Breast cancer is one of the most common cancers affecting women. Mastectomy, the surgical removal of one or both breasts, is commonly performed as a treatment for breast cancer for women at extremely high risk of cancer.
There are different types of mastectomies, which are indicated in different situations and for different risk profiles.
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There are several types of mastectomies that can be performed. They are:
Simple or total mastectomy, which is the removal of the entire breast, but no other tissue.
Modified radical mastectomy, which includes the removal of the underarm lymph nodes.
Radical mastectomy, which includes the removal of the underarm lymph nodes and the chest wall muscle under the breast.
Partial mastectomy, where the cancerous lump and some normal tissues are removed. This is more extensive than a lumpectomy.
Skin-sparing mastectomy, which includes removal of all of the breast, nipple, and areola, leaving most of the skin over the breast intact.
Nipple-sparing mastectomy. All of the breast is removed, but the skin and nipple are left alone, which can result in a better aesthetic result. This is followed by immediate breast reconstruction.
All types of mastectomies may be single or double (bilateral). Usually, a double mastectomy is done preventively for women with the BRCA gene mutation, but surgeons may also recommend removing the second breast if there is an unusually high risk of recurrence.
This article will focus on radical mastectomies, who needs them, and specific concerns.
Radical mastectomies are rarely performed. Most breast cancer patients who need a mastectomy get a simple mastectomy or a modified radical mastectomy. Generally, this is just as effective.
A radical mastectomy is only performed if the tumor is growing into the pectoral muscles.
Several women can avoid having mastectomies. Generally, early-stage breast cancer is treated with breast-conserving surgery (BCS)¹ followed by radiation therapy.
Mastectomies are only recommended in the following cases:
Not a candidate for radiation therapy.
Have particularly large or multicentric tumors in separate quadrants.
Present with diffuse suspicious microcalcifications.
Where the extent of disease is not known.
When breast-conserving surgery results in persistently positive surgical resection margins.
Inflammatory breast cancer.
The primary reason surgeons now avoid radical mastectomies is increased side effects without significant survival benefits. However, if you have a tumor affecting your chest muscle, then radical mastectomy may still be recommended.
The radical mastectomy technique² first described by William Halstead in 1894 involved the removal of the breast, pectoralis major muscle, and regional lymphatics. This often means a skin graft is required. You are more likely to have a modified radical mastectomy, leaving your chest muscles intact.
The typical side effects of mastectomy surgery in general are:
Pain at the site of surgery.
Tenderness at the site of surgery.
Swelling at the site of surgery.
Hematoma, or a build-up of blood in the wound.
Seroma, a build-up of clear fluid in the wound, which has to be drained.
Limited movement of the arm or shoulder on the affected side.
Numbness in the chest or upper arm
Radical mastectomies tend to affect arm or shoulder motion. There is also the risk of post-mastectomy pain syndrome (PMPS)³, in which nerve pain occurs in the chest wall, armpit, or arm. This pain is generally not severe but can be chronic and result in loss of mobility in the arm.
Another significant risk is the development of lymphedema⁴ from the removal of lymph nodes. This happens when lymph fluid builds up in the fatty tissues just under your skin.
Typically, the removal of the lymph nodes results in a reduced risk of cancer spreading into those nodes and thus into your lymphatic system in general.
Your oncologist will determine whether the benefits of removing lymph nodes outweigh the risks of lymphedema and issues with arm and shoulder mobility.
Lymph node removal is not recommended for cancer that is entirely confined to the breast or for prophylactic mastectomy. For the vast majority of patients, a simple mastectomy is sufficient and gives far better aesthetic results.
One major reason why lymph nodes are removed only when strictly necessary is that the follow-up requires certain lifestyle changes, which are permanent, to keep the affected arm from developing swelling, blood clots, and other problems. These include:
Any needles or IVs must be placed in the other arm.
Blood pressure measurements must be performed on the other arm.
Avoiding injury to the arm as best as you can.
Repeated elevation of the arm to drain lymphatic fluid.
Wearing gloves when gardening or doing any activity with the risk of a hand injury.
Wearing gloves when using strong or harsh chemicals.
Taking special care to avoid sunburn.
Not wearing any tight items such as jewelry or watches on the affected arm.
Avoid using the affected arm to carry heavy packages, purses, or bags.
Using insect repellent to avoid insect bites.
You will also have to do arm exercises as recommended by your doctor. Bilateral radical or modified radical mastectomy thus comes with significant issues and disabilities. This is the primary reason why radical mastectomy is now avoided except in cases where it is truly necessary.
If your doctor recommends one, you should consider getting a second opinion to decide if a less invasive procedure might be better.
A radical mastectomy⁵ takes two to three hours. The surgeon will make a horizontal or diagonal incision across the breast, remove the affected breast tissue, lymph nodes, and muscle, then place a drainage tube. This will remain in place for several days.
You will need to avoid taking aspirin or similar products for ten days before the surgery and eating or drinking six hours before the surgery. You will need somebody to accompany you to and from the hospital.
Typically, you will be in the hospital for one or two nights, depending on how well you are recovering. Make sure to bring an overnight bag with toiletries, toothpaste, etc. Wear loose-fitting clothes that are easy to remove and put back on. This includes the day after, when you may be trying to dress with a sore arm, drains still in your chest, etc.
It typically takes about four weeks to recover from a radical mastectomy, longer if you have immediate reconstruction surgery. Some women prefer to have the reconstruction done right away so that they only have to deal with one hospital stay. Others might prefer to wait.
You should avoid strenuous activity for this recovery period, and you should not drive until the drains are out if you are taking opiates. Follow your surgeon's instructions about wound care.
Contact your doctor if you have excessive swelling (some swelling is normal), bloody dressing, discoloration beyond the wound area, pain that is not affected by medication (nerve pain), or high fever. If there is a discharge or odor from the wound, this might indicate an infection.
Some people also suffer from anxiety, depression, or insomnia, whether from the effects of the surgery or the medication.
You may also be receiving post-surgical follow-up treatments, such as chemotherapy or radiation therapy. If this is the case, then full recovery is likely to take months.
Expect to need assistance while recovering, whether from a friend, partner, or family member, or a professional home aide. You will probably not regain full use of your affected arm for some time and may always have some impact on it. Do any exercises your oncologist or physical therapist recommends to help restore mobility.
Radical mastectomies generally make breast reconstruction more challenging for a surgeon due to the loss of muscle and extensive scarring. It's also common to need some surgery on the healthy breast to ensure that they match.
An immediate reconstruction is an option. It can extend your recovery time but can be helpful psychologically. However, there are a lot of things you already have to think about. You may want to delay reconstruction. If you are getting radiation therapy, your surgeon will likely recommend staged reconstruction, in which a temporary tissue expander is used, and reconstruction is done later after the other treatment is completed.
Or you can wait until you have healed to get reconstruction then. Some women may opt not to get breast reconstruction surgery, either because of health issues or because they don't want another surgery. If you have decided not to get reconstruction⁶, talk to your surgeon about it to ensure they do their best to get a pleasing result.
You can then use a prosthetic or breast form to restore a normal appearance while clothed or wearing styles that draw attention from your chest area. The choice of what type of reconstruction to get, if any, should be entirely your own. Don't let anyone put pressure on you.
Radical mastectomies are seldom performed anymore, but if your surgeon recommends one, then it's helpful to know what to expect. Make sure to pick the right surgeon and talk to them ahead of time about what you want in terms of aesthetic results and reconstruction as well as their skills and qualifications to help ensure you get the best possible aesthetic effect.
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