Mastectomy surgery type – Double, Bilateral, Radical, Modified

What Is Mastectomy? Overview A surgical procedure to remove all breast tissue from a breast as a way to treat or prevent breast cancer is called mastectomy One treatment option for those with early-stage breast cancer, a mastectomy may be conducted. Breast-conserving surgery or lumpectomy, in which the tumor only is removed from the breast, […]

What Is Mastectomy?

Overview

A surgical procedure to remove all breast tissue from a breast as a way to treat or prevent breast cancer is called mastectomy

One treatment option for those with early-stage breast cancer, a mastectomy may be conducted. Breast-conserving surgery or lumpectomy, in which the tumor only is removed from the breast, may be another option.

Decision between having a mastectomy and lumpectomy can be difficult. Both of the procedures are similarly effective for preventing a breast cancer to reoccur. People with breast cancer, lumpectomy is not an option, and others prefer to undergo a mastectomy.

Newer techniques of mastectomy can preserve breast skin and allow for a more natural breast appearance following the surgery. This is also called as skin-sparing mastectomy.

Surgery undergone to restore the shape to your breast called as breast reconstruction which may be done at the same time as the mastectomy or during a second operation at a future date.

 

Why is mastectomy done?

If a person is having breast cancer or there is a risk of developing breast cancer then a mastectomy is used to remove all breasts. One may have a mastectomy to remove one breast known as unilateral mastectomy or both breasts known as bilateral mastectomy.

 

Types of mastectomy

 

There are several types of mastectomy. They include:

Total (simple) mastectomy: This involves the surgeon removing the entire breast but leaving the muscles under the breast and the lymph nodes in place.

Double mastectomy: This involves the surgeon removing both breasts, usually as a preventive measure — if genetic features indicate a high risk of breast cancer, for example.

Bilateral mastectomy:  A bilateral mastectomy is the surgical removal of both breasts to treat or prevent breast cancer. This Bilateral mastectomy reduces only the risk of a new cancer in the breast. It does not reduce the risk of a new cancer in another part of the body.

Radical mastectomy: This involves the surgeon removing the entire breast, the underarm lymph nodes, and the chest wall muscles.

Modified radical mastectomy: This involves the surgeon removing the entire breast and underarm lymph nodes but leaving the chest wall muscles intact.

Skin-sparing mastectomy: This involves the surgeon removing the breast tissue and nipple but leaving the skin intact. A surgeon also reconstructs the breast during the procedure.

Nipple-sparing mastectomy: This relatively new procedure involves leaving the skin, nipple, and peripheral breast tissue intact.

Preventative mastectomy: Prophylactic mastectomy is surgery to remove one or both breasts to reduce the risk of developing breast cancer. According to the National Cancer Institute, prophylactic mastectomy in women who carry a BRCA1 or BRCA2 gene mutation may be able to reduce the risk of developing breast cancer by 95%.

 

Breast-conserving surgery

Less invasive procedures — known collectively as breast-conserving surgery — are now an option for many people with a diagnosis of breast cancer.

Examples of these procedures include:

Lumpectomy: This involves the surgeon removing a tumor and the surrounding tissue, but leaving the breasts generally intact. The person may need radiation therapy as well as surgery.

Quadrantectomy: This is a partial mastectomy. It involves removing more breast tissue than in a lumpectomy, but the surgeon still leaves most of the breast tissue intact.

Skin-sparing mastectomy: This newer procedure involves preserving breast skin and reconstructing a more natural-looking breast. It may only be an option if no cancer cells are close to the skin.

Reconstruction

Reconstruction is a type of aesthetic surgery that can restore the original appearance of the breasts. A person may have reconstruction during the same procedure as a mastectomy or in a second surgery, often 6–12 months later.

Other people choose to “go flat.” They opt not to have reconstructive surgery for various reasons.

 

Mastectomy for breast cancer treatment

A mastectomy can be an option for treatment for many types of breast cancer, including:

 

  • Ductal carcinoma in situ (DCIS), or noninvasive breast cancer
  • Early-stage breast cancer
  • Locally advanced breast cancer — after chemotherapy
  • Inflammatory breast cancer — after chemotherapy
  • Paget’s disease of the breast
  • Locally recurrent breast cancer

The doctor may recommend a mastectomy instead of a lumpectomy with radiation if:

 

  • One has more than two tumors in separate areas of the breast.
  • One has a widespread or malignant-appearing calcium deposits (micro calcifications) throughout the breast that have been diagnosed to be cancer after a breast biopsy.
  • Previously conducted radiation treatment to the breast region and the breast cancer has recurred in the breast.
  • Pregnant and radiation creates an unacceptable risk to the unborn child.
  • The patient had a lumpectomy, but cancer is still present at the margin or edges of the operated area and there is a risk about cancer extending to elsewhere in the breast.
  • One carrying a gene mutation that gives a high risk of developing a second cancer in the breast.
  • There is a large tumor relative to the overall size of the breast. Enough healthy tissue may not be left after a lumpectomy to achieve an acceptable result.
  • Patient having a connective tissue disease, such as scleroderma or lupus, and the side effects of radiation to the skin may not be tolerated.

Mastectomy to prevent breast cancer

A mastectomy can also be considered if not having breast cancer, but have a very high risk of developing the disease.

A preventive, prophylactic or risk-reducing mastectomy includes removing both of the breasts and significantly reduces the risk of developing breast cancer in the future.

A prophylactic or preventive mastectomy is kept for those who have a very high risk of breast cancer, which is determined by a strong family history of breast cancer or the presence of certain genetic mutations that escalate the risk of breast cancer.

 

Risks

Risks attached to a mastectomy may include:

  • Bleeding
  • Infection
  • Pain
  • Swelling (lymphedema) in the arm if having an axillary node dissection
  • Formation of hard scar tissue at the surgical site
  • Shoulder pain and stiffness
  • Numbness, particularly under the arm, from lymph node removal
  • Buildup of blood in the surgical site

 

Preparation for Mastectomy

Meet with the doctor to discuss the options

Prior to the surgery, the patient should meet with a surgeon and an anesthesiologist to discuss about the operation, review medical history and determine the plan for anesthesia.

This would be a good time to ask the doctor questions and to make sure to understand the procedure, including the reasons for and risks associated with the surgery.

One issue to discuss with the surgeon is whether the patient will have breast reconstruction and when. Another option may be to have the reconstruction done immediately after the mastectomy is conducted, while still being anesthetized.

 

Breast reconstruction may involve:

  • Using breast enlarger with saline or silicone implants
  • Using the body’s own tissue (autologous tissue reconstruction)
  • Using a combination of tissue reconstruction and implants

Reconstruction of breast is a complex procedure performed by a plastic surgeon, also called a reconstructive surgeon. If one is planning a breast reconstruction at the same time as a mastectomy, they should meet the plastic surgeon prior to the surgery.

 

Instructions will be given about any restrictions before surgery and other things needed to know, including:

 

  • Telling the doctor about any medications, vitamins or supplements being taken. Some substances could interfere with the surgery.
  • Avoid taking aspirin or other blood-thinning medication. A week or longer before the procedure, talk to the doctor about which medications to avoid because they can increase the risk of excessive bleeding. These include aspirin, ibuprofen (Advil, Motrin IB, others) and other pain relievers, and blood-thinning medications (anticoagulants), such as warfarin (Coumadin, Jantoven).
  • Before the surgery don’t eat or drink for 8 to 12 hours. Specific instructions will be received from the healthcare team
  • Prepare to be admitted in the hospital. Ask the doctor about the length of stay to be expected. . Bring a robe and slippers to be more comfortable in the hospital. Pack a bag with toothbrush and something to help pass the time, such as a book.

 

 

Sentinel node biopsy

A mastectomy is a wider term used for several techniques to remove one or both breasts. In addition to this, nearby lymph nodes may also be removed to determine whether the cancer has spread.

During an axillary node dissection, the surgeon removes a number of lymph nodes from the armpit on the tumor side.

In a sentinel lymph node biopsy, only the first few nodes are removed by the surgeon into which a tumor drains i.e. sentinel nodes.

 

Lymph nodes which are removed during a mastectomy are then being tested for cancer. If there is no cancer present, further lymph nodes will not need to be removed. But if cancer is present, the surgeon will discuss options, such as radiation to the armpit. If this is what is decided to do, no further lymph nodes will need to be removed.

A modified radical mastectomy is removing all of the breast tissue and most of the lymph nodes. Latest mastectomy techniques remove less tissue and fewer lymph nodes.

 

Other types of mastectomy include total mastectomy, Nipple-sparing mastectomy and Skin sparing mastectomy

A total mastectomy, also called as a simple mastectomy, involves obliteration of the entire breast, including the breast tissue, areola and nipple. A sentinel lymph node biopsy could be done at the time of a simple or total mastectomy.

A skin-sparing mastectomy involves obliteration of all the breast tissue, nipple and areola, excluding the breast skin. A sentinel lymph node biopsy can also be done. After the mastectomy, breast reconstruction can be performed immediately. For larger tumors the skin-sparing mastectomy may not be suitable.

A nipple- or areola-sparing mastectomy involves obliteration of only breast tissue, sparing the skin, nipple and areola. A sentinel lymph node biopsy also may be done. Afterwards the breast reconstruction is performed immediately.

 

Before the procedure

The doctor or nurse will tell about when to arrive at the hospital. A mastectomy surgery without reconstruction usually takes around one to three hours. The surgery is often done as an outpatient procedure, and most people are discharged from the hospital on the same day of the operation.

The surgeon or a nurse may draw markings on the breast to mark where the incision will be made. Generally this is done with a felt-tip marker. The markings are made when sitting up while this happens so that the natural crease of the breast can be marked.

If both breasts are being removed i.e. having a double mastectomy, the patient is expected to spend more time in surgery and possibly an additional day stay in the hospital. If having breast reconstruction following a mastectomy, this surgery also takes longer and may be admitted in the hospital for a few additional days.

 

If having a sentinel node biopsy, before the surgery a radioactive tracer and a blue dye are injected into the place around the tumor or the skin which is above the tumor. The tracer and the dye travel to the sentinel node or nodes, allowing the surgeon to see where they are and remove them during surgery.

 

During the procedure

A mastectomy is usually executed under general anesthesia, so the patient is not awake during the surgery. The surgeon starts by making an elliptical incision around the breast. The breast tissue is removed and, depending on the surgery, other parts of the breast may also be removed.

Mastectomy incisions in most cases are in the shape of an oval around the nipple, running across the width of the breast. In skin-sparing mastectomy, the incision will be smaller, including only the nipple, areola, and the original biopsy scar. If it is a nipple-sparing mastectomy, a variety of incisions can be used.

Regardless of which type of mastectomy is performed, the breast tissue and lymph nodes that are removed will be sent to a laboratory for analysis.

If the breast reconstruction is conducted at the same time as a mastectomy, the plastic surgeon will coordinate with the breast surgeon to be available at the time of surgery.

One option for breast reconstruction includes placing temporary tissue expanders in the chest. These temporary expanders will shape the new breast mound.

For women who will have to go through the radiation therapy after surgery, one option is to place temporary tissue expanders in the chest to hold the breast skin in place. This allows to delay final breast reconstruction until after radiation therapy is conducted.

If the radiation therapy is to be done after the surgery, meet with a radiation oncologist prior to the surgery to discuss benefits and risks, as well as how radiation will impact the breast reconstruction options.

When the surgery is completed, the incision is covered with stitches (sutures), which either dissolves or are removed later. One or two small plastic tubes might have to be placed where the breast was removed. The tubes will help to drain any fluids that accumulate after surgery. The tubes are sewn into place, and the ends are attached to a small drainage bag.

 

After the procedure

After the surgery, one can expect to:

 

  • Be taken to a recovery room to monitor blood pressure, pulse and breathing
  • Have a bandage over the surgery site
  • Feel some pain, numbness and a pinching sensation in the underarm area
  • Receive instructions on how to be taken care at home, including taking care of the incision and drains, realizing any signs of infection, and understanding activity restrictions
  • Talk with health care team about when to resume wearing a bra or wearing a breast prosthesis
  • Prescriptions will be given for pain medication and possibly an antibiotic

If the patient is in pain or feel nauseous from the anesthesia given, let the hospital staff know so that medication can be given

The surgeon or nurse may show an exercise routine in order to prevent arm and shoulder stiffness on the side where the surgery is done. After the surgery the exercises will be started the morning. Until the drains are removed some exercises should be avoided. Ask the surgeon any questions which one may have to make sure the exercise routine is right. The surgeon should also give written and well-illustrated instructions on how to do the exercises.

 

Results

After the mastectomy, the results of the pathology report should be available within a week or two. At the follow-up visit, the doctor will explain the report.

If more treatment is needed, the doctor may refer to:

 

  • A radiation oncologist so that the radiation treatments can be discussed, which may be recommended if the patient had a large tumor, many lymph nodes that tested positive for cancer, cancer that had spread into the skin or nipple, or cancer still remaining after the mastectomy
  • A medical oncologist to discuss other types of treatment after the operation, such as hormone therapy if cancer is sensitive to hormones or chemotherapy or both
  • A plastic surgeon, if the patient is considering breast reconstruction
  • A counselor or support group to help cope up with having breast cancer

 

 

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