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[masto- + -ectomy]
Surgical removal of the breast. The procedure usually is performed as treatment for or prophylaxis against breast cancer; it can be curative in more than 90% of cases in which the disease is histologically noninvasive and grossly confined to the breast. In patients with more extensive disease, it is one part of a treatment strategy for breast cancer that also may include chemotherapy, radiation therapy, and/or hormone therapy. Radical mastectomy (no longer performed) involved the removal of the breast tissue as well as the pectoralis major muscle, pectoral fascia, axillary contents, nipple, and areola. In modified radical mastectomy, the pectoral fascia is removed but the pectoralis major muscle is left intact. The rest of the operation mimics radical mastectomy. In simple mastectomy, only breast tissue, pectoral fascia, nipple, areola, and axillary fat pad are removed. In tissue-saving mastectomy (modified-radical or simple) tissue is removed through a nipple and alveolar area circular incision, to limit muscle and nerve incisions and prepare the patient for immediate or delayed saline or silicone implant(s) or flap reconstruction. In the management of breast cancer, because none of these techniques has been proven superior to lumpectomy followed by radiation treatment, patient and practitioner preferences often determine which therapy is used. Mastectomy still is preferred in some breast cancer patients, e.g., pregnant women, who should not receive radiation therapy.
SEE: breast cancer; SEE: lumpectomy
Preoperative: The patient is encouraged to discuss treatment options with her surgeon and her partner, as well as with other women who have had the various treatment options. Preoperatively, the patient may be scheduled for bone, lung, and liver studies (scans, etc.) to determine the presence of metastatic disease and assist in determining staging and the needed treatment regimen. A chest x-ray, ECG, blood work, urinalysis, and anesthesia consult are carried out. Postoperative care measures are discussed, and sensation messages provided (drains, dressings, analgesia, pulmonary and thromboembolytic concerns, etc). Surgery may be in a same-day center with discharge to home or in an overnight hospital facility. In either case, a home health nurse will be needed postdischarge to assist in patient care.
Intravenous access for fluids, sedation, and/or anesthesia is established, and cardiac monitor leads applied. Graduated compression hose or intermittent pneumatic dressings usually are applied for the surgical period. Before any sedation is given, the surgeon and patient together identify and mark the breast requiring surgery in the presence of a nurse, and this information is documented. An informed consent is obtained. Vital signs, cardiac rhythm, and the quantity and character of wound drainage are monitored throughout the surgery. Sentinel lymph node biopsy is done and sent to the pathologist to assess for cancer cells. If this node is negative, axillary nodes can be spared; if positive, axillary node dissection is carried out.
Postoperative: Vital signs are monitored until stable, and the patient is positioned with the arm on the affected side elevated on a pillow above heart level. Suction drain(s) will be in place, and drainage should be monitored for character and volume. Drains are removed when volume decreases to a minimal amount daily. Dressings also are inspected (anteriorly and posteriorly) for drainage. Intake and output should be monitored for 48 hr, if general anesthesia was employed. Active and passive exercise of the arm is encouraged to prevent joint contracture and muscle shortening. Prescribed analgesics are provided as ordered.
Turning, ambulating, deep breathing (incentive spirometry), and coughing are encouraged, and the patient is reminded that all of these will be more easily accomplished if analgesic drugs are used to prevent pain from escalating, rather than waiting until it is severe. The patient is taught not to allow any blood draws, intravenous devices, injections, or blood pressure measurements to be done on the affected arm; she is advised to carry or wear identifying information concerning this need. In the acute care setting, a bright pink bracelet provides this warning to health care providers. The incision is inspected for healing by the nurse/home-health nurse, and the patient and her partner are encouraged to view the incision as soon as they feel able to do so.
The patient and partner should both be made aware that breast surgery does not interfere with sexual function, although sensation may be absent in the surgical area; thus sexual activity and esp. foreplay touching, stroking, and other loving gestures may be resumed as soon as the patient desires. Sometimes tingling or pins-and-needles sensations (phantom breast syndrome) occur, so the patient should be prepared for this possibility. Emotional and psychological support is provided to help the patient and family to cope with the diagnosis and subsequent grief response and/or depression, and to adjust to changes in body image and self-concept. The patient is taught protective measures for lymphedema and is offered information about breast prostheses and reconstructive surgery.
The patient is prepared for adjuvant therapies that may be required, depending upon staging, estrogen receptor and Her2 status. Referrals are provided to local support groups as available, and to the American Cancer Society’s Reach for Recovery group, which provides counseling, instruction, caring and sharing, and sometimes prosthetics and wigs or other head coverings for chemotherapy patients. (ACS: 800-ACS-2345; www.cancer.org).