Mastectomy: types, preventive mastectomy and recovery

When is a mastectomy recommended?

A mastectomy may be advised when a tumour is large compared with the size of the breast, when there are several tumours in different areas of the breast, when radiotherapy is not possible, after a recurrence, or when a woman prefers it to breast-conserving surgery. It is also an option for women with a very high inherited risk who choose preventive surgery.

For many early cancers, breast-conserving surgery followed by radiotherapy gives long-term results similar to mastectomy. The decision is made together with your breast team and should reflect both the medical facts and your own preferences. Our overview of breast cancer treatment explains how surgery fits with other treatments.

Breast-conserving surgery (lumpectomy)

A lumpectomy or wide local excision removes the cancer with a rim of healthy tissue and keeps the rest of the breast. It is usually followed by radiotherapy. If the excision leaves a dent or makes the breasts uneven, "oncoplastic" techniques – borrowed from breast reduction and breast lift surgery – can reshape the breast at the same time, and the other breast can be adjusted for symmetry.

Types of mastectomy

• Simple (total) mastectomy: removes the breast tissue, skin and nipple, but not the muscles underneath.
• Skin-sparing mastectomy: removes the breast tissue and nipple but keeps most of the skin envelope, which helps immediate reconstruction look natural.
• Nipple-sparing mastectomy: keeps the skin and the nipple-areola complex; it is suitable only when the cancer is not close to the nipple, or for preventive surgery.
• Modified radical mastectomy: removes the breast together with the lymph nodes of the armpit (axillary clearance), used when the nodes are affected.
• Radical mastectomy: removal of the chest muscles as well – rarely needed today.

The lymph nodes are usually checked first with a sentinel node biopsy, which removes only the first one or few nodes; a fuller axillary clearance is done only if needed.

Preventive (prophylactic) mastectomy and BRCA

Women who carry a BRCA1, BRCA2 or another high-risk gene change, or who have a very strong family history, may consider a risk-reducing mastectomy. It lowers the risk of breast cancer substantially but does not remove it completely, because a small amount of tissue always remains. The decision is personal and should follow genetic counselling and a discussion of alternatives such as enhanced screening with MRI and medication.

Preventive mastectomy is usually done as a skin-sparing or nipple-sparing operation with immediate breast reconstruction, using implants or the woman’s own tissue.

Recovery after a mastectomy

Most patients stay in hospital for one to a few nights, depending on whether reconstruction is done at the same time. Drains are often placed for several days. Expect:

• tiredness and tightness across the chest for a few weeks;
• numbness of the chest skin and sometimes the inner arm;
• gentle arm and shoulder exercises from the first days, to prevent stiffness;
• avoiding heavy lifting for around four to six weeks;
• a return to desk work after two to four weeks for a simple mastectomy, longer with reconstruction or further treatment.

Possible complications include seroma (fluid collection), infection, wound healing problems and, after lymph node surgery, lymphoedema (swelling of the arm). Your team will tell you which signs to report. Emotional recovery matters as much as physical healing; breast care nurses and support groups help many women.

Preparing for surgery: questions to ask

Before a mastectomy, it helps to write down your questions and bring someone with you to the consultation. Useful questions include:

• Is breast-conserving surgery an option for me, and why or why not?
• Which type of mastectomy do you recommend, and can my skin or nipple be preserved?
• Will my lymph nodes be removed, and what is my risk of lymphoedema?
• Am I likely to need radiotherapy, and how does that affect reconstruction?
• Can I have immediate reconstruction, and who will perform it?
• How many nights will I stay in hospital, and when can I drive, work and exercise again?

Practical preparation also helps: front-opening tops and a soft, front-fastening post-surgical bra, help at home for the first week, and stopping smoking well in advance, because smoking increases wound-healing problems. Tell your team about all medicines and supplements, especially blood thinners. If you are travelling for surgery, plan to stay near the hospital until your drains are out and your surgeon has checked the wounds, and arrange follow-up with your local doctor on your return. Our travel guide and safety page cover the practical side of surgery in Istanbul.

Reconstruction and prostheses after mastectomy

After a mastectomy you can choose immediate reconstruction, delayed reconstruction, an external breast prosthesis worn in a bra, or to "go flat" with a smooth chest wall contour. All are valid choices. Our guide to breast reconstruction explains implants, expanders, DIEP flaps and fat grafting.

How New City Clinic can help

Whether you are facing a mastectomy, considering preventive surgery or want a second opinion on a proposed operation, the oncology and breast surgery team at New City Clinic can review your reports online, free of charge. Your WhatsApp coordinator arranges consultations, interpreters and stays at accredited partner hospitals in Istanbul. More background is available in our article on breast cancer treatment in Turkey on newcityclinic.com.