Mastectomy

Overview

Breast cancer is the most frequent cancer among women in the United States, and treatment standards are continually changing. Breast cancer therapy frequently includes surgery, such as breast-conserving surgery or mastectomy. A mastectomy is a surgery in which all or portion of the breast is removed.

Mastectomy definition

A mastectomy involves the removal of tissue from one or both breasts by a surgeon. The phrase is derived from the Greek word mastos, which means "woman's breast," and the Latin term ectomia, which means "excision of." Mastectomy is divided into four types: partial, simple, modified-radical, and radical. Skin-sparing mastectomy and nipple-areolar sparing mastectomy are two more variants in terminology or method that frequently accompany breast reconstruction.

Anatomy and Physiology

The breast is located on the anterior thoracic wall and is located above the pectoralis major muscle. The adult female breast's superior border approaches the level of the second or third rib and then continues inferiorly to the inframammary crease or fold. The sternal border is the breast's medial limit. The breast extends laterally to the mid-axillary line. Approximately two-thirds of the breast overlies the pectoralis major muscle posteriorly, while the remaining half overlies the serratus anterior and upper section of the oblique abdominal muscles.

The axillary tail of Spence refers to the region of the upper breast that extends superior-laterally toward the axilla. The breast is divided into four quadrants, allowing for uniformity in the reporting of physical examination or breast imaging results. Upper inner, upper outer, lower inner, and lower outer are the four quadrants. The upper outer quadrant of the breast contains the bulk of the breast tissue, including the axillary tail of Spence. As a result, it has the highest incidence of breast cancer.

The breast is made up of mammary tissue and is surrounded by subcutaneous fat and skin, as well as superficial and deep fascial layers. The superficial layer of fascia goes deep into the dermis and covers the anterior breast before extending over the medial and lateral breast. The deep layer of superficial fascia covers the breast's posterior surface and is located prior to the pectoralis major fascia.

Suspensory ligaments of Cooper are fibrous bands of connective tissue that run across the breast parenchyma and enter perpendicular to the dermis from the deep layer of superficial fascia. The weakening of these ligaments is what causes breast ptosis. Breast tissue is made up of epithelial parenchymal parts as well as stromal tissue.

The epithelial component accounts for around 10 to 15% of total breast volume, with the remaining made up of stromal parts. The breast stroma is made up of 15 to 20 lobes, which are further subdivided into 20 to 40 lobules. Lobules are made up of tubuloalveolar glands that are branching. Adipose tissue can be seen in the gaps between the separate lobes. Each lobe drains into a large lactiferous duct that runs all the way to the nipple.

95 percent of the time, breast lymphatic drainage occurs through the axilla. Anatomists and surgeons differ slightly in their descriptions of lymph node groupings. Typically, axillary nodes are defined by their connection to the pectoralis minor muscle. Level I lymph nodes are those placed lateral to or below the lower border of the pectoralis minor muscle and often include the external mammary, axillary vein, and scapular lymph node groups.

The central lymph node group and probably some of the subclavicular nodes are found deep to the pectoralis minor muscle in level II lymph nodes. The subclavicular lymph nodes are located medial or superior to the top border of the pectoralis minor muscle in level III axillary nodes. Rotter's or interpectoral nodes, which are positioned between the pectoralis major and minor muscles, are also routinely identified by surgeons.

Mastectomy Indications

Breast cancer is the most common reason for having a mastectomy. Most breast cancers need targeted surgical treatment (either mastectomy or breast-conserving surgery), which can be combined with neoadjuvant or adjuvant therapy, such as radiation, chemotherapy, or hormone antagonist drugs, or a combination of these.

Tumor parameters such as size and location, as well as patient desire, play an important role in the decision-making process, considering that survival rates for patients following mastectomy or lumpectomy with adjuvant radiation therapy are often comparable.

In brief, breast cancers can have both invasive and non-invasive histologies. Invasive ductal carcinoma is the most frequent kind of breast cancer, accounting for roughly 85 % of all invasive breast cancers. In contrast, invasive lobular carcinoma and other uncommon histologies, such as breast sarcoma or lymphoma, are far less prevalent. Breast non-invasive carcinomas include ductal carcinoma in situ and lobular carcinoma in situ. The latter is frequently viewed as a risk factor for future breast cancer and may be better classified as a benign precursor lesion.

Patients with Paget's disease of the breast may also be candidates for mastectomy. Paget's disease is an uncommon kind of breast cancer in which neoplastic cells are seen in the nipple-areolar complex epidermis. While the illness may be limited to one location, 80 to 90 percent of individuals will have an associated malignancy elsewhere in the affected breast.

The usual method to surgical therapy of Paget's disease has been total mastectomy with axillary sentinel node biopsy. When combined with whole breast radiation therapy, central lumpectomy with complete excision of the nipple-areolar complex has been shown to be successful for local control in patients with no other cancer in the breast.

Due to tumor load inside the dermal lymphatic pathways and more widespread involvement of the underlying breast parenchyma, patients with inflammatory breast cancer are treated with mastectomy in addition to systemic chemotherapy and radiation treatment.

Patients who have had breast-conserving surgery (lumpectomy or partial mastectomy) and have margin involvement with tumor cells may be candidates for mastectomy if margin re-excision fails or is not technically or aesthetically possible. Clear or negative margins after removal of an initial tumor are an important component in lowering the likelihood of recurrence. Mastectomy is also recommended for individuals with recurrent breast cancer who have previously had lumpectomy and radiation therapy.

In rare instances, mastectomy may be an option for risk reduction or prophylaxis in individuals who do not have a cancer diagnosis. Patients who are found to have a harmful BRCA genetic mutation are at an elevated risk of developing breast cancer throughout their lives. Carriers of the BRCA1 or BRCA2 mutations have an 80 to 85 % lifetime chance of developing breast cancer.

Contraindications to mastectomy

If medically recommended, mastectomy may usually be performed safely and easily. There are a few critical issues to consider as surgical contraindications. These are frequently divided into two categories: systemic and locoregional. In individuals with established distant metastatic illness, mastectomy may be contraindicated. Furthermore, due to the burden of their general health and low-performance status, weak or elderly patients with major medical co-morbidities or systemic organ failure may not be candidates for surgery.

Patients who are at a high risk of death from surgery or anesthesia are not suitable for surgery. Mastectomy may be comparatively contraindicated in patients with advanced locoregional illness at the time of diagnosis if there is skin or chest wall involvement and concerns about the capacity to seal the surgical incision or obtain a negative surgical margin. In some cases, neoadjuvant chemotherapy, radiation, or hormone therapy may be beneficial in reducing the volume or extent of local illness and allowing for surgery.

Types of Mastectomy

Unilateral vs. bilateral mastectomy

Preventive (prophylactic) mastectomies are also done bilaterally in persons who are at high risk but have not been diagnosed with breast cancer. Many women who have early-stage cancer in one breast have the option of having a unilateral or bilateral mastectomy. It's not always an easy choice.

Some women choose a bilateral mastectomy even though unilateral mastectomy is an option for them because of:

Concerns about the cosmetic appearance of the chest if only one breast is removed or reconstructed. Fear that new second breast cancer will develop in the unaffected breast.
Concerns about the ongoing need for surveillance. Concerns about the possible need for future biopsies in the unaffected breast.

Over the last two decades, an increasing number of women in the United States who have been diagnosed with early-stage breast cancer in one breast have opted for a bilateral mastectomy. Contralateral prophylactic mastectomy refers to the removal of the other breast that does not have cancer.

A simple mastectomy involves the surgeon removing all of the breast tissue, skin, nipple, and areola (the dark area around the nipple) Typically, the surgeon will also conduct a sentinel lymph node dissection, which involves the removal of 1-3 lymph nodes beneath the arm on the side of the tumor to determine whether cancer has migrated there. Sentinel lymph nodes are the first lymph nodes to which cancer might spread.

Lymphatic mapping is performed the day before, the morning of, or during surgery to assist the surgeon in locating the sentinel nodes. In this procedure, a radioactive liquid, a blue dye, or both are injected beneath the nipple or near the tumor location. In Radical mastectomy, the surgeon removes all of the breast tissue, skin, nipple, and areola during a modified radical mastectomy. The surgeon will also do an axillary lymph node dissection, which means that many lymph nodes (typically approximately 10) beneath the arm on the tumor's side will be removed to see if cancer has migrated there.

Breast-sparing mastectomy

A nipple-sparing mastectomy removes all of the breast tissue but leaves the nipple, areola, and skin of the breast intact. Lymph nodes are typically removed as well in order to determine whether cancer has progressed beyond the breast (unless the mastectomy is prophylactic). Depending on your exact diagnosis, a sentinel lymph node dissection or an axillary lymph node dissection will be performed. In addition, tissue from beneath the nipple and areola is taken to look for cancer cells. If cancer is discovered in that area, the nipple and, in most cases, the areola must be removed.

This is normally done in a separate surgery later on. Another reason the nipple may require removal in a separate treatment is if it lacks adequate blood flow and develops necrosis (tissue breakdown). During a nipple-sparing mastectomy, the breasts are usually promptly rebuilt with tissue expanders, breast implants, or tissue flaps. If the nipples must be removed, they can be rebuilt afterwards via nipple reconstruction surgery, nipple tattoos, or both.

Because treatment produces superb, natural-looking aesthetic outcomes with minimum scars, nipple-sparing mastectomy with rapid reconstruction has grown in popularity. However, if you get a nipple-sparing mastectomy, you should not expect much (or any) feeling in your nipples following the operation. Also, following this operation, your nipples may appear to be erect all of the time. If you have a tumor near or affecting the nipple or areola, you may not be a candidate for nipple-sparing mastectomy.

Furthermore, the operation is not advised for those with inflammatory breast cancer. Being a smoker, having scarring around the nipples from previous operations, or having had radiation to the breast in the past might reduce your chances of getting a favorable result from a nipple-sparing mastectomy. In certain situations, having big and sagging breasts might make getting a decent aesthetic outcome after a nipple-sparing mastectomy more challenging.

There is a risk, for example, that the nipples will not be in the proper place. In this case, your surgical team may advise you to undergo a series of surgeries. For example, you might have a lumpectomy followed by a breast lift or reduction (or both), and then your nipple-sparing mastectomy as a second operation. Mastectomy with skin preservation The surgeon removes all of the breast tissue, the nipple, and in rare circumstances the areola during a skin-sparing mastectomy, but the majority of the skin above the breast remains intact.

Preparation for Mastectomy

Mastectomy is often an elective operation, and patients are expected to report to the hospital or surgical facility on the day of their procedure. Patients having a mastectomy, with or without axillary surgery or reconstruction, should get pre-operative antibiotics to decrease the risk of surgical site infection. Unless the patient is allergic or has a history of methicillin-resistant Staphylococcus aureus infection, a first-generation cephalosporin is the antibiotic of choice for prophylaxis.

After anesthesia is administered, the patient is placed in a supine posture in the operating room, and the breast, chest wall, axilla, and upper arm are exposed. Many surgeons will include the contralateral breast in the surgical field. The surgical field is sterilely prepared using an agent that reduces the presence of skin flora and the risk of surgical site infection. For surgical antisepsis, alcohol-based skin preps such as chlorhexidine gluconate are commonly used.

Surgeons should prepare patients for their surgery and discuss the expected postoperative course and care with them perioperatively. Many surgeons choose to insert a drain during the mastectomy to remove any fluids that may build in the wound bed and to enhance flap adhesion to the chest wall. Patients benefit from teaching on drain maintenance and keeping an accurate output journal. Patients should also be counseled about postoperative restrictions such as lifting, driving, and any other limits in the initial recovery period.

Surgical Technique

While surgical excision of the breast dates back to the 18th century, William Halsted detailed his radical mastectomy approach in 1894, stating that "suspected tissue should be removed in one piece." This aggressive procedure is a total en bloc resection of the breast, including the pectoralis major muscle and regional lymphatics.

With this method, a large quantity of skin was lost, and a skin transplant was frequently required for covering of the chest wall defect. Women were left with major malformations and impairments as a result of this treatment. As a result, various improvements to the procedure have been made in order to lessen the morbidity of the surgery. David Patey improved the Halsted radical mastectomy in the 1940s by maintaining the pectoralis muscle, and his outcomes were good for less postoperative problems such as discomfort, lymphedema, and upper extremity movement impairments.

In 1972, John Madden described the current norm for a mastectomy. This method entails creating an elliptical incision around the breast, including the nipple areolar complex, and preserving the tumor location as a focal marker. The breast tissue is separated from the skin flaps and removed across the pectoralis major fascia, while both pectoral muscles are preserved. As a result, minimal damage of neighboring neurovascular and lymphatic tissues is required.

Madden's modified radical mastectomy procedure originally included level I-III axillary lymphadenectomy for staging purposes, and this was assumed to have a therapeutic advantage as well. Total mastectomy, in contrast to this modified radical mastectomy approach, refers to the surgical removal of entire breast tissue. However, axillary node dissection is not required.

Nipple-sparing mastectomy removes the mammary tissue and pectoral fascia while leaving the nipple-areolar complex and the whole skin envelope of the breast intact. Only patients having urgent breast reconstruction are given this surgical method. It is crucial to maintain blood flow to the nipple-areolar complex using this method to avoid flap ischemia or collapse.

All of the abovementioned mastectomy procedures generate uniform flaps by dissecting just above the superficial layer of the breast's superficial fascia. The appropriate flap thickness has been hotly debated, with the ultimate objective of eliminating all feasible breast tissue while retaining skin viability. As previously stated, regardless of the style or location of skin incision employed, mastectomy dissection should continue until the anatomic borders of the breast.

While the surgeon retracts the breast tissue away from the surrounding tissue, the flaps are lifted and retracted at a right angle to the chest wall. The skin flap is elevated superiorly to the clavicle, laterally to the anterior boundary of the latissimus dorsi, medially to the sternal border, and inferiorly to just below the inframammary crease. Once the overlaying flaps have been dissected, the breast is excised with the pectoralis major muscle, working from the superomedial to the inferolateral border. A closed suction drain is frequently implanted in the wound bed behind the skin flaps, and the incision is closed in two layers with absorbable suture.

Mastectomy Complications

In most cases, patients handle mastectomy successfully, with little morbidity and death. However, various difficulties are conceivable. Seroma or hematoma development, wound infection, skin flap disintegration or necrosis, and lymphedema are examples of these. A seroma is a collection of fluid in a surgically produced cavity caused by artery and lymphatic transection.

To slow the growth of seromas, most surgeons employed closed suction drains beneath the skin flaps. Surgical site infection affects roughly 8% of people following breast surgery. Staphylococcus aureus and Streptococcus epidermis are the most prevalent organisms implicated, and infections should be treated with an appropriate antibiotic, with or without wound opening. Similarly, flap necrosis affects roughly 8% of patients and is associated with insufficient blood flow to the flap, wound closure under strain, obesity, and style of incision. Necrosis is treated with debridement and, if necessary, skin transplant covering.

Lymphedema has been less prevalent since the introduction of modified mastectomy methods. With a reported prevalence of more than 20%, axillary lymph node dissection is the most major risk factor for the development of lymphedema. Lymphedema develops in 3.5 to 11% of individuals who receive sentinel lymph node biopsy. Early intervention with physical therapy and decompressive massage techniques in individuals who acquire lymphedema can assist prevent development and, in some situations, minimize lymphedema.

Conclusion

Mastectomy is the sole breast cancer surgical option for some women. The surgical removal of the whole breast is known as a mastectomy. Since Halsted originally reported his drastic surgery in the late 1800s, there have been considerable breakthroughs in the patient care of breast cancer patients. Breast conservation is becoming more popular, and various studies have been conducted to evaluate the efficacy of breast-conserving surgery to traditional mastectomy approaches.

Some women are given the choice between mastectomy and lumpectomy (commonly known as breast-conserving surgery) plus radiation therapy, and they choose mastectomy.