Breast Removal (Mastectomy)

What is a mastectomy?

Mastectomy is the surgical procedure for removing a breast when invasive cancer is found in the breast.

When is it used?

Mastectomy is the first treatment choice when a cancer is too large to be removed without removing the entire breast. Mastectomy is also necessary when there is more than 1 cancer in the breast.

Sometimes a large cancer may shrink with chemotherapy so it can be removed without removing all of the breast. This procedure is called a lumpectomy, which is removal of just the tumor with some surrounding breast tissue. Talk with your healthcare provider about this possibility.

Lymph node removal is usually done at the time of either lumpectomy or mastectomy. Your surgeon may advise you to have a procedure called sentinel lymph node biopsy in order to avoid removing all the underarm lymph nodes. This procedure involves injection of a special dye around the cancer and removal of underarm lymph nodes that are affected by the dye (usually 1 to 3 nodes). Your surgeon will go ahead with the lumpectomy or mastectomy but it will take 2 to 3 days to determine if the lymph nodes contain cancer. If cancer is found in these sentinel lymph nodes, then all of the lymph nodes in your armpit will be removed with a second surgical procedure called axillary dissection. The advantage of sentinel lymph node biopsy is that you may be able to avoid removal of all of the lymph nodes. The disadvantage is that you may have to have a second procedure to remove all of the lymph nodes if cancer is found in the nodes. Make sure you discuss this choice with your surgeon.

Different types of mastectomies are:

• Total (simple) mastectomy: The surgeon removes the whole breast. Some lymph nodes under the arm may also be removed. A total mastectomy might be used for a larger cancer that cannot be removed with lumpectomy. If a sentinel lymph node biopsy has confirmed that cancer has not spread to the lymph nodes, the nodes will not be removed.
• Modified radical mastectomy: The breast and most or all of the lymph nodes under the arm are removed. Often, the lining over the chest muscles is removed. A few small chest muscles also may be taken out to make it easier to remove the lymph nodes.

Mastectomy can be avoided in some cases by using chemotherapy to shrink a large cancer to a size that can be removed with a lumpectomy.

You should ask your surgeon about your choices for treatment. Take notes as you talk since there are many possible combinations of surgical treatment. Also, it is helpful to have a family member or friend listen to the choices with you.

How do I prepare for this procedure?

Before you have a mastectomy, discuss with your surgeon the options for breast reconstruction. This is a plastic surgery procedure to rebuild the shape of the breast. It may be done at the same time as a mastectomy or later. If you are not sure, talk with your surgeon about options for reconstruction later.

Plan for your care and recovery after the operation. Find someone to drive you home after the surgery and stay with you for the first night or two. Allow for time to rest and try to find people to help you with your day-to-day duties. Ask your healthcare provider if there is a breast cancer support group you could contact. Reach To Recovery (phone: 800-ACS-2345) is an example of such a group. They can help you find and talk with other women who have had a mastectomy. They can also talk to you about simple, practical ways to aid your recovery.

Follow your provider's instructions about not smoking before and after the procedure. Smokers heal more slowly after surgery. They are also more likely to have breathing problems during surgery. For these reasons, if you are a smoker, you should quit at least 2 weeks before the procedure. It is best to quit 6 to 8 weeks before surgery.

If you need a minor pain reliever in the week before surgery, choose acetaminophen rather than aspirin, ibuprofen, or naproxen. This helps avoid extra bleeding during surgery. If you are taking daily aspirin for a medical condition, ask your provider if you need to stop taking it before your surgery.

Follow any other instructions your provider gives you. Eat a light meal, such as soup or salad, the night before the procedure. Do not eat or drink anything after midnight or the morning before the procedure. Do not even drink coffee, tea, or water.

What happens during the procedure?

You are given a general anesthetic. A general anesthetic relaxes your muscles and puts you to sleep. It prevents you from feeling pain.

The surgeon makes a cut (incision) over the breast and lifts the skin away from the breast tissue. The surgeon separates this tissue, including the nipple, from the muscle that lies between the breast and rib cage. Once the surgeon has removed the breast and tissue around it, the skin flaps are sewn in place and a tube is temporarily put under them to drain fluid. If the breast is rebuilt, these skin flaps are used in the reconstruction.

The surgeon may also remove tissue under the armpit. This tissue contains lymph nodes that may also have cancer.

What happens after the procedure?

• You may stay in the hospital about 24 hours. Talk with your provider about the plan for your discharge from the hospital. Ask how to take care of yourself at home during the first days after surgery.
• For 5 to 7 days you will have 1 or 2 drains that remove extra fluid from the area of the surgery. Your provider will tell you how to care for these tubes and the attached bottles and when to return for removal of the drains.
• Your surgeon will give you medicine for pain when you leave the hospital.
  • Usually a nonsteroidal anti-inflammatory medicine (NSAID), such as ibuprofen, will relieve most of the pain. It is easier to prevent pain with pain medicine than to relieve it once it gets severe. Take the anti-inflammatory medicine even if you do not have pain for the first day or two. NSAIDs may cause stomach bleeding and other problems. These risks increase with age. Read the label and take as directed. Unless recommended by your healthcare provider, do not take for more than 10 days for any reason.
  • A prescription drug, such as codeine, may be used for more severe pain. Use the codeine at the first sign of pain not relieved by the anti-inflammatory drug.
• The breast area will heal fully in about 3 to 4 weeks.
• Follow your healthcare provider's recommended schedule for checkups.
• A mastectomy is usually followed by hormone therapy, chemotherapy, or both.
• If you were regularly taking estrogen hormone medicine before the surgery, ask if you should keep taking it after the surgery. Estrogen is usually stopped after breast cancer surgery, and often an anti-estrogen medicine is prescribed. Ask about this and all other medicines that you were taking before surgery. Find out when and whether you should start taking them again.

What are the benefits of this procedure?

It may provide your best chance to survive breast cancer.

What are the risks of this procedure?

• There are some risks when you have general anesthesia. In older adults, confusion can occur. Discuss these risks with your healthcare provider.
• Fluid may collect under the skin flaps after your drains are removed. The surgeon will remove the fluid with a needle and syringe.
• Nerves in the area of the surgery are damaged. As a result, the underside of your arm may be numb. After the surgery you may have trouble moving some of your shoulder muscles because of tenderness. Special exercises will help you regain normal movement of your shoulder.
• You may develop arm swelling, called lymphedema. This is caused by interference with normal lymph drainage from the arm. Surgery alone usually does not cause this condition. It can occur when you have a mild infection in the arm on the mastectomy side, even years later. Ask your provider about how you can help avoid this problem. It is important to report any infection in the arm or hand on the side of the mastectomy because early treatment may prevent lymphedema.
• There is a chance a lumpy scar will develop. This is called a keloid. Tell your provider if you have other scars that have healed this way.
• This procedure may not remove all of the cancer cells and further treatment may be necessary.
• The cancer may come back.
• You may have infection or bleeding.

You should ask your healthcare provider how these risks apply to you.

When should I call my healthcare provider?

Call your provider right away if:

• You have a fever of 100°F (37.8°C) or higher.
• The area of the incision is red.
• You have unusual drainage from the incision.
• You have pain that gets worse.
• Fluid collects under the skin flaps.

Call during office hours if:

• You have questions about the procedure or its result.
• You want to make a follow-up appointment.