Reconstruction of the breast after prophylactic mastectomy presents a significant challenge to the reconstructive surgeon. Many issues are involved in providing successful treatment for these patients, both in the preoperative decision-making process and in the accurate application of sound surgical technique. However, when this is done successfully, the results can be both dramatic and gratifying for patient and surgeon alike. This chapter focuses on the surgical techniques that can be applied to these patients to provide the most aesthetic results possible with the fewest complications.

It is beyond the scope of this chapter to provide definitive scientific evidence to support prophylactic mastectomy for any individual patient. So many factors are involved that such an attempted discussion would be meaningful to only a small group of patients. Pertinent preoperative risk factors include family history of breast cancer in first-degree relatives, positive genetic testing revealing the presence of known genetic markers for possible malignant degeneration of the breast, histologically proven proliferative breast disease, and personal history of breast cancer. Other conditions that can lead some patients to consider prophylactic mastectomy include difficulty in examining the breasts due to cystic mastopathy, presence of dense mammograms that are difficult to interpret, a history of multiple previous negative breast biopsies, severe and incapacitating mastodynia, and chronic mastitis. Special circumstances can also arise as in the patient who has had a previous lumpectomy and radiation with subsequent complications such as pain or an unfortunate aesthetic result. These patients may also choose to undergo complete prophylactic mastectomy with reconstruction. The important point to take away from this discussion is that prophylactic mastectomy is a procedure the patient chooses to have performed. Although the surgeon, oncologist, geneticist, and radiation therapist can all provide a myriad of percentages and potential outcomes, the best that can be accomplished is an informed estimate of the risk any patient has for the future development of breast cancer. This risk assessment must then be evaluated in the context of the patient’s own level of concern for the possible development of breast cancer. Some patients, for varying reasons, will not accept even the slightest chance that one or both breasts could undergo malignant degeneration and will choose prophylactic mastectomy, even though the risk assessment is only modestly positive. Alternatively, other patients will be very resistant to the idea of prophylactic mastectomy, even in the face of profound risk factors. Whatever the circumstance, it is the responsibility of the surgeon to properly assess the patient, evaluate the potential risk for the development of breast cancer, and then offer appropriate methods of reconstruction as indicated. It then becomes the responsibility of the patient to choose how to proceed (1—6). One caveat to this discussion must be emphasized. Many patients will choose prophylactic mastectomy, and in particular, prophylactic subcutaneous mastectomy, with the expectation that the reconstruction will restore them to perfect health with a breast that is either unchanged or improved in appearance when compared with their preoperative state. In a sense, they are relying on the quality of the reconstruction to make the decision to undergo prophylactic mastectomy acceptable. This is a situation that must be avoided because it sets unrealistic expectations. A reconstructed breast is inferior to an unoperated breast in nearly every circumstance for a whole host of reasons. Besides the obvious aesthetic difficulties that can arise, at the very least there will be sensory disturbances, even in a perfect reconstruction. If these potential complications compromise the result in any way, the potential for dissatisfaction with the whole treatment process is significant. For this reason, it is my practice to insist that the patient’s state of mind with regard to prophylactic mastectomy be such that it will be a relief just to have the breast tissue removed and the risk for the future development of breast cancer reduced as much as possible, regardless of whether there is any reconstruction performed. After this philosophy of treatment is accepted by the patient, as well as any other significant people in the patient’s life, reconstruction can then proceed with a good chance of success, with success being measured as a high level of patient satisfaction.

In evaluating the patient for prophylactic simple mastectomy, many factors must be taken into account when planning the reconstruction. Perhaps the most important variable to be considered is the extent of the mastectomy defect that will be created. By design, and for the purposes of this chapter, it is assumed that the nipple and areola will be included with the mastectomy specimen. This, of course, completely eliminates any concern related to retained ductal tissue in the nipple or areola as in a subcutaneous mastectomy. However, after that,
many alternative skin patterns can be used to try to limit scars and preserve as much of the mastectomy skin envelope as possible. To this end, the same skin-sparing mastectomy approach used in traditional reconstruction after modified radical mastectomy is used (7,8). This requires that the skin flaps left behind after mastectomy are viable. Familiarity with the surgical technique of the oncologic surgeon performing the mastectomy can help the reconstructive surgeon anticipate any potential problems that might develop with regard to flap viability, and alterations in the planning of the skin incisions can be made accordingly. After the skin incision pattern is decided, the exact method of reconstruction must be chosen. Many factors will influence this decision, including the body habitus of the patient, the preoperative size of the breast, anticipated problems with skin envelope viability, what surgical treatment is being rendered to the opposite breast, as well as the expectations of both the patient and the surgeon. Often, if a modified radical mastectomy is performed on one side, it is the magnitude of that defect that determines the type of reconstruction that is chosen. Generally, the selected technique is then simply applied to the prophylactic side as well.

The incision patterns used today for mastectomy with reconstruction differ considerably from those used in the past. Gone are the days when every patient received an elliptical skin excision designed to remove not only the nipple and areola, but also a good portion of the skin envelope. Although there may be an oncologic rationale for such a pattern in some instances when the tumor is close to the skin, one major advantage of the elliptical excision is that the resulting mastectomy wound closes with good contour, and there is no redundancy to the skin flaps, which then lie flat against the chest wall. However, when immediate breast reconstruction is performed, concerns over redundancy of the skin flaps are eliminated because the volume of the breast is restored with the reconstruction. This then opens up a number of options for skin-sparing mastectomy, which can strategically place the scars associated with the mastectomy in aesthetically ideal locations, thus improving the appearance of the overall result.

The most important factor in determining which incision pattern to use is the preoperative size of the breast. Tumor location, placement of the biopsy incision, presence of previous scars, and patient goals also factor into incision choice. In the most straightforward cases, where no actual tumor is present and no scars are present on the breast, the incision patterns generally associated with augmentation and augmentation mastopexy are used. In small to medium-size breasts with no ptosis, a simple periareolar incision can be used to remove the nipple-areola complex (NAC), as well as the breast. In most instances, it is my practice to add a laterally positioned horizontal extension to provide access for the mastectomy and also to facilitate exposure for the reconstruction (Figs. 22.1A to 22.1F). With this pattern, a skin island is required to replace the defect created by removing the NAC. For this reason, this pattern is best used in conjunction with a latissimus dorsi musculocutaneous (LD) flap or a transverse rectus abdominus musculocutaneous (TRAM) flap, both of which can readily supply a circular-shaped skin island without difficulty. When used with a tissue expander or implant alone, the circular defect is simply closed as an ellipse along the axis of the lateral extension. This strategy still preserves skin; however, it does create a transverse mastectomy scar that must be dealt with at the second stage when the NAC is reconstructed. If any degree of ptosis is present, an eccentrically placed oval is diagrammed around the ptotic NAC and positioned to remove skin above the NAC. If the resultant defect is not large enough to facilitate easy removal of the breast, a lateral extension of the incision can be added without difficulty. Reconstruction proceeds as described with the additional maneuver of adding a purse-string closure of the enlarged periareolar opening. This strategy can function to lift the position of the NAC and actually improve the appearance of the breast after the reconstruction is completed. Again, this pattern is best used with an LD flap or a TRAM flap, where the skin island is positioned in the NAC defect. When using tissue expanders or implants alone, the NAC defect is closed as an elipse along the axis of the horizontal extension. In more profound cases of ptosis, the eccentrically placed oval is used in conjunction with a vertically oriented inferior skin resection. This circumvertical skin pattern is a powerful method to manage the skin envelope of patients with significant preoperative ptosis. It not only results in a lifting of the NAC, but also provides an increase in the projection of the breast with a narrowing of the base diameter. These patients often experience a significant improvement in the appearance of their breasts after reconstruction is completed (Figs. 22.2A to 22.2F). Finally, in patients with macromastia, the same circumvertical skin pattern strategy is used; however, the dimensions of the periareolar and vertical components are larger. This provides more than adequate exposure for the mastectomy and the reconstruction, and accomplishes what amounts to a reconstructed “breast reduction.” The pattern also affords the additional benefit of removing the very skin that is most at risk for the development of ischemia and potential necrosis after mastectomy. Alternatively, a Wise pattern inverted T skin incision pattern can also be used. Whatever reduction skin pattern is used, these patients tend to achieve aesthetic results with the added benefit of a reduction of breast volume, which tends to relieve the upper torso symptoms generally associated with macromastia (Figs. 22.3A to 22.3E).