In the 19th century, anesthesia was invented, and surgical options improved. Dr. William Halsted revolutionized breast cancer surgery by popularizing the radical mastectomy. This procedure typically removed not only the breast, but also the lymph nodes and chest wall muscles. The radical mastectomy became the treatment of choice for women with breast cancer. While it removed an extreme amount of tissue, the procedure saved lives.
The women’s movement of the latter half of the 20th century called radical mastectomy procedures into question. Surgeons perfected the modified radical mastectomy, a total mastectomy with axillary lymph node dissection. This time period also saw the development of breast conservation therapy, consisting of a lumpectomy, sentinel lymph node biopsy, and radiation. At the same time, breast reconstruction emerged.
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 and several other companies started manufacturing implants both for breast augmentation and breast reconstruction after mastectomies. Women found that silicone implants looked and felt better than the saline alternative.
However, those early generation implants exhibited problems over time. Silicone leakage led to breast scarring and sometimes painful deformities. Health care advocacy groups alleged that breast implants could cause cancer or autoimmune diseases, fueling mass litigation. By then over one million women had silicone implants.
In 1992, the Food and Drug Administration banned silicone implants. 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 remained. During this period, large scale studies were performed on the health effects of silicone implants. Numerous reports from institutions, including the Mayo Clinic and the National Institute of Medicine, corroborated that there was no causal relationship between breast implants and illnesses like cancer or lupus. A national adjunct study 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.
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-seeming 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 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.
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.