I’m Dr. George Xipoleas. I’m a board certified plastic surgeon here at the Long Island Plastic Surgical Group. I have been doing breast reconstruction surgery since I started here. And that’s approximately eight years.
So women may opt to undergo a prophylactic or preventative mastectomy for multiple reasons. In women who have a disease in one side, they may opt to undergo prophylactic mastectomy on the opposite breast or the contralateral breast to decrease their risk for cancer occurrence, or they may do so for symmetry reasons. Women who have no disease, however they have a family history, a strong family history of breast cancer, or they have undergone genetic testing and have been found to have these high penetrance genes, such as BRCA1, or BRCA2 genes may undergo mastectomy because it decreases their risk for developing breast cancer through their lifetime.
So breast reconstruction after mastectomy is the creation of a breast mound or the transfer of tissue to create a breast mound in these patients who have undergone this type of surgery. It broadly falls into two separate categories. It falls into autologous reconstruction, and that is where we move the tissue, the skin, subcutaneous fat, sometimes the muscle from one part of the body to the other. For the most part, if a woman is undergoing bilateral prophylactic mastectomy, she can have what’s called an immediate reconstruction.
When the plastic surgeon and the general surgeon do the mastectomies, it is a team effort. There’s a lot of discussion. And we attempt to do the surgeries at the same time, whether it be with a flap at the time of surgery or in a staged manner with tissue expanders, and then permanent prostheses afterwards. In certain instances, if the skin flaps are healthy enough, we can do what’s called a direct to implant. And that is when we put the permanent silicone prosthetic in the… Underneath the skin flaps at the time of surgery.
If for any reason, the general surgeon thinks that she, or the breast surgeon thinks she will need radiation therapy postoperatively radiation therapy changes the tissues as a whole. So if that is the case, we don’t want to take our flap, which is nice, healthy tissue, put it in the area and then radiate it. So if that occurs, what we do is what’s called a delayed immediate reconstruction in which we put tissue expanders, which are basically saline-filled implants under the skin, and sometimes under the muscle to maintain the breast mound, to maintain the amount of skin that we have, and then the patient undergoes their chemotherapy, their radiation therapy. And then six months down the line, after everything is healed up, we can then do their permanent reconstruction.
In terms of recovery, every individual is different and that’s the one thing that we can’t stress enough. Everybody will recover at their own pace, but it does vary from surgery to surgery. If we do implant-based reconstruction, the recovery is a bit quicker. In terms of implant-based reconstruction, we can then divide it into prepectoral and sub-muscular reconstruction where any time we’re doing muscle work, that recovery is a bit more painful and can last a little bit longer. And when we’re doing flap surgery, that recovery would be the longest recovery because we are moving tissue from one part of the body to the other. We’re now asking for two parts of the body to heal rather than one.
With implant-based reconstruction women go home the following day from the hospital, if everything is okay, and then they convalesce at home. And as long as they’re not in expanders, if the permanent implants are in, they can usually get back to normalcy within a couple of weeks. They go back to work in a couple of weeks, they can start working out usually after about a month. With flap surgery, women are in the hospital anywhere between three and seven days postoperatively. And as long as they are healing well, they can go back to light working out, normal activities within four weeks. But because sometimes we do use those muscles to reconstruct the area, they can’t go back to full working out for eight weeks.
In prophylactic mastectomies or preventative mastectomies the studies have shown that women who undergo this, who have a high likelihood of developing breast cancer, they decrease their risk of breast cancer by 90% or higher. When the general surgeon performs a prophylactic or preventative mastectomy, while we do try to remove the majority of the breast, we can’t remove every last cell. That interface between the normal, what we call subcutaneous fat, and the breast tissue is very similar. So to remove every last cell may thin out the skin so much there may be wound healing complications. So while it doesn’t reduce anything to zero, it does reduce the risk substantially.
Most studies show that a woman is undergoing bilateral prophylactic mastectomy between the age of 20 and… Between 25 and 30, you increase your life, your survival and your life expectancy by up to five years. The studies have shown that if you wait longer, your chances of developing breast cancer are higher. And it’s important for these patients to have conversations with their doctors. Not only because of that, but there’s a lot of connotations with that in terms of… Because 25 is very young, especially now. Many women aren’t having children when they’re in their early twenties. So what these women need to realize is while they are decreasing their risk for cancer, they won’t be able to breastfeed if they do get a prophylactic mastectomy. They will not have normal sensation in their breasts moving forward. And while they may appear to be normal breasts after the reconstruction, they will not be for all intents and purposes, normal breasts.
And this is important for patients to realize, and to have very candid discussions, not only with their breast surgeon, but with their plastic surgeon as well. If you are “high risk,” or if you think you’re high risk because your mom had breast cancer or your sister or someone, they usually send you to a medical geneticist and they will go over everything. They usually do the genetic testing. And then there’s a very nice team approach between sometimes the breast surgeon and the genetic testing, or sometimes the primary care and the genetic testing facility. And they basically will sit down and they’ll tell you, this is the gene that is mutated. This is what that gene does because you hear BRCA. And you’re like, “Oh my God, what is that do?” And when you think about it and you say, well, “BRCA is a gene that helps repair damage in DNA.”
So if you have a BRCA gene that’s not functioning well, your DNA is not getting repaired well. So any sort of insult that happens, your chances of developing a tumor are higher. So there are a lot of these what are called tumor suppressor genes. So when you know this gene increases my risk of breast cancer X amount, or you know of the patients with BRCA positive, 40% will get breast cancer. At least the patient can make an educated decision on how they want to proceed. Because again, even a prophylactic mastectomy, it’s not 100% but again, decreasing it by 90%, increasing a woman’s life expectancy by five years. When you say, “Oh, five years, five years is a lot of time.” It’s watching your kid graduate college. It’s watching your grandkid take their first steps. It’s a lot of time.