Future of Breast Reconstruction

Scientists have now been searching for the cure for cancer for over a century. While significant advances have been made, most researchers agree that we are still a number of years away from completely eradicating the disease.

However, many forms of cancer, including breast cancer, can be successfully treated, if caught early. To aid detection, regular screening and physical examination are essential, before the cancer has had an opportunity to spread to other areas.

The traditional methods of breast cancer treatment involve cutting tumors out with a knife, burning them with radiation or killing them, cell by cell, with chemotherapy. All these treatment modalities may distort or significantly alter the appearance of the breast. This may affect breast function (reproduction and lactation), breast aesthetics and the emotions or psychology of our patients.

Plastic surgeons are uniquely equipped to deal with the complex reconstruction of the breast. Based on the defining principle of replacing ‘like with like’ perforator flaps represent the current ‘gold standard’ of reconstructive options.
The essential component of perforator flap surgery is an intimate understanding of the blood supply of tissues and a customized approach to their transfer, offering the best functional and aesthetic outcome to our patients with the least donor site morbidity.

Since the early 1990’s, perforator flap surgery has blossomed and the number of citations in the world’s scientific literature has increased exponentially. This is due to the high success and patient satisfaction that this technique delivers.

Over the next decade further application will undoubtedly improve our understanding of potential flap designs, indications, contraindications and potential results. With communication and careful clinical study, plastic surgeons will further refine perforator flap surgery in the field of breast reconstruction.

Unfortunately, significant controversy still exists surrounding the financial implications of providing perforator flap surgery for breast reconstruction patients. The learning curve is steep and novice surgeons may take more time to dissect these flaps than the more conventional musculocutaneous approach. This means heavier initial investment, both in real and financial terms, from insurance companies, hospitals, surgeons, and patients. In the current climate of health care cutbacks, it is not always easy to justify the long-term benefits to insurers, administrators or even colleagues. However, substantial evidence exists supporting the cost-effectiveness of perforator flaps for breast reconstruction and in our opinion, the long term clinical benefits for our patients are so important that this investment of time and money is absolutely essential.

The perforator flap concept is equally applicable to the transfer of whole units of tissue. As outlined in Ian Taylor’s angiosome theory, tissue including bone, muscle, tendons, fascia and nerves can be transferred on a single blood vessel. The extrapolation of this is that surgeons can harvest other tissues, in addition to skin and fat, to augment a reconstruction, where deficiencies exist. Attempts are being made to transfer large volumes of fat to the breast but without this source blood vessel and rich vascularized network in place, long term fat survival has so far been disappointing.

Recently, allotransplantation (the transfer of tissues from one human body to another) of the larynx, face, arm and hand, has been employed worldwide with excellent results. The main restriction in its adoption is the difficult problem of immunosuppression, as foreign tissue is always rejected by the body. If this can be overcome, we may soon be in a position to surgically transfer subunits of tissue including the ear, nose, thumb or even breast.

However, applying the principles of perforator flap surgery in future allotransplantation is probably just an intermediate step in the whole new area of “regenerative medicine”. Instead of transplanting tissues within the same body or from a different person, we may soon be able to generate tissues in a laboratory environment, both small and large or simple and complex. “On demand” tissue could possibly be grown depending on the exact type, size and composition of the defect. Harvesting of tissues will no longer be required, avoiding complex surgery and unsightly donor area scars. More importantly, no immunosuppressive drugs will be required.

That being said, a perfect knowledge of vascular anatomy and in particular, the perforator vessel network will be absolutely crucial to manufacture these tissue units. We strongly believe that the work of the perforator flap surgery pioneers and their clinical experience in autologous tissue transplantation will be the cornerstone of future vascular constructions and modern complex tissue engineering.

It is difficult to say exactly how far we are away from this dramatic revolution in tissue replacement but once we are able to build a three-dimensional vascular structure comparable to the subcutaneous perforator vessels, the gateway will be open to the creation of autologous, tissue engineered, complex and implantable 3-dimensional composite tissues, announcing the arrival of a whole new era of tissue transplantation.