What is it?
Mastectomy means removal of a breast. The end result of a mastectomy is smooth skin across half the chest with a scar across it.
At the same time, some or all the glands in the armpit (axilla) may be taken out. The glands are small clusters of cells that are connected to tiny draining pipes in the breast and axilla, called lymphatics.
When cancer 'travels' and spreads through the lymphatics, the glands will be affected and will get bigger.
You will be given a general anaesthetic and be completely asleep during the operation. The operation takes between 1 and 2 hours.
Leaving things as they are would mean that the problem in the breast will get worse.
Simply taking out the diseased part and using X-rays treatment for the rest of the breast is not for you. This is because a safe margin of healthy breast tissue cannot be achieved, or the background tissue is not stable, or you are not happy with the idea.
X-ray treatment on its own would not be as good in your case. Neither would drug treatment on its own. Coring out the breast tissue would not give a safe-free of cancer margin. Re-building the breast with an implant at the time of mastectomy is often risky from the point of view of healing.
Before the operation
If you know that you have problems with your blood pressure, your heart, or your lungs, ask your family doctor to check that these are under control.
Check you have a relative or friend who can come with you to the hospital, take you home, and look after you for the first week after the operation.
Bring all your tablets and medicines with you to the hospital. On the ward, you will be checked for past illnesses and will have special tests to make sure that you are well prepared and that you can have the operation as safely as possible.
Many hospitals now run special preadmission clinics, where you visit for an hour or two, a week or so before the operation for these checks.
You should already have met the breast specialist nurse. She will continue to help you during and after your hospital stay. You will have the operation explained to you and will be asked to fill in an operation consent form.
Before you sign the consent form, make sure that you fully understand all the information that was given to you regarding your health problems, the possible and proposed treatments and any potential risks. Feel free to ask more questions if things are not entirely clear.
Any tissues that are removed during the operation will be sent for tests to help plan the appropriate treatment. Any remaining tissue that is left over after the tests will be discarded.
Before the operation and as part of the consent process, you may be asked to give permission for any 'left over' pieces to be used for medical research that has been approved by the hospital. It is entirely up to you to allow this or not.
Many hospitals now run special preadmission clinics, where you visit a week or so before the operation, where these checks will be made.
After – in hospital
You will be able to drink within an hour or two of the operation provided you are not feeling sick.
The wound has a dressing which may show some staining with old blood in the first 24 hours. The dressing will be exchanged for a clean one which stays until the drain tubes are removed after four to five days.
You will probably have a fine, thin plastic drip tube in an arm vein (small draining blood pipe) and also one or two fine plastic drainage tubes in the skin near the wound. They are there to drain any residual blood or any other fluid from the area of the operation. If any blood or fluid is not drained, it can cause a lot of pain and tension under the skin, delay the healing of the wound, and may even get infected.
The drain will be removed when it drains only a very small amount of fluid. This can take anything from a few days to two weeks.
There is some discomfort on moving rather than severe pain. You will be given injections or tablets to control this as required. Ask for more if the pain is not well controlled or if it gets worse.
Many hospitals are now using what is called PCA (patient controlled analgesia). By pressing a button on a device you can inject painkillers into your bloodstream through a very fine plastic tube that goes into one of the small blood vessels (veins) in your hand. A small computer controls the amount of painkiller that is released and prevents any accidental overdose.
Alternatively, you may have a fine tube in your back through which pain relief can be given to help control the pain. You will most likely be able to get out of bed with the help of the nurses the day after the operation, despite some discomfort. You will not do the wound any harm, and the exercise is very helpful for you.
You may be given a blood-thinning injection in your skin once a day to prevent any blood clots in your legs. This can happen in the first few days after the operation until you can move around a bit more. Those clots can be very dangerous because they can 'travel north' through your blood stream to your heart and lungs and cause very serious problems and even death.
The second day after the operation you should be able to spend most of your time out of bed and in reasonable comfort. You should be able to walk slowly along the corridor. By the end of one week the wound should be virtually pain free.
There will probably be stitches or clips in the skin. They will be taken out in 7 to 10 days. Sometimes the wound is held together underneath the skin with stitches that just melt away and do not need further attention.
You can wash as soon as the dressing has been removed but try to keep the wound area dry until the stitches/clips come out. If the stitches are only inside the wound, try to keep the wound dry for a week after the operation. Soap and tap water are entirely adequate. Salted water is not necessary.
The wound gradually improves for one to two months after the operation. You may be fitted with a soft, sponge filling for your bra to give you some shape until a more permanent filling can be fitted when the wound has settled down.
A check-up will be arranged for a week or so after you leave the hospital. The results from the examination of the breast tissue will be available then. You will be informed about deciding on any further treatment.
The nurses will advise about sick notes, certificates etc.
After – at home
You are likely to feel very tired and need to rest two to three times a day for a week or more. You will need to continue arm and shoulder exercises to prevent getting a stiff shoulder. You will gradually improve so that by the time a month or so has passed you should be able to return to your usual level of activity.
You can drive as soon as you can make an emergency stop without discomfort in the wound, i.e. after about 10 days. You can safely wear a seat belt.
You can restart sexual relations within a month or so, when the wound is comfortable.
You should be able to return to a light job after about four weeks and a heavier job within eight weeks.
It is not unusual after an operation like this to experience some psychological problems. Some studies show that almost up to 40 per cent of women who have had this operation can feel depressed, anxious or have sexual difficulties. The hospital has well organised counselling services (including discussions with patients who had a similar experience with yours) that can support and help you before and after the operation. This is very effective most of the time.
As with any operation under general anaesthetic, there is a very small risk of complications related to your heart and lungs.
The tests that you will have before the operation will make sure that you can have the operation in the safest possible way and will bring the risk for such complications very close to zero.
If you think that all is not well, please let the doctors or the nurses know.
Bruising may be troublesome. Occasionally some old blood collects under the wound, but this can easily be removed with a needle in the two or three weeks after you leave hospital. Although unlikely, if the bleeding persists you may need another operation to fix the problem.
Occasionally the wound edge does not heal well in places. This settles down, but may take three or more weeks to do so. There is up to a 20 per cent chance that you will develop a seroma after this operation. This is a collection of clear fluid under the wound. The risk increases according to how extensive the operation was and the number of glands removed.
If it happens, you will need regular evacuations (aspirations) of the fluid using a needle which is passed through the skin into the collection of fluid. This continues until there is no more fluid under the skin, If the fluid collection is large then after numbing the skin area on top of the collection with an anaesthetic injection, a fine plastic tube is placed through your skin into the collection to drain the fluid. The tube will remain in place until no more fluid comes out. In the meantime, you will be given antibiotics to make sure that the seroma does not get infected.
Another possible complication is the development of lymphedema. This is swelling of the arm, forearm and hand on the side of the mastectomy. It happens because during the operation the surgeon removes glands (lymph nodes) from your arm pit (axilla) and the tiny tubes (lymphatic vessels) that are connected to them and drain a fluid called lymph. This is a fluid produced in all the areas of the body and it's drained back to the heart via the lymphatic vessels to be re-circulated in the body.
When the lymphatic vessels are removed the lymph cannot be drained properly, accumulates and causes swelling. About 40 per cent of women can experience mild to moderate lymphedema after the mastectomy. Most of the time this goes away with proper exercises.
In about 5 per cent of cases it becomes a chronic problem and you will need further consultation and treatment to deal with the problem.
About 30 per cent of women experience what is called 'phantom breast pain'. This is pain or itching that is felt in the breast area and as if the breast has not been removed with the mastectomy. This gradually gets better and very rarely becomes a chronic problem.
Relatively rarely, you may experience some stiffness or numbness of the arm on the side of the mastectomy or even some loss of strength of the arm on this side. This gets better most of the times with proper exercise. Overall the chance of infection after this operation is 1 to 3 per cent. If it occurs it usually settles down with antibiotics in a week or two.
If a seroma is present and is not treated promptly, the chance of infection can be two to three times higher. An infection can be serious and you will need to have it treated with intravenous (through a vein in your arm) antibiotics.
Aches and twinges may be quite troublesome in the wound, shoulder and arm for up to six months. Occasionally there is a numb patch in the skin of the armpit and down the inside of the upper arm. This patch slowly lessens in size but may always be present.
Finally, and very rarely, a blood vessel or a nerve can be damaged during the operation and you will most probably need another operation to fix the problem.
The mastectomy, although still a major operation, is much less of an undertaking than was the rule 10 or more years ago. Patients are usually surprised that the discomfort experienced is much less than expected. However it may take a year or two before they feel comfortable about having had a mastectomy.
Details of further treatment, including possible rebuilding of the breast, will be discussed with you and your surgeon. These notes should help you through your operation. They are a general guide. They do not cover everything. Also, all hospitals and surgeons vary a little.
If you have any queries or problems, please ask the doctors or nurses.