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Breast reconstruction in 2013

The article by Wong et al. in this issue of the journal proffers a solution to the low take-up rates for breast reconstruction (BR) in Australia that is largely a ‘one stop shop’ approach. In their experience, the discussion of BR by the breast surgical oncologist (SO) prior to mastectomy led to a take-up rate for reconstruction, either immediate or delayed, of 41%, more than three times the national average reported in 2008 by Cancer Australia. They contrast this with a report by Takahashi that only 30% of Japanese breast surgeons discussed reconstruction with their mastectomy patients. Takahashi cited barriers in Japanese society including concerns about safety, age, marital status, lack of reconstructive training among surgeons and paucity of plastic surgical referral services. Other authors have cited barriers such as distance from tertiary referral centres and socio-economic factors including cost. Although all these barriers have varying relevance, the sociological and institutional differences between Japan and Australia make comparisons problematic. It is doubtful that in 2013 such a low rate of discussion of reconstructive options with patients prior to mastectomy prevails. The Internet has spawned a massive increase in available information for these patients, and patient-driven enquiry of a much more sophisticated kind, concerning all aspects of cancer treatment and reconstruction, is now commonplace. In Western medicine, particularly in the United Kingdom, there has been a marked trend to train oncoplastic breast surgeons to deal with both sides of the problem: oncologic and reconstructive. Although this seems to offer a seamless solution, there is evidence that the reconstructive options made available often represent ‘second-best’ solutions. There is widespread agreement among plastic surgeons that the most natural, durable and cosmetically acceptable reconstructions are autologous tissue based, and usually require extensive training in microsurgical techniques (for a discussion of these options, please see References). Plastic surgical training typically spans 5 years, and BR training usually requires additional experience gained in Fellowship positions. It is highly unlikely a breast ‘oncoplastic’ surgeon could achieve the competency required without joining a plastic surgery training programme. It has long been hoped that multidisciplinary clinics could offer a full range of options, both oncologic and reconstructive, by involving the full range of specialists. That would include surgical and medical oncologists, radiotherapists, breast care nurses, physiotherapists and plastic surgeons. However, the conundrum for the plastic surgeon is that, although almost every patient will require oncological surgery, only a minority will end up under a plastic surgeon’s care. This means that while he or she may learn a lot about breast cancer treatment by attending the clinic, much of his or her time will be wasted. This mandates a secondary referral process, which may be difficult for the patient for many reasons. The offer of a ‘one stop shop’ therefore becomes more attractive to the patient. A question that should be asked here is whether the SO, who may have a limited armamentarium of reconstructive options, nevertheless might persuade the patient to undertake a reconstructive procedure that is suboptimal, simply because it is convenient. It is recognized, however, that not every patient requires the most sophisticated approach. In the last decade or so there has been a trend to less skin destructive types of mastectomy, and even for certain tumours, nipple-sparing techniques. These procedures can often be married with tissue expander and implant-based techniques, with or without matrix support, that are less technically demanding. In fact, performing nipple-sparing or skin-sparing mastectomies without immediate volume replacement is counter-productive, as the whole basis of the procedures is to keep the skin envelope in as natural shape as possible. The two biggest issues with implant-based reconstructions have always been symmetrization and the deleterious effects of radiotherapy. Nevertheless, maintaining an expanded skin envelope, even during radiotherapy, has advantages. Here is where breast SOs and plastic surgeons can meet on common ground. Providing that the SO is well trained in the use of tissue expansion and implant-based reconstruction, there is no reason why he or she should not offer to appropriate patients having skin-sparing or nipple-sparing mastectomies, a tissue expander. For many this will offer a quick and relatively easy solution to their lack of a breast and, although only temporary, allows the patient time to investigate the best permanent reconstructive options available. If radiotherapy follows, however, it is likely that permanent implantbased reconstruction may prove to be a poor choice. Those patients, and others who do not tolerate tissue expansion, should be referred to a plastic surgeon with the ability to perform autologous tissue transfer, the ‘platinum standard’ now being the deep inferior epigastric perforator flap. Those SOs who are not trained in reconstruction, or who prefer not to do so, should involve a plastic surgical colleague at the time of mastectomy if the patient requests immediate reconstruction. Ideally that means the patient should consult the plastic surgeon before the procedure. Patients who face formal skin-sacrificing mastectomies are in different category. Tissue expansion techniques are frequently unable to match the opposite breast in shape. These patients do even more poorly if radiation and implants are combined. In the opinion of the author, the majority of those patients should be offered at least a consultation to discuss the options of either immediate or delayed autologous tissue reconstruction. The exception may be the bilateral mastectomy patient who is not to undergo radiotherapy. Symmetrization, although still a technical challenge, is not quite as difficult in those patients. In summary, in the author’s opinion, SOs and plastic surgeons both have a place in BR. However, in the 21st century, patients should not be denied the best available reconstructive option simply for convenience’ sake or for lack of immediately available reconstructive expertise.