Mastectomy

Mastectomy procedure is of two types- unilateral mastectomy (one breast removed) and bilateral mastectomy (both the breasts removed). The selection of the procedure depends on the level of spread of cancer cells.

Mastectomy is useful in treating various types of breast cancer like:

• Paget’s breast disease
• Inflammatory breast cancer after chemotherapy
• Locally recurrent breast cancer
• Noninvasive breast cancer, or ductal carcinoma in situ.
• Breast cancer (early stage) stage I and II.
• Breast cancer (locally advanced) stage III, after chemotherapy.

Doctors advise mastectomy instead of lumpectomy with radiation in the following scenarios:

• Multiple tumors in different parts of the breast.
• If the patient is pregnant, then performing lumpectomy may be a risk to the unborn fetus.
• Malignant and widespread calcium depositions or microcalcifications in the entire breast, which is confirmed to be cancerous after the biopsy procedure.
• Previous radiation therapy on the breast might cause certain risks on further exposure to the radiations for the breast.
• History of SLE or systemic lupus erythematosus or any chronic inflammatory disease. If radiation therapy is given in such cases, the condition of the patient may become worse.
• If a patient has a history of scleroderma, then performing the surgical procedure of lumpectomy may create problems for the patient. In scleroderma, the skin of the patient becomes very hard and thick and hence, healing is very difficult after the lumpectomy procedure.
• If the cancer cells have spread in the entire breast including the overlying skin, it is difficult to remove all the infected cells with the lumpectomy procedure. In such cases, doctors advise mastectomy. Lumpectomy is only helpful in removing some portion of the affected breast.
• If the sample from the biopsy report confirms cancer or shows signs of cancer, then the doctor might advise going for further treatment options like mastectomy.
• If the size of cancer or tumor is large and breast size is small, lumpectomy may give poor aesthetic results and hence, mastectomy is preferred.

Mastectomy is a procedure not only to treat breast cancer but also, to prevent the risk of getting the cancer. So, the procedure can also be advised in the following cases:

• If the patient does not have breast cancer at present but is at a very high risk of developing it.
• Prophylactic mastectomy is also advised to prevent the risk of getting breast cancer in future. This occurs in patients with a strong family history with breast cancer cases.

There are some risks and complications associated with mastectomy procedure, which are as mentioned.

• Severe pain
• Bleeding
• Tenderness
• Infections
• Changes in the appearance and shape of the breast after the mastectomy procedure.
• Swelling, lymphedema.
• Formation of a hard scar or tissue at the site of mastectomy.
• Numbness usually under the arm, after the mastectomy due to nerve damage.
• Hematoma (collection of blood at the site of surgery).
• Shoulder stiffness and pain.

If the mastectomy procedure is under general anesthesia, then some patients may have some of the following complications due to the anesthesia effect:

• Nausea
• Vomiting
• Uneasiness
• Dizziness
• A temporary state of confusion
• A feeling of cold or shivering

The doctor discusses the details of the mastectomy procedure, including the risks and the benefits of the surgery, with the patient. Some of the points to be considered before the surgery are as mentioned.

• The doctor takes a complete medical history and physical examination test before performing the surgical procedure. The patient may be asked about the age and weight of the patient, any past surgeries, allergies to any medicines, previous personal history and family history of heart attacks. In the physical examination, the doctor examines the patient very carefully for any other concerning signs and symptoms.
• The doctor also advises some tests such as some blood investigations, before the surgery
• If a patient is diabetic, the patient is advised to ask the doctor if he/she should continue taking insulin before the procedure or not. The patient is also asked to inform the doctor about any past allergies or surgeries, if any.
• The patient is advised to quit smoking and avoid alcohol, avoid drinking or eating anything after midnight or one night before the surgery.
• The patient is advised to inform the doctor if he/she is taking any blood thinning medications or any supplements. Accordingly, the doctor would decide if the medication is to be stopped or can be continued.
• The patient is advised to empty the urinary bladder and bowel, before the test.
• The patient has to remove or avoid any jewelry, eyeglasses, hairpins, electronic gadgets or any metal objects and is asked to change into a hospital gown, during the procedure.
• This surgical procedure does not need hospitalization after the procedure.
• The patient is advised to bring a companion along to take care of the patient after the surgery and drive back home safely

Breast reconstruction surgery:

This breast reconstruction procedure is done either along with or after the mastectomy surgery. The breast reconstruction is used to restore the breast shape which helps in conserving the appearance of the breast. Breast reconstruction can be done using the following techniques.

• Using the tissue from the patient’s body. This procedure is also known as autologous tissue reconstruction.
• Using silicone implants or breast expanders with the help of saline.
• Using a combination of implants and tissue reconstruction.

The procedure of breast reconstruction is complex and is done by the reconstructive or plastic surgeon.

Mastectomy:

Mastectomy is actually a broad term for various procedures done on the breast such as removal of one or both the breast, or just the removal of the lymph nodes from the armpit of the patient for biopsy testing, in order to confirm cancer and its spread.

A sample of the breast tissue is taken to identify the cancer spread. The sample can be taken by two methods, as mentioned below.

• Axillary node dissection – This method is performed, if the doctor is sure that the cancer cells are present in the breast before the surgical procedure. In this procedure, the surgeon dissects a number of affected lymph nodes from the patient's armpit, besides the tumor site.
• Sentinel node biopsy - Sentinel node biopsy is a procedure in which a small tissue sample is taken to test the presence of cancer and its spread into the lymphatic system. In this procedure, primary or first few lymph nodes are removed, wherein the drainage of the tumor is commonly observed

If the cancer is not present, then the lymph nodes are not removed. However, if the presence of cancer is detected, then the doctor suggests going for radiation therapy.

The various types of mastectomy procedures are as mentioned.

• Modified radical mastectomy – This type of mastectomy procedure is suggested in the cases, where the cancer cells have spread to a very large area of the breast. It involves the removal of one or both the breast entirely inclusive of the breast tissue, nipple, areola, and many underarm lymph nodes. This includes complete axillary node dissection approach.
• Simple or total mastectomy – This procedure involves the removal of the whole breast tissue, nipple and areola i.e. the entire breast.
• Skin-sparing mastectomy – In this procedure, the breast tissue, nipple, and areola are removed, leaving behind the breast skin. This helps to conserve the aesthetics or appearance of the breast.
• Nipple-sparing mastectomy (subcutaneous) – In this type of mastectomy, only breast tissue is removed, leaving the nipple, breast skin and areola. The procedure is followed by the breast reconstruction surgery and also, sentinel node biopsy may be done.

During the procedure:

Before the procedure, the vital signs of the body such as pulse rate, body temperature, oxygen levels or breathing rate, and heart rate, are monitored continuously. General anesthesia is given to the patient to prevent from feeling any pain during the surgery.

The surgeon then gives an elliptical incision around the breast of the patient. The breast tissue and the other parts like nipple, areola and breast skin are removed, as per the type of procedure conducted on the patient.

The surgeon sends the biopsy sample of the breast tissue and the lymph nodes, irrespective of the mastectomy procedure performed. In case there is a requirement of breast reconstruction, a plastic surgeon would also be present during the surgery.

In the procedure of breast reconstruction one of the following may be involved:

• Using the tissue from the patient’s body. This procedure is also known as autologous tissue reconstruction.
• Using silicone implants or breast expanders with the help of saline.
• Using a combination of implants and tissue reconstruction.

The above-mentioned breast expanders will be placed behind the chest wall muscles, forming a new breast mound.

In the cases, where radiation therapy is necessary, the surgeons place temporary breast expanders to hold the breast skin in place, till the radiation therapy is performed. The permanent breast expanders then replace the temporary breast expanders, after the radiation therapy completes.

After the completion of the mastectomy, the incision is closed with the sutures. There are some tubes attached to the breast area and to the drainage bags to collect any drainage from the surgical site.

After the procedure:

The patient is shifted to the recovery room after the surgery wherein he/she is kept under continuous monitoring and observation. The vital signs of the body such as pulse rate, body temperature, oxygen levels or breathing rate, and heart rate, are monitored continuously.

The patient is allowed to go home the next day of the surgery and he/she can return back to normal routine activities, after consulting with the doctor. The speed of recovery depends on the medical condition of the patient. If any complications appear after the mastectomy, then the physician can extend the stay in the hospital, until the condition of the patient is completely stable.

If the axillary node dissection technique is followed, then the hospitalization of the patient may be extended for a day or two. The hospitalization period would depend on the post-surgery pain or bleeding signs. The doctor advises on when to start wearing a bra or breast prosthesis. Pain killers may be advised by the doctor.

The patient is asked to avoid taking bath or showers for a few days after the procedure. The site of the biopsy should be kept clean, dry and moisture free. The detailed pathology report of the patient will be available within 2 weeks after the surgery and the doctor discusses it with the patient in detail.

After the procedure if the patient experiences any of the following signs, he/she should call the doctor immediately.

• Chills
• Severe or uncontrollable pain
• Fever
• Heavy bleeding from the biopsy site
• Drainage or discharge from the biopsy site
• Severe itching or any signs of infection
• Swelling
• Redness
• Warm feeling