The breast tissue removal is always total — the question is not how much we remove, but how we rebuild. Nipple-areola complex preservation, NAC sacrifice, or flat closure: three strategies, always a shared decision. Conventional, endoscopic, or robot-assisted approaches.
Mastectomy means removing the entire mammary gland. But behind that somewhat blunt word lies a whole family of procedures — and a strategy built with you, not around you.
Concretely, we remove all the glandular tissue of the breast. It is the standard procedure when lumpectomy is not enough: tumor too large relative to the breast, multiple foci, extensive in situ disease, inability to undergo radiotherapy, BRCA mutation, local recurrence, or inflammatory breast cancer.
One important thing to know: oncologic outcome is equivalent to breast-conserving surgery (lumpectomy + radiotherapy) whenever that option is technically feasible. The historical randomized trials (Milan 1973, NSABP B-06 1976) and the EBCTCG meta-analysis demonstrated this with 20-year follow-up. Mastectomy is therefore not an oncologic "plus" — it is the right answer to a situation where conservation is not appropriate.
The procedure is performed under general anesthesia. Its duration ranges from 1.5 to 5 hours depending on what is associated (axillary surgery, immediate reconstruction). Hospital stay is 1 to 5 days, with suction drains in place for 5 to 10 days to drain serosity.
Three questions structure the decision, asked in order: 1) is there an associated axillary procedure? 2) can the nipple-areola complex be preserved? 3) would you like reconstruction, and if so, which type? The next section walks through these steps one by one.
Three questions, asked in order. Each answer guides the next. The decision is made together, in consultation, after the workup.
For invasive cancer, we biopsy the sentinel lymph node at the same time as the mastectomy — the first node that drains the breast. It tells us whether the disease has begun to spread. If several lymph nodes are already known to be involved at diagnosis, we perform an axillary lymph node dissection (ALND) instead.
→ Everything is explained here: sentinel lymph node biopsy & axillary dissection
Preserving the nipple-areola complex (NAC) depends on several criteria assessed case by case: tumor-to-nipple distance (ideally >1 cm), no NAC involvement on imaging, degree of breast ptosis, skin quality, and active smoking which compromises healing.
Nipple and areola preserved. The scar is hidden:
The skin envelope is preserved but the nipple and areola must be removed. The scar is central oblique.
Secondary NAC reconstruction remains possible: 3D tattooing, graft, or local flap.
A deeply personal choice. Whether or not the NAC is preserved, reconstruction remains possible in every case. And not reconstructing is also a legitimate choice.
Under the same anesthesia, avoiding the "flat-chest interval". Possible with or without NAC preservation. Several techniques to choose from based on your anatomy:
→ All techniques in detail: breast reconstruction
→ Also possible as a delayed procedure (3 to 12 months later)
Available only with NAC preservation — minimally invasive approaches do not allow removal of the nipple-areola complex.
Inframammary or axillary access with a video scope. Short, discreet scars. Indication: nipple-sparing mastectomy with immediate implant reconstruction.
da Vinci system. Enhanced precision and anatomical access. Longer operative time, but optimized aesthetic outcome. Available in equipped centers.
Together we go over the workup results, examine you, and walk through the three questions that structure the decision: axillary surgery, NAC preservation, reconstruction. If you opt for immediate reconstruction, you also meet the associated plastic surgeon. Reflection time is guaranteed — nothing is decided in haste.
Therapeutic plan validation in a multidisciplinary team meeting (medical oncologist, radiation oncologist, pathologist, surgeon). Anesthesia consultation at least 48 hours before surgery.
Standing surgical marking by the surgeon: incision lines, NAC landmarks, inframammary fold, surgical approach axis. Tracer injection for the sentinel lymph node. Operating room.
Under general anesthesia. First step: axillary surgery — sentinel lymph node biopsy if invasive cancer, or axillary lymph node dissection if multiple nodes are already known to be involved. Second step: mastectomy — complete removal of the gland, with or without NAC preservation, via conventional, endoscopic, or robot-assisted approach depending on the strategy. Third step if immediate reconstruction: implant, expander, DIEP flap, latissimus dorsi flap, or lipofilling. Total duration: 1.5 to 5 hours depending on associated procedures. Suction drains. Hospital stay 1 to 5 days. Clinique Hartmann or American Hospital of Paris.
Scar examination. Drain removal if still in place. Review of the final pathology report (histologic type, grade, margins, lymph nodes). Presentation of the adjuvant treatment plan validated by the multidisciplinary team: post-mastectomy radiotherapy according to characteristics, chemotherapy, hormone therapy according to profile.
The hospital stay is 1 to 5 days, the time needed to monitor the drains, manage pain, and organize discharge home.
Suction drains are kept in place for 5 to 10 days on average, depending on output. They evacuate serous fluid and promote skin adherence. A home-care nurse monitors the drains and removes them. A compression bra is worn for 1 month.
Sutures are absorbable — no need to remove them. Pain is moderate, controlled with simple analgesics (paracetamol ± anti-inflammatories) and rest. Bruising is common and resolves within a few weeks.
Loss of sensation. Loss of skin sensation in the operated breast is constant, including with NAC preservation. The preserved skin and nipple lose their tactile sensitivity. Neurotization techniques (microsurgical reinnervation) may partially restore sensation in some centers.
Baths and sports activities are contraindicated for 1 month. Driving can be resumed after about 15 days. Return to work depends on the type of activity (3 to 6 weeks on average, longer if reconstruction by flap).
No mammography on the operated side — there is no remaining glandular tissue. Surveillance is done by clinical examination and complementary imaging (ultrasound, MRI) according to risk profile. Post-mastectomy radiotherapy may be indicated according to tumor characteristics (lymph node involvement, margins, size).
Mastectomy is a standardized surgery, with infrequent complications. It remains a surgical procedure that carries a small but real risk. The main complications are listed below:
The historical randomized trials — Milan 1973 (Veronesi et al.) and NSABP B-06 1976 (Fisher et al.) — showed no long-term survival difference (20-year follow-up) between lumpectomy followed by radiotherapy and mastectomy. The EBCTCG meta-analysis confirms this equivalence. Mastectomy is indicated for large or multifocal tumors, extensive ductal carcinoma in situ, contraindications to radiotherapy, BRCA1/BRCA2 mutations, and recurrences after conservation. The decision is always shared and discussed in MDT. → To go further: lumpectomy or mastectomy: how to choose?
Preservation of the nipple-areola complex — called nipple-sparing mastectomy — depends on several criteria reviewed case by case: distance between the tumor and the nipple (ideally >1 cm), absence of NAC involvement on imaging, degree of breast ptosis, skin quality, and active smoking, which compromises wound healing. When feasible, the scar is hidden (inframammary, axillary, or periareolar) with optimal cosmetic outcome. If the NAC must be sacrificed (skin-sparing), a secondary reconstruction of the areola and nipple remains possible (3D tattoo, graft, or local flap).
If the NAC is preserved: inframammary fold approach (preferred, scar hidden in the fold), axillary approach (scar in the armpit), or periareolar approach. If the NAC is sacrificed: central oblique scar. Minimally invasive approaches possible in equipped centers: endoscopic mastectomy (inframammary or axillary) and robotic mastectomy (da Vinci system) — fewer visible scars, but longer operating time.
This is a personal decision, discussed in consultation. Immediate breast reconstruction (IBR) is performed under the same general anesthesia as the mastectomy, with an associated plastic surgeon. It avoids the "flat-chest interval". It is possible with or without NAC preservation — keeping the nipple is not a prerequisite. Formal contraindication: inflammatory breast cancer. Delayed reconstruction (3 to 12 months later) is also an option. Techniques: implant (definitive prosthesis or expander), lipofilling, autologous flaps (DIEP, latissimus dorsi). Reconstruction and contralateral breast symmetrization fall within the scope of post-mastectomy reconstruction coverage.
1.5 hours for a simple mastectomy without reconstruction. 2 to 3 hours with implant-based reconstruction. 3 to 5 hours with autologous flap reconstruction (DIEP, latissimus dorsi). General anesthesia. Hospital stay 1 to 5 days depending on the strategy.
Yes. Mastectomy is covered by the French national health insurance under long-term illness status (ALD 30 — cancer). Breast reconstruction and contralateral breast symmetrization also fall within the scope of post-mastectomy reconstruction coverage, without any specific medical prescription. Out-of-pocket fees may apply in sector 2 practice (Dr Zeitoun practices in sector 2 non-OPTAM; a detailed quote is provided during consultation).
Yes — it is a fully legitimate and increasingly recognized choice. Flat closure means leaving the chest flat and harmonious after mastectomy. It avoids the complications of reconstruction. An external breast prosthesis can be offered secondarily (reimbursed by national health insurance). Many patients live very well with a flat chest — the key is informed choice. → If you are unsure, see also the breast reconstruction page detailing the available techniques.
Yes — loss of skin sensation is consistent after mastectomy, including with NAC preservation. The preserved skin and nipple lose tactile sensitivity. Neurotization techniques (microsurgical reinnervation) are being developed in some centers and may partially restore sensation. Erotic sensitivity of the nipple is permanently lost, even when the NAC is preserved.
No mammography on the operated side (no remaining glandular tissue). Regular clinical follow-up by the surgeon and oncologist. Ultrasound ± breast MRI according to profile. If implant-based reconstruction: ultrasound surveillance of the implants (including for BIA-ALCL — breast implant-associated anaplastic large cell lymphoma, exceptional but monitored). Annual mammography + ultrasound/MRI of the preserved contralateral breast.
A consultation to discuss your case, understand the options available to you, or a surgical second opinion — feel free to book an appointment.
