History and Anatomy

Published on 09/05/2015 by admin

Filed under Plastic Reconstructive Surgery

Last modified 09/05/2015

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CHAPTER 1 History and Anatomy

History

Gregory R.D. Evans and Elizabeth J. Hall-Findlay

Breast Reconstruction

Breast cancer diagnosis and management have always been an issue in society. If Cleopatra had developed breast cancer, it would have been treated with cauterization in the hope of burning out the disease.

Even when breast cancer could be diagnosed, treatment was prevented by a lack of adequate anesthesia. William Halsted would not have been able to develop his radical mastectomy procedure without the advent of anesthesia. Unfortunately, breast cancer recurrence presented in spite of this disfiguring and invasive operation.

In the 1970s most breast surgeons began to favor the modified radical mastectomy when they realized that removing the pectoralis muscle did not improve the outcome. This became the gold standard for breast cancer treatment and any suggestions of an even more ‘modified’ approach were met with derision.

Finally, surgeons began to accept that segmental resections and lumpectomies combined with chemotherapy and radiation offered realistic alternatives.

Patient requests were rarely considered in the past, but surgeons can now offer patients several different options that suit their disease, their genetic and family predisposition status, their own self body image, and their personal lifestyles.

Initially, diagnosis and treatment were aggressively combined so that patients had their biopsies booked as possible mastectomies and lymph node dissections. Today, core sampling can establish the diagnosis and imaging and sentinel node biopsy can further clarify the extent of the disease.

Chemotherapy can be given before and/or after definitive treatment and radiation and, if used, can be given before or after the reconstruction. Surgery, chemotherapy, and radiation decisions are not separate issues but can be combined to suit the disease and patient desires.

Reconstruction following breast cancer was slow to develop. In fact today, even though our options for reconstruction are multiple and women have significant choices, only about one-third of the women seeking surgical options for their breast cancer seek reconstruction. Probably the most common method of reconstruction today occurs with the placement of a silicone or saline implant. Reconstruction options today are numerous and there is no correct answer. This is so different from the days when anyone who questioned radical mastectomy was treated as a pariah. Reconstruction was not even discussed back then as a future possibility.

The evolution of the use of autogenous tissue led to more options for women seeking reconstruction. Further, some women concerned about the use of implants turned to autogenous reconstruction as a viable alternative. Numerous techniques have evolved to allow for reconstruction using natural tissues. The earliest utilized muscles to provide blood flow to the skin and create a breast mound. The latissimus dorsi flap was the most popular form of autogenous tissue reconstruction in the 1970s. Although there are currently still limitations to this form of reconstruction, this option is still utilized today for patients seeking improved reconstructive outcomes.¹^–⁵

In 1982 the first transverse rectus abdominis flap (TRAM) flap procedure was performed. This transfer of the lower abdominal muscle, fat, and tissue improved the shape of the breast and allowed a more acceptable donor site for autogenous breast reconstruction. The flap has remained a workhorse for reconstruction but is still complicated by issues related to blood supply and donor site morbidity. As microsurgical techniques evolved, our ability to improve the vascular supply of the TRAM flap also increased. As our microsurgical skills improved, further refinements of flap harvest were performed. The goal was to continue to decrease the potential for donor site morbidity. Initial attempts included techniques of muscle sparing. This allowed the harvest of part of the rectus muscle while sparing other components, leaving the rectus muscle intact in certain locations. Perforator flaps were introduced in the late 1990s and early 2000s as a mechanism to decrease the abdominal donor site morbidity. The deep inferior epigastric perforator flap and the superficial inferior epigastric flap allowed transfer of these autogenous tissues while sparing the harvest of the rectus abdominis muscle. With improved microsurgical skills, additional locations for reconstruction were examined. The gluteal artery perforator flap allows the use of skin from the buttocks. The gracilis myocutaneous flap allows the use of skin and a portion of muscle from the inner thighs. The latissimus dorsi was again utilized without harvesting of muscle to supply bulk in the creation of a breast mound.¹^–⁵

Issues today still concern primarily control of the disease. Treatment now needs to be integrated with various reconstructive decisions, coverage and types of implants when used, as well as treatment of the skin envelope (excision, skin sparing, mastectomy, and even nipple-sparing mastectomy).

Plastic surgeons were seeking new options because some of the initial procedures were disappointing. Now plastic surgeons have a vast array of options available, but there is still resistance from the general surgeons and oncologists. Not enough patients are being given the opportunity to participate in decision making and they are not being presented with all the treatment and reconstructive options available.

Breast Reduction

It has long been recognized that overly large breasts can be a significant burden for women. Treatment was delayed until the advent of anesthesia.

Initially, amputation techniques were used because they were relatively simple and straightforward. Surgeons began to understand that resection of parenchyma and skin should be designed to preserve nipple and areolar circulation. Numerous techniques were described over the years to reduce bulk, preserve the nipple and achieve an aesthetically desirable effect. Preservation of sensation and breast feeding potential were secondary.

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