Breast Cancer Surgery: Lumpectomy, Mastectomy & Lymph Nodes

What surgery is used to treat breast cancer?

The two main operations for breast cancer are breast-conserving surgery, which removes the tumour with a rim of healthy tissue, and mastectomy, which removes the whole breast. Most women also have some of the lymph nodes in the armpit checked during the same operation, usually with a sentinel lymph node biopsy.

Surgery is one part of a wider plan. Many people also have chemotherapy, radiotherapy, hormone therapy or targeted drugs, either before or after the operation. The order and the choice of operation are agreed by your multidisciplinary oncology team — the breast surgeon, oncologists, radiologist, pathologist and breast care nurse — based on your scans, biopsy results and your own preferences. You can read more about that wider plan in our guide to breast cancer treatment.

Dr. Fatih Kılıç is a plastic and reconstructive surgeon, not an oncologist. The cancer operation itself is decided and performed by your breast surgical team. Our role is reconstruction: helping you understand how each type of surgery affects the shape of the breast, and planning reconstruction together with your breast surgeon where that is wanted.

The questions most people ask at this stage are:

• Can I keep my breast, or do I need a mastectomy?
• Will the lymph nodes under my arm be removed?
• Can I have reconstruction at the same time?
• How long will recovery take, and what are the risks?

This page answers each of these in turn.

Lumpectomy or mastectomy: which is better?

For women who are suitable for both, breast-conserving surgery followed by radiotherapy gives the same long-term survival as mastectomy. Large clinical trials that followed women for more than twenty years showed this, and it is the basis of current guidance from bodies such as NICE, ESMO and NCCN.

Breast-conserving surgery is also called lumpectomy, wide local excision or partial mastectomy. It is often suitable when the tumour is small compared with the size of the breast and is in one area. Mastectomy is usually recommended when the cancer is large relative to the breast, is spread through several areas of the breast, when radiotherapy is not possible, or when clear margins cannot be achieved after re-excision. Some women choose mastectomy even when breast conservation is possible, for example because of a strong family history or a wish to avoid radiotherapy. That choice is valid, and your team will talk it through with you.

Neither option is “better” in general. The right choice depends on the cancer, the breast and what matters most to you. If you are unsure, it is reasonable to ask for more time or a second opinion before deciding.

What are clear margins, and why might I need a second operation?

A clear margin means that, when the pathologist examines the removed tissue under the microscope, no cancer cells reach the cut edge. This lowers the chance of the cancer coming back in the same breast.

For invasive breast cancer, many guidelines accept “no tumour at the inked edge” as a clear margin when radiotherapy follows. For ductal carcinoma in situ (DCIS), a slightly wider margin, often around 2 mm, is usually preferred. Your surgeon will explain the standard your team uses.

The final margin result is usually available a week or two after surgery. If cancer cells are found at or very close to the edge, your team may recommend:

• Re-excision — a second, smaller operation to remove a little more tissue from the affected edge.
• Mastectomy — if the margins remain involved, or the disease turns out to be more widespread than the scans suggested.

Needing a re-excision is not unusual and does not by itself mean the cancer is more serious. Depending on the hospital and the type of cancer, roughly one in ten to one in five women having breast conservation need a further operation for margins.

Wire and marker localisation

If the cancer cannot be felt, it is marked before surgery so the surgeon can find it precisely. This is called localisation, and it is guided by mammogram or ultrasound.

At the time of the biopsy, a tiny metal marker clip is often placed in the tumour. Before or on the day of surgery, the radiologist then places one of the following:

• A guide wire — a thin wire inserted through the skin with its tip at the tumour, usually on the morning of the operation.
• A small seed or reflector — magnetic, radar-based or low-dose radioactive markers that can be placed days or weeks beforehand and detected with a probe during surgery.

After removal, the tissue is often X-rayed in theatre to confirm the marker and the tumour are inside the specimen. A marker clip may also be placed in an abnormal lymph node before chemotherapy, so that the same node can be found and removed later.

What are the different types of mastectomy?

All mastectomies remove the breast tissue; they differ in how much skin, nipple and lymph node tissue is removed. The main types are:

• Simple or total mastectomy — removes the breast tissue, nipple and areola and some skin, leaving a flat chest wall with a horizontal or slightly diagonal scar.
• Skin-sparing mastectomy — removes the breast tissue, nipple and areola but keeps most of the breast skin. It is mainly used with immediate reconstruction, because the preserved skin envelope helps create a natural shape.
• Nipple-sparing mastectomy — keeps the skin and the nipple-areola complex. It may be suitable when the cancer is not close to the nipple and there is no nipple involvement. The kept nipple usually has little or no sensation, and there is a small risk of nipple skin loss.
• Modified radical mastectomy — a total mastectomy combined with removal of most of the lymph nodes in the armpit (axillary lymph node dissection).

The older radical mastectomy, which also removed the chest muscles, is now very rarely needed. For a closer look at how skin-sparing and nipple-sparing techniques affect reconstruction, see reconstruction after mastectomy.

What is a sentinel lymph node biopsy?

A sentinel lymph node biopsy removes the first one to three lymph nodes that drain the breast, to check whether cancer has spread to the armpit. If these “sentinel” nodes are clear, the other nodes are very likely to be clear as well, so they can be left in place.

To find the sentinel nodes, the team injects a tracer near the tumour or nipple. This may be a small dose of radioactive liquid, a blue dye, a magnetic tracer, or a combination. The tracer travels to the sentinel nodes, which the surgeon then finds through a small cut in the armpit, usually during the main breast operation.

Sentinel node biopsy has largely replaced routine removal of all the armpit nodes for women whose nodes look normal on scans. Because fewer nodes are removed, the risk of arm swelling (lymphoedema), numbness and shoulder stiffness is much lower. Some people notice temporary blue-green urine or a blue patch on the breast skin after blue dye; this fades over weeks to months.

For some older women with small, low-risk, hormone-sensitive cancers and normal armpit scans, recent trials suggest the sentinel node biopsy itself may sometimes be safely omitted. Whether this applies to you is a decision for your breast surgeon.

When is axillary lymph node dissection still needed?

Axillary lymph node dissection — removing most of the lymph nodes in the armpit — is now used much less often than in the past. Today it is usually reserved for women with clear evidence of significant cancer in the armpit nodes.

It may still be recommended when:

• cancer in the armpit is confirmed by biopsy before surgery and has not responded fully to chemotherapy given before the operation;
• several sentinel nodes contain cancer, or the cancer has grown outside the node;
• the sentinel node cannot be found.

Large trials have shown that many women with cancer in only one or two sentinel nodes can avoid a full dissection, especially when they have breast conservation followed by whole-breast radiotherapy, or when radiotherapy to the armpit is used instead. After chemotherapy given before surgery, a “targeted” approach that removes the sentinel nodes plus the previously marked node may also spare some women a full dissection.

A full dissection carries a higher risk of lymphoedema — roughly one in five women over the following years, compared with a few per cent after sentinel node biopsy alone — as well as numbness in the inner upper arm, shoulder stiffness and fluid collections.

Should I have both breasts removed?

For most women with breast cancer who do not carry a high-risk gene change, removing the healthy breast (contralateral prophylactic mastectomy) does not improve survival. It reduces the chance of a new cancer in the other breast, but that chance is usually low to begin with.

The situation is different for women with a high-risk inherited change such as BRCA1, BRCA2 or PALB2, or a very strong family history. In these cases, removing both breasts may substantially lower the risk of a future cancer, and many teams discuss it as a reasonable option. Genetic testing is often offered when a woman is diagnosed young, has triple-negative breast cancer, or has a strong family history. See hereditary breast cancer and BRCA for more.

Points worth weighing before deciding:

• A bilateral operation is longer, with roughly double the risk of complications and a longer recovery.
• Many women value symmetry, and reconstructing both sides at once can make that easier.
• Others prefer to keep a healthy breast and its natural sensation.
• The decision does not need to be made in a hurry; risk-reducing surgery can also be done later.

If you are considering it, our page on risk-reducing mastectomy and reconstruction explains the reconstructive side.

What is oncoplastic breast surgery?

Oncoplastic surgery combines removal of the cancer with plastic surgery techniques, so that the breast keeps a natural shape after breast-conserving surgery. It allows larger areas of tissue to be removed with clear margins while limiting dents and distortion.

There are two main approaches:

• Volume displacement — the remaining breast tissue is rearranged to fill the gap, often using a breast-reduction or lift pattern. The other breast may be reduced or lifted for symmetry, at the same time or later.
• Volume replacement — tissue from nearby, such as a small flap from the side of the chest, is moved in to fill the space while keeping the breast size.

Oncoplastic techniques may make breast conservation possible for some women who would otherwise need a mastectomy, particularly those with larger breasts. They are usually planned jointly by the breast surgeon and a plastic surgeon before the operation. Read more in our guide to oncoplastic surgery.

Can I have breast reconstruction at the same time as mastectomy?

Yes, many women can have reconstruction in the same operation as the mastectomy; this is called immediate reconstruction. Others choose, or are advised, to wait and have delayed reconstruction months or years later.

Immediate reconstruction

Immediate reconstruction means waking up with a breast shape, often with better use of the preserved skin. It can be done with an implant or tissue expander, or with your own tissue, for example a DIEP flap from the abdomen. The main drawback is that it can sometimes delay the start of chemotherapy or radiotherapy if there is a wound-healing problem, and radiotherapy given afterwards may affect the result.

Delayed reconstruction

Delayed reconstruction gives time to complete cancer treatment, recover and decide without pressure. It is often advised when radiotherapy to the chest wall is likely. Some teams use a temporary expander first (“delayed-immediate”) to preserve the skin until radiotherapy is finished.

Both routes can give good results. Every woman should be told whether reconstruction is possible before her mastectomy, even if she decides against it. Our breast reconstruction overview compares the options in detail.

What is going flat after mastectomy?

Going flat means choosing not to have breast reconstruction after mastectomy and living with a flat chest. It is a valid, common and well-supported choice.

A good flat result should not be an afterthought. An aesthetic flat closure means the surgeon removes extra skin and fat so that the chest wall is smooth and even, without loose folds or “dog ears” at the ends of the scar. If you plan to go flat, it is helpful to say so clearly before surgery and to ask how the closure will be done.

Some women who go flat wear an external breast prosthesis in a pocketed bra; others prefer not to. If you change your mind later, delayed reconstruction is usually still possible, and if a flat closure is uneven, a revision operation can often improve it.

What is recovery like after breast cancer surgery?

Most women go home the same day or the next day after breast-conserving surgery, and after one to two nights following mastectomy without reconstruction. Recovery is usually longer when reconstruction is done at the same time.

Drains and wound care

After mastectomy or axillary surgery, one or more thin tubes (drains) may be left to remove fluid. They are usually taken out when the drainage has reduced, often within one to two weeks. Fluid can still collect after the drain is removed (a seroma); this is common and can be drained with a needle in clinic if it is uncomfortable.

Arm and shoulder exercises

Gentle arm exercises, usually started the day after surgery, help keep the shoulder moving and reduce stiffness. Your team or a physiotherapist will show you which exercises to do and how quickly to progress. Some women develop tight, cord-like bands in the armpit (axillary web syndrome); stretching and physiotherapy usually help them settle.

Getting back to normal

• Light daily activities: often within a few days.
• Driving: when you can turn and brake safely without pain, often after one to three weeks.
• Work: often two to six weeks, depending on the operation and your job.
• Heavy lifting and strenuous exercise: usually after four to six weeks, or as advised.

The final pathology results, including margins and lymph nodes, are usually discussed at a follow-up appointment one to two weeks after surgery, when the next steps of treatment are confirmed.

What are the risks of breast cancer surgery?

Breast cancer surgery is generally safe, but like any operation it carries risks. Most are uncommon and treatable.

• Wound infection — usually treated with antibiotics.
• Bleeding or haematoma — a collection of blood that occasionally needs a return to theatre.
• Seroma — fluid under the skin or in the armpit.
• Numbness — of the chest skin, and of the inner upper arm after axillary surgery; it may improve over months but can be permanent.
• Persistent pain — some women have long-lasting nerve-type pain in the chest wall or armpit.
• Shoulder stiffness — usually helped by exercises.
• Lymphoedema — swelling of the arm, hand or breast, more likely after axillary dissection or radiotherapy to the nodes.
• Skin or nipple loss — mainly after skin-sparing or nipple-sparing mastectomy, more often in smokers.
• Changes in breast shape — after breast conservation, especially when combined with radiotherapy.

Not smoking, keeping blood sugar well controlled and staying active before surgery may lower some of these risks. Always contact your team if you notice increasing redness, swelling, fever or a sudden increase in fluid.

Where does breast reconstruction fit in?

Reconstruction is a choice, not a requirement. Some women want it at the time of their cancer surgery, some years later, and some never; all of these are reasonable.

If reconstruction is of interest, the most useful moment to discuss it is before the cancer operation, because the type of mastectomy and the position of the scars affect what is possible later. If you have already had surgery, reconstruction is still usually possible — including after radiotherapy — using implants, your own tissue such as a latissimus dorsi flap, or fat grafting. Shape problems after breast conservation can also often be improved.

Going flat, or wearing an external prosthesis, is an equally valid path. Whatever you choose, it should be your decision, made with full information and without pressure.

Can I get a reconstruction opinion before or after my surgery from abroad?

If you are planning breast cancer surgery at home, or have already had it, you can share your reports — scans, biopsy and pathology results, and your oncology team’s treatment plan — with Dr. Fatih Kılıç for an opinion on reconstruction options and timing. This is advice on reconstruction only: your cancer surgery and treatment stay with your own oncology team, and any reconstruction plan is coordinated around their recommendations. See international patients or contact us to begin.

Frequently asked questions

Medically reviewed by Dr. Fatih Kılıç, Plastic, Reconstructive and Aesthetic Surgeon. This page is for general information and does not replace an individual consultation.