Mastectomy

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The removal of the entire breast is called mastectomy or ablatio mammae. This can be especially necessary in women with breast cancer if breast-conserving surgery is not possible. Read everything about the mastectomy process, when it is performed and the risks involved.

What is a mastectomy?

A mastectomy is the removal of the mammary gland on one or both sides (one or both sides mastectomy). Other names for this operation are mastectomy or ablation mammae. Various procedures are available for breast removal:

• simple mastectomy
• radical mastectomy (operation according to Rotter and Halsted)
• modified radical mastectomy
• subcutaneous mastectomy
• skin sparing mastectomy

You can find more information on the individual procedures below (under: "What do you do with a mastectomy?").

The treating physician chooses the surgical procedure in consultation with the patient, depending on the reason for the procedure. If necessary, the removed mammary gland can be restored in the same procedure, for example with silicone implants or with autologous fat.

When to do a mastectomy

The most common indication for breast removal is breast cancer. A malignant tumor in the breast is one of the most common forms of cancer in women. In most cases it can be operated on to conserve the breast. In some patients, however, the complete breast removal cannot be avoided. However, it is carefully considered because a mastectomy is psychologically very stressful for many women. The following conditions in a malignant neoplasm in the breast require a mastectomy:

• unfavorable tumor-to-breast size ratio
• Multiple cancer foci in different quadrants of the breast (multicentricity)
• "inflammatory" breast cancer (inflammatory breast cancer)
• Comorbidities that do not allow chemotherapy or radiation therapy
• Probably unsatisfactory cosmetic result with breast-conserving therapy
• if post-irradiation is not possible after breast-conserving therapy
• Wish of the patient

In addition to cancer, there are other situations that require breast removal in women. These include large and possibly shape-changing benign tumors or the desire for a sex change in transsexuals (i.e. in men who are "in the body of a woman").

Special case: prophylactic mastectomy

A preventive or preventive mastectomy (prophylactic mastectomy) can be useful if women can be shown to have a genetic predisposition to the disease.

Women who carry such risk genes sometimes decide to have a mastectomy as a precaution - before a tumor can develop. A prominent example of this is the actress Angelina Jolie.

In studies with women with proven BRCA mutations, prophylactic mastectomy was able to increase survival. It is advisable to remove the entire breast including the nipple.

However, genetic predisposition is only responsible for a few cases of breast cancer: risk genes can only be detected in an estimated five to ten percent of all women with breast cancer.

Mastectomy in men

A total mastectomy is almost always performed in men with breast cancer; breast-conserving surgery is usually not useful here.

Apart from malignant diseases, abnormal breast growth in men (gynecomastia) can also be the reason for a mastectomy (gynecomastia surgery).

What do you do with a mastectomy?

The chest is a glandular body that lies above the pectoral muscles. It consists primarily of glandular and fatty tissue that is embedded in connective tissue. Milk ducts lead from the gland cells in which milk is produced in women during breastfeeding to the nipple and open there. In addition, there are nerve tracts as well as blood and lymph vessels in the chest. Most of the tissue fluid flows through the lymph vessels to lymph nodes in the armpit area, but also to lymph nodes on the sternum. Therefore, in the case of cancer, it may also be necessary to remove the lymph nodes in these areas.

Before the operation

Before the operation begins, the patient is given general anesthesia so that she sleeps and painlessly spends the entire procedure. In the operating theater, the patient is lying on her back. The chest and surrounding areas are disinfected and the patient is then covered with sterile cloths - only the head and chest remain free. If necessary, the surgeon marks the planned incision on the patient's skin with a sterile pen. Then he can begin the actual operation.

The actual intervention

How the actual mastectomy takes place in detail depends on the selected surgical procedure:

Simple mastectomy

With a simple mastectomy, the surgeon makes a spindle-shaped incision that runs transversely around the nipple. From this he removes the breast - nipple and skin, the fatty tissue and the connective tissue covering of the breast muscle. The lymph nodes in the armpit are left in place.

Radical mastectomy (Rotterdam and Halsted operation)

In addition to the breast, the doctor removes all lymph nodes in the armpit and around the breastbone and the large and small pectoral muscles. Since the cosmetic result is very stressful for the patient, and the radical mastectomy has not proven to be better than other procedures, this extreme procedure is rarely performed today.

Modified radical mastectomy

The modified radical breast removal is the most common type of mastectomy nowadays. In addition to the entire mammary gland and the overlying skin and nipple, the underlying muscle shell of the large pectoral muscle is removed. The doctor also takes a sample of what is known as the sentinel lymph node in the armpit. This is in the first place, so to speak, in the drainage of the tissue fluid. Only when the sentinel lymph node is infected by tumor cells are the remaining lymph nodes removed.

Subcutaneous mastectomy and skin-sparing mastectomy

In a subcutaneous mastectomy, the breast tissue is removed through an incision in the underbust crease. The skin of the breast and the nipple are preserved. A variant of this technique is the skin-sparing mastectomy: Here the doctor removes the nipple, but not the skin covering the breast.

The advantage of both procedures is that sufficient covering skin is left for a planned reconstruction of the breast. The disadvantage, however, is the increased risk of tumor cells remaining in the tissue.

After the operation

When the procedure is over, the surgeon places a wound drainage system into the wound cavity using a rubber tube. This allows blood and wound secretions to drain off after the operation. The edges of the wound are now placed against each other without tension and carefully sutured. The doctor then bandages the wound in a sterile manner, and the patient is taken to the recovery room to recover from the anesthesia.

What are the risks of a mastectomy?

Possible complications and risks of a mastectomy are:

• Bleeding and secondary bleeding that may require a blood transfusion or reoperation
• Bruising and accumulation of wound fluid
• Injury to nerves
• Infection and inflammation
• Wound healing disorders
• Lymph drainage disorder due to the removal of the lymph nodes
• excessive scarring
• cosmetically unfavorable result with indentations / deformations
• rare: dying skin, especially with skin-sparing mastectomy
• psychological stress due to changed body image

For many women, breast loss is accompanied by a sense of loss of femininity and sexual identity. This can especially be the case if the breast reconstruction was not possible at the same time as the breast removal.

What do I have to consider after a mastectomy?

Since the lymph nodes in the armpit are often removed during a mastectomy, it can lead to drainage disorders and thus to fluid accumulation in the tissue in the arm (lymphedema). If necessary, your doctor will prescribe lymphatic drainage therapy in which the lymph flow is promoted by stroking and massaging the arm.

You can prevent lymphedema after the mastectomy yourself:

• Elevate the arm, for example with a pillow
• If possible, keep your arm outstretched and slightly angled from the upper body
• Avoid tight clothing
• Avoid excessive heat exposure (sauna, sunbathing), generally no heat treatment of the affected arm
• Avoiding strain, for example through heavy lifting

In order to avoid overloading the wound, you should seek support in everyday activities (such as personal hygiene, getting dressed) in the first few days after the mastectomy, even if you are feeling fit.

If you have had a unilateral mastectomy (unilateral mastectomy), the asymmetry can lead to a change in your posture. This in turn leads to muscle tension in the shoulder and neck area. A physiotherapist can show you exercises that can counteract muscle tension without putting strain on the suture.

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