Over the past 40 years, breast restoration following breast removal for cancer has been transformed from a rarity to the standard of care in major U.S. cancer centers. Concurrent with this development have been changes in extirpative surgical practices, medical and radiologic cancer treatments, and financial and political factors impacting the management of breast cancer. Significant among the latter was the passage of the Women's Health and Cancer Rights Act (WHCRA) in 1998. This federal law was inspired by the case of a woman from Long Island, New York who was denied breast reconstruction coverage by her insurer on the grounds that the company considered it to be a “cosmetic” rather than “medically necessary” operation. The WHCRA mandates that health insurance companies and group health plans which cover mastectomies must also provide coverage of mastectomy-related procedures, including breast reconstruction surgery, prostheses, and procedures to restore symmetry in the contralateral breast.1 The practical implication of this law is that, with few exceptions, every woman who now undergoes a mastectomy covered by her insurer also has coverage for subsequent breast reconstructive procedures. The authors feel strongly that every woman who undergoes a mastectomy should at minimum be offered a consultation with a reconstructive surgeon to discuss the possibility of breast reconstruction, preferably prior to any breast surgery so as to optimize the eventual outcome.
The frequency of breast reconstruction, and the techniques used, has been greatly impacted by changes in the surgical treatment of carcinoma of the breast. Radical mastectomies, so common a half-century ago, are performed only rarely today. An increasing emphasis on breast conservation means that for many patients, lumpectomy or quadrantectomy are deemed sufficient to gain surgical control of their cancers. Many of these patients will do well from an aesthetic standpoint, with no reconstruction needed; in those cases where a significant partial breast deformity necessitates reconstructive surgery, autologous tissue flaps or fat grafts are the preferred techniques.2 The reconstruction of the conserved breast will not be discussed in this chapter, which focuses on implant-based reconstruction after mastectomy.
For those patients with breast disease requiring a mastectomy, or those who mastecctomy amonst different treatment options, the use of modified radical and simple mastectomies and the techniques of skin-sparing and nipple-sparing have resulted in defects that are more amenable to reconstruction than in the days of Halsted. Simultaneously with the development of these techniques, the technology of prostheses for breast reconstruction has evolved since the early use of breast implants in the 1960s by Cronin and Gerow.3 The use of tissue expanders (TEs) and breast implants has been successful to the point where the majority of breast reconstruction done in the United States at this time is implant based.4 Alternative means of breast reconstruction, including flap-based reconstruction and autologous fat grafting, are discussed in Chapters 155 and 158, although we will touch upon the factors that may make one choose these options over implant-based reconstruction.