What Is Radical Mastectomy?

Mastectomy is a surgical practice performed in cases of breast cancer to remove malignant breast tissue. There are different types of mastectomy.

• standard (or simple) mastectomy: the whole breast tissue is removed 
• radical mastectomy: total removal of the breast alongside the axillary lymph nodes and chest muscles (now a rare practice given the extreme removal of the tissues) 
• modified radical mastectomy: saves both pectoralis muscles that are otherwise removed during the traditional radical mastectomy

Radical mastectomy is a surgical intervention that aims to remove the whole breast tissue, which includes:

• Mammary gland
• Chest muscles (pectoralis major and minor muscles)
• Local lymph nodes of the armpit
• Overlying skin

When is radical mastectomy indicated?

Mastectomy is mainly indicated to remove the affected tissue in cases of breast cancer. Given the invasiveness of the operation, radical mastectomy is nowadays usually not the first option to consider in cases of breast tissue removal, and so it is indicated in case of extensive breast lesions that have a significant involvement of the skin and the chest muscles, after undergoing chemotherapy treatment in preparation for the surgery. Radical mastectomy is occasionally indicated to have more local control at the armpit and chest muscles level by removing most of the malignant tissue to be on the safe side.¹

Evolution of radical mastectomy

Radical mastectomy was first introduced by William Halsted in 1882, who created guidelines for the procedure. Radical mastectomy procedure involves an en-bloc resection of the entire breast including chest muscles and lymph nodes, causing significant visible physical and cosmetic irregularities. During the 19th century and until the 1970s, this technique was used on over 90% of the patients with breast cancer in the US.²

It is an invasive technique due to the big incision and tissue removal required. Because of this in the past, there were discussions over how to make it less invasive and save tissues while maintaining the successful outcome of the surgery. First Haagensen in 1935, then Bernard Fisher in 1971 showed results on different techniques used with similar effectiveness, that represented the evolution of radical mastectomy into a less traumatic intervention that can preserve part of the breast tissue.^2,3

Radical mastectomy procedure

Pre-operation: how to prepare for surgery

Before undergoing the radical mastectomy the patient will be required to take antibiotics to prevent or reduce the risk of infections during surgery.

The patient undergoes general anaesthesia once moved onto the operating table in a supine position, allowing a small elevation of the shoulder and part of the chest close to the edge of the operating table. Both shoulder and chest should be free to move, also letting the elbow flex and extend freely.^1,4

Operation procedure

The procedure starts with the arm resting relaxed and extended on a support. An elliptical incision around the breast, including the nipple, is made as suggested by the guidelines from the standard procedure from 1972. Delimited margins are set 3-5 cm from the centre of the tumour, usually wider than other mastectomy techniques to ensure complete tumour clearance from the affected area.

The procedure will require an en-bloc resection of the breast and overlying skin, pectoralis major and minor muscles, and complete dissection of the axillary. This is followed by elevation of the skin flaps to expose the underneath components to remove breast tissue.¹

Radical mastectomy vs modified radical mastectomy

There are two types of radical mastectomy:

• Traditional radical mastectomy
• Modified radical mastectomy

Traditional radical mastectomy is the technique documented by Halsted, which involves a large tissue removal of the whole breast. It is considered an invasive option in cases of breast cancer that require surgical intervention. On the other hand, we have a modified radical mastectomy, described by Madden in 1972, which is the current standard chosen for mastectomy interventions in case of breast cancer. 

Both traditional and modified radical mastectomy results in removing the whole breast, with the difference that in the radical mastectomy, all of the lymph nodes located in the armpit are removed as well as the chest muscles, whereas in the modified radical mastectomy some of the lymph nodes are removed, but the pectoral muscles are left intact. Studies and history have demonstrated that better results are obtained by not removing the pectoral muscles.² 

Contraindications for radical mastectomy

Mastectomy is usually quite safe if done correctly, and it is considered an easy operation to perform. However, it is not recommended if: 

• You are affected by a metastatic condition
• You are an elderly patient or your general health is compromised by other significant medical disorders
• Performing surgery and anaesthesia can be life-threatening for you
• Your breast cancer is already at an advanced stage with a large involvement of skin and chest muscles

In any of these cases, you might not be the right candidate to go under such an invasive surgical intervention. A better option to consider would be to start chemotherapy, radiotherapy or endocrine therapy to first control and reduce the size of the tumour, to then proceed with surgery if the doctor deems it clinically necessary.⁴

What are the complications of radical mastectomy?

Surgical removal of breast cancer is generally safe to perform. However, all surgical interventions can have some consequences, even when they are low-risk procedures. In cases of radical mastectomy, some complications could be:

• Wounds infection (in about 8% of the patients)⁴
• Skin necrosis (in about 8% of the patients)⁴
• Abnormal accumulation of blood (hematoma)
• Abnormal accumulation of plasma and lymphatic liquid (seroma)
• Swelling of the arm, caused by the accumulation of lymph fluid (lymphedema). Less common in the case of modified radical mastectomy
• Blood vessels may get damaged during the intervention
• Nerve injury and consequences depending on the damaged nerve
• Acute pain (chest, arm, shoulder, armpit)

Pain is a very common complication after surgery for most of the patients. It starts as acute pain which progresses into chronic pain if not treated, affecting quality of life. Painkillers taken immediately after surgery can help to control the incidence and severity of pain starting with an intravenous administration at the hospital to then proceed with pain medications taken orally.^3,4,5

Long-term complications

Breast cancer survivors can be affected by several post-surgery long-term effects. Patients could face changes in physical strength, mobility and performance, but also toxicity caused by the treatment they undergo or even suffer from psychological consequences linked to the extreme procedure of breast amputation. Some of the long-term complications you could face are:

• Functional changes
• Chronic pain
• Phantom breast syndrome
• Lymphedema
• Psychological distress

Functional changes 

About 90% of women end up having some sort of physical dysfunction with possibly long-term effects over the years that can lead to the worsening of the quality of life and a psychologically negative perception of their own body. Studies have shown that 24% of women still have physical impairment after a year from surgery. The intervention with chemotherapy in those who need it also seems to worsen the conditions due to lower muscle strength and lack of grip.

Having less mobility in the shoulder makes simple actions more complicated, such as getting dressed or washing your hair. The presence of overriding axillary tissue (axillary web syndrome) can also cause further obstacles as it creates impediments to the physiological range of mobility in the shoulder.⁶

Chronic pain syndrome

Chronic pain is the main complication experienced by breast cancer survivors after undergoing surgery, which could last for longer than 3 months. There are risk factors that could influence negatively such as being of a younger age, being overweight, having been treated with radiotherapy, and the involvement of lymph node dissection during the intervention.

Phantom breast syndrome

Phantom breast pain can be experienced if you sense pain in the removed breast, or phantom breast sensation if you don’t feel pain but feel some sensations such as itching, burning or tingling. It is present in 30%-80% of women after mastectomy.

Psychological distress

Mastectomy can significantly impact women’s psychology after surviving breast cancer. About 80% of women are usually afraid this could happen again in the future, about 60% experience grief and identity crisis, and about 30% of women are anxious or depressed up to 10 years after the intervention.⁶

Post-operation: what to do after radical mastectomy

The post-surgery phase is a delicate time and it’s important to take good care of your body and mind to best overcome its complications. The medical approach to treat consequences described such as pain syndromes or depression and anxiety will be managed and evaluated by the doctor. On the other hand, you could consider following some precautions.

Exercise

Stay physically active and exercise regularly. Try to spend 150 minutes doing some moderate activities or 75 minutes of more intense exercise on a weekly basis. It helps improve mood, self-esteem, and strength leading to a better quality of life from a mental and physical perspective. Combining exercise and lymphatic drainage with a gentle massage is effective in reducing the appearance of the scar left from surgery, inflammation, and lymphedema. 

Water exercises, yoga, and pilates are great options to consider as they improve lymphatic conditions and mobility of the shoulder on a long-term intervention.⁶

Healthy lifestyle

A correct diet can help prevent breast cancer from happening again. Increasing the consumption of whole grains, fruits and vegetables could be a significant change for a healthy lifestyle. Stop smoking and reduce alcohol consumption (not more than one drink per day), because these can dramatically affect your general health and increase the risk of recurrence.

Drinking green tea might have a positive influence on reducing the risk in women who have early-stage breast cancer. Yoga and meditation make it easier to deal with the fear of recurrence by decreasing anxiety and increasing a sense of well-being.

Seek psychological support

If you had breast cancer and underwent the complete removal of your breast it is normal to feel negative emotions and it is okay to ask for help. Some women still experience emotional distress for up to 10 years after mastectomy. Cognitive behavioural therapy shows significant improvement in controlling negative feelings and thoughts.⁶

Summary

Radical mastectomy is the removal of the whole breast including skin, lymph nodes and chest muscles and it is now a rare practice given the extreme removal of a large area of the breast tissue. Modified radical mastectomy is a more standard practice that does not affect the pectoral muscles instead.

It is generally safe but could still present contraindications if you are a frail patient and/or have complications after surgery. It is important that you follow the recommendations provided by the health care professionals, have a healthy lifestyle, and that you ask for help if you are experiencing emotional distress.