Having a Mastectomy for Breast Cancer

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A mastectomy is sometimes necessary for breast cancer if the tumour is large in relation to the size of the breast, or if widespread areas of the breast are affected by small tumours (multifocal disease). In pre-invasive cancer, a condition called ‘ductal carcinoma in situ’ (DCIS), a mastectomy may also be necessary to adequately treat the disease and to prevent an invasive cancer forming. In invasive breast cancer, a mastectomy is performed to remove the tumour completely and to reduce the risk of recurrence which may negatively influence outcome.

How is the operation performed?

A simple mastectomy is synonymous with a total mastectomy. In this operation, the breast is removed including an ellipse of overlying skin. The breast is separated from the chest wall skin on its superficial surface and off the lining of the underlying muscle (pectoralis muscle) at the deep surface. The nipple is removed with the specimen. When the edges of the resected skin ellipse are brought together you will be left with a straight line on your chest wall, either orientated transversely (horizontally) or obliquely (at an angle running from the armpit end down to the lower end of the breast bone).

A modified radical mastectomy is an operation in which the breast is removed in a similar way to a total or simple mastectomy, but the modified radical element refers to removal of the lymph nodes from under the arm. This is done as a block dissection. With modern methods of surgery, there in no need to divide or remove any of the underlying muscles.

A modified radical mastectomy is closed leaving a scar that is horizontal (transverse) or lying obliquely (from the axillary end towards the lower end of the sternum). For axillary surgery associated with a mastectomy, please refer to the next section.

Historically, when the pectoralis major muscle was removed, this was termed a radical mastectomy. A Patey mastectomy refers to an operation in which the pectoralis minor (that lies below the pectoralis major) is removed. These more mutilating forms of mastectomy are now rarely performed as it is indicated only in very specific unusual circumstances.

Following a simple mastectomy, when the armpit operation is not necessary, you will have one or two tube drains coming out from the side of the chest wall. These stay in place for one or two days before removal. Following a modified radical mastectomy there will be two drains; one from the breast bed, the other in the axilla. The axillary drain normally needs to stay in place for five days. Dissolvable stitches are used which do not need to be removed.

At the time your mastectomy is discussed, your choices of immediate versus delayed or no breast reconstruction will have been offered. The general principles outlining these choices and options are discussed below. If you have elected against an immediate reconstruction, you will have a flat chest on one side and scars lying either transversely or obliquely, as previously shown.

Are there any adverse effects or complications following mastectomy and axillary surgery?

Surgical incisions following a mastectomy usually heal without difficulty, as a faint straight line flush with skin. Wound infection is rare but this may delay healing and require a course of antibiotics. This occurs in less than 2% of mastectomies. The surgical incisions sometimes heal with an immature/hypertrophic scar. This may be itchy or hypersensitive. Rarely, keloid scars which are raised, prolific scars that spread beyond the incision occur. Pigmented, darker skin types are more prone to this problem, which fortunately is also rare.

A fluid collection may occur beneath the mastectomy skin flaps on the chest wall. More commonly, it occurs after the axillary operation, when a seroma (a collection of fluid beneath the scar where the contents of the axilla has been removed) forms a soft swelling and becomes tense as the fluid collects. A seroma, if symptomatic by causing discomfort, pain or restricted shoulder movement, may require aspiration with a fine needle in out-patients. Sometimes, more than one aspiration is necessary. If multiple aspirations are required, it is often at weekly intervals.

A haematoma is a collection of blood within the space of the surgical resection where the breast or the axillary contents have been removed. This is, fortunately, rare. Small haematomas can be left to resolve, but larger ones may require an operation to remove the blood clot.

Over-sensitivity and pain in the scar can occur after a mastectomy. Sometimes this also extends to the lateral chest wall. During axillary surgery, a nerve called the ‘intercostolbrachial nerve’ that supplies the upper inner border of the upper arm is sometimes divided or damaged. As a result, women sometimes experience loss or reduced sensation in the upper inner arm. The sensation usually returns but sometimes does not recover completely. Chronic pain following breast surgery occurs to a varying degree. Early mobilisation, shoulder exercises, and swift return to normal function help to reduce the risks of troublesome symptoms. Most women have surgery of this type with no complications and return to full and normal activity.

Bruising in the skin is a common occurrence after breast surgery. This often settles without any further problem. Minor post-operative swelling in the chest wall also subsides without treatment.

Recovering from a mastectomy

Whilst on the ward, the physiotherapists will show you a graded set of exercises for shoulder mobilisation that also help with lymphatic drainage. These are self-instructional and you should continue these exercises following your discharge. The dressings covering the incisions are placed under a plastic sheet which is waterproof, allowing you to wash and shower in the normal way without worrying about getting the incision and dressings wet. These will be taken down when you come to see me in out-patients. Before you leave the hospital, our breast nurse will see you to fit a comfy, that is, a soft external breast prosthesis which you can place in your bra. She will also arrange for the subsequent fitting of an external more definitive prosthesis when you have recovered from the operation.

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