Evolution of Breast Reconstruction

Breast reconstruction techniques have evolved over more than 100 years beginning with a case by Dr. Vincenz Czerny who transplanted a lipoma (fatty tumor) from the buttocks to reconstruct a breast in 1893.  Other early methods included use of local chest and back tissues, as well as the use of the opposite breast.  Paraffin and Silicone were injected in liquid form for both enlargement and restoration of breast deformities.  In 1964 Dr. Thomas Cronin introduced the silicone gel-filled implant.  These implants were quite firm and had a Dacron patch on the deep surface to stimulate implant attachment. Thus, breasts reconstructed with these implants were hard and immobile.  Subsequent generations of the implants were designed to try to address these deficiencies through changes in the implant shell and the consistency of the gel.  Consequently, these early modifications resulted in softer implants, with thinner more pliable shells.  However, these implants had significant rupture rates particularly after 10 years.  In the late 70’s and early 80’s breast reconstruction using implants were complicated by the lack of adequate skin envelope in most post-mastectomy patients.  As a result, these reconstructions were often limited in the size of implant that could be used, as well as plagued by the frequent occurrence of capsular contracture. A capsular contracture is a result of a tight fibrotic scar around the implant because of the body’s response to a foreign material.  The use of textured implants and implant-expanders were only partially successful in reducing these problems.    By the early 80’s the use of the latissimus myocutaneous (skin and muscle) dorsi flap was popularized.  The advantages of this flap are that it restores missing skin and fatty soft tissue needed to reconstruct the breast, sometimes without need for an implant.  However, in most instances an implant is still needed under the latissimus flap to match the size of opposite breast.  Other disadvantages of the latissimus flap are the donor site fluid accumulations (seromas), a scar on the back, and loss of some muscle function of the shoulder.  The Fleur de Lis modification of the latissmus dorsi flap was advanced by Dr. John Mc Graw as a means to obtain additional fatty tissues to create a larger breast and obviate the need for implants.  The back scars, however, were significant.  Also, beginning in the early 1980’s the use of the rectus abdominis myocutaneous flap (abdominal muscle, skin, and fat) was developed.  The flap design changed from a vertical skin paddle proposed by Dr. Melvin Dinner to a horizontal (transverse) one which placed the scar in a position that could be hidden by underpants.  This became known as the TRAM (transverse rectus abdominis myocutaneous) flap which was popularized by Dr. Carl Hartrampf.  He placed the skin paddle low on the abdomen so that the scar was similar to that of an abdominoplasty (tummy tuck). The TRAM flap provides a large volume of soft tissue to reconstruct the breast and eliminates the need for an implant entirely.  Additionally, the TRAM flap can be used either as a pedicle (attached) flaps, or as a microvascular free flap (transplant) with reconnection of its blood supply to blood vessels of the chest wall. The TRAM flap offers a valuable option to patients who have had radiation as it brings vascularized tissue to reconstruct the chest wall.  The TRAM flap, however, can have problems with abdominal weakness and/or abdominal hernias.  Modifications to the TRAM flap technique were made to reduce hernia by including only a small amount of fascia and muscle with the subcutaneous and skin tissue of the flap.  Additionally, to reduce the chance of hernias, or abdominal weakness the use of mesh to reinforce the repair of the fascia after harvesting the flap became more common.  While, these maneuvers reduce the hernia rate, other, new flaps were also considered.  Although Dr. Fujino from Japan had performed a breast reconstruction with the microvascular transfer of the gluteus maximus (buttocks skin and muscle) myocutaneous free flap as early as 1975, it was not until the mid 1980’s when the gluteal flap was popularized by Dr. William Shaw that US surgeons began to perform this procedure.    The gluteal flap had the advantage of good soft tissue volume, a favorable donor scar, and minimal donor site disability.  However, the flap involves a very tedious dissection and has a rather short pedicle (blood vessel) length.  The short pedicle makes vascular anastomosis (reconnection) somewhat cumbersome, and also makes pedicle compression and circulation problems more likely.  For this reason the myocutaneous gluteal free flap never gained wide usage and better flaps were sought.  The TRAM free flap was developed in an effort to address some of the short comings of the attached pedicle TRAM.  This flap included a vascular pedicle with a portion of muscle attached to the skin and subcutaneous tissue.  In an effort to reduce the chance of abdominal hernias the TRAM flap was modified so that only a very small amount of muscle was included.   Gradually TRAM flap techniques evolved to harvest the pedicle through the muscle, leaving the muscle in place, and harvesting a flap that consisted of only the vascular pedicle with its connections to the skin and subcutaneous tissues.   This new type of flap is termed a perforator flap.  The perforator flap is the latest generation of flaps for breast reconstruction. Perforator flaps for breast reconstruction include the DIEP, SIEP (SIEA), SGAP, and IGAP.    These acronyms stand for the following: DIEP or Deep Inferior Epigastic Perforator SIEP (SIEA) or Superficial Inferior Epigastric Perforator SGAP or Superior Gluteal Artery Perforator IGAP or Inferior Gluteal Artery Perforator  These flaps preserve the connection of the pedicle vessels to the skin and fatty tissues without including the muscle that the vessels penetrate.  Thus, the muscle is spared, and the vessels that perfuse the skin and subcutaneous tissues are preserved.  This provides a good pedicle length and reduces the chance of hernia and donor site morbidity.  Interestingly, the anatomy and vascularity of the new flaps had already been described in various ways as long ago in the 1860’s, and then re-discovered in the 1960’s, 1970’s, and 1980’s.  Because of this better understanding of the body’s vascular anatomy, new cutaneous (skin), muscle, and myocutaneous (muscle and skin) flaps and free flaps were able to be designed and developed.  These flaps are called “autogenous” because they consist of your own fat, skin and muscle tissues. Since these reconstructed breasts are your own living tissue, they are soft, warm, and natural to the touch.

            Cosmetic Plastic Surgeon specializing in Breast Reconstructive Surgery.  Located in Manhattan, New York City, NY and servicing Brooklyn, NY, Queens, NY, Manhattan, Bronx, Staten Island, New Jersey,  NJ, Conneticut, CT and Westchester.  Call for your Plastic Surgery appointment to meet with Dr. Valauri.

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