I read with great interest the Editorial on “underpromising” published in the Journal.1 I really wish to compliment Dr. Spear, who was brilliant in his point of view. He began putting together some successful cases in breast reconstruction where patients were clearly disappointed and uncomfortable. All of us have similar examples in our daily practice. Unfortunately, they are not too few, even in our top outcomes. He therefore concluded in his Editorial that, considering the risks and morbidity of this type of surgery, it is necessary both to “underpromise” and then, if it is possible, to “overdeliver” outcomes to the patients.
However, the disturbing question here is, Why is it occurring despite all advances we have had in breast reconstruction? Dr. Spear said that maybe we are becoming victims of our own success.1 I agree with him, but I think that, unfortunately, this is not enough to explain and help to solve the problem. There are some technical points and a particular paradigm we should confront.
Breast reconstruction was classically founded on three pillars: patient’s individualization in surgeon’s technical choice, oncologic safety, and aesthetics. Technical choices in breast reconstruction today are increasingly broad and better than two decades ago. Outcomes, in some cases, really rival those in cosmetic breast surgery. However, many times, even in experienced hands, reconstructed breasts are less attractive than natural breasts (and clearly not comparable to outcomes achieved in cosmetic operations). The reason for this is that breast reconstruction is highly dependent on the quality of oncologic surgery, the type of adjuvant or neoadjuvant systemic treatments that the patient has undergone or will undergo, and, of course, the presence or absence of radiotherapy. These factors together lead us to a conclusion that we should stop comparing cosmetic breast surgery with breast reconstruction. They are different patients, in different conditions, with different expectations, and under different treatments, even if some surgical techniques are similar.
Advances in breast oncology are at least one step ahead of breast surgery. Breast reconstruction is achieving better results, in part because of this great oncologic development. Mastectomy is now less aggressive and oncoplastic surgery is gradually becoming a rule more than an exception. Thus, oncologic safety is higher and based on strong evidence. Breast cancer patients are living longer and better. These are changing times with new challenges for surgeons. However, maybe one of the greatest challenges is to change our perception of our own possibilities and limits, and how to transmit it to the patients—the real aim of breast reconstruction in a real world.
Aesthetics is a branch of philosophy dealing with the nature of art, beauty, and taste. It is clearly difficult and maybe impossible to define what is a beautiful or a perfect breast. Most Brazilian women, for example, hate ptosis and prefer large breasts. American women maybe have the same feelings. But what about French, Iranian, African, and Japanese women? Culture, history, and local values clearly are not the same. Beauty, femininity, and the concept of what is an “attractive” breast also differ. Thus, when we define “aesthetics” as one of the pillars of breast reconstruction, we will be always vulnerable to dissatisfaction and medicolegal claims. Recently, we evaluated aesthetic results in oncoplastic surgery and in immediate breast reconstruction with implants, comparing a specific software program with a specialist’s opinion and the patient’s opinion. There was no agreement between them.2,3
Then, more than “underpromising,” which is of course necessary, we should change the promise and refine our own feelings about outcomes and limits. Breast reconstruction’s aim is symmetry and, whenever possible, from an oncologic point of view, to leave breasts more appealing than before cancer treatment. Promising more than this is a utopia of enthusiastic surgeons, resulting in disproportionate expectations by the patients and dissatisfaction.
The author has no conflict of interest to report.
Cicero Urban, M.D., Ph.D.
Hospital Nossa Senhora das Graças Breast Unit
Positivo University Medical School and
Biotechnology Post-Graduation Program
1. Spear SLUnderpromise.Plast Reconstr Surg20161371961–1962
2. Santos G, Urban C, Edelweiss MI, et alLong-term comparison of aesthetical outcomes after oncoplastic surgery and lumpectomy in breast cancer patients.Ann Surg Oncol20152225002508
3. Kuroda F, Urban CA, Zucca-Matthes G, et alEvaluation of aesthetic and quality-of-life results after immediate breast reconstruction with definitive form-stable anatomical implants.Plast Reconstr Surg2016137278e–286e
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