For women with the BRCA1 or BRCA2 gene mutations, a preventative mastectomy, otherwise known as a prophylactic mastectomy, can reduce the risk of developing breast cancer by 90 to 95 percent. However, having a prophylactic mastectomy doesn’t guarantee that the patient will never develop breast cancer because it is not yet possible to remove all of the breast tissue during the surgery. Breast tissue can be found in the chest, armpit, skin, above the collarbone, or on the upper part of the abdominal wall. As with any surgery, a prophylactic mastectomy has potential complications, including: bleeding, infection, pain, anxiety, complications arising from breast reconstruction, or the need for multiple operations.
Breast reconstruction is an optional step in this process and one that many women elect to go through for personal and aesthetic reasons. The choice to undergo reconstruction isn’t just about how a woman will look after her surgeries, it is also about how she will feel. There are alternatives for women who do not want to have reconstructive surgeries like prostheses or going flat. It’s important to keep in mind that this process can be traumatic, stressful, and emotional for a woman. Throughout my research, I am consistently finding advice to be as prepared as possible; prepared with knowledge and information, as well as being physically and mentally prepared for the surgeries. I do intend to undergo reconstruction and I am finding that there are quite a few options out there for me.
- Immediate or Delayed Reconstruction: Immediate breast reconstruction (also called direct-to-implant reconstruction) is done, or at least started, at the same time as the mastectomy surgery. After the surgeon removes the breast tissue, a plastic surgeon puts in breast implants. The benefit of immediate reconstruction is that breast skin is often preserved, which can produce better-looking results. Women also do not have to go without a breast shape. Delayed breast reconstruction means that the rebuilding is started later, after the mastectomy surgery is done. For this type of reconstruction, a short-term tissue expander is placed during the mastectomy to help prepare for reconstructive surgery later. The expander is a balloon-like sac that starts off flat and is slowly expanded to the desired size to allow the skin to stretch. Once the skin over the breast area has stretched enough, a second surgery is done to remove the expander and put in the permanent implant.
- Over or Under the muscle: Over the muscle placement (a.k.a., “subglandular” placement) refers to placing implants on top of the chest muscle, called the pectoralis major muscle, and under the glandular breast tissue. This approach is usually recommended for women with a fair amount of natural breast tissue, as the tissue provides coverage and support for the implants. Adequate implant coverage is crucial to achieving a result that looks naturally enhanced, instead of artificially inflated. Placing implants over the chest muscle is a slightly easier procedure with a slightly shorter recovery. Women who have implants placed over the muscle tend to have less post-operative discomfort because the chest muscle is not manipulated during surgery. Placing implants under the chest muscle (a.k.a., “submuscular” placement) is a good alternative for women with little natural tissue. The chest muscle offers the coverage and support the implants need to achieve a natural-looking result. The procedure to place implants under the muscle is a little more involved and causes slightly more post-operative discomfort than subglandular placement.
- Nipple sparing or Nipple removal: A nipple-sparing mastectomy leaves the nipple and areola intact, along with the breast skin. All the breast tissue underneath the nipple, areola, and breast skin is removed. The tissue beneath the nipple and areola are checked for cancer. If cancer is detected, the nipple and areola are then removed. Still, because nipple-sparing mastectomy is a relatively new type of breast cancer surgery, not much research has focused on long-term outcomes, including recurrence rates after the procedure. Removing the nipples decreases breast cancer risk slightly more than nipple sparing procedures.
- Implant or Autologous (“flap”) reconstruction: Implant reconstruction involves inserting an implant that’s filled with either saline (salt water) or silicone gel. Autologous or “flap” reconstruction involves using tissue transplanted from another part of the body (such as the belly, thigh, or back). Autologous reconstruction also may include an implant. Both options have advantages and disadvantages. Implant reconstruction is easier on the front end: an easier surgery, easier to recover from, easier to understand. Flaps are more difficult to perform, more time-consuming, and a longer recovery. But on the back end, things flip. Over time, implants are more prone to problems and often require additional procedures to correct these problems. Flaps perform better over time; a flap done well should not need more attention over the course of a lifetime. So it’s all a matter of what’s right for the woman and her individual situation (says Frank J. DellaCroce, M.D., FACS, plastic surgeon and co-founder of the Center for Restorative Breast Surgery).
Sources:
Pre-Cancer Kenzie 