Unilateral (one side) versus bilateral (both sides) mastectomy patients demand different approaches for breast reconstruction. Unilateral patients require operation only on one side for reconstructing a breast that has similar volume to the contralateral (other) side. Symmetry, however, may not be very close. Expander / implant reconstructions look least like the opposite breast because the implant gives unique fullness and superior rounding. TRAM flap and other autogolus (self tissue) type reconstructions usually do a better job. To improve the match, the contralateral breast may be lifted, reduced, or augmented with an implant as indicated. This contralateral surgery is typically covered by insurances and does not put the breast at higher risk for cancer.
Patients with bilateral mastectomy defects require two operations for reconstruction, but have the advantage that achieving symmetry is usually easier. My favored approach in this setting is the expander / implant method. Symmetry may be more difficult when one side has been radiated. I frequently do unilateral or bilateral latissimus flaps in patients who have been radiated. I do perform bilateral TRAM flaps in appropriate patients, but use this technique less as the abdomen must have enough tissue for both sides and the abdomen may be weakened excessively. These patients may benefit from bilateral DIEP (perforator) free flaps, but this operation is usually done at University Centers with dedicated programs and large volumes.
I sometimes see women before their mastectomies when they are deciding if unilateral or bilateral operations would be best. I believe that this decision is best made by the general surgeon, oncologist, and patient. I respect the division between tumor removal and reconstruction because what are ultimately aesthetic concerns should not impact upon optimal cancer management. That said, I do try to help patients talk through their options if they have been presented a choice between unilateral versus bilateral by the oncologic team.
The advantages of a unilateral operation are limiting potentially unnecessary surgeries, maintaining possibly important erotic nipple sensation, and preserving a remaining anatomic structure which may make an important contribution to the patient’s feminine identity. The advantages of a bilateral operation are optimizing symmetry and minimizing potential contralateral cancer. There is no right or wrong answer, just what each patient and her oncology team feels will be in her best interest.
Is contralateral mastectomy justified? Medical literature reviews are many times quite complicated and often reveal contradictory studies. In patients with high genetic risk or strong family history, bilateral mastectomy has been shown to improve survival. In patients without these factors, bilateral mastectomy may not change survival, but it may reduce the incidence of cancer in the contralateral breast and increases feelings of well being. Bilateral reconstruction patients may have high satisfaction rates, but only if accompanied by low incidence of complications. That is a primary reason why I recommend approaches which minimize potential risks and problems. If requested by the oncologic surgeon, insurers typically cover contralateral mastectomies.
Below are shown several limited before and after views of patients with a variety of presentations. I hope to demonstrate that satisfactory results may be achieved under most conditions once the oncologic choice has been made.