Plastic Surgery of the Breast: A 75-Year Journey.

Abstract

Innovation and plastic surgery go hand-in-hand. Over the past several decades, the plastic surgical subspecialty of breast surgery has been revolutionized and transformed by truly remarkable advancements. The authors of this editorial can all attest to the myriad changes in breast reduction, mastopexy, augmentation, and reconstruction that have occurred since completing their residencies. Techniques have been refined, adverse events minimized, and outcomes improved. This editorial reviews significant innovations and advancements in plastic surgery of the breast (Fig. 1).Fig. 1.: Seventy-five years in breast plastic surgery has seen development of new ideas, resurgence of old concepts, and evolution in design and technology. The future of breast surgery promises enhanced outcomes driven by technological advances, physician innovation, and feedback from the patient.Reduction Mammaplasty and Mastopexy Reduction mammaplasty is a very versatile operation because there is virtually no other operation in our specialty that has so many different ways to achieve good to excellent functional and aesthetic outcomes. With respect for breast vascularity, breast reduction can be safely performed with a variety of pedicles and skin incision patterns, with the primary goal being to reduce breast volume and maintain perfusion to the nipple-areola complex. Inherent in this is the understanding that the blood supply to the cutaneous envelope of the breast is separate and distinct from that of the breast parenchyma. A plethora of pedicles have been described to maintain the perfusion to the nipple-areola complex that include but are not limited to inferior, superior, medial, lateral, superomedial, superolateral, vertical bipedicle, horizontal bipedicle, central mound, and lateral central. In addition, a number of incisional skin patterns have been described that include the inverted-T, I pattern, J pattern, L pattern, S pattern, circumvertical, horizontal (Passot), SPAIR, and Regnault B. The pedicles and skin incision patterns can be used interchangeably in most circumstances. The adage “everything old is new again” certainly holds true for techniques associated with breast reduction. Many surgeons today routinely use short-scar techniques for reduction mammaplasty as popularized by Lassus, Lejour, and Hall-Findlay. What is notable is that many of these short-scar techniques were actually developed over 100 years ago but abandoned because of inconsistencies with final breast shape and volume. The inverted-T pattern was described by Robert Wise in 1958 as a means of increasing predictability and improving outcomes at the expense of adding a horizontal incision along the inframammary fold. Although the inferior pedicle Wise pattern breast reduction has been criticized for poor shape and bottoming-out, advancements in technique predict and account for the poor shape and predictable stretching of the lower pole by performing pedicle shaping sutures and setting the nipple-to–inframammary fold distance artificially low in anticipation of this stretching. The resurgence of short-scar techniques began in the 1980s as a means of once again eliminating the horizontal incision. The 1990s and 2000s were marred with controversy, as the “scar wars” era emerged, where the merits of short- and long-scar techniques were debated. Today, most plastic surgeons have adopted both short- and long-scar strategies and choose based on patient anatomy, prior incisions, and expectations. Mastopexy options and techniques mirror those of reduction mammaplasty with regard to skin pattern and pedicle design. However, instead of large resections, mastopexy procedures can offer autoaugmentation with retention of the inferior pedicle–supplied tissue to augment a superior/medial pedicle breast lift or, conversely, retention and rearrangement of lateral, superior, and medial tissue to supplement the inferior pedicle mastopexy. Breast Augmentation The history of breast augmentation is fascinating when considering that the first attempts to augment the breast involved the transplantation of fat (lipoma) from one part of the body to the breast. One hundred years later, we have come full circle and are revisiting fat transplantation for primary breast enhancement. Within this time frame, devices for breast augmentation have been described and include solid and fluid-filled devices. Solid devices include the Ivalon sponge (First Aid Bandage Co., New London, Conn.), polyurethane, and polytetrafluoroethylene, whereas fluid-filled devices have included saline, soybean oil, and silicone gel. Silicone gel breast implants have been preferred by the majority of plastic surgeons and patients; however, these devices have been marred by controversy over the past 50 years. Since the introduction of silicone gel breast implants by Cronin and Gerow in 1962, controversies surrounding their use have been noted resulting in the U.S. Food and Drug Administration making multiple public statements regarding safety and efficacy in 1976, 1982, 1992, 2005, 2011, 2016, 2017, 2018, 2019, and 2020. Clinical experience and investigation have resulted in numerous changes that include implant shape, gel cohesivity, and surface qualities. Most of the advances have had clinical advantages, with more natural results and minimization of rippling, wrinkling, and contour irregularities. The advantages of the textured devices in offering natural long-term results, assistance in maintaining implant positioning, and some protection against capsular contracture in the subglandular plane have been offset by their association with breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Over the past decade, surface qualities have dominated the discussion based on our understanding of the cause of BIA-ALCL and resulted in the elimination of macrotextured surface devices in most parts of the world. Because shaped or anatomical implants have textured surfaces, the use of these devices had declined dramatically. As such, most plastic surgeons are now using smooth surface, round silicone gel implants for breast augmentation. The heightened awareness of implants and their association with BIA-ALCL has also led to increased awareness and resurfacing of symptoms described as breast implant-associated illness. Although few data support the association of breast implants and systemic illness, it is largely accepted that it is possible for breast implants to trigger symptoms in select patients. Much like reduction mammaplasty, there are many ways that breast augmentation can be performed. Incisional approaches have included inframammary, periareolar, axillary, and umbilical. Implant location has included total subpectoral, partial subpectoral, subfascial, and subglandular. The use of autologous fat as an adjunct to breast augmentation or as a primary filler material has increased over the past decade. Fat can be placed in the subcutaneous layer of the breast, pectoralis major muscle, subglandular space, sternal region, and upper pole of the chest. The concept of composite breast augmentation using small implants and supplemental fat grafting has been receiving more attention given the current concerns with anatomical and textured devices. With this technique, smaller devices can be used and placed in the subfascial position, and the fat can be placed in the upper and medial pole of the breast. The results are usually excellent, patient satisfaction is high, and adverse events may be minimized. Moving forward, this may be the preferred technique for patients who are good candidates and understand the risks inherent in fat grafting, including cysts, calcifications, and lumps. Breast Reconstruction Akin to breast reduction and augmentation, breast reconstruction has evolved steadily over the years. Currently, breast reconstruction is one of the busiest aspects of reconstructive plastic surgery, and there are numerous methods to accomplish this. From the innovations in breast implant surface composition, fill volume, gel cohesivity, shape, and design to the tissue expander by Radovan, prosthetic devices have evolved as the mainstay for breast reconstruction. The evolution of mastectomy to skin- and nipple-sparing procedures and the steady rise in contralateral prophylactic mastectomy in the past two decades has been followed by a significant increase in prosthetic breast reconstruction. Currently in the United States, approximately 80 percent of breast reconstruction is implant-based. The use of biologicals, such as acellular dermal matrices, has allowed more support and control in reconstruction, including partial submuscular one- and two-stage reconstruction, prepectoral reconstruction, and salvage of reconstructions marred by implant malposition. The resurgence of autologous fat grafting has empowered surgeons to get the best possible outcomes for the patients by fine tuning the soft-tissue envelope. Textured surface devices have largely taken a back seat to smooth devices secondary to BIA-ALCL and the worldwide recall of Natrelle (Allergan, Inc., Dublin, Ireland) macrotextured devices. Simultaneously with the progress and change of implant-based breast reconstruction, autologous reconstruction has enjoyed a similar evolution. Although veteran workhorse autologous flaps such as the pedicled transverse rectus abdominis musculocutaneous flap and the latissimus dorsi flap still enjoy widespread popularity, perforator flap breast reconstruction has blossomed. Popularized by Allen and Blondeel, the deep inferior epigastric perforator flap has become the most common autologous flap in many centers around the world. This flap has the advantage of sparing the rectus abdominis muscle and the attendant morbidity that accompanies its sacrifice. A great understanding of anatomy and perforator dissection has allowed surgeons to harvest autologous flaps from multiple locations, including the chest wall, abdomen, buttocks, and thighs. These flaps have the advantage of harvesting skin and fat while preserving muscle. Autologous tissue flaps have the advantages of feeling more natural than implants (avoiding secondary replacement operations) and enhanced performance in the setting of radiation therapy. Microsurgery has become a routine technique in plastic surgery training programs. The abundance of well-trained microsurgeons and imaging techniques has allowed the field of autologous breast reconstruction to make great strides. This has similarly resulted in the development of surgical techniques for the treatment of lymphedema, an unfortunate and challenging complication of breast cancer treatment. Breast reconstruction has become an integral part of breast cancer treatment. Through the technological advancements over the past 50 years, women facing the deformities that result from lumpectomy or mastectomy have excellent options to improve their quality of life. With the development of the BREAST-Q, we can now numerically measure these improvements and compare outcomes from the patient perspective. CONCLUSIONS Seventy-five years in breast plastic surgery has seen development of new ideas, resurgence of old concepts, and evolution in design and technology. The future of breast surgery promises enhanced outcomes driven by technological advances, physician innovation, and feedback from the patient.