Ultrasound-Assisted Two-Incision Subcutaneous Mastectomy with Immediate Implant Reconstruction

Introduction BRCA gene mutations lead to a 45% to 75% lifetime risk of developing breast cancer [1]. To this date, the most effective prevention of breast cancer incidence in high–risk populations is surgical removal of breast tissue [2]. Prophylactic subcutaneous mastectomy reduces breast cancer incidence in BRCA gene mutation carriers by approximately 90% [3]. However, subcutaneous mastectomy with implant placement often results in breast implant rippling. Case Presentation A 29-year-old female with a confirmed BRCA2 gene mutation and a positive family history of breast cancer underwent prophylactic subcutaneous mastectomy and immediate reconstruction with implants. The surgical procedure involved axillary and inframmary folds incisions on both sides, with ultrasound assistance to separate the breast glandular tissue from the skin, subcutaneous tissue, and pectoralis major muscle. Microtextured implants were placed, covered superiorly by the m. pectoralis major and by the skin and residual tissue inferiorly. Seven months later, a III degree capsular contracture of the left breast implant was diagnosed. Revision surgery involved release and refixation of the pectoralis major muscle. Two flaps – the serratus anterior muscle and remaining pectoralis major muscle with capsule - were rotated anteriorly to cover the inferior pole of the replaced smooth implant to provide suspension. The final step was fat grafting to achieve symmetry. Discussion Ultrasound assistance and the double-incision technique reduce blood loss, minimize tissue injury, shorten hospitalization, and improve skin and subcutaneous tissue homogeneity. Implant placement under the pectoralis major muscle allows to cover the superior portion of the implant reducing the risk of implant rippling. Conclusions The use of ultrasound and fat grafting helps achieve uniform tissue thickness while creating a smooth breast contour by reducing the likelihood of implant rippling. The two-incision technique aids in bleeding control and shortens the duration of hospitalization. The serratus anterior muscle and the remaining pectoralis major muscle with capsule could be used for lower part breast reconstruction when implant capsular contracture occurs.