Most women with breast cancer do not need to have a mastectomy. However, if your breast cancer mass is large, especially if it’s taking up the central area behind your nipple, or if you have several smaller masses of cancer in different parts of your breast that can’t be individually removed without deforming your breast, you’re more likely to need a mastectomy.
A mastectomy is often also needed if you have inflammatory breast cancer, which can be aggressive in its progress. A lumpectomy, which only removes the cancer mass and a rim of normal tissue around it, is not usually recommended to treat inflammatory cancer as this potentially leaves some breast tissue, skin and lymph tissue that may still harbour cancer cells.
To understand what a mastectomy involves, it helps to first understand the anatomy of the breast.
The breast contains glandular tissue, which includes milk-producing lobules, ducts that carry the milk to the nipple, fatty tissue and fibrous tissue that provides support, including special ligaments called Cooper’s ligaments. The nipple is surrounded by a round area of darker skin called the areola.
A mastectomy may involve removing only the breast tissue (glandular, fibrous and fatty tissues) and some or most of the breast skin. It may also involve removing the nipple and/or areola if needed. A mastectomy can be carried out with or without breast reconstruction and breast reconstruction can be immediate or delayed.
A mastectomy without immediate reconstruction removes the breast tissue, nipple, areola and a variable ellipse of skin that results in a completely flat chest with no bulge or fold. The top and bottom flaps of skin are sewn together, producing a straight or slightly curved scar across the chest. This operation usually takes one hour to complete.
It is usually performed if an individual doesn’t want or can’t have breast reconstruction surgery or wants to wait until their cancer treatment has completed before having their breast reconstructed at a later stage (ie delayed reconstruction).
A mastectomy without breast reconstruction has lower risks and a faster recovery than a mastectomy with immediate reconstruction.
If your breast is reconstructed at a later date, skin and a tissue flap may be taken from another part of your body and used to create a new breast. For example, the latissimus dorsi (LD) muscle flap and overlying skin from your back can be brought forward to reconstruct your breast. Alternatively, the deep inferior epigastric perforator (DIEP) flap procedure can be used to remove a section of your lower abdominal skin, with its underlying fat and blood vessels, to create a new breast. This tissue is similar to the tissue removed during a tummy tuck surgery.
For immediate reconstruction of your breast, a skin-sparing or nipple-sparing mastectomy is performed. A skin-sparing mastectomy involves removing your breast tissue, nipple and areola while keeping the rest of your breast skin intact so it can cover the reconstructed breast.
During a nipple-sparing mastectomy, your nipple and areola are also left intact and your breast tissue is removed via a cut made on the underside or the side of your breast or around your areola.
In either case, your new breast is then reconstructed using either an implant or using a flap, where skin and tissue is taken from elsewhere on your body, usually your abdomen (deep inferior epigastric perforator (DIEP) flap) or back (latissimus dorsi (LD) muscle flap), to create your new breast. An implant reconstruction usually takes one to two hours to complete, while a flap reconstruction usually takes longer (on average two to three hours for LD flaps and six to eight hours for DIEP flaps).
As a risk-reducing procedure, a skin-sparing or nipple-sparing mastectomy with immediate reconstruction is most often performed for individuals with a high risk of developing breast cancer due to a strong family history of breast cancer or faults they carry in their BRCA1 and BRCA2 genes.
It takes around two to four weeks to recover from a simple mastectomy (mastectomy without reconstruction) and four to six weeks to recover from a mastectomy with breast reconstruction. Your recovery will follow two phases: immediate and prolonged.
Immediate recovery occurs in the first few hours after your surgery and involves controlling your pain with pain relief medication and reducing your risk of deep vein thrombosis (DVT) by taking blood-thinning medication (eg heparin) and wearing compression stockings to help your leg muscles pump blood from your legs back to your heart.
An hour or so after your surgery when you have left the recovery room and are returned to the ward, you will be asked to start moving (eg walk to the bathroom, gradually walk longer distances within the ward). This will also help reduce your risk of DVT.
In most cases after a mastectomy, you will be discharged to go home on the same day as your surgery or the next day. Your prolonged recovery period will then begin.
It is important to continue controlling your pain by taking pain relief medication as prescribed by your doctor. As you recover, you can wean off your pain relief medication.
You will need to protect your wound site, which will take around seven days to heal, as well as your breast.
You should, therefore, wear a surgical bra that can be zipped or clipped at the front of your chest to avoid unnecessary straining when you’re removing your bra to change your wound dressings.
You will need to wear your surgical bra 24 hours a day for at least the first four to six weeks as your internal tissues heal. This will protect your wound site and if you have had an implant, will prevent the implant from moving and give it time to settle. During this time, you should avoid strenuous or straining activities (eg sports, heavy lifting, overreaching for objects, household chores) and ideally also driving.
However, you should not remain still or inactive during your recovery. Staying mobile helps reduce swelling after surgery and reduces your risk of DVT. Gradually return to your usual daily activities eg walking and shopping (without carrying heavy bags).
You will have a follow-up appointment after your surgery to check your recovery is proceeding as expected.
Mr Walid Sasi is a Consultant Oncoplastic, Reconstructive, and Aesthetic Breast Surgeon at Spire Leicester Hospital, specialising in breast cancer and oncoplastic surgery, cosmetic breast surgery and one-stop breast clinics. He has performed over 5,000 surgical procedures and is a leading member of the UK Breast Cancer Group (UKBCG) and the International Oncoplastic Breast Consortium (OBC). As an active member of the research community, Mr Sasi is a member of the European Breast Cancer Research Association of Surgical Trialists (EUBREAST), a network of renowned European breast cancer surgeons with the goal of researching less extensive approaches to breast cancer surgery. Mr Sasi has strong educational interests in surgery as he is the Undergraduate Lead for Breast Surgery at the University of Leicester Medical School and is also the Training Programme Director of postgraduate Core Surgical Training Programme in East Midlands (South), Health Education England (HEE). He is also a Founding Fellow of the Confederation of British Surgery (CBS).
If you're concerned about symptoms you're experiencing or require further information on the subject, talk to a GP or see an expert consultant at your local Spire hospital.