BRCA Mastectomy Reconstruction

A BRCA mastectomy, also known as a prophylactic or preventive mastectomy, is the surgical removal of one or both breasts to reduce the risk of developing breast cancer. This procedure is often chosen by individuals who carry a mutation in the BRCA1 or BRCA2 genes, which significantly increases the risk of developing breast and ovarian cancers.

Individuals with BRCA1 or BRCA2 mutations have a higher lifetime risk of developing breast cancer—up to 70%. A mastectomy can reduce this risk by approximately 90%. Some people choose this surgery to prevent cancer rather than face ongoing screenings and the anxiety (or “scanxiety”) of potentially developing cancer.

• Total mastectomy: Removal of the entire breast, including all skin, ducts, glands, fat, and the nipple and areola.
• Skin-sparing mastectomy: Removal of the breast tissue while preserving most of the breast skin, often done in preparation for immediate reconstruction.
• Nipple-sparing mastectomy: Removal of the breast tissue while preserving the nipple-areola complex and most of the breast skin. This option is typically best suited for preventative mastectomies where there is no cancer diagnosis yet.

Breast reconstruction is a surgery to rebuild the shape of the breast after a mastectomy. It can be done immediately (at the same time as the mastectomy) or delayed (months or even years after the mastectomy). The timing depends on the individual’s health, preferences, and any additional treatments, such as chemotherapy or radiation.

There are many options for breast reconstruction based on your personal anatomy and goals for your reconstruction. The most common reconstruction techniques include:

Considerations for choosing a breast reconstruction technique include your body type and the availability of sufficient donor tissue for flap reconstruction, as well as your personal preferences and desired outcomes, including the shape and feel of the reconstructed breast. You will need to consider your medical history including previous surgeries, radiation therapy, and your overall health, and the recovery time because some methods will have longer recovery periods than others.

Like all surgeries, mastectomy and breast reconstruction carry inherent risks. Potential risks include infection at the surgical site, bleeding, bruising, scarring (although many scars can be hidden by the body’s natural curves and lines), and numbness or loss of sensation. Implants and flap surgeries also come with unique risks. Implants can be at risk of capsular contracture (hardening around the implant), rupture, or displacement, while flap complications can include transplant necrosis (tissue death).

Recovery time varies based on the type of mastectomy and reconstruction. Generally, implant-based reconstruction initial recovery takes 4-6 weeks, with full recovery in several months. Flap reconstruction recovery can be longer, often 6-8 weeks initially, with complete recovery in several months to a year. Your surgeon will provide specific expectations based on your procedure.

After your initial mastectomy and reconstruction, you may require additional surgeries for revisions to improve the appearance or symmetry of the reconstructed breasts, implants may need to be replaced after 10-15 years, and additional aesthetic finishes like nipple and areola reconstruction if that tissue was not preserved during your mastectomy.

Unfortunately, if both breasts are removed during your mastectomy, breastfeeding will not be possible because all of the milk ducts and glands will also be removed. If only one breast is removed, it might still be possible to breastfeed from the remaining natural breast; this will depend on the type of reconstruction and surgery performed.

The decision to undergo a BRCA mastectomy and reconstruction is deeply personal and can have emotional impacts. While many women feel relief at reducing their cancer risk and not having to worry about developing the disease or continued scans, you may also experience feelings of loss or grief for the life you imagined before your diagnosis or screening results. You may also experience changes in your body image and sense of self. Before undergoing mastectomy and reconstruction, it’s important to seek support from healthcare providers, counselors, and support groups so you will have a network of support during and after your procedure.

In the U.S., the Women’s Health and Cancer Rights Act (WHCRA) requires that most major insurance plans that cover mastectomy also cover breast reconstruction. This includes any surgery you need for symmetry, prostheses, revisions, and to treat complications. However, coverage can vary, so it’s essential to check with your insurance provider and team of surgeons to make sure you understand your coverage options.

Look for a board-certified plastic surgeon with experience in all aspects and techniques for breast reconstruction, particularly for patients with BRCA mutations. It’s important to consult with both your breast surgeon and plastic surgeon to understand your options, risks, and what outcomes you can expect.