MASTECTOMY

Mastectomy involves removal of the entire breast.

A mastectomy may be recommended if

• There is cancer in more than one area of the breast

• The cancer is large compared to the size of your breast

• Clear margins cannot be obtained with breast conserving surgery

• You cannot have radiotherapy

• You find out that you have the BRCA1 or BRCA2 gene mutation at time of your breast cancer diagnosis

Total (simple) mastectomy involves removal of the whole breast including the nipple and areola and most of the overlying skin.

Skin sparing mastectomy involves removal of the breast tissue, nipple and areola but preservation of most of the skin over the breast. This is combined with immediate breast reconstruction.

Nipple sparing mastectomy involves removal of the breast tissue, including the ducts going to the nipple and areola but preservation of the skin of the nipple and areola. This is combined with immediate breast reconstruction. 

Some women who need a mastectomy in one breast choose to have the other breast removed as well. This is known as a contralateral prophylactic mastectomy. A double mastectomy may be recommended if you have the BRCA1 or BRCA2 gene mutation, because the mutation increases the risk of developing another breast cancer. Some women with average risk also choose to have a double mastectomy, even though it does not normally make any difference to survival rates. 

• Radiotherapy may not be required, but it depends on the type of cancer.

• Women who have a mastectomy tend to worry less about cancer coming back than women who have breast conserving surgery.

• You will no longer require a mammogram or ultrasound to the treated side. The other breast will still need to be checked with a mammogram and ultrasound every year.

• The whole breast is removed leaving the chest flat. Some women find this quite upsetting and confronting. In most cases, breast reconstruction is available either at the time of mastectomy or at a later time. It is also possible to wear a prosthesis in your bra if you choose to have no reconstruction.

• You may feel unbalanced after one breast is removed, especially if you have large breasts.

• Your hospital stay may be one to two days longer if you have a mastectomy rather than breast conserving surgery. This is because it is a bigger operation and there is usually a drain in the wound to stop build-up of fluid.

The operation is performed under general anaesthesia.

For a simple mastectomy, an elliptical incision is made in the skin to include the nipple areola complex. Breast tissue is removed. A drain is routinely inserted. The incision is closed with dissolvable sutures.

Surgery for invasive breast cancer will usually involve a separate procedure to remove some or all of the lymph nodes in the armpit to be tested for cancerous cells. There are 2 types of axillary surgery - sentinel node biopsy (removal of a few nodes) and axillary dissection (removal of all the lymph nodes). Recommendations for treatment to the lymph nodes are separate to recommendations to the treatment to the breast. For example, mastectomy can be combined with sentinel node biopsy or axillary dissection.

All surgery has risks despite the highest standard of practice. The following possible complications are listed to inform not to alarm. There may be other complications that are not listed.

• Bleeding
• Infection
• Seroma, a build-up of fluid in the cavity where the tissue has been removed. Sometimes it can cause a swelling and the fluid may need to be removed with a needle and syringe.
• Scarring
• Post mastectomy pain syndrome, tingling or shooting pain where your breast was which can last for 6 months or longer
• A change in posture or balance due to the loss of breast weight. This can be improved by wearing a prosthesis.
• Scar and fatty tissue in the armpit area (dog ear) that comes very prominent. This can be improved with a small operation at a later time if it is uncomfortable or interfere with your bra fitting well.

Hospital Stay. Most people go home the morning after surgery. It is recommended that you be accompanied home by a carer who will stay with you (or very close by) for the first 24 to 48 hours.

Drain Care. You will go home with drains, which may stay in for 2 weeks. You will be taught how to look after the drains prior to discharge. Community nurses will visit you at home, and remove the drains when the drainage is less than 30 ml/day for 2 consecutive days.

Wound Care. Your wounds are closed with dissolvable sutures and skin glue and covered with a special suction dressing. The suction dressing stays on for 1 week. You can shower normally. When your suction dressing is removed, surgical tape (Micropore) will be applied over the scar. The tape will need to be changed weekly for 2 months - this helps prevent the scar from stretching. You can massage your scar at 3 weeks over the surgical tape using your fingers in a firm circular motion for at least 10 minutes twice a day for 2 months. 

Driving. You should not drive until the drains have been removed.

Physical Activity. You are encouraged to do as much walking as is comfortable. Avoid lifting (over 1 kg), pushing or pulling with the side your surgery was performed until the drain is removed - this includes lifting children and housework such as vacuuming or hanging out the washing. Avoid strenuous activity, heavy lifting and vigorous exercise for 4-6 weeks. You can start exercising at 25% of your normal level after 6 weeks, and gradually increase to your usual level over 4 weeks. 

Work. Most people with desk jobs can return to work after 2-3 weeks, but people with more physical jobs (especially repetitive arm movements) need a minimum of 4-6 weeks off work. 

For patients with private health insurance, there is No Gap billing from Dr Ling for cancer surgery. There may be out-of-pocket costs for the anaesthetist and hospital excess. 

For patients without private health insurance, the total cost including surgeon’s fee, anaesthetist’s fee and hospital fees starts from $7000. There will be additional costs related to pathology services. You will be eligible to claim a portion of the fee (approximately $1300) back from Medicare. 

Dr Mary Ling performs breast cancer surgery at Gosford Private Hospital and Brisbane Waters Private Hospital on the Central Coast. Dr Ling welcomes patients from Newcastle, Lake Macquarie, the Hunter Region and Northern NSW.