INTRODUCTION
The cancer that most affects women around the world is breast cancer1. In addition to the harm that the active disease is capable of causing, after the
cure, the consequences continue to torment the lives of thousands of women. The psychological
trauma of mutilation can have psychological repercussions that are difficult to control.
Mastectomy saves the life of a woman with breast cancer; however, breast loss can
keep the patient sick in the biopsychosocial aspect2. Rebuilding the breasts then becomes crucial in the treatment of these women.
With the evolution of medicine, cancer treatment became less aggressive and enabled
the advancement of techniques to reconstruct women’s femininity through the breast.
As a result, local control of the disease can now be safely achieved with more conservative
operations, offering the plastic surgeon an important place in the treatment. Furthermore,
it was established that the biology of breast cancer is not altered by reconstruction,
which does not compromise the proper treatment of the disease3.
Studies and reflections by plastic surgeons worldwide have enabled the standardization
of a series of techniques and tools for breast reconstruction, which will make up
the arsenal of the modern surgeon. It includes techniques with local flaps, such as
the plug flap4 and mammoplasty techniques, neighborhood flaps, such as the thoracodorsal flap5, alloplastic materials (tissue expanders and prostheses), the numerous autologous
flaps6, including microsurgical flaps or, also, the combined techniques for the various
types of cases. At the same time, the medical-hospital products industry has developed
alloplastic materials (prostheses and expanders) that are adequate and of better quality,
which provide safer and more predictable reconstructions concerning the use of implants7.
Taking advantage of the history and evolution of surgical techniques allows the surgeon
to understand the diagnosis and treatment better. Thus, History moves towards improvement
and, like an artist who portrays all the world’s diversity on a canvas, towards the
anatomical diversity of women, the more options the plastic surgeon has, the better
his technical indication and the consequent result will be.
The evolution of anatomical knowledge, breast cancer physiology, oncology, anesthesia
and, finally, surgery allowed the evolutionary history of breast reconstructions that
we will discuss here. Evidence-based medicine combined with the artistic tone of plastic
surgery transcends the human body, and they walked together since the beginning with
Hippocrates, armed with a great capacity for clinical observation. However, with the
knowledge he was given, he thought: “…and they appear hard tumors in the breast, some
larger, and others smaller, that do not swell but that keep growing and getting harder.
Hence, occluded cancers are born. When at last the cancers appear, the mouth becomes
more bitter, and everything the patients eat tastes bitter to them, and if they want
to give them more food, they refuse it and close their mouths. They start to delirious,
the eyes are still and cannot see clearly, the pain born in the breast reaches the
neck and shoulder blades, thirst sets in, the nipples become dry, and the whole body
is emaciated. When patients reach this state, they do not recover and die from their
illness. It is better not to apply any treatment in cases of occluded cancer because
if treated, patients die quickly, but if not treated, they still last a long time…”3. The evolution of this knowledge has been significant up to the present day, and,
in the complete lucidity of the 21st century, complex challenges are still faced in
the daily lives of surgeons who treat the breast.
History
The magnitude of medical knowledge squandered today owes its toll to the discoveries
of past centuries. For example, with the discovery of anesthesia in 1846, painless
operations began, as everything that existed before “was just darkness of ignorance,
suffering, fruitless attempts in the dark.” (Bertrand Gosset - Book: The Century of
Surgeons, 1956)8.
In the nineteenth century, with Halsted9, surgeries were extensive and removed a large amount of skin, pectoral muscles and
sometimes even the ribs, justified by the need to cure breast cancer. Thus, a population
with important aesthetic, functional, social and psychological sequelae began, since
the breast reconstruction of these patients was discouraged by Halsted himself, for
fear of impairing the diagnosis of local recurrences of the disease and the healing
process9.
With such aggressive surgeries, attempts to close the defect primarily and under tension
were often unsuccessful. Dehiscence requiring closure by the second intention was
not rare, causing great morbidity and mortality to the patients. Halsted modified
his technique to alleviate this problem, using skin grafts to cover the defect, avoiding
closure under tension, but with poor and even mutilating aesthetic results10.
The history of breast cancer treatment led to increasingly less aggressive behavior.
In the 19th century, the use of autologous tissues marked the beginning of modern
treatments for breast reconstruction. However, it was only in the second half of the
20th century that the concept of breast reconstruction after mastectomy became popular
with the initial introduction of pedicled flaps and, subsequently, free flaps supported
by perforators. The first successful reconstruction was described by Czerny, in 189511, a German surgeon who autotransplanted a lipoma from the lumbar region to the site
of previous subcutaneous mastectomy; according to the author, the reconstructed breast
maintained good shape, with a one-year follow-up.
Soon after Tansini, in Italy, in 189712, he began his studies and performed the first rotation of the latissimus dorsi flap
(Figure 1), used at that time to cover a defect in the chest wall, an incipient breast reconstruction.
This procedure was not very well received and soon fell into disuse due to the belief
that immediate reconstruction would make it challenging to detect local recurrence,
a concept spread by Hasted and which was perpetuated for many years12. Tansini (1906)13 advocated complete ablation of the mammary gland as a way to reduce recurrences.
He was also an advocate of expanding surgical margins to ensure complete removal of
the disease, a principle adopted in the techniques most used in Europe in the first
two decades of the 20th century.
Figure 1 - Ignio Tansini and photos of his work.
Figure 1 - Ignio Tansini and photos of his work.
At the beginning of the next century, the French surgeon Ombredanne (1983)14 described the use of the pectoralis minor muscle flap for immediate breast reconstruction,
in which the skin was repaired by a thoracoabdominal flap pedicled in the axillary
region. However, following what happened with Tansini (1906)13, the technique was not well received for fear of harming the monitoring of the disease.
Shortly after that, in 1917, Bartlett8 published six breast reconstruction cases, post-subcutaneous mastectomy for cystic
fibrous mastitis, with a fat graft taken from the anterior abdominal regions, external
thighs and gluteal regions. According to his technique, to remove subcutaneous fat
approximately 50% larger than the removed breast tissue was recommended to supply
the anterior volume of the breast added to the graft atrophy that always occurred.
To reduce the degree of resorption, dermal or dermofat grafts were used, with the
epidermis decorticated. However, they also proved to be insufficient to maintain the
desired breast size.
Kleinschmidt, in 192414, following reasoning similar to that of Ombredanne (1983)14, in the same period, developed a local lateral skin flap, based on the axilla, which
rotated itself to cover the defect and form the mammary mound15.
Sometime later, important surgeons in the scientific evolution of the last century,
Gillies and Millard (1957)10 and Holdsworth (1956)16, developed breast reconstruction techniques using tubular skin flaps, obtained in
areas other than the defect, aiming at the reconstruction of the amputated glandular
volume17. These were flaps from the abdomen or lower chest, based on a tubular pedicle and
through multiple operative procedures, and which were transferred to the mastectomized
area. The reconstructive process was time-consuming, took months or years, and had
high morbidity. These procedures, associated with poor aesthetic results, did not
establish the technique among surgeons in the 1940s.
In 1959, Longacre et al.18, using decorticated submammary neighborhood flap, obtained in the inframammary region
and inserted into the breast to provide volume after subcutaneous mastectomy, observed
volume maintenance and no signs of resorption after a follow-up of up to eleven years,
attributing the preservation of an extensive subcutaneous network of blood vessels.
In 1956, Holdsworth16 published a tubular flap from the pendular portion of the opposite breast, which
was transferred to the mastectomy defect. In 1973, Pontes19 refined the use of the contralateral breast as a donor area, describing a technique
that used a flap consisting of its inner half to reconstruct the lost breast in a
single time.
Reconstructions with implants
At the beginning of the last century, they developed alloplastic materials as an alternative
to autologous reconstructions. The idea started using a concept proposed by Gersuny
in 1899 20, when he introduced, through injection, paraffin to enlarge the breast20. The innovative idea led other surgeons to experiment with other injectable products,
vegetable oils, lanolin, silicone and beeswax. However, this technique was soon abandoned
due to the numerous and severe local complications, such as paraffinomas, ulcerations
and fistulas, in addition to pulmonary, cerebral and retinal embolisms.
Several materials and attempts were made to obtain the best type of breast implant
from then on. Nevertheless, it was only in the 1960s that the first silicone prosthesis
was implanted in humans, in Texas, by Blocksma and Braley21, formed by a thick outer layer and filled with a moderately cohesive silicone gel,
in addition to seams and fixation seals. Then came the future of breast implants.
However, it took much evolution to reach the modern silicone prostheses we have today.
In 1965, the first saline-filled prostheses also appeared in France. This type of
filling introduced some advantages, such as the possibility of insufflation in loco,
allowing insertion through smaller incisions and a better and more acceptable contracture
rate than the previous one. However, the difficulties with the high deflation rates
and consistency away from the natural breast bothered patients and surgeons22.
In order to overcome these difficulties, Daher, in 1972, started some reconstruction
cases with the use of successively replaced silicone prostheses, initially placing
a smaller one and changing every 90 days for a larger one, thus achieving skin expansion.
This idea, although original, was replaced by the ingenious publication by Radovan23, in the same decade, of tissue expanders, which allow the placement of larger implants
under pre-expanded skin. This has rekindled the use and popularity of breast reconstruction
with tissue expanders in various shapes, sizes, shapes and textures. In addition,
modern expanders have been increasingly improved to guarantee an aesthetic result
for both the reconstructed breast and the contralateral breast, especially concerning
its symmetry23.
Still in the early 70s (1972), the Plastic Surgery Service at the Hospital das Forças
Armadas, in Brasília, in partnership with the oncology service, with very advanced
positions for the time, admitted more conservative resections and, above all, indicating
subcutaneous mastectomies as a preventive procedure, also known as adenectomies. It
was the beginning of surgeries today called skin sparring. “We performed an emptying
of the breasts, leaving skinny dermocutaneous flaps that covered the silicone implants,
produced by ‘dow corning,’ and with exciting immediate results. Soon after, we evolved
to the same procedure with submuscular implants.” (Daher, 1972)
In 1984, Becker24 described an expander with two compartments inside, one filled with silicone gel
and the other empty to be filled later with saline solution, according to the desired
size. The Becker expander was a pioneer in one-stage breast reconstruction, eliminating
the need for a second surgical procedure where permanent silicone implants would replace
the expanders.
Most breast reconstructions with expanders had satisfactory results over time until
Clough et al. (2001)25 reported a deterioration of the result over the years. Most results were acceptable
initially but got worse as time went on, probably due to asymmetry and aging of the
implants. Elliot and Hartrampf (1990)29 listed several causes that could limit this technique, including the great need for
visits to the doctor’s office (for the gradual expansion of the tissue), the risk
of perforation of the expander with the consequent need for replacement. Others criticized
the expansion technique for taking too long and requiring several subsequent surgical
revisions. Gradually, interest in breast reconstructions with autogenous tissues gained
ground in the 80s26.
Over time, the goals of breast reconstructions became more refined. Surgeons and patients
started to look for more precise contours, better symmetry and breast positioning.
However, these goals were commonly limited due to the defects created by mastectomy.
The mastectomy technique is the main factor influencing the outcome of the reconstruction.
These techniques have also undergone essential evolutions, from the radical removal
of all breast tissue and adjacent tissues to the tissue-sparing philosophy. The skin-sparing
mastectomy technique preserves the entire cutaneous envelope of the breast, resulting
in fewer scars and good quality remaining skin coverage on the chest wall.
Myocutaneous flaps
In the late 1970s, we entered the era of myocutaneous flaps, initially the latissimus
dorsi. Tansini described this flap in 190613, but its systematic use for breast reconstructions is due to McCraw (1978)27 and Bostwick (1979)28, who created the possibility of taking skin from the back to the mastectomy region,
it can be combined with a silicone implant to provide volume to the region. With the
advent of expanders, the remaining tissues of the anterior chest wall were expanded,
often with the latissimus dorsi flap already taken to the region.
Despite being timeless and used on a large scale until today, the latissimus dorsi
flap, analyzed chronologically, was replaced by the transverse rectus abdominis (TRAM)
flap. The first descriptions of using a pedicled musculocutaneous flap based on the
rectus abdominis muscle for chest and abdominal wall reconstructions were by Dreaver
in 198129, in the vertical form. Later, in 1979, Robins30 described the same vertical flap, but to reconstruct the breasts, which then, in
1982, was modified by Hartrampf34, and made in a transverse shape, give the origin of the transverse rectus abdominis
muscle flap - TRAM, quickly becoming an essential alternative for breast reconstructions.
Oncology and mastology evolved to more conservative resections, quadrantectomies,
which required other solutions from plastic surgery, now no longer for the total reconstruction
of the breasts but their partial reconstruction. Thus, when the plug flap appeared
- an island flap of the breast published by Daher in 19934, this first flap in an island of the breast, which we call the plug flap, is a cylinder
of breast tissue, pedicled in the rib cage, topped by a fragment of skin or areola,
which will be transposed to the quadrantectomy region. This is a safe flap, as it
has pedicles based on anatomical studies performed by the author, who dissected twenty
breasts raised in the form of a tent, exposing the vascularization of the anterior
chest wall.
The free patches
Microsurgery was the most recent advancements that made it possible to develop flaps
with more limited vascularization or even performed reconstructions with flaps brought
from a distance and minor damage to the donor areas.
In 1976, Fujino32 performed the first free flap transfer for breast reconstruction from a portion of
the gluteus maximus muscle. Holmstrom performed the first free abdominal flap in 197933. The socalled free abdominal flap was designed based on an abdominoplasty skin flap
on unilateral, inferior epigastric vessels. Since then, autogenous free flap transfer
has become the method of choice in many breast reconstruction centers.
With the popularization of gluteal flaps in 1990, Allen et al. performed the first
superior gluteal artery flap (SGAP) and, in 2006, Allen et al.38 described the use of a flap based on the inferior gluteal artery (IGAP) for breast
reconstruction, with an unpleasant scar resulting in the inferior gluteal fold34.
In recent years, with the increase in conservative surgeries indicated by mastologists
and the use of quadrantectomies, dermoglandular neighborhood flaps have taken over.
Island flaps in the thoracic region gain space, such as the plug flaps by Daher (1993)4 and in 2003, with Graf et al.35, who created a technique using a chest wall flap with a bipedicled muscle flap from
the pectoralis major muscle. in a vertical scar.
Screens and dermal matrix
Synthetic polypropylene mesh was first used in 1981 by Johnson36 to correct breast ptosis during mammoplasty. In 1996, Góes37 introduced a polypropylene mesh technique to promote shape and support in the upper
pole of the breast.
DISCUSSION
The plastic surgeons’ desire for breast reconstruction may find among its motivations
more specific and deeper psychoanalytic explanations, in addition to the desire to
reconstruct the specialty itself. We are used to saying that Melaine Klein, an eminent
psychoanalyst of the last century, formulated her theories about the good breast and
the bad breast, converging with our search for the whole, beautiful, unmutilated breast
or with the recovered mutilation.
The advent of silicone prosthesis was the outstanding contribution of engineering
and industry to plastic surgery and a critical point in the chapter of breast surgery
in general. It served cosmetic surgery for augmentation mammoplasty and became a powerful
tool weapon for breast reconstruction soldiers. It served for the first attempts to
create breast volume where there was none. However, its use was initially limited
because the reconstruction cases followed mastectomies performed using Halsted, Stewart,
Pattey and Pattey techniques. The first three performed extensive skin resections
with skinny flaps, which would hardly support silicone in an attempt at reconstruction.
The proposal of reconstruction by dividing the remaining breasts, although extremely
ingenious and of great value to the patients who used it, was abandoned, above all,
by the enormous resistance of mastologists. At the time, they were highly conservative
in the face of precarious imaging exams (the most advanced mammography device manufactured
by France could see tumors 1 cm above, which is very little by today’s standards).
Moreover, they feared the hypothesis that we were taking potentially cancerous glandular
tissue; after all, the principles of bilaterality of certain tumors to the contralateral
wall were already known.
Nevertheless, in the early 70s, two facts began to change the course of breast reconstructions:
more daring breast cancer specialists pushed for more conservative surgeries, with
more minor skin resections, leaving slightly thicker flaps, reaching the modified
Pattey technique that, with horizontal incision and thicker flaps, he dared to preserve
the greater pectoralis or both, thus protecting the anterior pillar of the axillary
hollow. This improvement in conditions in the area of mastectomy led plastic surgeons
to attempt, albeit timid, to use the silicone implant, whichever fit, which began
with breaking the other taboo of conservative oncologists: reconstructions could only
take five years later the mastectomy. The boldness of the more progressive breast
cancer specialists associated with the everimproving improvement of plastic surgeons
showed that the reconstruction does not worsen the prognosis, but, on the contrary,
it improves by providing the patient with the quality of life.
In the last two decades, tissue engineering research has been studying the possibility
of developing ultra-realistic synthetic fabrics. The potential use of these techniques
in breast reconstruction can enable the use of autologous tissues without the need
for a satisfactory donor area, in addition to avoiding the morbidities involved in
their mobilization.
The acellular dermal matrix, which was initially used in breast augmentation revisions
to prevent rippling and changes in breast contour, has lately been used in breast
reconstructions associated with a dual plane or total submuscular implants. Its use
became better known in 2005, after a case report of its use as a sling to cover the
inferolateral pole35. The use of acellular dermal matrix has two major advantages: coverage of the silicone
implant in the inferolateral pole when the pectoralis major muscle is absent or insufficient;
and less postoperative pain complaint, less morbidity of the donor area and better
aesthetic results36-38.
Like art, the evolution of plastic surgery has no endpoint; it evolves according to
human existence. Its relationship with the knowledge and treatment of breast cancer
is increasingly mixed. We are witnessing the emergence of a new aspect of plastic
surgery, called oncoplastic surgery, which requires more profound knowledge about
the conduction and advanced techniques for treating breast cancer, from mastectomies,
indications for neoadjuvant chemotherapy and its proposal for debulking.
Thus, the current state of the art in breast reconstruction finds well-founded historical
pillars and advanced technological support, providing conditions for refined treatments,
which are highly demanding and prepared by the artist. It is up to us surgeons to
know how everything got here and be aware of modernity and the newest evidence that
is released to us every day, as only then will we be able to dispense the proper best
treatment for reconstructed breasts.
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1. Hospital Daher Lago Sul, Brasília, DF, Brazil
Corresponding author: Tristão Maurício de Aquino Filho SHIS, QI 7, Conj. F - Lago Sul, Brasília - DF, Brazil. Zip Code: 71615-660, E-mail:
dr.tristaomauricio@gmail.com
Article received: September 30, 2020.
Article accepted: January 10, 2021.
Conflicts of interest: none.
