Mastectomy

Mastectomy is surgery that removes all of the tissue from the breast to treat breast cancer. Mastectomy can be done on one or both breasts (double mastectomy) to remove breast cancer, or to lower the risk of developing breast cancer in people at high risk.

There are different types of mastectomy options recommended for different reasons. These include:

• Skin-sparing mastectomy. This type of mastectomy is an option for most people, and removes all of the breast tissue, the nipple, and the areola (the area of skin around the nipple), but leaves the breast skin intact.
• Nipple-sparing mastectomy. This mastectomy technique allows a person to keep their breast skin, nipple, and areola, and can be an option for some people.

Skin-sparing and nipple-sparing mastectomy allow for breast reconstruction techniques to be used at the same time as mastectomy surgery, or at a later date. These are just two of the mastectomy types we’ll talk about on this page.

Thinking about losing a breast can bring up a range of emotions, such as sadness, fear, or grief. Many people have concerns about how they will look and feel after a mastectomy. If restoring your breast shape is important to you, know that there are many types of reconstruction available that are typically covered by health insurance. People who don’t want reconstruction may choose to wear a breast prosthesis (breast form) instead or go completely flat after mastectomy. There are many options — and many places to find support with making these decisions if mastectomy is part of your treatment plan.

A number of different factors can determine whether a person has a mastectomy rather than a lumpectomy, which removes just the cancer and a small area of healthy tissue around it, but preserves most of the breast tissue.

• Some people aren’t eligible for lumpectomy, either because the breast cancer is too big, there are many areas of cancer in one or both breasts, or the cancer has characteristics suggesting it is more aggressive and more likely to recur.
• People who have a high risk of a future breast cancer diagnosis — whether due to a strong family history, a cancer-related genetic mutation, or both — often choose double mastectomy. It’s important to know that lumpectomy can also be an option for some high-risk individuals. If you’re at high risk, talk with your doctor about what makes the most sense for you.
• Radiation therapy is almost always recommended with lumpectomy, and not everyone is able to have, or wants, radiation therapy.
• Some people feel they will have greater peace of mind if they have a mastectomy.

Your care team can help you weigh the options and determine whether mastectomy is the right choice for you.

Who is eligible for a mastectomy?

There are many reasons why a woman and her care team may decide that mastectomy is a good option.

In some cases, it comes down to personal preference: Some women want to have all of the breast tissue removed, even if they are eligible for lumpectomy (breast-conserving surgery). Although research suggests that lumpectomy plus radiation therapy can be just as effective as mastectomy for early-stage cancers, some women feel that they’ll be less worried about breast cancer returning if all of the breast tissue is removed.

In other cases, mastectomy may be recommended due to the characteristics of the cancer, such as:

• A tumor larger than 5 centimeters (about 2 inches), or a tumor that is large relative to the breast size; in some cases, lumpectomy that uses plastic surgery techniques can be an option for cancers of this size
• Having several tumors in different parts of the breast
• Having tumors in the nipple area
• A diagnosis of inflammatory breast cancer, an aggressive type of cancer that involves the breast skin

Some women choose to have a mastectomy because they cannot, or do not want to, have radiation therapy after lumpectomy, which usually means daily treatments over several weeks. Radiation therapy is not recommended for women who:

• Previously had radiation to the same breast
• Are pregnant
• Have a connective tissue disease, such as lupus or scleroderma, which makes them more sensitive to the effects of radiation therapy

Mastectomy also may be recommended if a woman already had a lumpectomy but the surgical team was unable to remove all of the cancer through that procedure.

Finally, double mastectomy is often recommended for women who are at high risk for developing breast cancer in the future, whether due to a strong family history or testing positive for a high-risk genetic mutation such as BRCA1, BRCA2, or PALB2, among others. Testing positive or having a strong family history does not mean that you have to undergo mastectomy, though. Talk with your doctor and genetic counselor about your personal risk, and whether lumpectomy or mastectomy is a better option for you.

When breast cancer happens in men, it’s usually treated with mastectomy. Men have small amounts of breast tissue; in addition, male breast cancer often grows behind and into the nipple. If the cancer has spread beyond the breast, men may need to have the lymph nodes removed along with the breast tissue (a surgery called modified radical mastectomy) and sometimes the chest muscles as well (radical mastectomy).

Types of mastectomies

Although mastectomy means that the whole breast is removed, there are different ways mastectomies can be done. Differences include:

• How much surrounding skin and tissue is taken
• How many underarm (axillary) lymph nodes are removed
• What surgical approach is used

Total mastectomy

In a total (or simple) mastectomy, the surgeon removes all of the breast tissue as well as some breast skin, the nipple, and the areola. Some lymph nodes under the arm may also be removed to check for cancer cells, using sentinel lymph node biopsy or axillary lymph node dissection.

If the breast skin is preserved, this is known as a skin-sparing total mastectomy. Although many people are eligible for skin-sparing mastectomy, surgeons may not recommend it if the breast cancer is either very close to the skin surface or involves the skin, as in cases of inflammatory breast cancer.

Modified radical mastectomy

A modified radical mastectomy removes all of the breast tissue, most of the breast skin, nipple, and areola along with most or all of the underarm lymph nodes (also known as axillary lymph node dissection), but not the pectoral (chest) muscles. If necessary, the lining over the chest muscles may be removed as well.

If the skin is preserved, this is known as a skin-sparing modified radical mastectomy. Although many people are eligible for skin-sparing mastectomy, surgeons may not recommend it if the breast cancer is either very close to the skin surface or involves the skin, as in cases of inflammatory breast cancer.

Modified radical mastectomy is the most common surgical treatment for male breast cancer.

Going flat after total or modified radical mastectomy

If you’re not planning to have any breast reconstruction, a total mastectomy or modified radical mastectomy may be a good option for you. In this case, you can ask for an aesthetic flat closure after mastectomy. Flat closure is a form of reconstruction that involves the chest wall. The surgeon removes extra skin, fat, and other tissue in the chest area to achieve a smooth, flat look. In some cases, a plastic surgeon may be brought in to assist the breast surgeon.

Radical mastectomy

As is name suggests, a radical mastectomy is the most extensive type of mastectomy. The surgeon removes the entire breast, most or all of the underarm (axillary) lymph nodes, and the chest wall muscles under the breast, also called the pectoral muscles. Although radical mastectomy used to be the standard treatment for breast cancer, it’s rarely performed anymore in women or men, since more limited surgery has proven to be just as effective.

Radical mastectomy may still be used if someone has a very large breast cancer that has grown into the chest wall, but this is a rare situation. If cancer is found in the chest wall, surgeons usually only remove the portion of muscle that contains cancer. In some cases of muscle involvement, radiation therapy may be recommended after mastectomy, which reduces the need to remove the entire chest wall.

Skin-sparing mastectomy

A skin-sparing mastectomy removes all of the breast tissue, as well as the nipple and areola, but leaves the breast skin intact. Most women are eligible for this type of surgery, unless the tumor is quite large or there is cancer close to the surface of the skin.

Women often choose skin-sparing mastectomy when they are planning to have breast reconstruction, either during mastectomy surgery or at a later date. A plastic surgeon can reconstruct the breast in different ways, including:

• Placing an implant that fills the skin pocket
• Using tissue, called a flap, taken from another part of the body, such as the lower belly, thigh, buttock, hip, upper back, or under the arm

Whether a person chooses breast reconstruction with an implant or flap, skin-sparing mastectomy can minimize scarring and lead to a more natural-looking result.

Nipple-sparing mastectomy

A nipple-sparing mastectomy removes all of the breast tissue but leaves the breast skin, nipple, and areola in place. Usually, the surgeon will remove some breast tissue from underneath the nipple to make sure it doesn't contain any cancer cells. People with one small, early-stage tumor that is not close to the nipple can be good candidates for this type of mastectomy. Right away or later on, a plastic surgeon can use either an implant or a flap of tissue from the belly, buttock, thigh, or other part of the body to reconstruct the breast.

There are some risks specific to nipple-sparing mastectomy, such as:

• More tissue is left behind than with other types of mastectomy, which could increase the risk of recurrence. The level of risk is still being researched.
• The nipple will have little or no feeling.
• If there’s not enough blood supply to the nipple, it can shrink or become deformed.
• With larger breasts, the nipple may look out of place after breast reconstruction. So, if you have large breasts, your surgeon may not recommend this type of mastectomy.

Your breast surgeon and plastic surgeon can help you decide if nipple-sparing mastectomy or skin-sparing mastectomy (which spares the skin but removes the nipple) is a better option for your situation.

Double mastectomy

A double mastectomy, also called bilateral mastectomy, is any type of mastectomy that removes both breasts. This surgery is done when cancer is diagnosed in both breasts.

Still, some people undergoing mastectomy for breast cancer in only one breast choose to have their remaining healthy breast removed, too. This is known as a prophylactic, or preventative, mastectomy. It’s also called contralateral prophylactic mastectomy.

A person may also decide to have a double mastectomy if they know they’re at high risk of developing breast cancer in the future, whether due to a strong family history, a positive test for a breast cancer-associated genetic mutation such as BRCA1 or BRCA2, or both.

In general, doctors do not feel it is necessary to undergo preventive mastectomy on a remaining, healthy breast if you do not have an inherited high-risk mutation, a strong family history, or other high-risk factors. And if you do have high risk factors, mastectomy isn’t always your only option. Talk with your care team about your own individual risk and your quality of life needs. This includes whether it’s important to you to have both breasts look balanced and symmetrical after mastectomy, and whether a mastectomy on the remaining breast plus reconstruction can restore a balanced look — a valid need for many women.

Other reasons people choose double mastectomy can be highly personal, such as:

• They feel they will have intense anxiety about keeping the other breast and having to go through future breast cancer screenings.
• They don’t want reconstruction and would rather not wear a prosthesis (breast form).
• Instead of keeping one breast, they would rather go completely flat.

If you’re thinking about double mastectomy, it’s important to talk with your care team. They can help you make a decision that works for your individual situation.

Patients have more options than ever, and it is my job to make sure that I explain them thoroughly and respect patients’ wishes once they fully understand these options. It may seem confusing at first, but having these options is important and gives women a sense of agency about their breasts and the increasing ways we can reduce their risk with approaches that are not just surgery-related, and that is a positive aspect of this journey.

Prophylactic mastectomy

Prophylactic mastectomy, also known as preventive mastectomy, is surgery to remove one or both breasts to reduce the risk of developing breast cancer.

Contralateral prophylactic mastectomy means having the remaining healthy breast removed after cancer has been diagnosed in the other breast. Bilateral prophylactic mastectomy means both breasts are removed to reduce the risk of cancer.

Bilateral prophylactic mastectomy decreases the risk of breast cancer by at least 95 percent in women who have the inherited gene mutations BRCA1 or BRCA2. By age 70, a BRCA mutation can increase the risk of developing breast cancer to a range of 45 to 65 percent. For women with a strong family history of breast cancer, the surgery can reduce the risk of breast cancer by up to 90 percent.

Women may consider prophylactic mastectomy if they have:

• A strong family history of breast cancer
• A BRCA1, BRCA2, or other breast cancer-related gene mutation
• A diagnosis of cancer in one breast
• Had radiation therapy to the chest for another cancer, usually in childhood

Some women may consider prophylactic mastectomy after a diagnosis of lobular carcinoma in situ. LCIS is not cancer, and it is not an immediate threat to your health, but it is a marker that you have a higher-than-average risk of developing breast cancer in either breast in the future.

If you had a lumpectomy or single mastectomy in the past and recently tested positive for a BRCA or other breast cancer-related mutation, talk with your care team about whether you should consider a prophylactic mastectomy to reduce the risk of a future recurrence or new breast cancer.

If you are thinking about preventive surgery but you’ve never had genetic testing for a high-risk breast cancer mutation, it makes sense to review your family history with your care team and a genetic counselor. They can help you figure out your personal risk and determine if genetic testing makes sense for you.

“We counsel patients based upon their family history, hereditary considerations, desire to reduce risk, and symmetry (if cancer is present), and it is a rightfully complex conversation,” says Monique Gary, DO, MSc, FACS. “Patients have more options than ever, and it is my job to make sure that I explain them thoroughly and respect patients’ wishes once they fully understand these options. It may seem confusing at first, but having these options is important and gives women a sense of agency about their breasts and the increasing ways we can reduce their risk with approaches that are not just surgery-related, and that is a positive aspect of this journey. Women have the right to exercise all their options and do what is right for them at the time that is right for them. Just because she opts for surveillance now doesn’t mean that she can’t decide to undergo risk-reducing surgery later.”

To learn more, visit the Prophylactic mastectomy page.

Side effects

The side effects of mastectomy can vary depending on what type you have, how extensive the surgery is, and whether you have breast reconstruction at the same time. Possible side effects can include:

• Pain, tenderness, or swelling in the chest area
• A buildup of blood (hematoma) or clear fluid (seroma) at the surgery site
• Stiffness and limited range of motion in the arm and shoulder
• Numbness or tingling in the upper arm

Numbness in the chest and breast area is also a common side effect after mastectomy. This can be temporary or permanent. Numbness happens because removing breast tissue also cuts the nerves that provided feeling to the breast.

Some people who have breast reconstruction or aesthetic flat closure may be able to have a nerve repair procedure that aims to restore some feeling to the breasts. One example of nerve repair is called Resensation. This technique uses donated, sterilized human nerve tissue to connect nerve endings in the chest to nerves in the reconstructed breast. To learn more, visit breast reconstruction.

Another potential mastectomy side effect is called post-mastectomy pain syndrome (PMPS), which can include nerve pain in the chest area, armpit, or arm that feels like a tingling, burning, or shooting sensation. This pain may go away over time or it can sometimes persist. Some people experience other symptoms such as numbness or itching. There are ways to treat and manage PMPS, so talk with your care team if you’re experiencing any of these symptoms.

Lymphedema can be a risk if you’ve had lymph nodes removed with sentinel lymph node biopsy or axillary lymph node dissection. Lymphedema is a condition in which lymph fluid builds up in the arm, hand, breast, or torso, leading to pain and swelling. There are many ways to reduce the risk of lymphedema, and to manage it if it does happen.

Your care team can help prepare you for what to expect and what you can do to relieve side effects, such as taking pain medications, doing gentle arm exercises, and working with a physical therapist who specializes in breast cancer rehabilitation.

Treatment after mastectomy

About a week or so after mastectomy surgery, you’ll receive a pathology report that explains the cancer’s characteristics. Your care team will make recommendations about any additional treatments you may need, based on this report.

Treatments are given to reduce the risk of recurrence. Most people who have mastectomy do not need to have radiation therapy, which is typically given after lumpectomy (breast-conserving surgery). The most common treatments used after mastectomy include:

• Hormonal therapy. If the breast cancer tests positive for receptors to the hormones estrogen or progesterone, it means that one or both of these hormones is helping the cancer to grow. Your care team will likely recommend hormonal therapy, which involves taking medicine to lower the amount of estrogen in the body or to block estrogen’s impact on breast cells. The most common examples are tamoxifen and a class of medicines known as aromatase inhibitors, which are typically prescribed for 5 to 10 years. There are also other treatments that suppress the function of the ovaries, the body’s main source of estrogen before menopause. Your care team will talk with you about hormonal therapy options, based on the results of hormone-receptor testing and whether you are premenopausal or postmenopausal. To learn more, visit Hormonal therapy.
• Chemotherapy. Chemotherapy medicines are taken intravenously (through a vein) or by mouth to destroy cancer cells that are growing and dividing quickly. Chemotherapy works to reduce the risk of cancer recurrence. Your care team may recommend genomic testing to better understand your risk of cancer recurrence. Genomic testing can determine whether chemotherapy can help lower your risk of recurrence. A recommendation of chemotherapy is also based on certain characteristics of the cancer, such as tumor size, grade, and whether cancer cells were found in the underarm lymph nodes. To learn more, visit Chemotherapy.
• Targeted therapy. Targeted therapies are treatments that target specific features of cancer cells, such as proteins or markers, that help the cancer to grow. For example, some breast cancers test positive for a protein called HER2. This means that the cells make too many HER2 proteins, which tell the cancer cells to multiply. HER2-targeted medicines can attach to HER2 proteins on the inside or outside of a cancer cell and block signals that tell the cells to multiply too quickly. Targeted therapies can also work in other ways, targeting specific processes in the body that help cancer to grow. These medicines can be used alone or with other targeted therapies, hormonal therapies, or chemotherapy medicines. Learn more about Targeted therapy.