be performed, where all of the skin, including the nipple is left behind. Although the nipple is preserved, it usually loses sensitivity. This type of mastectomy is still an area of debate among surgeons, and long-term local recurrence is still being studied.
A mastectomy is usually done in a hospital under general anesthesia. After a date is set, someone on your surgeon’s staff will review with you the admission process for the particular hospital where the operation will take place. Find out whether your insurance covers surgical fees, hospital room, anesthesiologist’s fees, and other charges.
Make a list of all the medications you are taking, both prescription and over-the-counter, since some of them may have adverse effects during anesthesia or surgery. (For example, aspirin-containing preparations can increase bleeding.) Some medications may need to be discontinued several weeks before surgery. Be sure to mention your allergies, smoking history, colds or tooth decay.
Blood transfusions are rarely needed during lumpectomies or mastectomies, but may be required for certain types of breast reconstruction. Many people are concerned about contamination of banked blood with HIV, the virus that causes AIDS. You may wish to discuss with your physician the possibility of donating and storing your own blood before your surgery so that it can be used, should you need it. You will need to donate the blood at least one week before surgery.
Pack all the personal belongings you may need: a nightgown, slippers, toiletries, books or an iPod, perhaps a favorite pillow, and a change of loose clothing that buttons in front, to wear when you go home.
Most people undergoing surgery enjoy having a friend or relative accompany them to the hospital and meet them after the procedure. If you are going to be sent home the same day, you will definitely need someone to drive you.
You’ll be instructed not to eat or drink anything after midnight on the night before the surgery.
On the day of the surgery, you’ll first go through an admission process at the hospital. The hospital staff will ask you to sign an informed consent form listing your doctor’s name and the name of the surgical procedure you are having. Make sure you feel comfortable with what you are signing. If there is anything on the form that worries you, ask to see your doctor.
Your surgeon will meet you in the pre-op area to draw markings on your skin where the incisions will be made to achieve the best result possible.
The Surgical Procedure
The anesthesiologist or a nurse anesthetist will start an intravenous line (an “IV”) in one of your arms using a small needle, and perhaps give you something to help you relax.
When the surgical team is ready, you will be taken to the operating room. Several devices will be attached to you, such as an automatic blood pressure cuff, a heart monitor, and a blood oxygen monitor. The anesthesiologist will inject a drug into your vein through the tubing, and you will fall asleep almost immediately. A tube may be placed through your mouth to maintain a way for you to breathe during the surgery. Your blood pressure, pulse, and breathing will be closely monitored during the entire procedure.
The mastectomy procedure can take up to two to three hours. Breast tissue extends from the collar bone to the edge of the ribs, and from the breast bone to the muscles in the back of the armpit, and all of it needs to be removed.
The tissue will be sent to the pathologist, who will examine it for any evidence of cancer spread beyond the breast.
You may also undergo a procedure called an axillary lymph node dissection. It is described later in this chapter.
When the procedure is completed, one or two tubes called drains will be placed under the skin to help remove the fluid that accumulates at the site of surgery. Before you go home, you’ll be shown how to empty the suction bulbs attached to the drains and how to keep a record of the volume and color of the fluid. The drains will be removed at a follow-up visit to your surgeon, or as soon as the drainage decreases.
If you’ve decided to have immediate reconstruction of the breast, the plastic surgeon will take over while you are still asleep. Reconstruction can be done using your own tissues or using a synthetic implant. The procedure may take anywhere from an hour to six or eight hours, depending on the method used.
Recovery after Mastectomy
After surgery, you’ll be taken to the recovery room. As you wake up from the anesthetic, you may feel cold, and your throat may be sore from the tube used for anesthesia. You may fade between waking and sleeping for several hours.
Whatever surgery they are going to have, most women like to have a friend or relative meet them after the operation. You can ask your surgeon how long it will take before you will be brought to your room after surgery and to arrange with the hospital to allow that person to meet you there.
Most women will stay in the hospital for one or two nights after a mastectomy, and somewhat longer after a mastectomy with reconstruction.
Each woman reacts to surgery differently. Most can take a short walk in and out of their hospital room the day of surgery. The next day, most are able to eat a regular diet and get around.
Recovering at Home
Once you’re home, you’ll probably feel more tired than usual for a while. Don’t be discouraged. You’ve just been through general anesthesia and major surgery, and fatigue is to be expected.
Take sponge baths for a few days after surgery until your incision starts to heal. Don’t shower until your drains are removed, and the surgeon tells you that it is alright to get the incision wet. When you do shower, treat the skin gently and pat, rather than rub, the incision.
Immediately after surgery, you’ll probably have trouble moving your arm due to muscle tightness and soreness around the shoulder. Use the arm as tolerated immediately after surgery, but avoid active stretching or pulling until the drains are removed and you get your doctor’s approval. Don’t be afraid to enlist the help of a friend or relative until your arm function returns.
Many women return to work as soon as they feel better, even while their chemotherapy and radiation treatments are continuing. If your job requires lifting or strenuous physical activity, you may need to change your activities until you have fully regained your strength.
Risks of Mastectomy
Like all surgeries, mastectomy has some risks. You may experience numbness in the upper inner arm and armpit area, caused by injury to one of the nerves. If this happens to you, you may need to be particularly careful when you shave your underarm. The numbness will usually improve over months or years, but the sensation may never be completely normal. You may develop a fluid collection under the scar that may need to be drained with a needle by your physician. Wound healing problems or wound infections may also occur, although rarely. A side effect of axillary lymph node dissection is swelling of the arm, called lymphedema.
Exercises After Mastectomy
The goal of exercising your shoulder and arm after surgery is to regain the full range of motion as soon as possible. But don’t attempt to begin exercising without specific instructions from your healthcare provider.
Exercises must be done in stages. After the drains are removed, your doctor or physical therapist may assign pendulum-like movements with your arm, to begin loosening any tightness in the shoulder area.
Avera Cancer Center offers swimming, exercise, and other classes specifically for breast cancer patients.
Is Mastectomy Right for Me?
Numerous research studies, involving thousands of women and many years of follow-up, show that there is no difference in survival in patients treated with lumpectomy and radiation, or with mastectomy.
There is a slightly higher rate of local cancer recurrence (in the breast area itself) following lumpectomy: one out of a hundred women treated with lumpectomy will develop a local recurrence within a year. (In other words, there is a 1% per year recurrence rate. The chance of having a recurrence within ten years is 10%.)
Local recurrences are not life threatening, and can be controlled by performing a mastectomy at the time that the cancer recurrence is found. Since there is no difference in numbers of life-threatening distant metastases (cancer in other sites of the body) between lumpectomy and mastectomy, there is no difference in life expectancy between the two procedures.
So the choice is between running a slightly higher risk of a local recurrence following lumpectomy (which is not life threatening), or accepting a mastectomy.
The advantages of a mastectomy are that usually no radiation therapy is required, and there is a decreased risk of local recurrence. Some women prefer the procedure because of the peace of mind they expect after the removal of the breast.
The disadvantages include more extensive surgery, and the emotional impact of losing the entire breast, including the nipple.
Your choice will be dictated by various factors. Here are a few considerations that would favor mastectomy over lumpectomy:
• The tumor is larger than 5cm (2.5 inches)
• The tumor is so big or the breast is so small that the cosmetic result would not be satisfactory after tumor removal.
• There is more than one tumor location in the breast.
• You are unwilling or unable to undergo radiation treatment.
• You prefer to have a mastectomy.
It is important to remember that no decision needs to be made overnight. You can take up to several weeks to gather information. You do not need to make the decision alone. Consult your healthcare professionals, get a second opinion, and talk with your loved ones.