The History of Breast Reconstruction Is a Journey of Resilience

The history of breast reconstruction unfolds as a testament to our collective and unwavering commitment to overcome cancer and restore the human body and spirit. Paramount to the trajectory of breast cancer care has always been the patient, while the focus has evolved from survival to disease recurrence to patient-reported outcomes and quality of life. Breast reconstruction has mirrored this evolution of care.

William S. Halsted, MD, FACS, performed the first radical mastectomy for breast cancer in 1882, removing all the breast tissue, pectoral muscles, nodes, and overlying skin. He believed that leaving behind skin for subsequent reconstruction would lessen the chances of survival.¹ Dr. Halsted feared that breast reconstruction would hide tumor recurrence, increase the chance of recurrence, or alter the course of the disease.

In 1976, Cushman Haagensen, MD, a professor of surgery at Columbia University in New York, New York, was quoted in The New York Times as saying that breast reconstruction was “madness” and that “breast cancer could be spread by another operation.” However, the tide began to turn against disfiguring radical mastectomies and in favor of lumpectomy as well as breast reconstruction when mastectomy could not be avoided.

Rose Kushner, a prominent journalist known for her reporting about the Vietnam War, developed breast cancer in the 1970s and became an outspoken advocate for less radical surgery as well the availability of reconstruction. Her efforts raised public awareness of the physical, emotional, and psychological impact of a radical mastectomy, ultimately influencing the surgical community as well. Despite initial resistance, breast reconstruction has now become an integral component of breast cancer treatment.

The first breast reconstruction was performed by Vincenz Czerny, a professor of surgery in Heidelberg, Germany. In 1895, he published the case of a 41-year-old woman who was a dramatic singer. She had a large fibroadenoma removed and was concerned that the resultant asymmetry would affect her stage career. Czerny noted that she had a sizeable lipoma in the right lumbar region and used this for the successful reconstruction of the breast defect.²

In the early 1900s, several European surgeons developed novel techniques for breast reconstruction using autologous tissue. Iginio Tansini, from the University of Pavia in Italy, developed a latissimus dorsi musculocutaneous flap to close large radical mastectomy wounds. Other techniques included the distant tubed pedicle skin flap, with the umbilicus substituting for a nipple, introduced in 1917 by renowned surgeon, Sir Harold Gillies, known for his reconstructive efforts of severe war injuries.

These early approaches largely provided skin to cover the radical mastectomy defect without reconstructing the shape and aesthetics of the breast. The tubed pedicle flap required multiple staged operations and ultimately was replaced with other procedures requiring fewer operative stages and better aesthetic results.

In 1982, Carl Hartrampf Jr., MD, FACS, from Atlanta, Georgia, made a quantum leap in autologous breast reconstruction with the development of the transverse rectus abdominis myocutaneous (TRAM) flap.³ Other local and regional flaps for breast reconstruction such as the latissimus myocutaneous flap were popularized and refined during this period. Further advancements in microvascular surgery allowed the development of the free TRAM flap, which involves harvesting less muscle. Muscle-sparing methods were further explored to reduce patient morbidity, leading to the creation of the deep inferior epigastric flap in 1989, by Isao Koshima, MD, and Shugo Soeda, MD, from the University of Tsukuba in Japan.⁴

Alongside the autologous tissue breast reconstruction development, others pioneered implant-based reconstruction. In the 1950s, surgeons initially tried injecting liquid silicone into breasts, which led to significant complications such as migration of silicone to other body parts, and this technique was consequently banned in the 1970s.

Silicone breast implants were developed by Thomas Cronin, MD, from Houston, in the 1960s1 followed by the introduction of the saline-filled implant. Implant-based aesthetic surgery and reconstruction quickly gained popularity. However, the safety of silicone breast implants was questioned, and silicone implants were withdrawn from the market for aesthetic surgery in the 1980s. After extensive study, the use of silicone implants was approved for both aesthetic and reconstructive surgery. In 1982, the tissue expander was introduced for delayed reconstruction to gradually expand the overlying skin and ensure appropriate skin coverage.

Breast implants have undergone many advancements since the 1960s. Modern approaches such as skin and nipple-sparing mastectomies, when oncologically sound, preserve the natural appearance of the breast, areola, and nipple skin, which are difficult to reconstruct. Oncoplastic breast reductions have improved the shape of some lumpectomy defects. Fat grafting has grown in popularity to correct smaller deformities and asymmetries and allowed for refinement of breast reconstruction results.

It is important to emphasize that breast reconstruction goes well beyond physical restoration and plays a pivotal role in the psychological and emotional well-being of many women who undergo surgery for breast cancer. The BREAST-Q was developed by plastic surgeon Andrea Pusic, MD, FACS, as a way of analyzing patient-reported outcomes (PRO) after breast surgery.⁵

BREAST-Q measures PROs quantitatively and qualitatively with validated questionnaires that address quality of life domains and satisfaction after surgery. Studies using the BREAST-Q have demonstrated that reconstruction helps improve patients’ quality of life and physical functioning, satisfaction with their appearance, psychosocial, and sexual outcomes.

Unfortunately, not all women have access to breast reconstruction after mastectomy and disparities for minority women persist. While barriers to access need correction, the history of breast reconstruction stands as a testament to our capacity to provide physical and emotional healing to those affected by breast cancer, reaffirming the belief that every woman’s journey is worth celebrating.

Dr. Shyamin Mehra is a fourth-year surgical resident at Rutgers New Jersey Medical School in Newark. She is pursuing a career in breast surgical oncology and is dedicated to reducing disparities in breast cancer care.

References

1. Champaneria MC, et al. The evolution of breast reconstruction: A historical perspective. World J Surg. 2012;36(4):730-742.
2. Czerny V. Plastischer ersatz der brustdrüse durch ein lipom (Plastic replacement of the breast with a lipoma) [in German] Verhandl Dtsch Ges Chir. 1895;24:216-217.
3. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg. 1982 Feb;69(2):216-225.
4. Tomita K, Kubo T. Recent advances in surgical techniques for breast reconstruction. Int J Clin Oncol. 2023;28(7):841-846.
5. Pusic AL, Klassen AF, Scott AM, Klok JA, et al. Development of a new patient-reported outcome measure for breast surgery: The BREAST-Q. Plast Reconstr Surg. 2009;124(2):345-353.
6. Tansini I. Sopra il mio nuovo processo di amputazione della mammella. Gazzetta Medica Italiana. 1906; 15:141-142.  
7. Gillies H. Operative replacement of the mammary prominence. Br J Surg. 1945;32(128):477-479.