Bilateral prophylactic mastectomy and immediate breast reconstruction with implants

Bilateral prophylactic mastectomy (BPM) followed by immediate breast reconstruction (IBR) has been more frequently performed over the last 10 years to prevent breast cancer in high-risk women. Since this procedure is prophylactic, it is very important to provide detailed information regarding possible consequences of surgery. The overall aim of this thesis was to increase our knowledge of outcomes after bilateral prophylactic mastectomy and immediate breast reconstruction with implants in women with increased inherited risk of breast cancer. The women were operated on between 1993- and 2001 and 2004- and 2006 at Karolinska University Hospital in Stockholm, Sweden. Follow-up time was a minimum of two years after surgery.

Breast sensitivity was assessed quantitatively and qualitatively and was found to be significantly impaired in all respects compared to a control group of non-operated women. The prevalence of pain and/or discomfort in the breasts was high (69%), but no patient reported severe pain. With regards to impact of the BPM on patients sexuality, a majority reported lost or substantially impaired ability to experience sexual sensations in the reconstructed breasts. Sexual enjoyment was negatively affected in 75% of the women, particularly in those who rated their breasts as very important to their sexuality prior to BPM. Despite the negative effects in sensitivity and sexuality, feelings of regret were almost non-existent, as measured with the Decision Regret Scale. Health-related quality of life was measured with the short form-36 (SF-36) questionnaire, and no difference was seen in patients vs. a reference group of Swedish women.

Corrective procedures were performed in the majority of patients which is important to inform women ahead of BPM. No patient had a severe surgical complication. The aesthetic results were evaluated both objectively and subjectively. Breast symmetry was good and equivalent to non-operated women. Patients were satisfied with the overall aesthetic outcome, but not with nipple-areola-complex reconstruction. Aesthetic outcomes of BPM and IBR with anatomically-shaped vs. round implants were not significantly different.

In conclusion, BPM and IBR with implants is a safe procedure with good aesthetic results and high patient satisfaction for the majority of patients. It should be noted that a majority of patients will lose the capacity for sexual sensation and will experience impaired sensitivity and slight pain and discomfort in the reconstructed breasts for a long time after surgery.

List of scientific papers

I. Gahm J, Jurell G, Wickman M, Hansson P (2007). Sensitivity after bilateral prophylactic mastectomy and immediate reconstruction. Scand J Plast Reconstr Surg Hand Surg. 41(4): 178-83.
https://pubmed.ncbi.nlm.nih.gov/17701731

II. Gahm J, Wickman M, Brandberg Y (2009). Pain and discomfort in the breasts two years after bilateral prophylactic mastectomy in women with inherited risk of breast cancer - prevalence and impact on sexuality, quality of life and feelings of regret. [Submitted]

III. Gahm J, Jurell G, Edsander-Nord Å, Wickman M (2009). Patient satisfaction with aesthetic outcome after bilateral prophylactic mastectomy and immediate reconstruction with implants. Journal of Plastic, Reconstructive & Aesthetic Surgery. [Accepted]
https://pubmed.ncbi.nlm.nih.gov/19071075

IV. Gahm J, Edsander-Nord Å, Jurell G, Wickman M (2009). Aesthetic outcome and patient satisfaction of anatomical vs. round shaped expandable implants in bilateral breast reconstruction: a randomized study. [Submitted]