Amanda de Queiroz Germano

Risk-reducing mastectomy is a well-established strategy for patients at high risk of developing breast cancer, particularly those with known genetic mutations. However, in women presenting with large breasts and significant ptosis, skin-reducing mastectomy with immediate reconstruction is associated with higher rates of surgical complications, including skin flap necrosis, wound dehiscence, and implant-related issues. In this context, a staged surgical approach has been proposed as a safe alternative. The case of a 48-year-old asymptomatic woman carrying a germline pathogenic mutation in the TP53 gene, consistent with Li-Fraumeni syndrome, who presented with large breasts and grade III ptosis is reported. In this patient, a two-stage risk-reducing surgical approach was adopted. Initially, the patient underwent reduction mammoplasty to improve breast shape and optimize skin envelope conditions. This was followed by bilateral nipple-sparing mastectomy with immediate prepectoral implant-based reconstruction assisted by a bioabsorbable synthetic matrix (GORE® BIO-A®). The study was approved by the Institutional Ethics Committee (CAAE: 73596023.4.1001.5040), and written informed consent was obtained. Postoperatively, the patient developed a localized hematoma and partial superficial nipple necrosis, both of which were managed conservatively without the need for surgical reintervention. At 60 days of follow-up, the patient presented satisfactory aesthetic outcomes, with good breast contour, no requirement for opioid analgesia, and absence of animation deformity. A staged surgical approach may reduce complications and enhance aesthetic outcomes in patients with large and ptotic breasts undergoing risk-reducing mastectomy. Prepectoral reconstruction using a bioabsorbable synthetic matrix appears to be a safe and effective option in carefully selected cases. Further prospective studies are necessary to validate these findings and establish long-term outcomes.

Breast-conserving surgery (BCS) followed by adjuvant radiotherapy is the standard of care for early-stage breast cancer. However, reoperations after BCS may compromise aesthetic outcomes, increase surgical complications, and cause psychological distress. This study aimed to determine the reoperation rate after BCS in a multi-institutional cohort from Brazil and to identify predictive factors associated with reoperation. This retrospective multicenter cohort study included female breast cancer patients (AJCC clinical stage 0-III) who underwent BCS followed by adjuvant radiotherapy at six treatment centers in Brazil between January 2016 and December 2022. Logistic regression was used to assess the association between potential risk factors and reoperation. The overall reoperation rate was 5.2%, with a higher rate in the public hospital (9.9%) than in private hospitals (4.8%). Patients had a mean age of 58.2 years, with 70.5% aged over 50; 58.3% were White, and 89.8% were treated in private settings. The most common histological type was invasive ductal carcinoma (67.0%), with AJCC stage I (49.3%) and hormone receptor-positive tumors (54.6%) predominating. Logistic regression showed that ductal carcinoma in situ (DCIS) was significantly associated with an increased risk of reoperation (OR 2.59, 95% CI 1.08-5.76, p = 0.024), whereas the absence of multifocal tumors was associated with a reduced risk (OR 0.37, 95% CI 0.16-0.98, p = 0.031). Reoperation after BCS was infrequent in this cohort. DCIS was associated with an increased risk of reoperation, whereas the absence of multifocal disease was associated with a reduced risk. Higher reoperation rates observed in the public hospital should be interpreted with caution given the limited representation of this setting.