Breast Surgery: Lumpectomy, Mastectomy & Reconstruction

Types of Breast Surgery

Breast surgery may be used to diagnose, treat or prevent breast cancer. The main types of breast surgery include:

• Lumpectomy is surgery to remove a tumor in the breast. For people diagnosed with breast cancer, lumpectomy is often followed by radiation. Other names for lumpectomy include "partial mastectomy," "breast-conserving surgery," and "excisional biopsy."
• Mastectomy is the removal of one or both breasts. Mastectomy may be used for treatment or prevention of breast cancer. 
• Lymph nodes are often removed at the time of lumpectomy or mastectomy in people diagnosed with cancer to see whether, and how much the cancer has spread.
• Breast reconstruction is used to recreate the shape of breasts after mastectomy or lumpectomy.
• Aesthetic flat closure is a surgical technique used with mastectomy that removes excess skin to create a smooth, flat chest for people who choose not to have breast reconstruction.

Lumpectomy or Mastectomy?

Who is a candidate for lumpectomy?

Most people diagnosed with early-stage breast cancer are candidates for lumpectomy with radiation. Lumpectomy is a less extensive surgery than mastectomy and the recovery is often quicker.

Who is a candidate for mastectomy?

For people diagnosed with breast cancer, the decision between mastectomy and lumpectomy is a personal one. Those who may benefit from mastectomy include:

• People with inherited mutations linked to an increased risk for another breast cancer diagnosis.
• People with anxiety about a new breast cancer diagnosis. 
• People with large cancers or multiple areas of cancer in the breast.
• People who are not able to undergo radiation therapy.
• Men with breast cancer. 

For people who have not been diagnosed with breast cancer, guidelines on risk-reducing mastectomy vary by gene and situation. Visit our page on breast reconstruction for more information on these guidelines.

Types of mastectomy

Reconstruction or No Reconstruction

What are the options after mastectomy?

After a mastectomy, you may choose to leave your chest flat or have breast reconstruction surgery to restore the shape of one or both breasts. This is a personal decision, and there is no right or wrong choice.

Choosing whether to have reconstruction is only one of several decisions you may face after a mastectomy. People considering reconstruction can choose from several approaches, each with its own benefits, limitations, risks, recovery time, and cosmetic outcomes. Learning about the available options, including the option to remain flat, can help you make an informed decision that best fits your goals, lifestyle, and preferences. Discuss your options with your healthcare team to understand what each approach may involve.

Choosing whether to have reconstruction, and if so, which type of reconstruction is right for you, can feel overwhelming. FORCE offers several resources to help you explore your options and prepare for conversations with your healthcare team. Start with FORCE's Considering Mastectomy with or without Reconstruction decision guide, which can help you prepare for surgical appointments and make informed decisions. If you would like to see real-world results from different approaches, visit FORCE's secure Post-Mastectomy Gallery, which includes photos and videos shared by people who have undergone mastectomy with and without reconstruction. You can find support and community through FORCE's dedicated Mastectomy Preparation and Recovery support meetings. For more in-depth information, consider reading The Complete Guide to Breast Reconstruction by Kathy Steligo. 

Reconstruction Options

What is breast reconstruction surgery?

After mastectomy, the chest area can be reconstructed to restore the shape and appearance of breasts. Breast reconstruction can be done using implants, your own living tissue or a combination of the two. The Complete Guide to Breast Recontruction by Kathy Steligo is a comprehensive resource to help you understand all of your options and make decisions. Visit our password-protected photo and video gallery to view real outcomes shared by community members or to upload your own photos or videos to share with others.

Most reconstruction involves two or more operations over several months.
The initial surgery forms the breast mounds (breasts without nipples).
A shorter revision surgery later refines the shape and size of the new breasts and (if needed) creates nipples.

Tattooing adds color to the nipples, simulates the areolas and completes the reconstructive process. 

Types of Reconstruction

Reconstruction with breast implants

Most breast reconstruction involves implants that are filled with soft, thick silicone gel (saline implants are used less often). Implants may be placed under or over the pectoral chest muscle. Implants are not lifetime devices and eventually must be replaced.
Implant procedures include:

Expander-to-implant reconstruction: A temporary expandable implant is placed into a pocket under the chest muscle and is then gradually inflated over a few weeks in a plastic surgeon's office. Expansion stretches the chest skin and muscle until the pocket is large enough to fit the desired implant. A shorter surgery then replaces the expanders with implants that best fit the chest anatomy and desired size.

Direct-to-implant reconstruction (also known as "one-step"): Nipple-sparing mastectomy and reconstruction can be completed in a single operation. This is known as "direct-to-implant" breast reconstruction. A full-sized implant is secured into place, so no expansion is needed. With this reconstruction, the implants may be placed under or over the muscle, depending on patient and surgeon preferences.

Textured breast implants have been linked to a very rare cancer known as Breast Implant-Associated Anaplastic Large Cell Lymphoma or BIA-ALCL. For this reason, the FDA recalled certain textured implants (see full list of devices here) and surgeons in the U.S. may no longer use them. Currently, the FDA does not recommend removing textured implants unless someone has symptoms of BIA-ALCL or other complications.

Screening for breast implant rupture

The FDA recommends periodic imaging (e.g., MRI, ultrasound) of silicone gel-filled breast implants to screen for implant rupture. Implants must be labeled with this recommendation. Patients with these implants should have an ultrasound or MRI 5-6 years after their initial implant surgery and every 2-3 years thereafter, even if they have no symptoms. The FDA also recommends that anyone who has symptoms at any time or uncertain ultrasound results for breast implant rupture should undergo a breast MRI.

Tissue Reconstruction

Breasts can be reconstructed using excess fat, skin, and/or muscle removed from the tummy, hips, back, buttocks or thighs. This is known as "autologous breast reconstruction."

Older flap techniques, including TRAM and Latissimus Dorsi, remove muscle from the donor site, which can lead to pain or muscle weakness. Newer flap techniques, known as "perforator flaps" include DIEP, PAP, SIEA, GAP, TUG and others. These flap methods produce similar cosmetic results using only fat and skin and sparing the muscle. These muscle-sparing methods require a specially trained microsurgeon who connects blood vessels in the flap to blood vessels in the chest. The overall timeframe for completing flap reconstruction is shorter than breast reconstruction with tissue expansion, but it is more invasive and requires longer surgery and recovery times. Unlike breast implants, tissue flaps last a lifetime without needing to be replaced.

Fat Grafting

Fat grafting (also called fat transfer) is a breast reconstruction technique that uses a person's own fat to improve or rebuild the breast after a mastectomy. Fat is removed from the abdomen, thighs, hips, or buttocks using liposuction and then injected into the breast area. It may be used after reconstruction to fill in uneven areas, improve the feel, or restore volume that may be lost over time. Some people need more than one fat-grafting procedure to achieve their desired outcome.

In some cases, fat grafting can be used to rebuild part or all of a breast after mastectomy. This approach may involve multiple procedures performed over time to gradually create the desired breast shape and size. Newer techniques may combine fat grafting with an absorbable tissue-support structure (scaffold) that helps create space for the transferred fat and supports the developing breast shape while new blood vessels grow into the area. This approach may offer an alternative for some people who are not candidates for implants or traditional flap reconstruction.

Nipples and areola

People who do not have nipple-sparing mastectomy may choose to have nipple reconstruction nipple and areola tattooing. Visit our password-protected photo and video gallery to view real outcomes shared by community members or to upload your own photos or videos to share with others.

Nipple reconstruction

Nipple reconstruction is a short and simple procedure that creates a small flap of breast skin into the shape of a nipple. This surgery is usually done after the reconstructed breast has settled into position, about three or four months after revision surgery. Other people may choose to skip this reconstructive step, because reconstructed nipples have no sensation and do not react to cold or touch as natural nipples do. For women who decide to skip this step, some may choose 3-D nipple tattooing or temporary adhesive nipples.

Nipple and areola tattooing

Tattooing adds color to the new nipple and recreates the look of the areola. Tattoos may be performed by the surgeon, a specially-trained nurse or technician or a professional tattoo artist who is experienced with reconstructive tattooing. Depending on the procedure, multiple sessions may be required. Tattoos may fade over time, but they can be repeated if necessary. 3-D tattooing produces deeper variations of pigment to simulate the look and texture of a natural nipple and areola. This is best performed by a skilled tattoo artist who is experienced with this procedure.

A great breast reconstruction resource is The Complete Guide to Breast Reconstruction by Kathy Steligo. 

No Reconstruction

What are the reasons to go flat?

You may choose not to reconstruct because you:

• want to avoid additional surgery.
• want to return to your normal routine as quickly as possible.
• prefer, or are comfortable with the idea of a flat chest.
• are undecided about reconstruction at the time of mastectomy.
• have a health condition that precludes additional surgery.
• need radiation after mastectomy. (For reconstruction after radiation, the plastic surgeon can insert and inflate a tissue expander after mastectomy to preserve the breast skin and shape for later reconstruction—this is called a “delayed-immediate” procedure).

What happens when you go flat?

If you choose to go flat, the breast tissue and most of the breast skin is removed, leaving the chest flat or slightly concave. The incision will typically run across the middle of the chest. It may be possible for you to have nipple sparing mastectomy, even if you choose not to reconstruct. Make sure to ask your surgeon for an "aesthetic flat closure" as defined by the National Cancer Institute so they understand you want a smooth, comfortable flat chest with no extra skin left behind.

You can change your mind about going flat and undergo delayed reconstruction with tissue or implants at any time in the future.

Using prostheses

Some people who go flat like to wear breast-shaped forms (prostheses) that adhere to the chest or can be tucked into specially-made bras, camisoles, lingerie and swimsuits to temporarily restore their natural shape and profile. Prostheses come in a variety of shapes, sizes, textures, weights and with or without nipples. Customized silicone prostheses are the most realistic and the most expensive. Prostheses can be especially helpful after unilateral mastectomy to better fit into clothing and restore balance. A qualified fitter can help you find the right prostheses that fits your chest properly.

Goldilocks mastectomy

​If you don’t want a completely flat chest after mastectomy but also don’t want (or can’t have) breast reconstruction, you might consider a Goldilocks mastectomy. It is a skin-sparing mastectomy—the surgeon removes the breast tissue and then rearranges the breast skin and underlying fat to create a small breast mound. Results tend to be better for patients with very large breasts who have more fat to work with. No additional surgeries are required, although later fat grafting (an outpatient procedure) can improve volume and contour without the need for breast implants or donor sites.

You may choose to keep your nipples and areolas if they are clear of cancer cells, although they may flatten or look and feel differently. Other options would be to have them reconstructed or tattooed onto your breast mounds or simply leave your breast mounds without nipples.

The Goldilocks procedure may be as safe as other skin-sparing mastectomies. However, no large, long-term clinical studies have identified appropriate candidates, specific risks or shown long-term safety data.

Not all breast surgeons, general surgeons or surgical oncologists offer the Goldilocks procedure, so it is important to ask about a surgeon’s experience with this procedure. Ask to see photos of their Goldilocks patients, and discuss what you can expect in terms of the surgery, recovery and results.

Preparation and Recovery

You can take steps to help you prepare for and recover from lumpectomy or mastectomy with or without reconstruction. 

What to expect after surgery

• After surgery, most of your chest will be numb and may feel heavy. You may feel a pulling sensation under your arms as you recover; this will improve as your chest heals. It's important to take pain medications as prescribed, and tell your doctor if the medications are not controlling your pain.
• Most people remain in the hospital at least overnight. The length of your hospital stay will depend on whether you choose to go flat or reconstruct and which type of procedure you have. 
• You may have surgical drains to reduce the build-up of fluid in your chest. Your nurse will explain how to empty your drains. The temporary drains will be removed once your body stops producing fluid (usually 1-3 weeks). 
• Average recovery time after mastectomy with reconstruction is about 3-4 weeks but may be 6-8 weeks. During that time, you may be restricted from driving and activities that involve lifting or raising your arms over your head.

What factors affect recovery from mastectomy?

Surgical risks and complications 

Every surgery has potential risks; some are more serious than others. Some mastectomy and reconstruction risks can affect recovery. Others can affect the type of scarring and appearance of the reconstructed breast. Some possible risks include:

• Infection
• Fluid build-up at the surgical site (seroma or hematoma)
• Delayed healing
• Blood loss
• Blood clots
• Blood supply issues that cause damage to or the loss of a flap
• Pain (post-operative and long-term pain syndromes)

Long-term and late-onset effects and complications

Late-onset complications and long-lasting changes may occur after mastectomy with or without reconstruction, including the following:

• Lack of feeling in the breast or chest or sensation that occurs because nerves are severed when breast tissue is removed. The chest (with or without reconstruction) is usually permanently numb after mastectomy. Some options may be available to spare nerves during mastectomy or restore sensation after mastectomy. 
• Postmastectomy pain syndrome is a long-term complication of nerve damage during mastectomy that leads to persistent pain, tingling or phantom itching in the chest, armpit or arm. It is more likely to happen after radiation or when lymph nodes are removed during mastectomy. Treatment is available for this complication but might require a specialist. 
• Capsular contraction (hardening of the scar tissue around an implant) can occur at any time after implant reconstruction. Treatment usually involves removing and replacing the implant.
• Implant movement or rupture requires additional surgery to fix the pocket, remove the implant or replace an implant.
• Breast Implant Associated Anaplastic Large Cell Lymphoma or BIA-ALCL is a very rare cancer that has been linked to breast implants. Although the cancer is rare, the FDA recalled Allergan BIOCELL textured implants and expanders (see full list of devices here). Read more about BIA-ALCL here.

Some experts believe that breast implants may also increase the risk for certain immune-mediated diseases, but research has not proven a link. More research is needed to learn if there is a relationship between breast implants and these illnesses. 

It is important to discuss the possible surgical risks and long-term complications with your surgeon to understand the seriousness and likelihood of these risks before making decisions about surgery and reconstruction. Consider getting a second opinion on the best way to resolve serious complications or unsatisfactory results. 

Tips to prepare for and recover from surgery

You can take steps to prepare for and recover from mastectomy with or without reconstruction. Before surgery, many people:

• Prepare frozen meals or arrange for meal delivery to minimize the need for cooking.
• Move frequently used items to lower shelves. 
• Arrange for rides to follow-up appointments or to pick up children from school.
• Purchase pillows to improve comfort while resting or sleeping.
• Ask their surgeon for a referral for post-operative physical therapy.

FORCE has a mastectomy checklist with a more complete set of tips written by experts and people who have undergone the procedure. 

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