The chronologic history of post-mastectomy breast reconstructive surgery in the United Kingdom from 1975 to 2025

Introduction

The surgical options for breast reconstruction before 1972 were limited and very much depended upon the resultant deformity created by surgical and radiological treatment of often late presenting patients with visible malignant disease of the breast. The reconstructive outcome was poor and generally would only result in a mound rather than a symmetrical breast. Sponge or padding inserts in bras were the best way to disguise the deformity, particularly when clothed. The mutilating Halsted radical mastectomy originated in the 1890’s from the misconceived idea that a higher cure rate and a lower recurrence rate from breast cancer would follow a radical excision of all adjacent anatomy (Figure 1). This was still naively practiced up until the 1970’s until a ‘voice for women’ helped change the malpractice. This procedure included removal of all the breast with skin, the ipsilateral chest wall muscles that included pectoralis major and minor, and sometimes resection of ribs and all of the axillary lymph nodes (1), and it was also often followed up with ultra-radical radiotherapy. Severe deformity, intractable pain, lack of mobility of the arm, extreme lymphoedema, radiation necrosis and severe psychological impact followed. Eventually it became clear that neither survival nor local recurrence rates were improved by such aggressive surgery (2). A modified Patey approach was then put forward as a less aggressive modified radical mastectomy option (3). This technique removes only the breast and underlying pectoralis major fascia with axillary lymph nodes and conserves the pectoralis minor muscle (Figure 2). Often, especially with larger tumours, remaining chest wall skin was purse string sutured leaving small defects that accommodated a skin graft. The preservation of pectoralis major gave a less deforming, but still significant contour chest wall defect. Radiotherapy frequently followed surgical ablation with the concept of destroying local and planktonic cells; however, pre-ablative radiotherapy was, and is still given to reduce tumour size prior to mastectomy. The adjacent irradiated tissues became a problem with poor wound healing when primary closure, grafts or local flaps were attempted, and healing could only be achieved with confidence by the introduction of well-vascularised non-irradiated tissues. Unfortunately, wound healing also became a major issue when thin skin flaps were raised during skin preserving techniques especially when the wound was closed under tension. Reconstruction for both these scenarios proved extremely unsatisfactory, but was accepted by women because there were few alternative options available.

Figure 1 The patient presenting in 1986 with severe and symptomatic deformity as a result of a Halsted radical mastectomy on the right and a left lumpectomy and aggressive radiotherapy to the left chest wall.

Figure 2 Asymmetry and contour irregularity following a left simple mastectomy with axillary node dissection in 2024. The protection of blood supply to the skin flaps is reliant upon a layer of fat anterior to the external sheath of superficial fascia and removing this surgically in an uneven way will create the contour deformity.

In the 1970’s UK plastic surgeons started to work alongside general surgeons to offer novel methods of reconstruction. As a rule, breast cancer was primarily managed by general surgeons that only started to sub-specialise in the early 1980’s and then oncoradiotherapists and other caring specialties, including plastic surgeons, combined to give a multidisciplinary approach to patient care. More often this involved the plastic surgeons visiting district hospitals away from their main plastic surgery regional hub, to attempt primary reconstruction as new techniques became available. Delayed reconstructions were carried out at the plastic surgery hub, which in the United Kingdom were often sited away from the district general hospitals. Plastic surgeons doing major flap surgeries in district general hospitals without 24-hour patient support from specialty trained staff put outcomes in jeopardy, and this was one of the reasons why regional plastic surgery units moved to larger district general hospitals in the early 1990’s. This eventually led to the concept of oncoplastic surgery training and the centralization of expertise in main hubs that could offer the best in oncology and reconstruction. Externally worn prosthetics were rudimentary at that time, and bra fillers were provided by occupational therapists and patients themselves. Maxillofacial technicians joined the team from the early 1980’s and that increased the options for improving aesthetics including nipple areola tattooing and customised solid silicone external prostheses and implants. In these post war decades, the mastectomy surgeons were General Surgeons with the primary intention of saving the patient’s life with patients often presenting late with larger visible, offensively smelly, metastatic, and protracted malignancy. There was very little solid data upon which to gauge outcomes, but the adage ‘first do no harm’ was sadly what happened in many cases. Reconstruction was not an option until the late 1970’s. Eventually data was provided that showed no benefit to radical surgery and the response was for surgeons to reduce the extent of surgical excision, with many offering skin and nipple sparing mastectomy, lumpectomy, cancer excisional mastopexy or even cleavage sparing mastectomy. One breast surgeon even went to prison for misleading patients (4) and radiotherapy protocols were developed and adjunct therapies became available. Now with tumour characterisation and increased understanding of tumour behaviour, surgical options can be tailored to the individual patient needs. The modern reconstructive surgeon should have a portfolio of reconstructive techniques, including microsurgery and a training in aesthetic procedures.

Plastic surgery started as a specialty because of celebrated pioneering reconstructive surgeons such as McIndoe and Gillies during the world wars (5), they only had skin grafting and local, regional or waltzing tube pedicle flaps as options for reconstruction. The specialty was much in demand and the British association of plastic surgeons was formed in 1946 with Sir Harold Gillies as president. The British Journal of Plastic Surgery first published in 1948 with AB Wallace as editor. The generation of McIndoe and Gillies were aware of the axial blood supply to skin by known vessels, such as the intercostals, that allowed extended length of skin flaps well beyond the 1:1 base to length ratio limit of random pattern flaps. The donor site usually was skin grafted, giving poor cosmesis. The challenge for that generation of plastic surgeon was to cover an exposed tissue that could not take a skin graft because of poor blood supply and fibrosis, typically seen in patients with post radiotherapy necrosis and exposed rib. They called this breast ‘replacement’ rather than breast ‘reconstruction’ because they understood that replicating the lost breast was not aesthetically possible. Little was known of the ‘vascular territories’ of perforators until described by Palmer and Taylor in 1987 (6).

Introduction of breast screening programmes in the UK

From the early 1980’s more was understood about breast cancer and the variability in patho-physiological behaviour (7). This fundamentally changed the approach to breast cancer management and in particular clinicians were finally understanding the futility of a radical aggressive approach to surgery in early-stage disease. Simple mastectomy, skin sparing mastectomy, segmental mastectomy, nipple sparing mastectomy, and lymph node mapping have all been became popularised in the hope of leading to less disfigurement without compromising risk of recurrence. From 1988 a general awareness of the condition encouraged women into attending the newly started UK mammogram screening programme. Some argue that the national screening programme has not delivered an improved survival rate, but at least this encouraged earlier presentation, earlier diagnosis, and the development of more appropriate reconstructive techniques that have improved the general wellbeing of most affected women. Today, management protocols include early detection screening, identifying genetic markers, judicious use of controlled and targeted radiotherapy; there have also been major advances in chemotherapy, hormone therapy, vaccine therapy and mRNA antibody therapy.

Methods

This paper is based upon the clinical experience of the senior author who was a medical student at St Bartholomew’s Hospital, London in the early 1970’s and trained in breast cancer and reconstructive surgery at University College Hospital, London and in leading provincial hospitals before specialty training in plastic surgery at the North West Thames and the North East Thames Regional Plastic Surgery Units at Mount Vernon and St Andrews Hospital, Billericay respectively until 1990. He was then appointed as a consultant plastic surgeon at St. Andrews and had a specialty interest in immediate and delayed breast reconstruction that also incorporated a practice in Harley Street, before retiring from his surgical practice in 2025. He has published extensively on topics including breast implants and breast surgery, trained many plastic surgeons and presented/demonstrated surgery on a national and international stage. He is currently a full Professor at the School of Medicine at the Anglia Ruskin University.

The principles of surgical reconstruction of breast

A breast reconstruction after mastectomy usually needs a minimum of three staged procedures to optimise the aesthetic result. The first two procedures intend to establish a satisfactory mound with symmetry to the remaining breast, and the third stage involves reconstruction of a nipple. The latter is best done independently once the reconstruction has settled and that allows the correct symmetrical placement of nipples. All reconstructive options are considered based upon the starting point and clinical management of the malignancy, i.e., if radiotherapy is required or if there is pre-existing musculoskeletal structural asymmetry. In general, the more aggressive the mastectomy, the older the patient, or the need for adjunctive therapy will likely complicate a reconstructive plan. For those women that have the option for a reconstruction, the first stage can be performed immediately at the time of mastectomy or delayed until the wounds have healed and decisions on oncologic care are made. The patient must be carefully counselled, and the surgeon only proceed to a reconstruction if the patient is realistic in aesthetic expectation (Figures 3-7).

Figure 3 Deformity resulting from a skin sparing mastectomy in 2005. There is a skin redundancy that has folded upon itself. Since 1990, primary reconstruction was being offered to women with a suitable staging of breast cancer presenting to breast surgeons partnering with plastic surgeons. In 2025, after a reorganisation of services over 10 years, most breast cancer patients are referred to oncoplastic trained breast surgeons, within a multidisciplinary team. Note the aesthetic considerations in this case should include a right mastopexy.

Figure 4 Residual deformity following a left simple mastectomy patient in 2005. Residual fat pockets possibly containing breast tissue create a challenge in obtaining significant aesthetic improvement. These pockets should be removed and a general rebulking of the thinned breast skin flaps may include a total resurface of the lower half of breast with a lat dorsi flap or a DIEP flap. DIEP, deep inferior epigastric artery perforator.

Figure 5 Residual deformity after simple mastectomy in 2008. An acceptable contour remains with even thickness of skin flaps. The high transverse mastectomy scar is inelastic on the chest wall and will create problems in the later phases of reconstruction.

Figure 6 Implant based breast reconstructions in an elderly woman where the right breast saline implant has deflated.

Figure 7 A bilateral mastectomy reconstruction patient in 2023. It shows the contrast in aesthetic outcome between a denervated right lat dorsi flap with smaller implant versus a simple mastectomy and reconstruction using a larger breast implant. The flap provides bulk and soft tissue mobility and a better result.

Space fillers

Over the past centuries women have attempted to cosmetically increase breast volume by injection of substances such as silicone, intralipid, hydrogels, hyaluronic acid and even ox cartilage. All caused problems and are confined to history. The first use of non-vascularised fat graft in breast reconstruction was reported in 1895 when Czerny transferred a remote lipoma into the space remaining after removal of a large breast fibroadenoma (8). There is no subsequent report on whether this lipoma survived without the calcification that occurs when large non-vascularised dermofat grafts are buried. Some UK plastic surgeons were using this now obsolete technique in the 1960’s and some patients even had rolled up cellophane strips inserted by surgeons to act as space fillers in their frustration at lack of surgical options. The senior author has experienced both scenarios in clinical practice. Autologous fat graft has gained in popularity and is harvested using a suction cannula technique and transferred with ’stem cells’ to fill out contour irregularities. These are not of course primordial stem cells (9). Fat graft survival is variable, with best estimates at 20% to 50% of adipocyte volume remaining after 6 months and regraft may be needed to refine the result (Figures 8-11). Occasionally it is possible to add volume using Integra^TM minus the silicone layer then use fat graft to blend visible irregularities as a 2-stage procedure (Figures 12-14). Other artificial (acellular) dermal matrix (ADM) templates derived from animal or human tissues are also used by some surgeons to support implant-based reconstructions.

Figure 8 Post-mastectomy result after healing of ultrathin skin flaps and retention of fat causing visible unsightly contour defects, possibly also containing breast tissue.

Figure 9 Fat graft has been harvested into syringes using a small cannula prior to rigotomy and injecting into a contour defect within a breast reconstruction.

Figure 10 This is the same patient as in Figure 8. She has developed a medial soft tissue defect that is difficult to hide even in bra. The underlying implant has displaced laterally in the subpectoral plane. This displacement is in part because of repeated muscle contracting forces, but also because the Levick’s retaining ligament in the axilla had been disrupted during the original mastectomy and the natural lateral support has been weakened.

Figure 11 The same patient as in Figures 8,10, 24 months after fat graft and areola tattoo.

Figure 12 Encapsulation around heavy implants that are surrounded by lax tissues, plus a natural gravitational force, can cause lower pole sublaxation of the implant. In this elderly lady, it has exposed an upper pole contour defect. Integra^TM, minus its silicone surface, was used to simply fill the void.

Figure 13 Fine and coarsely textured silicone implants were used in the UK despite the controversies from 1992 to 2006. The latter has been associated as rarely causing BIA-ALCL and has thus been removed from the market. Conical polyurethane implants were used from 2006 to 2015 with evidence of reduced capsular contracture rates and reoperation rates. A polyurethane implant was used to bulk this woman’s left breast implant that had been inserted almost 10 years previously. The unaffected right breast has enlarged over the years to reveal an asymmetry that needed correction. Polyurethane conical implants were voluntarily withdrawn by the manufacturer in Europe in 2015, but in 2025 they have been reintroduced because of an excellent safety profile for use in reconstruction. BIA-ALCL, breast implant associated-anaplastic large cell lymphoma.

Figure 14 The same patient as in Figure 13. The soft tissue defect has been filled with a larger implant, and autologous fat graft to improve the contour.

Silicone breast implants

The historical use of silicone products in breast reconstruction is worthy of note and relevant to future developments. The journey that mastectomy patients take if implants are used remains a concern because of short- and long-term problems that are likely to present. They are however an important option in the reconstructive ladder. Following the cosmetic disasters seen after injecting liquid silicone into breast, Cronin and Gerow in 1962 used an anatomically shaped, transparent, smooth walled silicone bag to hold a liquid silicone gel (10). In the absence of proper Food and Drug Administration (FDA) scrutiny, a product line was developed and breast augmentation using these implants were made available to women in the USA and overseas. However, within only a few years disaster followed as silicone induced complications such as silicone granulomata, calcified capsular contracture and shell rupture became apparent. Silicone implants became subject to a moratorium by the FDA in the USA in 1992 causing Dow Corning and other manufacturers to enter liquidation after successful corporate litigation. Despite this the demand for breast augmentation remained, so more sturdy silicone shells filled ‘on-table’ with saline as the alternative to liquid silicone were introduced. These ruptured and often deflated at inconvenient times, but they were deemed safer than silicone implants. The FDA finally approved the use of silicone filled implants for use in the USA and Canada in 2006 after the submission of longitudinal study data sets by the two manufacturers still in business. Only one global company in Brazil continued to produce silicone implants and silicone implants with a polyurethane foam layer. Polyurethane implants have not gained FDA approval for use in the USA and Canada but remain popular in other countries. In the UK, polyurethane breast implants have proven to be very useful in breast reconstruction and augmentation, with a significantly lower incidence of capsular contracture rate with less need to insert them in a submuscular plane when there is adequate soft tissue cover (Figures 15,16).

Figure 15 Three commonly used silicone implants used in the UK between 1992 and 2018. The outer two implants are coarse textured implants (round and anatomical shape), and the middle implant is a conical polyurethane coated silicone implant.

Figure 16 Outcome study from use of polyurethane breast implants reveal a very low capsular contracture rate and very low complication rate within a 7-year follow-up period with over 900 patients.

Quality control testing of silicone implants was variable between nations and generally only FDA approved products were encouraged for use in the UK. However, the UK Medicines and Healthcare Authority (MHRA) and European CE Mark regulatory bodies also approved the use of other implants into the European market, including polyurethane coated implants made in Brazil and more recently in Germany. This approval was needed because of their designation as a Class 111 (high risk) medical device.

Implants are still inserted in primary mastectomy reconstructions, but also secondarily to reconstruct a breast mound when there is healthy and adequate soft tissue cover or to augment a low volume flap reconstruction of breast. Dow Corning implants were first used in the UK for some breast reconstructions in the late 1970’s and the original implants were smooth, anatomically shaped with a fabric tag designed to prevent rotation. They were nearly always used in delayed/secondary reconstruction of the breast, but the results were generally poor and ruptured implants released a liquid form of silicone that caused significant problems from granuloma formation. The tags became fixed within the tissue response causing the implants to frequently rupture due to shear forces where the remaining implant was mobile within a smooth walled fibrous capsule. Capsular contracture and its consequences were seen in all patients (Figure 17), and to try and counter this, implants were placed into a sub-pectoralis major plane, that sometimes included a sub-serratus anterior plane, to get better soft tissue cover (11). The intention was always to get the best cosmesis possible and residual asymmetries were corrected using external adjuncts and nipple prostheses and nipple reconstructions (Figures 18-22).

Figure 17 This young patient had an implant-only breast implant reconstruction after a simple mastectomy in 1979. The anatomical shaped Dow Corning implant has encapsulated, displaced and presents with an undisguisable rock-like hardness on the chest wall.

Figure 18 It is important that in a bra the symmetry of the reconstructed breast is as close as possible to the natural, sometimes ptotic uplifted breast. This patient is comfortable in her bra.

Figure 19 The result after simple mastectomy with reconstruction of the right breast using a silicone textured implant in 1996 and completion of the aesthetic appearance with a customised silicone stick-on nipple made in the maxillofacial department.

Figure 20 First-stage nipple reconstruction in 2023. A shared nipple graft provides the most natural appearance, but should only be considered for using if the donor nipple is well projected in a non-simulated state, otherwise a retracted donor nipple will be the outcome.

Figure 21 Where a contralateral nipple graft is not possible and the skin cover over an implant is under tension, so excluding the use of local flaps, consider using a composite graft from the tragus as shown in the case.

Figure 22 The same patient as in Figure 21 having completed the areola reconstruction using a semipermanent tattoo. This result is at 6 months following the procedure, but the colour may need freshening over time to maintain the appearance.

To counter problems associated with sweating of the low viscosity silicone liquid used to fill these implants after 1992 the shells were made more sturdy using a multilayer dipping technique and either finely surface textured on the outer layer by using the negative imprint from removal of polyurethane foam, or more coarsely texturing the surface using a salt extraction technique. The silicone gel being used as filler was made more viscous and re-labelled as a cohesive gel. A range of anatomically shaped implants became available. These implants were manufactured in factories in the USA, Ireland and Holland and sold globally (except in the USA and Canada), especially within the UK even though they were not approved for use in the USA until 2006. In 2016 implant controversies re-appeared in the media and micro-particles and impurities on the surface of implants became the issue. More coarsely surface textured implants were then either withdrawn or banned for use again by the FDA in 2019 due to the recognition of an association with anaplastic large cell lymphoma (ALCL) (12). This has not stopped the emergence of other silicone implant manufacturers despite concerns on silicone toxicity, silicone associated autoimmune disease and safety of silicones in general. Breast implant associated-ALCL (BIA-ALCL) has been formally recognized as a rare association with textured implants, but more recently breast implant associated squamous cell carcinoma (BIA-SCC) has also been reported and associated with smooth implants. BIA-ALCL is seen in rare instances in equal ratios in both reconstructed cancer patients and aesthetic patients with a guestimate incidence of 1 in 25,000. Polyurethane covered silicone implants have a reported incidence of about 1 in 150,000 women, although data is skewed in some reports by controversial Australian data (10).

Polyurethane breast implants have been mired in controversy around a debatable association and causation of BIA-ALCL, and a purely theoretical human risk of developing sarcoma caused by release of 2,4-toluene diamine (2,4-TDA) as the polyurethane naturally disintegrates (10). Neither link has been validated. Saline or dual compartment tissue expanders were also in vogue as they became available in the UK from mid-1980, but their claimed ability to create skin ptosis by overexpanding then replacing with a smaller silicone implant or beneficially using saline in preference to using silicone as filler has turned out to be false. Saline filled implants or expanders frequently rupture within 10 years and deflation requiring further surgery and perhaps financial costs that can cause much distress (Figure 23). There is a still ongoing controversy with silicone breast implants and silicone-associated-illness and over time it should be expected that all implants will need replacing or removing although further surgeries may not always be necessary nor desired.

Figure 23 A ruptured coarse textured double compartment silicone gel and saline tissue expander.

General principles and areola reconstruction

In many respects all breast reconstructions are about trying to create a mound that looks reasonable and is a mirror image to the other side, especially in a bra (Figures 18,19). It is unlikely there will be a normal looking sensate, soft, ptotic breast following ablative surgery in larger breasted women using implants alone and complications will be higher. However, for slim, small breasted women with no contralateral ptosis a small implant can give an excellent mound onto which a 2-stage nipple reconstruction using a composite chondro-cutaneous graft harvested from the ear tragus and a colour matching tattoo can give an excellent result. The colour will however change over time and further tattoo may be requested. An alternative method of forming a projecting nipple involves the use local skin flaps, but these will flatten over time especially if the closure is tight. Nipple areola tattooing is now widely used to complete a breast reconstruction.

History of autologous tissue use in reconstruction of a breast

Pedicled flaps

Islanded fasciocutaneous flaps, such as the scapular flap or local tissue transpositions have an occasional place in filling soft tissue contour defects in breast. Olivari, presenting at the British Association of Plastic Surgeons in 1974, introduced the latissimus dorsi myocutaneous flap to the UK (13) (Figure 24), although Tansini in 1896 had first described use of a latissimus dorsi flap for covering a chest wall defect (14). The Olivari flap revolutionised the focus of reconstruction away from the use of omental flaps or thoracodorsal transpositions in irradiated patients where local flaps were often doomed to failure. The provision of healthy soft tissue to the mastectomy defect enabled the combined use of silicone implants with flap coverage in breast reconstruction or the replacement of painful radionecrotic tissues with healthy soft tissue. To avoid abnormal muscle movements within the latissimus dorsi flap on the chest wall, the muscle is often detached from its origin and denervated. With well sited donor scars on the bra line this was the ideal and easiest way to get a good and acceptable reconstruction as a one stage procedure with low risk at that time (Figure 25). Cases of tumour spill into the space vacated by the latissimus dorsi started to appear in the literature (15) and others suggested that recurrence of tumour was more likely with extended time spent under anaesthesia, tumour site in relationship to skin, excisional margins and with blood transfusion (16-18). Further disadvantages were that patients needed to be transferred from a lateral position for flap harvest, and back to a supine position under the same anaesthetic to inset the flap, seromas were common, and implants were nearly always necessary (Figures 26-29). To circumvent the need to turn patients during the procedure and use more bulky tissues without implants, there is a cohort of patients that benefit from the use of abdominal wall vascularised pedicle flaps (Figures 30-33), as first described by Hartrampf in 1982 (19). This flap gave an option to the patient to avoid the risks associated with silicone breast implants. These flaps involved using the contralateral rectus abdominis muscle as a vascular conduit with a skin paddle fed by periumbilical perforators from the superior epigastric artery. Where blood supply and venous drainage were recognized to be poor a double pedicled superior epigastric flap was occasionally used. The disadvantages are the extensive time-consuming surgery involved and the significant donor site morbidity over and above the known complications of abdominoplasty (20), that may include upper abdominal wall bulging that will require mesh reinforcement (21), communication of the mastectomy space with the flap donor site via the subcutaneous tunnel, seroma, haematoma and an extensive donor site scar. In slim patients with little body fat, abdominal wall weakness is likely to be more obvious post operatively, and still there may be a need for a silicone implant to get volumetric symmetry. Many now argue that surgery to correct symmetry is best adopted by operating on the contralateral breast once the optimal volumetrics and positional reconstruction has been achieved, rather than pushing the reconstruction further. ‘Tailoring’ the contralateral breast is a separate skill altogether.

Figure 24 A diagrammatic sketch showing the extent of the latissimus dorsi muscle. The skin paddle should be raised and contain a sufficient portion of muscle cuff so that the flap edges can contour over an implant without leaving visible edges.

Figure 25 A latissimus dorsi flap donor site should be premarked so that the wound heals with a scar in the bra line, as in this case. Appropriate direction of scar should be made for women likely to wear a bikini bra top which should have a horizontal scar, and an all-in-one swimsuit where an oblique scar may be more appropriate.

Figure 26 Contralateral breast surgery is often considered during the reconstruction process to improve aesthetic outcomes. This lady presented in 2023 and has a mature left latissimus dorsi breast reconstruction with implant and a shared nipple graft with areolar tattoo and a vertical scar mastopexy scar on the contralateral breast. However, there is a waterfall ptosis of soft issues over the lower half of the reconstructed breast that could be improved by fat graft. In criticism the muscle flap has been inset slightly too high at the time of initial reconstruction.

Figure 27 Same patient as in Figure 20, presenting over 1 year later with good symmetry and of mound and nipples.

Figure 28 This figure shows an elevated latissimus dorsi flap with attached skin paddle.

Figure 29 Same patient as Figure 22. The flap is being tunnelled through Levicks triangle into an anterior position.

Figure 30 This lady shows the importance of implant selection and implant positioning, together with correct positioning of the latissimus dorsi muscle and the skin paddle.

Figure 31 An elevated bipedicle TRAM flap in a woman having bilateral mastectomies. The flap has been raised with both superior epigastric arteries. The flap will be divided centrally to enable each vascularised flap to be tunnelled into each respective side of the anterior chest wall. TRAM, transverse rectus abdominis myocutaneous.

Figure 32 The lower half subcutaneous hemi-mastectomy has left this lady with a considerable deformity and a contracted, malpositioned left nipple.

Figure 33 An inferior epigastric artery free flap was used to reconstruct the soft tissue defect shown in Figure 32. The flap has elevated and supported the nipple complex with an excellent result.

Free flaps

In 1973, Taylor and Daniel published the first vascularised ‘free flap’ (22). This turned out to be the breakthrough that enabled microvascular trained Plastic Surgeons and others to raise and revascularise composites and chimeras of any autologous tissue. Allogeneic and even xeno-composites of tissues and organs are now routinely transferred, however an immunosuppressive drug regime for life is mandatory and this itself can cause problems, meaning that it is unlikely to be available for breast reconstruction when there are now reasonable safer autologous alternatives. With regards to volumetric breast reconstruction, the clear advance has been with the ability to move and revascularise extensive amounts of living fat attached to large amounts of skin from the abdominal wall, based on muscle perforators and the long vascular pedicle of the inferior epigastric artery. The flaps are revascularised under magnification during microsurgery. In many cases now the preferred donor site is from the abdominal wall based on blood vessel perforators originating from the inferior epigastric artery sited behind the sub umbilical portion of rectus abdominis muscle. When harvested with a cuff of rectus abdominis muscle, it is a free ‘transverse rectus abdominis myocutaneous (TRAM)’ flap and when no muscle is included in the transfer, it is known as the deep inferior epigastric artery perforator (DIEP) flap (Figures 34,35). The literature is divided on who first described this free flap and this conundrum is described as the ‘Theory of Nultiples’ (23-25). Segmental denervation though may lead to a weakness of the abdominal wall with the development of a bulge when standing and coughing, so care must be taken. Fat necrosis does occur and revisiting anastomoses to salvage flap blood flow in the post-operative period is not uncommon. Flap failure rate should be between 1% and 5% but this is also dependent on the experience of the Surgeon and the specialist team members. The donor site scar is placed as low as possible on the abdomen and the umbilicus is re-sited. There is no communication between the reconstruction and the donor sites and drains should be unnecessary. The disadvantage is related to the longer duration of the surgery (3 to 6 hours) and of course the patency of the anastomosis directing blood flow into and out of the free flap, but the results from a successful DIEP flap reconstruction can be very acceptable over the long term (Figure 36). Often a breast surgery team and a plastic surgery team work together to speed up the procedure, but the anaesthetist greatly assists in maintaining body heat and perfusion to the flap with pharmacologic manipulation (26). Despite this, returns to theatre for revision of anastomosis or flap loss will happen in a small number of cases with devastating emotional and aesthetic effect. This disaster is psychologically difficult for patients because in addition to coping with the oncosurgery there is now a large donor site with serious morbidity that even with best cosmesis is not aesthetically comparable with the results from a ‘Modified Brazilian Abdominoplasty’ (27). Patients are sometimes inadvertently misled or fail to register risks, preferring to hear that they get a tummy tuck with a DIEP reconstruction. Patient selection and pre-operative counselling is vital to help in overcoming the psychological impact of a reconstruction that may result in asymmetry with the unaffected breast and remain insensate and a source of future surgeries. Smaller tissue defects caused during a segmental, skin sparing mastectomy, or partial mastectomy, can be filled with customised free flaps from the back, groin, buttock or inner thigh to try and reduce donor site morbidity. Other perforator-based flaps are available and perhaps more suitable in certain circumstances. These include the superficial inferior epigastric artery (SIEP), superior gluteal artery perforator (S-GAP) and inferior gluteal artery perforator (I-GAP) muscle sparing flaps (28).

Figure 34 A diagrammatic sketch showing the relevant anatomy of the DIEP flap. There is little disruption of the rectus abdominis muscle, and the inferior epigastric artery can be easily found behind the lower segment of rectus muscle to reveal the main muscle perforators supplying the skin paddle. DIEP, deep inferior epigastric artery perforator.

Figure 35 This is the UK’s first DIEP flap raised in 1992. There are clear advantages, but also disadvantages to consider the use of this flap, not least of which are the financial implications to the health service. DIEP, deep inferior epigastric artery perforator.

Figure 36 The long-term result of left breast reconstruction using a DIEP flap showing a mature scar and good cosmesis. Not all patients want to complete the reconstruction with nipple surgery. Long-term results are sustainable, and the patient is unlikely to require further procedures. This contrasts with the strong likelihood of a patient needing secondary work after implant-based reconstructions over the lifetime of the patient although at the time of mastectomy; in selected patients, they can the simplest and safest option. DIEP, deep inferior epigastric artery perforator.

Conclusions

The inherent risks of aggressive surgery have been known by surgeons for centuries (29), but contemporary improvement in the management of breast cancer has enabled reconstructive surgeons to greatly improve the wellbeing of many women and deliver acceptable aesthetic outcomes. However, breast reconstruction is an expensive and demanding procedure and can be problematic, with a significant morbidity in some patients. Any advance in breast cancer research that could reduce dependence on surgery should be encouraged. An increased understanding of the pathology, earlier diagnosis, advances in genomics, tissue engineering and especially research into exosomes, genetics and anti-tumour vaccines could be the future. The latter has shown potential in successfully treating some solid malignancies with little collateral damage to normal tissues (30-32) and may be able to influence future management of breast cancer. Today, the ability of surgeons to transfer and revascularise composites of autologous tissues will give the best long-term outcome in women undergoing immediate mastectomy reconstruction, but is especially advantageous for women having a secondary reconstruction after radiotherapy.

Acknowledgments

None.

Footnote

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-262/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-262/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Written informed consent was obtained from the patients for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

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