It was not until the late 1960s that strong evidence became available to prove that a less deforming operation was able to deliver similar rates of survival and local recurrence [10].

The third driving force that affected the change to a less deforming operation was the more frequent diagnosis of less advanced disease that did not require radical surgery. Shortly thereafter, evidence was presented that even less aggressive surgery (lumpectomy) followed by radiation therapy offered similar survival rates to mastectomy. Although conserving the breast, radiation therapy was necessary to provide comparable outcomes. In the United States, this external beam radiation was administered at 6,000 gray, although in Europe the dose was normally 4,500 gray. The number of patients in the United States who choose breast conservation (lumpectomy, followed by radiation therapy) has recently declined. This is in part due to many patients not wanting to undergo adjuvant radiation therapy after lumpectomy, partly due to the time commitment required and partly due to the adverse side effects associated with radiation therapy to the breast. The use of radiation therapy, which in the United States is normally given as 4500 gray with a “boost” of 1500 gray, has produced unfortunate radiation induced deformities in the residual breast (Fig. 17.2).

The concept of a skin-sparing mastectomy originated with Freeman in 1962. He suggested a modification of the traditional mastectomy before an implant-based breast reconstruction for benign disease [11]. The skin-sparing mastectomy as a cancer procedure was further described by Toth and Lappert in 1991 [12]. They described preoperative planning of mastectomy incisions to maximize skin preservation and to facilitate breast reconstruction. These modifications in tissue removal have made reconstruction much simpler to achieve. Along with the abandoning of the radical mastectomy in favor of the skin-sparing modified radical mastectomy, other devices were introduced to assist in reconstructing the breast mound.

An important milestone was the development of the silicone breast implant by Cronin (originally for breast augmentation) [13]. The concept of providing a breast mound substitute without a donor site was immediately attractive and popular with patients. Breast augmentation with silicone implants provided far superior results than previous materials, and it seemed possible to use the implants within the mastectomy defect. Unfortunately, postmastectomy reconstruction and augmentation are two very different surgical situations. In the augmentation patient, there is normally ample soft tissue coverage and supple skin. In the mastectomy patient, thinner flaps are the rule and the breast tissue is absent. This results in a lack of adequate soft tissue coverage over the implant, sometimes resulting in significant postoperative complications. These problems included a high rate of capsule contracture, exposure of the implant, deformity from skin rippling over the implant, frequent revision operations, and displaced implants.

The concept of tissue expansion developed by Radovan was an important step. The use of expanders could “recruit” additional soft tissues (skin, fat, and muscle) that attempt to make up for the deficiencies following mastectomy. In fact, the most common use of tissue expanders currently is in breast reconstruction [14]. An effort to improve the soft tissue envelope led to developing procedures that provide “total muscle” coverage of the implants using the serratus as well as the pectoralis muscle. The use of tissue expanders and the use of flaps were utilized to improve the soft tissue envelope. Although these efforts reduced the deformity from skin irregularities and exposure of the implant, the problems with capsule contracture and long-term failure of the reconstruction continued.

Acellular dermal matrix is a biologically altered product that is harvested from cadaveric donors and then processed to remove the cells. It has become popular as an adjunct to soft tissue coverage over the lower third of implants and expanders in cases of immediate breast reconstruction. These materials require no donor site and act as a dermal brassiere to help cover and support the implants. All of these efforts have improved the results of non-autologous reconstruction, still the most common procedure for breast reconstruction undertaken in the United States. Unfortunately, there is still a relatively high failure rate, both short and long term. The FDA post-approval CORE studies of breast implants describe, “between 20–40 % of augmentation patients and 40–70 % of reconstruction patients had re-operations during the first 8–10 years after they received their implants. Although routine replacement is not necessary, many women will need additional surgery to modify, remove, or replace their implants.” Additionally, 17 % of patients in whom implants were used for reconstruction had their implants removed without replacement [15].