**Abstract**

Restoring breast aesthetics and minimizing morbidity while providing excellent oncologic control has been the driving force in the evolution of both breast cancer and breast reconstructive surgery. This chapter will discuss recent developments using minimally invasive techniques to further move the needle towards even better patient outcomes. We outline the technical considerations and evidence behind minimally invasive breast reconstructive procedures including laparoscopic deep inferior epigastric perforator (DIEP) flap harvest, robotic DIEP flap harvest, and robotic latissimus dorsi flap harvest. We also introduce minimally invasive breast cancer surgery including robotic mastectomy. Finally, this chapter discusses future applications of emerging technology and the controversies surrounding the widespread adoption of minimally invasive techniques in breast cancer and breast reconstructive surgery.

**Keywords:** breast reconstruction, robotic surgery, mastectomy, DIEP flap, minimally invasive surgery

#### **1. Introduction**

Breast cancer surgery has dramatically evolved since Halstead first described the radical mastectomy in 1894 [1]. Over time, radical mastectomy with resection of the entire breast, chest wall musculature, and axillary nodes, was abandoned due to its high morbidity and failure to achieve superior oncologic outcomes compared to less aggressive resections. Since then, the field has recognized the importance of achieving excellent cancer outcomes while also minimizing morbidity and preserving breast aesthetics. Skin-sparing mastectomy, breast conservation surgery, sentinel lymph node biopsy, and now nipple-sparing mastectomy (NSM) in the appropriate patient have become the standard of care.

While initially avoided for fear of the loss of local control, breast reconstruction is now considered part of routine breast cancer care. The late 1800s and first half of the twentieth century are spotted with case reports and small case series of autologous tissue reconstruction; however, autologous reconstruction really took hold in the 1970s [2]. The advent of the silicone breast implant in the 1960s also ushered breast reconstruction into the modern age.

#### *Breast Cancer Updates*

Breast reconstruction using autologous flaps gained acceptance following descriptions of the pedicled latissimus dorsi flap in 1977 [2]. The flap was refined to allow for a single-stage reconstruction of breast defects; however, the volume was often insufficient to be used alone and thus the flap was paired with an implant. To replace the entire volume of the breast mound, surgeons turned to abdominal tissue. The pedicled transverse rectus abdominis myocutaneous (TRAM) flap was introduced by Hartrampf, Schelfan, and Black in 1982 [2]. The TRAM flap revolutionized breast cancer reconstruction as it allowed for a complete autologous reconstruction with an acceptable donor scar and body contouring effect similar to abdominoplasty. Unfortunately, the blood supply-to-tissue ratio from the superiorly-based pedicle contributed to high incidence of fat necrosis and harvest of the rectus abdominis muscle led to significant abdominal wall weakness. Initially described in 1979, the free TRAM uses microsurgical technique to transfer the disconnected abdominal tissue and connect the TRAM blood supply to distantly located recipient vessels. The free TRAM is based on the deep inferior epigastric vessels rather than the superior epigastric vessels that supply the pedicled TRAM. The deep inferior epigastric vessels are noted to be more robust and provide improved blood supply to the TRAM flap compared to the superior epigastric system. Therefore, the free TRAM optimizes the blood flow to the flap which reduces fat necrosis compared to the pedicled TRAM. The free TRAM did not, however, decrease abdominal wall morbidity compared to the pedicled TRAM. To address this, plastic surgeons adapted the dissection technique to reduce damage to the rectus abdominis muscle, first with the muscle-sparing TRAM (ms-TRAM) then the deep inferior epigastric artery perforator (DIEP) flap. Considered by most to be the current gold standard in autologous tissue reconstruction, the DIEP flap

minimizes muscle sacrifice by carefully dissecting the muscle away from the vasculature (**Figure 1**). Additional soft tissue donor sites have been introduced including the thighs, gluteal region, and lower back, yet the DIEP flap remains the preferred operative approach for autologous tissue reconstruction for the majority of patients.

As illustrated above, restoring breast aesthetics and minimizing morbidity while treating the patient's underlying cancer has been a driving force in the evolution of both breast cancer and breast reconstructive surgery. This chapter will discuss recent developments using minimally invasive techniques to further move the needle towards even better patient outcomes.
