For many, the thought of surgery can be frightening. But with a better understanding of what to expect before, during, and after the operation, many fears can be relieved. Depending on the likely extent of your surgery, you may be offered the choice of an outpatient procedure (you go home the same day) or admission to the hospital.
What to expect
Before surgery: Usually, you meet with your surgeon a few days before the operation to talk about the procedure. This is a good time to ask specific questions about the surgery and review potential risks. Be sure you understand what the extent of the surgery is likely to be and what you should expect afterward.
You will be asked to sign a consent form, giving the doctor permission to perform the surgery. Take your time and review the form carefully to be certain that you understand what you are signing. Sometimes, doctors give you material to look at before your appointment, so you will have plenty of time to read it and won't feel rushed.
You may be asked to donate blood before an operation such as a mastectomy, if the doctor thinks you might need a transfusion during or after the operation. You might feel more secure knowing that if you do need a transfusion, you will get your own blood back. If you do not receive your own blood, it is important to know that in the United States, a blood transfusion from another person is nearly as safe as receiving your own blood. Ask your doctor about your possible need for a blood transfusion.
Your doctor will review your medical records and ask you about any medicines you are taking. This is to be sure that you are not taking anything that could interfere with the surgery. For example, if you are taking aspirin, arthritis medicine, or a blood-thinning medicine (like Coumadin), you may be asked to stop taking it about a week or two before the surgery. Be sure you tell your doctor about everything you take, including vitamins and herbal supplements. Usually, you will be told not to eat or drink anything for 8 to 12 hours before the surgery, especially if you are going to have general anesthesia (will be "asleep" during surgery).
You will also meet with the anesthesiologist or nurse anesthetist, the health professional who will give you the anesthesia during your surgery. The type of anesthesia used depends largely on the kind of surgery being done and your medical history.
Surgery: General anesthesia is usually given whenever the surgery is a mastectomy or an axillary node dissection, and is most often used during breast-conserving surgeries as well. You will have an IV (intravenous) line put in (usually into a vein in your arm), which the medical team will use to give medicines that may be needed during the surgery. Usually you will be hooked up to an electrocardiogram (EKG) machine and have a blood pressure cuff on your arm, so your heart rhythm and blood pressure can be checked during the surgery.
The length of the operation depends on the type of surgery being done. A mastectomy with axillary lymph node dissection often takes from 2 to 3 hours.
What to expect after surgery: After your surgery, you will be taken to the recovery room, where you will stay until you are awake and your condition and vital signs (blood pressure, pulse, and breathing) are stable.
How long you stay in the hospital depends on the surgery being performed, your overall state of health and whether you have any other medical problems, how well you do during surgery, and how you feel after surgery. Decisions about the length of your stay should be made by you and your doctor and not dictated by what your insurance will pay, but it is important to check your insurance coverage before surgery.
Often, men having a mastectomy and/or axillary lymph node dissection stay in the hospital for 1 or 2 nights and then go home. However, it is becoming more common for the surgery to be done as an outpatient, with a short-stay in an observation unit before going home. Your doctor might arrange for a home care nurse to visit you at home to monitor your progress and provide care.
You will have a dressing (bandage) over the surgery site that may or may not snugly wrap around your chest. You may have one or more drains (plastic or rubber tubes) coming out from the breast or underarm area to remove blood and lymph fluid that collects during the healing process. Your health care team will teach you how to care for the drains, which may include emptying and measuring the fluid and identifying problems the doctor or nurse needs to know about. Most drains stay in place for 1 or 2 weeks. When drainage has decreased to about 30 cc (1 fluid ounce) each day, the drain will usually be removed.
Doctors rarely put the arm in a sling to hold it in place. Most doctors will want you to start moving the arm soon after surgery so that it won't get stiff.
Discuss how to care for the surgery site and arm with your health care team. Written instructions about care after surgery are usually given to you and your caregivers. These instructions should include:
- The care of the surgical wound and dressing
- How to monitor drainage and take care of the drains
- How to recognize signs of infection
- When to call the doctor or nurse
- When to begin using the arm and how to do arm exercises to prevent stiffness
- What to eat and not to eat
- Use of medicines, including pain medicines and possibly antibiotics
- Any activity restrictions
- What to expect regarding sensations or numbness in the breast and arm
- When to see your doctor for a follow-up appointment
Most patients see their surgeon within 7 to 14 days after the surgery. Your surgeon should explain the results of your pathology report at this visit and talk to you about the need for further treatment. If you will need more treatment, you will be referred to a radiation oncologist and/or a medical oncologist.
Types of breast surgery
Most men with breast cancer have some type of surgery. This usually involves an operation called a mastectomy. Many cancers may also require axillary (armpit) lymph node sampling and removal.
A mastectomy removes all of the breast tissue, sometimes along with other nearby tissues.
- In a simple or total mastectomy, the surgeon removes the entire breast, including the nipple, but does not remove underarm lymph nodes or muscle tissue from beneath the breast.
- In a modified radical mastectomy, the surgeon extends the incision to remove the entire breast and lymph nodes under the arm as well.
- If the tumor is large and growing into the chest muscles, the surgeon must do a radical mastectomy, a more extensive operation removing the entire breast, axillary lymph nodes, and the chest wall muscles under the breast. This is only needed if the cancer has grown into the pectoral muscles under the breast.
Breast-conserving surgery, such as a lumpectomy (removal of only the breast lump and a surrounding margin of normal tissue), is a treatment option for many women with breast cancer. It is not used as often in men, mainly because the male breast has only a small amount of tissue beneath the nipple. Removing most male breast cancers requires removing almost all of the breast tissue. And because men have less breast tissue, male breast cancers are more likely to have reached the nipple or skin over the breast or the chest wall at an early stage, which requires more extensive surgery. But breast-conserving surgery may be an option in some cases if the tumor is not thought to have reached the nipple. If this type of surgery is done, it is typically followed by radiation therapy.
Possible side effects of breast surgery
Aside from post-surgical pain, temporary swelling, and a change in the appearance of the breast, possible side effects of surgery include bleeding and infection at the surgical site, hematoma (buildup of blood in the wound), and seroma (buildup of clear fluid in the wound).
Lymph node surgery
To determine if the breast cancer has spread to axillary (underarm) lymph nodes, one or more of these lymph nodes may be removed and looked at under the microscope. This is an important part of staging and determining treatment and outcomes. When the lymph nodes are affected, there is an increased likelihood that cancer cells have spread through the bloodstream to other parts of the body.
Axillary lymph node dissection (ALND)
In this procedure, anywhere from about 10 to 40 (though usually less than 20) lymph nodes are removed from the axilla (the area under the arm) and checked for cancer spread. ALND is usually done at the same time as the mastectomy or lumpectomy, but it can be done in a second operation. This was once the most common way to check for breast cancer spread to nearby lymph nodes, and it is still done in some cases. For example, an ALND may be done if one or more of the underarm lymph nodes are known to contain cancer, based on a previous sentinel lymph node biopsy (see below).
Sentinel lymph node biopsy (SLNB)
Although ALND is a safe operation and has low rates of most side effects, removing many lymph nodes increases the chance that the patient will have lymphedema after surgery (this is discussed below). To lower the risk of lymphedema, the doctors may use a sentinel lymph node biopsy (SLNB) procedure to check the lymph nodes for cancer. This procedure tells the doctor if cancer has spread to lymph nodes without removing as many of them first.
In this procedure the surgeon finds and removes the sentinel node (or nodes) — the first lymph node(s) into which a tumor drains, and the one(s) most likely to contain cancer cells if they have started to spread. To do this, the surgeon injects a radioactive substance and/or a blue dye into the area around the tumor, into the skin over the tumor, or into the tissues just under the areola (the colored area around the nipple). Lymphatic vessels will carry these substances into the sentinel node(s) over the next few hours. The doctor can use a special device to detect the radioactivity in the nodes that the radioactive substance flows into or can look for lymph nodes that have turned blue. (These are separate ways to find the sentinel node, but are often done together as a double check.) The doctor then makes an incision (cut) in the skin over the area in the armpit and removes the nodes. These nodes (often 2 or 3) are then looked at by the pathologist.
The lymph node can sometimes be checked for cancer during surgery. If cancer is found in the sentinel lymph node, the surgeon may go on to do a full ALND. If no cancer cells are seen in the lymph node at the time of the surgery, or if the sentinel node is not checked at the time of the surgery, the lymph node(s) will be examined in greater detail over the next several days. If cancer is found in the lymph node, the surgeon may recommend a full ALND at a later time.
If there is no cancer in the sentinel node(s), it's very unlikely that the cancer has spread to other lymph nodes, so no further lymph node surgery is needed. The patient can avoid some of the potential side effects of a full ALND.
Until recently, if the sentinel node(s) contained cancer, the surgeon would do a full axillary lymph node dissection to see how many other lymph nodes were involved. A recent study has shown that this may not always be needed. In some cases, it may be just as safe to leave the rest of the lymph nodes behind. This is based on certain factors, such as the size of the tumor and what treatment is planned after surgery.
A sentinel lymph node biopsy is not always appropriate. If an underarm lymph node looks large or abnormal by touch or by ultrasound, it may be checked by fine needle aspiration. If cancer is found, a full ALND is recommended and a sentinel node biopsy is not needed.
Although this has become a common procedure, sentinel lymph node biopsy is a complex technique that requires a great deal of skill. It should be done only by a surgical team known to have experience with this technique. If you are thinking about having this type of biopsy, ask your health care team if this is something they do regularly.
Possible side effects of lymph node surgery: As with other operations, pain, swelling, bleeding, and infection are possible.
The main possible long-term effect of removing axillary lymph nodes is lymphedema (swelling) of the arm. This occurs because any excess fluid in the arms normally travels back into the bloodstream through the lymphatic system. Removing the lymph nodes sometimes blocks the drainage from the arm, causing this fluid to remain and build up.
This side effect has not been studied well in men, but in studies of women up to 30% of those who have a full ALND develop lymphedema. It also occurs in up to 3% of those who have a sentinel lymph node biopsy. Lymphedema seems to be more common if radiation is given after surgery. Sometimes the swelling lasts for only a few weeks and then goes away. Other times, the swelling lasts a long time. Ways to help prevent or reduce the effects of lymphedema are discussed in the section, "What happens after treatment for breast cancer in men?". If your arm is swollen, tight, or painful after lymph node surgery, be sure to tell someone on your cancer care team right away.
You may also have short- or long-term limitations in moving your arm and shoulder after surgery. This is more common after an ALND than a SLNB. Your doctor may give you exercises to ensure that you do not have permanent problems with movement (a frozen shoulder). Numbness of the skin of the upper, inner arm is another common side effect because the nerve that controls sensation here travels through the lymph node area.
Some patients notice a rope-like structure that begins under the arm and can extend down towards the elbow. This, sometimes called axillary web syndrome or lymphatic cording, is more common after an ALND than SLNB. Symptoms may not appear for weeks or even months after surgery. It can cause pain and limit movement of the arm and shoulder. This often goes away without treatment, although some patients seem to find physical therapy helpful.
Chronic pain after breast surgery
Some patients have problems with nerve (neuropathic) pain in the chest wall, armpit, and/or arm after surgery that doesn’t go away over time. This is called post-mastectomy pain syndrome (PMPS) because it was first described in women who had mastectomies, but it occurs after breast conserving therapy, as well. Studies have shown that between 20% and 30% of women develop symptoms of PMPS after surgery. It isn’t clear how common this is in men after breast cancer surgery. The classic symptoms of PMPS are pain and tingling in the chest wall, armpit, and/or arm. Pain may also be felt in the shoulder or surgical scar. Other common complaints include numbness, shooting or pricking pain, or unbearable itching. Most patients with PMPS say that their symptoms are not severe.
PMPS is thought to be linked to damage done to the nerves in the armpit and chest during surgery. But the causes are not known. It seems to be more common in younger patients, those who had a full ALND (not just a SLNB), and those who were treated with radiation after surgery. Because ALNDs are done less often now, PMPS is less common than it once was.
It is important to talk to your doctor about any pain you are having. PMPS can cause you to not use your arm the way you should and over time you could lose the ability to use it normally.
PMPS can be treated. Although opioids or narcotics are medicines commonly used to treat pain, they don't always work well for nerve pain. But there are medicines and treatments that do work for this kind of pain. Talk to your doctor to get the pain control you need.
Last Medical Review: 09/30/2011
Last Revised: 06/12/2012