The Background - Part II

Current statistics indicate that one in eight women will be diagnosed with breast cancer at some point during their lifetime and the National Cancer Institute projects that 226,870 new cases of invasive breast cancer will be diagnosed among women and approximately during 2012 (NCI, 2012). While newly diagnosed invasive breast cancer rates have mostly stabilized since 2003 and mortality rates have declined by 2.2% per year from 1990 to 2007 (American Cancer Society, 2011), breast cancer is still one of the leading types of diagnosed cancer. The last two decades has led to overall greater survivorship rates mostly attributed to cancer treatment breakthroughs and improved early detection of the disease, sometimes one to three years before symptoms of disease would be noticeable (ACS, 2011). Although likelihood of survival has increased, it is difficult to put into words the emotional and physical trauma that women endure upon receiving a diagnosis and their battle with cancer.

One form of treatment that has increased likelihood of survivorship is the use of surgery, in particular total mastectomy (removal of the whole breast) or radical mastectomy (removal of breast, lymph nodes, and chest muscle). Every year, 80,000 or so women have one or both breasts removed for a cancer-related condition in the United States.

Dr. William Halstead

Referring to the timeline I created on another website, instances of breast cancer have been reported as early 1600 B.C.E. in Egypt, but at the time treatment for the disease involved cauterizing the cancerous cells. Oftentimes, women would not survive the procedure. Thus, reports indicate that women opted out of  treatment and instead lived with the disease. 

The first radical mastectomy was performed by Dr. William Halstead in 1889, but Halstead refuted the proposal of breast reconstruction, insisting it was a "violation of the local control of disease" and insisted secondary operations not occur on the mastectomy site for fear of "sacrifice[ing] the patient to disease." Approaching cancer treatment from a strict medical prospective to completely eliminate the disease, Halstead set a precedent for radical mastectomies that focused on sacrificing the entirety of breast tissue (including lymphnodes, part of the chest wall, and in some circumstances, parts of the rib) to ensure likelihood of patient survival. Halstead's authority in the field limited the experimentation with breast reconstruction for nearly 100 years, his teachings so predominant that successful attempts at breast reconstruction utilizing muscle and musculocutaneous flaps (using muscle, tissue, and skin) went largely ignored. However, of the women and surgeons willing to attempt reconstructive work, oftentimes it required multiple surgical visits, increased scarring, and failure of the musculoucutaneous flap methods.

Reportedly, between 1910-1964 about 90% of US surgeries for breast cancer were Halstead mastectomies. What much of the medical discourse during those times seemingly failed to acknowledge however was the extensive disfiguring effects of Halstead's radical mastectomies for women. [A picture of a Halstead Mastectomy]. The late 1960s and early 1970s saw the advent of surgeons attempting tissue-sparing mastectomy procedures that sought to contain tissue removal to just the infected areas instead of Halstead's total eradication method. This method was promoted after research demonstrated that  Halstead's original procedure of radical mastectomy offered no improvement in survival rates in comparison with the less invasive and modified forms of radical mastectomy.

Timmie Jean Lindsey in 1962 before surgery

The next major turning point in the history of breast reconstruction occurred in 1962 when Thomas Cronin & Frank Gerow worked with the Dow Chemical Company to create the first silicone breast implant. Following World War II, Dow Chemical Company explored commercial uses for silicone and collaborated with the Houston area surgeons after they discovered that silicone implants were more pliable and "life-like" than the options available at the time.  Timmie Jean Lindsey was the first woman to receive the new silicone breast implants, originally designed for women who had undergone mastectomy. In an interview she conducted with the UK Daily Mail back in 2007, Lindsey discussed being approached to become a test case for surgery that she did not need at the time, nor necessarily desire. Lindsey had originally entered the Houston area hospital to have tattoos on her breasts removed and was instead told by Gerow that she would be an ideal candidate for a new procedure to reportedly help women with "sagging breasts." According to the interview, it was likely that Gerow was playing on Lindsey's insecurities and had wrangled up additional test subjects in a similar manner, including wives of medical students, without fully informing them of risks of the procedure or possible side effects. A colleague questioned if Gerow and become so insistent with the treatment because Gerow "liked big breasts" and needed to compete with surgical colleagues who had been in the process of creating heart implants.

Timmie Jean Lindsey in 2007 at age 75

What is perhaps most intriguing about this time period is that none of the articles evaluated for this post identify actual women who received implants because of previous mastectomy operations. Most describe the initial Dow Cronin-Gerow implants as being used for elective plastic surgery breast augmentation. So although Cronin & Gerow may have suggested that women who had undergone mastectomies would benefit from the development of the implant, the largest benefactors were the surgeons and chemical companies, including Dow, that were financially compensated with women's increasing bust lines. However, Lindsey reported that she has taken comfort in the fact that her contribution to medicine has aided "thousands of women," including her own granddaughter that underwent a double mastectomy in her breast cancer treatment and full reconstruction.

As difficulties and health concerns related to silicone implants began to surface, other forms of reconstruction began to appear in the 1980s, including the TRAM and DIEP musculocutaneous procedures. Breast reconstruction began to include discussion on nipple and areola recreation, and has largely relied upon medical tattooing since 1986. Since the shift to break-conserving surgeries, and the 1980s, women have had fewer breast scars, greater preservation of natural skin color and texture, and "reduced operating time, fewer revision surgeries, and greater patient satisfaction."

Latissimus Dorsi Flap

Psychologists in the early 1970s recommended that women should wait before pursuing reconstruction options so that they were given "time to grieve for the missing breast [and] to accept the loss" so that when a new breast was constructed they would have greater acceptance of the new form and higher body image satisfaction (Harcourt & Rumsey, 2001). Conversely, research performed in the mid-90s proposed that women opting for immediate reconstruction might actually be indicative of a positive adjustment to the diagnosis. However, contemporary research indicates that there is not necessarily an "ideal" time for reconstruction (immediate vs. delayed reconstruction), and that satisfaction with the outcome of the procedure is generally high regardless of when the surgery is performed (Harcourt & Rumsey, 2001). 

Current breast reconstruction options include mammary implants and/or expanders and tissue flap procedures. And while surgical advances have been made for treating breast cancer and reconstructing the lost tissue, no degree of surgery will provide a physically functioning or physiological attributes of a natural breast. Furthermore, there are inherent risks and side effects of each form of reconstruction procedure. With this in mind, according to Harcourt & Rumsey (2001) "electing to undergo breast reconstruction therefore carries with it the potential for significant physical and psychological benefits but also the chance of profound physical and psychological distress.” 



Harcourt, D. and Rumsey, N. (2001), Psychological aspects of breast reconstruction: a review of the literature. Journal of Advanced Nursing, 35: 477–487. doi: 10.1046/j.1365-2648.2001.01865.x