Mastectomy: Types, Procedure, Recovery, and What to Expect

What Is a Mastectomy?

A mastectomy is a surgery where doctors remove all or part of the breast. It is mainly done to treat or help prevent breast cancer. The word mastectomy comes from “Mastos”, a Greek word meaning breast, and “Ectomy”, a Latin word meaning removal or excision. Mastectomies are very common in the United States. Every year, doctors perform more than 100,000 mastectomy surgeries.

What Are the Types of Mastectomy?

There are different types of mastectomy surgeries:

• Single (Unilateral) Mastectomy: In this surgery, doctors remove one breast.

• Double (Bilateral) Mastectomy: In this surgery, doctors remove both breasts.

• Partial Mastectomy: In this procedure, doctors remove the tumor along with a small margin of surrounding healthy tissue, while preserving most of the breast.

• Simple (Total) Mastectomy: Doctors remove the entire breast tissue, including the nipple and areola. The chest muscles are left in place. Usually, the lymph nodes are not removed unless a separate biopsy is needed. This is the most commonly performed mastectomy.

• Radical Mastectomy: This is a more extensive procedure in which doctors remove the entire breast, including the areola, nipple, and skin, along with the lymph nodes of the underarm and the chest wall muscles beneath the breast. This surgery was first developed in the late 1800s by an American doctor named William Stewart Halsted.

• Modified Radical Mastectomy: Doctors remove the whole breast, including the nipple, areola, and skin, along with most or all axillary (underarm) lymph nodes. The chest muscles are usually kept intact.

• Nipple Sparing Mastectomy: Doctors remove the breast tissue and milk ducts, but keep the nipple, areola, and most of the breast skin.

• Skin-Sparing Mastectomy: Doctors remove the breast tissue, nipple, and areola, but preserve most of the natural breast skin. This can help during breast reconstruction surgery.

• Prophylactic Mastectomy: It is a surgery where doctors remove one or both healthy breasts to greatly reduce the risk of developing breast cancer. This surgery may be done for people who have a high risk of breast cancer, such as those with genetic mutations like BRCA1 (breast cancer gene 1) or BRCA2 (breast cancer gene 2), or people with a strong family history of the disease.

Mastectomy vs Lumpectomy

What Are the Anatomical and Physiological Considerations in Mastectomy?

Anatomy of the Breast:

• The location of the breast is on the front wall of the thorax and overlays the major pectoralis muscle.

• The adult female breast's upper boundary approaches the second or third level of the rib and then expands lower to the crease (spanning from the 2nd to the 6th rib).

• The sternal boundary is the median border, and the breast advances to the mid-axillary line laterally.

• About the breast, two-thirds overlap the major pectoralis muscle, and the remaining portion overlaps the serratus anterior and the top area of the oblique abdominal muscles.

• The top area of the breast expands towards the top and laterally, that is, to the axilla, and it is referred to as the axillary tail of Spence.

• The breast is divided into four quadrants. This helps in the examination and documentation of findings on breast imaging, too. The four quadrants are:

  • Upper outer.

  • Upper inner.

  • Lower outer.

  • Lower inner.

Components of the Breast:

The components of the breast include:

A. Glandular Components:

• Lobules: These are small glands responsible for producing milk.

• Lobes: The breast has about 15 to 20 sections called lobes. They are arranged around the nipple like the spokes of a wheel.

• Milk Ducts: These are tiny branches that carry milk from the lobules to the nipple.

B. Surface and Supporting Structures:

• Nipples: The nipple is the raised part in the center of the breast where milk comes out. It has many nerve endings, so it is very sensitive.

• Areola: The areola is the darker-colored skin around the nipple.

• Adipose Tissue: This is fatty tissue that fills the spaces between the lobules and ducts and helps give the breast its shape.

• Cooper’s Ligaments: These are strong bands of connective tissue that help support the breast and attach it to the chest wall.

• Pectoralis Muscle: This is the large chest muscle located underneath the breast and above the ribs.

C. Vascular and Lymphatic Systems:

Blood vessels:

• The medial part of the breast receives its blood supply from the internal mammary artery through multiple perforating branches.

• The lateral part is supplied by the posterior intercostal vessels, lateral branches, and branches of the axillary artery, including the superior thoracic artery and the pectoral branches of the thoracoacromial artery.

• The arteries and veins pass along the upper and lateral borders of the pectoralis major muscle to supply the breast.

Venous Supply:

• The venous drainage of the breast follows the arterial supply and mainly drains toward the axilla. It occurs through the internal thoracic vein, axillary vein branches, and perforating branches of the intercostal veins.

Lymphatic Drainage:

Most breast lymph drains through the axilla. Axillary nodes are divided into levels:

• Level I: Lateral to pectoralis minor; includes outer mammary, axillary vein, and scapular nodes.

• Level II: Deep to pectoralis minor; central nodes may involve subclavicular nodes.

• Level III: Medial/superior to pectoralis minor; includes subclavicular nodes.

Rotter’s nodes drain to central or subclavicular nodes and may skip metastasis. Other drainage pathways include the internal mammary chain, intramammary nodes, interpectoral nodes, and subclavicular node

Physiological Considerations in Mastectomy

• Pain and Nerve Damage: Surgery can affect nerves, causing pain, numbness, tingling, or a “phantom breast” feeling. Some patients may also develop post-mastectomy pain syndrome (PMPS). Medicines, gentle exercises, and therapy can help.

• Shoulder Function: Surgery and scar tissue may make the shoulder weak or stiff. Stretching exercises and physical therapy help improve movement and strength.

• Lymphatic System Disruption: Removing underarm lymph nodes can cause swelling (lymphedema) in the arm or chest and increase infection risk. Exercise, skin care, and physiotherapy can help manage this.

• Wound Healing: Healing can be slow after surgery, and fluid may collect under the skin. Good wound care and hygiene are important for recovery.

• Psychological and Emotional Impact: Losing a breast can affect body image, confidence, and feelings. Support, counselling, and reconstruction options can help people feel better.

What Are the Indications of Mastectomy?

• Breast Cancer: Mastectomy is often done to treat breast cancer. Treatment may also include medicines, radiation, or chemotherapy. Many people with breast cancer live long lives after treatment. Overall, about 85 % to 90 % of people with breast cancer survive for at least 5 years after diagnosis.

• Locally Advanced Breast Cancer: If the cancer is very large or has spread to nearby tissues, doctors may remove the whole breast.

• Inflammatory Breast Cancer: This is a rare and fast-growing type of breast cancer. A mastectomy is usually needed after chemotherapy.

• Multicentric or Multifocal Disease: Sometimes cancer is found in different parts of the same breast. In this case, mastectomy may be the best choice.

• Recurrent Breast Cancer: If breast cancer returns after earlier treatment like lumpectomy and radiation, mastectomy may be needed.

• Large Tumor Relative to Breast Size: If the tumor is large compared to the breast, removing only the lump may not look or work well.

• Contraindications to Radiation Therapy: Some people cannot safely receive radiation, such as during pregnancy or after previous chest radiation.

• Paget’s Disease of the Breast: This is a rare type of breast cancer that affects the nipple and the darker skin around it.

• Prophylactic Mastectomy: Some people choose mastectomy to lower the chance of getting breast cancer in the future, especially if they have a high risk.

• Phyllodes Tumor: It is a rare breast tumor that grows in the breast tissue and may require surgery.

• Male Breast Cancer: Men with breast cancer often have a mastectomy because there is only a small amount of breast tissue.

• Patient Preference: After learning about all treatment options, some people choose mastectomy because they feel it is the best choice for them.

What Are the Contraindications of Mastectomy?

These include:

• Uncontrolled severe comorbid illness that makes the patient unfit for anesthesia or major surgery

• There is an active infection in the breast area.

• Patient refusal of surgery.

• Severe mental or memory problems make it hard for the patient to understand or follow treatment instructions.

• Inflammatory breast cancer without prior neoadjuvant therapy, since standard management usually begins with systemic treatment before surgery

• Distant metastasis is not an absolute contraindication to mastectomy. Surgery may still be performed for palliation, hygiene, bleeding control, pain relief, or fungating tumors (toilet mastectomy). However, purely curative-intent mastectomy is generally not indicated in widespread metastatic disease.

• Progressive locoregional disease where immediate surgery is unlikely to achieve control; neoadjuvant chemotherapy, endocrine therapy, or radiotherapy may be required first

What Are the Risks and Complications of a Mastectomy?

Immediate Surgical Risks:

• Infection.

• Hematoma (a painful collection of blood under the wound).

• Seroma (clear fluid can build up under the skin where the breast was removed).

• Flap necrosis.

Long-term Complications:

• Lymphedema (a condition causing localized swelling in arms or legs).

• Post-mastectomy pain syndrome (PMPS) (long-lasting burning, tingling, or shooting pain in the chest, armpit, or arm because nerves were irritated during surgery).

• Shoulder stiffness.

• Chest numbness.

What Is the Procedure Involved in a Mastectomy?

Procedure includes:

1. First, you will go to the operating room. An intravenous (IV) line is inserted to give medications and fluids. General anesthesia is administered so the patient remains fully unconscious and pain-free during the procedure.

2. The chest and breast area are cleaned with a sterile antiseptic solution to reduce the risk of infection. A local anesthetic may also be injected to improve post-operative pain control.

3. The surgeon makes a surgical incision over the breast. The location and size of the incision depend on the type of mastectomy being performed.

4. The breast tissue is carefully dissected away from the underlying pectoral muscles and removed.

5. Since breast cancer may spread through the lymphatic system, the surgeon may perform a sentinel lymph node biopsy (a procedure that helps doctors check if cancer has spread to nearby lymph nodes) or an axillary lymph node dissection to remove lymph nodes from the armpit (axilla). These lymph nodes are sent for pathological examination to detect cancer cells.

6. If immediate breast reconstruction is planned, a plastic surgeon may begin reconstruction after the mastectomy. Reconstruction may involve placement of a tissue expander, breast implant, or autologous tissue taken from another part of the body.

7. One or more surgical drains are placed near the incision site. These flexible tubes help remove blood and fluid accumulation during healing.

8. Finally, the incision is closed using sutures, surgical staples, or adhesive strips. The area is covered with a sterile dressing or surgical bra to protect the wound and support healing.

9. A mastectomy surgery can take about 1 to 8 hours. It may take longer if the doctor also rebuilds the breast during the same surgery.

10. After a mastectomy, some patients go home the same day, while others may stay in the hospital for about 3 to 5 days.

When Is a Second Opinion Essential?

Getting a second opinion before a mastectomy can help patients feel more confident about their diagnosis and treatment plan.

• The test results are confusing or hard to understand.

• Different doctors give different treatment advice.

• A patient is thinking about removing both breasts (bilateral mastectomy).

• The patient is choosing between a lumpectomy and a mastectomy.

• The cancer is rare, serious, or has spread to nearby lymph nodes.

• The patient wants to learn about other treatments, clinical trials, or newer surgery options.

• The patient has worries about the risks, benefits, or possible side effects of surgery.

Conclusion:

A mastectomy is an operation where doctors remove one or both breasts to treat breast cancer or help stop cancer from happening. To do this safely, doctors need to understand the breast, the lymph nodes, and how the body changes after surgery.

A mastectomy can help people live longer and control cancer better, but it can also cause some problems. These may include pain, swelling in the arm called lymphedema, trouble moving the shoulder, and feeling sad or worried about changes in the body.

If you are thinking about having a mastectomy and want to know more, you can talk to a general surgeon. They can explain the surgery and answer your questions.

Key Takeaways:

• A mastectomy is an operation where doctors remove breast tissue to help treat or prevent breast cancer.

• There are different kinds of mastectomy surgeries. Some remove only the breast, while others remove nearby tissue too.

• After surgery, some people choose to have breast reconstruction.

• Emotional support and counseling are important because mastectomy can affect body image and mental health.

• After a mastectomy, how long someone lives mostly depends on how early the cancer is found, not on which surgery they have.

• Across early-stage cases, the 10-year survival rate after a single mastectomy is approximately 79% to 83%.