|Updated: July 2009
Breast Cancer Reconstruction History
Documented cases of breast cancer date back to 6000 BC, and following its history over the centuries is harrowing to say the least. If Cleopatra had breast cancer, the ancient Egyptian doctors would have cauterized her breast in hopes of burning out the disease. The treatment was so untenable that women neglected their disease if a lump was discovered. Their breasts became disfigured as their tumors took over their bodies. But the alternative was worse than the disease. George Washington’s mother succumbed to breast cancer. So did Queen Mary. Nabby Adams, the daughter of John and Abigail Adams, suffered through a mastectomy in which she was tied to a chair and without anesthesia her breast was removed. She survived the surgery only to die from the disease. This was common practice in the 18th century.
In the 19th century, anesthesia was developed and surgical options improved a great deal. Breast cancer surgery was revolutionized by Dr. William Halsted, who popularized the radical mastectomy as the treatment of choice for any woman with breast cancer. Even though an extreme amount of tissue was removed, women were surviving the operation and their breast cancers. He removed not only the breast, but the lymph nodes and the chest muscles. In some extreme cases, other surgeons performing radical mastectomies included removing part of the rib cage. This was so disfiguring though that the practice was soon stopped.
It was not until the latter half of the 20th century and the awakening of the women’s movement that these radical procedures were questioned. Modified radical mastectomy (total mastectomy with axillary lymph node dissection) was perfected. Breast conservation therapy consisting of lumpectomy, sentinel lymph node biopsy and radiation was developed. The emergence of breast cancer reconstruction took off.
The Evolution of Breast Implants
During World War II, Dow Chemical Company created commercial uses for silicone. The first use of silicone breast implants for cosmetic breast augmentation occurred in 1962. Dow Corning, along with several other companies, started manufacturing implants both for cosmetic augmentation and reconstruction after mastectomies. Women found that silicone implants looked and felt better than the saline alternative.
However, those early generation devices exhibited problems over time. Silicone leakage led to breast scarring and sometimes painful deformities. Allegations that breast implants could cause cancer or autoimmune diseases were made by health care advocacy groups, fueling mass litigation. By then over one million women had silicone implants. In 1992, the Food and Drug Administration banned them. David Kessler, the head of the FDA stated, “We want surgeons to stop using these implants in patients until this new evidence can be thoroughly evaluated, I’m asking patients to understand that the Food and Drug Administration commissioner cannot assure the safety of these devices at the present time.” Dow Corning stopped producing implants and later went into Chapter 11 bankruptcy.
Between 1992 and 2006 saline filled breast implants remained the only fully-approved type of implant on the market in the United States. Patient satisfaction was, and remains good, but the interest in silicone implants continued. During this period large scale studies of the health effects of silicone implants were performed. Numerous reports from institutions including the Mayo Clinic, the National Institute of Medicine, and other independent commissions all corroborated that there was no causal relationship between breast implants and illnesses like cancer or lupus. This led to the national adjunct study which was commissioned to prospectively analyze the outcomes of women using silicone implants for reconstruction. Plastic surgeons worked with the two remaining U.S. implant manufacturers, Mentor and McGhan (now Inamed/Allergan) to report data in an FDA approved protocol.
Finally, in November of 2006, the Food and Drug Administration reversed its ban on silicone-filled breast implants. The FDA’s press release stated, “The products have been determined to be safe and effective.” Now, silicone gel implants are widely used for both cosmetic breast augmentation and breast cancer reconstruction. These newer generation silicone devices are the safest, softest and most natural implants to date. Both saline and silicone implants are popular choices today.
The Evolution of Autogenous Tissue Reconstruction
Numerous techniques have evolved to allow for breast reconstruction using natural tissues from a woman’s body rather than an artificial implant. The earliest techniques utilized muscles to provide blood flow to skin and fat so that that this tissue could be transported to the chest to create a breast mound. The latissimus dorsi flap was the most popular form of autogenous tissue breast cancer reconstruction in the 1970s. Skin, fat and muscle from the back were rotated to the front of the body to create a breast. Today, this procedure is used in conjunction with implants to provide a fuller looking breast.
In 1982, the first TRAM flap (transverse rectus abdominus myocutaneous) procedure was performed. In this procedure, a woman’s lower abdominal skin and fat is used to make the breast. In this flap, the rectus abdominis muscle is used to support the skin and fat which is tunneled up into the breast area. Today, this flap remains the standard of care in this and other countries, creating natural appearing breasts and improved abdominal contours.
Nevertheless, there are drawbacks to using these muscles and so techniques have evolved to minimize or eliminate the need for sacrificing muscles for breast cancer reconstruction. The use of microvascular free flaps allows transplanting tissue from one part of the body to another without the use of a large muscle. The abdomen is the source of many varieties of such flaps. The TRAM free flap uses only a small portion of the rectus muscle, while the DIEP free flap (deep inferior epigastric perforator), and the SIEA free flap (superficial inferior epigastric) utilize none of the rectus muscle. The buttock is another source of skin and fat that can be used to create a breast. The GAP free flaps (gluteal artery perforator) allow a hidden donor site most useful for women with insufficient abdominal tissue. As a result of these procedures, women recover easier and have fewer complications from the donor site.
All of these procedures, as well as the techniques for creating a natural nipple and areola are explained further in the section on Types of Reconstruction.
The future is bright for breast reconstruction and breast cancer patients. It was a long, hard journey in the beginning. But with the advent of systemic therapy, new surgical procedures, and a healthy partnership between patient and doctor, women are living longer and looking better than ever before. This could be considered the golden age of breast cancer reconstruction. The only downside is trying to decide which procedure you want!
Written and edited by our medical board