Angelina Jolie's surgeon has revealed in detail the treatment the 37-year-old actress had before, during and after her preventative mastectomy procedure.
The actress made the brave decision to have three months of secret procedures after being told she had an 87 per cent chance of contracting breast cancer due to the BRCA1 gene.
Jolie is said to already be planning her next surgery - the removal of both her ovaries - as the gene means she has a 50 per cent chance of developing ovarian cancer.
Now, in a blog post on the Pink Lotus Breast Center website, her surgeon Dr Kristi Funk has explained the different stages of Angelina's medical treatment to help other women seeking information about BRCA gene mutations and what it might mean for them.
Speaking about Jolie's journey and recovery, she said: "To a large extent, I believe recovery reflects expectation. Angelina expected to feel well, to be active.
"On Monday, the pathology returned and I called Angelina to confirm our biggest hope: all of the breast tissue was benign.
"On day four after her mastectomies, I was pleased to find her not only in good spirits with bountiful energy, but with two walls in her house covered with freshly assembled storyboards for the next project she is directing.
"All the while she spoke, six drains dangled from her chest, three on each side, fastened to an elastic belt around her waist.
Dr Funk added: "It is important to emphasise that each woman's case is different. Surgery will not necessarily be the right choice for everyone, and there are alternatives available. As Angelina says in her article, the important thing is to be aware of your options."
The first stage, says Dr Funk, is to gather data and information. "BRCA stands for BReast CAncer. BRCA genes help you fight cancer when it happens in your body.
"Women carrying BRCA1 or BRCA2 gene mutations have up to an 87 per cent lifetime chance of breast cancer and 54 per cent chance of ovarian cancer versus a general population risk of 12 per cent for breast cancer and less than 1 per cent for ovarian cancer.
"Given the high likelihood of getting breast or ovarian cancer with BRCA mutations, family history usually triggers testing for the gene. Angelina's mother had breast cancer, and sadly passed away from ovarian cancer. Her maternal grandmother was also diagnosed with ovarian cancer."
Women carrying a BRCA mutation then undergo a surveillance plan involving mammograms, breast examinations, pelvic ultrasounds and blood tests to check for CA-125, which is a marker of ovarian cancer. If and when a woman commits to a preventative mastectomy, there are a number of questions a woman has to address, says Dr Funk.
The first is whether or not to preserve the nipples. "Women undergoing preventive mastectomies can always consider keeping their nipples."
Jolie had a technique called Nipple Delay, performed one to two weeks before the actual mastectomies. This uses the planned mastectomy incision and lifts half of the skin off of the breast surface.
"A small disc of the tissue directly behind the nipple and areola is also removed and analysed by a pathologist," says Dr Funk.
"This is done to rule out the presence of any disease directly behind the nipples, which would make preserving them a dangerous proposition. Additionally, it recruits extra blood flow to the area, lessening the chances of nipple and skin loss due to insufficient blood supply after the mastectomy."
Jolie was in the operating room for the first operation, the nipple delay, on February 2, 2013.
"Her partner was on hand to greet her as soon as she came around from the anesthetic, as he was during each of the operations," said Dr Funk.
"After the operation, her skin was slightly bruised but soon returned to normal. Two days after her procedure, great news arrived: the tissue behind both nipples came back completely normal.
"On February 16, she had the main surgery, which can last up to eight hours. The mastectomies went smoothly, with sentinel nodes identified but not removed."
When it came to the incisions, "for Angelina, her optimal incision choices were around the areola, or underneath the breast in the inframammary fold - the latter was chosen," says Dr Funk.
"After the mastectomies, I assisted plastic surgeon, Dr Jay Orringer, as we performed the first stage breast reconstruction by placing tissue expanders with allograft.
"Implants are the most common reconstruction, often requiring two stages, whereby a tissue expander is placed prior to the final implant.
"A tissue expander is a deflated implant that goes behind the pectoral muscles and gets slowly inflated with saline over a period of 2-3 months, until the chosen volume is reached. A second operation is performed to swap the expander for the final implant (usually silicone).
She adds that "Angelina's body type was best suited to an implant reconstruction with allograft.
"This uses synthetic sheets of material, that create a more natural look. Although tissue expanders required an additional operation, she preferred to use them.
"The next day she had her first injection of saline into the expanders, thus beginning the process that would gradually prepare the tissues for the final stage of her operations, reconstruction.
"Four of the six drains were removed. Four days after that, on postoperative day nine, the last two drains were removed. A second saline fill occurred on March 4. Over the next four weeks she was hard at work.
"The final operation occurred on April 27, 2013, ten weeks after the mastectomies: reconstruction of the breasts with implant, which went extremely well, bringing an end to her surgical journey."
- DAILY MAIL