The lifetime risk of any woman developing breast cancer is currently estimated to be 1 in 8. The vast majority of these breast cancers occur in much older women. Some younger women, because of genetic factors, have a much higher risk of developing breast cancer. This ‘high risk’ group can be managed in 2 ways:

• Screening: in which they can either undergo yearly xrays or MRI to identify any worrying signs early.
• Risk reducing mastectomy: in which they can have both breasts removed before any cancer develops. The aim of this operation is to remove as much breast tissue as possible in order to reduce the chance of the breast tissue turning into breast cancer. A mastectomy cannot remove 100% of the breast tissue, and as such, there will always be a small chance of developing cancer afterwards. However, a risk reducing mastectomy does massively (90-95%) reduce the risk of developing cancer.

If a woman has a strong family history of breast cancer then they should discuss this with their family doctor who will probably refer them to their local breast cancer unit. Here, a full team of specialists will be available to help with advice. A geneticist will be able to estimate the lifetime risk of developing breast cancer and may also offer gene testing (a simple blood test). If the patient is thought to be at high risk, then a breast surgeon will discuss the options of regular xrays or surgery. If the patient wishes to proceed with surgery, then a clinical psychologist will help the patient talk their decision through and a plastic surgeon will discuss the reconstructive options.

Once a decision has been made to undergo a risk reducing mastectomy there are several things to consider:

Do I want a reconstruction? not everyone wishes to undergo a breast reconstruction – some women just want to have their breasts removed to reduce the risk of getting breast cancer. Most women however do want breast reconstruction.

What will the results of reconstruction be like? It is important to realise that the newly reconstructed breasts will not be normal breasts. They will feel somewhat numb, and are usually a little firmer than normal breasts. There will be no ‘erogeneous’ sensation in the nipples and of course, breast feeding will not be possible. However most women are delighted with the outcome of surgery and are confident that they made the right decision.

What reconstruction should I have? The key choice here is whether you want an implant-based reconstruction or a living tissue reconstruction. A living tissue reconstruction gives the best cosmetic outcome, and produces soft, natural looking breasts which usually ‘last a lifetime’; however, this is a big operation, takes a long time to recover from and results in a donor site scar and possible donor site complications. An implant based reconstruction is a smaller, safer, simpler operation which does not require a donor site. Recovery is generally faster which makes this a popular reconstruction option for younger women who have a young family. The final outcome is not usually quite as good, but because both breasts are being replaced the outcome will be symmetrical and the ‘breasts’ will behave similarly over time. The disadvantage with implant based reconstruction is that the implants may not last forever and may need further operations at some stage in the future.

What should I do with the nipples? The aim of the risk reducing mastectomy is to remove as much breast tissue as possible in order to maximally reduce the risk of developing breast cancer. A small amount of breast tissue is present within the nipples. Removing the nipple therefore maximally reduces the risk of cancer. However, it is difficult to reconstruct a realistic nipple and many surgeons advocate keeping the nipple. This results in a cosmetic advantage and only very slightly increases the risk of developing a cancer (about 1% more). Furthermore, if any cancer does occur, it would present as a lump in the nipple, which would be easy to feel and detect.

When should I have risk reducing mastectomy? This is a personal choice and depends upon individual circumstances. Factors to consider include; the average age when family members developed breast cancer; whether or not you plan to have children; are you as fit as you could be.

Some gene abnormalities (eg BRCA2) also increase the risk of developing ovarian cancer and this risk is often managed by removing the ovaries. There has been much discussion about whether this could be done at the same time as a risk reducing mastectomy. Personally, I advise against this combined surgery as the potential complications of one operation may jeapordise the outcome of the other.

• Implants – dermofascial flap
• – Strattice
• – two stage reconstruction with tissue expander, then implant
• Living tissue – ELD
• - TRAM/DIEP/FREE TRAM
• - SGAP/IGAP/TUG