Breast Reconstruction for Prophylactic Mastectomy

An Informative Article by Frederick G. Weniger, MD
Mastectomy patients can be left with physical defects that can be difficult to accept. In fact, it is known that mastectomy can lead to psychological problems such as depression, loss of sexual interest, a negative body image and loss of femininity, increased fear of cancer recurrence, and self-consciousness even in clothing.

Breast reconstruction lessens these emotional burdens and allows the patient to focus on her success and her recovery. Breast reconstruction is currently considered to be an integral part of prophylactic mastectomy. After decades of development of new techniques, we now enjoy multiple options for breast reconstruction. In general, breasts can be reconstructed with breast implants or with tissues of a woman’s body moved from other areas to create the new likeness of a breast. These procedures are often done immediately after the mastectomy is completed on the operating table, so that the woman awakens with her breast reconstruction procedure completed, not ever having to cope with the frank absence of her breast.

For most women, the best reconstructive option is a breast implant. Although this was the very first reconstructive option available approximately 30 years ago, technology has developed to make this a very attractive option for most patients. Implant reconstructions are relatively fast, safe operations that add little extra recovery to the mastectomy operation. These operations can even be done in an outpatient setting. Both saline and silicone breast implants are available for this purpose. Currently, many implant reconstructions are done in stages, with the immediate operation consisting of placing a tissue expander prosthesis. This device, which is shaped like a breast implant, is then gradually filled in the plastic surgeon’s office over the following two months in order to slowly stretch out the skin. Eventually, the expander is removed and the permanent breast implant is placed into the stretched “pocket” of skin and muscle, thus more reliably delivering a soft, natural appearing breast. Breast implant reconstructions are especially good in prophylactic mastectomy patients because they provide a relatively easy method to achieve symmetrical, natural results without the need for extensive surgery.

In contrast, other patients will elect to have an “autologous tissue” reconstruction, made of their own excess tissues taken from other areas. Most commonly, the excess skin and fat is taken from the abdomen, similar to an abdominoplasty. This operation is called a Transverse Rectus Abdominus Myocutaneous Flap (TRAM Flap). Another option is to take skin and fat from the back and create a new breast mound out of this tissue. As one might expect, there is often not much bulk from this area compared to the abdomen. For this reason, a breast implant is often added underneath this new breast to give more volume. This procedure is a Latissimus Dorsi Myocutaneous Flap. Other real tissue procedures exist as well. Although these techniques avoid some of the issues related to the use of implants, they generally are larger procedures than implant reconstructions, and require a more difficult recovery period.

Usually after mastectomies for breast cancer, new nipples and areolas must be reconstructed on the new breast mounds to complete the appearance of the breasts. This is because the nipples and areolas must be removed in most breast cancer scenarios because these structures contain duct tissue which may contain cancer cells. In contrast, many prophylactic mastectomies may preserve the nipple-areolar complexes which further improves the cosmetic outcome of the breast reconstruction. In such cases, scars from the mastectomies can be hidden in the crease under the breast, so that the final result can look just like the original breasts (since only the contents and not the covering of the breasts has been altered).

The best option for an individual patient is a decision based on discussions between the patient and the plastic surgeon, and must include dialogue from the breast cancer surgeon. In the end, the decision for a certain type of reconstruction must be a conclusion individualized to the patient’s aesthetic desires and her particular medical circumstances. Certainly the decision to have a prophylactic mastectomy is not an easy one. Fortunately, many options exist to reconstruct the breasts afterward with very nice aesthetic results. Therefore, the choice to proceed with prophylactic mastectomy can be based more on the medical benefits of the mastectomy than on cosmetic concerns.

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