La reconstruction mammaire par implant est la technique la plus courante après mastectomie. Elle restaure immédiatement le volume du sein, en un ou deux temps opératoires selon la qualité de la peau.
Dr Zeitoun, surgical oncologist specialising in breast surgery, sees patients treated with chemotherapy first, including those whose oncology care is provided elsewhere. The purpose: to go through your file, examine what your response to treatment genuinely allows, and discuss breast conservation, mastectomy and reconstruction before a date is fixed. Second opinions explicitly welcome.
When chemotherapy is given before the operation, the treatment is described as neoadjuvant. This sequence is common in breast cancer, particularly for large tumours, for triple-negative and HER2-positive disease, or where lymph nodes are involved.
Chemotherapy given first changes the operation itself. It changes what has to be removed, where it will have to be looked for, how the armpit will be explored, and what reconstruction becomes possible. A 4 cm tumour that required a mastectomy may become a 1 cm nodule suited to breast-conserving surgery. An axillary clearance that seemed unavoidable can sometimes be avoided altogether.
It also provides information that surgery-first will never give: you see how your disease behaves against treatment. That is a major prognostic finding, and it shapes the treatments that follow the operation.
You will not find here the detail of protocols, drug names or the management of side effects: those belong to your oncologist and are covered on the page devoted to chemotherapy for breast cancer.
This article answers the question that often goes unanswered through months of treatment: in practical terms, which operation are we talking about, and what will decide it? This is the surgeon's perspective — the person who will operate on you.
The four to six months of treatment are a valuable window, and one that often goes unused. It is the ideal moment for a genetics consultation and, where indicated, testing for an inherited predisposition.
The reason is directly surgical: the result changes the terms of the discussion between lumpectomy and mastectomy. Testing is no longer limited to BRCA1 and BRCA2: it now covers a panel of genes — PALB2, TP53, PTEN, CDH1, ATM, CHEK2 and others — several of which materially change surgical strategy. Where a predisposition is confirmed, the risk of developing a second cancer in the conserved breast is higher than without one. A mastectomy, possibly bilateral, is then offered and explained.
It is not imposed. Some patients carrying a mutation choose conservation with close surveillance, and that is an entirely acceptable choice provided it is an informed one. The surgeon's role is to set out both options with their real consequences, and then to respect the decision taken.
These analyses take several weeks, sometimes several months. Started during chemotherapy, the result arrives in time to inform the decision. Started after the final cycle, it arrives too late and surgery goes ahead without it.
It comes earlier than most patients imagine. Many meet their surgeon after the final cycle, once the operating date is already set and the options have narrowed by themselves.
A surgical consultation during chemotherapy, or partway through, makes it possible to confirm that marking of the tumour was properly anticipated, to discuss conservation or mastectomy from the outset, and to factor in any plan for reconstruction before radiotherapy complicates the planning. These decisions are better taken calmly than three weeks before surgery.
It is the most awaited sentence of the whole pathway, and the most misunderstood — whether it comes from the MRI, the mammogram or the ultrasound. It deserves clarifying, because it does not mean the operation will not take place.
A decision that only runs one way. It is always possible to move from a planned lumpectomy to a mastectomy: if the response is insufficient, if margins come back involved, or if the genetic result justifies it, the strategy adapts. The reverse is not true. A patient whose tumour was never marked cannot move back towards conservation, even with a perfect response. That is why the clip is placed at the beginning, before anyone knows how the tumour will respond.
Two different devices are involved, at two different moments. Confusing them is common, and it explains a good deal of misunderstanding.
A routine step, and one patients rarely hear about. As soon as the tissue is removed, it is radiographed before being sent to the laboratory. Within minutes the image confirms that the biopsy clip and the localisation device are both present in the specimen, that any microcalcifications have been taken, and gives a first impression of where the lesion sits in relation to the edges.
If the clip does not appear on that image, the correct area has not been removed. Further tissue is then excised immediately, during the same operation, until the check is satisfied. It is this control that prevents a missed target from being discovered too late.
A question to ask now. "Was a clip placed in my tumour, and which report does it appear on?" If the answer does not come straight away, there is still time to place one during treatment. After the final cycle, once the lesion has gone, it is too late.
Bring your MRI, your biopsy reports and the outcome of the multidisciplinary meeting. One consultation is enough to review what your response genuinely allows.
This is the central question, and the one on which chemotherapy first delivers most. It deserves to be framed precisely, because "being able to conserve" and "having to conserve" are two different things.
A substantial proportion of patients initially directed towards a mastectomy become eligible for breast-conserving surgery after a good response. It is the most tangible benefit of the neoadjuvant approach.
Some situations require mastectomy whatever response is obtained. That is the case where several tumours were diagnosed at the outset in different quadrants of the breast.
Some patients eligible for conservation prefer a mastectomy, to stop living under close surveillance or to avoid radiotherapy. That choice is legitimate and is discussed without judgement.
This needs saying plainly, because it is a frequent source of misunderstanding: an excellent response to chemotherapy does not make conservation possible in every case.
The operation is usually scheduled 3 to 4 weeks after the final infusion. That interval lets the blood count recover and wound-healing conditions return to normal. Operating too early raises the risk of infection; waiting beyond 6 to 8 weeks adds nothing and is not desirable.
It is a narrow window, and one more reason not to leave the surgical consultation until treatment ends: a second opinion requested at that stage often runs into the calendar.
This is where practice has changed most in recent years, and what patients know least about. It deserves explaining, because it affects the comfort of your arm for the rest of your life.
The sentinel node is the first lymph node draining the tumour. Removing it alone is enough to assess the armpit reliably: 1 to 3 nodes, a scar of 2 to 4 cm, and a lymphoedema risk of 5 to 7%. Axillary clearance instead removes all the nodal tissue — 10 to 20 nodes, a scar of 5 to 8 cm, a drain, one to two nights in hospital, and a lymphoedema risk of 20 to 30%, sometimes permanent. The gap is considerable, and it affects the comfort of your arm for the rest of your life.
After chemotherapy given first, a particular technique applies where a node was involved at the outset. It is known as TAD, for targeted axillary dissection.
It remains indicated in specific situations, notably where a node is still proven to be involved after treatment, in inflammatory breast cancer, or where the sentinel node could not be identified in theatre. The procedure then takes 20 to 30 minutes and involves a drain left in place for a few days.
A compression sleeve is routinely prescribed after a clearance, worn for two months postoperatively — the period of greatest risk — and thereafter on flights and during unusual exertion. It is not prescribed after a sentinel node alone, where the risk is too low. Any swelling, heaviness, redness or warmth in the arm should prompt a prompt consultation: lymphoedema caught early responds far better to drainage and compression.
The question to ask before surgery. "Was my involved node marked at the time of sampling?" and "is a sentinel node feasible, or is a clearance already planned?" Those two answers determine the risk of lymphoedema you will carry afterwards, and on their own they justify a surgical second opinion when a clearance is announced without discussion.
If a mastectomy is being considered, the question of breast reconstruction must be raised before the operation, not afterwards. That is particularly true after neoadjuvant chemotherapy, where radiotherapy is often on the programme.
An implant reconstruction placed immediately and then irradiated carries a markedly higher risk of capsule formation, distortion and further surgery. Where irradiation of the chest wall is planned — which is common after neoadjuvant chemotherapy with node involvement — several strategies come into play.
Where an inherited predisposition is found and bilateral mastectomy is under discussion, a question of timing arises. It is tempting to do everything in one operation: the affected breast and the healthy one, with reconstruction on both sides.
In practice this is rarely done, for a reason that has nothing to do with appearance. Operating on a healthy breast lengthens the procedure and adds its own risks — haematoma, infection, delayed healing. And any complication on the healthy side can delay the radiotherapy or the further treatment planned for the affected breast. Putting cancer treatment at risk for a preventive procedure that can wait a few months is not a good trade.
The usual strategy is therefore to treat the affected breast first, complete the treatment programme, and then schedule the preventive procedure on the other side once things have settled.
Reconstruction of the nipple and areola comes at a later stage, once the volume has settled. The full timeline is set out on the breast reconstruction page, where autologous techniques are compared with implants.
The commonest pitfall. Discovering after a mastectomy that immediate reconstruction would have been possible, or conversely undergoing an immediate reconstruction that is then compromised by radiotherapy nobody had anticipated. Both are prevented by one thing: raising the question of reconstruction before the operating date is fixed.
Are you being treated elsewhere and would like another view before surgery? It is a common step, and it does not disrupt your care in any way. Bring your reassessment MRI, your biopsy reports and the conclusion of the multidisciplinary meeting: one consultation is enough to review conservation, the armpit and reconstruction.
10 to 15 days after the operation, the pathological analysis of the surgical specimen is given to you at a consultation. It is that document, not the MRI, which provides the definitive answer.
A pathological complete response means that the analysis finds no remaining invasive tumour cells, either in the breast or in the nodes removed. It is the best possible result, and a favourable prognostic marker, particularly clear-cut for triple-negative and HER2-positive tumours.
Two points nonetheless need making. A complete response does not exempt you from the treatments planned after surgery: radiotherapy, hormone therapy or targeted therapy continue according to the tumour profile. And an incomplete response is not a failure: it leads to intensifying or changing postoperative treatment, which is precisely one of the contributions of the neoadjuvant approach.
The questions that come up most often in clinic. If yours is not here, ask it at your consultation — or ask Sophie, the site's assistant, at the bottom right.
For three reasons that add up. To shrink the tumour and widen the surgical options, making breast-conserving surgery possible where a mastectomy would have been needed. To treat the disease throughout the body from the outset. And to watch how sensitive your tumour is to treatment, something surgery-first never provides. In survival terms the two sequences are equivalent: it is on surgery and prognosis that the neoadjuvant route delivers — see the chemotherapy page for the treatment itself.
Yes, always. A normal MRI is an excellent sign, but it cannot rule out microscopic deposits. Only analysis of the surgical specimen can confirm a complete response, and that result determines your later treatment. It is also why a clip must have been placed in the tumour: it allows the area to be found once the lesion is no longer visible, and the specimen is then sent for pathological analysis.
Often, yes. A substantial proportion of patients initially directed towards mastectomy become eligible for conservation after a good response. It depends on the ratio between what must be removed and the size of your breast, on whether the residual disease is single or scattered, and on whether an oncoplastic technique can be used. This question is worth asking a breast surgeon before treatment ends, not after.
Not necessarily, and this matters. If your armpit was clear at the outset, the sentinel node suffices in most cases. If a node was involved, clearance is no longer automatic: chemotherapy frequently clears the armpit. That does, however, require the involved node to have been marked when it was first sampled. A clearance announced without that question having been raised justifies a second opinion.
Usually 3 to 4 weeks. That interval lets the blood count recover and wound-healing conditions return to normal. Operating earlier raises the risk of infection; waiting beyond 6 to 8 weeks brings no benefit. A reassessment MRI is performed at the end of treatment to plan the operation precisely.
Yes. It is your right, it is common, and it does not disrupt your existing care or need justifying to your team. It is particularly useful when a mastectomy is announced without conservation having been discussed, when an axillary clearance is planned from the outset, or when reconstruction has not been raised. Bring your MRI, your biopsy reports and the conclusion of the multidisciplinary meeting: one consultation is enough.
That depends chiefly on one factor: is radiotherapy planned for the chest wall? An implant placed and then irradiated carries a raised risk of capsule formation and further surgery. Depending on the case, reconstruction is delayed, a DIEP flap is preferred as it tolerates irradiation better, or an expander is used. This must be settled before the operating date is fixed.
It is an outcome the strategy itself anticipates. If the lesion does not shrink at the interim assessment, the protocol can be changed or surgery brought forward. Learning this during treatment rather than afterwards is precisely one of the advantages of the neoadjuvant route. No response does not make surgery impossible; it means planning it differently.
It is the best possible result and a very favourable prognostic marker, particularly for triple-negative and HER2-positive tumours. But it does not exempt you from the treatments planned after surgery: radiotherapy, hormone therapy and targeted therapies continue according to your tumour profile, and surveillance remains the same.
No: it is removed with the surgical specimen, since it sits at the centre of the excised area. Its presence is confirmed on the specimen radiograph taken in theatre, which verifies that the correct area was removed. This small metal marker is MRI-compatible and causes no discomfort during treatment.
These questions are addressed before chemotherapy begins, as treatment can affect fertility. A fertility consultation and possible egg preservation are arranged beforehand. If the subject has not been raised and chemotherapy has not started, ask without delay. After conserving surgery and radiotherapy, milk production from the treated breast is often reduced, but the other breast remains functional.
Dr Zeitoun operates exclusively at Clinique Hartmann in Neuilly-sur-Seine. Conserving surgery with a sentinel node is often a day case or a single night. A mastectomy usually requires 2 to 3 nights, longer where there is flap reconstruction. Returning to everyday activities takes 4 to 6 weeks, and longer where reconstruction has been performed — considerably longer after a DIEP flap, which involves an abdominal scar. The detail is set out on the recovery page.
Yes. The choice of surgeon is yours, and it stays open until the operation. Many patients begin treatment at one hospital and are then operated on elsewhere: this is common practice and does not disrupt care, provided a few weeks' notice is given. Your oncologist continues the medical treatment, and the surgeon takes over for the operation. You do not have to justify it, and nobody needs to be told before you have decided. Simply bring your complete file to the consultation.
Five things are enough: the biopsy report with the full biological profile, the initial and reassessment MRI, the axillary ultrasound report with the result of any node sampling, the conclusion of the multidisciplinary meeting, and the chemotherapy protocol received. If you have the images on a disc or a sharing link, bring them: reviewing the images themselves often yields more than the reports do.
It is common, but it is worth correcting before surgery. Where a mastectomy is being considered, the question of reconstruction must be raised beforehand, because it determines the operative technique itself — in particular whether the skin envelope is preserved. Discovering afterwards that immediate reconstruction would have been possible is an avoidable situation. If the subject has not come up, ask explicitly, or make it the reason for a second opinion.
Neither on their own. The strategy is agreed at a multidisciplinary team meeting bringing together surgeons, oncologists, radiologists, radiation oncologists and pathologists. The surgeon then decides the technical procedure, according to what the response to treatment allows and what you want. You are part of that decision: a surgical proposal should be explained, discussed, and can be reconsidered.
Usually not. The initial biopsy has already provided the histological type, grade, hormone receptors and HER2 status — everything that guides surgery. A repeat biopsy is considered only in particular situations: a lesion appearing in another part of the breast or in the other breast during treatment, doubt about progression, or the need to document an area not sampled initially.
Yes, this is a common arrangement. Surgery takes place at Clinique Hartmann in Neuilly-sur-Seine, and your oncology follow-up can continue perfectly well with your usual team. In practice, a first consultation reviews the file and sets the date; the operative report and the pathology result are then sent to your referring oncologist. For patients travelling from a distance, the preoperative consultation and the anaesthetic consultation can be grouped on the same day.
To go further into the decisions surrounding breast cancer surgery.
Indications, protocols, side effects and support: the reference page on the treatment itself.
OverviewFrom diagnosis to treatment: the whole pathway, the tests and the decisions, step by step.
SurgeryRemoving the tumour and reshaping the breast in one operation: what these techniques change about conservation.
The armpitHow the armpit is assessed without a clearance, and why that changes the risk of lymphoedema.
ReconstructionImplants, DIEP, lipofilling, flat closure: every technique and its place in the timeline.
SurgeryWhen it becomes necessary, how it is performed, and what it involves in the months that follow.
After surgeryPain, scarring, arm movement and returning to work: what to expect in practical terms.
Are you finishing chemotherapy given first and want to know what your response genuinely allows: keeping the breast, a sentinel node rather than a clearance, immediate or delayed reconstruction? Dr Jérémie Zeitoun, surgical oncologist specialising in breast surgery, trained at Gustave Roussy and Institut Curie, goes through your file with you, including where your care is provided at another hospital. Bring your MRI and your reports. Consultations at the practice in the 8th arrondissement of Paris, surgery at Clinique Hartmann in Neuilly-sur-Seine. Second opinions explicitly welcome.