What to know about double mastectomy?

What is a double mastectomy?

A double mastectomy is an operation to remove all of the breast tissue from both breasts. This may reduce your risk of breast cancer if you have a strong family history of breast cancer or the gene mutation called BRCA1 or BRCA2. The operation takes about 1-3 hours and you should be in the hospital for 1-2 nights. There are different ways of doing a mastectomy and you should discuss with your surgeon which is the best operation for you. These include skin sparing mastectomy (removal of all breast tissue but leaving skin behind), nipple sparing mastectomy, and immediate or delayed breast reconstruction. Your surgeon should discuss the advantages and disadvantages of each of these procedures with you to help you make a decision about which is best for you. Breast cancer in men is very rare. If a man is found to have a gene mutation that greatly increases the risk of breast cancer, he may also consider having a double mastectomy. It is important for men to be aware that there is a risk of lymphedema in the arm of the side of surgery. This is more common in men, and following removal of both breast tissue, they may be at an increased risk of developing breast cancer. It would be ideal for men to discuss this decision with a specialist breast surgeon.

Preparation

Make sure you have someone to drive you to the hospital the morning of surgery and that you will have someone to stay with you the first night home. You will need to discontinue any medications that thin the blood several days before surgery. This includes aspirin and medications containing aspirin. If you are over 50 or have a history of heart problems, lung problems, or blood clots, you will need to get a preoperative EKG and chest x-ray. These tests will be obtained through your primary care or the physician who specializes in the corresponding condition. You will also need to get a laboratory test within two weeks of the surgery. A form will be given to get a CBC with differential, PT, and PTT. This form should be taken to the outpatient laboratory. Getting all these tests can be a lot to remember, so be sure to obtain a written list from your surgeon. You will need to obtain a perioperative antibiotic at the outpatient pharmacy. This can be ordered by your surgeon. In the days coming up to your surgery, you may feel excited that something is finally happening. You may feel anxious about the unknown and the changes that are about to happen. You may feel frightened about the thought of surgery and hospitalization. You may feel relieved that something is finally being done about your breast cancer. You may feel angry that you have to go through the surgery in the first place. You may feel a number of these emotions or none of them at all. They are all normal reactions, but it is important to recognize them and talk about them. Ignoring your feelings will not make them go away.

During surgery

Surgical Technique

There are different types of mastectomy surgery with varying surgical techniques. Your surgeon will have discussed the most appropriate option for you. Subcutaneous mastectomies involve removing breast tissue but not breast skin. Skin sparing mastectomies preserve most of the breast skin to aid reconstruction and healing. Nipple sparing mastectomies attempt to remove all breast tissue from within the breast envelope and areola, leaving only the skin. Double incision mastectomies are usually required for larger chests and involve removal of the breast tissue and breast skin with free nipple grafts. This is the most common form of mastectomy surgery for FTM, large chested, or overweight patients.

Incision

The type and size of the incision will be determined by the surgical technique and your body shape. Skin sparing mastectomies usually involve an incision around the nipple and areola, or a horizontal incision. The double incision is made below the breast and can either be straight or curved. Nipple sparing mastectomies and subcutaneous mastectomies involve an incision around the areola and not across the breast. Your surgeon will have discussed these options with you during the consultation, taking into account your wishes.

Anaesthetic

The type of anaesthetic given during a mastectomy is dependent on a number of factors. These include your health state, the surgeon’s preference, the surgical technique being used, and how long the surgery will take. General anaesthetic is most commonly used, putting you to sleep for the duration of the surgery. Local anaesthetic may also be used, especially when checking the position of the mastectomy in relation to the tumor.

Recovery tips

Rest as much as possible. Accept any help that is offered to you.Take at least a couple of weeks off work. You need to use your energy to recover. Physically, and emotionally. Do gentle exercises with your arms to increase your mobility. It may be helpful to ‘set your post op puppy’, by putting your arms on a pillow in front of you. Try using a set of small weights to increase the mobility in your arms and shoulders, don’t overdo it. Try taking up some yoga classes over the months, it gently helps your mobility and is good for the soul. Don’t try and do a headstand! You may have to wear drain bottles for a week or two. Fill your spare time by doing things you enjoy and that relax you. This will help to speed up the recovery process. For example, reading, gardening, painting. If you usually sleep on your side you may find it more comfortable to sleep in a semi-reclined position. Use several pillows to prop yourself up so you’re not completely flat. It may also be a good idea to put a towel or sheet over the bottom sheet of your bed in case you have any night sweats. You can throw the towel off in your sleep and it saves you having to completely change your bed in the middle of the night! Night sweats are quite common with stress. Stress is also the cause of nightmares. Gradually over time the stress of the operation will subside and so will the night sweats and nightmares. If they don’t and you have a higher body temperature, or any other signs of infection, consult your doctor, as this can be a sign of an infection due to the seroma. High body temperature, severe aches, and a fever are signs of an infection due to the wound. It’s unlikely you’ll need antibiotics, but it’s still advisable to get a doctor’s opinion.

Reconstruction

Choice of Surgeon and Place of Surgery

It is important to find a surgeon who specializes in breast reconstruction. It may be possible to be referred to a surgeon at a different institution if the closest one to you does not meet your requirements. Due to the broad range of options and complexity, it may be beneficial to be seen at a large hospital offering a range of specialties. This also ensures access to immediate treatment in the unlikely event of surgical complications.

Choice of Surgery

For most women, there are several options, each with its own advantages and disadvantages. Some women will not be able to choose among all the options due to the limitations of their medical situation, so it is important to find a reconstructive surgeon who is experienced with many techniques. The three main categories of reconstructive surgery are:

1. Implant-based reconstruction, which is usually the quickest and simplest. It involves insertion of a silicone or saline implant. Due to the potential risks of future surgery under adverse circumstances caused by the progression of breast cancer or a different problem with the implant, and the fact that the implant may need to be removed and/or replaced, implant-based reconstruction may not be a good choice for younger women.
2. Autologous tissue reconstruction, which involves the creation of a new breast (or breasts) using tissue from elsewhere in your body (usually the abdomen or back). This tissue may be tunneled beneath the skin to the chest from a distant site in a procedure called TRAM flap. Autologous tissue reconstruction is more complex and has a longer recovery period, since there are essentially two surgical sites drawing on the same energy reserves. However, unlike an implant, the reconstructed breast made of living tissue will change and age with the rest of your body. Also, with no foreign body in place, there is less concern about long-term complications. Autologous reconstruction can sometimes partially be performed at the time of mastectomy in a procedure called skin sparing mastectomy.
3. A third less common option is the creation of a breast from a composite of autologous tissue and allografts (donated human tissue).

The third option is a combination of the first two, sometimes called « tissue expander and implant ». This can be thought of as a delayed form of implant-based reconstruction. The first stage involves insertion of a « tissue expander » which is slowly enlarged by injection of saline over a period of time. This is done by a plastic surgeon in the outpatient clinic. After several months of expansions to gradually stretch the skin, the tissue expander is replaced by an implant in a minor surgery.

Reconstruction post-mastectomy or post-lumpectomy is never easy, but it is an option for most women and an important step towards feeling whole again. The timing of your reconstruction will depend on your medical situation, personal preferences, other treatments, and the requirements of your insurance provider.

Side effects

Numbness and swelling in the upper arm on the same side as the breast removal can occur. This condition is known as lymphedema. The onset occurs soon after surgery or may occur months or years later. A feeling of tightness in the arm may occur and lasts for a long time. If severe, lymphedema can be decreased through physical therapy. Pain in the underarm, shoulder, and/or chest area is a common side effect of surgery, though it may last only a short time. It is unclear whether the pain, discomfort, and limited arm and shoulder movement are caused by the surgery itself or the removal of many lymph nodes. These side effects can be decreased through physical therapy, though it often takes many months to decrease the symptoms and the patient may need to continue the exercises indefinitely. Stiffness in the arm on the side of the surgery can be caused by the removal of many lymph nodes and lasts for a long time. Once again, physical therapy can help to decrease these side effects. In a few patients, radiation therapy can cause a fracture in the shoulder blade or the arm bone. If this occurs, you will need further treatment and a lasting fracture can cause pain and limit movement of the arm and shoulder. Step by step exercises are needed to maintain and improve arm and shoulder movement after a mastectomy. High-dose radiation therapy to the axillary lymph nodes can irritate nerves in the armpit and cause numbness, tingling, pain, and/or weakness in the arm and shoulder on the same side as the breast removal. This condition is known as brachial plexopathy and can occur soon after the radiation or may not occur until many years later. There can be a decrease in the quality of life due to the limits on arm and shoulder movement and the pain and discomfort caused by this condition.

Emotions

The second type of emotions are those related to the treatment of breast cancer. These may include temporary reactions to surgery such as shock, numbness, or perhaps a sense of unreality. Such feelings should gradually give way to a more secure emotional state. You may wish to take some time to fully understand and cope with the surgery chosen. This is normal and should be communicated to the surgeon or specialist. Any lasting feelings of severe depression, anxiety, or anger should be addressed with a more intensive treatment. This can help to improve emotional response, in turn improving physical condition. Note that the stress of deciding on a treatment may cause fatigue and a sense of being overwhelmed. This can be counteracted by having a well-informed understanding of the situation.

Emotions experienced by those with breast cancer can be divided into two main types. The first are reactions to the diagnosis itself. It is common to experience disbelief and anger after being told one has cancer. Many will also experience anxiety and fear. At this time, it is important to communicate emotions to loved ones. Keeping emotions bottled up inside can add more stress at a time when stress is already high. This step may be difficult for those who are used to taking care of others. It is essential to remember that facing breast cancer is a time to concentrate on oneself. It is also a good idea to gather as much information about breast cancer as possible. The more one knows and understands about breast cancer, the less frightening it will seem.

Emotions, or feelings, thoughts, and actions concerning breast cancer and its treatment set apart each individual. The emotional challenge of breast cancer can have a lasting impact on the spirit, quality of life, and even recovery. While there is no specific way to predict how breast cancer will affect emotions, many individuals with breast cancer have reported struggling with intense emotions. Understanding and addressing these emotions can improve quality of life and possibly even improve the chance of recovery.