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Prophylactic mastectomy (risk-reducing mastectomy) with immediate reconstruction

A woman who has had breast cancer, a woman with a high-risk of breast cancer or a woman who carries a genetic abnormality that increases her risk of breast cancer may decide to have both her breasts removed (double mastectomy) or commonly termed a risk-reducing bilateral mastectomy or a prophylactic mastectomy.

Patients that have a strong family history of breast cancer may decide to have risk-reducing double mastectomy and immediate breast reconstruction to reduce their future risk of breast cancer. The future risk of breast cancer in patients who have undergone a risk reducing mastectomy is less than 2% over their lifetime, significantly lower than the population risk of approximately 8%. No further imaging is required postoperatively.

Prophylactic mastectomy or risk-reducing mastectomy is performed in women that have a high risk of breast cancer. Often, these women will carry a mutation in a gene that increases the lifetime risk of breast caner (e.g. BRCA1/2 mutation or p53 or PTEN or PALB2 mutations).

There are a variety of decision aids which are web-based (e.g. BRECONDA) which may help women to make decisions regarding whether or not they will have a bilateral prophylactic mastectomy, delayed reconstruction, or immediate breast reconstruction. Thus far, these decision aids have helped women to feel less convicted about their decision and less worried about making the decision.

The surgery involves removing all of the breast tissue but maintaining the skin overlying the breast and may include maintaining the nipple and areolar complex combined with an immediate breast reconstruction (eg- a new breast is made). Evidence shows that it effectively reduces the future risk of breast cancer in women at high risk of developing breast cancer.

All of the microscopic breast tissue can be removed with preservation of the breast skin envelope including the nipple and areolar complex. The single stage reconstruction can be undertaken with either a tissue expander/cohesive silicone gel implant or autologous tissue (this tissue can be taken from a variety of donor sites in the body including the fat over the lower abdomen, the muscle in the back, and tissue over the buttocks).

Tissue expanders are regarded as a simple method for immediate breast reconstruction following mastectomy; however, in order to achieve a satisfying cosmetic result and avoid complications associated with the procedure, specific technical aspects are required, as well as careful patient selection.

After performing the skin-sparing mastectomy, a tissue expander is inserted into a pocket made in the pectoralis muscle (muscle covering the chest). The expander is then inflated to expand the muscle and skin layer. This expansion usually occurs several weeks postoperatively and once the expansion is completed, the patient is returned to the operating theatre to have the expander removed and the permanent implant inserted. This procedure is performed as a day case.

In some patients who have small native breasts who do not wish to increase their breast size postoperatively, they may be suitable for insertion of a permanent implant with the use of acellular dermal matrix at the time of initial surgery.

The objectives of the reconstruction with expanders are to restore the breast shape and volume to optimally resemble the contralateral (opposite) breast and to reconstruct the inframammary fold with an adequate degree of ptosis such that symmetry bilaterally is achieved.

Immediate breast reconstruction with expanders is recommended in patients with small or moderate size breasts with minimal or no ptosis. This is more common in young ladies, women who wish to have minimal scarring and wish to avoid additional donor site morbidity, patients that are not concerned about having a foreign body (silicone implant), and patients that are unfit or unwilling to undergo autologous tissue reconstruction. Elderly ladies, obese ladies, very thin ladies, smokers, and patients with major medical comorbidities may be ineligible for autologous tissue reconstruction.

Patients who are undergoing bilateral breast reconstruction may be suitable for implant style reconstruction even if their breasts are large with a significant degree of ptosis as the skin envelope can be reduced and the ptosis can be improved to allow a good result with implants.

Some patients may require a contralateral opposite side mastopexy or reduction to improve symmetry.

The expander may be inflated immediately with saline depending on the quality of the soft tissue/skin coverage over the expander. Expansion will usually begin 2-3 weeks after surgery but depends on the skin flap viability and wound healing. The expander is gradually expanded using magnetic port locators, saline every 2-3 weeks until the desired volume/breast size is reached. The expander is usually slightly overexpanded to gain more tissue for creating a more natural ptosis. New tissue expanders which will allow patients to self-inflate with air will soon be available. Expansion is usually maintained over a 2- to 6-month period, although some women will leave tissue expanders in for a prolonged time. After removal of the tissue expander, the patient may decide to undergo breast reconstruction with insertion of an implant or at that stage may decide to use autologous tissue. This is usually with the use of a free-flap.

Patients that are undergoing radiotherapy will usually have the radiotherapy delivered while the expander is in situ and will proceed to the permanent reconstructive procedure at least 6 months after radiotherapy.

The advantages of implants include the absence of donor site morbidity and the simplicity of the breast reconstruction. However, some patients do not like the unnatural feel or look of the breast and there is always the possibility that further procedures are required, in particular implant exchanges due to capsular contracture. Some patients may perceive that the implant placed under the muscle is a foreign body. There is increased risk of capsular contracture after chest wall irradiation.

The use of autologous tissue improves the natural look reconstruction of breast and in most cases provides a long-term natural result. The ideal tissue for breast reconstruction is fat. Thus, good source for this fat is taken from the patient’s lower abdomen. The fat in this area is typically soft and easy to shape. For most patients, an added bonus of an abdominal donor site is improved abdominal contour following the removal of the flap as in abdominoplasty (tummy tuck). Breast reconstruction using autologous tissue from the lower abdomen was first described by Holmstrom in terms of a free flap in 1979. The technique has been improved over the years and the latest evolution of soft tissue flap is currently the DIEP flap (deep inferior epigastric perforator flap). The use of this flap minimises the donor site morbidity (reduces the risk of bulges, hernias, and weakness of the abdominal wall) and optimises flap durability of transferred tissue. The deep inferior perforator flap was developed by Koshima and Soeda in 1989. The use of this flap is associated with a left postoperative pain and a shortened recovery time compared to TRAM flap (transverse rectus abdominus myocutaneous flap). Abdominal wall strength in patients with breast reconstruction with DIEP flap is maintained.

The patient’s general health needs to be carefully examined before the procedure. It is important that psychological situation and motivation for planned bilateral mastectomy and immediate breast reconstruction is considered. At this usual practice, patient undergoing risk-reduction/prophylactic mastectomy is seen by a counsellor/psychologist before proceeding to the operating theatre. There are significant issues always raised regarding sexuality, femininity, and self-confidence when discussing removal of breast for prevention of breast cancer.

Not all patients will be suitable for autologous tissue reconstruction. Patients who had a previous history of abdominoplasty; patients who have major medical comorbidities including cardiovascular, autoimmune, or chronic lung disease; patients who are smokers; and patients who have previously had liposuction of the lower abdomen may be contraindicated for the surgery.

If the nipple and areolar complex is sacrificed at the time of surgery, there are a variety of reconstructive options to create a new nipple and areolar complex. These include local flap, free flap (skin taken from another area in the body) to recreate the nipple and areolar complex, and nipple tattooing. The nipple reconstruction is usually done at a later date.