Angelina Jolie’s Breast Surgery

Since Angelina Jolie’s disclosure of her bilateral mastectomy and breast reconstruction this week in the New York Times, I’ve been asked a lot of questions about it.  As you probably already know, she carried the BRCA1 gene which gave her a much higher risk for breast cancer.  One way to drastically reduce this risk is to undergo prophylactic bilateral mastectomy, a drastic approach some might argue.  I’m not going to go into the genetics or epigenetics of this marker for breast cancer, or even whether or not it was a wise decision to do what she did.  It was certainly a reasonable option.  If you want information about these issues, you can find many articles online about breast cancer and the BRCA gene.  

I want to instead use this opportunity to discuss the breast reconstruction aspects of her surgery.  Regarding the specifics of her surgery, I only know what she wrote in her article, and I will infer the rest.

Here’s a synopsis of what she had done:  Her surgical team likely consisted of a general surgeon who removed the breasts followed by a plastic surgeon who performed the first stage of the reconstruction.  She had a nipple/areola sparing technique, meaning that her nipple and areola were preserved, along with the skin of the breast.  The breast tissue immediately behind the nipple was first biopsied to make sure there was no cancer there (which would require removal of the nipple/areola, and a more “traditional” mastectomy), and then soon thereafter the removal and immediate reconstruction was performed.  It sounds as though she had expanders placed, as a first stage in her reconstruction.  If so, subsequent procedures will include filling the expanders with saline in the office, followed by a surgical procedure to replace them with permanent (likely silicone gel) implants.  This is the standard way to do it.  I have sometimes placed the permanent implant at the time of the mastectomy when the skin quality is good, or perhaps after a short delay (days) waiting for pathology results or a decision regarding need for radiation.  Placing the permanent implant immediately can shorten and simplify the reconstruction process.

In breast reconstruction cases like Jolie’s, the likelihood of a beautiful, near-normal appearance is very high.  The importance of how the breast is removed to the ultimate aesthetic outcome cannot be over-estimated.  (See my previous blog post about this here).  To get such an appearance requires a few caveats, so not everyone can expect the exceptional outcome that I predict for her:  1)  The original breasts must be nicely shaped and not too big.  This technique doesn’t work well with large or pendulous breasts or with someone who is obese.  2)  The nipple/areola, and all or nearly all the breast skin must have been preserved.  3)  The reconstruction starts immediately, at the time of the mastectomy.  Reconstructions that begin months or years  after the mastectomy will always be a compromised result.  4)  No radiation.  Radiation before, or planned for after surgery, will preclude this technique.

Remember, in Jolie’s case, she didn’t actually have cancer.  She was only high risk, so there was no actual cancer to treat.  Actual cancer, depending on the size, location, and type may require removal of skin and/or the nipple, and may involve radiation.  These issues will change the reconstructive options available, and compromise the ultimate aesthetic outcome.  However, even women with a diagnosis of breast cancer can have very good aesthetic outcomes after breast reconstruction.  Certain early cancers may also be eligible for a nipple sparing technique like Jolie’s.  It is important that the woman have a breast-specialist general surgeon that is knowledgeable and experienced in these techniques and their indications.  Be wary of “old school” general surgeons who only do aggressive mastectomies on nearly everyone with no real regard for the potential aesthetic ramifications, while justifying their aggressive approach on the philosophy of overkill so as not to leave behind any cancer.  Nowadays, there are better, more nuanced ways of diagnosing, monitoring, and treating breast cancer.

I will bet that if Jolie bares herself in some future movie, her result will look normal and natural.  We’ll see.

Douglas J. Mackenzie, MD, FACS
Santa Barbara, CA

Author
Douglas J. Mackenzie M.D., F.A.C.S.

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