Novel Approach for Risk-Reducing Mastectomy: First-Stage Implant Placement and Subsequent Second-Stage Mastectomy

Prepectoral breast reconstruction: an ideal approach to bilateral risk-reducing mastectomy

Background

Bilateral risk-reducing mastectomy (BRRM) has increased its popularity in the last years because of its aim to minimise the chances of developing breast cancer in high-risk patients. Women undergoing this procedure must be considered highly demanding patients given the need to combine aesthetical, functional and preventive desires. This study aims to present the authors' experience in performing BRRM followed by single-stage prepectoral reconstruction (PPBR) with implant completely covered by acellular dermal matrix (ADM) and to report indications, surgical techniques, functional and aesthetic results.

Methods

A single-centre prospective data collection was carried out from January 2017 to January 2021 of patients at high risk of developing breast cancer undergoing BRRM and immediate PPBR with ADM. Patients were subdivided into two groups according to the breast shape: Group A had small and medium size breasts and Group B had large and ptotic breasts. Oncological and surgical outcomes were collected. Satisfaction with reconstruction and related quality of life were evaluated through the BREAST-Q questionnaire.

Results

A total of twenty-three patients met the inclusion criteria. Seventeen patients were included in group A and six patients in group B. Average follow-up was 18.4 months. Minor complications occurred in four breasts: one seroma, one hematoma and two cases of wound dehiscence. Capsular contracture was not observed. All patients were satisfied with the final result according to the post-operative BREAST-Q questionnaire.

Conclusions

Immediate prepectoral breast reconstruction could represent the ideal reconstruction option after BRRM and should be offered to all women that fulfil the inclusion criteria.

Current knowledge of risk reducing mastectomy: Indications, techniques, results, benefits, harms

The last twenty years have seen a complete change in society's attitude to the strategy of risk reduction of breast cancer in high-risk individuals by means of proactive mastectomy. Once termed 'prophylactic mastectomy', risk reducing mastectomy (RRM) was considered two decades ago not only extreme, but in some quarters almost unethical. RRM is now commonly undertaken in specialist breast units for women at high individual breast cancer risk, by virtue of an inherited breast cancer related gene mutation or from calculated high statistical risk from family history data, and the efficacy of RRM in reducing subsequent incident diagnoses of breast cancer has been published from a number of centres. RRM is offered routinely in conjunction with total breast reconstruction, using the whole range of reconstructive surgical techniques. The public announcement by the actor Angelina Jolie in 2013 that she had inherited and harboured a BRCA1 gene mutation, and was undergoing RRM and breast reconstruction to lower her intrinsic breast cancer risk, had a significant effect on public attitudes and perception. Whilst there are other means of lowering breast cancer risk by means of selective oestrogen receptor modulators, such as tamoxifen and raloxifene, their lowering effect on risk of breast cancer remains substantially less than that afforded by surgical removal of 'at risk' breast tissue. The progressive development and increasing sophistication of techniques of breast reconstructive surgery has paralleled the trend for more RRM surgery, and the substantial majority of women who opt for RRM choose immediate breast reconstruction.