What is masectomy and how is it performed

What is a mastectomy?

A mastectomy is generally defined as the complete surgical removal of the breast, most often including the nipple/areola complex. A simple or total mastectomy includes all breast tissue, down to, but not including, the chest wall muscle. It may or may not include removal of the nipple/areola complex. It does not include removal of the lymph glands. The result is the complete absence of a breast on the chest wall, with a horizontal scar where the breast was once located. A modified radical mastectomy is a total mastectomy with removal of the axillary (underarm) lymph nodes. A radical mastectomy, performed only in extreme cases, also includes removal of the major and minor pectoral (chest) muscles. There are also more minor procedures sometimes categorized as mastectomy. These include: a quadrantectomy, where a quarter or defined section of the breast skin and all soft tissue is removed, often including local lymph nodes; and a partial or segmental mastectomy, where a larger segment of the breast than in a lumpectomy is removed, but some of the breast tissue and skin is preserved, and, in limited cases, this may include the nipple/areola complex. In addition, skin-sparing mastectomy has recently become a very positive alternative to a standard mastectomy.

How is a mastectomy performed?

A mastectomy is major surgery and should always be performed in a hospital setting under general anesthesia. Your doctor will likely recommend a short hospital stay following your mastectomy. The reasons for an in-patient stay include the need for both a physical and emotional recuperation following mastectomy. You will likely have drainage tubes for several days following surgery, and require careful monitoring for pain management and any immediate complications. At the time this article was written, the Breast Cancer Patient Protection Act of 2004 was pending, requiring insurers in the United States to allow coverage for a minimum two-night hospital stay following a mastectomy. Senator Mary Landrieu (D-LA) and Representative Rosa DeLauro (D-CT) will reintroduce this act in Congress in 2005 bi-partisan legislation to end this practice. This petition is a partnership with physicians, advocates, and survivors across the nation. Mastectomy completely removes the breast, but immediate reconstruction is possible for most candidates at the time of mastectomy, including:

• Any one of several flap surgery techniques

• Tissue expansion and the subsequent placement of a breast implant

If you are considering immediate reconstruction, your breast surgeon and cosmetic surgeon should both be consulted prior to surgery, and should communicate with one another. However, due to additional treatments and therapies, or to your current health condition, a delayed reconstruction may be recommended. In this case, for the best possible aesthetic outcomes, you still should consult with both surgeons prior to your mastectomy and have the surgeons consult with one another. Your plastic surgeon may have specific recommendations for your mastectomy with regard to incision patterns and the resulting scar placement that could greatly influence the results of your reconstruction. If you have decided to delay reconstruction yourself, or are uncertain about your decision for reconstruction, it is still advised that you consult with a cosmetic surgeon about your options. What you learn during your consultation may, in fact, help you to make your reconstruction decision. You certainly may make the choice to forgo reconstruction; it is your choice. The same candidates for breast conserving surgery (lumpectomy and subsequent localized radiation therapy) may also be candidates for mastectomy. Mastectomy will most likely be recommended if: cancer has recurred following lumpectomy; cancer is present in more than one area of the breast; the cancer is particularly invasive, depending on the stage of cancer diagnosed and based on your own breast health history and your family breast health history; or if a lumpectomy will result in an aesthetically unacceptable breast. Nearly all mastectomy candidates are candidates for breast reconstruction. Even women with high risk factors such as diabetes, connective tissue disorders, or heavy smokers, have the potential for reconstruction if the health conditions or behaviors that may impair healing can be controlled or eliminated.

Good candidates for immediate reconstruction (reconstruction performed at the time of mastectomy) are women whose subsequent course of cancer treatment (radiation to the chest area or chemotherapy) will not interfere with healing, and who are otherwise in good health and able to withstand the additional surgery. In addition, women who are having emotional difficulty facing their diagnosis and prescribed course of treatment may be advised to first manage their health, and then weigh reconstructive options once they feel strong enough to undergo surgery again. Mastectomy is an inpatient hospital procedure performed under general anesthesia. It is major surgery lasting from two to three hours if immediate reconstruction is not planned, and requires a team of medical professionals who include: your surgeon or surgeons, an anesthesiologist, and a team of nurses or surgical assistants. An incision is made on the breast, and underlying fat, tissue, and glands are excised (separated from the surrounding tissues and removed). Even if the nipple/areola is not removed, the mammary glands and surrounding nerves are detached from the nipple and removed.

After mastectomy, if the nipple is preserved, sensation to the nipple is minimal, and normal breastfeeding is not possible. Once the breast tissue has been removed, any remaining skin is sutured together or closed with temporary metal clips. A slightly curved and slightly angled horizontal incision will remain across the chest where the breast once was positioned. The incisions may, however, vary and if you have any consideration of future reconstruction, it is best to have your cosmetic surgeon consult with the breast surgeon on mastectomy incisions and resulting scar location. If you are having immediate reconstruction, your surgery may be extended by one or several hours. During closure for mastectomy or mastectomy with immediate reconstruction, small flexible tubes are likely to be placed from your incisions to drain any excess fluid that accumulates.

Don’t think you will feel like yourself. You will cry. You will be angry. And there will be times that you will be hopeful for the future.The support of those you love, and new friends that you meet in support groups, are essential to your experience before and following surgery. There are always those goodintentioned friends and relatives who want to help that you would rather not have around. Don’t feel you have to accept the help of everyone, and especially those with whom you cannot share your emotions.Take and ask for help from those you want. And there is nothing wrong with politely declining help from those with whom you just don’t have complete comfort. If they really care about you and your feelings, they will understand and give you the space and time you need. Your surgical stay following mastectomy may range from two days to as many as eight days or more, depending on: your surgery; your overall health; the recommendations of your surgeon or surgeons; whether or not you had immediate reconstruction or any subsequent treatments; and what your insurer will allow.

You will experience discomfort in the first few days following surgery in the chest area in general and in any donor sites if you have had immediate reconstruction. Oral medication and a pain pump can help control your discomfort. In addition, you may experience some swelling in the arm and chest, and in any donor sites if you have had immediate flap reconstruction. Some patients experience discomfort raising their arms, or a pulling sensation in the chest region. This is particularly true of radical mastectomy and if the axillary (underarm) lymph glands were also removed. Drainage tubes may be removed within a few days or a week or more following your surgery. In addition, before being released from the hospital, you will be given detailed instructions for wound care and cleansing. Other instructions will include: activity restrictions and suggestions; proper diet and required exercise; when you may resume wearing a bra and what type to wear; and if you have not had reconstruction when you may begin wearing a prosthesis. In addition, you will be given medications for pain and to prevent infection, be instructed about specific changes to look for in the surgical site and your overall health, and when these require you to contact your doctor.

Cautions following mastectomy are like those of any breast surgery. In addition, it is not uncommon for women to have sensations following mastectomy with or without immediate reconstruction, such as itching, nerve impulses or numbness, pressure, and throbbing. Report any of these feelings to your doctor immediately, as there are treatment options to alleviate these often uncomfortable experiences. You will be given specific instructions with regard to resuming normal activity and exercise. Follow these instructions carefully. While getting back to life is an important part of your physical and emotional recovery, to do so too soon, or too strenuously, can compromise your health and cause bleeding, tearing of healing skin and tissue, and even orthopedic injury to adjacent muscles. Depending on your overall health, additional treatments recommended, the extent of your mastectomy, and if you have had immediate reconstruction, you can plan on getting back to a moderate pace of activity within two to three weeks following your surgery. If you have had immediate reconstruction, you will likely follow up with your breast surgeon and your plastic surgeon. In addition to the support of your family and friends, ask your surgeon about special support groups and one-on-one sources of support from other breast cancer survivors and women who have undergone mastectomy. Your physical rehabilitation is very important. Equally important is your need for emotional support and healing. If you have not had reconstruction, but are considering it, you may follow up with your cosmetic surgeon when you feel ready. According to the American Society of Cosmetic Surgeons, breast reconstruction procedures numbered nearly 62,930 in 2004. That is a slow and steady decline over recent years. The likely cause is an increase in the number of lumpectomies for small tumors and a decrease in the number of mastectomies.