By William Byron Barber II, M.D.

Q. I am 31 years old with one child. My mother developed breast cancer at age 41 and my older sister was diagnosed with breast cancer at age 37. My mother and my sister were treated with a mastectomy. My ob/gyn doctor recommended I have the BRCA gene mutation test to see if I am at higher risk for breast cancer. I had the blood test and it came back positive for the mutation. After consulting with a genetic counselor, talking to my family doctor and an oncologist, I have decided to have a prophylactic double mastectomy and I would like to have the surgery where the nipple is spared. Here is the problem, I went to see a surgeon who told me that my breasts are too big to have a nipple sparing mastectomy. I wear a DD bra. He said the complication rate is higher in women who have large breasts when preforming a nipple sparing mastectomy. He has suggested a standard mastectomy on both sides. I have seen the results for a nipple sparing mastectomy and a standard mastectomy and I like the results of the nipple sparing mastectomy much better. Is the advice that I have been given correct?

A. First, let me say that I think you were so smart to have the BRCA gene mutation test. I am sorry that the results were positive, but now you can decide what you want to do about your breasts without waiting and wondering what might happen in the future. I am certain that you have been told that with the BRCA mutation you have a higher risk of developing breast cancer than the general female population. You have also likely been told that you can markedly reduce that risk if you electively decide to remove your breasts. In patients who chose to remove the breasts before the diagnosis of cancer, there are options for surgery, including the nipple sparing surgery, and you have the luxury of doing the surgery on your schedule. To answer your question, your surgeon is 100% correct that a nipple sparing mastectomy in large breasted women has a higher complication rate, specifically issues with wound healing and nipple viability after the surgery. The nipple can lose a critical amount of its circulation during the mastectomy and it can die, then you end up with no nipple or areolar. For this reason, some surgeons prefer to do a standard mastectomy. There is, however, an alternative that has been studied and found to dramatically reduce the complication rates in large breasted women undergoing nipple sparing mastectomy. A staged mastectomy, meaning two different surgeries are performed. The first surgery is a breast reduction performed by a plastic surgeon to get the breast down to a smaller size, say a C cup. Then, 4-6 months later the breast cancer surgeon performs a nipple sparing mastectomy with reconstruction. Studies have documented that the complication rate in staged mastectomy is similar to the rate in women who do not have large breasts and have a nipple sparing mastectomy as the only procedure. This is an important discovery and opens the door for women in your shoes. The staged mastectomy is an option for you, and you should consult with a plastic surgeon who works closely with a breast cancer surgeon who can tell you whether you are a candidate. Good luck on your journey.