Mastectomy Surgery - Breast Removal Surgery

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Ask what kind of mastectomy, and what happens to the skin and the nipple

Four different operations go by this name, and which one you are offered decides what you look like afterwards and what reconstruction is possible. Send the biopsy report with the receptor results, the grade and the HER2 status, the mammogram and ultrasound reports, the breast MRI if you have had one, the armpit ultrasound and any node biopsy, the genetic test result if you have had one, and your medication list. A breast surgeon and a reconstructive surgeon review the file together and tell you which type is appropriate, what the reconstruction options are, and what going without one would mean. No fee, no obligation, and a coordinator replies in your own language.

Four operations, one name

Mastectomy means removing the breast tissue. How much skin and which structures go with it varies enormously, and the word on your consent form should say which of the four is planned.

An older radical mastectomy, which removed the chest muscle as well, has essentially disappeared from practice, so if anybody uses the word radical to you, ask whether they mean the modified version, because the two operations leave very different chests.

The day itself

Why a breast comes off

Six reasons account for nearly all of them, and they are not equally strong.

• Disease too extensive to remove with a margin. Cancer in several parts of the breast, or suspicious calcification spread across it. The strongest reason on the list and the one that is genuinely not negotiable.
• Radiotherapy is impossible. Usually because the chest has been irradiated before. Conservation without radiotherapy is a different proposition, so this reason converts many women to mastectomy on its own.
• Margins that will not clear. After one or two attempts at conservation, the operation is telling you something about how far the disease reaches through the breast.
• Inflammatory breast cancer. A distinct disease with a distinct sequence, and removing the breast is always part of it.
• Tumor size against breast size. The weakest reason on this list, because reshaping techniques and drug treatment given before surgery have both moved the boundary a long way. Worth a second opinion before you accept it.
• You would rather not keep the breast. Entirely legitimate, and a common choice. Somebody who does not want years of scans and worry is making a decision about her life and not about her tumor, and it should be respected rather than argued with.

The three ways forward

Once the breast is coming off, three routes exist and all three are legitimate endings.

• Nothing. A flat chest, closed carefully. The shortest recovery, no foreign material, no further operations, and an external prosthesis available if you want one, and it was chosen first instead of settled for by nearly three-quarters of the women in the largest survey of this group.
• An implant. A silicone or saline device, either placed at the same sitting or reached in stages through a tissue expander that is gradually filled, and it is the shorter reconstruction with no second wound elsewhere on the body, and the one with the higher long-term failure rate.
• Your own tissue. Skin and fat taken from the abdomen, and less often the back or the thigh, transferred with its blood supply and reconnected under a microscope, which makes it a far bigger operation with a second scar, and the one that ages best and tolerates radiotherapy best.

One long-range comparison is worth carrying into the decision. A Texas registry study surveyed 647 women about ten years after diagnosis, comparing breast conservation with radiotherapy against mastectomy and reconstruction. Satisfaction with the breasts did not differ, and neither did physical wellbeing. The mastectomy and reconstruction group scored significantly worse on psychosocial wellbeing and on sexual wellbeing a decade on. Decisional regret did not differ between the groups, which is the finding that matters most here, because it says women in both groups largely stood by the choice they made.

Implant or your own tissue

An American consortium followed 2,343 women having reconstruction at eleven centers and reported both the complications and what the patients themselves said two years later, and the two halves of that work point in different directions, which is exactly why the choice is hard.

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Now or later

Reconstruction at the same sitting gives you the skin envelope, one anesthetic, and no period of living with a flat chest. Reconstruction later means two operations and a wait, and it lets the cancer treatment finish before anything is built, and although most units default to doing it immediately, the evidence for that default is thinner than the enthusiasm around it suggests. In the same American consortium, 151 women had delayed reconstruction and 1,806 had it immediately, and the delayed group had lower odds of any complication at 0.38, lower odds of a major complication at 0.52, and a failure rate of 1.3 percent against 6 percent. Satisfaction and wellbeing at two years did not differ between them.

Immediate reconstruction pushed the start of chemotherapy back by an average of 3.50 days across 29 studies and roughly 156,000 women. Statistically real, and clinically almost nothing. The odds of a delay beyond 90 days were not raised at all.

So the timing argument is not about delaying chemotherapy, which it barely does. What it is about is complications, which immediate reconstruction roughly doubles at an odds ratio of 2.04 in that same analysis, and that has to be weighed against the thing nobody measures well, which is what it is like to wake up without a breast and wait a year. Some women find that period intolerable and some find it a relief to have one thing at a time. That preference is legitimate data and it belongs in the decision alongside the odds ratios.

Radiotherapy afterwards

Many women assume that removing the breast removes the need for radiotherapy. Sometimes it does. Whether it does turns almost entirely on the lymph nodes, and a pooled analysis of 8,135 women across 22 randomized trials divided them into three groups.

1. No positive nodes. Among 700 such women, radiotherapy did nothing measurable. Recurrence carried a rate ratio of 1.06 and breast cancer mortality 1.18, both with confidence intervals crossing one. No benefit was demonstrated in this group.
2. One to three positive nodes. Among 1,314 women, radiotherapy cut recurrence at a rate ratio of 0.68 and breast cancer mortality at 0.80, with a confidence interval of 0.67 to 0.95, and this was the finding that changed practice, because women in this group were previously left untreated as often as not.
3. Four or more positive nodes. Among 1,772 women, recurrence fell at a rate ratio of 0.79 and mortality at 0.87. Radiotherapy has been standard here for decades and remains so.
4. What it means for a reconstruction. If radiotherapy is likely, the reconstruction decision changes. In a study of 109 irradiated women, implant-based reconstructions failed in 21 percent while none of the reconstructions using the patient's own tissue failed, and satisfaction scores were significantly higher in the flap group.

Sequencing is the practical consequence, and it is a question to raise before the operation instead of afterwards, so ask whether radiotherapy is expected and, if the answer is probably, ask what that means for the reconstruction being proposed to you.

Choosing to stay flat

Reconstruction is presented as the default in most consultations, and staying flat is presented as what happens when reconstruction is not possible. The largest survey of women who made that choice tells a different story.

What decides satisfaction

The same survey looked at what separated the women who were happy with their decision from the women who were not, and the answer is uncomfortable for the profession.

A surgeon who did not support the decision carried odds of 3.85 for the patient being dissatisfied afterwards. Being given adequate information about the options cut the odds of dissatisfaction to 0.48, and having a surgeon whose practice was specialized in breast surgery cut them to 0.56.

Two of those three findings are about the conversation rather than the operation. Neither the scalpel nor the anatomy explains them. What they describe is a woman leaving a consultation either believing her decision was heard or believing she had to defend it, and that difference following her for years afterwards. A body mass index of 30 or above also predicted dissatisfaction, at odds of 2.74, which points at the technical difficulty of getting a smooth flat contour on a larger chest and is worth raising directly with the surgeon before the operation. If you feel you are being steered, say so out loud and ask for the reasoning. A good unit will give you one.

Keeping the nipple

Nipple-sparing mastectomy gives the best cosmetic result available after breast removal. Two separate questions decide whether it suits you, and they have different answers.

Pain and lost sensation

Two consequences of this operation get mentioned far less often than they should and both are permanent for some women, the first being chronic pain in the chest, armpit or inner arm that lasts beyond healing and is sometimes burning or electrical in character. Published estimates put it somewhere between 28 and 52 percent, which is a wide range reflecting how differently studies define it, and the risk factors that show up consistently are younger age, extensive surgery in the armpit, a total mastectomy rather than a smaller operation, and having chronic pain somewhere else already. Treatments exist, from local anesthetic blocks to nerve pain medication to psychological approaches, and the evidence behind all of them is thin and inconsistent, but what matters practically is that this is a recognized condition and not something you are imagining, and that saying so early gets it treated earlier. Ask before the operation what this unit does about it, because the units that answer well are the ones that offer a nerve block at the time of surgery and a named person to raise it with afterwards.

Numbness is the second. Removing breast tissue divides the nerves supplying sensation to the skin over it, so the chest is usually numb afterwards, and that holds whether or not the breast is rebuilt. A reconstructed breast looks like a breast and generally does not feel like one. Surgeons have begun reconnecting those nerves during reconstruction, and in a study of 132 patients the ones who had it reported significantly better psychosocial wellbeing at 71.6 against 62.8 on a validated scale, and better sexual wellbeing at 56.9 against 47.3. The technique is available in relatively few centers and it is worth asking about if reconstruction is on your list.

Implants, honestly

If an implant is part of your plan, two specific things deserve saying plainly instead of being left for you to find on the internet at two in the morning.

Above the muscle or beneath it

Implants were traditionally placed under the chest muscle and increasingly they are placed above it, and a prospective comparison of 94 patients found that the group with the implant under the muscle reported more pain and used more painkillers over the first fortnight. Animation deformity, where the reconstructed breast moves and distorts when the chest muscle contracts, did not occur at all in the group with the implant above the muscle. Capsular hardening was more frequent below it. The trade-off runs the other way on appearance, since the outline of the implant was more visible when it sat above the muscle. Satisfaction and physical wellbeing at twelve and twenty-four months favored the position above the muscle, though only in patients whose skin was good enough to support an implant sitting there.

The lymphoma associated with textured implants

A rare cancer of the immune system can develop in the scar capsule around a breast implant, years after it is placed. It is not breast cancer. It is not usually fatal when caught early, and its association is with textured implant surfaces and not smooth ones. Estimates of how common it is have risen as reporting improved, and a review putting the numbers together gave a figure of one in 2,832 for the most heavily textured category of implant, while stressing that the denominators are unreliable because implant registries are patchy and cases go unreported. An American consensus review of 145 papers reached the same broad conclusion about texture. The practical instruction is short. Ask what surface your implant has, get the make, model and lot number in writing before you leave, and report any new swelling of the reconstructed breast years later and do not assume it is nothing.

Complications by the numbers

A mastectomy on its own is a safe operation with a short list of problems, and almost everything in the table below becomes more likely once a reconstruction is added, which is the trade being made.

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Without a cancer

Some women have both breasts removed with no cancer present because a genetic result puts their lifetime risk very high, and two questions arise from that decision with different answers, which is why they are worth asking separately.

How much cancer it prevents

Cancers prevented is the part that is not in dispute. Among 460 carriers who chose risk-reducing surgery and 745 who chose imaging surveillance instead, the annual rate of new breast cancer was 2.4 percent overall and fell to 0.15 percent after the operation, a relative reduction of 94 percent. Nine women, about 2 percent, turned out to have a cancer nobody had detected, found in the tissue removed at the operation itself.

Whether it makes you live longer

Here the evidence is divided, and both halves belong in the conversation. A Dutch cohort followed carriers for a mean of 10.3 years and found that among BRCA1 carriers, risk-reducing surgery was associated with lower overall mortality at a hazard ratio of 0.40 and dramatically lower breast cancer mortality at 0.06, with breast cancer specific survival at age 65 running at 99.7 percent against 93 percent under surveillance. For BRCA2 carriers the mortality difference did not reach statistical significance. The more recent study found breast cancer deaths of two in the surgery group and four in the surveillance group, a difference that was not statistically significant. Read those together and the honest position is that the operation reliably prevents cancers, that a survival benefit is well supported for BRCA1 and less certain for BRCA2, and that surveillance remains a defensible choice for a woman who prefers it. This is a decision to take slowly, with a genetic counselor, and it should never be bolted onto a decision about a cancer you already have.

Recovery and flying home

A mastectomy alone usually means one night, occasionally none. With an implant reconstruction expect one or two, and with tissue transferred from the abdomen expect four to six, because the blood supply to the flap is monitored closely for the first days. Drains are the thing that shapes the early weeks. They stay until the fluid coming out drops below an agreed volume, which is somewhere between five days and a fortnight, and you will be taught to empty and record them. That teaching is worth taking seriously, because a drain removed too early is the commonest reason for repeated needle drainage afterwards.

Shoulder exercises begin within a day or two and they are not optional. A shoulder protected for a fortnight stiffens, and unstiffening it takes months. Desk work is reasonable at around two to three weeks after a mastectomy alone and considerably later after a flap. Flying is generally cleared at seven to ten days after a mastectomy with or without an implant, and at around two to three weeks after tissue transfer, and later again if a drain is still in. Ask for the clearance in writing if your airline or insurer wants one.

Once you are back home the follow-up has three strands. A wound and drain check in the first fortnight with a doctor or nurse near you. An oncology appointment to start endocrine therapy or arrange chemotherapy and radiotherapy, booked before you fly. And, where a reconstruction is in progress, a plan for the expander fills or the second stage, which needs a named surgeon at home or a scheduled return. Get in touch about redness spreading from a scar, pain increasing after the third day, a fever, discharge, a wound edge opening, a reconstructed breast that swells or changes color, or skin over an implant that darkens. The last two need to be seen the same day. None of that list is a reason to be frightened of the operation, and every item on it is treatable when somebody hears about it in time, which is the only reason it is written out here in this much detail.

Questions to ask

Start with which of the four operations is planned and whether the skin or the nipple is being kept, since that single answer determines almost everything about the result. Ask what is happening to the armpit, and whether it is a sentinel node biopsy or a clearance, because the arm consequences differ enormously between them. Ask whether radiotherapy is expected afterwards, and if it is likely, ask what that means for the reconstruction being offered, given that implants failed in 21 percent of irradiated patients in one series while flaps did not fail at all.

Then ask the questions about the choices. Whether a delayed reconstruction has been discussed as a real option rather than a fallback, since the delayed group had fewer complications and the same satisfaction two years on. What a flat closure would look like in your case and who in the unit does them well, and if an implant is planned, what surface it has, whether it sits above or below the muscle, and what the make, model and lot number are. And finally, ask this surgeon's own complication and reoperation rates and not the published ones. A team that knows its own numbers is a team that measures itself.

Reading a quote

No figure appears on this page, and quotes for this operation are the hardest in breast surgery to compare, because a mastectomy alone and a mastectomy with a flap reconstruction are different undertakings that arrive under one heading. Six things belong in writing. Which of the four operations the quote covers, since a nipple-sparing procedure and a modified radical are not the same piece of work, and whether reconstruction is included and if so which type, because an implant and a microsurgical flap sit far apart on any price list. Whether the second stage is included where a tissue expander is being used, given that the expander is only half the job. Whether the armpit procedure is inside or added. Whether the pathology examination is included, which is the report the rest of your treatment is built from, and how many nights are budgeted, given the difference between one night for a mastectomy and five or six for a flap.

Your own file moves the total more here than almost anywhere in this specialty. Whether you are having a reconstruction at all, which type, whether both sides are being operated on and whether the armpit is being cleared are the four variables that decide the number.

Packages published by Turkish hospitals and medical travel agencies for breast cancer surgery generally include the airport transfer, pre-operative testing, the surgeon and anesthesia fees, the operating room, the planned nights, the pathology, an interpreter and the review before departure. They generally exclude flights, insurance, radiotherapy, drug treatment, the second stage of a reconstruction, treatment of a complication and hotel stays past an agreed number. Read what arrives against both lists.

Coming to Istanbul

Ten to fourteen days covers a mastectomy with or without an implant, assuming the diagnostic work is already done, while a reconstruction using your own tissue needs longer, in the region of three weeks, because the hospital stay is longer and flying is cleared later. Assessment and the multidisciplinary meeting fill the first days, the operation takes a morning or most of a day, and the pathology report decides how long you stay after that. Send the biopsy report before anything else, with the receptor status, the HER2 result and the grade written out. Add the mammogram and ultrasound reports with the measurements, any breast MRI, the armpit ultrasound and any node biopsy, the genetic test result if you have one, and your medication list. If a previous surgeon recommended a mastectomy, send that recommendation in whatever form you have it, because a second opinion has to engage with the specific reason given rather than the conclusion.

Say in your first message whether you want a reconstruction, whether you would consider staying flat, and how you feel about implants, because those three answers change which surgeons need to be in the room. Somebody who wants a flat closure needs a surgeon who does them properly and says so, and that is a reasonable thing to ask for by name. Only one coordinator holds your file from the first message to discharge, and the international patients team works in English, Arabic, French, Russian, Serbian, Romanian and Spanish, with other languages arranged on request. Ask in your first message if you would prefer a female physician. Someone can stay overnight with you on the ward, where the rooms carry a companion bed. Meals from the hospital kitchen cover halal, vegetarian and diabetic diets and a prayer room is available. The international patients office books accommodation for both of you, arranges the airport transfer and daily transport, and prepares the appointment confirmation and the invitation letter naming the hospital and your treating doctor for a medical visa application, around ten days before travel.

Take home the pathology report itself and not a summary, with the tumor size and type, the grade, the margin status, the number of nodes removed and involved, and the full receptor results. Take the operation note, which should name which type of mastectomy was performed and what was done to the armpit. If an implant was used, take the make, model, size and lot number, because you will need them years from now and reconstructing that information later is difficult. Add the multidisciplinary meeting conclusion with its recommendation about radiotherapy and drug treatment. Address the file to a breast oncologist near you and book that appointment before you fly. Once you are back home, your coordinator stays reachable on the same WhatsApp number, so a question about a drain or a line in the report reaches somebody with your notes in front of them. Keep that number long after the wounds have healed, because the questions that matter most in this operation arrive months and years later, when a reconstruction needs revising or somebody at home asks exactly what was implanted.

Mastectomy FAQ