Options for Managing the Opposite Breast in Breast Reconstruction

James D. Namnoum

David Otterburn

The goal of breast reconstruction is to create an aesthetically beautiful breast mound balanced with the opposite side. Ideally, the breasts should demonstrate perfect symmetry. Thus, performing symmetry procedures for the contralateral, noncancerous breast are almost as important as reconstructing the ipsilateral breast, and at times help guide the selection of the technique utilized for reconstruction. The value of these procedures in restoring postoperative quality of life cannot be underestimated; significant asymmetry following surgery for breast cancer is associated with depression and self-stigmatization as a result of cancer treatment (1).

Most patients’ overriding goal is to have a reconstructed breast that matches the opposite side. As a consequence, some type of balancing procedure is generally necessary to help meet that goal. Balancing procedures may be safely performed at the time of initial reconstruction or may be delayed until some months later. Each approach has its advocates. Delaying definitive second-stage procedures allows time for tissues to settle and soften following autologous reconstruction, and in the case of significant fat necrosis or partial flap loss, permits adjustment of the operative plan at the second stage (Fig. 70.1). For patients undergoing expander/implant reconstruction, a two-stage approach affords an opportunity to assess volume needs in a more relaxed environment (1,2,3). Often, once the charged emotional atmosphere following diagnosis and initial treatment diminishes, patients reevaluate their preoperative goals and are able to focus more attentively on the aesthetic aspects of their care.

Oncologic Issues

Patients undergoing treatment for breast cancer have a threefold to fivefold increased risk for developing a second cancer in the opposite breast compared with the general population, and this fact must be kept in mind when discussing balancing procedures (4,5). Patients must be informed that all operative procedures performed on the contralateral breast interfere to some degree with radiologic and physical surveillance and may delay the diagnosis of a metachronous lesion. Mastopexy and reduction cause internal scarring within the breast and may lead to the formation of calcifications or fat necrosis, which could obscure the presence of a suspicious lesion within this breast. Fortunately, it is usually possible to distinguish these changes radiographically from more worrisome lesions (6,7,8). A mammogram is recommended at 1 year to reestablish the new baseline in this breast (9). Augmentation with breast implants interferes with visualization of the breast particularly when implants are placed in a subglandular position or when significant capsules are formed. Subpectoral placement of devices is preferred in these patients. Compared with nonaugmented patients, augmented patients who develop breast cancers present more frequently with invasive tumors, axillary metastases, and false-negative mammograms (9,10). Informed consent is consequently of great importance, and a thorough discussion of the risks and benefits of balancing procedures should take place prior to surgery.

Patient Selection

The decision to proceed with a specific technique for breast reconstruction depends on a number of variables. While patient and surgeon preferences play a dominant role, the size, shape, and ptosis of the opposite breast may be the ultimate determinant of the technique selected. Other critical variables include patient health and comorbidity, risk stratification for developing a second malignancy in the opposite breast, radiation history, laterality, immediate or delayed status, and tobacco use. While patients may present with a particular approach in mind, it may be unrealistic or inadvisable to proceed in accordance with their wishes. It is the responsibility of the surgeon to guide them to the most judicious decision.

Technical Aspects of Managing the Opposite Breast

General Principles

The options for management of the opposite breast following breast reconstruction include breast reduction, mastopexy, augmentation, and augmentation/mastopexy. Some patients prefer that nothing be done to the opposite breast and seek a reconstructive procedure that confers symmetry without additional balancing of the contralateral side (Fig. 70.2). In general terms, symmetry procedures involving the placement of an implant require implant placement bilaterally. It is otherwise virtually impossible to duplicate the same degree of central projection. Patients with smaller cup sizes may have a desire for larger breasts; the reconstructive technique selected will therefore involve a device with or without additional tissue as they meet their goal of an enhanced contralateral breast mound.

Prophylactic Mastectomy

The decision to proceed with prophylactic mastectomy of the opposite breast merits a separate discussion. Prophylactic mastectomy has become a popular option for management of the opposite breast. In patients with hereditary (BRCA) disease,
prophylactic mastectomy confers an 85% to 90% risk reduction for developing a second cancer in the opposite breast (11,12). Further analysis has suggested that all women with a high or moderate risk of developing a breast cancer also can expect a 90% risk reduction following prophylactic mastectomy (13). Concerns about developing a second breast malignancy (cancer phobia), unusually dense breasts that are difficult to monitor by exam or radiography, or the need for frequent biopsies to assess suspicious lesions all may be indications for a prophylactic mastectomy to reduce risk. Symmetry procedures in this setting involve duplicating the reconstructive solution on both sides (Figs. 70.3 and 70.4).

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