Generality
Mastectomy is the surgical removal of a breast; this operation, in most cases, is necessary on women suffering from breast cancer or at high risk of developing it.
There are different operating procedures: the choice of one method rather than another is up to the surgeon and depends on the severity of the neoplasm.
The results are satisfactory, provided that the diagnosis is early and that no serious complications arise (which, in any case, are quite rare episodes).
Removing one or both breasts can cause various discomforts, especially in women. For this reason, it is also possible to undergo breast reconstruction surgery.
What is a mastectomy?
Mastectomy is the surgical procedure that is used to remove, totally or only partially, a breast (or mammary gland).
The double mastectomy (or bilateral mastectomy) is the same operation, however, performed on both breasts.
All the details, relating to when it is put into practice and how it is carried out, will be dealt with in the next chapters.
According to an Italian statistic, between 2001 and 2008, 117,762 mastectomies were performed (on average, just over 14,500 each year).
BREAST RECONSTRUCTION
Those who undergo a mastectomy have the opportunity to have their breasts reconstructed with a specific intervention, in which a prosthesis (made of silicone and / or organic material) is used.
Breast reconstruction, as we will see, is very important to alleviate the aesthetic and psychological discomfort that a mastectomy could cause in a female person.
When you do
Mastectomy is reserved for people with breast cancer or who are at high risk of developing it (preventive mastectomy).
Usually, it is women who undergo mastectomy, but it is not excluded that men may also need it, as breast cancer is not an exclusively female neoplasm.
BREAST CANCER EPIDEMIOLOGY
Breast cancer (or breast cancer) is the most frequent cancer in women: it represents, in fact, as much as 29% of all cancers that affect women.
It has been calculated that approximately one in eight women get sick and that for 16% of patients the outcome is bad.
As mentioned, it is not an exclusive pathology of the female sex, as it can also affect men, albeit very rarely (it represents only 1% of all male cancers).
MASTECTOMY FOR THE TREATMENT OF BREAST CANCER
Mastectomy, for the removal of breast cancer, is recommended when:
- The mass of cancer cells (or tumor mass) is large and disproportionate to the affected breast.
- The tumor has formed in several places on the breast.
- A preneoplastic lesion, called ductal carcinoma in situ (DCIS), has invaded a large part of the breast.
Once the neoplasm has been diagnosed, the tumor must "be treated immediately, because, otherwise, there is a real risk that it may expand and spread to other parts of the body (metastases), with dramatic results.
PREVENTIVE MASTECTOMY
All those women who have not yet developed breast cancer, have been assessed to be at high risk, can undergo a preventive double mastectomy.
Figure: Famous American actress Angelina Jolie recently revealed that she had a preventive double mastectomy because she discovered she was predisposed to breast cancer.
The danger of contracting the neoplasm is measured by means of a "genetic analysis, which concerns the BRCA1, BRCA2 and p53 genes. After years of scientific studies, in fact, it has been ascertained that one or more alterations (or genetic mutations) of these three genes predispose notably breast cancer.
According to a "statistical survey, high-risk women, if they decide to undergo a preventive mastectomy, reduce the chances of getting sick by 90%.
Preventive mastectomy, for those not considered at risk, is not a recommended intervention.
It is highly recommended that genetic testing be obtained whenever there is a family history of breast cancer.
Pre-operative phase
Some breast cancers, when they are very extensive, require preoperative sessions of chemotherapy and hormone therapy. These pharmacological treatments are aimed at reducing the tumor mass and consequently making future mastectomy surgery less invasive.
Chemotherapy aims to kill all rapidly growing cells, including cancer cells.
Hormone therapy, on the other hand, aims to block the activity of estrogen hormones, which seem to be one of the main causes of breast cancer growth.
The success of chemotherapy and hormone therapy can be instrumental in making mastectomy more effective.
INFORMATION ABOUT THE INTERVENTION
A member of the treating medical staff has the task of explaining, to or to the patient, the entire surgical procedure, including that of breast reconstruction (if any), to convince him of the vital importance of the operation. This preoperative aspect should not be neglected at all, because, very often, the patients are not very serene and fear the mastectomy precisely because of the consequences it has on the aesthetic aspect.
In addition, it is very important to follow the following guidelines to the letter:
- On the day of the mastectomy, go fasting from the previous evening, as general anesthesia is required.
- Stop smoking, to reduce healing times. In fact, smoking alters blood flow, consequently reducing the wound healing process.
PREOPERATIVE CHECK-UP
Like any surgery, mastectomy, before being performed, requires a complete check-up of the patient's health conditions. During this meticulous check, it is also analyzed how the tumor has responded to chemotherapy and hormone therapy (if these fall within the therapeutic plan).
Procedure
There are different types, or methods, of mastectomy; the choice of one type rather than another mainly depends on the "area of the breast affected by the tumor and the severity of the latter". Very serious neoplasms require a "massive removal, not only of the mammary gland, but also of the nearby axillary lymph nodes and of the pectoral muscles (pectoralis major and pectoralis minor), on which the breast rests; vice versa, those circumscribed and small in size allow, to the surgeon, to act in a less invasive way.
In any case, whatever the type of surgery practiced, general anesthesia is required, with which the patient falls asleep, and a horizontal or diagonal surgical incision on the breast, which will then leave a scar.
GENERAL ANESTHESIA
General anesthesia involves the use of anesthetics and pain relievers, which make the patient unconscious and insensitive to pain.
The administration of these drugs, carried out intravenously and / or by inhalation, takes place before and for the entire duration of the surgery.
In fact, once the operation is completed, the pharmacological treatment is stopped to allow the patient to regain consciousness.
Upon awakening, the operated individual is likely to feel confused: this is a normal effect of anesthetics, which gradually disappears within a few hours.
TYPES OF MASTECTOMY
The most important and most practiced intervention methods are:
- Standard mastectomy. The entire breast is removed, including areola and nipples, but not the axillary lymph nodes and pectoral muscles (with rare exceptions). Although it is a rather invasive operation, it is very popular because it is effective. The standard mastectomy is also a good solution for the preventive mastectomies, while it is not among the most suitable if a breast reconstruction is planned.
- Skin-sparing mastectomy. The entire mammary gland is removed, with areola and nipple, but the surrounding skin lining is "spared" (as far as possible). This method is applied when there is "the" intention of reconstructing the operated breast.
- Subcutaneous mastectomy. It involves the removal of the mammary gland, but not the areola and nipple. Most preventive mastectomy operations, combined with breast reconstruction, are performed according to this method.
- Radical mastectomy. Also called Halsted's mastectomy, it is the most invasive method among those possible. In fact, the removal of the entire mammary gland (including areola and nipples), of the surrounding skin, of the axillary lymph nodes and of the pectoral muscles is envisaged. It is practiced in advanced cases of breast cancer, in which the tumor mass has significantly expanded A radical mastectomy does not allow for breast reconstruction.
- Modified radical mastectomy. It consists in the "removal" of the entire mammary gland, including areola and nipples, and of the nearby axillary lymph nodes. Unlike radical mastectomy, it "spares" the pectoral muscles and allows for breast reconstruction. However, this surgery cannot be done at the same time as the mastectomy.
REMOVAL OF LYMPH NODES
Figure: the scar, following the surgical incision (in this case diagonal) on the breast. From the site :irurgplasticadrcicogna.com
Breast tumors, at an advanced stage, can also affect the axillary lymph nodes (about twenty), present in the vicinity. When this occurs, it is necessary to remove them, because otherwise they could spread the neoplasm to the rest of the body (metastasis).
To find out if the axillary lymph nodes have been contaminated by the tumor, the doctor carries out specific diagnostic tests before surgery.
Their removal involves an "incision in the armpit", which is closed again at the end of the mastectomy.
Breast reconstruction
The reconstruction, when it is foreseen and it is possible to carry it out, can be carried out in the following ways:
- With a silicone prosthesis
- With a tissue transplant from another part of the body (usually the abdomen or lower back)
- With a silicone prosthesis combined with a tissue transplant.
Breast reconstruction can be performed either during the mastectomy or at a later time.
If it is carried out at a later time, the patient can resort to the use of a temporary prosthesis, that is an artificial breast to be placed inside the bra.
Post-intervention phase
In most cases, the mastectomy patient recovers completely and without complications within 3-6 weeks.
During this time, it is advisable to follow your doctor's advice to the letter, so that everything goes smoothly and smoothly.
RECOVERY
The mastectomy operation requires hospitalization for at least one day. The night or nights spent in the hospital are for precautionary purposes, because, if complications arise, the medical staff is ready to intervene.
For very invasive mastectomies, due to a severe tumor, the hospitalization can be up to 3 or 4 days.
AFTER THE OPERATION
Upon awakening, the patient may feel dizzy: these are the after-effects of general anesthesia, which generally last a few hours or until the following day.
It is also very likely that the operated person feels pain: in these cases, if the painful sensation is very intense, it is good to report it to the medical staff, who will provide "adequate pain-relieving treatment."
Finally, it is quite common for the patient to be fed by infusion, as the latter may have difficulty eating certain foods.
WOUND REMARGINATION
Wound drainage. Before bandaging the wound, the surgeon inserts small tubes into the operated area to drain any fluid that may accumulate after the operation. This liquid, if not eliminated, could cause painful swelling or infection. The permanence of these drainage tubes is variable: from 24 hours to several days, depending on how invasive the mastectomy was.
Bandage. The bandage serves to protect the wound and to prevent it from becoming infected. Generally, it should be kept for at least two days, but, in some cases, even for a week. Hygiene is very important.
Stitches. If the sutures are resorbable, it is not necessary to remove them, as they disappear on their own. If, on the other hand, they are not absorbable (because they are made of metal), you have to wait 7 to 10 days before having them removed.
Scar. Once the scar has healed, it may be more or less evident, depending on how invasive the operation was. With immediate reconstruction from the breast, its appearance can also be improved in an appreciable way; however, it should be remembered that not all patients can undergo such surgery. For these, there is "another" solution: cosmetic surgery. The results are variable: from very good to little more than fair.
Not smoking. As a final point, remember not to smoke, as smoking slows down and alters the healing and healing process of the wound.
AT HOME
Once home, it is essential to observe a period of complete rest. After that, it is good to start doing light physical exercises for the arm (the one on the side of the operated breast), to promote blood circulation. In fact, the scarce use of the limb could cause thrombosis episodes.
For any information on what to do or not to do after discharge, you can contact the medical staff, who during the hospitalization has however already reported all the most important precautions.
The return to work depends on how the recovery proceeds.
Activities to avoid in the first 3-4 weeks:
- To drive. Recovery only needs to happen once you feel completely recovered
- Lift weights or perform repetitive activities, such as ironing or vacuuming
- Swimming or contact sports
Risks
It is very rare for a mastectomy to cause serious complications. Usually, in fact, the intervention, as well as the post-operative phase, proceeds without particular hitches.
It is in the norm:
- Feeling pain in the first days after the operation.
- The formation of seroma, which is a subcutaneous effusion of lymphatic fluid (or lymph). This appears in the operated area and has the appearance of a swelling. Generally, it resolves spontaneously, but if this does not happen it can be drained by the doctor, with a syringe.
- The formation of a scar at the point where the surgical incision took place.
Instead, you should contact your doctor if:
- The wound becomes infected. The signs for recognizing an infection are: redness, pain and swelling that do not go away (indeed they get worse) and loss of fluid.
- Lymphedema forms in the arm (on the operated breast side). This disorder, which consists of an abnormal accumulation of lymph, is due to the removal of the axillary lymph nodes. The affected arm swells noticeably and hardly goes unnoticed. The formation of lymphedema is not always immediate: in some cases, in fact, it can also occur after months or years.
- The reconstructed breast shows signs of infection. It is possible that the implant, used for the reconstruction of the operated breast, becomes infected; if this happens, it must be removed.
Results
Thanks to recent advances in surgical techniques, mastectomy guarantees excellent results: in fact, healing is a "more than concrete" hypothesis, the risks associated with the surgery are limited and remission takes place very quickly.
However, the success of the operation on the tumor also depends on how severe the tumor itself is and on the diagnosis, whether early or late. In other words, advanced breast cancer, even if undergoing an exemplary mastectomy, has however many chances of a bad outcome.
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