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Mastectomy

Mastectomy
Literature review current through: Jan 2024.
This topic last updated: Dec 20, 2022.

INTRODUCTION — Mastectomy (complete removal of the tissue of the breast) is one option for the surgical treatment of breast cancer and the only surgical option for breast cancer risk reduction.

This topic will address the types, indications, techniques, and complications of mastectomy. Breast-conserving therapy for breast cancer and the surgical management of regional lymph nodes in breast cancer patients are reviewed separately. (See "Breast-conserving therapy" and "Overview of management of the regional lymph nodes in breast cancer" and "Overview of sentinel lymph node biopsy in breast cancer".)

SURGICAL ANATOMY — The mature adult breast lies between the second and sixth ribs in the vertical axis and between the sternal edge and the midaxillary line in the horizontal axis. Breast tissue also projects into the axilla as the axillary tail of Spence. The breast is comprised of three major elements: skin, subcutaneous tissue, and breast tissue. (See "Breast development and morphology", section on 'Anatomy'.)

The superficial pectoral fascia envelops the breast and is continuous with the superficial abdominal fascia (of Camper). The undersurface of the breast lies on the deep pectoral fascia, covering the pectoralis major and serratus anterior muscles. Connecting these two fascial layers are fibrous bands (the Cooper suspensory ligaments) that represent a natural means of support for the breast.

Axillary anatomy and the techniques of sentinel node biopsy and axillary dissection are discussed elsewhere. (See "Sentinel lymph node biopsy in breast cancer: Techniques" and "Technique of axillary lymph node dissection".)

INDICATIONS FOR MASTECTOMY

Breast conservation contraindicated or unsuccessful — The criteria that preclude breast conservation are presented here briefly and addressed in detail elsewhere. (See "Breast-conserving therapy", section on 'Patient selection for BCT'.)

Inflammatory breast cancer (IBC). For patients with IBC, the standard of care is neoadjuvant chemotherapy followed by modified radical mastectomy and postmastectomy radiation therapy, even if the patient has a complete clinical response to neoadjuvant chemotherapy. (See "Inflammatory breast cancer: Clinical features and treatment".)

Multicentric disease with two or more primary tumors in separate quadrants of the breast. However, ongoing research is assessing techniques that could permit breast conservation for selected multicentric diseases with a satisfactory cosmetic outcome.

Diffuse suspicious microcalcifications on mammography such that the extent of disease is not clearly evident. (See "Diagnostic evaluation of suspected breast cancer", section on 'Mammographic features of breast cancer'.)

A history of prior therapeutic radiation that included a portion of the affected breast, which, with the addition of whole breast radiation therapy (WBRT), would result in an excessively high total radiation dose to the chest wall. This includes patients who had prior breast radiation as well as those who received chest wall radiation for other reasons, such as mantle radiation for Hodgkin's lymphoma (see "Second malignancies after treatment of classic Hodgkin lymphoma", section on 'Breast cancer'). Ongoing studies are assessing partial breast irradiation alternatives to WBRT for these patients, which could permit breast conservation. (See "Radiation therapy techniques for newly diagnosed, non-metastatic breast cancer", section on 'Accelerated partial breast irradiation'.)

Pregnancy is an absolute contraindication to the use of breast irradiation; however, there are some patients in the later stages of pregnancy who, following surgery and/or chemotherapy, may safely defer radiation to after delivery, allowing for breast conservation. (See "Gestational breast cancer: Epidemiology and diagnosis".)

Inability to clear persistently positive resection margins after reasonable attempts at reexcision.

Breast conservation contraindicated or unsuccessful, as an example, large tumor size in relation to breast size. Although neoadjuvant systemic treatment has the potential to downstage large tumors and improve the chances for successful breast-conserving surgery, insufficient response to neoadjuvant chemotherapy or endocrine therapy requires mastectomy. Alternatively, oncoplastic surgery may permit breast conservation in this scenario. (See "General principles of neoadjuvant management of breast cancer", section on 'Patient selection' and "Oncoplastic breast surgery".)

Patient preference — Some patients may choose to have a mastectomy rather than breast-conserving therapy for various reasons, including a desire to avoid postoperative radiation, further screening, or biopsies.

When both breast-conserving surgery and mastectomy are clinically and oncologically acceptable, patients should be presented with the advantages and disadvantages of both approaches. This should include discussion of cosmetic concerns because breast-conserving surgery may result in unacceptable cosmetic results if the patient has a small amount of breast tissue. Discussion should also include a realistic risk assessment of the likelihood of a recurrence or second primary as studies have shown that many women grossly overestimate this risk. Careful review of the risks and benefits of both options, including the long-term complications of mastectomy, the limitations and complications of breast reconstruction, and the absence of a survival benefit from mastectomy, is critical for optimal shared decision making.

Breast cancer risk reduction — For women without a personal history of cancer who carry a known deleterious mutation in a breast cancer susceptibility gene, such as BRCA1/2, TP53, PTEN, STK11, CDH1, or PALB2, bilateral prophylactic mastectomy reduces the risk of developing cancer by more than 90 percent [1-3]. Similarly, for those patients diagnosed with unilateral breast cancer and who harbor a mutation, a contralateral prophylactic mastectomy may be an option. However, the decision about whether to undergo such surgery is based on patient preference, given that with enhanced screening/surveillance, often incorporating magnetic resonance imaging (MRI), there is no demonstrable survival benefit to contralateral prophylactic mastectomy in this patient population. (See "Cancer risks and management of BRCA1/2 carriers without cancer" and "Contralateral prophylactic mastectomy".)

CHOICE OF MASTECTOMY — Types of mastectomy used in modern breast surgery include modified radical mastectomy (MRM), simple (total) mastectomy, skin-sparing mastectomy (SSM), and nipple-areolar-sparing mastectomy (NSM). Radical mastectomy is a legacy procedure that is rarely indicated (figure 1).

Following mastectomy, breast reconstruction can commence at the same time ("immediate") or after the completion of cancer treatment ("delayed"). The timing of the planned reconstruction has important implications on the choice of mastectomy techniques [4]. (See "Overview of breast reconstruction", section on 'Timing of breast reconstruction'.)

Delayed or no reconstruction — For patients who are not having immediate reconstruction, an MRM or simple mastectomy is performed. MRM includes level 1 and 2 axillary lymph node dissection and is utilized in patients undergoing mastectomy who have biopsy-proven axillary metastases or fail to map for sentinel lymph node biopsy. Clinically node-negative patients should undergo simple mastectomy and sentinel lymph node biopsy. (See "Overview of management of the regional lymph nodes in breast cancer".)

Modified radical mastectomy — An MRM is a complete removal of the breast and the underlying fascia of the pectoralis major muscle, along with the level I and II axillary lymph nodes. Several randomized trials have documented equivalent survival rates with MRM compared with radical mastectomy, with less morbidity [5-8]. The equivalent survival outcome of the two procedures was further confirmed in an analysis of 3236 women enrolled in four randomized trials [9,10].

Simple mastectomy — A simple or total mastectomy also entails complete removal of the entire breast and the underlying fascia of the pectoralis major muscle. The only difference between MRM and a simple mastectomy is that the former includes a level 1 and 2 axillary dissection. With the emergence of sentinel node biopsy, simple mastectomy is performed more frequently than in the past. (See "Overview of sentinel lymph node biopsy in breast cancer" and "Sentinel lymph node biopsy in breast cancer: Techniques".)

Immediate reconstruction — For patients planning either therapeutic or prophylactic mastectomy with immediate reconstruction, an SSM or NSM should be considered. The decisions regarding how much skin to preserve, whether the nipple-areolar complex (NAC) can be spared or removed, and the appropriate incisions to use require coordination between the breast surgeon and the plastic surgeon.

For most patients having mastectomy for prophylactic purposes (typically with immediate reconstruction), an SSM or NSM will most often provide the best cosmetic result. However, there are exceptions (eg, women with large, pendulous breasts or women wishing to be reconstructed to a larger cup size).

Skin-sparing mastectomy — The SSM is a surgical technique in which the majority of the natural breast skin envelope is preserved [11]; by contrast, a conventional mastectomy incision (for MRM or simple mastectomy) removes a larger portion of the overlying skin. (See 'Incisions' below.)

The entire breast parenchyma and the NAC are excised. In some cases, the existing biopsy scar and/or the skin overlying the tumor is also excised. A reconstructive procedure is typically performed in the same setting as an SSM. Thus, the skin incision is planned with the plastic surgeon.

Preservation of the skin of the breast and the inframammary fold provides the reconstructed breast with a more natural shape and contour. The superior cosmetic result has resulted in the increasing popularity of this approach in both the United States and Europe [12]. (See "Options for autologous flap-based breast reconstruction", section on 'General considerations and flap types' and "Overview of breast reconstruction", section on 'Choice of reconstruction'.)

Retrospective and prospective studies found that the local recurrence rates following an SSM range from 0 to 7 percent, comparable to those of a standard mastectomy, provided the dissection between the breast and the skin is meticulously performed [13,14]. In a meta-analysis of retrospective studies (median follow-up 37 to 101 months), no significant difference in local recurrence was identified between patients with an SSM and immediate reconstruction (n = 1104) and those undergoing a conventional mastectomy without reconstruction (n = 2635) [14].

SSM is contraindicated for inflammatory breast cancer because of cancer cell invasion of the dermal lymphatics [15]. (See "Inflammatory breast cancer: Clinical features and treatment", section on 'Surgery'.)

Nipple-areolar-sparing mastectomy — An NSM differs from other mastectomy techniques in that it preserves the dermis and epidermis of the nipple but removes the major ducts from within the nipple lumen [16], whereas other techniques remove the NAC. If the nipple cannot be preserved, there is also an option of removing the nipple and preserving the areola (areolar-sparing mastectomy), which can also preserve the cosmetic outcome, particularly in women who do not have a sizable nipple [17].

Historically, mastectomy has resected the NAC with the mammary gland because the NAC may harbor occult tumor cells in 5 to 12 percent of patients [18]. Over time, NSM for the treatment of breast cancer became more widely accepted [19,20]. Because this technique results in long skin flaps, it is primarily utilized for women with small- to moderate-sized breasts with minimal ptosis. NSM in a large breast risks flap and nipple necrosis, while NSM in a ptotic breast risks nipple necrosis and malposition [21].

Most retrospective studies of NSM have limited its use to women with small, peripherally located tumors (tumors <2 cm with a tumor to NAC complex distance >2 cm) without multicentricity [22,23]. However, some studies have suggested it may be reasonable in selected patients with larger tumors or tumors closer to the NAC as long as there is no direct involvement of the NAC [24].

There are no randomized trials of NSM, and long-term follow-up in clinical series is limited [24-28]. Nevertheless, a 2018 systematic review and meta-analysis of 14 studies found no difference between NSM and SSM in five-year disease-free survival and mortality rates, and local recurrence rates were similar at 3.9 and 3.3 percent, respectively [29]. A 2015 meta-analysis of 20 studies also reported survival and local recurrence rates of NSM that were comparable to those of MRM and SSM [30].

NSM may be particularly attractive for patients undergoing mastectomy for prophylaxis [3], although some mutation carriers may not be comfortable with leaving the NAC containing all of the terminal ducts, which have a small theoretical risk of harboring breast cancer.

In a retrospective study, a total of 548 risk-reducing NSMs in 346 BRCA carriers were performed at nine institutions [31]. With a median and mean follow-up of 34 and 56 months, respectively, no ipsilateral breast cancers occurred after prophylactic NSM. Using risk models for BRCA1/2 mutation carriers, approximately 22 new primary breast cancers were expected without prophylactic NSM. Other studies with short or intermediate follow-up (three to four years) reached the same conclusions [32-34]. Long-term outcome data, however, are lacking.

The advantage of NSM over SSM is mainly aesthetic. Multiple studies have demonstrated the superior cosmetic outcomes of NSM over SSM [26,35]. Quality-of-life scores (particularly psychologic and sexual) were also higher after NSM [36]. This is in spite of the fact that nipple sensation is largely or completely lost after NSM [37] and increased complications such as nipple loss due to ischemia. (See 'Nipple necrosis' below.)

The eligibility criteria for NSM are evolving [38]. NSM is contraindicated in patients with inflammatory breast cancer, clinical or radiologic involvement of the NAC, nipple retraction, Paget disease, or bloody nipple discharge [39,40].

Radical mastectomy — Radical mastectomy is rarely used in modern breast surgery. A radical (Halsted) mastectomy consists of en bloc removal of the breast, the overlying skin, the pectoralis major and minor muscles, and the entire axillary contents (level I, II, and III nodes). This extensive resection was originally proposed to provide a better chance of disease control than lumpectomy alone and was the standard of care for treating breast cancer for many years, largely in an era where systemic therapy was unavailable [41]. However, despite improved local control, the curative potential of this operation remained limited. In a series that followed 1438 women who had undergone radical mastectomy over 30 years, only 13 percent were free of disease, and 57 percent had died of breast cancer [42]. Attempts to further expand the field of resection by including the internal mammary nodes [43], known as an "extended radical mastectomy," failed to improve survival [44].

PREOPERATIVE PREPARATION

Mark the site and side — The patient should be examined in the perioperative holding area, and the correct breast to be removed should be identified, confirmed with the patient, and marked with a permanent skin marking pen.

Antibiotics — A preoperative antibiotic that covers skin flora, such as cefazolin, should be administered within one hour before the incision is made (table 1) [45]. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)

Venous thromboembolism prophylaxis — The American Society of Breast Surgeons suggests chemoprophylaxis for patients undergoing mastectomy with immediate reconstruction and/or general anesthesia for >3 hours and chemoprophylaxis for those who are at high risk of developing thromboembolic events (eg, Caprini score >5) [46]. Early ambulation and sequential compression devices are suggested for all other patients undergoing mastectomy. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)

ANESTHESIA — Mastectomy is usually performed under general anesthesia. Pectoral nerve blocks (Pecs) types I and II are commonly performed by an anesthesiologist before the procedure or by the surgeon during the procedure. They are a part of the multimodal analgesic strategy to reduce both postoperative narcotic requirement and postmastectomy pain syndrome. (See "Postmastectomy pain syndrome: Risk reduction and management", section on 'Risk reduction'.)

The technique of Pecs I and Pecs II blocks is discussed in detail elsewhere. (See "Thoracic nerve block techniques", section on 'Fascial plane blocks of the chest wall'.)

SURGICAL TECHNIQUE

Positioning — The patient is positioned supine with their arms extended on padded arm boards at ≤90 degrees abduction from the chest wall (figure 2). Arm positioning with >90 degrees of abduction increases the potential for stretching the brachial plexus and should be avoided. It is important to position the arm while the patient is awake to make sure the arm is not abducted beyond what is comfortable for the patient, especially if there are preexisting problems with shoulder mobility. The ipsilateral arm can be included in the prepped field, which allows the arm to be mobilized during the procedure.

Axillary staging — If the patient is having a sentinel lymph node biopsy, it should be performed before the mastectomy, which could disrupt the lymphatic flow. Sentinel lymph node biopsy or axillary lymph node dissection may be performed through the mastectomy incision or require a separate axillary incision, depending on whether adequate access to the axilla can be obtained through the mastectomy incision [47]. A study of 44 patients showed that the sentinel node biopsy could be removed via the breast incision in 98 percent of cases [48]. (See "Sentinel lymph node biopsy in breast cancer: Techniques" and "Technique of axillary lymph node dissection".)

Incisions — The choice of incisions will depend upon tumor location, tumor size, and whether immediate reconstruction is planned. Given that skin-sparing mastectomy (SSM) and nipple-areolar-sparing mastectomy (NSM) are typically performed with immediate reconstruction, the incisions may be planned with the plastic surgeon.

For a simple or modified radical mastectomy (MRM) without immediate reconstruction, the most common incision is a transverse or oblique elliptical incision including the nipple-areolar complex (NAC) with an appropriate skin paddle, with lateral extension toward the axilla (figure 3). However, if the tumor involves the skin, the incision may need to be adjusted according to the tumor location (figure 4 and figure 5 and figure 6 and figure 7). The incision should not be extended across the anterior axillary line to avoid scar contractures that could decrease the range of shoulder movement. The axillary lymph nodes are accessed through the mastectomy incision.

For an SSM, the incision may be a small ellipse around the NAC or a circular incision with or without a lateral extension if needed (figure 8). Sentinel node biopsy is sometimes performed through a separate axillary incision, though this is rarely necessary.

NSM can be performed via a variety of incisions (inframammary, midlateral, circumareolar, or a combination) depending on patient anatomy and surgeon preference [21,49,50]. Circumareolar incision has been associated with a higher risk of nipple necrosis [51]. (See 'Nipple necrosis' below.)

A robot-assisted technique of NSM has been proposed but remains experimental [52,53].

Skin flaps — Skin flaps are raised superiorly to the level of the clavicle, inferiorly to the insertion of the rectus sheath, medially to the ipsilateral sternal border, and laterally to the latissimus dorsi muscle edge (figure 9). Flap thickness will vary with patient body habitus and technique used (eg, tumescent) but generally is approximately 7 to 8 mm thick. The flaps are raised in the plane deep to the subcutaneous tissue and superficial to the breast parenchyma, using scissors, scalpel, or electrocautery (figure 10 and figure 11) [54-59].

An alternative method for creating skin flaps is the tumescent technique [60], which allows for potentially less blood loss. The subcutaneous tissue is infiltrated with 1 liter of Lactated Ringer solution mixed with 30 mL of 1% lidocaine hydrochloride and 1 mL of dilute epinephrine (1:1000) [61]; the breast tissue is then sharply dissected from the subcutaneous tissue. Electrocautery is usually not used with this technique.

Nipple margin assessment for NSM — In NSM, it is particularly important to remove all of the breast tissue directly behind the nipple, taking care not to injury the nipple or compromise the blood supply. The tissue directly below the nipple is typically sent as a separate specimen ("nipple margin") to pathology for intraoperative frozen section [21]. The nipple must be removed if any carcinoma is identified [16]. However, these biopsies of the areola and nipple are not completely reliable in predicting occult involvement in patients with a breast cancer [62-64]. Although the intraoperative biopsy of the retroareolar margin must be histologically negative for malignancy, the precise measurement of a negative margin has not been defined.

Dissection from the chest wall — The breast tissue is dissected off the muscle, using cautery to decrease bleeding from the muscle (figure 12). The pectoralis fascia is traditionally removed with the breast tissue in all modern mastectomies (MRM, simple, SSM, and NSM). A trial of 247 breast cancer patients undergoing mastectomy randomized patients between removal (n = 122) versus preservation (n = 125) of the pectoral fascia and reported a trend toward increased risk for chest wall recurrence when the fascia was preserved [65]. There were 18 chest wall recurrences in the pectoral fascia preservation group versus 10 in the pectoral fascia removal group (hazard ratio 1.8, 95% CI 0.8-4.0).

Tumor adherence to the muscle requires removal of that portion of the pectoris muscle with the breast specimen with a surrounding margin and placement of clips in anticipation of subsequent postmastectomy radiation therapy [50].

It is important to remove the breast tissue that lies at the superior-lateral border where the pectoralis major muscle inserts into the humerus. When the lateral border of the breast is reached, the pectoralis muscle is gently retracted medially and the clavipectoral fascia incised to expose the axillary contents, and axillary dissection or sentinel lymph node biopsy can be performed if indicated. (See "Technique of axillary lymph node dissection".)

Drains — Closed suction drains are placed through separate stab wounds inferolateral to the main incision and sewn in place (figure 13). Generally, one drain is positioned beneath the inferior mastectomy skin flap, where it will best drain dependent fluid when the patient is upright. If an MRM is performed, a second drain is positioned into the axilla, trimmed so that it will not abrade the axillary vein. A second drain is not used if only a sentinel lymph node biopsy was performed.

The drains are left in place until the drainage of serous fluid has decreased to approximately 25 to 30 mL per drain per day for two consecutive days or when they have been in place for longer than 30 days. If the drains are removed too soon, a seroma may occur, which will require management with aspiration and/or placement of a seroma catheter [66-69]. (See 'Seroma' below.)

Closure — The incisions are usually closed in two layers, using absorbable sutures. Prior to that, the flap may be fixed to the chest wall with sutures. Suture fixation of the flap has led to significantly fewer aspirations of postmastectomy seromas (7.3 versus 17.5 percent) in one trial [70].

The patient with obesity or large breasts will often have redundant tissue, which can result in an unsightly and uncomfortable "dog-ear" deformity at the axillary end of the incision. Various techniques have been described for addressing this, either at the time of primary surgery or as a staged procedure.

As an example, a "Y"-shaped incision can be used to excise excess skin and avoid this deformity [71]. Instead of suturing the full length of the wound, the medial one-half to two-thirds of the wound is first sutured using a subcuticular suturing technique (figure 13 and figure 14). The lateral tip of the incision is then approximated to the midline of the closure, excess skin is removed, and the final wound will be "Y" or "fish-tail" shaped with two "arms" facing toward the lateral side of the wound. In a study of 117 women who underwent mastectomy with a "Y"-shaped incision, the cosmetic outcome was improved and <1 percent developed skin flap necrosis [72].

Alternatively, two additional oblique incisions (figure 13) can be added to the traditional transverse elliptical incision at the lateral part of the mastectomy incision site. The resulting lateral triangular flap is advanced medially during the closure of the wound, and the redundant skin in the superior and inferior areas is excised.

For patients planning on delayed reconstruction, these incisions can complicate that reconstruction, and therefore it may be better to temporarily accept a dog-ear deformity until reconstruction, where it will be corrected. For patients who were considering delayed reconstruction but ultimately opt not to, any residual dog-ear deformity can subsequently be excised.

COMPLICATIONS — Major surgical complications can negatively impact breast cancer survival. In a large Swedish database study, major surgical complications (those requiring readmissions or reoperations within 30 days) were more common after mastectomy than breast-conserving surgery (7.3 versus 4.3 percent) [73]. Having a major postoperative complication is associated with worse 5-year overall survival (hazard ratio [HR] 1.32, 95% CI. 1.15 to 1.51) and breast cancer specific survival (HR 1.31, 95% CI 1.04 to 1.65). This correlation is most prominent among patients who undergo mastectomy without reconstruction.

Complications of mastectomy include seroma, wound infection, skin flap necrosis, nipple necrosis (following nipple-areolar-sparing mastectomy [NSM]), chest wall pain, phantom breast syndrome, and arm morbidity.

Seroma — Seroma formation, a collection of serous fluid under the skin flaps, is commonly seen after breast and axillary surgery [74,75]. Untreated seroma formation results in delayed wound healing, wound infection, wound dehiscence, flap necrosis, delayed recovery, and poor cosmetic outcome [76]. The pathophysiology of seroma formation is poorly understood, but seroma formation is increased with obesity, extensive surgery, and the use of electrocautery for skin flap dissection [77]. Seromas are more likely to occur after mastectomy than with breast conservation [78,79].

Drains are effective for seroma prevention in most cases because they obliterate the dead space between the skin flap and the pectoralis muscle (see 'Drains' above). Another method of reducing the dead space is by suturing the skin flaps to the underlying muscle, although this may compromise the cosmetic outcome and thus is rarely used [75]. Other techniques, such as sealants and sclerotherapy, tetracycline, fibrin glues, patches, and the use of external compression dressings, are generally not useful.

Vigorous postoperative shoulder exercises, as opposed to gentle range-of-motion exercises, can increase seroma formation. While patients are encouraged to use their arms normally postoperatively for activities of daily living such as brushing their hair or brushing their teeth, formal exercises should be postponed until the drains are removed and any seroma is resolved. A meta-analysis of six randomized trials showed that delaying formal exercises significantly decreased seroma formation (odds ratio 0.4; 95% CI 0.2-0.5) [80].

Wound infection — The rates of postoperative wound infection after breast surgery are low because these are clean procedures [81]. As an example, the wound infection rate after breast surgery was 2.9 percent in a study of 1400 patients [82]. Obesity, smoking, older age, and diabetes mellitus have been identified to be associated with an increased risk of infection after breast surgery [83]. Smoking, in particular, increases the risk of wound infection fourfold after breast surgery [84]. (See "Risk factors for impaired wound healing and wound complications".)

A meta-analysis of 2587 surgical breast procedures found a wound infection rate of 3.8 percent [85]. Most are staphylococcal infections, caused by skin flora.

Most postoperative cellulitis can be treated with oral antibiotics, but nonresponsive or extensive infection requires intravenous antibiotics. A small number of postoperative infections will develop into an abscess requiring drainage by reopening the original surgical incision.

Skin flap necrosis — The rate of skin flap necrosis from modified radical mastectomy (MRM) or simple mastectomy is estimated at 10 to 18 percent [86,87]. Full-thickness skin flap necrosis requires surgical debridement and may require skin grafting and result in delays in adjuvant treatment and diminished cosmetic outcome [88]. Prior radiation treatment, obesity, older age, and a smoking history can increase the rates of flap necrosis. Technical methods of decreasing the risk of skin flap necrosis include minimizing the use of electric cautery method in dissection, maintaining appropriate skin flap thickness, and avoiding tension on closure of the incision.

The use of tumescence solution (ie, 1% lidocaine with epinephrine) injected into the subcutaneous tissue is associated with a higher risk of flap necrosis in some [88,89] but not all studies [90].

Nipple necrosis — Nipple-areolar complex (NAC) necrosis is a complication that occurs after NSM. In a pooled analysis of 12,358 NSM procedures, the overall complication rate and nipple necrosis rate were 22 and 6 percent, respectively [91]. A prospective study of 59 prophylactic NSM reported a complete and partial nipple necrosis rate of 3 and 12 percent [92].

Factors predisposing to nipple necrosis included large breast volume, ptotic breast, smoking, prior radiotherapy, and periareolar incision. The selection criteria for NSM are partially based on avoidance of these risk factors. (See 'Nipple-areolar-sparing mastectomy' above.)

The majority of the partial nipple necrosis (6.5 percent) and some complete nipple necrosis (2.9 percent) can be managed conservatively, though a small percentage warrant complete removal of the NAC [18].

In a meta-analysis comparing NSM to skin-sparing mastectomy (SSM), the overall complication rate of NSM was higher than that of SSM (23 versus 14 percent), but the majority of this is attributable to a 15 percent nipple necrosis rate associated with NSM [29]. Rates of other complications (such as wound infection, skin loss, and implant loss) were not significantly different between NSM and other types of mastectomies.

Pain — Burning, aching, and tight constriction of the axilla, upper arm, and chest wall with superimposed lancinations and scar sensitivity are characteristic of postmastectomy pain. In the past, fewer than 10 percent of patients undergoing mastectomy developed chronic pain [93]; subsequent surveys have reported chronic pain, paresthesias, and phantom sensations in up to one-half of cases [94]. This trend may be related to the radiation and chemotherapy, which are often needed in addition to surgery. Although the available data are scant, at least one long-term follow-up study suggests that approximately one-half of cases resolve over time, while the remainder persist long-term [95].

Factors that contribute to the development of postmastectomy pain include axillary dissection [96] and breast reconstruction with implants after mastectomy [97]. Submuscular implant placement can cause injury to the long thoracic, thoracodorsal, lateral-pectoral, and medial-pectoral nerves. Capsule formation around the implant also may entrap the long thoracic and the two pectoral nerves.

Evaluation of chest and arm pain after mastectomy should focus upon the nature of the pain and its location and a neurologic examination to define the areas of sensory loss and hypersensitivity. Pain that is not typical of postmastectomy pain syndrome should prompt evaluation for infection, tumor recurrence, or other causes of chest pain, such as cardiac, pulmonary, or esophageal disease. Progressively worsening pain should prompt suspicion for recurrent disease.

Postmastectomy pain syndrome is discussed in other dedicated topics. (See "Clinical manifestations and diagnosis of postmastectomy pain syndrome" and "Postmastectomy pain syndrome: Risk reduction and management".)

Phantom breast syndrome — Patients may describe a change in chest wall sensation after mastectomy sometimes described as "phantom breast syndrome" [98]. The sensation of residual breast tissue can persist for years after surgery [99]. The most common complaint is pain, but itching, nipple sensation, erotic sensations, and premenstrual-type breast soreness are also described.

Although the cause is unknown, psychologic factors related to mastectomy have been implicated [98]. Patient education before mastectomy, outlining the possible changes in chest wall sensation and the possibility of phantom breast syndrome, may help to relieve patient anxiety if symptoms develop and may even reduce the frequency of this syndrome.

Arm morbidity — Arm morbidity is common after mastectomy (particularly modified radical mastectomy, which includes axillary lymph node dissection) and can include arm swelling, arm pain, arm numbness, arm stiffness, shoulder stiffness, shoulder pain, or nerve injury [100]. Postmastectomy radiation also contributes to arm morbidity and shoulder dysfunction. Complications of axillary surgery are discussed separately. (See "Technique of axillary lymph node dissection", section on 'Complications'.)

After breast cancer surgery, patients should be provided with rehabilitation services as needed and informed about methods to improve shoulder function and reduce the risk of lymphedema [101-105]. A randomized trial of 392 patients who underwent breast cancer surgery found that a structured exercise program improved upper limb function compared with usual care without any adverse effects; specifically, exercise lowered pain intensity and reduced upper limb disability symptoms at 12 months [106].

Prevention and treatment of arm edema are discussed separately. (See "Clinical features and diagnosis of peripheral lymphedema" and "Clinical staging and conservative management of peripheral lymphedema".)

Brachial plexopathy — Patients can develop brachial plexopathy from a stretch injury caused by malpositioning in the operating room. This can be avoided by careful positioning and the use of padded armboards. (See 'Positioning' above and "Brachial plexus syndromes".)

POSTMASTECTOMY RADIATION THERAPY — Postmastectomy radiation is indicated for patients at high risk for local recurrence, such as T4 tumors and patients with positive margins and/or positive axillary lymph nodes. If postmastectomy radiation is likely, the choice of mastectomy type, choice of the reconstructive approach, and optimal timing of the breast reconstruction (immediate versus delayed) may be affected. Thus, preoperative coordination of care between the breast surgeon, the reconstructive surgeon, and the radiation oncologist assures the best outcome. Sentinel lymph node (SLN) biopsy prior to mastectomy is sometimes useful in helping to assess which patients will require postmastectomy radiotherapy. Postmastectomy radiation is discussed in detail elsewhere. (See "Overview of breast reconstruction", section on 'Integrating radiation therapy and breast reconstruction'.)

BREAST RECONSTRUCTION — Most women undergoing mastectomy are candidates for immediate or delayed breast reconstruction. (See "Overview of breast reconstruction".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Breast surgery".)

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Basics topics (see "Patient education: Seroma (The Basics)")

SUMMARY AND RECOMMENDATIONS

Indications for mastectomy – A therapeutic mastectomy is indicated for patients with a breast malignancy who are not candidates for breast-conserving therapy or who prefer mastectomy. A prophylactic, or risk-reducing, mastectomy is performed to reduce the risk of developing breast cancer. (See 'Indications for mastectomy' above.)

Mastectomy techniques – The choice of mastectomy depends on the clinical scenario (see 'Choice of mastectomy' above):

For patients having a therapeutic mastectomy without immediate reconstruction, a modified radical mastectomy (MRM) or simple mastectomy is performed. An MRM includes axillary dissection and is utilized in patients who have biopsy-proven axillary lymph node metastases. Clinically node-negative patients should undergo simple mastectomy and sentinel lymph node biopsy instead. (See 'Delayed or no reconstruction' above.)

For patients having a therapeutic mastectomy with immediate reconstruction, a skin-sparing mastectomy (SSM) or nipple-areolar-sparing mastectomy (NSM) may be considered. The decisions regarding how much skin to preserve, whether the nipple-areolar complex (NAC) can be spared or removed, and the appropriate incisions to use require coordination between the breast surgeon and the plastic surgeon. Both SSM and NSM are contraindicated in patients with inflammatory breast cancer. NSM is also contraindicated in those with clinical involvement of the NAC, nipple retraction, Paget disease, or bloody nipple discharge. (See 'Immediate reconstruction' above.)

For patients having mastectomy for prophylactic purposes who desire reconstruction, either an SSM or NSM may provide good cosmetic results.

Complications of mastectomy – Complications after mastectomy include seroma, wound infection, skin flap necrosis, nipple necrosis (mostly after NSM), chest wall pain, phantom breast syndrome, and arm morbidity. Major surgical complications can negatively impact breast cancer survival. (See 'Complications' above.)

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Topic 14981 Version 32.0

References

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