A mastectomy is a surgical procedure that removes one or both breasts, usually to treat or prevent breast cancer. Depending on the location and size of the cancer or your preferences, it may involve the removal of your nipples or lymph nodes in your underarm area, though nipple-sparing mastectomies are becoming increasingly common.Â
When it’s done for FTM chest masculinization surgery, a mastectomy is often called “top surgery.”Â
Your doctor may recommend a mastectomy if:
You may also choose to have a prophylactic mastectomy preventively—to remove one or both breasts and reduce your cancer risk—if you have a family history of breast cancer or carry a BRCA1 or BRCA2 gene mutation, which puts you at high risk of developing the disease. A prophylactic mastectomy can usually be done simultaneously with breast reconstruction.Â
Mastectomy is a major surgery, performed under general anesthesia.
Pros
Cons
Thanks to the Women’s Health and Cancer Rights Act of 1998, private health insurance and Medicare are legally required to cover lumpectomy, mastectomy, and reconstructive surgeries for breast cancer patients. Policies about covering prophylactic surgery (to prevent future breast cancer) vary.
Even when they have insurance coverage, most patients still have to pay a portion of the cost out of pocket. How much you'll have to pay will depend on your deductible.
Consult your insurance provider to understand the specifics of your policy.
There are several mastectomy procedure options. An experienced breast surgeon will recommend the best one for you based on your age, overall health, and menopause status as well as the tumor size, your cancer stage and grade, your hormone receptor status, how far the cancer has spread, and whether lymph nodes are involved.
“It is important to discuss with both your breast surgeon and your plastic surgeon whether you would benefit from possibly having both breasts removed (bilateral or double mastectomy) or if you want to only remove one breast (unilateral mastectomy),” says Dr. Lisa F. Schneider, a New York City plastic surgeon who focuses on reconstructive procedures. “Having one breast versus two breasts removed (unilateral versus bilateral mastectomy) can affect the result, including symmetry and what options are available for reconstruction.”
Undergoing a unilateral (one-sided) mastectomy can still leave you at risk for developing breast cancer on the other side, so some women choose to have a double mastectomy even if they have cancer in only one breast. If you choose a lateral mastectomy, a yearly mammogram of the remaining breast is still recommended.
Related: I Had a Preventive Double Mastectomy When I Learned I Had the BRCA2 Gene Mutation
A lumpectomy, sometimes called a partial mastectomy, is a breast-conserving surgery that removes only the cancerous tissue. According to BreastCancer.org, a lumpectomy followed by radiation therapy can be as effective as a mastectomy at treating tumors that are under four centimeters, in only one area of the breast, and with clean margins (no cancer cell spread in the surrounding tissues).Â
Dr. Anne Peled, a plastic surgeon in San Francisco specializing in breast reconstruction, says that lumpectomies now account for the majority of breast cancer surgeries in the U.S. She points out that they offer the benefit of broader reconstruction options—from fat transfer, to fill in a divot, to a breast lift that can leave breasts looking better than before.
Ideally, breast cancer surgery is performed by a team that includes a general surgeon specializing in breast surgery and a plastic surgeon. The breast surgeon performs the mastectomy, and the plastic surgeon reconstructs the breast (as part of the same procedure—or months or even years later), if you opt for breast reconstruction.Â
“You want to make sure that you’re connected with a breast cancer surgeon you like and trust,” says Dr. Schneider. “Any surgeon who is operating on you (especially not in an emergency situation) should be someone you trust to make the right decisions when you are asleep.”
Your oncologist will likely refer you to a surgeon, but it’s also smart to verify that they’re a member of the American Society of Breast Surgeons. This organization promotes surgical training on the latest breast surgery techniques, including Hidden Scar surgeries that create better aesthetic outcomes.Â
Dr. Peled notes that before this technique was developed, “older surgical training really focused on just taking the tumor out, without thinking much about aesthetic scars.” She trains other surgeons on the Hidden Scar technique, seeing it as an essential part of cancer recovery. “We focus so much, as we should, on survival. But if you leave people with a scar that reminds them every day that they had cancer, we haven’t fully supported their survivorship,” she says.
When it comes to choosing a plastic surgeon, Dr. Schneider emphasizes finding a good fit. “For many patients, breast reconstruction is a journey and not a one-step process,” she says. “Make sure your plastic surgeon is a person you want to have on your team, especially if you come across any challenges.”
You absolutely can and should consult with multiple board-certified plastic surgeons before making your choice. Read patient reviews and check out real before and after photos in order to help inform your decision.
Many women also choose to get breast reconstruction, either simultaneously with their mastectomy (immediate reconstruction) or as a second operation later (delayed reconstruction), often after chemotherapy, radiation therapy, or hormone therapy. “There are pluses and minuses to each approach,” says Dr. Schneider. “In immediate reconstruction, when the patient goes to sleep, she has a breast. When she wakes up after surgery, she still has a breast, although it is now a reconstructed one. Psychologically, that can be helpful in terms of managing the sense of loss that comes with the mastectomy surgery and removal of the breast. In patients who undergo direct-to-implant or autologous (the body's own tissue) reconstruction, that single combined surgery may be the only one they need.” “However, it is important to note that for the majority of patients, at least one additional (typically outpatient) surgery is required, whether to exchange a temporary tissue expander for a more permanent breast implant, perform adjustments or revisions, or even just construct a new nipple.” Immediate reconstruction may be off the table for a number of reasons, says Dr. Schneider:Â
In cases where cancer treatment must take precedence, a hybrid option between immediate and delayed reconstruction may be considered. “I often recommend to patients to place a tissue expander or temporary implant at the time of the initial mastectomy,” says Dr. Schneider. “This gives the patient at least some breast, which is helpful psychologically and also preserves the skin envelope.”
Interestingly, according to 2014 research, 59% of women in urban areas and 71% of women in rural areas decide against reconstruction in favor of just “going flat” or wearing a breast prosthesis under their clothing. It’s possible that many of these women don’t have health insurance, don’t know that their insurance is legally obligated to cover breast restoration, or aren’t aware of their options. According to the BRAVE Coalition Foundation, fewer than 30% of women know their breast reconstruction options.
In a 2015 review of common misconceptions about breast reconstruction, Dr. Schneider and coauthor Dr. Babak Mehrara concluded, “Breast reconstruction might not be the right choice for every patient, but every patient deserves to have a complete discussion before cancer treatment to make a fully informed decision. The more involved they are in the decision process, the more likely they are to be satisfied with postoperative outcomes.”
Related: 5 Things You Need to Know About Your Breast Reconstruction Options
It typically takes four to six weeks to recover from a mastectomy. Your recovery timeline and what you can expect will depend on the type of surgery you have.
You’ll be sore and feel numbness due to injury to the skin or muscles, so rest and take pain medication as needed, especially for the first few days afterward. Ice packs may help reduce swelling, but many doctors say to avoid them due to the risk of compromised blood flow. Defer to your surgeon’s recommendations.
Many surgeons recommend—and will show you—exercises to prevent arm and shoulder stiffness and avoid a pulling in of the chest muscles. You may be referred to a physical therapist, who can help you regain your full range of motion, and learn how to manage lymphedema (if you’ve had lymph nodes removed).Â
If surgical drains are placed, you’ll need to empty the collecting fluid a few times a day, noting how much is collected. Doctors on RealSelf say there’s nothing you can really do to reduce drainage, but contact your surgeon with any concerns. The drains will be removed by your doctor at a follow-up appointment.
Risks and potential side effects associated with a mastectomy include bleeding, infection, and hematoma (buildup of blood at the surgical site) or seroma (buildup of clear plasma and inflammatory fluid) during recovery as well as phantom pain and hardness or tightness from scar tissue at the surgical site.
If lymph nodes are removed, there’s an additional risk of numbness in the area and swelling (lymphedema) in the arm.
Post-mastectomy pain syndrome, a chronic neuropathic pain disorder, can present as pain, numbness, or itchiness from nerve damage. It typically resolves on its own as nerves regrow, but uncomfortable sensations may persist.
Updated February 20, 2024