PLASTIC SURGERY
THE EVER-EVOLVING FIELD of Breast
Cancer Reconstruction
Brad Wilhelmi, MD
B
reast cancer reconstruction is
an extremely emotional topic by
virtue of its anatomic location
and the importance of the female
breast in today’s society. Breast
reconstruction continues to be popular as
it provides mastectomy patients the oppor-
tunity to be whole again, through breast
mound creation with implants or flaps. The treatment algorithm
is complex and individualized specifically to patients depending
on their adjuvant treatments, job demands and aesthetic expecta-
tions. Only through a close alliance between the surgical oncolo-
gist and plastic surgeon can the patient’s emotional, physical and
oncologic needs be addressed. To know where the field of breast
reconstruction is progressing, it is valuable to know its origin and
progression.
In the 1800s, the prognosis of patients with breast cancer was
poor, with local recurrence rates ranging from 50-85 percent.
Eventually, Dr. William Halsted presented his advance with rad-
ical mastectomy producing only six percent recurrence rates. He
believed that “the slightest inattention to detail and/or attempts
to hasten convalescence by such plastic operations as are feasible
only when a restricted amount of skin is removed may sacrifice
his patient to the disease.” This aggressive approach based on the
Halstedian Theory of breast cancer treatment, would remain the
mainstay of breast cancer surgery for the next 50 years. Therefore,
true attempts at breast cancer reconstruction would have to wait
for almost 50 years.
Breast reconstruction for defects other than cancer were in-
troduced over the years. In 1895, Vincenz Czerny autotransplant-
ed a large lipoma from his patient’s flank to a breast defect after
fibrocystic mass resection. Iginio Tansini described the first use
of the latissimus dorsi myocutaneous flap (LDM) in 1906. Unfor-
tunately, this remarkable operation would not gain acceptance for
another 70 years.
In 1942, Sir Harold Gillies of England started using tubed
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pedicle technique for breast reconstruction. In this operation he
would “waltz a flap from the abdomen to the chest to reconstruct
the breast.” Although this technique was successful, the multiple
procedures and prolonged treatment course precluded its wide-
spread application.
Since 1970, many advances in reconstructive surgery have
occurred and been applied to breast reconstruction. The devel-
opment of breast implants was the first of these revolutions. In
1963, the silicone breast implant was introduced for breast aug-
mentation and quickly adopted for breast reconstruction. In 1963,
Thomas Cronin and Frank Gerow presented a series of patients
who received implants for reconstruction of mastectomy defects.
For the first time, the plastic surgeon had a procedure that could
simulate the missing breast without the need for multiple pro-
cedures and a prolonged treatment course. In many ways, it was
the simplicity and safety of breast implants that ignited interest in
breast reconstruction. By the late 1970s, reconstruction was being
performed immediately after breast ablation.
The development of muscle, musculocutaneous and fasciocu-
taneous flaps and microsurgical transplantation has had a tremen-
dous impact on breast reconstruction. The ideal material to recon-
struct any defect is like-tissue. Until the early 1970s, such tissue
was only available in limited quantities for breast reconstruction.
The landmark work by Carl Manchot on vascular territories of the
body was rediscovered, and surgeons were then able to exploit the
basic knowledge to design flaps based on axial pattern of named
blood vessels. These technical developments allowed surgeons to
reliably rearrange tissues and more precisely reconstruct all types
of defects including those of the breast. These advances paved the
way for flap developments and refinements including the LDM
flap from the back, the TRAM flap from the abdomen, the SGAP
flap from the buttock, the TUG flap from the medial thigh, and the
Rubens flap from the upper hip. These flaps have the advantage of
providing like-tissue, however at a cost of donor site scarring and
potential weakness. Therefore, implants have continued to be the
primary choice of patients for breast reconstruction over the years.