Therapeutic Mammoplasty for Breast Cancer: Can It Help Me Avoid a Mastectomy?

 

When I meet someone who has just been diagnosed with breast cancer, one of the first questions is often:

“Do I need a lumpectomy or a mastectomy?”

But modern breast cancer surgery is not always as black-and-white as that.

For some women, there is another option.

Therapeutic mammoplasty combines breast cancer surgery with techniques normally used for breast reduction and breast uplift. It allows me to remove the cancer and then reshape the remaining breast tissue, rather than simply closing the space left behind.

For the right patient, this can achieve two things: a better breast shape after cancer surgery and, in some circumstances, the opportunity to preserve a breast that might otherwise require a mastectomy.

WATCH VIDEO → What is oncoplastic breast surgery?

 

What is a therapeutic mammoplasty?

A traditional lumpectomy – also called a wide local excision – involves removing the breast cancer with a margin of surrounding breast tissue.

If I only need to remove a relatively small amount of tissue compared with the size of the breast, the remaining breast can often be closed without significantly changing its shape.

But imagine removing a 4 or 5 cm area from one part of a breast.

Simply bringing the remaining tissues together can sometimes leave an indentation, distortion or displacement of the nipple.

This is where oncoplastic breast surgery changes what is possible.

Instead of thinking only about how I remove the cancer, I plan from the outset how I am going to reshape the breast afterwards.

In a therapeutic mammoplasty, I use many of the principles of breast reduction or uplift surgery to rearrange the remaining breast tissue and create a new breast shape.

The result is usually a breast that is smaller and more uplifted than it was before surgery.

 

Why might I recommend therapeutic mammoplasty instead of a standard lumpectomy?

The decision isn’t based simply on the diameter of your cancer.

When I plan your operation, I am thinking about:

• the size and position of the cancer;
• how large it is relative to your breast;
• how much tissue needs to be removed;
• whether abnormal tissue is present in more than one area;
• your existing breast size and shape;
• where your nipple will sit after tissue has been removed;
• the other cancer treatments you may need; and
• importantly, what matters to you about your breasts afterwards.

That last point matters.

Cancer surgery must first and foremost treat the cancer safely. But that does not mean that the appearance of your breast should become an afterthought.

For some patients, removing the cancer with a straightforward lumpectomy could leave a poor breast shape. A therapeutic mammoplasty gives us another way of approaching the same problem.

 

Can therapeutic mammoplasty help me avoid a mastectomy?

Sometimes, yes.

This is one of the reasons I have a particular interest in oncoplastic breast surgery.

If removing a larger cancer would leave too little breast tissue or significantly distort the breast, a mastectomy may otherwise need to be considered.

Therapeutic mammoplasty allows me to remove a larger volume of tissue and then reconstruct the breast using the tissue that remains.

For appropriately selected patients, this can extend the possibilities of breast-conserving surgery.

But it is equally important to say that therapeutic mammoplasty cannot – and should not – avoid every mastectomy.

There are cancers for which mastectomy remains the safest or most appropriate operation. The distribution of cancer within the breast, breast size, genetics, previous treatment and several other factors can influence that decision.

My role is not to persuade you towards breast conservation or towards mastectomy.

It is to explain what is oncologically safe for your cancer, and then explore the choices available to you within those boundaries.

 

Does removing more breast mean better cancer survival?

Patients sometimes understandably assume: “If you remove the whole breast, surely that gives me the best chance of surviving the cancer?”

That isn’t necessarily the case.

Long-term randomised trials established that, for appropriately selected early breast cancers, breast-conserving treatment provides similar long-term survival to mastectomy.

More recent observational studies have raised an even more interesting possibility: in some groups of women with early breast cancer, breast-conserving surgery followed by radiotherapy has been associated with better overall survival than mastectomy.

That does not prove that choosing breast conservation causes better survival. These modern studies are observational and differences between the patients receiving the two treatments may partly explain the results.

It is nevertheless important evidence, and it challenges the idea that having a bigger operation automatically gives you a better cancer outcome.

LATEST RESEARCH → How Far Can We Safely Push Breast Conservation? – including the latest evidence on extreme oncoplasty and breast conservation for cancers spanning more than 50 mm.

I will discuss what this evidence means for you and your cancer when I see you in clinic.

 

How do I plan a therapeutic mammoplasty?

This is where oncoplastic surgery becomes very individual.

Before an operation I am effectively asking myself two questions:

1. What tissue do I need to remove to adequately treat the cancer?
2. How can I reconstruct the breast once that tissue has been removed?

That second question is one of the reasons therapeutic mammoplasty is more complex than performing a standard breast reduction.

On the morning of surgery, I make detailed markings on your breasts while you are standing. These help me plan the cancer removal, movement of breast tissue and the new position of the nipple.

WATCH VIDEO → See how I plan and mark the breast before oncoplastic surgery

During surgery, I remove the cancer and then mobilise and rearrange the remaining breast tissue.

The nipple and areola will often need to be moved higher on the breast while maintaining their blood supply. The exact technique and scars depend upon the position of the cancer and the amount of tissue I need to remove.

 

What will my breast look like after therapeutic mammoplasty?

The operated breast will normally be smaller and more uplifted.

The scars are often similar to those following a breast reduction. There may be a scar around the areola, a vertical scar running towards the crease beneath the breast and, for some operations, another scar running along the breast crease.

But there isn’t one standard therapeutic mammoplasty.

The cancer determines what I need to remove. I then design the reconstruction around it.

It is also important to be realistic about the word reconstruction.

My objective is to create a good breast shape, but your breast will not look exactly as it did before cancer treatment. Scars are permanent. Initially there will be swelling and bruising. Wounds need time to heal. Radiotherapy can subsequently alter the breast’s size, texture and shape.

I think real patient journeys explain this much better than diagrams.

 

Real patient journeys

Patient journey 1: combining cancer treatment with the breast reduction she had already considered

One of my patients was 55 and had relatively large breasts.

Before being diagnosed with breast cancer, she had already been considering a breast reduction and uplift.

She was subsequently diagnosed with a 3 cm breast cancer.

The position and size of the cancer meant that a breast-reduction approach gave us a useful way of removing the cancer while simultaneously reshaping the breast.

But there was an important part of the consultation that had nothing to do with an X-ray or pathology report – She didn’t want to be dramatically smaller.

What bothered her was predominantly the excess breast tissue below her nipples. She didn’t want a major reduction.

That affected how I designed her operation.

Before surgery and during the early stages of recovery following therapeutic mammoplasty. Early photographs are useful because they show the swelling and scars before they have had time to settle.

This illustrates something important about oncoplastic surgery: I am not treating an X-ray. I am treating a person.

Two patients with apparently similar cancers may make very different choices about breast size, symmetry and whether they want anything done to the other breast.

For someone who had already been considering breast reduction or uplift, there can occasionally be something of a silver lining during an otherwise extremely difficult time: we may be able to combine the cancer operation with some of the changes she already wanted for her breasts.

 

Patient journey 2: the same principle, but a very different goal

Another patient demonstrates why the conversation about what you want from your breasts after surgery is so important.

She had cancer in two areas of the breast, but unlike the first patient, she wanted to be much smaller after her operation.

That meant we could plan a more significant breast reduction as part of her cancer surgery.

This patient wanted a much greater reduction in breast size. Her therapeutic mammoplasty was therefore planned around both the tissue that needed to be removed to treat her cancer and her preference to have considerably smaller breasts afterwards.

These first two patients illustrate the same principle but with almost opposite objectives.

Therapeutic mammoplasty isn’t simply a technique for removing a breast cancer. It gives us an opportunity to discuss what you would like your breasts to be like afterwards.

One patient may say: “I would like to preserve as much of my breast size as possible.”

Another may say: “If I need breast surgery anyway, I would actually like to be much smaller.”

Both can be perfectly reasonable objectives.

The cancer determines the boundaries of what I can safely do. Within those boundaries, your preferences help me design the operation.

 

Patient journey 3: preserving the breast despite a large cancer

A very different example involved a young woman with a large cancer in the upper outer part of her left breast.

Her investigations ultimately demonstrated an abnormality measuring approximately 5 cm, with a biopsy confirming cancer in an axillary lymph node.

This meant her first treatment was not surgery.

She received systemic anti-cancer treatment before her operation, and her subsequent scans showed an excellent response, including normalisation of the previously abnormal-looking axillary nodes.

When we eventually planned her surgery, we were therefore dealing with a very different challenge from the first two patients.

We needed to remove a substantial area of breast tissue and appropriately treat the axilla, while breast preservation remained important to her.

We planned a Magseed-guided left therapeutic mammoplasty with targeted axillary surgery and a right-sided symmetrising reduction.

Planning a therapeutic mammoplasty. These markings do much more than define a breast-reduction pattern: I need to integrate the position of the cancer, the tissue that needs to be removed, the blood supply to the nipple and the way I intend to reconstruct the remaining breast.

The principles of reshaping the breast following cancer removal. The reconstruction has to be designed around the oncological operation rather than the other way around.

The eventual result was a reasonably symmetrical breast appearance while avoiding a mastectomy despite an original cancer measuring approximately 5 cm.

But I think the subsequent photographs are just as important as the immediate result.

The journey does not end with the operation. These photographs demonstrate both slower wound healing on one side and subsequent changes to the treated breast following radiotherapy.

I deliberately want patients to see this.

Too often, surgical results are presented as a perfect “before and after”.

Cancer treatment isn’t like that.

There is a journey between the operation and the eventual result. Wounds heal at different rates. Swelling changes. Scars mature. And radiotherapy can change the appearance and feel of the treated breast.

That is part of making an informed decision too.

 

What about my other breast?

This is a very individual decision.

If I make the cancer-affected breast smaller and more uplifted, it may no longer match the other breast.

One option is therefore to reduce or uplift the opposite breast as well – sometimes called symmetrising surgery.

For some patients it makes sense to do this during the same operation.

For others, there are good reasons to complete cancer treatment – particularly radiotherapy – and then reassess the breasts afterwards.

And some patients don’t want an operation on the other breast at all.

There isn’t a universal correct answer.

We make the decision according to your cancer treatment, your breasts and your priorities.

 

What is recovery really like after therapeutic mammoplasty?

Therapeutic mammoplasty is a bigger operation than a straightforward lumpectomy.

In my practice I routinely use a PICO negative-pressure dressing, usually for seven days and occasionally for up to 14 days depending on wound healing.

I generally avoid drains unless I think one is necessary – for example, if an axillary lymph-node clearance is being performed at the same time.

I normally recommend a supportive, front-fastening postoperative bra for around 6-8 weeks.

As a broad guide, I advise allowing approximately:

• 2-3 weeks before driving, depending upon your recovery;
• 2-4 weeks away from work, depending particularly on your occupation; and
• 4-6 weeks before strenuous upper-body exercise or heavy lifting.

These are guides, not deadlines. Your operation and your recovery are individual.

HAVING THERAPEUTIC MAMMOPLASTY? → Read my full Therapeutic Mammoplasty Patient Information Leaflet 

 

What are the disadvantages and risks?

Therapeutic mammoplasty gives us additional options, but it achieves this by performing more extensive breast surgery than a standard lumpectomy.

Important risks include bleeding or a haematoma, infection, delayed wound healing, permanent scars, altered nipple sensation, problems with the blood supply to the nipple or skin, fat necrosis, differences between the breasts, and the possibility of further surgery.

 

What is fat necrosis?

Breast tissue has to be moved and reshaped during mammoplasty.

Occasionally an area of fatty tissue loses some of its blood supply. This is called fat necrosis and can result in a firm or hard lump in the breast.

Because any new breast lump after cancer treatment needs to be taken seriously, this can occasionally lead to further imaging and sometimes a biopsy to confirm what it represents.

 

Could I still need another cancer operation?

Yes.

This is important to understand before choosing therapeutic mammoplasty.

The tissue I remove is examined by a pathologist after surgery. Occasionally cancer cells are found at, or very close to, one of the surgical margins.

Current NICE guidance recommends further surgery where invasive cancer or DCIS is present at the radial margin, and recommends considering further surgery for certain close margins according to the type of cancer and the individual circumstances.

If this applies to you, I will explain exactly what the pathology shows and what I recommend.

Depending upon the result and the original operation, further surgery might mean removing some additional breast tissue or, less commonly, proceeding to a mastectomy.

 

Will I still need radiotherapy?

In most situations, yes.

Therapeutic mammoplasty is a form of breast-conserving surgery rather than a substitute for the other parts of breast cancer treatment.

Current NICE guidance recommends whole-breast radiotherapy after breast-conserving surgery for invasive breast cancer with clear margins, although there are specific circumstances where partial-breast radiotherapy or omission of radiotherapy may be considered.

Your oncology team and I will explain what applies to you once we have your final pathology.

Radiotherapy may subsequently alter the colour, texture, firmness, size or shape of the breast. This is another reason why I think it is helpful to see photographs of patients after their complete cancer treatment, rather than judging the operation only from an early postoperative photograph.

 

Is therapeutic mammoplasty right for me?

There isn’t a simple checklist.

When I meet you, I am considering the cancer and the breast at the same time.

I need to understand what cancer operation you need.

But I also want to understand what matters to you.

Would you prefer to remain approximately the same breast size?

Would you actually welcome being considerably smaller?

How important is symmetry to you?

How do you feel about scars?

Would you consider surgery to your other breast?

How important is preserving your breast to you, if breast conservation is oncologically appropriate?

Those conversations are an important part of oncoplastic breast surgery.

A cancer diagnosis can suddenly take away an enormous amount of control.

Where it is medically appropriate, I want my patients to remain involved in decisions about both their cancer treatment and the body they will live with afterwards.

 

Further information

WATCH: What is oncoplastic breast surgery?

WATCH: How I plan and mark the breast before oncoplastic surgery

READ: Therapeutic Mammoplasty Patient Information Leaflet

RESEARCH: How Far Can We Safely Push Breast Conservation?

 

References / evidence for editorial review

1. National Institute for Health and Care Excellence (NICE). Early and locally advanced breast cancer: diagnosis and management (NG101). https://www.nice.org.uk/guidance/ng101
2. Association of Breast Surgery / BAPRAS. Oncoplastic Breast Reconstruction Guidelines for Best Practice (2021). https://associationofbreastsurgery.org.uk/professionals/information-hub/guidelines/2021/oncoplastic-breast-reconstruction-guidelines-for-best-practice
3. Veronesi U, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 2002;347:1227-1232. PubMed PMID: 12393819.
4. Litiere S, et al. Breast conserving therapy versus mastectomy for stage I-II breast cancer: 20 year follow-up of the EORTC 10801 phase 3 randomised trial. Lancet Oncol. 2012;13:412-419.
5. Rajan KK, Fairhurst K, Birkbeck B, et al. Overall survival after mastectomy versus breast-conserving surgery with adjuvant radiotherapy for early-stage breast cancer: meta-analysis. BJS Open. 2024;8(3):zrae040. PubMed PMID: 38758563. https://pubmed.ncbi.nlm.nih.gov/38758563/

Editorial note: Patient cases and photographs are individual examples. Confirm appropriate consent for public educational/website use before publication. Results and recovery vary between patients.