Breast removal: the main types of surgery and their consequences

In many cases, mastectomy is an inevitable stage of treatment for cancer in this location, and sometimes the only possible way to get rid of the oncological problem or prolong life. Although cancer is unpredictable, and even such an operation, alas, does not guarantee the cessation of the pathological process...

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Indications for mammary gland removal

Indications for mammary gland removal accepted in clinical mammology are mainly related to malignant neoplasms. Most doctors insist on performing a mastectomy if:

• the woman has tumors in more than one quadrant of the breast;
• radiation therapy has already been performed on the affected breast;
• the tumor is more than 5 cm in diameter and has not shrunk after neoadjuvant chemotherapy;
• The biopsy showed that the initial segmental resection of the tumor had not removed all of the cancerous tissue;
• the patient has connective tissue diseases such as systemic lupus or scleroderma, which cause very severe side effects from radiation therapy;
• the tumor is accompanied by inflammation;
• The woman is pregnant, but radiation therapy is not possible due to the risk of harm to the fetus.

This method is recognized as the main way to prevent breast cancer recurrence, especially when a BRCA gene mutation is detected. At the same time, leading world experts in the field of mammology note that complete removal of the breast affected by cancer reduces the risk of tumor recurrence in the same breast, but does not exclude the possibility of cancer appearing in the other breast.

Preparing for breast removal

The operation is prescribed when the patient has been diagnosed, i.e. mammography has been performed and a biopsy of the tumor tissue has been performed. Therefore, preparation for mastectomy is limited to a general blood test, repeated chest and breast X-rays, and an electrocardiogram (ECG).

When referring a woman for surgery, the doctor must make sure that the patient has not taken any blood thinning medications (aspirin, warfarin, phenylin, etc.) several days before the scheduled surgery (or better yet, a couple of weeks before it). The surgeon and anesthesiologist must also be informed about the patient's use of any herbal preparations or herbal infusions. Thus, stinging nettle, water pepper, yarrow, and ginkgo biloba leaves can increase the risk of bleeding and, therefore, should not be used at least two weeks before any surgical intervention.

A dose of antibiotics may be administered to prevent inflammation. The patient should stop eating 8-10 hours before the operation.

Breast Removal Surgery

Such surgical intervention as removal of mammary glands in women has various modifications that are designed to solve specific problems taking into account the diagnosis of a particular patient, the clinical picture and stage of the identified disease, the degree of damage to the gland itself, as well as the involvement of the surrounding tissues and regional lymph nodes in the pathological process.

Removal of breast cancer, especially large tumors in later stages of the disease or when tumors may occupy a significant area within the contours of the breast, can be performed by a simple or total mastectomy. That is, the surgeon removes all breast tissue and an ellipse of skin (including the skin of the nipple), but does not remove the muscle tissue under the breast. In this type of surgery, a biopsy of the nearest (control or sentinel) lymph node is always performed. The postoperative scar is usually transverse.

A skin-sparing approach to breast removal (subcutaneous mastectomy) is practiced, in which the tumor, all breast tissue, nipple and areola are removed, but almost 90% of the breast skin is preserved, the incision and, accordingly, the scars are smaller. However, if the breast is large, then the incision is made downwards, and then the scars after breast removal will be larger.

Resection of the gland is also performed with preservation of the nipple and areola, but this is only possible when the tumor is located at a significant distance from the nipple area. In this case, an incision is made on the outer side of the breast or along the edge of the areola and all tissue is removed through it. In modern clinics, this method includes either simultaneous reconstruction of the gland or placement of a special tissue expander in place of its removed structures for subsequent breast reconstruction.

In radical resection of a widespread malignant neoplasm, it is necessary to remove not only all structural parts of the gland, but also the underlying chest muscles, tissue from the armpits, axillary lymph nodes, and often deeper tissues. If the milk gland is removed together with the internal mammary lymph node, then an extended radical mastectomy is performed.

All these operations have a clear methodology, and specialists know what is at stake when it is necessary to perform a mastectomy according to Halsted, Patey or Madden.

When an anomaly such as an accessory mammary gland is formed in the armpit area, the accessory mammary gland is removed. Usually, glandular and fatty tissues predominate in the structure of the extra organ; they are cut out, the muscle tissues are stitched, and a suture is applied on top, which is removed after about a week. If the accessory gland is large, the fat can be removed by pumping it out.

It should be noted that the cost of a mastectomy operation depends on the stage of the disease, the size and location of the tumor and, of course, on the status of the medical institution and the prices of the pharmacological agents used.

Removal of both breasts

The above surgical methods are also used to remove two mammary glands, a double or bilateral mastectomy. The need for such an operation may be caused by the presence of a tumor in one breast and the woman's fear of the risk of developing cancer in the other, contralateral breast. Most often, such fears haunt women who have a family history of gynecological oncopathologies.

As you may recall, the topic of Angelina Jolie and the removal of mammary glands has been discussed for a long time, since the contralateral mastectomy surgery performed by the actress in 2013 was preventive, that is, it prevented the development of breast cancer. In addition to the fact that her mother and grandmother (Marcheline and Lois Bertrand) died of ovarian and breast cancer, the results of genetic analysis for BRCA confirmed a high (up to 87%) risk of developing malignant neoplasms in the actress's breast. As reported, after the resection of both breasts, the probability of developing cancer in Jolie decreased to 5%.

Even with a complete double mastectomy, not all breast tissue that may be at risk for developing cancer in the future may be removed, according to the National Cancer Institute. In addition, the surgeon cannot remove tissue from the chest wall or supraclavicular area during this procedure, but breast stromal cells may be present.

Sectoral removal of the mammary gland

Sectoral mammary gland removal (segmental resection or lumpectomy) is a gland-preserving and less invasive surgical method, when the tumor itself and part of the surrounding normal tissues (without atypical cells) are resected. In this case, regional axillary lymph nodes can be removed through a separate incision. This technique is applicable for stage I-II cancer, and 5-6 weeks of radiation therapy should be performed after surgery.

By means of resection, a focus of chronic purulent mastopathy, as well as a large hormone-dependent benign cystic or fibrous formation, can be removed from the mammary gland. However, only phylloid fibroadenoma of any size that threatens malignancy and significant fibrocystic neoplasias prone to degeneration are subject to mandatory resection. Although fibrosis of breast tissue reappears in almost 15 cases out of 100.

In other cases, enucleation (excision) or laser therapy is performed, and removal of a breast cyst can be performed without excision: by sclerosing its cavity through aspiration.

Male Breast Removal

In case of oncological diseases of the mammary glands, the mammary glands are removed in men. Regardless of age, mastectomy is considered a medical necessity when there is a fear that breast enlargement in a man may be carcinoma of the mammary gland. Naturally, the final decision on the need for surgical intervention is made only after a comprehensive examination - with mammography and biopsy.

Pathologically enlarged glandular tissue is also removed in cases of gynecomastia in men over 18 years of age when testosterone hormone therapy is ineffective.

In adolescence - against the background of hormonal imbalance of the pubertal period, mastectomy is not performed, since this pathology can spontaneously regress over time. In addition, mastectomy before the completion of puberty can cause a relapse of gynecomastia.

In cases of elementary obesity in adult men, which is often manifested by excess deposition of fatty tissue in the mammary glands, liposuction can be used.

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Consequences of breast removal

A natural consequence is pain after breast removal, which is relieved by taking painkillers (primarily NSAIDs). Also, this operation is characterized by the release and accumulation of significant volumes of serous fluid in the wound cavity and under the skin. To remove it, wound drainage is mandatory for at least seven days. In addition, a fairly tight elastic bandage is applied around the chest, and it must be worn for at least a month.

Experts note the following main complications after breast removal:

• postoperative bleeding and hematomas;
• temperature associated with suppuration of the postoperative wound or necrosis of poorly supplied blood tissues at the incision site;
• damage to the skin of the chest by beta-hemolytic streptococcus, which causes erysipelas;
• as a result of scarring of the cut tissues, scars are formed, this process often causes discomfort and can be painful;
• development of a more prolonged neuropathic pain syndrome, which manifests itself as stabbing pain, numbness and tingling in the chest wall, armpit or arm;
• depressive mood, feeling of inferiority.

Almost always, after a month or a month and a half, a violation of the natural outflow of interstitial fluid appears and lymphostasis develops. This violation is especially pronounced due to the cessation of normal lymph flow during the removal of the axillary lymph nodes. Lymphostasis leads to the fact that on the side of the removed organ not only swelling of the arm appears, but also numbness of the skin on the inner surface of the arm. Frozen shoulder syndrome is also noted - a short-term or longer limitation of the range of motion of the arm in the shoulder joint. This syndrome can appear within several months after surgery, and its cause lies in damage to the nerve endings located in the area of surgical intervention.

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Recovery after breast removal

You can get up and walk after 1.5 days after the operation, but it is not recommended to force the restoration of motor activity: it should be gradual, since the stitches are removed approximately 1-2 weeks after the operation.

Most patients recover from breast removal within 4-6 weeks, but it can take longer (this largely depends on the complexity of the surgery and your overall health).

The list of things that are prohibited after a mastectomy includes prohibitions on:

• taking a shower (and bathing) before the stitches are removed;
• physical activity, heavy lifting and vigorous movements;
• exposure to heat and UV radiation;
• any injections into the arm on the side of the removed breast;
• swimming in ponds and pools (at least two months);
• sexual contacts (within 1-1.5 months).

In connection with lymphostasis, mammologist surgeons give their patients the following recommendations after breast removal:

• maintain personal hygiene and clean hands;
• avoid injuries to the hands that damage the integrity of the skin, and in the case of even the slightest scratch, use antiseptics;
• do not sleep on the side on which the gland was operated;
• wear a special elastic bandage (providing soft compression to improve lymph flow and reduce swelling);
• do massage regularly: in the form of ascending strokes of the hand in the direction from the fingers to the shoulder joint.

After the stitches are removed, it is necessary to purposefully develop the arm. Gymnastics consists of the following exercises:

• in a standing or sitting position, raise your straight arms to the sides and up;
• in the same position, place your hand behind your head (at first you can help with your other hand);
• in a standing position, bend your arms at the elbows in front of your chest and raise your elbows to the sides as high as possible;
• in a standing or sitting position, place your hands behind your back.

The diet should include enough calories, but be light, that is, fatty and spicy foods are not recommended, as well as sweets. It is useful to eat more often, but in smaller portions, the diet should include regular products (cereals, meat, fish, dairy products, vegetables and fruits). Animal fats should be replaced with vegetable fats, and the consumption of salt and sugar should be reduced.

Treatment after mastectomy

Oncological patients undergo treatment after mammary gland removal – adjuvant therapy. At any stage of cancer after complete or partial mammary gland removal, in order to destroy the remaining atypical cells and avoid relapse, chemotherapy (with Cyclophosphamide, Fluorouracil, Mafosfamide, Doxorubicin, Xeloda, etc.) and a course of radiation therapy are prescribed.

If the tumor is a hormone-dependent neoplasm, hormonal drugs are used. The tablet anti-estrogenic drug Tamoxifen (other trade names: Zitazonium, Nolvadex, Tamoplex, Cytofen, Zemid, etc.) is taken 1-2 times a day, 20-40 mg.

Toremifene (Fareston) is prescribed to women after menopause; the standard daily dosage is 60 mg, but the doctor can increase it 4 times (up to 240 mg).

The drug Letrozole (Femara, Letrosan) also suppresses the synthesis of estrogen in the body; it is prescribed only to patients aged once a day, one tablet (2.5 mg). Anastrozole tablets (synonyms - Arimidex, Anastera, Selana, Egistrazol, Mammozol, etc.) are not prescribed to women in premenopause; the drug should be taken 1 mg once a day.

The anticancer effect of drugs for targeted therapy is achieved by precisely targeting the molecules of cancer cells that ensure tumor development. Thus, drugs of this group are able to stabilize the pathological process and prevent relapse of the disease. Targeted drugs Bevacizumab (Avastin), Trastuzumab (Herceptin) are used intravenously once every two or three weeks; Lapatinib (Tyverb) in tablets (orally 1000-1250 mg per day).

Life after breast removal

The main thing to remember is that life continues after breast removal, although for all women who have undergone such an operation, it is already a slightly different life...

Firstly, a woman receives disability after a mastectomy. Specifically: according to the "Instructions for establishing disability groups" approved by the order of the Ministry of Health of Ukraine (No. 561 of September 5, 2011), a unilateral mastectomy suffered by a woman due to a malignant neoplasm is an indisputable basis for establishing disability group III - for life (i.e. without the need for periodic re-examination).

Secondly, it concerns the reconstruction of the lost gland (plastic surgery) or the creation of the appearance of its presence. The second option is, of course, much cheaper and can be temporary.

You can choose or order breast pads, as well as removable prostheses – textile or silicone.

Today, so-called exoprostheses for women who have lost their breasts are produced by many companies in a wide range: these are fabric prostheses for the first time, and silicone ones for permanent use, in various sizes and modifications.

There is also a large selection of orthopedic underwear, as you will need a bra to fix the breast prosthesis. These are quite elegant and at the same time functional and comfortable bras with "pockets" into which the prosthesis is inserted, and wide straps. Special swimsuits are also sold.

Plastic surgeons themselves claim that plastic surgery after mastectomy is a complicated and rather expensive operation. This may be a plastic surgery to install a silicone implant or mammoplasty using tissues taken from other parts of the body (skin, subcutaneous tissue, muscles). But in any case, a woman gets a mammary gland that is very similar to a natural organ, which, of course, has a positive effect on the overall emotional and psychological state of patients who have undergone mastectomy.