PATIENT INFORMATION BREAST SURGERY - MASTECTOMY AND AXILLARY CLEARANCE - WRITTEN BY THE BREAST UNIT - PRODUCEDJUNE2005 REVIEWEDJANUARY2007

Patient Information

             Breast Surgery –
     Mastectomy and axillary clearance

                     Written by the Breast Unit

Produced June 2005                         Reviewed January 2007

Contents

Your operation and what it involves """""4

Other options"""""""""""""""..5

Risk and possible after effects"".""""".6

Before surgery..."""""""""""""".7

During and after surgery""""""""""10

Your recovery"""""""""""""""11

Advice after surgery""""""""""""12

Follow up care""""""""""""""..17

Further information"""""""""""".18

Breast Surgery – Mastectomy and axillary clearance

This leaflet gives you information about your planned operation and
explains what will happen before, during and after surgery. We hope
this will help you to be more aware of what to expect around the time
of your operation, and allow you and your family to feel more
prepared.

The purpose of this operation is:
• to remove the cancer,
• to find out whether cancer cells have spread to the lymph nodes
  (glands)
• if cancer is in the lymph nodes and the lymph nodes are removed,
  this helps to stop the cancer from growing there
• to help plan other treatments

What does the operation involve?

The operation is carried out under general anaesthetic and takes
about 1½ hours.

The operation involves surgery to the breast and armpit on the
affected side.
The surgeon will make a suitable incision (cut) into the skin of the
breast removing the breast tissue and some of the overlying skin
including the nipple. The axillary nodes (glands) are found throughout
a pad of fat in your armpit and this is excised through the same
incision to remove the majority of your axillary nodes, which is about
10 - 25 nodes for most women.

The skin is then closed together leaving a scar that is flat across the
chest wall.

As all the breast tissue is removed in this operation radiotherapy is
not always necessary after surgery.

How long will I be in hospital?
Many patients are well enough in themselves to be discharged after a
day or two, but usually would stay in hospital for 4 to 7 days until the
wound drain(s) are removed. An early discharge programme is being
introduced to allow patients who wish to, to continue their recovery at
home with their axillary drain in place.

Are there any other options?
Surgery has an important role in the treatment of breast cancer and
is often recommended as the first stage of treatment.

The main surgical options for the treatment of breast cancer are
mastectomy (removal of the breast), or breast conserving surgery
(just removing part of the breast tissue).

The decision to do a mastectomy instead of a breast conserving
surgery is influenced by:
  • the size and type of cancer in the breast
  • the position of the lump
  • whether there is more than one lump
  • the size of your breast
  • any other medical problems

It is our policy to offer breast conserving surgery when possible, but
mastectomy will usually be advised when the cancer affects a
significant proportion of the breast tissue, or when there are two or
more areas of cancer which are apart from one another.

Surgery to reconstruct the breast may be possible at the same time
or at a later date.

Chemotherapy given before surgery (known as neoadjuvant
chemotherapy) can be used to try and shrink a large cancer and then
less extensive surgery may be possible.

Treatment with medication or radiotherapy may be considered for
patients with complex medical problems who may not be fit enough

to have a general anaesthetic or able to cope with having an
operation.

Breast cancer surgery usually also involves removal of lymph nodes
from the armpit.
A relatively new technique called sentinel node biopsy offers the
potential to minimise the extent of surgery needed to find out if
cancer cells are present in the axillary lymph nodes. This may be an
appropriate option for some women, but not all. During surgery, a
blue dye is injected into the breast around the cancer or into the
nipple area. Lymphatic vessels carry the dye into the “sentinel node”.
This is the first lymph node that the breast cancer drains into, and so
if cancer cells have travelled from the breast cancer to the lymph
nodes, this is the node most likely to be affected. The surgeon then
finds and removes the blue node/s.

If the pathologist’s examination finds that the sentinel node contains
cancer cells you will be advised to another operation to remove the
rest of the lymph nodes in the affected armpit. If the sentinel node is
cancer-free, no further surgery to the lymph nodes is required.

It is important to stress that every patient’s case is unique and the
treatment considerations will be different for each individual. The
breast care team will discuss your situation with you in relation to
suitable treatment options and the associated risks and benefits.

What are the risks of surgery?
All operations have a small risk of side effects, such as pain,
bleeding, infection and poor wound healing. The risks associated
with general anaesthesia include potential breathing and heart
problems, as well as possible reactions to medications, but such
complications are very rare.

The after effects of mastectomy and axillary clearance can include:

• changes in sensation
   It is common to have altered sensation after surgery. There

may be some numbness or tingling in the inside of the upper arm.
    This will usually become less noticeable as time goes by but may
     not resolve completely.
• shoulder stiffness
     After underarm surgery, there can be a natural tendency to limit
     arm movement, which can lead to muscle tightness of the
     underarm and shoulder. You will be given advice about arm
     exercises and by carrying these out regularly you will help to
     restore your arm movements to normal.
• seroma
    Serum is a clear straw coloured fluid produced by all wounds. A
   seroma is a collection of this fluid under the skin of the wound.
   This will usually be absorbed by the body as the wound heals but if
   the fluid builds up to an extent that it is causing swelling, tightness
   and discomfort it can be withdrawn with a needle and syringe by
   one of the specialist breast team in the breast clinic.
• lymphoedema
    Lymph is a colourless fluid that forms in the tissues of the body. It
    normally drains back into the blood stream through a network of
    lymph vessels and nodes. The lymph nodes under your arm drain
    lymph fluid from your chest and arm. Surgery to remove the
    axillary lymph nodes can change the normal lymph drainage
    pattern. If the lymph is not able to drain adequately it will build up
    in the tissue causing swelling. This is called lymphoedema. This
    can affect between 10–25% of patients to some degree after
    breast cancer treatment. You will be given exercises and arm
    care advice to try and reduce the risk of developing
    lymphoedema.

____________________Before surgery_____________________

Before surgery you will need to attend for pre-assessment so we can
check your general health and find out any special needs you may
have. It is important we know what medicines you are taking so
please bring them with you to this appointment.

At this visit you will:
  • meet nursing staff and one of the doctors from the surgical
     breast care team.
  • be asked questions about your medical history and general
     health.
  • have blood tests taken and your temperature, pulse, blood
     pressure and urine will be checked. Other investigations such as
     a chest x-ray and electrocardiogram (ECG – recording of the
     heart rhythm) may also be carried out as necessary.
  • be examined by the doctor

Preparing for Surgery
The West Middlesex Hospital leaflet: “A guide for patients coming
into hospital” gives general information about being in hospital and
suggests items to bring in with you. We suggest you bring nightwear
that opens at the front and is loose fitting as this is the most practical.
You should keep a bra with you in hospital. We recommend a soft,
comfortable, full cup bra without wires or bones such as leisure or
sleep bra. Ask your breast care nurse if you need further advice.

It can be helpful to plan ahead to reduce household activities and
make things easier when you get home from hospital.

If you have any difficulty making suitable arrangements for
transportation to or from hospital, please let us know in advance.

This is an anxious time for many patients. Getting answers to your
questions can help, so if you have any queries after reading this
leaflet please call your breast care nurse.

Admission arrangements
You will usually be admitted on the morning of your operation but if
you are diabetic or on blood thinning tablets we will arrange to admit
you 1 or 2 days before surgery.

A member of the ward team will phone you the afternoon before your
planned admission day to confirm arrangements. Your doctor should
have advised you whether to take your usual medicines.

Do feel free to ring the ward directly on 8321 6532 or 8321 6533 if
you prefer or if you have not been contacted by 6pm.

On the day of admission please report to the Richmond suite, 1st
floor main building at the designated time. A family member or close
friend may accompany you to the ward, and wait with you until it is
time for you to go to the Operating Suite.

Operation day
You should not eat or drink for six hours before your operation, but
you may have sips of water up to two hours before. With an empty
stomach there is less likelihood of vomiting during or after your
anaesthetic. Please do not smoke or chew gum.

When you arrive on the ward a member of the ward team will show
you to your bed. She/he will check your details and put on your
identification bracelet. You will be asked to change into a gown and
be measured and fitted with special support stockings. These are
used to prevent blood clots, and should be kept on during your stay
in hospital.

The anaesthetist will see you to discuss your medical history, any
previous anaesthetics, current medications and any allergies.

The consultant or specialist registrar will visit you to check that all the
necessary preparations have been made and that you have given
your written consent for the operation to take place. He/she will then
put some markings on the skin to clearly identify the site of operation.

For safety reasons you will be asked to remove any dentures/plates,
contact lenses, glasses, false nails, hearing aids or any other
prosthesis before going to surgery. Make up, nail varnish, wigs, hair
clips and jewellery (apart from a wedding band which should be
covered with tape) should also be removed.

The nursing staff will help you prepare for surgery and accompany
you to the operating suite. The nurse will introduce you to a member
of the operating theatre team, hand over your notes and pass on any
important information. You will then be taken through to the
anaesthetic room.

__________________During surgery_______________________

An intravenous line (‘drip’) is put in your arm on the opposite side to
your operation to give you fluids and medication.

Three small sticky patches will be put on your chest and connected to
a monitor that shows your heartbeat. A small clip (pulse oximeter) is
placed on your finger to measure your pulse and the amount of
oxygen in your blood.
You will be given medication to relax you and make you sleepy. You
will be anaesthetised for the duration of the operation and closely
monitored.
When the operation is completed the skin will be closed together with
a continuous stitch and steri-strips (small white strips of tape) or
clips. You will have two drainage tubes in place just below the armpit
to prevent the build up of blood and serum in the wound. The
drainage tubes will each be connected to a plastic bottle.

___________________After surgery________________________

After your operation you will wake up in the recovery room. You may
have a mask over your nose and mouth to give you oxygen. You may
feel sleepy. While you are in the recovery room, your pulse, blood
pressure and the amount of oxygen in your blood will be checked
regularly.

Once your condition is stable, you will be transferred back to
Richmond Suite. The nurses will continue to monitor your blood
pressure, pulse, temperature and breathing. They will also check the

wound dressing regularly and monitor the amount of drainage in the
bottles. Your nurse will ask about any discomfort, pain or nausea you
are having, and give you medications to help.

When you are fully awake you will be offered sips of water, and then
depending how you feel, this can be gradually increased. Once you
are drinking normally, you can progress to solid food. The drip fluids
and tubing will then be disconnected and your medications will be
given by mouth.

You will be encouraged to cough, deep breathe and to move around
as soon as you feel you can. This is important to help prevent
complications. You may turn to a comfortable position, but try to
avoid lying on the arm of your surgery. Resting your arm on one or
two pillows can help comfort and circulation. You can start to use
your arm as you feel able, but at first you should avoid stretching,
limit raising your arm to no more than 90 degrees (i.e. your elbow no
higher than your shoulder) and do not lift anything that weighs more
than a couple of pounds.

  ____________________Your recovery_____________________

Recovery time will vary according to individual circumstances but as
a guide, most women will feel well enough to be up out of bed the day
after surgery (sometimes the same day!). The nurses will help you the
first few times as needed. You may then walk about as you feel able.

You should use your arm for self-care activities, but avoid raising
your elbow higher than your shoulder until the drains are removed.
The physiotherapist will see you while you are in hospital and give
you exercises to help ease tightness in your arm and shoulder.

The breast care team will visit you on the ward to check your
progress. You will usually be discharged home once the wound
drains have been removed.

__________________Advice after surgery___________________

Personal care and hygiene
While the drains are in place you may sponge bathe or have a
shallow bath. Once the drains are out, you may shower or bath
provided you have a waterproof dressing covering the incision. Take
care not to spray the wound directly and avoid soaking the wound
area while the dressing is in place and the wound is healing. After
bathing, pat the area dry with a clean, soft towel. We advise you wait
until the skin is completely healed before applying deodorant, body
spray or talcum powder directly over the wound.

Your wound and dressings
The area may appear bruised and/or swollen at first, but this will
gradually lessen as the tissues heal. The wound will usually be
covered with an adhesive clear plastic dressing, which is waterproof.
The amount of fluid in each drain will be measured daily and when it
is less than 30 millilitres in 24 hours the drain will be removed. Your
dressing will be changed before you go home and then provided
there is no leakage, can then be left in place until you return to clinic.
Clips/non-absorbable stitches are taken out in clinic 12 - 14 days
after surgery.

When the scar-line is completely healed, you should very gently
massage the skin with wheat germ oil, Aqueous Cream or a bland
moisturiser to help keep the skin supple. The area around the scar
may feel firm or thickened at first. In time (3 – 6 months or longer),
the scar should fade and the skin and tissues will relax and soften.

Concerns about how your body will look after surgery are common
and you may feel unsure about looking at your wound at first. Do
discuss your reactions and feelings with your nurse so she can
support you and explain the changes expected during the healing
process.

Before you go home, your breast care nurse will provide you with a
soft, lightweight breast form to wear in your bra temporarily while the

wound is healing. When the skin is fully healed and any swelling has
resolved, you can be fitted with a more substantial breast form that
will give a more natural looking shape. The breast care nurses will
contact you about six weeks after your operation and arrange a fitting
appointment with you.

Keeping comfortable
You may feel some discomfort with arm movement after surgery.
Pain relief tablets will be prescribed and we suggest you take these
regularly at first to avoid discomfort while exercising, but as this
eases, the painkillers can be reduced then stopped. Try to take pain
medications with food to prevent nausea.

It is quite usual for the arm and chest area to feel “different” after the
operation. You may experience sensations such as soreness,
tenderness, stiffness, tightness, aches or twinges as the tissues heal.
The sensory nerve supplying the inside of the arm may be affected
by surgery and you may be aware of numbness or tingling in the skin
of the upper arm below the armpit. Normally this will slowly improve
over a period of months, but may not resolve completely.

Lymphoedema information and advice after lymph node surgery
The axillary lymph nodes drain and filter fluid (lymph) from the arm
and chest and help protect your body from infection and disease.
After surgery to the axillary lymph nodes we advise that you take
care to try and prevent infection in the operated arm and not to
restrict the circulation of fluid in the arm. The aim being is to try and
minimise the risk of developing lymphoedema.

You should use your arm as normally as possible but would advise
the following precautions:

• Carry out your arm exercise routines regularly and use your arm
   normally as movement helps the lymphatic drainage
• Avoid vaccinations, injections or having blood samples taken from
  the affected side.
• Whenever possible have blood pressure measurements taken on
  the non-operated arm.

• Prevent chapping and cracking of the skin by drying the skin
  thoroughly after washing and applying Aqueous Cream, E45 or
  similar moisturiser.
• Take care when cutting nails and avoid cutting the cuticles
• Use an electric shaver for underarm shaving rather a blade razor.
• Wear protective gloves for gardening and also for household
  chores such as putting food in and out of the oven, washing up,
  cleaning etc., especially when using harsh chemicals or steel wool.
  Use a thimble for sewing.
• Be sure to clean thoroughly any cuts, burns, bites or abrasions on
  the hand or arm and apply an antiseptic cream. Report any signs of
  infection such as redness, tenderness, swelling or discharge to
  your doctor as soon as possible.
• Avoid sudden strenuous movements such as heavy digging,
  pushing and pulling heavy furniture etc.
• Avoid carrying anything heavy with the affected arm
• Always use a high factor sun cream and take care to avoid getting
  sun burnt.
• Use insect repellent preparations as necessary to prevent bites.
• Try to keep your weight within normal limits

If at any time you notice swelling of the operated arm or hand you
should report it to your doctor or breast care nurse. Advice and
treatment at an early stage is important in managing this condition.

Diet
You may eat as normal. Constipation (difficulty evacuating the bowel)
is quite common after surgery and we would advise plenty of fruits,
vegetables and fibre to help prevent this. A good fluid intake of at
least 8-10 glasses of water or juice per day will also help.
Further information on healthy eating is available if needed.

Sleep and rest
It is normal to feel more tired for the first few weeks after surgery.
Your body is using energy to heal and recover so allow yourself time
to rest.

If you are having difficulty sleeping, do discuss this with your GP or
one of the breast care team.

Feelings and emotions
You may feel more “emotional”, experiencing strong feelings, both
ups and downs. Sharing your thoughts and feelings can help you
come to terms with all that is happening. Identifying sources of
strength and support will help you move forward. It is important to
cope in a way that suits you. Try to recognise what helps and what
doesn’t.

Support is available from the breast care nurses and other health
professionals as well as from organisations such as The Mulberry
Centre, The London Haven, Breast Cancer Care, Cancerbackup and
local support groups.

Activities
Pacing your activity is key to recovery after any surgery. At first, you
should avoid strenuous activity. Tasks should be carried out in
moderation according to your level of active movement and comfort.
You may need to carry out some tasks in stages and rest in between
if necessary to avoid getting over-tired or over-exerted. As you feel
more comfortable, you can start to work on gradually increasing your
activity, stamina, strength and range of movement. A gradual and
steady increase in regular exercises can help your body systems
work more effectively.

Arm and Shoulder Exercises
You should carry out arm exercises at least twice a day until you
have regained your normal range of movement. If you are having any
difficulty progressing with your exercises please contact the breast
care nurses.

If you go on to have radiotherapy, we advise that you continue doing
arm and shoulder exercises for a few months after radiotherapy
treatment is completed.

Housework
Keep to light housework such as dusting at first, then gradually
progress as you feel able. The most difficult activities will be those
requiring you to reach up, out and around such as cleaning windows,
hanging out washing etc and these are best avoided for the first six
weeks.

Driving
You may restart driving when the wound has completely healed and
you feel safe and comfortable turning the wheel, handling the gears,
the hand brake and stopping quickly.

Sports and Gym
Swimming and water activities can be gently introduced when the
wound is completely healed but are best avoided during radiotherapy
treatment.

Other sporting activities can usually be resumed about eight to
twelve weeks after your operation. Be guided by how you feel,
starting very gradually at first, taking rest periods. If you are holding
equipment such as a racquet or golf club, try to release your grip
from time to time to allow your arm to relax.

Work
Going back to work will vary according to the type of work you do and
your individual circumstances so please discuss this with your doctor
or breast care nurse.

If you need a sick certificate for your stay in hospital please inform
one of the ward nurses before you leave hospital.

Sex
You can restart sexual relations as soon as you feel comfortable.
Your thoughts and emotions are likely to affect how soon you feel
ready to do so. There may be concerns on both sides so try to be
open with your partner about your mutual feelings. Please do speak
to the breast care nurses or one of the healthcare team if you would
like to discuss anything further.

__________________What to look out for ___________________

When you are at home, check your wound each day. Infections can
occasionally occur and are best treated promptly. If you notice any
redness, increased soreness, swelling or discharge from the incision,
you should seek medical advice, as you may need antibiotics. Other
symptoms to report are a raised temperature or if you feel generally
unwell.

Fluid may collect under the skin around the wound or armpit
(seroma). If this starts to feel very swollen, tight and uncomfortable,
the fluid can be withdrawn by one of the breast care team using a
syringe and fine needle.

_________________Follow up Care________________________

You will be given an appointment to return to the Breast Clinic. At this
appointment we discuss your progress, check the incision is healing
and will usually take out any non-absorbable stitches/clips. Your
specialist will explain the results from your operation and you will
usually have a consultation with one of the medical cancer specialists
(clinical oncologists) from Charing Cross Hospital. The more detailed
information from the pathologists report helps to guide
recommendations for additional treatment and this will be discussed
with you. There can be a lot of information to take in at his
appointment so you may find it helpful to bring someone with you.

_________________If you have any questions________________

If you are concerned about your progress or have any other queries
please contact the Macmillan Breast Care Nurses on 020 8321 5885
or 8321 6786.

____________________Further information__________________

This is one of a series of information leaflets. If would like details of other
titles and resources or support information please ask a member of the
breast team or ward staff.

The breast unit website address is www.vashishtsurgicalservices.co.uk

Information is also available from:

www.besttreatments.nhs.uk

www.cancerhelp.org.uk

Breast Cancer Care
Help line: 0808 800 6000
Textphone: 0808 800 6001
www.breastcancercare.org.uk

Cancerbackup
Tel: 020 7240 7236 or 020 7613 2121
Or freephone: 0808 800 1234
www.cancerbackup.org.uk

The Mulberry Centre
West Middlesex Hospital
Tel: 020 8321 6300
www.themulberycentre.co.uk

NOTES

West Middlesex University Hospital
       Twickenham Road
        Isleworth, Middx.
            TW7 6AF

 Main Switchboard - 020 8560 2121
www.west-middlesex-hospital.nhs.uk