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The optimization of pharmaceutical tumor treatment in breast cancer is associated with an improvement of the outcome and simultaneous de-escalation of surgical treatment. Data regarding oncological endpoints and patient reported outcome (PRO) show worse results for mastectomy (ME) compared to breast-preserving treatment. Patients with skin-sparing ME (SSME) have comparable oncological results to ME but better PROs after surgery. The PROs are influenced by the treatment methods and change over time. In patients with low-risk breast cancer a sentinel node biopsy (SNB) can be omitted. In patients with cN0 and pN1sn, irradiation of the axilla should be carried out and not axillary lymphadenectomy (ALNE). Patients with cN+ should undergo neoadjuvant pharmacotherapy and SNB or total axillary dissection (TAD) if they convert to a cN0 situation. In ypT0 and ypN0sn patients omitting irradiation of the thoracic wall and lymph drainage channels (LAW) can be discussed. The complication rates are lower after epimuscular than after submuscular implant-based reconstruction. The total breast reconstruction with autologous fat transfer is an alternative method to expander implant-based reconstruction. Intraoperative indocyanine green (ICG) angiography, local application of tranexamic acid and postoperative topical application of nitroglycerin can reduce the complication rate of breast reconstruction.