Since Angelina Jolie announced in May that she’d undergone a double mastectomy, the procedure has been a regular feature in the news, with women in similar situations choosing to tell their story. Having a mastectomy, for risk-reducing reasons or to treat cancer, is a major decision and it can be scary to even consider it if you’re unfamiliar with what’s involved in the procedure.
Mr Stephen McCulley, MDChB, FCS(SA)Plast, FRCS (Plast), is one of the leading breast reconstruction surgeons in the world and in this article he takes us through a step by step guide to mastectomies.
Step One – Diagnoses and Decisions
The very first step in the mastectomy process usually occurs when a woman is diagnosed with breast cancer and the treatment required is to remove the cancerous tissue in one or both of her breasts, this is often followed by radiotherapy or chemotherapy to ensure any remaining cancer in the rest of the breast tissue is treated.
A risk-reducing mastectomy is an elective process where there is a high risk of the patient developing cancer in the future. For example, in the case of Angelina Jolie, she tested positive for the “faulty” breast cancer gene BRCA1 (which stands for breast cancer susceptibility gene 1). If this hereditary gene mutates then this could lead to breast cancer. Although it’s a huge decision to undergo a risk-reducing mastectomy, it can dramatically reduce the risk of breast cancer.
Step Two – Surgery Options
Breast reconstruction after a mastectomy can usually be done by using implants or done organically by using tissue from another part of the patient’s body including the bottom, thigh, back or tummy.
There are three main choices for the timing of reconstructive surgery too: either immediate surgery where breasts are reconstructed during the same operation or delayed surgery where the reconstruction happens in a separate operation. With delayed reconstruction, your skin will have time to heal before the reconstructive operation; if you are having a mastectomy to treat cancer, then it’s often during the time between surgeries that you will have any radiotherapy or chemotherapy.
Immediate reconstructions are often the choice for patients who are having preventative surgery as a surgeon can use a skin-saving method to preserve as much of a patient’s skin as possible for the reconstruction. It can also mean that in many cases the nipple can be saved as well.
There is a third option for surgery called immediate-delayed reconstruction where an expander is placed under the chest muscle after the initial surgery. This expander, which looks a little like a deflated balloon, is then slowly filled with saline over a number of weeks which stretches the chest tissue. After the tissue has expanded to the correct capacity and has healed and if the patient needs no other cancer treatment, the surgeon will then replace the expander with either the patient’s own tissue or an implant. Angelina Jolie opted for immediate-delayed surgery as part of her procedure.
Step Three – Saving or Reconstructing the Nipple
Whether or not a nipple can be saved during a mastectomy is a question many patients have as nipples are so closely linked with femininity. In many cases, patients can opt for a mastectomy where the nipple and breast skin are spared but it’s important to remember that although the nipples will be the patient’s own, the sensation will be different after surgery.
Full mastectomies leave the breast with no nipple so it’s completely smooth. Some women are happy with this result but for others, it’s vital that they are able to keep their nipple or have a realistic alternative. If the patient doesn’t want to undergo any further surgery then they could choose to have a nipple tattooed on the breast skin but it’s important to bear in mind that the breast will still have a smooth texture as this ‘nipple’ with be flat. Patients can also opt for prosthetic nipples which stick to the skin and are extremely realistic. Prosthetic nipples also replicate the texture of a nipple so they have lifelike structure through clothing.
Nipples can be reconstructed from the patient’s own body tissue by taking tissue from an existing nipple if it’s a single mastectomy. For patients who have had a double mastectomy, nipples can be constructed from tissue in the centre of the breast which is formed into a nipple shape.
Reconstructed nipples can also be enhanced with tattooing so they look as much like natural nipples as possible. Nipples which have been reconstructed are prone to flattening and shrinking which will need to be corrected through further reconstruction.
Step 4 – Recovery
As with any major surgery, patients feel soreness after the operation but you will be made to feel comfortable with appropriate painkillers. The length of your hospital stay will depend on your individual circumstances and the surgery you’ve had.
Usually patients who have had immediate reconstructive surgery will stay in hospital longer as the operation is more complex. This is also the case if a patient has had reconstructive surgery which has taken tissue from another area of the body.
Patients who are having these more complex surgeries can expect to be in hospital for around a week. For the more straightforward operations, such as having implants inserted in place of an expander, patients can expect to be in hospital for around three days.
Please note, the above is an overview of the processes available to mastectomy patients. Every patient is different so it’s important to discuss your individual situation with a trusted surgeon who will find the right solution for your unique circumstances.
Stephen McCulley is one of the few Consultants in the UK that offers both the cancer surgery and the full spectrum of breast reconstruction options. Stephen is registered with the General Medical Council (No 3336078) and on the specialist register for Plastic Surgery, is a member of the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) and the British Association of Aesthetic Plastic Surgeons (BAAPS).