Double mastectomy

Overview

A double mastectomy is surgery to remove both breasts. It also is called a bilateral mastectomy. It may be recommended to treat breast cancer or to greatly lower the chance of breast cancer in people at very high risk.

Deciding whether to have a double mastectomy can be difficult.

While the goal of a double mastectomy is to remove as much breast tissue as possible, it's not possible to remove every breast cell. As a result, the surgery lowers the risk of breast cancer but does not eliminate it completely. After surgery, breast cancer can still develop or return in the skin, chest wall or nearby lymph nodes.

A double mastectomy may be combined with breast reconstruction. Breast reconstruction is surgery that rebuilds the shape of one or both breasts. It can begin during the mastectomy or later. The timing depends on your treatment plan and preferences.

Types

The type of double mastectomy depends on the reason for surgery. It also depends on the location and extent of cancer, plans for reconstruction, previous treatment and personal preferences.

• Total or simple double mastectomy. The surgeon removes the breast tissue, nipple and areola from both breasts. The surgeon also may test or remove lymph nodes.
• Risk-reducing double mastectomy. The surgeon removes both breasts before cancer develops. This may be an option for people with inherited changes in certain genes, such as BRCA1 or BRCA2, that greatly increase the risk of breast cancer. It also may be an option for people with a strong family history of breast cancer or another factor that greatly increases the risk of breast cancer.
• Skin-sparing double mastectomy. The surgeon removes the breast tissue, nipple and areola but keeps most of the breast skin. The skin that is not removed can be used for immediate reconstruction.
• Nipple-sparing double mastectomy. The surgeon removes the breast tissue but keeps the breast skin, nipple and areola. This may be an option when cancer does not involve the tissue under the nipple and the skin and nipple have a good blood supply.
• Double mastectomy with reconstruction. The surgeon removes both breasts, and a plastic surgeon rebuilds the breast shape. Breast reconstruction may use implants, tissue from another part of your body, such as a deep inferior epigastric perforator (DIEP) flap or transverse rectus abdominis myocutaneous (TRAM) flap, or a combination of both. Reconstruction may begin during the mastectomy or in a later operation.

Why it's done

A double mastectomy may be recommended to:

• Treat cancer in both breasts. Removing both breasts may be part of treatment when cancer is present in both breasts.
• Treat cancer in one breast. This can lessen the risk of a new cancer in the other breast. This is called contralateral prophylactic mastectomy. It lowers the chance of a new cancer in the opposite breast. But it does not improve survival for most people who do not have a high inherited risk of breast cancer. The decision to treat only one breast depends on your age, the type and stage of your cancer, inherited risk, and your treatment goals and preferences.
• Lower a very high risk of breast cancer. A mastectomy to remove both breasts may be discussed with people who have an inherited gene change that greatly increases the risk of breast cancer. It also may be discussed with people who have a strong family history of breast cancer or who have had certain types of radiation treatment in the past. Before surgery, genetic counseling and discussions with your healthcare team can help you understand your risk, treatment options and expected outcomes.
• Create a more even breast or chest appearance. Some people choose to have both breasts removed when only one breast must be removed. This may create a more even chest appearance or improve breast reconstruction.

A double mastectomy may not be the only treatment or risk-reduction option. Depending on the situation, alternatives may include:

• Breast-conserving surgery.
• Removal of one breast.
• More-frequent breast cancer screenings.
• Risk-reducing medicine.
• A combination of approaches.

Talk with your healthcare professional to understand how each option may affect how well your cancer is managed, future screening, complications and quality of life.

Risks

Most people recover without serious complications, but they can happen.

Possible risks and side effects of double mastectomy surgery include:

• Bleeding or a collection of blood called a hematoma. Some bleeding may require another procedure.
• Infection. Infection can occur in the incision, around a drain or around an implant.
• Fluid buildup called a seroma. Fluid can collect in the surgical area after breast tissue is removed. Drains and follow-up visits help your healthcare team monitor and manage the fluid.
• Issues with wound healing. Skin or nipple tissue may not receive enough blood. Some or all of the tissue may die. Smoking, diabetes, earlier radiation treatments and other factors can increase risk.
• Pain, numbness and tightness. Numbness across the chest is common because sensory nerves are cut. Some people have persistent nerve pain, chest tightness or discomfort.
• Shoulder stiffness or reduced arm movement. Early, guided movement and physical therapy can help restore function.
• Lymphedema. Swelling can develop if lymph nodes are removed or treated with radiation. Sentinel node biopsy, which removes a few lymph nodes most likely to contain cancer, generally carries less risk of swelling than axillary lymph node dissection, which removes more lymph nodes from the armpit.

Reconstruction complications. Complications may include:

• Implant infection or loss. An infection can develop around a breast implant. A severe infection may require removal of the implant.
• Capsular contracture. Scar tissue that forms around an implant can tighten and make the breast feel firm, painful or look different.
• Implant rupture. A breast implant can develop a tear or hole that allows the material inside to leak.
• Flap problems. Tissue used to rebuild the breast may not get enough blood flow, which can damage or cause loss of some or all of the tissue.
• Fat necrosis. Fatty tissue can become damaged and die, sometimes causing a firm lump in the reconstructed breast.
• Weakness at the donor site. The area where tissue was taken to rebuild the breast, such as the abdomen, may become weak.
• The need for additional surgery. Another surgery may be needed to treat a complication or correct a problem with the reconstruction.

A double mastectomy also can affect emotional and sexual well-being. Changes in body image, breast sensation and intimacy vary from person to person. Counseling, peer support and rehabilitation may be helpful.

Risks during or after surgery may include:

• Blood clots. A blood clot can form after surgery and may travel to the lungs.
• Heart or breathing problems. Heart or breathing complications are not common but can happen during or after surgery. They may happen if the surgery is very long or if you have underlying medical conditions. Your surgical team carefully monitors your heart, breathing and oxygen level throughout the procedure.
• Reaction to anesthesia. Anesthesia is generally safe, but side effects or reactions can happen. Before surgery, the anesthesia team reviews your medical history, medicines and allergies to help reduce these risks. The team also monitors you closely throughout the procedure.

How you prepare

Preparing for a double mastectomy includes learning about the procedure and planning for your recovery. Your healthcare team explains what to expect before, during and after surgery and gives you instructions based on your treatment plan.

Prepare for surgery

Before surgery, you may meet with a breast surgeon, plastic surgeon, anesthesia professional, oncology team, genetic counselor, physical therapist or other specialists. At this time, you may:

• Review the operation. Ask which breast structures and lymph nodes your surgeon plans to remove, whether reconstruction is planned, and whether more than one operation is likely.
• Discuss medicines and supplements. You may need to stop or adjust medicines that increase the risk of bleeding. Do not stop prescription medicines unless your healthcare professional tells you to.
• Stop tobacco and nicotine use. Smoking and nicotine reduce blood flow and increase the risk of wound-healing problems and reconstruction complications.

Prepare for your recovery at home

Recovery from a double mastectomy takes time. Before surgery, make plans for your recovery at home. Having help and the supplies you need ready ahead of time can make the first days after surgery more comfortable and allow you to focus on healing.

• Plan for help at home. Arrange transportation, meals, help with children or pets, and assistance with drain care and household tasks.
• Prepare clothing and supplies. Loose, front-opening shirts and a way to secure drain bulbs can make recovery more comfortable.
• Follow eating and drinking instructions. Your care team tells you when to stop eating and drinking before surgery.
• Discuss work and activity. Recovery time varies. Ask your healthcare professional when you may be able to return to work, drive and resume other activities. Your surgery plan and whether you have reconstruction may affect how soon you can return to these activities.

What you can expect

Before the procedure

At the hospital, your healthcare team confirms the surgical plan and marks the surgical sites. You change into a gown, and a healthcare professional places an intravenous (IV) line. Your healthcare team may give you antibiotics to help prevent infection. The anesthesia team gives you general anesthesia, which keeps you asleep and free of pain during surgery.

If lymph node evaluation is planned, a contrast may be used to help find sentinel lymph nodes. If immediate reconstruction is planned, the breast and plastic surgery teams coordinate the operation.

During the procedure

The breast surgeon makes incisions based on the type of mastectomy and reconstruction planned. The surgeon removes breast tissue from both breasts and one or more lymph nodes, if needed. The tissue is sent to a laboratory for testing.

If you are not having reconstruction, the surgeon closes the chest incisions to create a flat or gently contoured chest. If you are having reconstruction, the plastic surgeon rebuilds the breast shape.

Common reconstruction approaches include:

• Direct-to-implant reconstruction. The surgeon places a permanent breast implant during the mastectomy. A breast implant is a silicone shell filled with silicone gel or saline. This option may be possible when enough healthy skin can be preserved, and it fits your treatment plan.
• Tissue expander followed by an implant. A temporary tissue expander is a balloonlike device placed under the skin and chest muscle. The expander is gradually filled with saline during office visits to stretch the skin and make room for a permanent breast implant. In a later operation, a surgeon replaces the expander with a permanent implant. This staged approach gives the skin time to heal and stretch before a permanent implant is placed. It also allows your healthcare team to adjust the reconstruction plan if needed.
• Autologous reconstruction. In this approach, skin, fat and sometimes other tissue from another part of the body are used to rebuild the breast. One common option is a deep inferior epigastric perforator (DIEP) flap, which uses skin and fat from the lower abdomen while preserving the abdominal muscles. Other flap procedures use tissue from the abdomen, back, thigh or buttock.

Surgery without reconstruction often takes several hours. Immediate implant reconstruction usually adds time. Reconstruction using your own tissue, such as a DIEP flap, generally takes longer.

The exact length of surgery depends on:

• The type of mastectomy.
• Whether lymph nodes are removed.
• The reconstruction method.
• Whether reconstruction is performed during the same operation.

After the procedure

You wake up in a recovery area while the team monitors your breathing, blood pressure, pain and the surgical sites. Dressings cover your incisions. One or more drains may carry fluid from each side of your chest to small collection bulbs.

Hospital stay

Some people go home the day of surgery or after one night. A longer stay may be needed after complex reconstruction or if complications occur. Before discharge, the team explains pain medicine, drain care, bathing, arm exercises, activity limits and when to call for help.

Pain management

Pain is usually strongest during the first few days after surgery and improves over time. Most people find that pain becomes easier to manage as they heal. You may have numbness, tightness, a pulling feeling or brief, shooting pains. Your healthcare team may recommend a combination of pain relief methods. These may include an anti-inflammatory medicine when it's safe for you, numbing medicine given during surgery, and opioid pain medicine for a short time, if needed.

Drains

Your surgical team removes the drains when enough fluid has drained and the incisions are healing well. The timing depends on your surgery and recovery. Many people have drains for about 1 to 3 weeks, although some people have them removed sooner or need them longer.

Activity

Your healthcare team may encourage you to start walking soon after surgery. Your healthcare team tells you when to begin gentle arm and shoulder exercises. Avoid heavy lifting and strenuous upper body exercise. Also avoid driving until you can move comfortably, react quickly, wear a seat belt safely and are no longer taking medicine that impairs alertness. Some people return to driving in about 2 to 4 weeks, but reconstruction and complications can lengthen this timeline. Ask your healthcare team when you can return to heavy lifting and strenuous exercise.

Recovery

Initial healing usually takes about 4 to 6 weeks, but everyone heals at a different pace. Energy, range of motion, swelling and comfort may improve for several months. Recovery after flap reconstruction generally takes longer than recovery without reconstruction or with implant-based reconstruction.

Routine care and follow-up

After a double mastectomy, you may have your blood pressure checked, blood drawn or an intravenous (IV) line placed in either arm. If you have lymphedema, an active infection, a dialysis access or another reason one arm should not be used, ask your surgical team which arm is safest to use. If lymph nodes were removed from both sides, ask your healthcare team what to do. This care may take place while you are still in the hospital or during follow-up visits.

Results

A pathology report describes what was found in the removed breast tissue and lymph nodes. Results may include the type and extent of cancer, whether the edges of removed tissue are free of cancer, and whether lymph nodes contain cancer. Your healthcare team uses these results, along with imaging tests and other information, to decide whether you need more treatment.

If you had a double mastectomy to treat breast cancer, surgery lowers the risk of cancer returning in the breasts. However, it does not eliminate the possibility that cancer could return elsewhere in the body.

A double mastectomy does not always eliminate the need for radiation therapy, chemotherapy, targeted therapy or hormone-blocking medicine such as tamoxifen or an aromatase inhibitor. These treatments depend on the biology and stage of the original cancer, not only on whether breast tissue was removed.

If you had a risk-reducing double mastectomy, surgery greatly lowers the chance of developing breast cancer. Because a small amount of breast tissue may remain, surgery does not completely eliminate the risk. Continuing follow-up care with your healthcare team is important.

Screening mammograms

After a double mastectomy, routine screening mammograms are usually not recommended. This is because there is too little breast tissue to image. Instead, your follow-up care generally includes regular visits with your care team and checking for any new lumps, skin changes, swelling or pain. Your healthcare professional may order imaging if you have a new lump, breast pain, swelling or a change in the shape or feel of the breast or implant. Imaging also may be recommended for certain breast implants.

Recovery and follow-up care after a double mastectomy vary from person to person. Your healthcare team monitors your healing, answers your questions and recommends any further treatment or follow-up care based on your individual needs. You do not have to go through recovery alone.

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