3 How to Incorporate Oncoplastic Surgery Into Your Practice

10.1055/b-0037-144848

3 How to Incorporate Oncoplastic Surgery Into Your Practice

Albert Losken, Moustapha Hamdi

Partial breast reconstruction using oncoplastic techniques has increased in popularity as the demand for breast conservation continues to rise. The number of indications for breast conservation is growing with improved neoadjuvant chemotherapy and breast imaging, the increased use of postmastectomy radiotherapy, and the application of oncoplastic techniques. Women no longer need to tolerate poor cosmetic results to preserve their breasts, and, to this end, partial breast reconstruction has become an invaluable addition to the management of women with breast cancer. The therapeutic advantages of combining partial mastectomy with partial breast reconstruction are numerous. However, given the logistics of breast cancer treatment in certain countries, incorporating this approach into your practice can be difficult.

The first decision that needs to be made is whether the surgeon will perform these techniques using a single-surgeon approach or as part of a surgical team.

Although these two approaches differ in some aspects (see Chapter 2), they both essentially rely on a multidisciplinary team for comprehensive patient management. When the same surgeon performs both the resections and reconstructions, the inherent difficulties with incorporating oncoplastic techniques into your practice are less numerous.

Some centers specialize in this approach and have shown excellent results; however, most involve a two-surgeon team, with one focusing on the tumor resection and the other focusing on reconstruction. It is critical in these situations that both surgeons have a thorough understanding of breast cancer management and breast aesthetics to effectively treat the patient.

Reconstructive breast surgery is not simply filling a defect; it encompasses a wide knowledge of tissue handling, perfusion, and healing, in addition to achieving good aesthetic results.

Individual cases should be discussed at multidisciplinary team meetings, and surgical treatment can then be planned easily and included within protocols.

This chapter focuses mainly on the two-team approach from our perspective as reconstructive surgeons and provides some insight into the various ways to incorporate oncoplastic surgery into your practice.

Who Benefits from the Oncoplastic Approach

The first question that needs to be addressed when using the oncoplastic approach is, “Who benefits from the oncoplastic approach to breast conservation?” The answer is threefold. The patient benefits because she is able to preserve her breast, with a reduced chance for a deformity. The ablative surgeon benefits because he or she is able to remove the tumor with generous margins. As reconstructive or plastic surgeons with an interest in breast reconstruction, we benefit from our continued involvement in the management of these patients. If reconstructive surgeons do not choose to participate in partial breast reconstruction, it might be lost to other specialties.

The Patient’s Perspective

Patients often seek the advice and expertise of members of the health care team and trust them in the decision-making process. Women with breast cancer are no exception. We are expected to provide them with all treatment options and to educate them on the various approaches. Together, we decide on the most appropriate treatment plan for their anatomy, pathology, and desired outcome. However, with the increased use and availability of the Internet, patients are now educated consumers and often have treatment plans in mind at the initial consultation.

Reconstructive surgeons do not determine the initial treatment plan and do not necessarily control the inflow of patients with breast cancer in most centers. One way to increase the use of oncoplastic techniques in their practices is through patient education.

If patients are familiar with the concepts and know to inquire about possible oncoplastic options, the potential for more referrals to the reconstructive surgeon increases. The ablative surgeon may not always consider this as a good alternative; however, the patient raising the issue may stimulate reconsideration. Patients are now becoming more aware of the options available to conserve their breasts, with patient demand being one of the driving forces for the rise in breast-conserving surgeries. Patients need to realize that they do not necessarily need to live with a deformed breast and that reconstructive options are available to minimize the potential for a partial mastectomy deformity. If patients know to ask about breast conservation and reconstructive options, not only will quality control be enhanced, but the creation or development of oncoplastic teams may be encouraged in your practice.

Educational Tools for Patients

The following options may be used to distribute necessary information to your patients:

Develop educational seminars on breast reconstruction, including partial breast reconstruction.
Provide brochures on partial breast reconstruction that include available options and patient examples.
Establish support groups for women with breast cancer who decide to conserve their breasts.
Inform patients about helpful education sites on the Internet.

The Ablative Surgeon’s Perspective

Most surgeons who treat women with breast cancer have witnessed an increase in breast conservation. The indications, in addition to patients’ desires for breast conservation, have led to an increase in poor cosmetic outcomes. Surgeons often face difficult situations. For example, even though a patient has requested them, a surgeon may hesitate to use breast-conserving techniques if there is the potential for poor cosmetic results or if there are concerns regarding the inability to obtain clear margins. If surgeons know and understand the available options for partial breast reconstruction, these predicaments could be minimized.

Many ablative surgeons are not aware of reconstructive procedures that could broaden the indications for breast conservation and improve aesthetic results. Ablative surgeons are often involved in the initial decision-making process regarding breast cancer management; therefore, their participation in this approach is paramount to our involvement as plastic surgeons.

Without appropriate preoperative coordination, partial breast reconstruction will only be performed in the delayed setting for patients who are unhappy with their results, and this is often more challenging.

If we are interested in incorporating oncoplastic techniques into our practices, we need to educate ablative surgeons about the reconstructive options available. They also should gain a thorough understanding of the concepts of the ideal breast shape and breast aesthetics. Educational seminars should involve patient examples that demonstrate improved cosmetic results and should provide insight into the many other oncologic advantages of these techniques (for example, generous resection). We also need to demonstrate both the benefits of partial reconstruction before irradiation therapy in select patients and the oncologic safety of combined techniques. In addition, we must explain that postoperative surveillance is not impaired by reconstruction of partial mastectomy defects. Once they are familiar with the options, ablative surgeons also can offer breast reduction techniques for women with large breasts to improve breast conservation and symptoms of macromastia. Margin status is always a concern and needs to be addressed by discussing the possibility of performing the reconstruction once the final margin status is confirmed. With time, it will become clear that there are many benefits to managing these patients as part of a surgical team. As patients become more educated and request certain treatment plans and alternatives to breast conservation to improve their outcomes, ablative surgeons also stand to benefit, from a productivity standpoint, by incorporating this approach into their practices.

The ablative surgeon should be able to predict which patients have the potential for poor cosmetic results and which patients may benefit from a referral to a reconstructive surgeon.

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