Mastectomy

A
mastectomy is surgery to remove a breast. Sometimes other tissues near the breast,
such
as lymph nodes, are also removed. This surgery is most often used to treat breast
cancer. A mastectomy might also be done to help prevent breast cancer in women who
have
a very high risk for it.

A
mastectomy may be done as part of treatment for breast cancer. It might be suggested
if:

  • The
    tumor is large, or large compared to the size of your breast
  • You
    have more than 1 tumor and they’re not near each other
  • You
    can’t have radiation therapy. This may be the case if you’re pregnant, have a
    connective tissue disease such as rheumatoid arthritis, or have had radiation in the
    past.
  • You
    prefer this surgery instead of getting radiation
  • You’ve
    had radiation therapy to your breast in the past
  • You
    have inflammatory breast cancer
  • The
    cancer has come back after other treatment
  • You
    have a gene change such as a BRCA mutation that puts you at high risk for another
    breast cancer

In
some cases, women with a high risk for breast cancer may want to have a mastectomy
before cancer develops. This includes women with genes linked to breast cancer, such
as
the BRCA1 or BRCA2 gene. In these cases, a mastectomy is done to try to keep breast
cancer from occurring.

There may be other reasons for your doctor to advise a mastectomy.

What are the different types
of mastectomies

Any type of mastectomy may include removing lymph nodes. These are
small, bean-shaped organs connected to lymph vessels. They are part of the lymphatic
system, which is part of your immune system. A clear fluid called lymph carries
infection-fighting white blood cells and cell waste all around your body through the
lymphatic system. The lymph nodes filter this waste. Cancer cells often spread into
the lymphatic system and collect in the nodes. Nodes removed during mastectomy are
tested to see if there are cancer cells in them. This information is used to plan
your treatment after surgery.

Three-quarter view of female underarm area showing breast anatomy ghosted in. Outline around tissue for simple mastectomy.
Three-quarter view of female underarm area showing breast anatomy ghosted in. Dotted line shows tissue and lymph nodes removed in modified radical mastectomy.

There are many types of mastectomy procedures. Your surgeon will talk with you about
the surgery that is advised for you. Options tend to depend on where the tumor is
and
how big it is. The size of your breast may also help decide what type of mastectomy
is best.

  • Total
    (simple) mastectomy.
    This surgery removes the whole breast,
    including the nipple, the colored ring around the nipple (called the areola), and
    most of the overlying skin. Sometimes lymph nodes under arms are removed, too.
  • Modified radical
    mastectomy.
    The entire breast is removed. This includes the nipple, the areola, the
    overlying skin, and the lining over the chest muscles. Some of the lymph nodes
    under the arm are also removed. Breast cancer often spreads to these lymph nodes.
    It can then spread to other parts of the body. 
  • Radical mastectomy. The entire breast is removed, including the nipple, the areola, the overlying
    skin, the lymph nodes under the arm, and the chest muscles under the breast. This
    was once the standard surgery, but today it’s rarely done. It may be needed for
    large tumors that are growing into the chest muscles.
  • Skin-sparing mastectomy. The breast tissue, nipple, and areola are
    removed. But most of the skin over the breast is saved. This type of surgery is
    used only when breast reconstruction is done right after the mastectomy. It may
    not be a good option for tumors that are large or near the skin surface.
  • Nipple-sparing mastectomy.

    This is a lot like a skin-sparing mastectomy. All of the breast tissue,
    including the ducts going all the way up to the nipple and areola, is removed. But
    the breast skin and the nipple and areola are kept. During surgery, the tissues
    under and around the nipple and areola are carefully cut away and checked for
    cancer cells. If no breast cancer is found close to the nipple and areola, these
    areas can be saved. If cancer is found, the nipple must be removed. Reconstruction
    is done right after this mastectomy.

Breast reconstruction surgery
after mastectomy

You may worry about how your breast will look after a mastectomy. Most women can
have breast reconstruction surgery. This surgery rebuilds the breast so it’s the size
and shape of your other breast. Some women have breast reconstruction done at the
same time as a mastectomy. Others wait and have it done later, as a second surgery.

Not all women want reconstruction. Some prefer a breast form (breast prosthesis),
a
special mastectomy bra, or going flat.

The choice is yours. Talk with your doctor about your options.

All
surgeries have some risk. Some complications of mastectomy include:

  • Short-term breast swelling
  • Breast
    pain, soreness, or both
  • Hardness or lumpiness because of scar tissue that can form at the site of the cut
    (incision)
  • Wound
    infection or bleeding
  • Swelling (lymphedema) of the arm, chest, and neck, if lymph nodes were removed
  • Pain in
    the breast that has been removed (called phantom breast pain). This may be helped
    with medicines, exercise, or massage.
  • Numbness
    or trouble moving the arm if nerves were damaged during surgery

A
buildup of clear fluid (seroma) can happen in the breast after a mastectomy. If this
bothers you, it can be drained in the surgeon’s office. If needed, it can be treated
with compression. Or you may get an injection that helps to harden the space in the
breast to help keep fluid from collecting there.

You’ll likely have a scar at the mastectomy site. Scar tissue may also cause a pulling
feeling near or under your arm after surgery.

You
may have depression and feelings of loss of sexual identity after a mastectomy.

Your
healthcare team will talk with you about the type of mastectomy you’re getting and
the
risks that come with it. Be sure to discuss any concerns with your doctor before
surgery.

  • Your doctor will explain the surgery to you and give you a chance to ask any
    questions that you might have.
  • You’ll
    be asked to sign a consent form that gives permission to do the surgery. Read the
    form carefully and ask questions if anything isn’t clear.
  • Your
    doctor will take your health history. A physical exam will be done. This is to be
    sure you are in good health before the surgery. You may also need blood tests, an
    EKG, or imaging scans.
  • You’ll
    be asked to not eat or drink anything for some time before the surgery. Your surgeon
    will give you instructions.
  • Tell
    your provider if you are pregnant or think you may be pregnant.
  • Tell
    your provider if you are sensitive to or allergic to any medicines, latex, tape, and
    anesthesia medicines (local and general).
  • Tell
    your provider about all the medicines you take. This includes both over-the-counter
    and prescription medicines. It also includes vitamins, herbs, other supplements, and
    marijuana. Let your doctor know if you use illegal drugs. Many of these can cause
    problems during and after surgery.
  • Tell
    your provider if you have a history of bleeding problems. Let your provider know if
    you are taking any blood thinners, aspirin, ibuprofen, or other drugs that affect
    blood clotting. You may need to stop taking these before surgery.
  • Tell your provider if you smoke. You may need to stop before
    surgery, and your doctor can help with that. Smoking can slow your recovery and
    increase your chance of problems after surgery.
  • You may
    be given medicine to help your relax (a sedative) before surgery.
  • Your
    healthcare provider may have other instructions for you based on your medical
    condition. Be sure you know what you can and can’t do as you get ready for
    surgery.

You
will likely need to stay in the hospital for at least 1 night after mastectomy. It
depends on your overall health, how you feel after surgery, and your doctor’s
practices.

For
the most part, a mastectomy follows this process:

  1. You’ll
    be asked to remove your clothing and given a gown to wear.
  2. An IV
    (intravenous) line will be started in your arm or hand. You’ll be given medicine
    through the IV. This will help you relax and put you into a deep sleep during the
    surgery so you don’t feel pain.
  3. You will
    lie on your back on the operating table.
  4. Your
    heart rate, blood pressure, breathing, and blood oxygen level will be watched closely
    during the surgery.
  5. The skin
    over your chest will be cleaned.
  6. A cut
    (incision) will be made in your breast. The type of cut and where it is depends on
    the type of mastectomy you have.
  7. The
    surgeon will gently cut free and remove underlying tissue.
  8. Lymph
    nodes might be removed after the breast or breast tissue has been removed.
  9. If you
    ‘re having breast reconstruction along with the mastectomy, a plastic surgeon will
    do
    the reconstruction after the mastectomy.
  10. Breast
    tissue and any other tissues that are removed will be sent to the lab for
    testing.
  11. One or
    more drainage tubes may be put in the breast to keep fluid from building up as the
    area heals.
  12. The
    skin will be closed with stitches, glue, or adhesive strips.
  13. A
    sterile bandage or dressing will be placed over the site. A stretchy band will be
    wrapped around your chest. This will stay on for a few days.

In the hospital

After surgery, you’ll be taken to the recovery room and watched closely. Your
recovery process will depend on the type of mastectomy and the type of anesthesia
used. Once your blood pressure, pulse, and breathing are stable and you are awake,
you’ll be taken to a hospital room.

You’ll likely stay in the hospital for a day or so after your mastectomy. This will
depend on the extent of your surgery and if you had breast reconstruction done.

At home

Once you’re home, keep the surgical area clean and dry. Your doctor will give you
bathing instructions.

You’ll also be taught how to take care of the drainage tubes. They’re often taken
out
after about 2 weeks or at the first follow-up exam.

The amount of pain you have will vary. It depends on the amount and location of
tissue removed during surgery. Most soreness lasts a few days. Take pain medicine
as
advised by your doctor. Aspirin and some other pain medicines may increase your
chance of bleeding. Be sure to take only advised medicines.

If lymph nodes were removed with your mastectomy, your doctor may have you see a
physical therapist and will want you to do certain exercises. These can help limber
up your shoulder and arm and help prevent swelling. Soreness after surgery may cause
you to keep your arm and shoulder very still. This can make your arm and shoulder
stiff. But overdoing the exercises can also hurt you. Start the exercises slowly.
Do
them regularly, and progress a little each day. You may be asked to do these
exercises even if you didn’t have lymph nodes removed.

You can often go back to your normal activities in a few weeks, based on your
doctor’s advice. In the meantime, don’t do any strenuous activities, such as mowing
the lawn, using a vacuum cleaner, working out, or playing sports. Listen to your
body. If an activity causes pain, stop.

Your doctor will tell you when you can start driving again and when you can go back
to work. You’ll also be told when it’s okay to start wearing a bra or prosthesis.

When to call your doctor

Your doctor will talk with you about when call. You may be told to call if you
have:

  • Fever of 100.4°F (38°C) or higher, or as advised by your healthcare provider
  • Chills
  • Cough or shortness of breath
  • Rapid, irregular heartbeat; new chest pain
  • Signs of infection around the incision, such as redness, drainage, warmth, and
    pain
  • Drainage from the incision site
  • Incision opens up or the edges pull apart
  • Increased pain around the incision site
  • Any abnormal bleeding or bleeding that soaks the bandage
  • Trouble passing urine or changes in how your urine looks or smells
  • Swelling, numbness, or tingling in your hand, arm, or chest that gets worse or is
    not getting better a week or 2 after surgery
  • Pain, redness, swelling, or warmth in an arm or leg

Your doctor may give you other instructions, too. Ask about signs you should watch
for and when you need to call. Know how to get help after office hours and on
weekends and holidays.

Arm care after lymph node removal

Removing lymph nodes can affect how lymph fluid drains from your arm, neck, and chest
on the affected side. Problems with lymph drainage can cause swelling in your arm.
This swelling is called lymphedema. You may also be at greater risk for infection
from injury to your arm. But it’s important to use your arm like you normally
would.

You’ll have to follow certain safety steps for the rest of your life after lymph node
removal. Once lymphedema starts, it cannot be cured. But there are things you can
do
to help keep it from starting and prevent problems in your affected arm. Some of
these safety steps include:

  • · No needle sticks or IVs in the affected arm
  • · Try to have your blood pressure taken in your unaffected arm
  • · Follow instructions about arm exercises carefully.
  • · Don’t overtire your arm or do repetitive motions. Don’t do any heavy pulling or
    lifting.
  • · Don’t expose your arm to extreme temperatures such as ice packs or heating
    pads. Don’t use saunas or hot tubs.
  • · Use lotion to keep your skin soft. 
  • · Try not to get scratches or splinters in your affected arm. Clean any injuries
    right away and watch for signs of infection.
  • · If your arm aches or swells, raise (elevate) it, with your hand above your
    elbow, to help drain lymphatic fluid.
  • · Wear gloves when gardening or doing any activity where there’s a risk for
    getting cuts in your fingers or hands. Also wear gloves when using strong or harsh
    chemicals, such as detergents or household cleaners.
  • · Protect your skin in the sun. Don’t get a sunburn.
  • · Use a clean razor to shave under your arm.
  • · Wear loose-fitting bras with straps that don’t dig into your shoulders.
  • · Don’t wear any tight items on the affected arm. This includes elastic cuffs,
    tight watches, or other jewelry.
  • · Use your unaffected arm or both arms to carry children, heavy packages, bags,
    or purses.
  • · Don’t get insect bites or stings. Use insect repellent or wear long
    sleeves.
  • Get to and stay at a healthy weight.

Talk with your doctor about seeing a lymphedema specialist to learn more about what
you can do to help protect yourself.

Before you agree to a test or procedure, make sure you know:

  • The
    name of the test or procedure
  • The
    reason you’re having the test or procedure
  • What
    results to expect and what they mean
  • The
    risks and benefits of the test or procedure
  • What
    the possible side effects or complications are
  • When and
    where you are to have the test or procedure
  • Who
    will do the test or procedure and what that person’s qualifications are
  • What
    would happen if you did not have the test or procedure
  • Any
    alternative tests or procedures to think about
  • When and
    how will you get the results
  • Who to
    call after the test or procedure if you have questions or problems, even at night
    and
    on weekends
  • How much
    you will have to pay for the test or procedure