Friday, December 26, 2008

Some Hidden Choices in Breast Reconstruction

The New York Times published an interesting article on breast reconstruction (  The premise of the article was that some plastic surgeons do not offer their patients all of the available options for breast reconstruction because they are not proficient with all of the techniques.  The was some suggestion that some complex surgical options are not discussed by plastic surgeons at all because the insurance reimbursement is disproportionately low, which deters some plastic surgeons from performing those procedures at all.

I have discussed making decision for surgical treatment in earlier posts.  This article highlights that some women are making reconstructive choices based on only limited information.  Amy Alderman, MD is quoted in the article, and she highlights a larger problem that many women who have breast cancer are not even made aware that reconstruction is available to them, and that limits the decision making process one step before a patient may even see a plastic surgeon.  

Remember that these issues may even affect the initial surgical decision options.  How many breasts surgeons discuss breast conservation therapy using oncoplastic techniques, where a plastic surgeon may be able to reshape the remaining breast tissue at the time of  extensive lumpectomy to prevent a breast deformity?  How many breast surgeons discuss skin sparing or nipple sparing approaches in prophylactic breasts surgery?  If a breast surgeon is being reimbursed disproportionately high to place a MammoSite catheter in the breast in their office, is there a disincentive to discuss mastectomy and the fact that reconstructive surgery is available?  How many breast surgeon discuss the Women's Health and Cancer Rights Act at the time of initial surgical decision making?

What I strive to do in a preliminary consultation is to offer patients a general overview of all of the available surgical options from implant based techniques to autologous techniques, using a patients own tissues.  I hope to outline the different surgical approaches including microsurgical techniques.  What is even more important, however, is realizing that the shared decision model demands a customized risk factor analysis to take be performed which allows patient to make more informed choices.  

While some patients find the option of using their own tissues for breast reconstruction attractive because of the possibility of improved body contour if abdominal tissue is used, they may be at higher risk of complications related to comorbidities like hypertension and diabetes, or patient risk factors like high BMI (body mass index), previous abdominal incisions, or smoking history.  While some find options of using breast implants for breast reconstruction more attractive, they may be at higher risk of complications if they have had previous radiation therapy to the breast or may require post-mastectomy radiation.  There is also a higher inherent risk of re-operation related to scar formation around the implants and implant rupture.  There are also aesthetic limitations that may be inevitable when implants are used for breast reconstruction, especially if an implant is used to reconstruct one side only.

A shared decision model relying on providing the complete range of options to patients and performing a customized risk factor analysis for possible complications of each option in each patient is the current model that I prefer.  Patients need to be informed of their rights under the Women's Health and Cancer Right Act at the time of initial diagnosis of breast cancer, that may precede their initial surgical evaluation by several days or weeks.  

There are several excellent books that women should consider reviewing at the time of their initial breast cancer diagnosis that will allow them to ask better questions and make more informed choices for regarding breast reconstruction - A Woman's Decision: Breast Care, Treatment & Reconstruction and The Breast Reconstruction Guidebook.

1 comment:

Breast Enlargement Surgeon said...

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