Hardly any field of surgery has changed as much over the past 130 years as breast surgery. A mutilating cancer operation has become a discipline in which tumour removal and restoration of the breast’s shape go hand in hand. An overview of the most important milestones.
The era of the radical mastectomy
At the end of the 19th century, the US surgeon William S. Halsted developed the radical mastectomy: removal of the breast together with the pectoral muscles and axillary lymph nodes. This major operation only became possible with the introduction of anaesthesia (1846) and antisepsis. The operation reduced the rate of local recurrence but was very burdensome and left considerable functional impairment. For almost a century, it was considered the standard.
The shift to breast-conserving therapy
From the 1970s onwards, large trials – such as those of Bernard Fisher (NSABP B-06) in the USA and Umberto Veronesi in Milan – showed that breast-conserving surgery combined with radiotherapy is as safe as removal of the whole breast for many women. The long-term results of both trials were published in the New England Journal of Medicine in 2002. Today, breast-conserving therapy is the standard for most women with early breast cancer, supplemented by sentinel lymph node biopsy, which often makes complete axillary clearance unnecessary.
Early reconstructions with autologous tissue
- In 1895, the Heidelberg surgeon Vincenz Czerny transplanted a lipoma (benign fatty tumour) into a patient’s breast – one of the first documented breast reconstructions.
- In 1906, the Italian Iginio Tansini described the latissimus dorsi flap from the back to cover the defect after mastectomy. The technique was forgotten and rediscovered in the 1970s.
- In 1982, Carl Hartrampf introduced the TRAM flap: skin and fat from the lower abdomen, supplied via the rectus abdominis muscle.
The silicone implant
In 1962, the Texan surgeons Thomas Cronin and Frank Gerow implanted the first silicone gel-filled breast implant. Saline implants, implants with a textured surface and form-stable (“cohesive”) gels followed. The history of implants is also a history of safety debates: in the 1990s, the US Food and Drug Administration (FDA) temporarily restricted silicone implants; in 2010, the scandal surrounding substandard PIP implants caused a stir; and since 2016, the rare lymphoma BIA-ALCL associated with textured implants has been intensively investigated. Today, Germany has a mandatory implant registry.
Microsurgery and perforator flaps
The operating microscope made it possible to detach tissue completely and connect it to vessels in the chest area. A milestone was the DIEP flap, described for breast reconstruction by Robert Allen and Pierre Treece in 1994: skin and fat from the lower abdomen are transferred via a small vessel without sacrificing the abdominal muscle. In many places it is now considered the gold standard of autologous reconstruction.
Autologous fat and modern concepts
As early as 1893, Gustav Neuber reported on the transplantation of fatty tissue. However, the procedure only became widely used after Sydney Coleman developed a standardised technique in the 1990s. Today, autologous fat is used to smooth contours, conceal implants or rebuild smaller breasts entirely with the patient’s own tissue. Oncoplastic procedures combine tumour removal and shape correction in a single operation.
Conclusion
Breast surgery has evolved from an “as radical as possible” strategy to an individual, interdisciplinary concept. For patients, this means more safety, more choice – and a reconstruction that today can often be planned as early as the cancer operation.
Note: This article is for general information only and does not replace medical advice.
Sources and further information
- Fisher B. et al.: Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 2002; 347: 1233–1241.
- Veronesi U. et al.: Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 2002; 347: 1227–1232.
- Allen RJ, Treece P: Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 1994; 32(1): 32–38.
- S3-Leitlinie Mammakarzinom (Leitlinienprogramm Onkologie, AWMF 032-045OL, 2026)
