What You Need to Know About Preventative Mastectomy and Breast Reconstruction
According to the National Breast Cancer Foundation, 1 in 8 American women will be diagnosed with breast cancer in her lifetime. Breast cancer is the second most common form of cancer in women, and as a board certified plastic surgeon who regularly performs reconstructive breast surgery, I am passionate about helping women overcome this disease.
While there is no way to completely prevent breast cancer, for women with increased risk factors—such as testing positive for certain gene mutations or having already had cancer in another breast—a risk-reducing surgery like a preventative mastectomy followed by reconstruction can be worth considering.
Why women get preventative mastectomies
Prophylactic mastectomy, or preventative mastectomy, is surgery that removes one or both of a woman’s breasts to reduce her risk of contracting breast cancer. Reasons why you may consider undergoing a preventative mastectomy include:
- Testing positive for certain gene mutations. According to the CDC, 3% of all breast cancers result from mutations in either the BRCA1 or BRCA2 genes. These genes are inherited from your parents and normally protect you from breast cancer but are prone to mutation. If your family has a history of breast cancer, you may consider having a genetic test performed to find out if you have a mutation known to cause hereditary breast cancer.
- Having a family history of breast cancer. As the CDC stat above shows, most breast cancer is not hereditary; however, if you have one or more relatives in your nuclear family who have had breast cancer, you may be at an elevated risk. Some women are also more at risk of contracting breast cancer based on their ancestry. If you are of Jewish or Eastern European descent, you may be at an increased risk.
- Having already had cancer in another breast. If you’ve had breast cancer in one breast already, you may have a higher risk of developing cancer in the other breast.
- Having lobular carcinoma in situ (LCIS). This is a rare condition in which abnormal cells form in the milk glands, and is known to increase a woman’s chances of having breast cancer.
While a prophylactic mastectomy can substantially reduce an at-risk patients’ likelihood of contracting breast cancer, it is a significant step to take and should be thoroughly discussed with your doctor.
Types of preventative mastectomies
There are 2 types of preventative mastectomies:
- A bilateral prophylactic mastectomy, also called a risk-reducing double mastectomy, removes both of a woman’s breasts. This is the more common of the 2 surgeries and can reduce a woman’s risk of developing breast cancer by 95%.
- A contralateral prophylactic mastectomy, also called a risk-reducing single mastectomy, removes just one of a woman’s breasts and is most often chosen when cancer has appeared in the opposite breast (unilateral breast cancer). This version of the procedure is most often performed for local control of breast cancer, to reduce further risk, or to facilitate symmetry in reconstruction.
When undergoing a prophylactic mastectomy, you and your doctor will weigh many variables to determine if your mastectomy should be subcutaneous (nipple-sparing) or total (non-nipple-sparing). Though subcutaneous mastectomies allow for more natural-looking breasts after reconstruction because they maintain the nipple and areola, a total mastectomy offers the greatest cancer risk reduction because it removes the greatest amount of tissue.
Making a personal choice about breast reconstruction
If you are predisposed to breast cancer and are considering a preventative mastectomy, it’s important that you also consider your breast reconstruction options before undergoing surgery. This will allow your surgical team to plan ahead according to your wishes and help you get the best possible results.
For many women, reconstructive surgery helps them reclaim a feeling of wholeness after having their breasts removed.
I was honored to recently assist local breast cancer patient Valerie Gansen with breast reconstruction surgery following her double mastectomy. Valerie chose to have both of her breasts prophylactically removed in order to prevent her stage 0 breast cancer from metastasizing. Following surgery, the pathology report showed that her breast cancer was actually stage 2, not stage 0, making it very clear that Valerie’s decision to have a preventative mastectomy was the right choice.
Another smart choice Valerie made was to consider her breast reconstruction plan before undergoing her mastectomy. This allowed me to work with her surgical oncologist to preserve as much skin as possible, and thus provide a very pleasing reconstruction.
However, this is just one patient’s story, and when it comes to your body, you get to decide which path is best for you when it comes to mastectomy and reconstruction. For example, some women prefer to use prosthetics post-mastectomy rather than adding a reconstructive step to their surgical process. But, if you do choose to undergo reconstruction following your mastectomy, know that it is your right to have your health insurance pay for the procedure, and that for many women, reconstructive surgery helps them reclaim a feeling of wholeness after having their breasts removed. Here are a few other reasons women choose to undergo breast reconstruction:
- To gain a sense of closure after having lost one or both breasts
- To restore a classically feminine shape
- To facilitate physical activities affected by changes in your chest shape, such as swimming
- To create a more symmetrical appearance after a unilateral lumpectomy or mastectomy
Types of breast reconstruction surgeries
There are 2 main types of breast reconstruction surgeries: autologous reconstruction, which uses your own tissue to recreate a breast shape, and implant reconstruction, which employs an implant to create the breast mound. The goal of either approach is to restore your breasts to a nearly normal shape, appearance, and size following mastectomy.
The reconstruction option you choose will depend on many factors, including your personal preferences, body anatomy, whether you’ll need radiation treatment, and more. No one method is best, and your medical team can help you make the right choice.
Autologous or “flap” reconstruction methods
- TRAM Flap. A transverse rectus abdominis myocutaneous (TRAM) flap surgery uses blood vessels, skin, fat, and muscle from your lower abdomen to build new breasts. Your surgeon will relocate skin, fat, and muscle from your lower abdomen up to your chest wall subcutaneously (underneath the skin) to create natural-looking breasts. The TRAM flap can be used for reconstructing one or both breasts. For women undergoing unilateral reconstruction, the TRAM flap can offer better symmetry than using an implant. Since TRAM flap reconstruction borrows tissue and muscle from your stomach, many women like the added benefit of having a flatter and slimmer waist after surgery, although they will lose abdominal muscle. TRAM flap surgery will also leave a slight horizontal scar running between your hip bones, but it will be hidden just beneath your bikini line. Recovery time for TRAM flap surgery typically takes between 6 to 8 weeks.
- DIEP flap. In DIEP flap surgery, blood vessels called deep inferior epigastric perforators—as well as the skin and fat connected to them (but not muscle)—are removed from the lower abdomen and shaped into breasts without the use of implants, resulting in breasts that look and feel very natural. Unlike TRAM flap surgery, your abdomen remains strong since no muscle is removed. Recovery time from DIEP flap reconstruction also tends to be quicker than TRAM flap reconstruction. If you have ample abdomen tissue and don’t want breast implants, discuss DIEP flap reconstruction surgery with a board certified plastic surgeon. Patients typically require 6 to 8 weeks to recover from DIEP flap surgery.
- SGAP and IGAP flap. Gluteal artery perforator flap, or GAP flap, surgery utilizes skin from the buttocks to reconstruct the breast. The 2 types of GAP flap surgeries are superior (SGAP) and inferior (IGAP). In SGAP flap surgery, fat, skin, and blood vessels are harvested from the upper part of the buttocks. Surgeons performing IGAP flap surgeries harvest these from the lower buttocks. GAP flap surgeries tend to be more time-consuming than other breast reconstruction surgeries, and are generally only used by surgeons if other methods are not possible. Recovery time from GAP flap surgeries is usually between 4 to 6 weeks.
- LD muscle flap. Used successfully by surgeons for over 30 years, the latissimus dorsi flap, or LD muscle flap, reconstruction method is a standard procedure for breast reconstruction. In this method, a surgeon makes a skin “flap” using skin from the patient’s back and shoulder to create a natural-looking breast shape. The LD muscle flap procedure is commonly combined with a tissue expander (I’ll discuss these below) and a breast implant for the most natural-looking results. This procedure is commonly used when a patient has received radiation therapy. It typically takes patients about 4 weeks to recover from LD muscle flap surgery with an implant.
Breast reconstruction with implants often involves the use of tissue expanders—devices that are used to create space for your implant. An expander is temporarily placed in the breast pocket and then gradually filled with saline fluid at intervals until your tissue has expanded enough to accept a permanent implant. This process is usually conducted over a series of weekly appointments for about 3 months.
An alternative option to implant reconstruction with tissue expanders is immediate, or direct-to-implant, reconstruction. In this technique, your plastic surgeon will insert your implants immediately after mastectomy. The benefit of immediate reconstruction is that you won’t need to undergo a secondary surgery to have your implants inserted, however, this choice is only appropriate for some patients.
Implant reconstruction can be very desirable for patients who want to use the opportunity to increase their breast size or make other shaping improvements. However, If you will require radiation treatment following your mastectomy, breast implant reconstruction may not be an appropriate choice, as radiation following implant-based reconstruction can lead to complications or additional surgery.
To learn more about breast reconstruction surgery, read my post, “6 Things You May Not Know About Breast Reconstruction.”
If you undergo a total mastectomy and have your nipples removed, they can be reconstructed after your new breasts have healed (about 3 to 4 months). Nipple reconstruction has advanced significantly in recent years with techniques such as skin grafting and 3D tattooing to create nipples that look and feel completely natural.
The most common form of nipple reconstruction uses skin from your nipple’s future location to create the nipple. By making small incisions around the nipple’s target site, your surgeon can elevate this tissue to mimic the look and feel of a natural nipple. After the nipple has been created and has time to heal (about 3 months), the areola is recreated with 3D tattooing.
Skin grafting for the areola
Some surgeons choose to use a skin graft to create the nipple’s areola. In this procedure, the nipple is first created from tissue at the nipple site. Next, skin from a different part of your body—usually taken from where skin was harvested for your breast reconstruction—is grafted onto your breast to create the areola. After the nipple and areola has healed properly, the areola’s appearance can be enhanced through 3D tattooing, which approximates the pigment of a natural nipple.
Instead of having their new nipples recreated from skin, some women prefer to have them tattooed directly onto their reconstructed breasts. These tattoos can be incredibly realistic and can be touched up over the years. One benefit of choosing a tattooed nipple over one created with your skin is if you decide to go braless, you don’t need to worry about your nipples showing through your clothing. There is minimal discomfort associated with nipple tattooing.
Will insurance cover my prophylactic mastectomy and breast reconstruction?
In 1999, the federal government passed the Women’s Health and Cancer Rights Act (WHCRA), requiring most health insurance plans that cover mastectomies (including preventative mastectomies) to also cover breast reconstruction surgeries. This law has helped countless women afford breast reconstruction, and can help you, too, if you are considering breast reconstruction following a mastectomy.
However, laws around prophylactic mastectomy coverage vary from state to state. Often, the procedure will be covered if you are at risk and your doctor recommends it as a preventative measure. I encourage you to contact your insurance provider to learn more about your mastectomy and breast reconstruction coverage.
Breast reconstruction surgery in Eugene
If you are in the Eugene, Oregon area, I would love to assist you with your breast reconstruction. My name is Dr. Kiya Movassaghi and I am a board certified plastic surgeon specializing in breast surgery, including breast reconstruction. I am a member of the Oregon Care Alliance, a team of breast care specialists including oncologists, pathologists, radiologists, and surgeons who provide coordinated care to breast cancer patients. In this role, I work with my patients and their doctors to choose the best reconstruction options to fit my patients’ medical needs and aesthetic preferences.