Types of breast cancer surgery

Most people begin their breast cancer treatment with surgery. There are different types of surgery. The types include:

• removing an area of cancer (breast conserving surgery or lumpectomy)
• removing the whole breast (mastectomy)
• removing the lymph nodes (sentinel lymph node biopsy, targeted axillary dissection or axillary lymph node dissection)

You might also have surgery to make a new breast (breast reconstruction) after you have had a mastectomy.

The type of surgery you have depends on:

• the size of the cancer
• where the cancer is in your breast
• whether there is more than one area of cancer
• if you have had any treatment before to the breast and chest area such as breast surgery, radiotherapy or a pacemaker fitted for your heart
• your general health and level of fitness
• your personal wishes and feelings

Depending on your situation, your surgeon might recommend that you have a particular operation. Or you might have a choice of operations to consider.

The following is an overview of the different types of breast surgery to treat breast cancer.

Surgery to remove just the area of cancer

Surgery to remove an area of cancer from the breast is called breast conserving surgery. It is also known as a lumpectomy or a wide local excision.

The surgeon takes away the cancer and a border (margin) of healthy tissue all around it. They leave behind as much healthy breast tissue as possible.

You usually have radiotherapy to the breast after this type of surgery. You might not need radiotherapy and have 5 years of hormone therapy instead in certain early stage breast cancers, for example, if you’re over 65 years of age with:

• a small cancer that is grade 1 or 2 cancer
• you have oestrogen receptor positive (ER+) breast cancer
• you have human epidermal growth factor 2 (HER2) negative cancer

Your doctor will talk through your treatment plan with you and explain if you need radiotherapy or not. 

Surgery to remove your whole breast

Some women need surgery to remove their whole breast. Or they might choose to have this operation. This is called a mastectomy.

There are different types of mastectomies. The type of mastectomy you have depends on:

• how big the cancer is
• where it is in the breast
• if you’ve had breast surgery before
• whether you wish to have breast reconstruction, go flat or wear a breast shape (prosthesis)

A simple mastectomy includes removing the breast tissue (including the nipple and some of the skin) and the tissues that cover the chest muscles. This type of mastectomy doesn’t involve reconstruction, so you end up with a flat chest.

Other types of mastectomies that involve immediate reconstruction include a:

• skin sparing mastectomy – removal of the breast tissue and nipple but keeping  most of the skin
• nipple and skin sparing mastectomy – removal of the breast tissue but keeping  most of the skin, the nipple and the area around the nipple (areola)
• skin reducing mastectomy - removal of the breast tissue and some of the skin. You keep the breast shape but makes your reconstructed breast smaller. In some cases you may keep the nipple. This is called a skin reducing and nipple sparing mastectomy.

You will usually have radiotherapy after a mastectomy if:

• there are cancer cells in 4 or more lymph nodes in the armpit
• the border of tissue around the cancer (margin) has cancer cells
• the size of the cancer is 5 cm or more
• the cancer has grown into the skin or chest wall or both
• you have a rare type of breast cancer called inflammatory breast cancer

Breast reconstruction

Breast reconstruction is surgery to make a new breast after removal of the breast (mastectomy). The aim is to make a breast of similar size and shape to your original breast.

The main ways of making a new breast include:

• implants to replace all or some of your breast tissue
• using tissue taken from another part of your body (autologous or "flap" reconstruction)
• or a combination of both

The tissue your surgeon might use includes skin, fat or muscle. Or you might have a combination of these. 

Your surgeon will talk to you about the different options for breast reconstruction before your operation.

You might have it at the same time as the operation to remove the breast (immediate reconstruction), or sometime later (delayed reconstruction). 

Partial breast reconstruction

Some women will need to have a larger amount of breast tissue removed. This type of surgery leaves a dent in the breast and means the treated breast ends up smaller than the other breast. But it is sometimes possible to get back the shape with a partial reconstruction of the breast by filling the dent with a small area of living tissue.

The surgeon may use tissue from your back to fill in the dent. This is called a latissimus dorsi flap (LD flap). There are other ways to do this. Your surgeon will explain these to you.

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.

Removing the lymph nodes

Lymph nodes are found in many parts of the body. They filter out bacteria and damaged cells from the lymphatic fluid, and contain cells that fight infection.

Cancer cells can break away from the breast tissue and go to other parts of the body. If this happens, it usually first spreads to the lymph nodes in the armpit (axilla) close to the breast.

Before your breast surgery you will have an ultrasound scan to check the lymph nodes in the armpit close to the breast. You will have a biopsy of the lymph nodes if they look abnormal. This is to see if they contain cancer cells.

Your doctor will usually suggest surgery to remove all or most of the lymph nodes in your armpit if the results show that you have cancer cells in the lymph nodes. You can have this at the same time as your breast cancer surgery. This is called an axillary lymph node dissection or clearance.

If the lymph nodes look normal on the ultrasound, you will usually have a sentinel lymph node biopsy during your breast surgery. This is to make sure that cancer has not spread to the sentinel lymph node. The sentinel node is the first node fluid drains from the breast into the armpit.

Treatment options

Your doctor might give you a choice of treatments. This might be because the treatments work equally well in curing the cancer but they each have different advantages and disadvantages.

You might have a choice between removing the whole breast (mastectomy) or having just the area of cancer removed (breast conserving surgery) and then having radiotherapy.

We have information on things to consider and the advantages and disadvantages between these two surgeries.

Having your operation

Before you have your operation, you have an appointment at the pre assessment clinic. This appointment prepares you for the operation.

You have a general anaesthetic for breast cancer surgery. This means you are asleep the whole time and can’t feel anything during the operation.

Many people now have breast surgery as a day case or go home the following day. If you have breast reconstruction at the same time you are more likely to be in hospital for 2 to 7 days.

When you wake up after the operation you might have a wound drain in place. You can go home with a drain still in. Your nurse will give you written instructions on how to take care of it. 

Everyone having treatment for breast cancer should have a specialist breast care nurse or key worker. They will support you throughout diagnosis, treatment and follow up. Do ask your surgeon about this if you have not been introduced to someone.

Davina's breast cancer story

Davina had a lumpecomy and lymph nodes removed. 

“I’m getting stronger every day by doing the exercises I was shown at the hospital.”