Professional Documents
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Breast Reconstr
Breast Reconstr
Breast Reconstruction
A Century of Controversies and Progress
Antoine Homsy, MD,* Eva Rüegg, MD,* Denys Montandon, MD,† Georges Vlastos, MD,‡1
Ali Modarressi, MD, PD,* and Brigitte Pittet, Pr*†
Annals of Plastic Surgery • Volume 00, Number 00, Month 2018 www.annalsplasticsurgery.com 1
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Homsy et al Annals of Plastic Surgery • Volume 00, Number 00, Month 2018
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Annals of Plastic Surgery • Volume 00, Number 00, Month 2018 Breast Reconstruction History
FIGURE 2. Portrait of Louis Obredanne (1871–1956) (A) and drawings (B) reproduced from Ref.20
technique slowly replaced the pedicled flap as microvascular surgery (SGA) free flap. The inferior gluteal artery (IGA) free flap was then
techniques improved. It lowered the risk of partial necrosis being based introduced in 1988.51 The evolution of techniques led to the introduc-
on the inferior profound epigastric artery. Afterwards to reduce the do- tion of the SGA and IGA perforator flaps in 1995 and 2002, respec-
nor site morbidity, the muscle-sparing and even extreme-muscle sparing tively.52 The SGA flap has a more reliable pedicle than the IGA and
free TRAM was developed where the amount of muscle harvested was the donor site has the advantage of a better cosmetic outcome.
decreased.45 The progress from musculocutaneous flaps to muscle- The musculocutaneous gracilis flap was introduced in 1976 for
sparing flaps led to the advent of fascio-cutaneous flaps relying on per- the coverage of different soft tissue defects.53 The skin paddle was then
forator arteries. The deep inferior epigastric perforator (DIEP) flap was designed vertically, overlying the muscle. In 1993, Yousif et al. designed
first described in 198946 and introduced in breast reconstruction in the transverse myocutaneous gracilis flap (TMG).54 Since then, the reli-
1994 by Allen.47 This technique requires only a rectus muscle fascia in- ability of the flap has been well demonstrated and it became a popular
cision and dissection of the vascular pedicle without muscle harvest. alternative for breast reconstruction.55–57 Allen recently introduced
Even if the DIEP flap is actually considered as the gold standard for au- the profunda artery perforator flap (PAP)58 to provide a large and well
tologous breast reconstruction, it is more challenging and requires a vascularized flap without muscle harvest. However, it requires more
longer learning curve in comparison to free TRAM flaps. The superfi- meticulous muscle dissection.59
cial inferior epigastric artery (SIEA) flap, based on a subcutaneous vas- Gluteal and thigh based flaps are an alternative when abdominal
cular pedicle, was described for the first time in 1991 and allows flaps are not indicated.
transferring the same lower abdominal flap as a DIEP without incising The lateral upper thigh is also a source of a possible donor
the fascia.48 Although it preserves completely abdominal muscle wall, site. The tensor fasciae latae myocutaneous free flap was first used
SIEA is rarely indicated due to anatomical variety of its vascular pedicle for breast reconstruction in 199060 and introduced as a perforator
and the small vessel diameter that may increase the risk of flap failure.49 flap in 2011.61 It has recently emerged as a possible alternative for
breast reconstruction compared to the SGA perforator flap.62 The re-
Gluteal and Upper Thigh-Based Flaps ported advantages are the longer pedicle and avoiding changing from a
Fujino et al. first reported on breast reconstruction using a but- prone to supine position, with a comparable volume. However, limita-
tock free flap in 1975,50 by introducing the superior gluteal artery tions include wound dehiscence at the donor site if the skin paddle is
FIGURE 3. Portrait of Iginio Tansini (1855–1943), Reproduced from Ref.31 The latissimus dorsi myocutaneous flap.
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Homsy et al Annals of Plastic Surgery • Volume 00, Number 00, Month 2018
TABLE 1. Historical Summary of Breast Cancer Management and Reconstruction Milestones (1590–2012)
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Annals of Plastic Surgery • Volume 00, Number 00, Month 2018 Breast Reconstruction History
TABLE 1. (Continued)
Breast Cancer Management Breast Reconstruction
1995—Allen and Tucker—SGAP86
87
1997—Veronesi—Sentinel lymph node biopsy
2001—Cothier-Savey et al.—laparoscopically harvested omental
flap (LHOF)88
2002—Peek et al.—Gracilis perforator flap89
2002—Higgins and Blondeel—IGA perforator (IGAP)90
2004—Guerra et al—IGAP91
2011—Kind—lateral femoral circumflex artery perforator flap61
2012—Allen—PAP Flap58
too large and a lateral scar sometimes demanding a balancing procedure local recurrence and survival rates.70 Patey’s technique gained rapid
in unilateral cases. acceptance in Europe, but had few supporters in the USA. One of these
was Madden, who introduced the “modified” radical mastectomy in
DISCUSSION 1965,92 also preserving the pectoralis minor.
Since the introduction of the radical mastectomy by Halsted, Radiologic developments in diagnosis and treatment had also a
women had to wait almost a century before being offered the opportu- major influence on the surgical management of breast tumours. In the
nity of a satisfactory breast reconstruction. The dogmas, the psycholog- 1970s, the diagnosis of cancer by mammography was popularised.83
ical context, and the surgical limits have played an undeniable part in The earlier diagnosis of cancer lowered the proportion of women
the difficulty for breast reconstruction to be recognised as an integral undergoing radical mastectomy. As early as 1928, Keynes66 defended
part of the treatment for breast cancer (Table 1). The historical med- radium radiation therapy associated with tumour resection as an alter-
ical context is important to keep in mind in order to better understand native to a radical procedure. In the 1950s, several studies showed that
this evolution. Moreover, the tremendous development of oncological conservative surgery with radiotherapy had the same survival rates as
understanding in tumour biology, radiological improvements in diagnos- radical surgery.93–95
tics, and the findings of systemic treatments have permitted an evolu- Regarding systemic treatments, Gianni Bonadonna77 presented in
tion towards a more conservative surgery.63 1976 the first reports on the efficiency of a chemotherapy combination
In parallel to the ultra-aggressive treatment defended by the (cyclophosphamide, methotrexate and fluorouracil) as an adjuvant treat-
Halstedian school of thought, Europeans proposed a more conservative ment for breast cancer. These treatments, when performed before the
surgical approach. Already in the 1950s, Patey challenged Halsted’s surgery, allow increasing indications for less mutilating surgical ap-
view by preserving the pectoralis major, while offering a comparable proaches such as modified or skin-sparing mastectomy, and nowadays
FIGURE 4. Mastectomies and breast reconstructions from 1993 to 2015 at our institution. Effect of the introduction of a preoperative
multidisciplinary consultation for breast cancer patients in 2000 and of dedicated supplementary OR vacancy. University of Geneva
Hospitals, Geneva, Switzerland.
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Homsy et al Annals of Plastic Surgery • Volume 00, Number 00, Month 2018
even nipple-sparing mastectomy. These more conservative oncologic re- 7. Bard M, Sutherland AM. Psychological impact of cancer and its treatment. IV.
sections permitting better aesthetic results, thanks to the preservation Adaptation to radical mastectomy. Cancer. 1955;8:656–672. Epub 1955/07/01.
of the skin envelope of the breast. 8. Watson TA. Cancer of the breast. The Janeway Lecture—1965. Am J Roentgenol
Radium Ther Nucl Med. 1966;96:547–559. Epub 1966/03/01.
The multiple operations often needed for the breast mound
reconstruction have been an important drawback until the end of the 9. Maguire P. The psychological and social consequences of breast cancer. Nurs
Mirror Midwives J. 1975;140:54–57. Epub 1975/04/03.
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Together with the progress of surgical techniques, such as micro- 11. l'assurance-maladie. Cfdpgd. Avis du 23 août 1984. RAMA. 1984:212, ch.3.
surgery, the rediscovery of anatomical myocutaneous units in the 1980s 12. Goldwyn RM. Vincenz Czerny and the beginnings of breast reconstruction.
and of cutaneous vascular territories have allowed the development of Plast Reconstr Surg. 1978;61:673–681. Epub 1978/05/01.
an important variety of flaps and new reconstruction options. In parallel, 13. Bartlett W. An anatomic substitute for the female breast. Ann Surg. 1917;66:
the progress of anaesthesia has also allowed to perform these longer and 208–211. Epub 1917/08/01.
challenging interventions in a safe manner. 14. Legueu MF. De l’autoplastie par glissement du sein. Congrès français de
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plastic surgeons is mandatory for patient access to breast reconstruc- 15. Morestin H. De l‘autoplastie par déplacement de sein. Archives Générales de
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sultation for breast cancer patients is included in guidelines for breast 16. Harris HI. Automammaplasty. J Int Coll Surg. 1949;12:827–839. illust. Epub
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appreciate the natural feeling and longevity of results obtained by
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Innovation in surgery is dependent not only on technical and
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