Prophylactic mastectomy: is it worth it?

Breast cancer is the second mortality-related cancer and the leading cause of general mortality in women aged 40-55. Prophylactic mastectomy has proved to be effective in several clinical scenarios but is still a somewhat controversial procedure.

We performed a retrospective study by reviewing the records of all patients who underwent prophylactic mastectomy in a 25-year period. We evaluated the aesthetic and long-term oncologic outcomes, complications, and patient satisfaction.

We had 52 patients, 40 of them unilateral cases (contralateral prophylactic mastectomy) and 12 bilateral (bilateral prophylactic mastectomy) for a total of 64 mastectomized breasts. We had 1 (1.56%) case of unexpected breast cancer in the mastectomy specimens. Forty-two (65.62%) cases had a subcutaneous prophylactic mastectomy and 22 (34.37%) cases had a simple total prophylactic mastectomy. Fifty-eight (90.62%) cases underwent reconstruction with alloplastics and 6 (9.37) cases with autologous tissue of which 5 (7.81%) cases received latissimus dorsi flaps with alloplastic implants and 1 (1.56%) case had a TRAM flap. The complications included 4 (6.25%) breasts that developed capsular contracture, 2 (3.12%) cases of hematoma, and 1 (1.56%) infection. Concerning patient satisfaction, 39 (75%) patients reported being highly satisfied, 10 (19.23%) partially satisfied, and 3 (5.76%) unsatisfied. When we performed the aesthetic evaluation according to our scale, we got an overall aesthetic index of 8.8.

Prophylactic mastectomy is becoming an increasingly frequent procedure. Plastic surgeons should consider the aesthetic outcome when planning mastectomy and reconstruction. Our ability to predict the high-risk population has improved and it is that population who can get the best benefit from this intervention. The recommendation against subcutaneous prophylactic mastectomy lacks scientific evidence. There is plenty of evidence that prophylactic mastectomy lowers the risk of breast cancer in the high-risk population in at least 95%. Our experience with prophylactic mastectomy is extremely satisfactory, with an overall patient satisfaction rate of 94%, no mortality, and an oncologic long-term outcome of 0% of ulterior development of breast cancer. Our series, although relatively small, should provide some insight into the power of this technique and we think all plastic surgeons should have it in their surgical armamentarium and should share their experiences so that this procedure may become more widely accepted. We also think that plastic surgeons should strive for perfecting the technique to reduce the complication rate and therefore help the procedure gain acceptance by the medical community.