Mastectomy Surgery - Comparing Types of Mastectomies

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What is a Mastectomy? Mastectomy Surgery Explained

Healthy Breast Tissue
Healthy Breast Tissue. Photo © A.D.A.M.

A mastectomy is the surgical removal of a breast.

The vast majority of mastectomies are performed on women as a breast cancer treatment, although men may develop breast cancer and require the procedure, too. In some cases, a lumpectomy may be another surgical treatment option for these patients. Those with more extensive breast cancer may require a bilateral mastectomy, which is the removal of some or all of the tissue in both breasts.

Some men with a condition called gynecomastia, in which the breast tissue becomes overdeveloped, opt for a mastectomy for cosmetic purposes.

There are several types of mastectomies. The decision of what type of mastectomy should be done should be made with the assistance of the surgeon performing the mastectomy, the oncologist and the plastic surgeon performing the reconstruction. Some techniques may not be able to be considered, depending on the location and severity of the cancer. The emotional needs of the patient must also be weighed.

The decision to have breast reconstruction surgery should be made before the mastectomy surgery is done. The reconstruction may be able to be done right after the mastectomy or at a later date.

The surgery is done under general anesthesia and typically lasts 2 to 3 hours, although it may take longer if a procedure to remove the lymph nodes is planned or reconstructive surgery is being performed immediately after the mastectomy.

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Simple Mastectomy (Total Mastectomy)

Breast Lump Before Surgery
Breast Lump Before Surgery. Photo © A.D.A.M.

A simple mastectomy, also known as a total mastectomy, is a procedure that removes all of the breast tissue of the affected breast. The most common form of the surgery, referred to as traditional total mastectomy, includes the removal of the areola and nipple. However, the surgery can be performed using skin and nipple sparing techniques. It also leaves the muscle under the breast left intact.

The procedure is performed using an elliptical incision 6 to 8 inches in length that begins on the inside of the breast, near the breast bone, and extends upward and outward toward the armpit. The incision can also be altered to remove scar tissue from previous procedures, which can improve the cosmetic outcome if reconstruction is desired.

Once the breast tissue is removed, the incision is closed with either absorbable sutures, which the body slowly absorbs over time, or staples that are removed during an office visit 10 to 14 days after surgery. There may also be a drain, a device that helps remove excess fluid from the body to promote healing and decrease swelling, in place. The drain will be under a bandage to protect the surgical site and the drain placement. In most cases, the drain will be removed during an office visit after discharge from the hospital.

When this type of mastectomy is combined with an additional procedure to remove lymph nodes from under the arm it is called a modified radical mastectomy. It, too, can be paired with a breast reconstruction procedure.

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Modified Radical Mastectomy

After Mastectomy Without Reconstruction
After Mastectomy Without Reconstruction. Photo © A.D.A.M.

A modified radical mastectomy is a type of mastectomy that combines the removal of all breast tissue from the affected breast with lymph node removal from the armpit on the affected side of the body. This surgery typically includes the removal of both the nipple and areola, but the surgery can be performed using skin and nipple sparing techniques.

Like a simple mastectomy, the procedure is performed using an elliptical incision 6 to 8 inches in length that begins on the inside of the breast, near the breast bone, and extends upward and outward toward the armpit. The incision can also be altered to remove scar tissue from previous procedures, which can improve the cosmetic outcome if reconstruction is desired.

Once the breast tissue is removed, the incision is closed with either absorbable sutures or staples that are removed during an office visit 10 to 14 days after surgery. There may also be drains in place to decrease the amount of swelling in the area. These drains are covered with bandages to protect the incision site and the drain placement. The drains are typically removed after discharge from the hospital by the surgeon during a routine office visit after surgery.

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Radical Mastectomy (Halsted Mastectomy)

Before and After Mastectomy Surgery
Before and After Mastectomy Surgery. Photo © A.D.A.M.

A radical mastectomy, also known as a Halsted mastectomy, is not a commonly performed procedure. While this surgery was the standard of care in the past, it is now only performed on patients who have advanced breast cancer that has invaded the muscle wall under the breast tissue.

Like other types of mastectomy, a radical mastectomy removes all of the breast tissue of the affected breast. It also removes all of the lymph nodes under the arm on the affected side and the muscle that lies under the breast. Only the skin required to close the incision is left in place.

This procedure is not considered necessary for patients whose cancer has not invaded the muscle.

This surgery is considered the most disfiguring of the mastectomy procedures, leaving very little tissue other than skin over the rib bones. The scar left after this surgery is 6 to 8 inches long, with enough skin left to close the incision with sutures or staples.

The surgeon may also place drains in the areas of surgery which, as in the other procedures, will be covered for protection and then later removed by the surgeon during a routine office visit.

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Nipple and Skin Sparing Mastectomy Techniques

Steps of Mastectomy Surgery
Steps of Mastectomy Surgery. Photo © A.D.A.M.

Nipple and skin sparing techniques can be used in combination with most mastectomy surgeries to retain more skin than is done in a traditional mastectomy. A general guideline for retaining the nipple, areola and additional skin is this: The area of cancer should be a minimum of two centimeters away from the tissue that is to be saved. Therefore, a patient whose cancer is affecting the skin or nipple would not be a candidate for having those tissues retained after surgery.

Skin Sparing Mastectomy

This technique preserves the skin of the breast, but not the nipple and areola, which are removed. The breast tissue is then removed through that area. For women with large breasts, an additional incision may be made to allow the breast tissue to be removed, but the vast majority of skin is left behind after surgery.

Nipple Sparing Mastectomy

The incision to remove the breast tissue is made

around

the areola, thus preserving both the nipple and areola. This procedure, like the skin sparing procedure, may result in a larger incision than is necessary in the traditional procedure, especially if the breast is large in size.

Total Skin Sparing Mastectomy

This procedure, also known as a subcutaneous mastectomy, not only preserves the skin of the breast, but the nipple and areola, too. The incision to remove the breast tissue can be placed in the fold under the breast where it cannot be easily seen once healed, or the incision may be made around the areola.

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After Mastectomy Surgery

After Mastectomy With Expanders
After Mastectomy With Expanders. Photo © A.D.A.M.

The recovery from mastectomy surgery begins in the PACU, or post anesthesia care unit, where the patient is monitored while the anesthesia drugs wear off. After that, the patient is taken to a hospital room where they can be monitored for any problems for 34 to 48 hours after surgery.

During the recovery, the first 2 to 3 days will be the most painful, with the pain easing somewhat each day thereafter. It is best to avoid any sort of activity that includes a bouncing movement, such as running, during the recovery phase. Lifting is discouraged at this time, as is raising the arms above the head, which can put strain on the incision and cause increased pain.

Depression after the diagnosis of breast cancer, with or without surgery, is a problem for many patients. Depression can make it difficult for a patient to recover from surgery or take part in related decision making. It can also heighten the fatigue that patients feel after surgery as well as chemotherapy and radiation. It is easy to confuse the symptoms of a normal recovery from surgery, so it is important to be familiar with the symptoms of depression.

Physically, a patient with no surgical complications should be able to return to vigorous activity within 6 to 8 weeks, if additional treatments do not cause too much fatigue. Returning to a sex life after a mastectomy should also be possible at that time, if desired.

Patients who opt not to have reconstruction may need prosthetics that create a balance between a natural breast and a breast that has been removed. There are many mastectomy products available, primarily online, including bras, breast forms and swimsuits.

In addition to surgery, most patients have radiation therapy, chemotherapy or a combination of both. The decision is based upon the severity of the cancer, the wishes of the patient and the oncologist’s opinion.

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Sources

Sources:

Breast Cancer in Men. American Cancer Society http://www.cancer.org/Cancer/BreastCancerinMen/DetailedGuide/index

Breast Cancer Treatment By Stage. American Cancer Society http://www.cancer.org/docroot/CRI/content/CRI_2_4_4X_Treatment_by_Stage_Breast_Cancer_5.asp?rnav=cri

Breast Reconstruction. Susan G. Komen Foundation http://cms.komen.org/Komen/AboutBreastCancer/Treatment/3-5-8?ssSourceNodeId=99&ssSourceSiteId=Komen

Depression and Anxiety in Women With Early Breast Cancer. Burgess, Cornelius, et al, British Medical Journal. 2005. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=15695497

Signs and Symptoms of Depression. National Institutes of Health. http://www.nimh.nih.gov/health/topics/depression/men-and-depression/signs-and-symptoms-of-depression/index.shtml

Radiation Therapy & You. National Institutes of Health. http://www.cancer.gov/cancertopics/radiation-therapy-and-you/page2

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