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Updated: March 2011

BRCA Gene, Prophylactic Mastectomies,
Muscle-sparing Free TRAM Flaps

Pre-Op Bilateral Prophylactic Mastectomy
One year post-operative front
Before
After

This patient is seen before and after bilateral mastectomies and muscle-sparing free TRAM flap breast reconstruction. This approach was chosen given her pre-operative large breast size, and given that she has sufficient lower abdominal tissue for a free flap reconstruction.

Kathy's Breast Reconstruction Story:

 

I have a very strong family history of breast, ovarian and colon cancers. Two years ago, at 52-years-old, I learned that the BRCA1 gene had been found in a family member. I decided to go for genetic counseling and had the blood test to determine if I also was positive for the cancer gene. Just before Thanksgiving of 2008, the results were in and I have the exact BRCA1 gene as my aunt. By January 2009, my ovaries were removed.

At that time I was convinced I would just continue with mammograms, breast sonograms and breast MRI’s. If ‘something’ was found, it would be in the early stages and I would address the situation at that time. After all, back in 2006, I had a biopsy of ‘something’ in my left breast and that had turned out to be fine. March 2009 arrived and it was time to schedule another mammography and sonogram. These tests revealed that now there were three ‘things’ in my left breast to be watched.

Suddenly, with the knowledge that I was BRCA1 positive, I was feeling a little uneasy. Everyone in my family sees the same breast surgeon. Knowing he was aware of my family history, I decided to see him for his opinion about my options. I must say, I was not ready for what he had to tell me. He said that with my strong family history of breast cancer and having the BRCA1 gene, I had a very big decision to make. I asked for his recommendation. He said that he would recommend a prophylactic double mastectomy with reconstruction.

I decided to get a few more opinions. I spoke to some friends and my doctors and received the names of a breast surgeon and two plastic surgeons. I saw the breast surgeon first. She told me that if I chose to continue testing, that was fine. However, I would be on a very strict schedule for testing, including mammography, sonograms and MRI’s. I would also need to see an oncologist and start Tamoxifen. My head was spinning! Oncologist? Tamoxifen? She said the best route was the risk reducing surgery and that some people are candidates for reconstruction with their own tissue.

I only saw one of the plastic surgeons. I was so comfortable with him and what he had to say. I asked immediately about the reconstruction using your own tissue. He showed some photos of women who had undergone mastectomies with that type of reconstruction. I was amazed! They looked the same as before the surgery, only better! The way I saw this was, when all was said and done, I could have a breast reduction, tummy tuck and never have to have another mammography, breast sonogram or breast MRI. I decided right then and there this was the right way for me to go and the surgery was scheduled that day.

On July 7, 2009, I had a prophylactic double mastectomy with reconstruction at the same time. The surgery took all day and I don’t remember much of the next few days. I can tell you that I went to sleep with breasts and woke up with much smaller breasts and my large hanging belly was gone. It was amazing! I went home about four days later. It was tough at first. My biggest problem was the incision on my belly. Each day was a little better than the previous one. I would give myself little goals… to get up, to move around on my own, to get myself a drink and before long my goals were to shower by myself and get dressed by myself. Before I knew it, it was mid-October and I was back at work.

In December 2009 I had my nipple reconstruction. This surgery was on an outpatient basis. My breasts were even reduced a little more. My belly scar needed a little repairing and that was also done at the same time. This surgery was a breeze compared to the one in July. I was back to work in a week. At this point, I had beautiful new breasts and nipples as well! In May 2010 I had tattoos on my nipples to make them a natural color. This was done in the office in a short amount of time.

Next month will be two years since I learned that I was BRCA1 positive. I have made many choices in those two years. I do not regret any of them. I would do everything the same way tomorrow to have the peace of mind that I have now. I did not realize how much the testing was taking a toll on me. It was always in the back of my mind, from making the appointment, until the actual tests and awaiting the results. I was very lucky that the pathology reports were all negative for any cancer. I got my breast reduction and tummy tuck and I never have to have another mammography, breast sonogram or breast MRI again. Learning I am BRCA1 positive has been such a gift. It gave me information about my extreme high risk for breast cancer and the options for dealing with that risk.

 

Photos and Doctor Commentary

 

Pre-Op Bilateral Prophylactic Mastectomy

Pre-operative

Kathy’s body habitus pre-operatively was not amenable to all types of reconstruction. An implant-based reconstruction would have posed many challenges and aesthetically would not have provided an optimal result. Kathy was best suited for a flap-based reconstruction because of her ample abdomen as well as her pre-operative large breast size. There was sufficient tissue in her lower abdomen to allow for bilateral “full-figured” breast reconstruction using abdominal free flaps.

 

Pre-Op Markings for DIEP Flap reconstruction

Breast and abdominal markings

The initial breast markings were made to provide for a modest reduction in volume and a lifted nipple position. The lower abdomen was marked for the tissue that was to be removed and used to re-create Kathy’s full breasts. This included a midline marking to split the tissue removed into two flaps allowing for bilateral reconstruction (with each half going to one side of the chest).

 

 5 Months Post-Op Bilateral DIEP Flap

Five months after bilateral muscle-sparing free TRAM flaps

At the time of surgery it was determined that additional breast skin needed to be removed beyond what was initially marked. As can be seen post-operatively, this resulted in larger than originally intended skin islands (patches of skin taken from the abdomen), but did not affect her breast shape. Also visible post-operatively are two parallel lower abdominal scars. The upper scar is from the resulting “tummy tuck” that Kathy received after the tissue was removed for the breast reconstruction. The lower scar is from prior surgery and is not visible in the pre-operative photograph (first in the series above) because it was hidden under the extra lower abdominal skin.

 

Nipple-Areola Reconstruction Markings

Markings for nipple-areola reconstruction

Here Kathy is marked for her nipple-areola reconstruction. This is planned as a simple outpatient procedure where small local skin flaps are utilized to create new nipples. No additional skin is needed from elsewhere for the nipple reconstruction.

 

One year post-operative front 

 One year post-operative hr  One year post-operative hl

   One year post-operative left  One year post-operative right  

One year post-operative

This is Kathy one year after her mastectomies and abdominal free flap breast reconstruction. Following nipple reconstruction, her nipple tattoos were done as an office procedure, providing a natural color tone.