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Men generally have only a small amount of breast tissue, so an operation to remove breast cancer usually involves taking away all of the breast tissue and the nipple in the affected breast.
There are different types of mastectomy:
A simple mastectomy removes only the breast tissue, nipple and, usually, some lymph nodes in the armpit.
A modified radical mastectomy removes all the breast tissue, the nipple and all of the lymph nodes in the armpit (axilla). This mastectomy may also be referred to as a total mastectomy and axillary clearance.
A radical mastectomy removes all the breast tissue, the nipple and the lymph nodes in the armpit, together with the muscles behind the breast tissue. This mastectomy is only done if there is cancer in the muscle that sits just under the breast tissue.
Sometimes it’s possible to remove the cancer with some surrounding normal tissue. This operation is called a wide local excision or lumpectomy.
Before your operation, make sure that you have fully discussed with your surgeon what the surgery involves. After the operation all of the tissue that is removed will be carefully examined under a microscope. Your surgeon will want to know that all of the cancer has been removed with a distinct border, called a clear margin, of healthy tissue all around the tumour. If cancer cells are found in the margin (or very close to it) this may mean that not all of the cancer cells have been removed and further surgery or radiotherapy may be needed.
As part of any operation for breast cancer, the surgeon will usually remove lymph nodes from under your arm on the side of the cancer. This gives the team looking after you valuable information to help them plan what further treatment, if any, you may need.
There are approximately 20 lymph nodes in the armpit (axilla), although the exact number varies from person to person. The lymph nodes are examined to check if any cancer cells have spread into them from the breast. If you have cancer in the lymph nodes you will usually have all of them removed (axillary clearance). Your specialist may also recommend that you have additional treatment with chemotherapy and/or hormonal therapy to reduce the risk of the cancer coming back.
If you have DCIS,| rather than invasive breast cancer, you won’t usually need to have your lymph nodes removed. This is because the cancer cells in DCIS aren’t able to spread outside the breast.
Surgery to the lymph nodes can cause stiffness in the upper arm and shoulder immediately after the operation. It can also increase the chance that you will have some altered sensation, such as numbness or tingling, in the upper arm. These effects usually improve within a few weeks or months. Your breast care nurse or a physiotherapist will teach you exercises you can do to reduce arm stiffness and improve movement in your shoulder.
Having lymph nodes in your armpit removed can sometimes lead to swelling of the arm on the affected side, called lymphoedema. This may start to develop weeks, months or years after the breast surgery.
There is a higher risk that lymphoedema may develop if you have all of the lymph nodes under your arm removed. If you have radiotherapy to the armpit after surgery this will further increase the risk. Find out about reducing your risk of lymphodema| and knowing what symptoms to look out for.
The main methods for checking the lymph nodes are:
Sentinel lymph node biopsy (SLNB) is a way of checking just one or two of the lymph nodes to see if they contain cancer. The sentinel nodes are the first ones that lymph fluid drains to from the breast. By only removing the smallest possible number of lymph nodes (usually between one and three nodes), the risk of side effects that can occur after lymph node surgery are reduced. These side effects include swelling (lymphoedema) and stiffness of the arm.
The main benefit of SLNB is for men who are unlikely to have cancer spread to lymph nodes, and who therefore wouldn’t need any treatment to this area. So SLNB is mainly used in men with small cancers whose axillary lymph nodes appear normal before the operation.
SLNB involves injecting a tiny amount of radioactive liquid into the breast before surgery. The lymph nodes are scanned during surgery to see which ones have taken up the radioactive liquid first. A blue dye is also injected into the area of the cancer during the operation. The dye stains the draining lymph nodes blue. The nodes that become blue or radioactive are known as the sentinel nodes. The surgeon removes only the sentinel nodes so that they can be tested to see whether they contain cancer cells.
If the sentinel nodes don’t contain cancer cells, it’s very unlikely that other lymph nodes will have cancer in them, so no further surgery is needed. If there are cancer cells in the sentinel lymph nodes all of the remaining lymph nodes in the armpit will be removed (axillary clearance) or treated with radiotherapy.
When all of the lymph nodes under the arm are removed this is known as axillary clearance. It allows the doctor to check all of the lymph nodes for cancer. If there is cancer in the lymph nodes no further treatment is needed in the axilla (armpit) as the lymph nodes have all been removed.
This method is used less often now as sentinel lymph node biopsy is usually done. A few lymph nodes (about 4-10) may be removed from the armpit. This is often combined with the use of a blue dye injection (see sentinel node biopsy section above). This is called axillary node sampling. If any of the lymph nodes contain cancer cells, the remaining nodes may need to be removed by surgery (axillary clearance) or treated with radiotherapy.
After breast surgery there will be a scar across your breast in line with where your nipple used to be and there will be an indentation where the breast tissue has been removed.
A man with a mastectomy scar
The scar will be red at first, but this usually fades to a silvery white line over a few weeks or months. It’s common to have some swelling around the operation site to begin with. There are techniques for recreating the appearance of a nipple on the chest, which your surgeon or breast care nurse can discuss with you.
Any change to your appearance can lower your self-confidence and you may need time to come to terms with this. Many men find that after a while they get used to the change but it can help to talk things over with a partner or close friend.
When you return to the ward after your operation you may have a drip (intravenous infusion) going into a vein in your arm. This will usually be taken out within a few hours once you are drinking and eating normally.
There will be a dressing over your wounds and you may have a plastic tube with a small plastic bottle on the end, called a drain, coming from your wound to drain fluid. If you’ve had surgery to your lymph nodes it’s likely that you’ll have a drain coming from under you arm. The drains stop blood and fluid building up under your skin and helps the wound to heal. Each day a nurse will measure the amount of fluid coming out of the drains. Once the amount of fluid coming out is very small the drains will be taken out.
You may have some pain or discomfort after the operation. Tell the nurses if you’re in pain so that you can be given painkillers to help with this. If you are still sore it’s important to let the doctor or a nurse know, so that more effective painkillers can be prescribed for you.
After the operation you may notice numbness, tingling or increased sensitivity around the area of the scar and in your upper arm. This is quite common and can happen if nerves in the area have been affected during the operation. Altered sensation in the upper arm is more likely after an axillary clearance than after sentinel node biopsy. These effects usually improve gradually over weeks or months although in some men they can be permanent.
You may have some stiffness in your shoulder. A breast care nurse or physiotherapist will tell you how to do exercises that will help you with this. It’s important to keep doing these exercises when you go home.
About 3-5 days after a mastectomy most men are able to go home. Before you leave hospital, you’ll be given an appointment to attend the outpatient clinic so that the surgeon can check the wound is healing properly. At the outpatient clinic you will also be told the stage of the cancer (how large it was and whether it had spread to the lymph nodes).
Your doctors will discuss with you any further treatment that you may need. This is a good time for you to talk to them about any problems or questions you have.
When you get home, take things easy for a while. You may feel very tired, so try to have plenty of rest and eat a well-balanced diet. This will help your body to heal. You’ll be advised not to lift or carry anything heavy, nor to drive for a few weeks. Some insurance policies give specific time limits for not driving after surgery - so check this with your insurance company.
Try to do a bit more each day and rest inbetween so that you’re gradually building up the amount that you do bit by bit. Most people are back to their usual level of activity after 3-6 months. But this will depend on many factors including what other treatments you’re having, as well as your age and general fitness.
On average it takes about 2-3 weeks for a wound to heal. So when you go home your wound will still be healing. For the first three weeks use only unscented soap and water to clean the area around your wound and avoid using deodorant or anti-perspirant under your arm if you’ve had surgery to your lymph nodes.
It’s common to have some bruising, swelling and puffiness around the wounds. Swelling can be caused by a build-up of fluid. This should gradually go away over a few weeks. Occasionally, a lot of fluid can build up. This is called a seroma. If this happens contact your breast care nurse for advice.
If you develop a seroma the fluid can be drained by a doctor or nurse. This is done by putting a very small needle just below the wound and drawing excess fluid into a syringe.
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