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Total Mastectomy: Procedure, Indications, Recovery & Long-Term Considerations

Total (simple) mastectomy removes the entire breast parenchyma including nipple-areolar complex (NAC), skin envelope (variable), and fascia over pectoralis major. Axillary nodes are not routinely removed (unlike modified radical mastectomy).

Indications

  • Multicentric breast cancer, diffuse microcalcifications.
  • Large tumor relative to breast size (poor cosmetic outcome with BCT).
  • Prior chest wall radiation (precludes BCT + RT).
  • Genetic high risk (BRCA1/2) – risk-reducing (prophylactic) mastectomy.
  • Patient preference (avoid radiation, surveillance anxiety).
  • Inflammatory breast cancer (after neoadjuvant chemo).
  • Severe benign disease (recurrent abscess, giant fibroadenoma) – rare.

Variants

  • Skin-sparing mastectomy (SSM) – Preserves native skin envelope; best for immediate reconstruction.
  • Nipple-sparing mastectomy (NSM) – Preserves NAC; oncologically safe for selected tumors (>2 cm from NAC, no nipple involvement).
  • Modified radical mastectomy – Total mastectomy + axillary lymph node dissection (levels I–II).

Procedure Overview

  1. Elliptical or Wise-pattern incision (SSM/NSM: periareolar/inframammary).
  2. Subcutaneous flaps raised; breast tissue dissected off pectoralis fascia.
  3. Hemostasis; drains placed.
  4. Immediate reconstruction (implant, tissue expander, autologous flap) or delayed.

Recovery

  • Hospital: 1–2 days (longer with flap reconstruction).
  • Drains removed when output <30 mL/day (1–2 weeks).
  • Pain: moderate; multimodal regimen (acetaminophen, NSAID, gabapentin, limited opioid).
  • Activity: no heavy lifting >5 lbs × 4–6 weeks; progressive ROM exercises.

Long-Term Sequelae

  • Numbness: Intercostobrachial nerve sacrifice → medial arm/axilla numbness.
  • Lymphedema: Low after simple mastectomy (<5%); higher with ALND/radiation.
  • Body image / psychosocial: Counseling, peer support, reconstructive options.
  • Phantom breast sensation / pain.

Multidisciplinary team (surgical oncology, plastic surgery, medical oncology, radiation, navigation, psychosocial) optimizes outcomes.

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