I remember when I was first introduced to the concept of oncoplastic surgery. It was at the American Society of Plastic Surgeons/Plastic Surgery Educational Foundation Santa Fe Breast Symposium in the early 1990s. Werner Audrestch spoke of the experience in Germany and how lumpectomy defects were repaired before breast radiation as part of breast conservation therapy. It was revolutionary to many of us and very inspiring. I assumed that the same principles and practices would eventually take hold in the United States and predicted such in the first edition of my book, Surgery of the Breast: Principles and Art, published in 1998.
Some 20 years later, my thinking has changed. Now, when I think of “oncoplastic” surgery, I believe that all breast surgery should be oncoplastic. By that, I mean that all cosmetic breast surgery should take into account its oncologic implications, and any oncologic procedure should consider its cosmetic implications.
Although I cannot speak for the state of oncoplastic breast surgery in Germany in 2009, I can say that the idea of one individual surgeon looking over both the oncologic and aesthetic issues in breast surgery seems less and less realistic.
Recently, I was asked to help teach some principles of oncoplastic surgery to general surgeons with a keen interest in breast surgery. As I prepared my talk, much of it taken from my own book, I realized that reconstructing partial breast defects required more skill and judgment than elective breast reduction or mastopexy—hardly a good place for nonplastic surgeons in the United States to start.
From where I stand, to better serve women with breast cancer, we have a long way to go, and having American general surgeons perform oncoplastic surgery or breast reconstruction is probably not the best answer.
In many hospitals and communities, de facto teams have developed where surgical breast oncologists, medical oncologists, plastic surgeons, radiation oncologists, and genetic counselors all see the patient, either at the same time or as conveniently as possible. Many options may be considered, ranging from unilateral breast conservation to bilateral mastectomy with free flap reconstruction. Photographs, mammograms, and other studies become part of the record. Multiple eyes and brains from diverse disciplines focus on the patient, which often yields recommendations that would not have come from just one physician.
I have always believed that most errors in surgery are errors in judgment, not technique. We certainly see many women who would have been better served by a team approach to their breast cancer. Examples include women who are BRCA gene–positive and who have had unilateral breast conservation therapy, women with breast implants who have had breast conservation therapy, and women with very large or pendulous breasts who have had breast conservation therapy without correction of their underlying anatomical problem. All of those patients would have benefited from expert plastic surgery consultation before being treated.
On the technical side, plastic surgeons know that the most predictable path to a beautiful reconstruction is a well-performed mastectomy. General surgeons and plastic surgeons need to work together to lower the surgical complication rates of flap necrosis, hematoma, seroma, and infection. There is not much excuse for skin flap necrosis in a small breast, dissection well beyond the breast borders, or damage to muscles of the chest wall where tumor is not nearby.
If the goal is to optimize the treatment of breast cancer while optimizing the cosmetic results of the treatment, the right answer is a team approach. We have a precedent for such a team approach with our craniofacial teams across the country. Although the analogy may not be perfect, I doubt anyone would argue that we should abandon the craniofacial team concept.
One positive aspect of the current economic mess that we find ourselves in is the renewed interest by plastic surgeons in reconstructive surgery. Plastic surgeons need to be involved in their local breast cancer teams. As members of those teams, they need to bring into focus the cosmetic perspective as part of the decision making. They also need to stay on top of the best practices and techniques that plastic surgery has to offer these women and be able to provide these services as appropriate to their patients.
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