Two staged breast reconstruction following prophylactic bilateral subcutaneous mastectomy
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British Journal of Plastic Surgery (2005) 58, 299–305
Two staged breast reconstruction following
prophylactic bilateral subcutaneous mastectomy
A.M. Yiacoumettis*
Department of Plastic Reconstructive Surgery, Oncological 6th IKA Hospital Athens, 79, Sarantaporou
Street Halandri, Athens 152 32, Greece
Received 13 February 2004; accepted 4 November 2004
KEYWORDS Summary The aim of this retrospective study was to evaluate the results in
Mastectomy; patients who underwent bilateral subcutaneous mastectomy (BSCM) for prophy-
Subcutaneous; laxis against invasive breast cancer. All patients were operated on with the same
Prophylactic protocol regarding indications and surgical method. Reconstruction was com-
pleted in two stages with tissue expanders and permanent round or shaped rough
textured gel filled silicone implants. The study includes 52 patients with a mean
age of 39.5 years operated on in the period 1991–2000; the period of follow-up
ranged between 3 and 12 years with a mean of 7. In this series, not a single case of
invasive cancer developed, and the aesthetic results are considered very
satisfactory. This data strengthens the case of subcutaneous mastectomy as a
valid prophylactic operation.
Q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All
rights reserved.
Women with a high risk of developing invasive (LCIS) and finally, (6) ductal carcinoma in situ
breast cancer can benefit from prophylactic mas- (DCIS), which is an invasive-Ca precursor.
tectomy.1 Other forms of prophylaxis include Bilateral subcutaneous mastectomy (BSCM) in
chemoprevention, usually with tamoxifen, and which the nipple–areola-complex is preserved is one
close surveillance. 2 Identifying the high risk of the methods used to remove breast parenchyma.
patients is not always an easy task3 but most This type of mastectomy has been applied for many
studies agree that the main parameters to consider years,4–6 although its oncologic value has been
are: (1) positive family history (not genetically questioned and its results criticised in the past7–9
tested), (2) BRCA1 and 2 gene carriers, (3) atypical other types of mastectomy include simple mastect-
ductal hyperplasia, (4) prior breast cancer history, omy, skin sparing mastectomy and partial
(5) presence of extensive lobular carcinoma in situ mastectomy.
In an effort to evaluate results from the
oncologic and the reconstructive point of view,
we reviewed all our cases which underwent BSCM in
* Tel.: C30 210 6843754; fax: C30 210 6843395. the years 1991–2000. All patients were operated on
E-mail address: yiacoume@otenet.gr. with the same protocol, which included set
S0007-1226/$ - see front matter Q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2004.11.004
300 A.M. Yiacoumettis
indications and the same method of reconstruction. Surgical method
Besides criteria and indications, the burden of the
decision was laid onto the patients, who ultimately Each patient is examined in the upright position
chose this type of prophylaxis and granted informed before surgery. The location of the breasts on the
consent. chest wall and the estimated volume are noted. The
degree of ptosis is also measured. In cases of grade I
and grade II ptosis, skin envelope reduction is not
considered necessary. For cases with greater
Material and method degrees of ptosis and breast volume larger than
500 g, some form of mastopexy/breast reduction
Selection of patients design is applied ensuring a satisfactory derma-fat
pedicle for the NAC.
Since there is, as yet, no consensus on the absolute Subcutaneous mastectomy is performed preser-
indications for prophylactic mastectomy, the Mayo ving the integrity of the muscular fascia and
Clinic criteria.1 were followed as a general guide. ensuring that the thickness of the flaps is similar
Family history involving one or more first degree to those dissected for radical mastectomy. For
relatives with breast cancer was considered an cases necessitating skin reduction, the derma-fat
indication alone for BSCM since the life time risk pedicle is fashioned first and the portion of the
from this factor can be as high as 30%. In cases of surplus skin is discarded together with the gland.
BRCA positive patients, this probability rises up to The pocket for the expander should extend to
85%.10 Proliferate atypia and multiple biopsies were the limits of the area occupied by the base of the
also an indication as well as the presence of
breast. It is created through a muscle split at about
extensive LCIS. For DCIS, the BSCM was performed
2–3 cm medially and parallel to the edge of the
only for two cases in which the patients did not
pectoralis and 4–5 cm from the level of the
grant permission for removal of the nipple–areola-
inframammary fold. Once the rib periosteum is
complex (NAC) and rejected radiotherapy. Indi-
reached, the muscle is detached intact and in
cations also included mammographic evidence of
continuity with the serratus anterior laterally and
multiple microcalcifiacations suspicious of malig-
the upper end of the rectus abdominis medially.
nancy. Mastodynia alone did not constitute an
Extra care is exercised to preserve the sternal
indication. Psychological reasons for women who
attachment of the pectoralis. A fiber-optic illumi-
were unwilling to accept nonsurgical management
nated retractor is very useful at this point.
were also considered of importance and took a
significant part in the decision making. Heterolat- Emphasis is given to the lower half of the pocket
eral subcutaneous mastectomy is often carried out where the muscle attachment is denser, while the
in the process of delayed reconstruction on patients upper half is looser and not difficult to dissect.
who previously had radical mastectomy, but this Following careful haemostasis, an expander is
data is not included in this study. placed in the pocket making sure that it is spread
Counselling of the patients was considered a comfortably in the space provided. Interrupted
most important issue. A lengthy discussion of the sutures are placed approximating the edges of the
available options was encouraged between the muscle split incision, thus ensuring complete
patients and the members of the oncological muscular cover over the expander. For expanders
team, which included the breast surgeon, the bearing a remote valve, a suitable pocket is
plastic surgeon, a nurse and a female psychologist, fashioned subcutaneously below the inframammary
if her help was considered necessary. The patients fold at the mid-axillary line. Inflation to the
were given the risks and the prognosis related to maximum with normal saline through the valve,
their case as well as the likely aesthetic result. A using a 21G butterfly needle follows, under direct
point of importance was that not all breast tissue vision, observing the muscle integrity.
was removable with this type of operation and that The skin is then draped over the muscle and
follow-up was necessary after the surgery. Follow attention is given to the correct position of the
up is considered necessary because there is a small nipple. In the cases of simple subcutaneous mas-
potential risk of about 1–1.5% to develop invasive tectomy the inframammary incision is closed in two
breast cancer even after the operation. The layers after leaving a drain. In the cases with skin
potential complications were also discussed. An reduction the flaps are placed and sutured in the
instant decision was not acceptable, the patients correct position.
had to come again and grant their informed A dressing composed of ‘micropore’ paper tape is
consent. applied directly on the skin to ensure attachment of
Two staged breast reconstruction following prophylactic bilateral subcutaneous mastectomy 301
Table 1 Types of devices used Table 3 Type of operation performed
Expanders Simple BSCM (inframammary incision) 37
Round smooth surface (with remote valve) 64 Skin reduction with inferior pedicle 12
Anatomic textured (with incorporated valve) 40 for NAC transposition
Permanent prostheses Skin reduction with vertical pedicle 2
Round textured (gel filled) 52 for NAC transposition
Round textured (cohesive-gel filled) 10 Skin reduction and free NAC graft 1
Anatomic textured (cohesive-gel filled) 42
reduction. The preferred method was that of
the flaps to the underlying muscle. Gauze and fashioning an inferior derma-fat-pedicle bearing
elastoplast on top completes the dressing. This is the NAC in a design similar to the commonly used
removed on the third post-operative day and pattern of reduction mammoplasty, employing the
replaced by a firm elastic bra. Intra-operative inferior pedicle technique.11 On two occasions, a
antibiotics, usually of second generation cephalos- vertical bipedicle derma-fat technique with the
porin is given intravenously continued for 24 h and NAC in the centre of a horizontal fusiform incision
followed by per-os administration until the patient was employed (Table 3). In one case the NAC
is discharged on the forth day. complex was used as a free graft.
Inflation of the expander is resumed 2 weeks The follow-up was carried out annually and
after the operation and is continued at variable ranged between 12 years maximum and 3 years
intervals until complete satisfactory expansion is minimum period. This included palpation, mammo-
achieved. The expanders are replaced a few months graphy and sonogram as appropriate. None of the
later with permanent gel filled implants. The types patients was lost in the follow-up. No case of cancer
and sizes of expanders and implants used in this was detected in the study period.
series are shown in Table 1. Complications included one full thickness NAC
necrosis and four partial, all in patients with skin
reduction. All patients, except one, who developed
Results this complication, were smokers but no data are
available determining the number of cigarettes
Fifty-two patients were operated on in the period consumed daily. Minimal 1–2 cm flap necrosis at the
1991–2000. Their ages ranged from 28 to 56 years corners of the reverse-T junction, also in two cases
(mean age 39.5). Most of the patients fulfilled more with skin reduction, healed spontaneously, without
than one criteria, the most frequent being the surgical intervention. Wound dehiscence with
family history of breast cancer. A rare case of implant exposure did not occur, due to the
fibromatosis is included. Only three BRCA positive underlying muscle integrity. Capsule formation
patients are included, out of eight tested. Gene varied between grade II and III according to Baker’s
labelling was not possible in the early years of this classification.12 Implant replacement with capsu-
study and still remains difficult to carry out as a lotomy was necessary in only one of the cases in this
routine test (Table 2). series. Haematoma and infection did not occur.
Thirty-seven out of the total of 52 (71%) had a There have been no patients requesting removal
simple BSCM through an inframammary incision. of the implants. Acceptance of and satisfaction
The remaining 15 (31%) underwent a skin envelope with the results is considered high. The aesthetic
appearance of the breasts is satisfactory (Fig. 1(A)–
(D)). For cases with skin reduction the reverse T
Table 2 Numbers of operated patients according to type has been well accepted (Fig. 2(A)–(D)).
one or more indication criteria
Relatives with breast cancer 40
Relatives with ovarian cancer 1
Multiple biopsies 18
Discussion
Proliferative atypia 33
Mammographic evidence 19 Prophylactic mastectomy can reduce the risk of
LCIS 13 developing subsequent invasive breast cancer by
DCIS 2 well over 90%.13–15 It has been shown that this form
Breast fibromatosis 1 of drastic prophylaxis may be more effective
BRCA (C) not routinely performed 3 compared to chemoprophylaxis with anti-oestro-
gens and by surveillance alone. A significant302 A.M. Yiacoumettis Figure 1 (A) Pre-operative anterior view of a 35-year-old patient with LICS—the limit of the glandular resections is outlined. Further dissection towards the axilla is possible as indicated by the second doted line on the left axillary tale. Biopsy scar is evident on the inner half of the left breast. (B) Pre-operative oblique view of the patient. (C) Post- operative anterior view three years after BSCM through inframammary approach and reconstruction by tissue expansion in two stages. (D) Post-operative lateral/oblique view of the same patient. proportion of women at increased risk of developing be psychological sequelae. The decision to undergo breast cancer would consider prophylactic mastect- surgery is considered a highly personal one.17,18 omy.16 As no absolute indications exist, proper From the oncologic point of view, it is an operation counselling is of utmost importance. Besides the intended to remove as much breast parenchyma as it risk factor, surgical technique, potential compli- is possible, while preserving the NAC and sufficient cations and expected results must be thoroughly skin to refashion the breast. Skin flaps should be of the discussed. Bilateral subcutaneous mastectomy can same thickness as if one is doing any other type of offer a satisfactory solution. Women at high risk may mastectomy. By doing this, on an average, most of choose the option of mastectomy influenced by the the breast parenchyma can be removed and it is satisfactory aesthetic results. Careful selection of comparable to the extirpation achieved with radical candidates for surgery is mandatory, since there may mastectomies.19 Subcutaneous mastectomy is a safe
Two staged breast reconstruction following prophylactic bilateral subcutaneous mastectomy 303 Figure 2 (A) Design of skin reduction-subcutaneous mastectomy in a 48-year-old patient with family history of breast cancer. (B) Skin flaps following subcutaneous mastectomy and inferior derma-fat flap baring the NAC. (C) Anterior view of the same patient, following reconstruction by tissue expansion in two stages, 5 years after the operation. Partial loss of the left NAC was followed by reconstruction with a free full thickness skin graft from the genito-femoral crease. (D) Oblique view of the same patient. alternative to total mastectomies performed for muscle over a period of few months enabled us to early primary invasive breast cancer (not located place the most suitable permanent silicone gel under the nipple) and multifocal DCIS, since it caries filled implant. It is suggested that anatomically no higher risk of local recurrence.20 The probability of shaped textured expanders should be followed, in developing, at a later date, an invasive cancer in the the second phase, by anatomically shaped textured remaining tissue and particularly under the nipple is permanent implants.29 In a number of patients, insignificant. This development is relatively rare and however, round smooth surfaced expanders with a refers to case reports.9,21,22 Although in this series, remote valve were used. This did not affect none of the cases were operated for invasive cancer, subsequent use of textured and shaped permanent we should note that some controversy related to NAC implants. Migration of implants did not occur. preservation continues to be of concern.23 Even, in Shape and projection was satisfactory. Double mastectomies performed for small invasive cancer, lumen expanders were not used because of the occult nipple involvement is also rare.24 Recent potential of not maintaining shape and volume over publications on the question of preserving the the years. Softness was satisfactory to the patients NAC in skin sparing mastectomies suggest that it is and none of them requested surgical intervention. A a reasonable option for carefully screened variety of sizes and shapes of implants were used, a patients.25,26 It is our opinion that preserving the fact that verifies the concept that every operation NAC greatly enhances the aesthetic result and it does of this type is designed for the particular patient, not put the patient at higher risk. depending not only on the patient’s body measure- Despite several reports in the literature ments but also according to their wishes. In the suggesting one-stage reconstruction,27,28 in this majority of patients however, textured implants series, reconstruction was accomplished in two with cohesive silicone content were used without stages. This was done because by expanding the problems and with very satisfactory aesthetic results.
304 A.M. Yiacoumettis
Figure 3 (A) Pre-operative view of patient to undergo BSCM for multiple microcalcifiacations and family history of
breast cancer. (B) Lateral view of the same patient. (C) Same patient, 10 years later following BSCM. Two stage
reconstruction by tissue expansion and silicone breast implants. (D) Lateral/oblique view of the same patient.
It is our opinion that women at high risk who wish V. Venizelos, consultant breast surgeon, for his
to be relieved from the psychological burden of constructive criticism and help with this paper.
carrying potentially malignant breast tissue, may be
aided in their decision to choose the option of
subcutaneous mastectomy if the results are aesthe-
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