Subcutaneous mastectomy and immediate reconstruction for prevention of breast cancer for high-risk patients

Abstract

Breast cancer is the most common malignant tumor among females in the USA, with one out of eight American females developing breast cancer in their lifetimes. The latest studies show that 212,920 new cases of invasive cancer developed in 2006, which is 2.5 times more common than the incidence of lung cancer, and that 40,970 females will die from this disease each year. Therefore, awareness of this cancer is an important health issue, with more women beginning to assess their risk of breast cancer, either informally or with instruments such as the GAIL model. The availability of genetic testing for BRCA-1 and BRCA-2 has revealed many women who are at significantly increased risk. Many aggressive surveillance programs have been developed using advanced MRI and ultrasound, and reductions in breast cancer risk of 50% or more have been proven using chemoprevention strategies with tamoxifen and raloxifene. However, many women are starting to seriously consider prophylactic mastectomy for near-total reduction of breast cancer risk. At our institution, we have developed a procedure for prophylactic subcutaneous mastectomy via an inframammary incision that spares the nipple and is combined with immediate silicone implant reconstruction with the assistance of Alloderm. In this article we will describe the procedure and some of the important issues surrounding its implementation from our experience.

Nipple-sparing mastectomy

“…The majority of clinical series describing outcome after nipple‐sparing mastectomy for risk reduction report no primary breast cancers developing during follow‐up63, 64. In Sacchini et al 's series53, 124 procedures were for risk reduction and two women subsequently developed breast cancer, although neither was in the nipple.…”

“…The reported incidence of necrosis following nipple–areola complex preservation ranges from 0 to 48 per cent in the literature, with most series reporting less than 10 per cent45–48, 53, 55, 63, 66–72. Comparison between studies is difficult, as many of them are small and there is no standard measure of necrosis extent or severity.…”

“…This technique risks compromising nipple viability. The alternative method is to preserve a pad of breast tissue behind the nipple63, assuming that this tissue carries the blood supply to the nipple and accepting that leaving breast tissue may result in a higher risk of local recurrence or development of new disease. Petit et al 74 employed intraoperative electron‐beam radiotherapy to allow preservation of a glandular layer 0·5 cm thick without compromising the oncological principles of the surgery.…”

Breast Operative Technique for Single-Stage Reconstruction after Conservative Skin Sparing and Nipple Sparing Mastectomies: A Preliminary Study

“…[4][5][6][7] In addition NSM is becoming the gold standard for any prophylactic treatment as risk-reducing mastectomy. [8][9][10] Nevertheless preserving all skin envelope can represent a problem for both aesthetics and vascularity; some kind of skin-reducing mastectomy would be helpful in case of large ptotic breast. 11 Starting from the 90's, 12 single-stage reconstruction by implants was consistently considered more complicated and risky.…”

The iBRA (implant breast reconstruction evaluation) study: protocol for a prospective multi-centre cohort study to inform the feasibility, design and conduct of a pragmatic randomised clinical trial comparing new techniques of implant-based breast reconstruction

“…The techniques, collectively referred to as lower-pole sling reconstructions (LPSR), may avoid the need for a tissue expander by facilitating single-stage direct-to-implant reconstruction [7] and improve cosmetic outcomes through better lower-pole projection [8–15]. Various products are available and vary widely in cost from £200 for a synthetic mesh such as TiLOOP® [16] or TIGR® Matrix [17] to £1900 for biological alternative [7, 18] such as an acellular dermal matrix (e.g.…”