Prophylactic Mastectomy ± Reconstruction – A Conversation with the Experts
This live, interactive education session brings together leading surgical experts for an open and supportive conversation for anyone considering a prophylactic mastectomy, with or without reconstruction. Guided by a moderated interview format, the discussion explores surgical options such as reconstruction and aesthetic flat closure, as well as how to balance medical guidance with personal values and goals. The evening begins with questions submitted in advance and transitions into a live “Ask Me Anything” Q&A, giving participants the opportunity to ask surgeons their questions directly in a non-recorded, dialogue-focused setting designed to encourage honest discussion and personal perspectives.
Q&A
Questions for the Breast Surgeon:
Understanding surgery options and cancer risk
Does the type of mastectomy I choose affect my risk of the cancer coming back, or how recurrence would be found later?
For most patients undergoing a total mastectomy, outcomes are similar whether the surgery is a total mastectomy or a skin or nipple sparing mastectomy with reconstruction.
For women with a prior history of breast cancer, recurrence risk is more closely related to the characteristics of the original cancer than to the type of mastectomy performed.
Most recurrences, if they occur, are found just under the skin.
Routine imaging is not required after mastectomy.
If I have cancer, how do I decide between a lumpectomy and a mastectomy, and when would removing the healthy breast as well be recommended?
This is a multifaceted decision. Most average-risk breast cancer patients do not carry a hereditary breast cancer gene.
Decisions are based on tumour features, breast anatomy, tumour size relative to breast size, and how to optimize cosmetic and functional outcomes.
Recovery time and whether radiation therapy could be avoided with mastectomy are also considered.
Lumpectomy has been shown to be more effective than previously believed for average risk patients.
Patients with genetic risk are often recommended mastectomy due to a higher risk of a second breast cancer event.
If lumpectomy is chosen in patients with genetic risk, enhanced high-risk screening continues.
Can everyone have a nipple-sparing mastectomy, and does it change cancer risk?
It depends on the anatomy of the breast and how close a tumor is to the nipple
If a cancer is close to the nipple, the nipple may need to be removed to get a clear margin
If the mastectomy is prophylactic or tumor is away from the nipple, the nipple may need to be removed if the breast is larger (to ensure adequate blood flow for healing) or to ensure that the nipple is in the appropriate location considering the planned reconstruction
Why is lymph node sampling sometimes needed, including with DCIS?
Sentinel node biopsy is usually required for staging of an invasive cancer as knowledge about involvement of the lymph nodes is needed for decision making for radiation and systemic therapy
In the setting of DCIS (non-invasive cancer), lymph node sampling is usually done with mastectomy as there is a chance that invasive tumor may be found at pathology due to under sampling of the core needle biopsy. The less invasive sentinel node procedure cannot be done after a mastectomy (so if an invasive tumor were found the more full axillary node dissection would be needed had the nodes not been sampled)
Flat closure and other surgical approaches
What is an aesthetic flat closure, why does it sometimes not turn out flat, and how can patients advocate for the result they want?
“Aesthetic flat closure” can refer to different techniques depending on the surgeon (breast surgeon vs plastic surgeon)
Breast surgeons now aim for the chest to be as flat as possible after mastectomy, using techniques to reduce excess tissue (such as dog-ears) and allow easier use of prostheses.
Surgical outcomes are not always perfectly flat.
This procedure is different from chest contouring surgery performed by plastic surgeons.
At present, aesthetic flat closure is not routinely offered by all surgeons. Surgeons who perform a high volume of mastectomies are more familiar with techniques to optimize flat closure results
Physical and anatomical factors (such as body weight, skin laxity, and the need to preserve shoulder mobility) influence surgical decisions and outcomes.
Can I have a flat closure and keep my nipple.?
This is not impossible but is generally only feasible for very slim or small-breasted individuals.
Without recreating a breast mound, the nipple would otherwise sit in an anatomically incorrect position.
What to expect from surgery
What are the main risks and longer-term side effects of mastectomy, including pain, numbness, and changes in sensation?
There may be more post-surgical symptoms than are typically reported in the literature.
Chest discomfort tends to be less in patients who do not undergo reconstruction, but overall discomfort is higher after mastectomy compared to lumpectomy.
Some patients experience increased concerns related to body image, particularly without reconstruction. This is particularly true if patients aren’t offered the option of reconstruction. Emotional distress related to loss of bodily autonomy can occur.
Surgical risks include bleeding, infection, and wound-healing concerns.
Rates of skin-healing complications are lower in patients who choose flat closure compared to reconstruction
Why are surgical drains needed, and how long do they usually stay in?
Surgical drains are typically used for 1–2 weeks to collect fluid that develops normally during healing.
Drains are removed once fluid output is less than about 30 mL per day, which is approximately the amount the body can reabsorb on its own.
Drains help reduce swelling and make healing more comfortable.
What is recovery like after a mastectomy without reconstruction vs. with?
Without reconstruction: Most patients return to usual activities in 3–4 weeks, with lifting restrictions. Breast prostheses are typically not fitted for 3–4 months.
With reconstruction: Recovery depends on the type of reconstruction performed.
Planning and access
Why is it important to see a breast surgeon early, even if I am mainly thinking about reconstruction?
The healthcare system is structured so that patients first see breast surgeons, who are more numerous than plastic surgeons in BC.
Breast surgeons determine surgical eligibility and address mastectomy-specific questions (indications and options) and have a general discussion of reconstruction options before referral to plastic surgery.
Clarifying whether a patient wishes to proceed with mastectomy before plastic surgery referral helps reduce strain on limited plastic surgery resources.
Understanding the reason for surgery helps patients better prioritize reconstruction goals and risks. Meeting the breast surgeon answers the ‘why’ for surgery to allow the plastic surgeon to prioritize outcomes. The first decision to be made is whether a mastectomy is the right choice, then decisions can be made about reconstruction taking many individual patient factors into consideration. We try to meet all outcomes as best we can, but this never completely occurs.
What should people know about breast prostheses, including downsides and MSP coverage?
Downsides include discomfort, heaviness, fit challenges particularly with large breasts.
Patients can go to centres to see the options before making decisions
BC Cancer and the Canadian Cancer Society offer support programs.
Prescriptions can be written for coverage through extended health benefits.
Soft (knitted/fabric), prostheses are available
You can swim with a standard prosthesis
Questions for the Plastic Surgeon
Choosing a reconstruction option
How do you help patients decide whether reconstruction is right for them, and which type is the best fit?
Plastic surgeons focus on understanding patient goals, values, and expectations.
Some patients have not fully considered alternatives (reconstruction vs. no reconstruction), and discussions help explore potential regret or future decisions.
Key questions include:
What are your goals and motivations?
What does recovery look like for you?
Would you be willing to undergo revision surgeries?
Social circumstances (time off work, caregiving responsibilities, recovery support, and ability to manage complications) are important factors.
Patients also consider what reconstruction would mean if chosen years later (mastectomy with delayed reconstruction).
Reconstruction type depends on tolerance for risk, scars, long-term follow-up, and foreign materials, future surgery as well as physical anatomy (suitability for different types of reconstruction).
What are the main pros and cons of implant reconstruction versus flap reconstruction?
Implant reconstruction – Pros:
Shorter surgery and recovery
No additional scars elsewhere on the body
Greater control over breast size
Often same-day discharge
Many patients feel comfortable within two weeks
Implant reconstruction – Cons:
Not a one-time operation; implants do not last forever
Risk of rupture (~1% per year)
Risk of capsular contracture
Less natural feel compared to own tissue
Autologous (own-tissue) reconstruction – Pros:
More natural appearance and feel
Changes with body weight and natural aging
Lower rate of revision surgeries (50% minor revisions)
Avoids implant-related complications
Autologous reconstruction – Cons:
Longer surgery and recovery
Healing in two areas of the body
3–5 day hospital stay
Higher need for recovery support
Risk of flap failure (necrosis)
What is Goldilocks reconstruction, and who may be a good candidate for it?
Goldilocks reconstruction uses remaining breast skin after skin sparing mastectomy to form a small breast mound.
It is only an option for individuals with very large breasts.
The nipple-areola complex may be grafted onto the new mound.
Best suited for individuals with higher BMI who do not smoke.
This is not a commonly performed procedure.
Types of reconstruction
Why is DIEP flap reconstruction the most commonly offered flap option in BC?
DIEP flap reconstruction often matches patient body habitus well, as many patients have adequate abdominal tissue.
Other options are considered if the abdomen is not suitable.
Across BC, TRAM flaps (abdomen including muscle) and latissimus dorsi (back) flaps are also used in select cases.
Inner thigh and buttock flaps are also possible
Why do some people need tissue expanders instead of going straight to implants?
Most commonly used when radiation therapy is planned.
Expanders allow radiation to occur first, with permanent implant placed after 6 months to reduce complications.
Patients with drooping or pendulous breasts may need expanders to support healing due to lower blood flow to breast skin.
Expanders may also be used when a patient desires a different breast shape.
Implants
What are the key differences between saline and silicone implants?
• Saline implants:
Firmer feel if fully inflated
More visible wrinkling under the skin if not full (but then feel more natural)
Deflation is obvious if rupture occurs
If a saline implant deflates, prompt replacement is recommended due to skin contraction if left too long.
Silicone implants:
Softer, more natural feel
Feel cool to the touch
Rupture is often silent or with delayed symptoms
• Follow-up ultrasound imaging is recommended around 8 years post-operative to look for rupture
Silicone does not migrate to other parts of the body if there is a rupture
• Both types have similar size options and a rupture risk of about 1% per year.
Implants do not need to be removed just based on having been in place for a long time
Flap reconstruction, radiation, and surveillance
How does reconstruction affect future cancer screening and monitoring?
After mastectomy, routine breast screening imaging is no longer required.
Imaging may still be done for implant monitoring or to evaluate scars or new lumps.
Fat grafting can cause firm areas that may feel concerning but are assessed with imaging.
There is no increased biopsy rate or recurrence risk associated with reconstruction.
New cancers are typically felt right under the skin
Recovery and long-term outcomes
How satisfied are patients overall with different reconstruction options, and how do results change over time with aging or weight changes?
With DIEP flap reconstruction, breast size and shape change with body weight over time (behaves like where it came from).
Implant-based reconstruction does not change with weight fluctuations.
Dermal matrix used in BC helps support implants as skin elasticity changes with age
Additional considerations
When is fat grafting used, and is it considered safe?
Extensive studies show no increased breast cancer risk with fat grafting. (stem cells in fat that are now in the breast). Patients who had lumpectomy and radiation (a higher-risk group) commonly undergo fat grafting safely. One year wait post radiation is practiced.
Only 50% of the fat that is injected remains
It can cause lumps or cysts that need imaging to evaluate
Why are some people not eligible for reconstruction options due to smoking or BMI?
Smoking and high BMI are associated with the highest risk of surgical complications or reconstruction failure.
Offering reconstruction in these cases may cause harm.
Some high-BMI patients without other health issues may still be appropriate candidates.
Surgeon practices and thresholds vary.
Goldilocks reconstruction may be an option for select patients.
Can sensation be preserved by doing nerve grafting?
Research is ongoing.
Success rates are variable and not guaranteed.
Nerve grafting can be performed at the time of mastectomy but is not currently available locally for implant reconstruction.
It may take 1–2 years to determine whether sensation returns.
Overall implant reconstructions have the least sensation and flaps have medium sensation.
Questions for Both Surgeons
What can be done to reduce the wait times for prophylactic mastectomy with reconstruction.
Ideally, increased operating room time.
Better organization of waitlists to prioritize patients who are ready for surgery.
Providing education while waiting so patients can make informed decisions and feel prepared.