What is the difference between a radical mastectomy and modified radical mastectomy?

In the radical mastectomy (also known as the Halsted mastectomy) the doctor removes the breast tissue, the lymph nodes under the armpit, and the muscle under the breast. The modified radical, which most surgeons are now using, removes the breast tissue and the lymph nodes, but the muscle is left intact. The advantage of the modified radical is that it is cosmetically more attractive and does not handicap the motion of the arm. Studies indicate that the survival rate for the two operations is the same.

Is the choice of what surgical procedure I will have up to me or up to the doctor?

Of course your doctor is responsible for the surgery. But he cannot perform any operation unless you give your signed consent to have it done. You should have your doctor give you his complete explanation of what he recommends as his bestjudgment and ask him all the questions that concern you about the operation. Do not sign anything until you are certain you understand what you are signing. It is your right to refuse to sign the hospital form that gives blanket permission for a radical mastectomy. It is your right to refuse to sign the form that allows the hospital to do the biopsy and the mastectomy as a one stage procedure. It is your right to modify the form in your own handwriting to indicate you are giving permission only for a biopsy.

What will happen to a cancerous breast lump if it is not removed?

That is not a feasible alternative. Since cases differ, results differ. But the cancer will, in almost every case, continue to grow and spread, either in the breast area or to other parts of the body. Uncontrolled cancer of the breast is not a pretty or painless choice. In general, the life expectancy ofwomen with untreated breast cancer is about 1/2 years.

What can I expect to happen immediately before mastectomy surgery?

As for most surgical procedures, the area will be shaved and your breast washed with germ killing soap. The nurse will administer a sedative that should relax you completely and put you into a drowsy, semiconscious state. An IV (intravenous) needle will be placed in a vein in your forearm or hand on the side opposite the side to be operated on, and the needle will be taped to your skin. The IV will be used for intravenous feedings, to administer anesthesia, and to administer blood if needed. Depending on the procedure, the surgery will take between 2 and 4 hours. You will stay in the hospital from 7 to 10 days.

Will there be a drain in the area where I had surgery?

Yes. Your breast area will be bandaged, and a tube will be placed at the surgical site to drain away any fluid that may accumulate. Before you leave the hospital, the tube will be removed. Some ofyour stitches may also be taken out before you leave. The remaining stitches will be removed within 1 to 3 weeks at the doctor's office or clinic.

Is it unusual for my chest and arm to feel numb after a mastectomy?

No, it is not unusual. This is a normal reaction. The entire operated side will feel this way for quite some time after the operation, sometimes for months, although the time varies from person to person. In a few persons, some numbness may be permanent. The numbness is the result of nerves injured or cut during surgery.

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What does a mastectomy scar look like?

The appearance depends upon the extent of the operation and the doctor's personal method. Some doctors use a vertical cut, others a horizontal one. If you have a preference, you should discuss this with your doctor before the operation so your wishes can be considered and discussed.

How dangerous is a mastectomy?

Not dangerous at all as far as the surgery involved is concerned. Mortality rates referring to the mastectomy operation itself put it in the almost no risk category. It is a very safe operation.

How long will it take for the incision to heal?

The incision for a lumpectomy will usually heal within a week or 10 days. Wounds of more radical operations are usually healed within a month to 6 weeks after the operation.

I am thinking of having a preventive mastectomy. My mother and aunt died of breast cancer before they were 40. My breasts are lumpy, and the doctor has done several biopsies with a diagnosis of precancerous condition. Would I be wise to have both breasts removed?

Preventive mastectomy sometimes referred to by physicians as prophylactic subcutaneous mastectomy is the removal of one or both breasts to reduce the risk of cancer. It is sometimes suggested to women considered to be at high risk of developing breast cancer. There is some controversy about the advisability of this operation for highrisk women. Some doctors recommend instead that the women perform monthly breast examination and have checkups every 3 months. If you are considering a preventive mastectomy, you should discuss the procedure, reconstructive surgery, possible complications, and follow up care with your doctor and plastic surgeon. You may want to get a second opinion as well as requesting some information from a genetics counseling clinic affiliated with a university medical school. Furthermore, you may wish to talk with someone who has had a preventive mastectomy before you make this decision. It is a question that only the individual involved can answer. Part of the decision must be based on how worried you are about getting cancer and how important your breasts are to you. You need to carefully study the pros and cons before you make this decision.

Questions You Will Want to Ask Your Doctor Following a Mastectomy

• What arm exercises can I do?

• When can I start to shower again?

• What restrictions do you put on my affected arm?

• When will I be able to drive?

• Will you arrange for a Reach to Recovery volunteer to see me?

• When will the stitches be removed?

• Are there any restrictions on sexual activity?

• What kind of therapy is prescribed?

• Why is it being prescribed?

• What will it do?

• Can I lift things?

• When can I start doing my household chores?

• When can I start active sports again?

• When can I get a permanent prosthesis?

• When can I have reconstructive surgery?

• Will I have to have any additional treatment such as radiation or chemotherapy?

• Why? Does that mean that the cancer has spread?

• How long will I have to have those treatments?

How shall I care for my incision? 

Wash with soap and water gently and pat, don't rub, the area of your incision. You may take a shower within 2 to 3 days after the stitches are removed. If the stitches are not removed before you go home, they will probably be covered with a gauze pad to protect them from irritation. Your doctor will tell you when they are ready to be removed. Do not use any medications salves, creams, or lotions on your incision unless told to do so by your doctor. Watch for any signs of infection redness, swelling, pus discharge, tenderness, or fever and report them to your doctor as soon as possible.

One last word. Before you are discharged from the hospital, please force yourself to look at your incision carefully (even if you may not want to). This will help you to be alert to any changes that may occur. Ask the nurse for assistance and for guidance in evaluating it. It will appear swollen and red. This is normal. The swelling will go away, the color will return to normal, and the stitches will heal. But for your own sake, please don't avoid looking at the incision.

What is the role of Reach to Recovery? 

This is a volunteer program sponsored by the American Cancer Society. It is based on the idea that women who have been through breast surgery and have experienced the pain, anxiety, and convalescence are able to help others through the initial period following the mastectomy. The program is set up so that only the surgeon or doctor, with the patient's permission, can arrange to have the volunteer visit the patient in the hospital. In some areas ofthe country, the patient can request a visit from a Reach to Recovery volunteer after she leaves the hospital.

Some doctors still do not know about Reach to Recovery or misunderstand its goals and methods, feeling that somehow it will interfere with the doctor patient relationship. So, if you are interested, be sure to ask your doctor specifically if he will arrange for a Reach to Recovery volunteer to see you. Her visit offers help during the emotional, tense period of postoperative adjustment and allows you to talk frankly and honestly about a mutual problem. In addition to lending an understanding ear, the Reach to Recovery volunteer brings an invaluable kit with a realistically written manual of information and exercise materials as well as a temporary breast form and bra. She will demonstrate some of the basic exercises needed to facilitate recovery, and since she is a mastectomy patient herself, she is available to answer questions and give moral support.

Why is everyone so anxious to make me move my arm? 

There are good reasons for this. First of all, it will help prevent swelling of the arm and help the drainage of the wound. Changing the position ofthe arm will limit shoulder pain and help you to gradually build your affected arm back up to its fullest capacity as quickly as possible. Moving your arm is very important because it helps prevent the forming of adhesions which will later limit how much you can move it. Frequent exercising is necessary to relieve stiffness and a heavy feeling. Your doctor will tell you when you can safely begin to exercise. The amount and the extent of surgery will determine the problems you will have with your arm.

Are there any suggestions for activities I should be doing with my arm after the operation? 

The American Cancer Society's Reach to Recovery program makes the following suggestions:

• Use your elbow and hand as much as you can for normal activities.

• For the first few days after the operation, practice deep breathing often. Lying on your back, breathe in deeply, expanding your lower chest as much as possible. Then let the air out and relax. Concentrate on relaxing while letting the air out. Do this three or four times, breathing in deeply and relaxing.

• Check with the doctor about exercises you can do at various times after surgery.

• You should get full motion and strength back in your arm about 2 to 3 months after your mastectomy. If you are having difficulty regaining shoulder motion, ask your doctor for help or for a referral to a physical or occupational therapist.

• You will have normal shoulder motion when you can reach across the top of your head and touch the opposite ear without feeling a stretch in your armpit. Your upper arm should be right next to your ear. Do not put your arm behind your head so you can grab your ear more easily. Keep your head straight up. Another test for shoulder motion is to raise your arms as high as possible about your head with the upper arm touching your ears.

• You can begin exercises for shoulder motion when your doctor gives permission. It is usually all right to stretch your shoulder until you feel a mild pull. Any stretching should be done slowly and smoothly. The way to get your motion back is to work gradually, doing a little more each day.

• The stiffness and tightness felt in the tissues of the chest and armpit after surgery or radiation therapy will come and go for a while. Continue to work to improve your motion at least three times a day until that feeling of tightness is no longer a problem.

• Start on activities that are helpful in your regular routine for example, reach into cabinets, wash and brush your hair, put your arms behind your neck, fasten your bra.

What kind of arm exercises should I do? 

Your doctor will tell you when you can begin exercising and will probably give you his own list of exercises. A nurse or physical therapist will be happy to review them with you. Start exercising gradually and work up to doing each exercise five times a day, working up to a maximum of twenty times per day per exercise. Here are some of the suggested exercises:

• Squeeze a ball, a rolled up bandage, or a crumpled sheet of paper. Lying in bed, lift your arm straight up and alternately squeeze and relax the ball. If it is uncomfortable to hold your arm straight up, support the arm using several pillows.

• Stand erect, feet apart, with toes 6 to 12 inches from and facing a wall. Bend elbows and place palms against the wall at shoulder level. Work both hands up the wall parallel to each other until the incision pulls or pain occurs. Mark the spot so that you can check your progress. Work hands down to shoulder level. Move your feet and body closer to the wall if it is more comfortable. Rest and repeat.

• Stand erect, feet apart. Place the hand on the unoperated side on your hip for balance. Bend the elbow of the arm on the operated side, placing the back of the hand on the small of your back. Gradually work the hand up your back until your fingers reach the opposite shoulder blade. Slowly lower your arm. Rest and repeat. Information given to you by the Reach to Recovery volunteer will also include exercises for you to do.

Some people have swollen arms after a mastectomy. What causes that? 

The lymphatic system which normally drains fluid from your arm is disrupted with mastectomy surgery. Your arm may be more likely to swell or to become red, warm, or unusually hard if you develop an infection. Therefore, it is important for you to take special care to avoid injury, infection, and swelling of the arm. You must always be careful what you do with the arm on the side where the mastectomy is performed, since the swelling can occur even several years after the operation.

When can I start using deodorant again? 

It depends upon where the incision is made. You should wait until all the stitches are removed and the incision heals before using a deodorant.

What kinds of things should I watch for in order to protect the arm on the side where my mastectomy was performed? 

• Do not allow blood samples to be drawn from or blood pressure to be taken on the affected arm.

• Avoid injections and vaccinations on the affected arm.

• Do not wear tight jewelry or elasticized or tight sleeves on that side.

• Keep that side covered when you are out in the sun. Avoid insect bites by using protective insect repellent.

• Wash cuts promptly, treat them with antibacterial medication, and cover them with sterile dressing. Check often for redness, soreness, or other signs of infection.

• Avoid burns while cooking.

• Pamper your arm by carrying your purse or packages on the other side.

• Wear a thimble when sewing to avoid pinpricks.

• Wear gloves or mitts when gardening and working with sharp objects or hot objects. Use a mitt when taking hot dishes out of the oven. Use rubber gloves when washing with harsh detergents.

• Use an electric razor to avoid cutting this area. Underarm shaving may be a problem for a while because of the lack of mobility or numbness, so take great care.

• Never pick or cut cuticles or hangnails. Apply lanolin hand cream to hand and arm several times a day.

• If you do notice pain, swelling, or redness on your scar or arm, with or without fever being present, call your doctor. In the meantime, put your arm over your head and pump your fist.

• Though you should be cautious, it is also important to use your arm normally. Don't favor it or keep it dependent.

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What can I do if I have a swollen arm? 

The swollen arm (edema) is due to the disruption of the lymph channels. It is very important that you do the exercises described (or similar ones which your nurse, physical therapist, or doctor has ordered) and follow the suggestions for arm care so that the swelling is prevented. If swelling does occur, elevating the arm may help to reduce it. You can use a pillow, trying to keep your hand higher than the elbow and the elbow higher than the shoulder. You should maintain this position for at least 30 minutes and repeat the exercise several times each day. When you are lying down, keep your arm elevated on a pillow. Isometric exercises (such as making a fist and tightening your arm muscles for 3 seconds, then relaxing them) several times a day help to increase circulation of fluid from the arm. An elastic cuff that inflates and deflates, applying pressure, can be helpful. In addition, sometimes salt free diets are used. Some doctors will perform surgery if the swelling continues over a long period of time.