Radical Mastectomy: Overview

A radical mastectomy is done to remove one or both breasts. It involves taking the whole breast. This includes the breast tissue, nipple, areola, all nearby lymph nodes under the arm, and the chest wall muscles under the breast.

While it was once the standard approach to treating breast cancer, this method is not very common today. This approach is often reserved for cases in which breast cancer has spread to the muscles in the chest wall.

This article describes how to prepare for a radical mastectomy, what it involves, and common outcomes.

What Is a Radical Mastectomy?

A radical mastectomy is a surgical procedure performed to remove one or both breasts. The technique was established by William Halsted in 1894. The procedure is sometimes referred to as a "Halstead mastectomy." With slight modifications, it was used in mastectomies until the mid-1970s, when John Madden discovered that leaving the chest wall intact resulted in similar outcomes as removing them.

This technique has the most severe and disfiguring outcome of any type of mastectomy. A skin graft is often required to cover the wound.

A radical mastectomy is permanent and irreversible. Because it involves the removal of breast tissue and glands, a radical mastectomy changes breast function and sensitivity. In addition to physical effects, the procedure can involve emotional issues related to body image and sexuality.

Various Surgery Techniques

The technique used to perform a radical mastectomy is used as the foundation for all variations of the technique. Other mastectomy techniques evolved as advances in radiation therapy and breast reconstruction allowed surgeons to preserve more of the natural breast, reduce complications, and achieve results comparable to radical mastectomy for most patients. All types of mastectomies may be single or double (bilateral).

The type of mastectomy performed depends on factors that include the size, stage, and location of your breast cancer, your current condition, and your medical history. They include:

• Modified radical mastectomy: Like a radical mastectomy, a modified radical mastectomy involves the removal of the entire breast. This includes the breast tissue, skin, areola, nipple, and most axillary lymph nodes. In contrast to the radical mastectomy, a modified radical mastectomy leaves the chest muscles intact.
• Bilateral simple or total mastectomy: A simple (or total) mastectomy involves the removal of all breast tissue in both breasts, including the nipple, and areola. The chest muscles and underarm lymph nodes are left intact.

The following types of mastectomies are reserved for people whose breast cancer involves a tumor not less than 2 centimeters from the nipple-areola complex:

• Skin-sparing mastectomy: A skin-sparing mastectomy removes the nipple, areola, and all breast tissue, but leaves most of the breast skin intact to preserve a more natural appearance of the breast for breast reconstruction during surgery. It may not be appropriate if you're delaying breast reconstruction, or have inflammatory breast cancer or tumor cells close to or in the breast skin.
• Nipple-sparing-mastectomy: Nipple-sparing mastectomy removes all the breast tissue while leaving the skin, nipple, and areola intact. Having inflammatory breast cancer or a tumor or scarring close to or involving the nipple or areola may prevent you from having this procedure.

Some women prefer to have breast reconstruction at the same time as a radical mastectomy, while others prefer to wait until later. Your surgeon can discuss your options for this type of combined procedure. Factors such as your need for post-mastectomy breast cancer treatments may affect the timing of your breast reconstruction surgery.

Contraindications

A radical mastectomy is considered safe for most people who have breast cancer that affects their chest muscles. Your surgeon considers factors such as your age, stage, and location of your breast cancer to determine whether this surgery is appropriate.

There are few contraindications to a radical mastectomy. They include the following conditions:

• Inability to receive general anesthesia
• Proof that the disease has metastatic breast cancer
• Significant medical co-morbidities or systemic organ dysfunction, especially in daily or elderly patients
• Advanced locoregional disease that may complicate the surgeon's ability to close the surgical wound or achieve a negative surgical margin

For some people, chemotherapy, radiation therapy, or endocrine therapy may be helpful in reducing the local disease enough to make it safe to perform the procedure.

If you have a contraindication to having a radical mastectomy, your healthcare team will discuss alternative treatment options. These may include:

• Drug therapy
• Chemotherapy
• Hormonal therapy
• Other types of surgery
  

Potential Risks

A radical mastectomy is a major surgery that includes several risks and complications specific to this type of procedure. These problems can include the following issues:

• Hematoma
• Seroma
• Infection
  
• Persistent post-mastectomy pain (PPMP)
• Lymphedema of the arm
• Skin necrosis
• Phantom breast syndrome
• Limited arm and/or shoulder movement on the affected side

Having a radical mastectomy also involves the same general surgical risks associated with any invasive procedure.

Purpose of a Radical Mastectomy

The purpose of a radical mastectomy is to remove one or both breasts with the goal of containing breast cancer. It was created to mechanically remove all potentially malignant tumor cells in the breast and nearby lymph nodes. The technique for radical mastectomy was developed before the use of imaging and radiation therapy in breast cancer treatment.

Advances in imaging, chemotherapy, radiation therapy, and breast reconstruction provided the tools necessary to support less extreme surgical techniques. The shift away from radical mastectomies began when research indicated that a radical mastectomy did not provide significant survival benefits over less extreme breast-conserving types of surgery, like a modified radical mastectomy.

How to Prepare

During your surgical consultation, your surgeon or a staff member will provide you with specific instructions on preparing for your radical mastectomy. You must closely follow your instructions to achieve the best possible surgical outcomes.

While your pre-surgical guidelines will be personalized to your condition, common preparations for this type of surgery include stages of instructions.

About one month before surgery:

• Complete all required pre-surgical consultations and appointments
• Complete all advised preoperative testing, including blood tests and imaging studies, such as a chest X-ray and electrocardiogram (EKG)
• Report or update your medical history to include a complete list of current medications and medical conditions
• Make arrangements to donate your blood for use during surgery if you desire
  
• Make advised lifestyle changes which may include eating a healthy diet, drinking more water, and exercising regularly to promote healing after surgery
• Stop smoking
• Limit alcohol consumption as advised
• Coordinate with a responsible person to bring you home after surgery

Two to 10 days before surgery:

• Follow instructions on changing the dose or stopping medications that may cause excessive bleeding during surgery, such as Blood thinners, drugs that contain aspirin, products that contain vitamin E, non-steroidal anti-inflammatory drugs (NSAIDs)
• Pack a toothbrush, hairbrush, phone, phone charger, and other personal items you may need for a few days in the hospital
• Prepare to take loose-fitting clothing that you can put on without reaching over your head when it's time to go home
• Prepare your home so that you have everything you need during your recovery

On the day of surgery:

• Stop eating by midnight the night before your surgery
• Stop drinking liquids two hours or longer before surgery as advised
• Shower with an antiseptic skin cleanser if directed
• Do not wear makeup, lotion, nail polish, or deodorant
• Remove and leave jewelry at home
  
• Take only the medications approved by your surgical team
• Allow plenty of travel time to avoid the stress of rushing

What to Expect on the Day of Surgery

A radical mastectomy is performed at a hospital. When you arrive at the hospital, you are likely to have many of the same experiences involved in registering and preparing for any type of surgery.

You can expect to do the following:

• Register at the admissions office with a photo ID and insurance information
• Change into a hospital gown for the procedure
• Have an IV inserted in your arm so fluids and medications can be delivered to your vein before, during, and after surgery
• Wear sequential compression devices on your legs to promote blood circulation during and after surgery
• Undergo a series of checks for heart rate, blood pressure, and other vital signs before surgery
• Have markings made on the breast(s) to indicate where the incision will be made
• Be given general anesthesia for the duration of the procedure

You will be in surgery from one to three hours for a radical mastectomy. If your procedure includes breast reconstruction with breast implants or breast tissue expanders, you will be in surgery for about three to four hours. Having a radical mastectomy with breast reconstruction using tissue flaps from your abdominal muscle takes about six to eight hours.

Recovery

You will recover in the hospital's post-anesthesia care unit (PACU). You will remain here until the anesthesia drugs wear off and you are stable enough to move to a hospital room.

The length of your hospital stay will depend on the type of surgery you had and your rate of recovery. It is common to remain in the hospital for one or two nights after a radical mastectomy. If you had breast reconstruction at the same time as your mastectomy, you may stay from two to five nights.

After your surgery, you can expect:

• Feelings of numbness and heaviness in your chest
• A bandage and dressing over the incision when you leave the hospital
• One or more surgical drains to drain the fluid from your incisions and prevent swelling
• A pulling sensation under your arms which improves as your chest heals
• Phantom sensations that feel like your breast or nipple is still present
• A sensation of liquid going down your arm when it's not there as a result of nerves cut during surgery
  

Your priority is to rest during recovery so your body can heal. When you leave the hospital, your immediate recovery will likely include the following:

• Instructions for inspecting and changing the incision dressing and surgical drain when present
  
• Instructions for taking pain medication
• Other prescriptions such as antibiotics, as necessary
• Tips on how to shower 24-48 hours after surgery and protect the incision
  
• Direction to avoid lifting your arms over your head and doing strenuous activities
• Instructions for simple arm exercises to restore arm strength and flexibility
• Guidance on when to resume driving and return to work
• The need for help to accomplish household and personal tasks

You will likely meet with your surgeon about 10 to 14 days after surgery. Your healthcare provider will check your incision site and remove any remaining stitches or surgical drains, They will also discuss the results of the pathology tests performed on the tissue and lymph nodes removed during your surgery.

The average recovery time for a radical mastectomy with breast reconstruction is about three to four weeks, though the process can take six to eight weeks. Your rate of recovery will depend on many factors, including your age, general health, and the type of surgery performed.

Long-Term Care

While you may be able to return to work and normal activities in about four weeks, it can take several months for your body to adjust to the physical changes caused by your radical mastectomy. You may experience the following sensations that occur as a result of damage to sensory nerves that occurred during your surgery:

• Burning
• Pins and needles
• Numbness in your chest
• Pressure in your chest
• Persistent, unbearable itching
  
• Tenderness in the chest and arm

You can expect to continue regular follow-up appointments with members of your healthcare team to monitor your healing. You may have to begin post-surgery radiation therapy or other treatment after surgery. Your team will establish a schedule for treatment and future screening to monitor your progress and identify any early signs of breast cancer recurrence as early as possible.

You will also have to address your needs for emotional healing. Losing one or both breasts can trigger a wide range of emotions, including changes in your body image. Talk to your healthcare provider about ways to cope with feelings of anxiety or depression. Consider joining a support group or talking to a counselor to help you cope.

If you didn't have breast reconstruction during your radical mastectomy, you may want to consider it after you recover. Taking this step may help you feel more confident and restore lost self-esteem. Consider trying one of many prosthetic breasts that may help you feel more like yourself if you opt against breast reconstruction.

Summary

A radical mastectomy is a type of surgery that removes one or both breasts. It involves taking the whole breast. This includes the breast tissue, nipple, areola, all nearby lymph nodes under the arm, and the chest wall muscles under the breast. Once the "gold standard" of breast cancer treatment, this approach is seldom used now.

A Word From Verywell

It is rare to have a radical mastectomy. If your surgeon advises this treatment, make sure you understand your options. Don't be afraid to seek a second opinion to ensure you're making the right choice. Most people can achieve comparable results with less extreme, breast-preserving techniques combined with radiology therapy.