Breast Cancer Overview
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Peg Procedure Article
Explains surgery for patients
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For Restorative Breast Reconstruction
For women who have had or will require any kind of mastectomy,
Dr. Knowlton's innovative Peg Procedures provide the full benefits of a
mastectomy while restoring a normal appearing breast without a disfiguring scar.
The Peg Procedures offer a complete system of breast reconstruction stemming
from Dr. Knowlton's research. Largely based upon medically accepted techniques,
this novel system of reconstruction was originally published as the lead article
in the September, 1992 issue of Contemporary Surgery.
In 1994, the Peg Procedures
were presented at the American Society of Plastic and Reconstructive Surgeons
annual meeting in San Diego. And in 1995 the procedure was featured in an
episode of the popular television drama series, Chicago Hope.
Sadly, one in nine American women will develop breast cancer at some
point in her lifetime. Although alternatives such as lumpectomy and
radiation promise treatment without deformity, physicians agree that
mastectomy is the most definitive treatment.
This is particularly true for aggressive tumors in younger patients who
have a higher risk of recurrence over their normal life span.
The disfiguring mastectomy scar is an unappealing remnant
of treatment that is understandably feared by most women. This fear
is believed to contribute to the avoidance of early medical intervention --
a choice which can have grave consequences.
The Peg Procedures now allow a surgeon to recreate both the shape and
the size of the breast, including the unique contours of the nipple and areola.
The Peg Procedures can be performed with a patient's own tissue or with a
breast implant. They can be performed at the time of mastectomy or at a
later date, even years later. Large disfiguring mastectomy scars common with
other types of reconstruction simply are not necessary.
Until now, breast reconstruction could require several operations, with
sometimes unsatisfactory results. More recently many surgeons realized that
the breast skin outside the areola need not be removed as long as there was
no invasion of cancer into the skin. Although the nipple and areola must be
removed because they contain breast tissue, circular incisions around the areola
can be used to perform a skin-sparing mastectomy. This is done instead of
removing large amounts of breast skin common in traditional mastectomies.
These circular incisions help to preserve the shape of the reconstructed breast.
With this knowledge, Dr. Knowlton devised a strategy to fill the empty breast
with either a saline implant or with the patients own tissue from the back or abdomen.
Dr. Knowlton's investigation of a healed mastectomy led him to the most recent
Peg Procedure, the Pectoralis Peg. It uses only the remaining breast skin
after a mastectomy and relies on the body's post operative healing to create
a normal appearing nipple. When the body heals after a mastectomy, new blood
vessels grow (a process called neovascularization) into the skin from the
muscle on the chest wall, called the pectoralis.
The Pectoralis Peg technique uses this new blood supply to provide circulation
to the newly created nipple and areola. As a result, a separate skin graft from
another portion of thepatient's body is not needed. Bowtie shaped incisions and
tissue flaps from within the circular Peg allow the surgeon to recreate
the unique contour and projection of the entire nipple, including the areola.
These tissue flaps provide more precise control to shape a breast than was
possible before. With the Pectoralis Peg, a saline implant or a patient's
own tissue replaces the missing volume of the removed breast tissue.
As with the other Peg Procedures, the mastectomy and bowtie incisions
are hidden within the outline of the newly reconstructed nipple. In many
patients there is no visible scarring following the reconstruction. The
Pectoralis Peg can be performed with a 24-hour hospital stay or in an outpatient facility.
For most types of breast
cancer, the Peg Procedures provide patients with the
knowledge and comfort that a mastectomy no longer needs to
be feared.
Benefits of the Peg Procedures
Sources
1. Dao, T.L., Nemoto, T. "The Clinical Significance of Skin Recurrence After Radical
Mastectomy In Women with Cancer of the Breast." Surg. Gynecol. Obstet., 117:
447, 1963
2. Grossman, P.H., Novack, B.H., Karlan, S.R., Uyeda, R.Y. "An Alternative
Technique for Modified Radical Mastectomy with Immediate Reconstruction."
Contemp. Surg. 38 (6):20, 1991
3. Lovaas, M.E. "Immediate Pedicled TRAM Breast Reconstruction and
Simultaneous Nipple Reconstruction with a Skate Flap: A Review of 50 Patients."
Plastic Surgery Forum, 17:136, 1994
4. Olivari, N. "The Latissimus Flap." British J. Plast. Surg, 29:126, 12976
5. Knowlton, E.W. "Release of Axillary Scar Contracture with a Latissimus Dorsi
Flap." Plast. Reconstr. Surg. 74(1):124, 1984
6. Knowlton, E.W., Gorey, R., Taekman, H. "Total Immediate Breast
Reconstruction with 'Peg' Latissimus Dorsi Flap." Contemp Surg. 41(3):15, 1992
7. Knowlton, E.W. "The 'Peg' Latissimus Dorsi Flap Procedure: A One-Stage Breast
Reconstruction." Plastic Surgery Forum 17:180, 1994
8. Knowlton, E.W. "The 'Peg' Latissimus Dorsi Flap Procedure: A One-Stage Breast
Reconstuction (Peg Procedure Video, Vol. I)." Medical Media Productions, Mill Valley CA, 1992
9. Knowlton, E.W. "Breast Reconstruction with the 'Peg' Latissimus Dorsi Flap
(Peg Procedure Video, Vol. II.)" Medical Media Productions, Mill Valley CA, 1994. Presented
at the annual meeting of the American Society of Plastic and Reconstructive
Surgeons (San Diego, CA, 1994)
10. Knowlton, E.W. "The Pectoralis Peg with Bowtie Nipple-Areolar
Reconstruction (Peg Procedure Video, Vol. III)." Medical Media Productions, Mill Valley CA, 1997
11. Knowlton, E.W. US Patent No. 5,301,692, April 12, 1994. Method for Total Immediate
Post-Mastectomy Breast Reconstruction Using a Latissimus Dorsi Myocutaneous Flap.
12. Knowlton, E.W. US Patent No. 5,765,567, June 16, 1998. Surgical Method for Breast
Reconstruction Using a Tissue Flap.
13. Knowlton, E.W. US Patent No. 5,824,076, Oct 20, 1998. Surgical Method for Breast
Reconstruction Using a Neovascular Tissue Peg.
14. "Efficacy of Bilateral Prophylactic Mastectomy in Women with a Family History of Breast Cancer."
New England Journal of Med. 2:340, 1999
Latissimus Dorsi Peg flap with inclusion of subcutaneous fat over the muscle
After the Peg Procedure
The typical mastectomy deformity
The circular opening created
from a skin-sparing mastectomy
The Peg Procedures are designed so that the reconstructed breast maintains
its original shape. The straight line mastectomy scar is replaced with a
circular scar that is hidden within the border of the newly created nipple.
In less frequent circumstances, in which cancer is also invading the breast
skin, a standard mastectomy is performed that removes the nipple with the
involved breast skin. Even for these patients, the Peg Procedures will reduce
scarring and recreate the aesthetic contours of the breast.
The completed right breast reconstruction with a Peg Flap
Growth of new vessels into the remaining breast skin
Recently, the circulation of a healed mastectomy was investigated by
Dr. Knowlton. Most surgeons had previously believed that the pectoralis
chest muscle after mastectomy did not have a sufficient blood supply to
support an entire nipple areola reconstruction. Surgeons were therefore
performing techniques that used skin grafts from different areas of the body
such as the inner thigh. As a result, many patients required multiple
surgeries to complete their reconstruction.
The width of the Bowtie flap determines
the height of the nipple
A divergent shaped Bowtie Flap that is curved
The Bowtie nipple areolar flap
The relationship of a skin-sparing mastectomy scar with the Bowtie incision
