What is a Mastectomy?

Also referred to as breast removal surgery, a mastectomy is a surgical procedure that involves the removal of some or all of breast tissue in either one (unilateral) or both (bilateral) breasts. 

Read on to learn about the types of breast cancer and medical conditions that may require mastectomy, the entire mastectomy procedure from start to finish, the risks and complications associated with mastectomy, and more.

Introduction

A mastectomy is a surgical procedure that involves the removal of some or all of the breast tissue affected by, or at risk of, cancer. The skin surrounding the breasts and/or nipples may be saved to use for breast reconstruction.¹ 

Mastectomy acts both as a treatment and prevention strategy for people with breast cancer. Breast cancer is the most commonly diagnosed type of cancer in women worldwide, with 2.26 million new cases reported in 2020.² It is also the second most common cause of cancer death in women.

Types of mastectomy

There are different types of mastectomy that depend on how much breast tissue is removed including:¹ 

1. Total mastectomy (simple mastectomy): involves the removal of all of the breast tissue whilst leaving pectoral muscles under the breast intact. It can be performed on one breast (unilateral) or both breasts (bilateral) 
2. Skin-sparing mastectomy: involves the removal of the breast tissue whilst sparing most breast skin to use for breast reconstruction
3. Nipple-sparing mastectomy: involves the removal of the breast tissue whilst sparing the nipple and areola (coloured circular skin around the nipple) to use for breast reconstruction
4. Mastectomy with breast reconstruction: breast reconstruction can be performed during a skin-sparing or nipple-sparing mastectomy or after most mastectomy procedures
5. Modified radical mastectomy: involves the removal of the entire breast tissue as well as some underarm lymph nodes, which are usually the first site (primary site) where breast cancer grows and spreads
6. Radical mastectomy: involves the removal of the entire breast tissue, underarm lymph nodes, and pectoral muscles under the breasts. It is rarely performed nowadays due to the high risks and complications it carries, but may be necessary in cases where breast cancer has spread to the muscles

Indications for mastectomy

There are several cases that may indicate or act as a sign that a person requires a mastectomy, including:^1,3

• Inflammatory breast cancer
• Paget disease: breast cancer usually develops around the nipple/areola area in people with Paget disease
• Infiltrating ductal carcinoma
• Infiltrating lobular carcinoma
• Triple negative breast cancer
• Having a high breast cancer risk due to:
  • Genetic mutations: people who inherit mutations (changes in the DNA sequence) in certain genes - mainly BRCA1 and BRCA2, but also P53, CDH1, PTEN, and STK11 - have been demonstrated to have a high risk of developing breast cancer²
  • Family history: a family history of breast cancer is a huge risk factor for breast cancer, with research studies showing that approximately 13-19% patients with breast cancer have an affected first-degree relative² 

Procedure and recovery

A mastectomy involves multiple steps that occur before, during, and after the procedure is performed.¹ 

Before a mastectomy 

Prior to performing a mastectomy, your healthcare provider will have a thorough discussion with you about your condition as well as your preferences regarding the type of mastectomy and breast reconstruction you will have. Further cancer treatment options and/or cosmetic surgeries may also be discussed depending on your desired results and the severity of your breast cancer. 

During a mastectomy 

A mastectomy will involve the following steps:

1. The healthcare provider will provide you with a tube to breathe and insert a catheter into a vein to insert IV fluids and/or drain urine if the surgical procedure takes several hours
2. You will then be put under general anesthesia so you can sleep during the mastectomy without feeling any pain or discomfort
3. A surgeon will sterilise the surgical room and give you antibiotics through your IV to prevent infections
4. The surgeon will either inject a radioactive substance (called a tracer or a blue dye) into your breast tissue to help visualise the lymph nodes where breast cancer usually starts to develop
5. The surgeon will start to remove the breast tissue following the preferred mastectomy method
6. Depending on the stage of the cancer, the surgeon may remove one or multiple lymph nodes and send them to the lab for testing 
7. If you chose to have breast reconstruction during the mastectomy, the surgeon will perform breast reconstruction at this stage using some of the skin around the breast tissue or from the nipples. Alternatively, an artificial implant may be used to reconstruct the breasts
8. If the patient chose not to have breast reconstruction performed or chose to have it done at a later date, the surgeon will close the flap
9. A tube called a surgical drain will be used to drain excess fluid from the wound into a collection bulb outside the surgical room. It may be used for a week or two after the mastectomy 

After a mastectomy 

Procedure 

You will likely be required to stay in hospital for the night, or possibly even longer, depending on how much breast tissue was removed and how severe your condition is. During this time, you will be taught by the healthcare team how to use the surgical drain at home to decrease the risk of developing breast infections and streamline your recovery. 

Depending on lab results, you may need to undergo additional surgery to remove any remaining breast tumour cells that were not successfully removed from the breast tissue and/or lymph nodes. Further cancer treatment options, such as radiation or chemotherapy, may also be required. These can be performed before or after breast reconstruction. Breast reconstruction may require several follow-up surgeries (revision surgery) to give you your desired cosmetic result. 

Recovery and outlook 

The wound may take an average of three (four to six) weeks to heal. Following the mastectomy, you may experience tiredness and a variety of sensations, including twinges (shooting pain), soreness, stiffness, and numbness especially in the chest, arms, and shoulders. 

The sensations experienced in the chest are usually regained after about two years, but some patients never regain full chest sensations or experience chest sensations at the same intensity prior to the mastectomy. 

After a mastectomy, you may benefit from a variety of rehabilitation therapies that support emotional and mental health such as counselling and support groups and/or physical health such as physical therapy. Alternatively or in advance, you may decide to opt for complementary medicine techniques to manage symptoms including yoga, massage, meditation, and/or biofeedback.¹

Risks and complications

Although a mastectomy can greatly reduce the risk of developing breast cancer in people with genetic mutations in the two main breast cancer genes BRCA1 and BRCA2, as well as significantly improve the quality of life and survival rate of those with breast cancer, mastectomy carries heavy risks and complications including:¹

Early risks and complications

• Breast infections: the risk of developing breast infections following a mastectomy is less than 1% as surgeons
• Hematoma: this involves excess blood accumulating and ‘pooling’ under the incision wound
• Flap necrosis: this involves tissue death (necrosis) due to loss of blood supply to the cut tissue. It usually requires surgical removal of the dead tissue which may then be replaced with a skin graft. Fortunately, the risk of developing flap necrosis following mastectomy is low

Delayed risks and complications 

• Seroma: this involves excess blood accumulating and ‘pooling’ inside the incision wound, resulting in swelling and tenderness. It is more likely to occur in patients who do not have access to a surgical drain
• Post-mastectomy pain syndrome (PMPS): this encompasses various symptoms including shooting pain, tingling, prickling, burning, and itching. PMPS is experienced by over 20% of people who undergo mastectomy
• Lymphedema: this involves excess lymph fluid accumulating inside tissues mainly in the arms and legs, resulting in swelling. Patients who have some of their lymph nodes removed during mastectomy have a greater risk of developing lymphedema 

Summary 

Mastectomy is a surgery that is mainly used to treat breast cancer by removing some or all of breast tissue from either one (uniliteral) or both (bilateral) breasts. It also acts as an effective preventative strategy (prophylactic mastectomy) for: 

• People who have genetic mutations in certain breast cancer genes, mainly BRCA1 and BRCA2 
• People who have a first-degree relative with breast cancer 

During a mastectomy, the breast tissue may be totally removed (total mastectomy or double mastectomy) or removed along with lymph nodes (modified radical mastectomy), and the pectoral muscles underneath the breasts (radical mastectomy). Breast reconstruction may be performed during or after the mastectomy using some of the breast skin (skin-sparing mastectomy), nipples (nipple-sparing mastectomy), or artificial implants. 

Depending on the severity of the patient’s breast cancer, further cancer treatment options may be required, such as radiation and chemotherapy. 

The average recovery length from a mastectomy is three weeks, in which patients may experience pain, stiffness, soreness, and numbness. Breast infections, flap necrosis, hematoma, seroma, post-mastectomy pain syndrome (PMPS), and lymphedema are other risks and complications associated with a mastectomy. It may take over two years for patients to regain sensations in their chest after a mastectomy. However, in some cases, all sensation in the chest may be lost. 

Patients can improve their chances of recovery and decrease their risk of developing the above-mentioned severe complications of mastectomy via:

• Effective use of a surgical drain 
• Use of pain relievers 
• Physical therapy

Emotional and mental symptoms that may occur following a mastectomy such as body image disturbance, depression, and low self esteem may be improved through:

• Counselling
• Support groups
• Complementary medicine techniques such as yoga, mediation, biofeedback, and/or massage