Mastectomy - surgery to remove your breast
A mastectomy is surgery to remove all of the breast. If you have one breast removed this is known as a single or unilateral mastectomy. If you have both breasts removed this is known as a double or bilateral mastectomy.
Why you might have a mastectomy
Depending on your situation, your surgeon might recommend that you have a mastectomy operation. Or you might have a choice of operations to consider. This might be either:
- breast conserving surgery (lumpectomy) – this is when the surgeon removes the cancer with a surrounding border of normal breast tissue
- a mastectomy
There are advantages and disadvantages to these different types of surgery.
Your surgeon is most likely to recommend a mastectomy if you:
- have a large lump (tumour), particularly in a small breast
- have more than one area of cancer in your breast
- have large areas of
DCIS 
in your breast Paget’s disease (if it affects a large area)- are pregnant and you can’t have radiotherapy
- have a health condition that may make it difficult for you to cope with the possible side effects of radiotherapy, such as pulmonary fibrosis or connective tissue disease (such as scleroderma, lupus, Ehlers-Danlos)
- have had radiotherapy to the chest wall before
- have a type of breast cancer called inflammatory breast cancer
- male breast cancer
- have a very high risk of developing breast cancer due to family history or a change in the
gene (mutation)
If you have had a lumpectomy (breast conserving surgery) your surgeon might recommend a mastectomy if:
- cancer cells are in the margins of the area of breast tissue removed. You usually have a second operation first to remove further breast tissue, but if cancer cells are still found at the edges of the tissue you are likely to have a mastectomy. The margin is the border of normal breast tissue your surgeon removes around the cancer
- cancer is spreading to other areas in the breast
- cancer cells are present at the margins of the area of the tumour removed and you would prefer a mastectomy as your second operation instead of more tissue being removed
- a tumour has come back in the same breast (local recurrence) following breast conserving surgery and you had radiotherapy to the breast
Mastectomy and breast reconstruction
Breast reconstruction is surgery to make a new breast after removal of the breast tissue. The surgeon creates a new breast shape using tissue from another part of your body, or an implant, or both.
Your surgeon will talk to you before the operation about the options for breast reconstruction.
It is your choice whether you have breast reconstruction or not but you should be offered one. Some women choose not to have reconstruction.
When can you have breast reconstruction?
You might be able to have breast reconstruction at the same time as the mastectomy (immediate reconstruction). Or you might have it some months or years afterwards (delayed reconstruction).
Whenever possible you should be able to choose when you have a reconstruction operation. Everyone is different and some women prefer to have it at the same time as the mastectomy while others prefer to delay it.
You will have time to talk to your surgeon or breast cancer nurse and ask any questions you have. They may have photographs to show you of women who have had a breast reconstruction.
Delayed breast reconstruction
If you aren't having an immediate breast reconstruction, your nurse will show you artificial breast shapes (prostheses). You’ll first have a temporary prosthesis. They are often called softies or comfies. They are lightweight and made of fabric. About 4 to 6 weeks after your mastectomy you’ll be ready for your permanent prosthesis. The permanent prosthesis is made from silicone.
You put the prosthesis inside your bra to create a breast shape.
You usually go to a breast prosthesis fitting clinic. The staff help you find the right size and shape that suits you. They also explain how to care for it.
Choosing to go flat after a mastectomy
You might decide that you don’t want to wear a prosthesis or have a breast reconstruction after having a mastectomy. You may choose to be flat.
Women decide to do this for various reasons. It might be because you:
- don’t want to have more surgery
- want to get back to everyday life as soon as possible
- don’t want to wear prosthesis, or find them uncomfortable
Your surgeon and breast care nurse will talk to you about all your options. They will explain the pros and cons to help you make the right decision for you. You may need time to make your decision. Talking to family and friends about how you feel can help.
A charity called Flat Friends UK offers support to women who choose to be flat. You can get in touch with women who have had similar experiences through their online forum, Instagram, Facebook, Twitter, or face to face. The website also has information about research, fashion ideas and personal stories.
Radiotherapy after surgery
Radiotherapy means the use of radiation, usually x-rays, to treat cancer. You might need radiotherapy after a mastectomy if your doctor thinks there is a risk of the cancer coming back.
What happens?
The type of mastectomy you have depends on:
- how big the cancer is
- where it is in the breast
- whether you have a breast reconstruction
With a simple mastectomy, the surgeon removes the breast tissue, nipple and some of the skin. They also remove some of the lymph nodes from the armpit. Rarely, the surgeon also removes the muscles of the chest wall. This is called a radical mastectomy.
The scar from a simple mastectomy extends across the skin of the chest and into the armpit.
You may have a different type of mastectomy if you have breast reconstruction. These include:
- a skin sparing mastectomy – removal of the breast tissue and nipple but keeping most of the skin
- a skin and nipple sparing mastectomy – removal of the breast tissue but keeping most of the skin, the nipple and the area around the nipple (areolar)
- skin reducing mastectomy - removal of the breast tissue and some of the skin. You keep the breast shape but makes your reconstructed breast smaller. This is generally used for larger breasts. In some cases you may keep the nipple. This is called a skin reducing and nipple sparing mastectomy
- modified radical mastectomy - this is the combination of a simple mastectomy and removal of most of the lymph nodes
Your surgeon will tell you what type of surgery is best for you.
Checking lymph nodes
Sometimes breast cancer cells can spread into the lymph nodes in the armpit (axilla) close to the breast. It is important to know if there are cancer cells in the lymph nodes in the armpit and to find out how many of the lymph nodes contain cancer cells. This helps the doctors make decisions about your treatment.
Checking the lymph nodes before surgery
You have an ultrasound scan of the lymph nodes under your arm at the same time as having other tests to diagnose breast cancer. You have a of any lymph nodes that look abnormal. You have this to check if cancer cells have spread to the nearby lymph nodes. The biopsy is sent to the laboratory to check for cancer cells.
If this shows that the cancer has spread to the nodes in the armpit, you will have surgery to remove all or most of them. You have this at the same time as your mastectomy. This is called an axillary lymph node dissection (ALND) or axillary clearance.
You have a sentinel lymph node biopsy (SLNB) at the same time as your breast surgery if the:
lymph nodes looked normal during the ultrasound scan
results of an ultrasound guided needle biopsy of the lymph nodes showed no cancer cells
This is to check if cancer cells have spread to the .
Checking lymph nodes during surgery (sentinel lymph node biopsy)
The sentinel node is the first lymph node or nodes in the armpit where fluid drains to from the breast. This means sentinel nodes are the first lymph nodes the breast cancer could spread to.
Checking with a radiotracer and blue dye
A few hours before the operation, you have an injection of a small amount of mildly radioactive liquid into your breast close to the cancer. You usually have this in the nuclear medicine department in the hospital. The radioactive liquid is called a tracer.
During the operation, your surgeon may also inject a small amount of blue dye into the breast. The dye and the tracer drain away from the breast tissue into nearby lymph nodes.
The surgeon can see which group of lymph nodes the dye reaches first. They also use a radioactive monitor to see which group of lymph nodes the tracer gets to first.
Checking using the Magtrace and Sentimag system
In some hospitals surgeons use the Magtrace and Sentimag system to find sentinel lymph nodes. This is usually used in the hospitals that have limited access to or are without a nuclear medicine department.
Magtrace is a magnetic liquid tracer that is dark brown in colour. This is injected into the breast tissue around the cancer. It acts as a magnetic marker and dye. in the area soaks up the injected liquid and it gets trapped in the sentinel lymph nodes.
You can have Magtrace up to 30 days before your operation.
During your operation the surgeon uses a probe called a Sentimag to detect the magnetic liquid trapped in the sentinel lymph nodes. The liquid also acts like a dye so the surgeon can see where it is trapped. The surgeon can then remove the sentinel lymph nodes for testing.
Removing the nodes
The surgeon usually removes about 1 to 3 of these nodes. They might remove other lymph nodes if they look as though they might contain cancer cells. They send the nodes to the laboratory to check for cancer cells. The results can take a few weeks.
The dye can stain your breast slightly blue. It gradually fades over a few weeks or months. The dye may also turn your urine green for a few days.
If none of the lymph nodes contain cancer cells, you won’t need to have any more nodes taken out.
If there are cancer cells in the sentinel nodes, you might have another operation to remove most or all of the lymph nodes under your arm. This is generally about 2 weeks after you get the results.
Some people have radiotherapy to the armpit to destroy any remaining cancer cells instead of surgery.
Getting results during the operation
In some hospitals, the surgeon gets the results of the sentinel lymph node biopsy during the operation. This is called an intra operative assessment. They can then remove the rest of the nodes if necessary and you avoid having a second operation. This type of testing is called one step nucleic acid amplification (OSNA).
Your surgeon will explain this to you before your operation, so you know what to expect.
Lymph node sampling
Instead of sentinel lymph node biopsy, your surgeon might take a sample of 4 or more lymph nodes from under your arm to check for cancer cells. This is called axillary sampling. You may have this if the radioactive tracer and blue dye injections haven’t worked or couldn’t be injected.
What happens after surgery?
After the operation, you usually wake up in the recovery room before moving back to your ward or day unit.
Follow up after surgery
You have follow up appointments to check your recovery and sort out any problems. They are also your opportunity to raise any concerns you have.
You usually see your surgeon one to two weeks after your operation. They examine you and check your wound is healing well.
Your surgeon will explain the results of your surgery and talk about any further treatment you might need.
You'll have contact details of your breast care nurse or the ward if you need to contact someone before your follow up.
Supported self management or patient initiated follow up (PIFU)
In some hospitals you might have regular phone calls with your breast care nurse instead of seeing your doctor in clinic. You can also contact them between appointments if you have any new symptoms or are worried about anything. They can then arrange for you to be seen in clinic.
Possible problems after a mastectomy
There is a risk of problems or complications after any operation. Treating them as soon as possible is important. Some of the problems include:
- bleeding from the wound
- infection
- fluid collecting around the operation site (seroma)
- blood collecting around the operation site (haematoma)
- nerve pain
- shoulder stiffness
- swollen arm or hand
- scar tissue in the armpit (cording) if you have had lymph nodes removed
- blood clots
- feeling tired and weak
Research into lymph node surgery
Research is looking at treatment of the lymph nodes during and after breast surgery.
Davina's breast cancer story
This is how Davina coped with her diagnosis and surgery.
"Take things slowly there is no rush. Sleep when you can. Eat healthy and drink plenty of water. Keep positive thoughts in your head. Talk to people, your family and friends. Read information and don’t be afraid to ask questions."
Pam's breast cancer story
Read about Pam's diagnosis and treatment.
"I decided not to have a breast reconstruction. I felt that a mastectomy bra and breast sponge would be OK for me."
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