Overview of Mastectomy
A mastectomy is a surgery to remove all the tissue in the breast. There are different kinds of mastectomies depending on what the patient needs. The most common type is a simple mastectomy. This is where all the breast tissue is taken out, including the skin and nipple area.
There are some versions of this surgery that save more of the breast skin or even the nipple for reconstruction afterwards. There is also a modified radical mastectomy that removes breast tissue as well as some lymph nodes in the armpit.
An older type of mastectomy, called a radical mastectomy, would also remove chest wall muscles, but this isn’t done often these days.
While mastectomies used to be the standard treatment for breast cancer, we now understand more about the disease. We have better treatments like chemotherapy and radiation, and we know that breast cancer can spread throughout the body. This means that these days, people with breast cancer often have less invasive surgeries like lumpectomies, which only remove a portion of the breast.
But mastectomies are still a key part of treating breast cancer and certain non-cancerous breast conditions. This overview has concentrated on the anatomy of the breast, reasons for getting a mastectomy, and the different types of mastectomies.
Anatomy and Physiology of Mastectomy
The female breast is located on the upper front chest area, stretching from the second rib at the top, down to a crease below the breast, and it goes from the middle of the chest toward the side of the body. Most of the breast sits on top of a major chest muscle, called the pectoralis major muscle, with other muscles forming the back boundary. To better understand its structure, the breast is divided into 4 sections based on the nipple’s location. The upper outer section has the most glandular tissue, with extra tissue extending into the armpit – known as the axillary tail of Spence. During surgeries to remove the breast, this extension should also be removed.
The breast shape is maintained by the suspensory ligaments, also known as Cooper ligaments, that attach the breast to the front of the chest wall. The breast contains 15 to 20 lobules, small glands that produce milk, with ducts leading to the nipple. Also, the breast holds varying amounts of fat and fibrous tissue, which can change due to age, reproductive status, genetics, and health conditions.
Blood flow to the breast is provided by several arteries. On the inner side, a major artery sends smaller arteries that provide blood to the breast. On the outer side, multiple arteries, including branches from an artery in the armpit, give blood supply. These wrap around the large chest muscle to reach the breast. Venous drainage- how blood leaves the breast- follows a similar pattern, mainly directed towards the armpit. Knowing about venous drainage is important for understanding how breast cancer can spread through veins and lymphatic channels – vessels that drain fluid from tissues.
The lymphatic system in the breast, a network of tiny vessels and nodes, usually drains into the armpit nodes about 95% of the time. Other drain pathways include inside the chest, lateral and medial intramammary regions, between the chest muscles, and under the collarbone.
Two main nerves could be at risk during breast removal surgery – the medial and lateral pectoral nerves. These nerves make the pectoral muscles work. If these nerves are damaged, it can lead to muscle weakness, which can affect shoulder strength and how the chest looks.
Why do People Need Mastectomy
Breast removal surgery, also known as a mastectomy, is a medical procedure that has various reasons behind it and these reasons can frequently change and aren’t always set in stone. The basic form of mastectomy is usually recommended for those patients who can’t undergo breast-conserving therapy due to particular reasons or for those who prefer to go for mastectomy. These reasons could include:
* Having multiple instances of ductal carcinoma in situ (a non-invasive cancer that is restricted to the ducts of the breasts) or invasive breast cancer
* A past medical history of radiation treatment to the chest or breast
* As a preventive measure to lessen the risk of breast cancer
* When cancer has reached the skin or the chest wall
* Large size of the tumor as compared to the breast, which makes it impossible to conserve the breast
* When the edges of the cancerous tissue still show signs of cancer even after multiple surgeries
* When a patient does not wish to go through radiation treatment
* As a means of relief in advanced breast cancer
Mastectomy is also a part of the management strategy for gender dysphoria, a condition where a person feels discontent with their biological sex and identifies more with the opposite gender.
In some cases, if the cancer does not involve the nipple and the surrounding dark skin (areola), a type of mastectomy known as nipple-sparing mastectomy could be the right option. However, this method isn’t suitable in circumstances like Paget’s disease – a rare type of cancer involving the nipple, visible cancer presence in the nipple-areola area, inflammatory breast cancer, or certain physical characteristics like a significantly drooping (ptotic) breast.
A modified version of a mastectomy, where certain lymph nodes are also removed, is the treatment of choice for certain breast cancer situations such as:
* Anaplastic breast cancer – a rare and aggressive form of breast cancer
* When the lymph nodes can be felt upon physical examination
* When more than 3 sentinel lymph nodes (the first few lymph nodes that are likely to spread from the primary tumor) are cancerous
* When there are recurrent tumors in the armpit region
* When the patient can’t undergo radiation treatment
* When the sentinel lymph node biopsy (a sampling procedure to check for cancer spread) isn’t successful.
When a Person Should Avoid Mastectomy
A mastectomy, which is a surgery to remove the whole breast, might not be suitable for some people. If a person is too weak or sick to have general anesthesia, which is a medication that makes you sleep during the operation, they may not be able to have this surgery.
Also, the surgery usually isn’t the best option for people with metastatic disease. This is a condition where cancer has spread to other parts of the body from the original tumor. In these cases, a mastectomy is less likely to make a big difference in the overall outcome because the disease is already widespread.
However, for a few patients who have severe symptoms from the cancer, and where it’s spread a lot in the local area but radiation treatment isn’t available, doctors sometimes consider a mastectomy to help reduce discomfort or other symptoms, even though it can’t cure the disease. This is known as palliative mastectomy.
Equipment used for Mastectomy
No unique surgical tools are needed for a mastectomy, which is a surgery to remove all breast tissue to treat or prevent breast cancer. However, having lighted retractors can be beneficial, especially in nipple-sparing mastectomies. A retractor is a surgical instrument that holds the wound open, allowing surgeons to see and work. When it’s lighted, it provides better visibility. In a nipple-sparing mastectomy, the nipple is kept intact while the rest of the breast tissue is removed.
Who is needed to perform Mastectomy?
Treating breast cancer involves many medical professionals working together as a team. Once the right type of surgery has been chosen, the team in the operating room will include a specially trained surgeon, an assistant, nurses who specialize in surgery, anesthesia doctors who will make sure you’re comfortable during the operation, and special technicians. If you’re planning on having breast reconstruction which means rebuilding the shape of the breast, this will usually be done by a surgeon who specializes in plastic surgery and it will require the right type of artificial implants.
Preparing for Mastectomy
Before having a surgery like a mastectomy (breast removal), your doctor will thoroughly examine any images or information about the tissues (histopathology) they’ve collected. Then, you’ll get antibiotics, typically within half an hour before the surgery. This is to prevent any possible infections.
Usually, doctors use general anesthesia during a mastectomy so you’ll sleep through the surgery. They might supplement this with regional anesthesia, or medicine that numbs a large region of your body. This type of anesthesia can also help with pain after the surgery and may reduce lingering pain as you recover.
You might also hear your doctor mention something like “thoracic epidural,” “paravertebral,” or “pectoral blocks”. These are different types of regional anesthesia.
Right before the surgery, you’ll be lying flat on your back with your arms spread out. If the doctor needs to examine the lymph nodes in your armpit (axillary lymph node dissection), they will prepare and cover the arm on the side where they’re doing the procedure. This way, they can easily move your arm and access your armpit if needed.
How is Mastectomy performed
There are several ways to perform a mastectomy, a surgery that removes all breast tissue to treat or prevent breast cancer. One type is a modified radical mastectomy, which combines a basic mastectomy with another procedure that removes lymph nodes under the arm.
The Making of the Incision
The surgery starts with making a cut into the skin. Then, the surgeon deepens the cut through the outer layers of the skin. To lessen the bleeding, the deeper skin layers are cut using a tool called electrocautery. The exact position and shape of the cut will depend on the type of mastectomy being done:
– A basic mastectomy usually involves making an oblong-shaped cut that includes the nipple and areola (the darker area around the nipple). This cut is positioned diagonally, making it easier to hide under clothes. The width of the cut depends on breast size, so that the breast can be closed properly after surgery.
– Skin-sparing mastectomy: Similar to a basic mastectomy but keeps most of the skin on the breast, enabling immediate breast reconstruction, a surgery done to make a new breast.
– Nipple-sparing mastectomy: In this type of mastectomy, the nipple and areola are not removed. There are several ways to make the cut, but the most common is along the lower curve of the breast.
– Modified radical mastectomy: The cut is similar to a basic mastectomy but may go into the armpit in order to reach the lymph nodes.
Raising Skin Flaps
Next, the skin is lifted up using special tools while pressure is applied to the breast tissue. The surgeon then separates the breast tissue from the overlying skin and the fat underneath the skin to form skin ‘flaps’. The surgeon must be careful to avoid making the flaps too thin or too thick. The flaps extend upwards to the second rib, downwards to the lower border of the chest muscle, outwards to the border of a muscle on the side of the back, and inwards to the edge of the breast bone.
Removing Breast Tissue From the Chest
The breast tissue is then lifted off the chest muscle, usually starting from the middle and moving out towards the sides and from top to bottom. Any arteries in this area are sealed or tied off to avoid bleeding. The tissue layer covering the chest muscle is included with the removed breast. Once the breast tissue has been removed, it is marked and sent for further examination.
Closing the Incision
Finally, the cut is closed. The exact way this is done depends on the type of mastectomy. For a basic mastectomy, the skin edges are brought together without pulling too tight or leaving it too loose. The top and bottom flaps should lie flat against the chest to prevent fluid from collecting. If there’s excess skin or soft tissue, it may need to be trimmed off.
For a skin-sparing or nipple-sparing mastectomy, an artificial breast is usually inserted immediately after surgery.
In a modified radical mastectomy, the lateral incision may be extended for axillary access, or a separate incision may be created for axillary lymphadenectomy, the removal of lymph nodes in the armpit area.
After the operation
Patients are usually kept in the hospital overnight for observation. Limiting movement of the arm on the operated side for 24 to 48 hours and using a tight wrap over the surgery site can reduce swelling, fluid collection, and pain. A variety of pain relievers are used to minimize the use of strong opioids. Muscle relaxants can be helpful, especially if tissue expanders (devices that stretch the skin to create space for a breast implant) were placed during surgery. Drains (tubes that remove fluid from the wound) are generally removed when the liquid output decreases to less than 30 mL over 24 hours.
Possible Complications of Mastectomy
A mastectomy is a medical operation where a part or all of the breast is removed, commonly used to treat or prevent breast cancer. Though generally safe and well-tolerated, like any surgery, it can have some potential complications.
One common concern after a mastectomy is called a seroma, which is when fluid accumulates in the area where surgery was performed. Almost all mastectomies cause some amount of seroma, but the severity can differ greatly among patients. There have been studies to identify what might affect seroma formation and how to limit it. For example, the risk can increase with techniques like using electrical currents to stop bleeding (called electrocautery) or moving the arm too early after surgery. Doctors might try different methods to reduce seromas, such as applying special sealants or suction drains, using tight bandages, or closing the cavity space with sutures (stitches). However, firm evidence about the effectiveness of these techniques is still lacking. Most seromas go away on their own over time, but they can sometimes cause problems like infection, discomfort, or damage to the skin. If a seroma becomes large and bothersome, it might need to be drained.
Another possible complication is wound infection which can happen in about 5% to 8% of cases. Most can be typically controlled with antibiotics taken orally. Deeper infections or infections of a seroma or hematoma (a solid swelling of clotted blood within the tissues) might need drainage either via needle or surgery. Therefore, it’s crucial to use appropriate antibiotics before surgery and maintain sterile environments during the operation to prevent these infections.
Bleeding or hematoma formation might occur for some patients soon after surgery. This can be quite minor or sometimes severe enough to necessitate another trip to the operating theater. The bleeding usually happens within a day after surgery and often stops spontaneously. If bleeding is more severe or continuous, it might require immediate medical attention or surgical treatment. Careful control of bleeding during surgery and the use of certain devices or substances can help reduce the risk of such bleeding complications.
One lesser-seen complication is flap necrosis, which is mostly found after certain types of mastectomies where the skin and nipple are initially spared with an implant placed during the surgery. Flap necrosis happens when the skin flap doesn’t receive enough blood supply (ischemia). This condition often resolves on its own, but extensive cases might need further surgery.
Lastly, ongoing pain is experienced by some patients more than two months post-surgery. Often described as similar to nerve pain, this chronic pain tends to be more common with more extensive surgeries. It can be alleviated through treatments such as physiotherapy, behavioral therapy, and certain types of medications. In some cases, regional anesthesia given before the operation might help reduce the probability of this chronic pain.
What Else Should I Know About Mastectomy?
Since the late 1800s, when Halsted first introduced the concept of radical mastectomy (complete removal of the breast), there have been many significant improvements in how we treat breast cancer. One of these has been a movement towards preserving as much of the breast as possible. Several studies have taken a closer look at how effective breast-conserving surgery (surgery that removes the cancer but leaves as much of the breast as possible) is in comparison to standard techniques for removing the entire breast.
Alongside surgery, additional treatments have also been developed and implemented which have further improved the outcomes for patients. These include radiation and systemic treatments, such as chemotherapy and endocrine therapy (hormone therapy), which have helped to reduce the need for complete removal of the breast (mastectomy). However, it is important to remember that in some cases, mastectomy is still the best treatment approach and remains a crucial element of breast cancer care.
This is mainly important in regions where there’s limited access to treatments like radiation therapy and newer forms of chemotherapy. In such places, mastectomy is still the primary method for treating breast cancer.
