Mastectomy

Posted in Disease Information

Introduction

A mastectomy is an operation to remove a woman’s breast, usually because it has been affected by breast cancer. It is also used to remove non-cancerous breasts in order to reduce the risk of breast cancer developing in women who are at high risk. This is known as a prophylactic (risk-reducing) mastectomy.

Mastectomies are very safe procedures with minimal complications. Afterwards, most people recover well.

How effective a mastectomy can treat breast cancer will depend on the stage of the cancer when it was originally diagnosed.

Types of mastectomy

There are seven types of mastectomy, which are briefly described below.

• If a large segment of your breast is removed this is called a segmental mastectomy.
• If all the breast tissue and most of the skin covering it is removed this is called a simple mastectomy.
• If all of the breast tissue is removed and the nipple, but most of the skin covering it is left, this is called a skin-sparing mastectomy. This is carried out when you plan to have immediate breast reconstruction surgery after the mastectomy.
• If you have a skin-sparing mastectomy but the nipple is not removed, this is called a subcutaneous mastectomy. This is also done when you plan to have immediate breast reconstruction.
• A radical mastectomy is when all of the breast tissue is removed, plus the skin covering it, the two muscles behind the breast and the lymph nodes (glands) in the armpit. This is an uncommon operation which is only carried out if cancer has affected the muscles.
• If you have a radical mastectomy but the large muscle behind the breast (the pectoral muscle) is left in place, this is called a modified radical mastectomy.
• If you have a modified radical mastectomy but both of the muscles behind the breast are left in place, this is called a modified modified radical mastectomy. This is now the most common form of mastectomy.

If a lump is removed from the breast, the procedure used is called a lumpectomy. This is also known as breast-conserving surgery.

If you need to have a mastectomy, Dr. B C Shah will explain why you require the procedure and what type of mastectomy you need.

Breast reconstruction

After your breast has been removed, further surgery may be needed to create an artificial breast. This is known as breast reconstruction.

Why a mastectomy is necessary

Removing cancerous tissue

The aim of a mastectomy operation is to remove all cancerous tissue from a woman’s breast. This is very important because if any cancerous cells are left behind, there is a risk that the cancer will grow back or spread to other parts of the body.

A mastectomy is not always the most suitable treatment for breast cancer, although in many cases it is very effective.

Dr. B C Shah who is responsible for your care will be able to advise you about this.

A mastectomy may be recommended when:

• The tumour is large in proportion to the breast; although this may be avoided by using medication to reduce the size of the cancer
• The tumour is just behind the nipple; although it may be possible to remove the nipple and leave most of the breast in place
• The cancer is present in more than one area of the breast
• Pre-cancerous cells, called ductal carcinoma in situ, have affected most of the breast

Once a diagnosis of breast cancer has been confirmed, the condition should be treated as soon as possible. Early detection and treatment of breast cancer improves the chances of a successful outcome and a full recovery.

Prophylactic mastectomy

Prophylactic (risk-reducing) mastectomies are carried out on non-cancerous, healthy breasts to reduce the risk of breast cancer developing. The procedure may be considered if a woman has a very high risk of developing breast cancer. This might be because:

• She has a family history of breast cancer
• She is carrying certain genes (units of genetic material), known as BRCA1 and BRCA2, which can increase the risk of developing breast cancer

However, it is unclear whether prophylactic mastectomies are beneficial and they may not be necessary for most women. For example, even with these risk factors there is no certainty that you will get breast cancer. In some cases, a lumpectomy (removing a lump from the breast) may be all that is required, rather than removing the whole breast.

If you are concerned about your risk of developing breast cancer in a healthy breast, you should discuss the risks and benefits of surgery

Dr. B C Shah before making a decision. Prophylactic mastectomies are often not recommended if there is no evidence of an increased risk of breast cancer.

Before your mastectomy

Before having a mastectomy, you will be able to talk to Dr. B C Shah about how the procedure might affect you physically and emotionally. He can give you practical advice about bras and prostheses (bra inserts).

If you want to know what your scar will look like after your surgery, you may be able to see photographs of other women who have had the procedure.

Breast reconstruction

Discuss with Dr. B C Shah the option of having breast reconstruction at the same time as your mastectomy. This is surgery to create an artificial breast.

It may be possible for you to have breast reconstruction at the same time as a mastectomy. However, if you are having further treatment for breast cancer, such as radiotherapy, you may be advised to wait. Carefully consider what type of reconstruction you can have, and when you want it done, if at all.

Chemotherapy and hormone therapy

Before your operation, you may be advised to have:

• Treatment with anti-cancer (cytotoxic) medication to kill the cancer cells (chemotherapy), or
• Medication to stop the hormones in your body that encourage breast cancer (hormone therapy)

For some women, these treatments can be used to reduce the size of the tumour and, therefore, the amount of breast tissue that needs to be removed. This will improve the appearance of your breast after surgery, and it may mean that a mastectomy can be avoided.

Preparing for surgery

Before having surgery, you may have some tests to check that the cancer has not spread, plus a general check-up to make sure that you are fit for the operation.

If you are currently taking any medicines, find out whether you should continue taking them before your operation. Never stop taking a prescribed medication unless advised to do so by Dr. B C Shah .

If you smoke, you may be advised to stop smoking before your operation. This is because smoking can increase the risk of complications during your operation and during your recovery time after your operation.

It is common to be admitted to hospital on the same day of your operation, but you may be admitted the night before. You will be asked not to eat or drink for a few hours before the operation. A nurse will check your temperature, blood pressure and heartbeat.

How a mastectomy is performed

A mastectomy is performed under general anaesthetic, which means that you will be asleep during the operation and will not feel any pain or discomfort. However, you will feel sore when you wake up after the operation, which will take between one and two hours.

The type of mastectomy that Dr. B C Shah will perform will depend on many factors, such as:

• whether the cancer has spread – for example, to your lymph nodes (see below)
• whether you want, or are able, to have breast reconstruction surgery at the same time

These factors will be discussed with you before you agree to have the operation.

Removing breast tissue

A diagonal or horizontal cut is made across your breast and the breast tissue is removed. The amount of skin that is removed will depend on the type of mastectomy that you are having.

Dr. B C Shah will usually leave one or two drainage tubes in place, to stop fluid building up in the breast space.

Lymph nodes

In some cases, surgery may be carried out on the lymph nodes (glands) at the same time as the mastectomy. Lymph nodes are small, oval-shaped tissues that remove unwanted bacteria and particles from your body. They are part of the immune system (the body’s natural defence against infection and illness).

It is possible for breast cancer to spread to the lymph nodes under your arm. If this is the case, most or all of your lymph nodes may be removed at the same time as your mastectomy. It is standard practice for all removed tissue to be sent to a laboratory to be examined.

Dr. B C Shah will have explained the reasons for this before your operation, as well as any further treatment that you may need if your lymph nodes are affected.

Once the procedure is complete, stitches will be used to close the wound.

Breast reconstruction

Breast reconstruction is a procedure that involves making a new breast to replace the tissue that is removed during a mastectomy. The new breast can be created using:

• A silicone implant
• Tissue from another part of your body, such as your abdomen or back
• A combination of both of these

The aim is to create a shape that matches the removed breast or breasts.

Breast reconstruction can often be carried out at the same time as a mastectomy. Alternatively, the surgery can be performed at a later date. Some people decide not to have breast reconstruction at all. It is your decision and Dr. B C Shah will be able to discuss the options with you.

Endoscopic mastectomy

This is surgery to remove the breast using a small cut in the armpit or around the edge of the nipple. An endoscope, which is a long, thin, flexible tube with a light source and camera at one end, is used  to remove the breast tissue.

There is currently not enough evidence to confirm the safety and effectiveness of endoscopic mastectomies. Therefore, this type of surgery is not routinely used. Endoscopic mastectomies may be carried out as part of medical research, but only in units that specialise in breast cancer management and by surgeons who are trained in both breast cancer surgery and endoscopy.

Recovering from a mastectomy

Most people who have a mastectomy recover well after the procedure and do not develop complications. It may take three to six weeks for you to fully recover.

After the operation

When you wake up after the operation, it is likely that you will feel sore. This pain can be controlled with painkillers. It is very important to tell Dr. B C Shah when you are in pain because he can adapt your medication accordingly. This is essential to your recovery after the surgery.

After the operation, you may have a drip in your arm so that you can be given fluids until you are able to eat and drink again.

Wound care

Following the mastectomy, you may have one or more drainage tubes coming from the wound site. The purpose of the drainage tubes is to drain blood and tissue fluid away from the wound to prevent it collecting and causing swelling or infection.

Dr. B C Shah will decide how long the tubes need to stay in for. It may be as short as 24 hours, or up to a few days.

The dressing over your wound will need to stay in place for at least a couple of days. During this time, it may need to be replaced and the wound cleaned. In some cases, the same dressing will need to stay on for a week or so.

You may have dissolvable stitches that do not need to be removed, or you may have stitches that need to be removed after seven to 10 days. Your wound should have healed during this period of time.

Preparing for home

The length of your stay in hospital will depend on the extent of your surgery, but you may need to stay in hospital for two or three days.

Before you leave the hospital, Dr. B C Shah will talk to you about what to do when you get home. You are likely to need a lot of rest. Gentle exercises may be recommended to overcome the stiffness of your arm and to encourage healthy circulation in the area that has been operated on.

Dr. B C Shah will be able to discuss with you suitable bras and prostheses (bra inserts) if you have not had breast reconstruction. If this is the case, you will be provided with a lightweight artificial breast shape that you can put inside your bra. This is usually temporary until your wound has completely healed. You will eventually be given a permanent prosthesis.

Scars

After a mastectomy, you will have a scar going across your chest and under your arm. Dr. B C Shah will also be able to advise you about how to look after your scar. If you are uncomfortable about how your scar looks, there are a number of possible treatments, such as:

• correcting the scar with further surgery
• using make-up to cover up the scar

Talking to others

Recovering from a mastectomy can be emotionally difficult. Some people find it helpful to talk to others who have been through the operation, both before and after the mastectomy.

You can also find cancer support services in your area.

Complications of a mastectomy

In most cases, recovery from a mastectomy is straightforward and without complications. It is normal to experience certain side effects, such as short-term pain and swelling of the tissue over your chest wall. You will also have a scar.

You may have swelling at the site of your operation as a result of body fluid collecting underneath the skin. This is called seroma. It often goes away without treatment, although it may sometimes need to be drained in the outpatient clinic. You should speak to Dr. B C Shah if you think that you are developing seroma.

It is normal for the remaining skin to feel numb, but for your chest wall to feel tender. If you have had the lymph nodes (glands) removed under your arm, this area may also feel numb. These changes may be permanent.

Two other possible complications that can occur following a mastectomy are outlined below. Speak to Dr. B C Shah immediately if you think that you may be experiencing any of these symptoms.

Wound infection

Your wound may be infected if the wound site:

• Becomes red
• Becomes more painful and swollen (inflamed)
• Is leaking fluid (discharge)

This can be treated with antibiotics.

Lymphoedema

If you have some lymph nodes removed or have had radiotherapy to your armpit, you are more at risk of developing a condition called lymphoedema. This usually starts some time after surgery, but it can also develop many months or years later.

Lymphoedema is a build-up of fluid in the arm that causes swelling, pain and tenderness in your arm and hand.

Dr. B C Shah will tell you how to prevent lymphoedema using appropriate skincare techniques and exercises. If it occurs, lymphoedema can be controlled with early treatment.