Removal of the breast (mastectomy): total, partial, unrolled

Mastectomy or breast removal is breast surgery, performed in the context of certain breast cancers. What are the directions? When to consider it? How’s it going ? A mastectomy partial ? Total ? Is it painful? When to do a preventive mastectomy? All the answers with Dr. Françoise Rimareix, Head of the Oncological Breast Surgery Department at Gustave Roussy.

What is the definition of a mastectomy?

There non-conservative breast surgery (or mastectomy) is a surgical procedure performed under general anesthesia which consists of remove the entire mammary gland with more or less skin, we can in some cases keep the areola and the nipple. It is needed in about a third of breast cancers.

What is a partial mastectomy?

A partial mastectomy involves remove the tumor and some of the healthy tissue around it.

What is a total mastectomy?

The total or simple mastectomy consists of remove all of the breast and the tissue covering the chest muscles (pectoral fascia).

What are the indications for breast removal?

There are several indications for a mastectomy:

• large tumor relative to breast volume
• multiple tumors in the same breast
• cancer showing signs of inflammation first treated with chemotherapy
• recurrence of breast cancer that has already been treated with conservative surgery and radiotherapy
• after the first conservative surgery, when the histological analysis shows that it is necessary to complete the surgical treatment and that there is still some tumor on the microscopic analysis

When is the breast removed?

In general, the indication for removal of the breast is made when it is estimated that conservative treatment of the breast would involve a significant risk of local recurrence or incomplete treatment at the level of the breast. These situations correspond precisely to cases where the tumor exceeds a certain size or a certain proportion in relation to the size of the breast:

• An invasive breast cancer whose volume represents more than a third or half of the breast. The surgeon judges whether the remaining volume of the breast is sufficient or not to be able to have a satisfactory shape. If this is not the case, it is better to remove the breast with reconstruction.
• An invasive cancer that has not decreased in volume after chemotherapy
• An extensive in situ cancer whose size does not allow a satisfactory aesthetic or oncological result to be obtained. In this case immediate reconstruction is almost always possible.
• Multifocal tumors (several tumors in different quadrants in the same breast).
• Recurrences of breast cancer already treated with conservative treatment.
• Prophylactic surgery in certain situations, after validation in CPR.

Who should do a preventive mastectomy?

For 10 years in France, this surgical operation, called preventive mastectomy, can be done when there is a high risk of developing breast cancer. These are women with a strong genetic predisposition on the BRCA 1 and BRCA 2 genes. Their probability of declaring breast cancer may be 80%. It is currently estimated that 8% of breast cancers are linked to a genetic anomaly. In the general population, nearly one woman out of 9 in France had, has, or will have breast cancer before the age of 70. But in the event of an alteration of the BRCA1 gene, 65% of women will have been treated for breast cancer before the age of 70 and 40% before the age of 50. Even if these figures are high, it still means that a woman can be genetically predisposed and never get breast cancer. In prevention, two options are offered to predisposed women: regular monitoring and mastectomy.

The patient is received by the surgeon who is going to operate on him, so that the intervention is explained to him (the preparation, the procedure and the postoperative course) and that he can ask all the questions that concern him. “A consultation is also planned with an anesthesiologist, explains Dr. Françoise Rimareix, Head of the Oncological Breast Surgery Department at Gustave Roussy. The patient is questioned about his medical and surgical history, in particular allergic, cardiac, respiratory, renal, thromboembolic, as well as the treatments followed. He is also questioned about his tobacco consumption which has a great impact on the complications that can occur after surgery.“. A number of examinations may be prescribed (electrocardiogram, blood tests). If the patient suffers from dental problems (in particular loose teeth), he is invited to consult a dentist before the intervention, if time permits.

► During the procedure, the lymph nodes in the armpit (axillary region) are removed then analyzed to see if the cancer has remained localized or if it has spread. Either we just remove the sentinel lymph node, which is the first lymph node that can be affected by cancer, or an axillary dissection is done where between 10 and 20 lymph nodes are removed.

► Depending on the case, the mastectomy should be followed by chemotherapy or radiotherapy. Mastectomy is performed under general anesthesia, by a breast surgeon. It requires a few days of hospitalization. During the operation, the surgeon removes the entire mammary gland. The amount of skin removed depends on the type of cancer.

► In some cases, the areola and the nipple are left in place and at the same time an immediate reconstruction of the breast by implant is performed. “This immediate reconstruction is obligatory when the areola and the nipple are kept. It can be done even if treatments such as chemotherapy or radiotherapy are planned, reminds the doctor. These surgeries are performed in expert centers after a decision in a multidisciplinary consultation meeting and a concerted choice with the patient.“.

Is mastectomy painful?

For 3 years, the anesthetist has been performing loco-regional anesthesia by a nerve block before or during general anesthesia, this makes it possible to considerably reduce the postoperative analgesic drugs which are systematically prescribed and adapted to the intensity of the pain. Pain of neurological origin in the chest wall and at the level of the hollow of the armpit can persist in the event of associated dissection of the lymph nodes. “It is necessary to rehabilitate the arm the day after surgery, continues the specialist. An edema of the arm called lymphedema can appear in 10% of cases in the event of axillary dissection and then requires long-term management.“.

What are the consequences after the mastectomy?

Radiotherapy or chemotherapy treatments may be implemented after the mastectomy. In any case, regular medical follow-up will ensure that there is no recurrence and that the cancer has not metastasized.

Breast reconstruction

Any woman, regardless of her age or the degree of advancement of her breast cancer can, if she wishes, be a candidate for reconstruction subject to her general state of health and in particular her risk factors for complications after the surgery (smoking, significant overweight). “Different types of reconstruction are possible: placement of silicone prostheses under the muscle or under the skin, placement of flaps of skin with fat with or without muscle taken from the stomach (DIEP) or in the back (latissimus dorsi) or on another part of the body (thigh, buttock)explains Dr. Rimareix. There is also the technique of lipofilling or lipomodeling where only fat from the thighs or belly is used, which is removed by liposuction and which is reinjected to redo all or part of the breast.“. The technique is chosen by the surgeon according to the choice of the patient and according to her risk factors for complications. A technique is chosen where the benefit of the reconstruction is always greater than the risk of complications.

Thanks to Dr. Françoise Rimareix, Head of the Oncological Breast Surgery Department at Gustave Roussy