What is a mastectomy?
The mastectomy operation has been practiced since at least 548 AD when Aëtius of Amida offered the procedure to Theodora, a Byzantine empress, to treat what is thought to have been a form of breast cancer.
Curiously, he seemed to have derived the surgical approach from natural philosophers from 500 years prior.
The operation is most often carried out to remove existing cancerous cells within the breast and thereby reduce the potential for breast cancer to spread.
- There are different types of mastectomy to deal with different medical situations.
- Mastectomies can successfully treat a number of different cancer types.
- In some high-risk women, prophylactic mastectomy can cut the risk of breast cancer by up to 90 percent.
Types of mastectomy
The type of mastectomy most appropriate depends on the individual and will be decided by a doctor.
There are several types of mastectomy, including:
- Total (simple) mastectomy - the entire breast is removed, but muscles under the breast and lymph nodes are kept in place.
- Double mastectomy - both breasts are removed as a preventive measure; this is often used for high-risk patients who have specific genetic markers that make breast cancer more likely.
- Radical mastectomy - the entire breast, underarm lymph nodes, and chest wall muscles are removed.
- Modified radical mastectomy - the entire breast and underarm lymph nodes are removed, but the chest wall muscles are left intact.
- Skin-sparing mastectomy - the breast tissue and nipple are removed, but the skin is left to reconstruct the breast in the same operation.
- Nipple-sparing mastectomy - this relatively new procedure leaves the skin, nipple, and peripheral breast tissue intact.
Many patients opt for breast-conserving surgery, although this is not always possible. These procedures include:
- Lumpectomy - a lumpectomy involves the removal of a tumor and surrounding tissue, and leaves the breasts largely intact; the procedure is typically used in conjunction with radiation therapy. Lumpectomies, however, are not suitable for all patients.
- Quadrantectomy - is a partial mastectomy that involves the removal of more breast tissue than a simpler lumpectomy, but which still spares the majority of the breast tissue.
- Skin-sparing mastectomies - these are newer mastectomy procedures that preserve breast skin, allowing for the reconstruction of a more natural looking breast. This may only be an option if there is no sign of cancer cells close to the skin.
Some women have reconstructive breast surgery as part of the same procedure as the mastectomy or major lumpectomy, while others wait and have the option to undergo a second operation at a later date.
Women with a variety of conditions affecting the breasts may get a mastectomy, most commonly breast cancer. Mastectomies are used for cancers, including:
- Non-invasive breast cancer - including ductal carcinoma in situ (DCIS), the most common type of non-invasive breast cancer - 1 in 5 new cases of cancer in the United States are DCIS. This cancer forms in the milk ducts but has not yet spread out into the rest of the breast tissue.
- Stages 1 and 2 - early stage breast cancer.
- Stage 3 - locally advanced breast cancer (after chemotherapy).
- Inflammatory breast cancer - an aggressive disease in which cancer cells block lymph vessels in the skin of the breast (mastectomy is only suitable after chemotherapy for this form of cancer).
- Paget's disease of the nipple or breast - a rare type of cancer affecting the nipple.
- Locally recurrent breast cancer - cancer returning to the same breast.
In some cases, a mastectomy may also be performed for reasons not related to a diagnosis of breast cancer, such as where a person has:
- severe chronic breast pain
- fibrocystic breast disease
- dense breast tissue
- cancer phobia or a family history of breast cancer
These reasons for surgery are much less common and are not standard practice.
If a mastectomy is recommended, the type of mastectomy performed will depend on a range of factors including:
- The age of the patient.
- The patient's general health.
- Menopause status.
- The size of the tumor.
- The stage of the tumor (how far it's spread).
- The grade of the tumor (its aggressiveness, how quickly it is growing or spreading).
- Whether the tumor is hormone-receptive.
- The involvement of lymph nodes
Procedure and risks
The mastectomy is a surgical procedure that involves anesthesia and the removal of tissue. As such, there are associated risks, as is the case with any surgery; these include:
- Problems with anesthesia.
- Shoulder pain and general stiffness of the arm.
- Bleeding and infection.
- Scabbing, blistering, or skin loss along the site of the surgical incision.
- A "pins and needles" sensation where the breast used to be and, occasionally, under the arm.
- Lymphedema - swelling due to fluid build-up under the armpit and in the arm.
- Damage to nerves in the back, arm, and chest wall.
- Formation of hard scar tissue at the site of the surgery.
- Build-up of blood or fluid under the skin at the surgical site.
The mastectomy operation has been performed millions of times by surgeons around the world. Because of this, the operation is relatively safe considering its invasive nature.
Once the mastectomy procedure is complete, the patient will be monitored closely. Heart rate, blood pressure, level of pain, and feelings of nausea will all be regularly checked, and medicated as appropriate.
At the hospital
The average hospital stay for a mastectomy is 3 days, but if reconstructive surgery is completed in the same surgery, the stay may be slightly longer. Patients will be shown exercises to perform to minimize stiffness and scar formation. Patients will also be given advice on activities that should be avoided.
Before leaving the hospital, patients will be offered guidance on the following issues:
- Pain medication - appropriate use of analgesics will be discussed, and a prescription will be written for pain management medications.
- Care for dressings, bandages, and the surgical drain if one is provided.
- What to expect from stitches and staples, although most of the stitches used will dissolve and not require a follow-up appointment to be removed.
- How to recognize signs of infection and lymphedema.
- Types of exercises to complete regularly.
- When to resume wearing a normal bra or when to start using a prosthesis.
Mastectomy recovery at home
Recovery rates differ between individuals, but recovery from a mastectomy usually takes a few weeks. It will take longer if reconstruction is performed in the same surgical procedure. There is likely to be bruising, swelling, a low-level fever, and some patients will have a sore throat caused by the tube that was inserted down the throat during the procedure; this will resolve within a few days.
General guidelines to follow at home include:
- Rest - it is normal to feel tired after surgery. There is no reason to fight it; patients must allow themselves time to heal.
- Pain management - some discomfort is likely, so prescription medication must be taken as per the doctor's instructions. It is important to be honest about the amount of pain experienced when asked by medical professionals. If a personal pain management plan is not working, it can be altered.
- Washing - take sponge baths until drains, staples, and sutures have been removed.
- Managing constipation - medication can bring on constipation, an increased fluid intake is recommended along with eating high fiber foods.
- Exercising - continuing to carry out exercise as per the doctor's instructions.
- Asking for help - asking family members and friends to lend assistance in and around the house.
As the weeks turn into months, so-called "phantom sensations" or "phantom pains" may present themselves. These are normal and occur as the nerves heal.
These sensations may manifest as a crawling or itchy feeling or general over-sensitivity of the area. They will typically pass on their own and are not a medical concern. Doctors can sometimes prescribe NSAIDs (non-steroidal anti-inflammatory drugs) like acetaminophen and ibuprofen if they persist.
Recovery times will vary, but within a few months a sense of normality should resume. Many patients return to work within 3-6 weeks.
Emotional recovery after a mastectomy
One of the most important aspects of recovery from a mastectomy is dealing with emotional trauma.
The physical healing from breast cancer surgery is just one part of the recovery process. It is normal and common for people to have a strong emotional response to:
- The loss of a breast or both breasts, as well as to the physical limitations during recovery.
- The success or failure to eradicate cancer, which after a mastectomy can also take a significant emotional toll.
Patients may be offered specialized counseling while undergoing treatment for breast cancer, or they may wish to arrange to see their own therapist.
It is increasingly common for women to undergo a prophylactic mastectomy in an attempt to reduce the risk of breast cancer developing. These preventive mastectomies are known as prophylactic mastectomies. They are only performed in specific cases. They are used for women with a number of relatives who have, or had breast cancer, or if they screen positive for specific genetic markers.
A person may be given the option of a prophylactic mastectomy in the following situations:
- Strong familial incidence - if a mother, sister, or daughter had breast cancer, especially before their 50th birthday.
- Positive testing for mutations in BRCA1, BRCA2, or PALB2 - these genes normally help repair damaged DNA - if they are not functioning properly, tumors can be allowed to grow.
- Breast cancer in 1 breast - you are more likely to develop breast cancer if cancer has already arisen in either breast. This is referred to as a contralateral prophylactic mastectomy.
- Lobular carcinoma in situ (LCIS) - this is an area of abnormal cell growth and increases the risk of breast cancer.
- Patients who have had radiation therapy in the chest region before the age of 30.
- Women with dense breasts - diagnosing problems in dense breasts is difficult, and multiple biopsies and consequent scarring can also add to the difficulty. Sometimes - albeit rarely - women with dense breasts may opt for a prophylactic mastectomy.
- Women with microcalcification - tiny deposits of calcium in the breast are highly suggestive of the presence of cancer.
According to the National Cancer Institute, prophylactic mastectomy in high-risk women may be able to reduce the risk of developing breast cancer by 90 percent.