This post continues a series that asks a simple question with a long answer: What is a plastic surgeon?
Plastic surgery is not a single operation or a single anatomic region. It is a specialty built on shared foundation principles and then applied across reconstructive and aesthetic care. Earlier posts looked at Blair and Brown on split-thickness skin grafts and at Davis and Kitlowski on the Z-plasty. This one turns to breast reconstruction — and to a paper that shows how soft tissue can be staged, protected, and moved to restore form when contour has been lost.
The paper
Gillies H. Surgical replacement of the breast. Proc R Soc Med. 1959;52(8):597–602. doi:10.1177/003591575905200804
In 1959, Sir Harold Gillies published this account in the Proceedings of the Royal Society of Medicine. He was writing about reconstruction of the mammary prominence after mastectomy, radiation atrophy, or congenital absence — not as ornament alone, but as restoration of a contour whose loss he understood could weigh heavily on a woman’s outlook.
The technique he describes is a staged tube pedicle transfer of abdominal skin and fat to the chest. It is used less commonly today because microsurgery and implant-based methods have changed the reconstructive landscape. It remains essential to understand. The same logic of perfusion, delay, and soft-tissue manipulation still underlies the flaps we use now.
Who Gillies was
Gillies belongs among the founders of modern plastic surgery. He was born in New Zealand in 1882. Much of his reputation was forged after World War I, in the facial reconstruction of soldiers with devastating soft-tissue injuries — including complex burn and blast wounds. In that setting he developed and refined the tube pedicle flap: a way to carry skin and fat on a protected vascular bridge from a distant donor site to a defect that could not be closed locally.
That wartime experience — facial reconstruction under anatomic constraint — is part of what a plastic surgeon is. The 1959 breast paper is the same mind applied to another anatomically limited problem: how to rebuild a breast mound when the options of the era did not yet include tissue expanders or reliable silicone implants.
The tube pedicle, as described
Gillies’ approach begins with healthy, perfused tissue around the umbilicus. Skin remains attached so that blood flow is preserved. Exposed edges are protected by approximating the skin into a tube — the classic tube pedicle — so that the vascularized corridor can travel without desiccation or contamination of its raw surfaces.
The transfer is staged:
- The flap is developed, the tube is created, and the donor site is partially closed.
- After about a week, the tube is extended.
- After about three weeks, the flap is freed from around the umbilicus and transferred to the breast.
Once the tissue has reestablished blood flow at the recipient site on the chest, the intervening skin bridge that carried it there can be excised. What remains is transposed skin and fat fashioned into a neomammary prominence.
That sequence is slower and more staged than a modern free flap. The principle is the same one plastic surgeons still live by: respect the blood supply, move tissue only as far as perfusion allows, and build form without sacrificing viability.
From tube pedicle to TRAM, ms-TRAM, and DIEP
Gillies’ autologous idea — bring living abdominal skin and fat to recreate a breast mound — did not stop in 1959. It was further developed into the TRAM flap (transverse rectus abdominis musculocutaneous flap), classically described by Hartrampf and colleagues in 1982 as a transverse abdominal island flap for breast reconstruction. That lineage then advanced to muscle-sparing TRAM and to the DIEP flap (deep inferior epigastric perforator flap), in which the vessels that perfuse the skin and fat around the umbilicus are dissected free, the rectus muscle is largely or entirely spared, and the tissue is transferred as a free flap.
In DIEP reconstruction, the flap is disconnected from its abdominal blood supply and reconnected under the microscope. The most common recipient vessels today are the internal mammary artery and vein, typically exposed at an intercostal space (often with rib-sparing or limited costal-cartilage exposure). That is the standard pairing in contemporary practice; other recipients (such as the thoracodorsal vessels) remain available when anatomy or prior treatment makes the internal mammary system unsuitable.
From Gillies’ staged tube to a free perforator flap is a long technical road. The destination is the same: autologous soft tissue used to restore a breast contour.
Implant-based and autologous reconstruction
Today breast reconstruction is typically framed in two algorithms: implant-based and autologous. Gillies’ paper describes one of the original autologous techniques — written before tissue expanders and modern silicone implants had reshaped the field.
With advances in implant reconstruction, the majority of breast reconstructions today remain implant-based. That does not make autologous work optional knowledge. Every plastic surgeon engaged in breast reconstruction needs a working command of both pathways: when an implant is appropriate, when living tissue is better, and how to counsel a patient through the trade-offs of each.
Gillies also saw something that still sits at the center of the specialty. He identified and appreciated the psychological trauma of losing the mammary prominence — how that loss can affect a woman’s outlook and sense of self. Reconstruction is not only volume and scar. It is restoration of form that patients carry into daily life.
Beauty versus blood supply
Gillies’ maxim still holds: “Plastic surgery is a perpetual battle of beauty versus blood supply.” The wording varies slightly across attributions to his teaching and to The Principles and Art of Plastic Surgery, but the meaning does not. Almost every plastic surgery technique — and especially every aesthetic result built on living tissue — is a negotiation between how the reconstruction should look and what the circulation will safely allow.
That battle is why this paper belongs in a series on what a plastic surgeon is. Gillies moved from facial reconstruction and burn and blast soft-tissue injury to breast reconstruction. The knowledge was anatomic, staged, and passed forward. Decades later we still teach TRAM, muscle-sparing TRAM, and DIEP as descendants of that same idea: move soft tissue with respect for perfusion, and restore a form that matters to the patient.
Looking ahead
This series will keep asking what a plastic surgeon is by looking at the papers and principles that still train us. Skin grafting, Z-plasty, and autologous breast reconstruction are foundations. Reconstruction, aesthetic judgment, and wound biology sit underneath almost everything that follows.
This post is educational journal discussion. It is not a substitute for peer-reviewed literature, individual clinical judgment, or patient-specific consultation.
Tobias C. Long, MD
Founding Member
References
- Gillies H. Surgical replacement of the breast. Proc R Soc Med. 1959;52(8):597–602. doi:10.1177/003591575905200804
- Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg. 1982;69(2):216–225. doi:10.1097/00006534-198202000-00006
- Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg. 1994;32(1):32–38. doi:10.1097/00000637-199401000-00007
- Gillies H, Millard DR. The Principles and Art of Plastic Surgery. Boston, MA: Little, Brown and Company; 1957.