Implant-Based Breast Reconstruction after Risk-Reducing Mastectomy in BRCA Mutation Carriers: A Single-Center Retrospective Study

Preventive Paradox? Postoperative Outcomes After Risk-Reducing Mastectomy and Direct-to-Implant Breast Reconstruction

BACKGROUND

Risk-reducing mastectomy (RRM) with direct-to-implant (DTI) breast reconstruction is becoming increasingly important in breast cancer prevention. While the oncological benefits of RRM-DTI are well documented, there is a paucity of studies investigating its perioperative safety.

METHODS

The ACS-NSQIP database (2008-2022) was queried to identify all patients who underwent RRM-DTI. Outcomes of interest included 30-day occurrence of reoperation, readmission, and surgical and medical complications. Multivariate logistic regression was used to determine factors associated with postoperative complications.

RESULTS

A total of 1019 patients were included, with a mean age and BMI of 42.8 ± 10.9 years and 25.7 ± 5.8 kg/m², respectively. Complications occurred in 142 (14.0%) cases, with 103 (10.1%) reoperations and 51 (5.0%) readmissions. 62 (6.3%) surgical complications were recorded, the majority of which were superficial incisional infection (n = 19; 1.9%) and organ space infections (n = 19; 1.9%). Medical complications were rare (n = 13; 1.3%). Multivariable analyses revealed that higher BMI was significantly associated with any (OR:1.06, P < .0001), surgical (OR:1.08, P < .0001), and medical complications (OR:1.08, P = .04). Patients with bleeding disorders were at a significantly higher risk of any complications (OR:5.5, P = .03), while outpatient setting (OR:1.9, P = .03) and corticosteroid use (OR:6.6, P = .01) were identified as independent predictors of surgical complications.

CONCLUSION

The risk of adverse events following RRM-DTI should not be underestimated, with a 30-day complication rate of 14%. Higher BMI, bleeding disorders, outpatient setting, and corticosteroid use were identified as risk factors. These findings underscore the need for thorough preoperative risk stratification, patient counseling, and health optimization to optimize surgical outcomes.

Counselling Framework for Germline BRCA1/2 and PALB2 Carriers Considering Risk-Reducing Mastectomy

Female BRCA1/2 and PALB2 germline pathogenic variant carriers have an increased lifetime risk of breast cancer and may wish to consider risk-reducing mastectomy (RRM) for surgical prevention. Quantifying the residual lifetime risk and absolute benefit from RRM requires careful consideration of a patient's age, pathogenic variant, and their personal history of breast or ovarian cancer. Historically, patients have been counselled that RRM does not necessarily prolong survival relative to high-risk surveillance, although recent studies suggest a possible survival benefit of RRM in BRCA1 carriers. The uptake of RRM has increased dramatically over the last several decades yet varies according to sociodemographic factors and geographic region. The increased adoption of nipple-sparing mastectomy techniques, ability to avoid axillary staging, and availability of reconstructive options for most germline pathogenic variant carriers has helped to minimize the morbidity of RRM. Preoperative discussions should include evidence regarding postmastectomy sensation, the potential for supplemental surgery, pregnancy-related chest wall changes, and the need for continued clinical surveillance. Approaches that include sensation preservation and robotic nipple-sparing mastectomy are an area of evolving research that may be more widely adopted in the future.