Mastectomy

A mastectomy removes the glandular tissue of the breast, the part in which cancer develops. In a simple or total mastectomy the surgeon removes the breast tissue together with the nipple and most of the overlying skin, leaving a flat chest wall closed with a horizontal or slightly angled scar. In a skin-sparing mastectomy most of the breast skin is kept, and in a nipple-sparing mastectomy the nipple and areola are kept too; both are usually combined with immediate reconstruction, which fills the skin envelope with an implant or the person's own tissue. The muscle under the breast is normally left in place. The lymph nodes in the armpit are examined during the same operation. A sentinel node biopsy removes the first one to a few nodes that drain the breast, found with a tracer injected beforehand. An axillary clearance, which removes more nodes, is reserved for cancer known or found to have spread to them. A modified radical mastectomy is the term for a total mastectomy with axillary clearance.

Mastectomy is recommended when breast-conserving surgery is unlikely to remove the cancer with a good result. This includes a large tumour in relation to the size of the breast, cancer or DCIS in several areas of the breast, widespread suspicious calcifications on the mammogram, and margins that remain involved after one or more attempts at a lumpectomy. It is also used when radiotherapy, which normally follows breast-conserving surgery, cannot be given, for example after previous radiotherapy to the chest, or in some connective tissue diseases. Inflammatory breast cancer is treated with a mastectomy after chemotherapy. Risk-reducing mastectomy of both breasts is an option for people with a BRCA1, BRCA2 or other high-risk gene mutation, or a strong family history, and is decided after genetic counselling. Some people who could keep the breast choose mastectomy for personal reasons. For many early cancers, studies have shown similar long-term outcomes after mastectomy and after lumpectomy with radiotherapy, so this choice is discussed openly with your breast team.

The operation is done under general anaesthesia. Before surgery the breast is marked with you standing, and for a sentinel node biopsy a small amount of radioactive tracer, blue dye or magnetic tracer is injected into the breast, either on the day or the day before. The surgeon makes an incision planned around the type of mastectomy and any reconstruction, then separates the breast tissue from the skin above and from the chest muscle below. In skin-sparing and nipple-sparing techniques the incision is kept small, often under the breast fold or around the areola, and tissue under the nipple is sent for separate examination. Through the same or a small armpit incision the sentinel nodes are found with a probe and removed. If immediate reconstruction is planned, the plastic surgeon then places an implant or tissue expander, or transfers a tissue flap. One or two thin drains are usually left under the skin to remove fluid. A mastectomy alone usually takes about 1.5 to 3 hours.

Most adults with breast cancer or DCIS are candidates if they are fit for general anaesthesia, including older people. The plan is made by a multidisciplinary team after a confirmed biopsy diagnosis, imaging of both breasts with mammography, ultrasound and sometimes MRI, and an assessment of the armpit nodes. Some people receive chemotherapy or hormone therapy before surgery to shrink the cancer, which can change the type of operation. Nipple-sparing mastectomy depends on the distance between the tumour and the nipple and on breast size and shape. Smoking, diabetes and a high body weight raise the risk of wound and skin problems, so stopping smoking several weeks beforehand is strongly advised. Preparation includes blood tests, an anaesthetic assessment and a review of medicines, especially blood thinners. If you are considering reconstruction, it is best discussed before the mastectomy so the incision can be planned. International patients can usually send biopsy reports, slides and scans in advance for review.

You are helped out of bed within hours and can usually eat the same day. Pain is generally moderate and controlled with regular painkillers. Most people go home after one or two nights, with the drains still in place; they are removed when the fluid output falls, usually within one to two weeks. Gentle shoulder exercises start early to prevent stiffness, and a physiotherapist shows you what to do. Most people return to light everyday activities in about three to six weeks, and driving is usually possible once you can wear a seatbelt and turn the wheel comfortably. Plan to stay near the hospital for about one to two weeks, so that drains can be removed, the wound checked and the final tissue report discussed in person. That report decides whether chemotherapy, radiotherapy, hormone therapy or targeted therapy is needed, and those treatments can often be continued near home with a written plan. On the flight, walk regularly and drink fluids.

Mastectomy is a well-established operation, but every surgery carries risk. A seroma, a collection of fluid under the skin, is common after drains are removed and is easily drained with a needle if it causes discomfort. Wound infection, bleeding and blood clots can occur. After skin-sparing or nipple-sparing surgery, part of the skin or nipple can lose its blood supply and heal slowly. Numbness of the chest wall and the inner upper arm is common and often partly permanent. Shoulder stiffness usually improves with exercise. Lymphoedema, a lasting swelling of the arm, is uncommon after sentinel node biopsy and more likely after axillary clearance or radiotherapy to the armpit. Some people have persistent pain in the chest wall. A small risk of cancer returning remains in the skin or chest wall, and risk-reducing surgery lowers but does not entirely remove the risk of a new cancer. The emotional effect of losing a breast is real, and support is part of good care.