Mastectomy: Overview

A mastectomy is the surgical removal of a breast, usually performed to treat or prevent breast cancer. There are different types of mastectomies depending on a patient's underlying diagnosis. As with any operation, it's important to be knowledgeable about the preparatory and recovery process involved with this surgery, as well as any potential risks.

What Is a Mastectomy?

A mastectomy is performed by a general surgeon, sometimes called a breast surgeon, in a hospital under general anesthesia. The operation typically lasts two to three hours.

Many women who have a mastectomy opt to have reconstruction—surgery performed by a plastic surgeon to rebuild the removed breast(s). This can be delayed for months or even years, but it can also be done immediately after a mastectomy. If a woman chooses the latter, the procedures, altogether, will take longer.

Various Surgical Types

Depending on certain factors, most notably the stage of breast cancer, a surgeon will recommend one of several types of mastectomies. The three most common ones are:

• Simple (total) mastectomy: The entire breast is removed along with the nipple, areola, and skin over the breast. The surrounding lymph nodes and muscle under the breast tissue are left intact.
• Modified radical mastectomy: The entire breast is removed along with the nipple, areola, and skin over the breast. In addition, the lymph nodes from underneath the arm (called axillary lymph nodes) are removed.
• Radical mastectomy: The entire breast is removed along with the axillary lymph nodes and the muscle that lies underneath the breast. The only thing left is the skin needed to close the incision. Of note, this type of surgery is not standard anymore; it's reserved for patients who have advanced breast cancer that has invaded the muscle wall.

Additional Techniques

If a woman is undergoing immediate breast reconstruction and her cancer is not too large or too close to the skin surface, she may undergo a skin-sparing mastectomy. With this technique, most of the skin over the breast is preserved, so only the breast tissue, nipple, and areola are removed.

Another variation of the skin-sparing mastectomy is the nipple-sparing mastectomy. With this technique, the skin over the breast and the nipple are left in place. This technique is reserved for women who have a small, early-stage cancer that is located on the outer part of the breast.

Contraindications

A mastectomy may be contraindicated in the following cases:

• A patient has distant metastatic breast cancer (e.g., breast cancer has spread to the brain, for example)
• An elderly or frail patient has other significant medical conditions
• A cancer has certain features, like being too large, that make surgery technically difficult: Another treatment (e.g., chemotherapy or radiation) may be used first to shrink the cancer before surgery.

Purpose of Mastectomy

The main purpose of a mastectomy is to treat breast cancer, including these different types:

• Ductal carcinoma in situ (DCIS) (non-invasive breast cancer)
• Invasive breast cancers (e.g., invasive ductal carcinoma or invasive lobular carcinoma
• Difficult-to-treat cancers, such as triple-negative breast cancer and inflammatory breast cancer
• Less common breast cancers, such as Paget's disease of the breast

While a mastectomy is most commonly performed in women, men can also get breast cancer and require a mastectomy for treatment.

A mastectomy may also be done to prevent breast cancer. This is called a prophylactic mastectomy. In most cases, both breasts are removed.

Reasons for undergoing a prophylactic mastectomy include:

• A genetic mutation that increases the risk for developing breast cancer (e.g., BRCA, ATM, PALB2, and others)
• A strong family history of breast cancer
• History of chest radiation before the age of 30
• The presence or a history of cancer in one breast

Less commonly, a mastectomy may be done to treat a male with gynecomastia (enlargement of breast tissue). In these cases, a nipple-sparing mastectomy combined with liposuction is generally performed.

Mastectomy vs. Breast-Conserving Surgery

Patients with early-stage breast cancer often have the option of choosing between breast-conserving surgery (also called a lumpectomy) or a mastectomy.

With breast-conserving surgery (BCS), the surgeon removes the lump of cancerous breast tissue. If a woman chooses breast-conserving surgery, she will most likely also need radiation.

Even though patient preference is taken into account, mastectomy, as opposed to BCS, is generally advised in these cases: 

• A patient has inflammatory breast cancer
• A patient's breast was treated with radiation in the past
• A patient cannot undergo radiation because of an underlying medical condition that makes them sensitive to the side effects of radiation (e.g., systemic lupus erythematosus)
• A patient already had BCS and not all of the cancer was removed
• There are two areas of cancer within the same breast that are too far apart
• The breast cancer is larger than 5 centimeters (cm) across, or is larger relative to the patient's breast size
• A patient is pregnant and would require radiation during gestation
• A patient has a genetic mutation that increases their risk for a second breast cancer

How to Prepare

Once you have made the decision to undergo a mastectomy and scheduled your surgery date, you will receive instructions on what to do in preparation for your procedure. It may be suggested that you:

• Wear comfortable clothes on the day of your surgery
• Avoid wearing jewelry, makeup, or nail polish
• Stop eating after midnight on the eve of your surgery
• Stop certain medications for a period of time before your surgery (for example, blood thinners like aspirin)
• Bring personal items (e.g., toothbrush, hairbrush, phone) with you on the day of surgery
• Arrange to have someone drive you home once you are discharged

What to Expect on the Day of Surgery

Once you arrive at the hospital, you will be taken to a pre-operative room where the following events will occur:

• You will be asked to change into a gown.
• A nurse will place an IV in your hand for delivering fluids and medications.
• Your vital signs will be recorded and monitored.

At this time, members of the surgical and anesthesia team will likely come in to greet you and talk with you about the surgery. Then, you will be taken into the operating room where you will be given anesthesia medications to put you to sleep.

A mastectomy typically proceeds with the following steps:

• A six to eight-inch elliptical incision is made starting on the inside of the breast, near the breastbone, extending upward and outward toward your armpit.
• The breast tissue is removed and then the incision is closed, usually with either absorbable sutures or with staples.
• A drain may be placed to help remove excess fluid from the area where the cancer was removed.
• If the patient opts for immediate reconstruction, a plastic surgeon will take over at this point in the surgery to rebuild the breast.

After the surgery, you will first recover in the post-anesthesia care unit (PACU) before being taken to a hospital room. You can expect to remain in the hospital for approximately one to two nights.

Recovery

After recovering in the hospital for your mastectomy, your healthcare team will provide you with specific instructions on the recovery process, such as:

• Caring for your surgical site and drain (if you have one)
• Restricting or avoiding certain activities for a period of time (e.g., driving or exercising)
• Taking medications (e.g., pain relievers or possibly an antibiotic)
• Attending follow-up appointments: Your staples, if placed, and drain will be removed during one of these visits.

You may also be given instructions on performing arm exercises on your own or under the guidance of a physical therapist. These arm exercises will keep your arm flexible and help prevent stiffness.

If breast reconstruction is performed right after the mastectomy, a return to regular activities usually takes longer.

When to Seek Medical Attention

As you recover from a mastectomy, it's important to contact your doctor if you develop any of the following symptoms:

• Fever or chills
• Pain that is not eased with medication
• Excessive swelling in your arm, hand, or near the incision site
• Discharge or a bad odor from the wound or drain
• Unusual and/or bothersome symptoms like constipation, insomnia, or a potential allergic reaction to a medication

Long-Term Care

A mastectomy with or without breast reconstruction requires long-term care. Following up closely with your doctor is essential to ensuring a full recovery.

If you are undergoing treatment for breast cancer, some women may require additional therapies after surgery, such as:

• Chemotherapy
• Hormone therapy
• Targeted therapy
• Radiation therapy

Additionally, to lower your risk for developing recurrent breast cancer or new breast cancer (in the opposite breast), it's a good idea to adopt these lifestyle habits:

• Maintaining a healthy body weight
• Smoking cessation
• Avoiding or limiting alcohol intake
• Exercising daily

After a mastectomy, patients with breast cancer are more likely to experience depression than others. If you are experiencing symptoms of depression, be sure to talk with your doctor. You may benefit from taking a medication, seeing a therapist, or a combination of the two.

Potential Risks

As with any surgery, a mastectomy comes with potential risks and complications.

Immediate or short-term complications that may occur after a mastectomy include:

• Hematoma: A hematoma is a collection of blood within the wound site. It may lead to pain, swelling, and bruising underneath the breast.
• Seroma: A seroma is a collection of serous (pale yellow) fluid that collects in the dead space of the post-mastectomy skin flap, axilla, or breast. A seroma may cause pain and swelling.
• Wound infection: This complication is rare and usually due to staphylococcal bacteria, which is found normally on the skin. It may cause symptoms like fever, tenderness, warmth, redness, and/or swelling around the surgical site.
• Skin flap necrosis: Necrosis or death of the tissue that comprises the skin flap occurs when the blood supply to the skin flap is insufficient. This necrosis may be partial or full-thickness (more severe) and cause the breast skin to turn a dark blue or black color. Scabbing and fever may also occur.

Potential long-term complications of a mastectomy include:

• Persistent post-mastectomy pain (PPMP): Chronic pain described as a shooting, stabbing, pulling, tightness, burning, or aching sensation that persists over time may occur in the armpit, breast/chest wall, and upper arm after a mastectomy.
• Phantom breast syndrome: With this, patients report still feeling breast tissue after a mastectomy. This condition is analogous to phantom limb, in which a person senses that their limb is still there even though it has been amputated.
• Lymphedema: Swelling of the arm may occur if you had lymph nodes removed from your axilla. This occurs because fluid cannot adequately drain through the lymph system.
• Scar tissue formation: As a result of the mastectomy with or without breast reconstruction, scar tissue may form within the tissue, and it may be painful or lumpy.

A Word From Verywell

No doubt, a mastectomy is a major surgery in more ways than one. Even though the recovery process is typically relatively straightforward, it can be physically and emotionally taxing. Do not hesitate to reach out to your healthcare team if you are feeling overwhelmed, sad, or in need more support.