During the late 1980s I was in the midst of my general surgery residency, when a revolution in surgery occurred - the minimally invasive movement. General surgery had changed little since mid century. Laparoscopic technology came out of a non university hospital, Georgia Baptist, and changed for ever the way we performed gall bladder surgery. I was influenced by two realizations: first, we should have technology and surgical strategies that accomplish the therapeutic goals without collateral damage to innocent nearby tissues; and, secondly, these revolutions in surgical practice could be led by innovative private practice physicians who are empowered by their patients. None of the university establishment took laparoscopic surgery seriously; in fact, they slandered and criticized it at every chance - stoping just short of calling it malpractice. Despite this resistance from organized medicine, within a year laparoscopic cholecystectomy had become the new “gold standard” of care. If you didn’t use a laparoscope to remove the gall bladder, then you no longer were performing cholecystectomies. Patients voted with their feet, and a surgical paradigm had shifted.
The history of mastectomy has played out in a similar manner. Over the last century woman have sought less invasive and mutilating treatments for breast cancer. Let me be clear, surgeons were not cold and uncaring about their patients; they saw breast cancer the way they did a gangrenous leg - a serious and threatening disease without life saving amputation. But just as breakthrough understanding of infection led to antibiotic treatments combined with limb salvage surgical procedures, modern understanding of breast cancers has led to more effective chemo therapies which are opening the door for breast conserving cancer surgeries. Rather than a sudden, radical shift in technique, like cholecystectomy, mastectomy has been an evolving technique with more precision and less destruction of innocent tissues adjacent to the breast gland, or corpus mammae.
The story begins with the pre World War II gold standard of the Halsted Radicle Mastectomy. Radicle because not only was the entire breast removed with the nipple and immediate surrounding skin, but so too was the underlying pectoral muscle and all lymph nodes in the axilla. Surgeons in the early 20th century were so aggressive in their desperation to battle this disease that they frequently removed so much skin that the wound could not be closed and required skin grafts to the exposed chest wall.
In the '50s and '60s the modified radicle mastectomy became the norm. In this procedure the pectoral muscle was spared and enough skin was retained to close the wound without skin grafts. In the '70s lumpectomy followed by radiation was an alternative that conserved the the breast and saved the nipple in most cases. Unfortunately many woman were still left with deformity and asymmetry due to the large amount of tissue resected to completely remove the cancer or as a result of radiation damage to the skin. The '80s saw more woman choosing reconstruction after mastectomy, and in the 90’s many had their reconstruction started at the same time as their mastectomy. This decade also saw the wide spread use of sentinel lymph node sampling as apposed to complete removal of all axillary nodes. This advance greatly reduced the problem of swollen arms, as a result of lymph node removal.
In the last twenty years, reconstruction of the breast has swung from tissue expanders and silicone implant based reconstruction, to tissue “flaps” such as TRAM (tummy tuck) flaps and Latissimus muscle and skin flaps, back to implant based reconstructions again. The return to implants has become the dominant procedure because of the advance of the skin, then nipple sparing mastectomy. As cancer surgeons realized that the areolar skin was no different than other skin covering the chest, they became open to the idea of saving it. Most surgeons today preserve the areola and nipple, after a biopsy of the last bit of ductal tissue entering the nipple confirms the absence of cancer cells. Clinical studies over the last ten years have shown that this practice does not result in higher chances of cancer recurrence.
In our practice, we have performed skin and nipple sparing mastectomies for the last seven years. We evolved to a strategy of removing as much breast gland, and surrounding tissue in the region of the tumor, as needed to resect all the cancer. In other regions of the breast we remove all of the breast gland, or corpus mammae, but preserve the overlying and underlying layer of fat. This fat is part of a system of connective tissue, that shapes the skin, and contains the blood vessels and nerves that serve the skin and nipple (Superficial Fascia System). Being aggressive in the local region of the tumor, but sparing the innocent fat and connective tissue in the remainder of the breast, has been a breakthrough for our reconstructions. It has allowed us to reconstruct the breast with silicone implants on top of the muscle - since there is sufficient fat remaining to cover and hide the implant. This minimally invasive approach frequently allows us not to use drains and perform the surgery as an out patient procedure at greatly reduced cost. Fat grafting to the existing fat under the skin flaps can be performed at a later date, and has resulted in outcomes equivalent to cosmetic breast surgery in certain patients. Some of our patients have even chosen reconstruction without implants; instead they have undergone a series of fat grafting outpatient procedures that alleviates the need for silicone implants all together.
The future promises the development of tissue engineering techniques, using synthetic absorbable scaffolds that support fat grafts and thus reduce the numbers of fat transfers required to complete reconstructions. We have even seen research that is developing techniques that inject extra cellular protein grafts that instruct the patients body to make new fat cells.
We believe patients will continue to drive innovations that change the way we treat breast cancer and achieve truly minimally invasive surgical treatments.