Mastectomy

Medically reviewed by Rosemarie Garcia Getting, MD, FASA, May 16, 2024.

Mastectomies range widely in length and complexity, from lumpectomies performed as outpatient surgeries to modified radical mastectomies that may require overnight hospital stays. These differences in breast cancer surgeries impact decisions regarding anesthesia and pain management. Learn more about mastectomy types, anesthesia considerations, and options for reducing and managing postoperative pain, nausea, and vomiting.

What is a mastectomy?

A mastectomy is surgery to remove all or part of the breast, most commonly as a treatment for breast cancer. These surgeries often include a lymph node biopsy, in which some nodes in the armpit are removed to test whether the cancer has spread to them.

What are the types of mastectomy?

“Mastectomy” is a term used to describe many types of breast cancer surgeries. The National Cancer Institute describes these types:

Partial mastectomy—also referred to as breast-conserving surgery, breast-sparing surgery, lumpectomy, quadrantectomy, or segmental mastectomy. The surgeon removes cancerous or other abnormal tissue and some normal tissue around it, but not the breast itself. The surgeon may also remove some lymph nodes for biopsy, and part of the chest wall lining if the cancer is near it.
Total mastectomy—sometimes referred to as simple mastectomy. The surgeon removes the entire breast. Some lymph nodes under the arm may also be removed.
Radical mastectomy. In this now rarely used surgery, the surgeon removes the entire breast, the lymph nodes, and the chest wall muscles under the breast.
Modified radical mastectomy. The surgeon removes the entire breast and most of the lymph nodes.
Prophylactic mastectomy. This term is used for surgeries performed to prevent the occurrence of breast cancer in someone assessed to be at high risk for developing the disease. The surgery may involve complete removal of both breasts, including the nipples, or as much breast tissue as possible while leaving the nipples intact.

Differences in the length and complexity of the surgery influence decisions related to airway management and anesthesia.

What type of anesthesia is used for a mastectomy?

Differences in the length and complexity of the surgery influence decisions related to airway management and anesthesia. There are several types of anesthesia to consider:

Local anesthesia. This often entails the injection of a numbing medicine directly to the area being surgically addressed.
Regional anesthesia. This type of anesthesia numbs a larger portion of the body by using nerve blocks, in which an anesthetic is injected near nerves to block pain signals. The location of the injection varies by type of block. For patients unable to receive a nerve block, the intravenous administration of a numbing medicine called lidocaine may be an alternative.
Sedation. This type of anesthesia is used in combination with local or regional anesthesia. The anesthesiologist administers intravenous medications to cause patients to go into a state of moderate to deep sedation or sleepiness. Patients are kept comfortable and breathe on their own during the procedure while being monitored continuously. This type of anesthesia is known as monitored anesthesia care.
General anesthesia. This type of anesthesia renders the patient completely unconscious. To help the patient breathe while undergoing general anesthesia, a ventilator is often used with either endotracheal intubation or placement of a supraglottic airway device. Endotracheal intubation entails placement of a breathing tube down the throat and into the windpipe. A supraglottic device, such as a laryngeal mask airway, is placed above the voice box rather than in the windpipe and helps keep the upper airway clear for ventilation. It is used for patients and procedures that do not require intubation.

There are many factors to take into account when considering anesthesia options, including individual circumstances. For example, general anesthesia is typically used for surgery to remove the entire breast, but less complex partial mastectomies may be performed with sedation. Some procedures, such as a modified radical mastectomy, may call for the administration of both general and regional anesthesia. Your anesthesiologist will help determine the best options for you.

How can I reduce pain during mastectomy recovery?

The best way to reduce pain after surgery is to use multiple pain relief methods and medications before, during, and after surgery. You may hear this concept referred to as “multimodal analgesia.” Multimodal analgesia is beneficial for two reasons:

The methods and medications work by different mechanisms and have an additive or synergistic effect that makes them more effective when taken together than when used alone.
By using multiple types of pain relief, patients can avoid the need for a high dose of any one class of medication. This is especially important for minimizing the dosage for opioids, which are often needed to manage mastectomy pain but have more potential negative side effects than other drugs.

The best way to reduce pain after surgery is to use multiple pain relief methods and medications before, during, and after surgery.

Multimodal analgesia includes medications that are administered before, during, or after surgery to help with postoperative pain. These options include various classes of drugs, such as alpha-2 agonists (e.g., dexmedetomidine), anticonvulsants (e.g., gabapentin, pregabalin), corticosteroids (e.g., dexamethasone), local anesthetics (e.g., lidocaine), non-opioid analgesics (e.g., acetaminophen), nonsteroidal anti-inflammatory drugs (e.g., ibuprofen, celecoxib), and opioid analgesics (e.g., oxycodone, hydrocodone, tramadol).

All of the nerve blocks that may be used during surgery have also been shown to help reduce pain during recovery. The specific type of nerve block used depends in part on the type of mastectomy being performed and in part on patient preference. You can discuss the risks and benefits of each option with your anesthesiologist.

Also, cold packs may be applied after surgery to reduce pain and swelling.

Research is ongoing on ways to help patients avoid developing chronic pain—that is, pain that continues beyond three months after surgery. But researchers believe that any interventions to reduce acute pain after surgery, including the use of regional anesthesia and opioid-sparing techniques, have the potential to decrease the risk of chronic pain.

How can I avoid nausea and vomiting during mastectomy recovery?

Postoperative nausea and vomiting are common after breast cancer surgery, but there are ways to minimize the risk and extent of their occurrence. As a first step, your anesthesiologist will review your medical history and ask about things like your medications, smoking history, history of nausea or vomiting after prior surgeries, and proclivity for motion sickness to assess your risk factors for nausea and vomiting. This assessment helps the anesthesiologist identify appropriate steps to take before and during surgery.

Options to help prevent postoperative nausea and vomiting include:

Minimizing the time you go without fluids before surgery to avoid getting dehydrated, which increases the risk. For example, if you have been told that you can drink clear liquids as late as two hours prior to the procedure, don’t stop drinking them far in advance of that two-hour window. But always follow the instructions from your surgical team.
Taking certain medications shortly before surgery, as advised and prescribed by your anesthesiologist.
- Dexamethasone is a corticosteroid that prevents the release of substances in the body that cause inflammation. Given intravenously at the start of anesthesia, it can help with postoperative nausea and vomiting and with postoperative pain.
- Scopolamine transdermal helps prevent nausea and vomiting by blocking the effects of a natural substance (acetylcholine) on the central nervous system. It is administered by placing a patch behind the ear prior to surgery.
Taking ondansetron, which is given intravenously, at the end of surgery. This medication works by blocking the action of serotonin, a natural substance that may cause nausea and vomiting.

If nausea and vomiting still develop after surgery, it’s important to use a medication from a different class of drugs than any medication that has already been used. A class of medication that was not effective at prevention will not be effective for treatment when symptoms occur.

Does cancer treatment before surgery impact my mastectomy risks?

Yes, treatments such as hormonal therapy, chemotherapy, and radiation therapy can impact your risks in surgery. Your anesthesiologist will assess these risks, determine whether you need additional testing before surgery, and explain how any risk factors might affect your surgery. For example, some cancer treatments could contribute to:

Heart function issues. You may receive an echocardiogram (an ultrasound of the heart) and an electrocardiogram (a test of the electrical signals in the heart) prior to surgery to assess your heart function and determine whether extra monitoring will be needed during and after your surgery.
Anemia, in which your hemoglobin—a protein in red blood cells that carries oxygen to the rest of the body—is low. This condition should gradually improve after chemotherapy has been discontinued, but presurgical testing may be necessary.
Blood clots. Hormonal treatments can contribute to this risk. If you’re taking blood thinners to reduce your risk for clots, you may be advised to stop taking those medications for a period of time before surgery to lessen your risk for bleeding.
Nerve damage, which may increase your risk of injury from the administration of a nerve block for pain prevention during surgery. You should discuss the risks and benefits with your anesthesiologist.

Can I begin breast reconstruction during my mastectomy?

Yes, surgery to reconstruct a breast or breasts can be started or done completely at the time of the mastectomy. Just be aware that reconstruction may change your anesthesia care needs because it can add hours and some new complexities to the operation. This can change plans for airway management, pain relief medications and techniques, body positioning and warming, and more. Your anesthesiologist can explain these plans.