Mastectomy is surgical removal of the entire breast on the affected side. There are several options and different types of mastectomy performed and this depends on whether a breast reconstruction is being performed at the same time.
In this operation the entire breast is removed including some of the overlying skin and the nipple. This operation is performed when no breast reconstruction is being undertaken. The aim is to achieve a flat surface on that side of the chest to facilitate wearing of external prosthesis in a bra.
The scar position depends on the location of the tumour and the shape of the breast. However in most instances the scar is kept low so that it is not visible in low-cut clothing.
Modified radical mastectomy:
This procedure involves removal of the entire breast, some of the overlying skin and nipple. In addition the fascial lining over chest muscles and sometimes part of the chest wall muscle is also removed. This is usually done for large cancers, which appear to involve the underlying chest wall muscle.
Skin and nipple sparing mastectomy:
This type mastectomy is performed to preserve most of the skin over the breast to allow for immediate breast reconstruction. The entire breast including the nipple is removed. This operation is just as safe as a standard mastectomy as far as treating the cancer is concerned in suitable cases. Occasionally the nipple can be preserved in cases of prophylactic (preventative) mastectomy and this is called a nipple-sparing mastectomy.
Preparation for Surgery:
The following includes typical events that may occur prior to surgery; however, since each patient is unique, what will actually occur may be different:
Preoperative preparation includes blood tests, medical evaluation, chest x-ray and an ECG depending on your age, medical condition and anaesthetic recommendation
After Dr Noushi discusses the surgery including the potential risks and benefits of the operation, you will need to provide a written consent.
You should have nothing to eat or drink for 6 hours prior to your procedure. Dr Noushi and the hospital will be more specific about the time to begin fasting depending on the time of day that your procedure is scheduled. However you are allowed to have medications that Dr Noushi or his anaesthetist has told you are permissible to take with a sip of water prior to surgery.
It is recommended that you shower the night before or morning of the operation.
Medication may need to be adjusted or avoided. It is best to inform Dr Noushi and his anaesthetist of ALL your current medications as well as allergies to medications prior to the examination. Most medications can be continued as usual. Medication use such as aspirin, non-steroidal anti-inflammatories (arthritis medication), blood thinners (eg. Warfarin, clopidegral etc), antidiabetic medication (insulin), Vitamin E, St John’s wart and any dietary drugs should be discussed with Dr Noushi and his anaesthetist prior to the procedure. Blood thinners may need to be ceased for your procedure and this may require consultation with your other specialists.
It is also essential that you alert Dr Noushi and his anaesthetist if you require antibiotics prior to undergoing dental procedures, since you may also require antibiotics prior to this procedure (eg for patients with artificial heart valves).
If you have any major diseases, such as heart or lung disease that may require special attention during the procedure, discuss this with Dr Noushi and his anaesthetist.
Quit smoking and arrange for any help you may need at home.
Surgery and Aftercare:
You will be admitted on the day of surgery and be required to fast for 6 hours before surgery. On the day you will be re-examined and the site of the scar drawn on the breast. If your cancer was detected by imaging alone and cannot be felt then the radiologists may place a wire close to the cancer to assist with surgical excision.
The length of the operation and duration of hospital stay depends on the extent of breast and lymph node surgery undertaken. For most patients the operation takes 1-3 hour. Dissolving stitches are used and there will be a waterproof dressing over your wound. You can shower with the dressing on, however ensure you do not rub or soak it. This dressing can be removed in 1 week. You may be advised to wear a supportive bra day and night for a couple of weeks.
A pastic tube called a drain is placed at the time of surgery and tunnelled away from the wound. This is left in for between 2 and 10 days. This drain removes any residual blood and fluid that the body produces after an operation. You can move around while you have the drain in with the aid of a small bag to avoid pulling on it. Most patients will stay in hospital for 2-3 nights and can any go home with the drain. Nursing staff from APAC will visit you in the home and help you care for the drain. They will also remove it for you according to Dr Noushi’s instructions. Occasionally, fluid collects in the wound (seroma) even after the drain has been removed and this is aspirated with a syringe, painlessly.
Generally mastectomy is not associated with a lot of pain. Most patients have some discomfort after their operation treated by simple analgesic tablets. The discomfort is often related to the surgery performed to remove lymph nodes from under the armpit (axilla) or chest region (internal mammary nodes), which usually settles after a few days. Patients are able to perform normal activities within a few days of this operation. Their overall recovery and return to work will depend upon a variety of factors including the extent of surgery and what treatment is necessary after surgery.
As with all surgical procedures breast surgery does have some risk. Serious complications after surgery are rare. It is not usual to outline every possible and rare complication from an operation, however it is important that you have enough information to make an informed decision.
Any operation can be complicated by infection, bleeding, seroma and wound healing problems. Wound healing can be particularly affected by infection and smoking. Any operation can be associated with anaesthetic problems (nausea in particular), venous thrombosis and allergic reaction to drugs or dressings. Every effort is made to avoid these problems.
Some problems from breast surgery include (but not limited to) the following:
Bleeding — All visible bleeding is stopped during the operation, but sometimes blood vessels can reopen and bleeding can restart. A bit of bruising is common and is nothing to worry about. A lot of bleeding causing a lump underneath the wound may require another operation to find and stop the bleeding vessel.
Seroma — This is fluid that collects under the wound. It produces a swelling and sometimes some tightness. Some patients can hear a sloshing sound from the fluid moving around. This is a common problem but easily treated by removing the fluid with a needle and syringe in a relatively painless procedure. Some patients need this drained more than a couple of times, but this is not an important problem and usually settles within a few weeks of surgery.
Wound healing - The blood supply to the skin that is preserved can very occasionally fail. This is more common in smokers, which is why a skin sparing mastectomy may not be an option if you are a smoker. In otherwise fit ladies who don't smoke, this problem is very uncommon.
If the blood supply fails the edges of the wound may not heal immediately. This may require further nursing care with dressings to the wound but usually settles without any further surgery.
Wound Infection — Any operation site can become infected. This occurs in less than 0.5% of patients. If it were to occur then it will usually happen in the first week after surgery. The wound becomes red, swollen and tender, and there may be a discharge through the wound. It is usually treated with antibiotics alone, but sometimes the wound has to be re-opened to allow the discharge to drain.
Contour abnormality /Lumpy tissue — Sometimes you are left with extra tissue at the outer edge of the scar underneath the armpit or on the chest. The common name for this is a ‘dog ear’. This is tissue that is normally there but you are more aware of it because the breast is no longer present. It usually settles over time. Some patients ask for further surgery to trim this. Similarly with contour abnormality, if there is extra tissue surrounding where the breast was removed it will result in a slight shallowing of the wound. Usually it is minimal and would settle in time. However some patients would prefer further reconstructive surgery to fix this.
Pain & numbness — The nerves supplying the skin around the wound will have to be cut in this operation and that will leave an area of permanent numbness around the wound. This may get better with time, but will not completely go away. Most patients will have some pain after the operation and this will be treated with pain medication. Only a small number will have persisting pain that needs further treatment.
Shoulder & arm stiffness — After your operation you will have some stiffness as you are healing. Most patients have no significant long lasting stiffness.
Frequently asked questions:
Why am I not suitable for breast conserving surgery?
You may not be suitable for breast conserving surgery if the proportion of the breast that needs to be removed is so large that the residual breast would be very deformed and uncomfortable. Alternatively if there are multiple cancers or cancers located in cosmetic sensitive area then breast conserving surgery may not be unsuitable.
If I have a mastectomy, would it be possible to have breast reconstruction in the future?
Yes, this is usually possible.
I have had a mastectomy and the scar is unsightly and lumpy. Can anything be done?
Yes, sometimes you are left with extra tissue at the outer edge of the scar and the common name for this is a ‘dog ear’. Or the breast scar along the chest wall is irregular and lumpy. This sometimes settles over time. However scars can be revised and flattened. Any flaps of skin that are bothering you or making it difficult or uncomfortable to wear a bra or prosthesis can be corrected.