Breast Reconstruction following Mastectomy for Breast Cancer or Prophylactic Mastectomy: Therapeutic Options and Results

Abstract

(1) Importance of problem: Breast cancer accounted for 685,000 deaths globally in 2020, and half of all cases occur in women with no specific risk factor besides gender and age group. During the last four decades, we have seen a 40% reduction in age-standardized breast cancer mortality and have also witnessed a reduction in the medium age at diagnosis, which in turn means that the number of mastectomies performed for younger women increased, raising the need for adequate breast reconstructive surgery. Advances in oncological treatment have made it possible to limit the extent of what represents radical surgery for breast cancer, yet in the past decade, we have seen a marked trend toward mastectomies in breast-conserving surgery-eligible patients. Prophylactic mastectomies have also registered an upward trend. This trend together with new uses for breast reconstruction like chest feminization in transgender patients has increased the need for breast reconstruction surgery. (2) Purpose: The purpose of this study is to analyze the types of reconstructive procedures, their indications, their limitations, their functional results, and their safety profiles when used during the integrated treatment plan of the oncologic patient. (3) Methods: We conducted an extensive literature review of the main reconstructive techniques, especially the autologous procedures; summarized the findings; and presented a few cases from our own experience for exemplification of the usage of breast reconstruction in oncologic patients. (4) Conclusions: Breast reconstruction has become a necessary step in the treatment of most breast cancers, and many reconstructive techniques are now routinely practiced. Microsurgical techniques are considered the "gold standard", but they are not accessible to all services, from a technical or financial point of view, so pediculated flaps remain the safe and reliable option, along with alloplastic procedures, to improve the quality of life of these patients.

Keywords: autologous breast reconstruction; breast reconstruction; chest feminization; delayed reconstruction; immediate reconstruction; implant reconstruction of breast; prophylactic mastectomy; reconstruction following mastectomy; transgender; two-stage breast reconstruction.

Figure 1

Patient with stage Ia invasive ductal carcinoma of left breast and BRCA positive status. She underwent bilateral subcutaneous mastectomy with left sentinel lymph node identification using Indocyanine green followed by immediate bilateral reconstruction with 350 cc round implants: (A,B) aspect before reconstructive surgery; (C,D) aspect at 3 months after reconstructive surgery.

Figure 2

Patient with right radical mastectomy for breast cancer followed by radiotherapy; she underwent right breast delayed reconstruction using latissimus dorsi pediculated flap and a 225 cc round implant. (A) aspect before reconstructive surgery; (B) aspect at 3 months after reconstructive surgery.

Figure 3

Patient with right radical mastectomy for breast cancer followed by radiotherapy; she underwent right breast delayed reconstruction using latissimus dorsi pediculated flap and a 320 cc round implant simultaneous with prophylactic left subcutaneous mastectomy (due to BRCA-positive status) with immediate reconstruction using a pediculated inferior dermoadipous flap and a 350 cc round implant: (A) aspect before reconstructive surgery; (B) aspect at 3 months after reconstructive surgery.

Figure 4

Bilateral prophylactic mastectomy in patient with BRCA-positive status and heavy family history of breast cancer. Immediate reconstruction using 325 cc round implant and pediculated inferior dermoadipous flap followed by nipple–areola complex graft: (A) aspect before reconstructive surgery; (B) aspect at 3 months after reconstructive surgery; (C) final aspect at 32 months after reconstructive surgery.

Figure 5

Patient with right radical mastectomy for breast cancer; she underwent right breast delayed reconstruction using latissimus dorsi pediculated flap and a 275 cc round implant simultaneous with prophylactic left subcutaneous mastectomy (due to BRCA-positive status) with immediate reconstruction using a 325 cc round implant: (A) aspect before reconstructive surgery; (B) aspect at 3 months after reconstructive surgery.