SURGERY FOR BREAST CANCER: RADICAL MASTECTOMY

The more radical operation is increasingly less used. As already stated, it can be deforming. In addition to the removal of the cancer and an ellipse of skin around the breast, the whole breast is removed as in a simple total mastectomy, and the auxiliary lymph nodes are stripped to the apex of the armpit. To achieve this fully, the chest wall muscles also need to be excised, usually the pectoralis major and pectoralis minor muscles which contribute to the shape of the chest wall in men and women. A slightly less disfiguring operation involves the removal of the pectoralis minor muscle (as for a complete auxiliary lymph node clearance described above). This does not cause disfigurement and allows good access to the armpit to remove all the nodes that may be there.

The whole breast is removed from the underside of the remaining skin and then dissected off the underlying muscles. Two-thirds of the muscle underneath the breast is pectoralis major, and one-third is the serratus anterior. The breast is swung outwards and then the tail of the breast is dissected up to whatever level is considered necessary. Level 1 involves dissection of the lowest part of the auxiliary tail and lymph nodes, up to the lower border of the pectoralis minor. Levels 2 and 3 go beyond this, along the auxiliary vein to the apex of the armpit, and require either removal of the pectoralis minor or, in the more radical operation, of the pectoralis major.

Radical mastectomy is certainly beset with more complications than a simple mastectomy and is more painful and more disfiguring. It is claimed, however, that a mastectomy in which the pectoralis minor muscle is removed causes no more morbidity or mortality than a simple mastectomy with an appropriate auxiliary dissection.

At the end of the operation, the skin is usually closed with a subcuticular stitch of absorbable or non-absorbable material. Drains are commonly used after mastectomy to minimize the risk of a bruise developing underneath the skin flaps. The drains usually stay in place for at least 2 to 3 days. Their removal is not a painful procedure, being only a little more uncomfortable than having the stitch removed.

The even more radical operations in which some rib or sternum may be removed are no longer performed.

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