What To Expect Before, During, And After A Mastectomy
When it comes to breast cancer prevention, treatment, and recovery, mastectomies play an important role — but the surgery is often deeply personal and emotional.
Here, The AEDITION speaks with two preeminent reconstructive surgeons about the procedure.
EXPERT PERSPECTIVE – Samantha Stone10.01.2019
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Mastectomy – What to expect
Since 1985, October has served as Breast Cancer Awareness (BCA) Month — a period devoted to educating the public on the disease that, according to the Centers for Disease Control and Prevention (CDC), is the second most common form of cancer in women, regardless of race or ethnicity. Men can also be diagnosed with breast cancer (albeit at a much lower rate), and The AEDITION is devoting much of its coverage this month to BCA, from expert guides to mastectomies and reconstructive breast surgery to powerful patient perspectives and roundups of products that give back.
According to the U.S. Department of Health and Human Services’ National Cancer Institute, 268,600 women will be diagnosed with breast cancer in 2019. There will also be an estimated 2,670 new cases of invasive breast cancer reported in men. When it comes to breast cancer prevention, treatment, and recovery, mastectomies play an important role, but the surgery is deeply personal and emotional. Approaching the procedure and all the decisions that accompany it armed with the best information is key, and The AEDITION here to help.
WHAT IS A MASTECTOMY?
A mastectomy is a surgery to remove tissue from one or both breasts in an effort to eliminate cancer cells or prevent cancerous tumors from forming in the future. Not be confused with a lumpectomy, which extracts lumps of cancerous cells from the breast without removing all of the surrounding tissue, a mastectomy involves the removal of all the breast tissue. While a lumpectomy is a less invasive breast cancer treatment option — both physically and emotionally — it is not always an aggressive enough solution.
WHAT ARE THE TYPES OF MASTECTOMIES?
Whether the procedure is being used for breast cancer prevention or treatment, there are four main types of mastectomies that can be performed unilaterally (removing one breast) or bilaterally (removing both breasts). Which technique is chosen often depends on a patient’s body and diagnosis.
Simple (a.k.a. Total) Mastectomy: A surgeon removes the entire breast (including the skin, tissue, nipple, and areola) but does not perform a lymph node dissection.
Radical Mastectomy: Reserved for rare cases when the cancer has spread into the underlying muscles, the procedure removes the breast, three levels of underarm lymph nodes, and the chest muscles under the breast. In a more common modified radical mastectomy, the breast tissue and lymph nodes are removed but the muscles of the chest wall remain.
Skin-Sparing Mastectomy: For patients who wish to combine a mastectomy with breast reconstruction surgery, this technique seeks to preserve as much of the breast skin as possible — regardless of whether a simple or radical procedure was performed.
Nipple-Sparing Mastectomy: Surgeons remove the breast tissue but keep the skin, nipple, and areola to aid the reconstruction process.
DO WOMEN CARRYING THE BRCA1 OR BRCA2 GENE NEED A PROPHYLACTIC (I.E. PREVENTATIVE) MASTECTOMY?
About 12 percent of women in the general population will develop breast cancer in their lifetime. Of women carrying BRCA1 or BRCA2 mutations, an estimated 72 and 69 percent will develop breast cancer by the age of 80, respectively.
While the decision is a personal one, National Cancer Institute data shows that women with either gene who undergo a prophylactic (a.k.a. preventative) mastectomy reduce their risk of breast cancer by 95 percent. Women who have a strong family history of breast cancer, meanwhile, see their risk mitigated by up to 90 percent with the procedure.
Nashville-based board certified plastic surgeon Jacob Unger, MD, who specializes in reconstructive surgery following trauma and cancer, answers some of the most common questions that accompany mastectomy procedures.
The AEDITION: Is a mastectomy a 100 percent guarantee to be breast cancer-free?
Dr. Unger: No, there is always a chance of recurrence. No surgery can guarantee removal of every single cell of breast tissue. Recurrence rates are usually between one and five percent, depending on multiple factors for each individual person.
The AEDITION: Can men get breast cancer and need a mastectomy?
Dr. Unger: Yes, men can absolutely get a mastectomy. Depending on the size of the man’s breast, the scar pattern will vary, but the goal is to create a flat chest with aesthetically acceptable scar patterns that are hopefully hidden in the creases of the male pectoral muscles, if it all possible.
The AEDITION: When would someone get a unilateral versus bilateral mastectomy?
Dr. Unger: There are times where bilateral mastectomy is indicated from the cancer standpoint — such as if you have cancer in both breasts or have a particular type of cancer that leads to a very high risk of having cancer in the opposite breast as well as one that is primarily diagnosed.
I typically have a long conversation with patients talking about the pros and cons of unilateral versus bilateral mastectomy. One of the common reasons for bilateral mastectomy is many women do not feel comfortable keeping one natural breast. In these cases, there is also the additional upside of being able to attain symmetry much more easily due to the fact that I, as the reconstructive surgeon, am able to create the same thing on both sides. This is more difficult to do with one natural breast and one reconstructed breast.
Young women with a higher lifetime risk or women with large and low ptotic breasts are often best suited for bilateral, from both the risk standpoint and to create better shape and more symmetric breasts.
The AEDITION: How does a patient choose between a skin-sparing and nipple-sparing mastectomy?
Dr. Unger: The data is fairly clear that, unless there is direct nipple involvement, it is equally safe to get a nipple-sparing mastectomy or skin-sparing mastectomy. The reasons to get skin-sparing mastectomy and remove the nipple are, again, if there is direct involvement of the nipple with cancer thus being unable to keep it; or if the nipple is in a very poor position — such as too low — making it an impediment for creating an aesthetically pleasing outcome. Smaller breasts and even some larger, well-shaped breasts are often good candidates for nipple-sparing mastectomy.
WHAT IS LIKE TO GET A MASTECTOMY?
Given each patient will have a unique medical history and diagnosis, everyone’s process will look a little different. After finding the right surgeon(s) and determining the best course of action for your condition (some mastectomies may be combined with radiation or other treatments), the mastectomy procedure generally involves the same course of action.
Without breast reconstruction, a mastectomy is usually an outpatient procedure that lasts one to three hours and is performed under general anesthesia. The surgeon typically begins by making an elliptical incision around the breast (more incisions may be needed for a nipple-sparing surgery) and removing the tissue and any other part of the breast (i.e. the nipple, skin, areola) decided upon. The sentinel node or axillary lymph node dissection will also be performed as needed.
If a reconstructive procedure is not being performed in tandem, the surgeon will insert surgical drains to accommodate excess fluid and close the incision (the drains will be removed during the first post-op appointment, about one to two weeks after the procedure). The entire surgical site is then wrapped with a bandage.
Mastectomy side effects are similar to those of most surgeries, and many doctors will prescribe pain medication to deal with the symptoms. Most patients experience pain and swelling, buildup of blood at the surgery site, limited mobility, and numbness. Infection is also possible, as is lymphedema (fluid build up), in cases where the nodes are removed.
Depending on the type of mastectomy performed, some patients may be able to go home the same day, while longer hospital stays (up to three days) may be needed for bilateral and reconstructive procedures.
So, what can patients expect in the aftermath of a mastectomy? The AEDITION spoke to Leif Rogers, MD, a Beverly Hills-based board certified plastic and reconstructive surgeon who is a pioneer in advanced breast reconstruction, about what to expect post-op.
The AEDITION: What does the chest look like after a mastectomy?
Dr. Rogers: How a chest looks after mastectomy is completely dependent on the oncological breast surgeon. Different surgeons have different preferred techniques. If a traditional mastectomy is performed without a skin-sparing technique, the chest has a transverse scar on it running from the axillary lymph nodes (armpit area) to almost the sternum. If skin-sparing is performed and a tissue expander or implant is placed at the time of mastectomy, the breast can look relatively normal immediately. Additional surgeries are often needed to fine tune the result for symmetry and optimal cosmesis.
The AEDITION: When it comes to breast reconstruction after a mastectomy, what can patients expect?
Dr. Rogers: There are a great many things that can be done for breast reconstruction. Many of the old limitations for reconstruction — especially after radiation therapy — no longer apply. I can build a breast using an implant or a patient’s own tissue. If a patient elects to use her own tissue, there are many different procedures to choose from. I feel the best three, in terms of cosmetic outcome of the breast and minimal donor site morbidity, are the DIEP flap (deep inferior epigastric perforator, which runs through the abdomen), the TUG flap (transverse upper gracilis in the upper thighs), and autologous fat grafting. All of these techniques can be used to create one or both breasts without the use of an implant.
Implant reconstructions have also gotten much better with the addition of autologous fat grafting. Fat grafting can smooth out the contours and make almost any implant reconstruction look like a natural breast. Nipples can also be reconstructed using one of a number of techniques and can look 90 percent like the original. Nipple reconstruction has been less often required in recent times due to the acceptance of nipple-sparing mastectomies.
The AEDITION: When do you recommend patients get reconstructive surgery?
Dr. Rogers: I alway recommend starting the reconstructive process at the time of mastectomy. The cosmetic outcomes are far superior. I also recommend skin-sparing and, if possible, nipple-sparing mastectomies. I find that even if a flap procedure is the chosen method of reconstruction, a primary placement of a tissue expander improves the cosmetic outcome and decreases complication significantly.
While a mastectomy is never an easy procedure for the patient or their loved ones, much progress has been made in surgical and reconstruction methods. Finding the right surgeons and treatment for your diagnosis will ensure you get the best care possible, and, for those who choose to undergo a reconstructive procedure in tandem (or in the future), natural breasts are attainable through implants, fat grafting, or a combination of the two.