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The “Oncoplastic” Movement Among General Breast Surgeons: Will Plastic Surgery Lose the Turf War Over Breast Reconstruction?
Theresa Y. Wang, MD, Jennifer McGrath, BS, Brynn Wolff, MD, Brian Czerniecki, MD, Liza C. Wu, MD.
University of Pennsylvania, Philadelphia, PA, USA.
PURPOSE: Breast reconstruction has long been a core practice in plastic surgery. No other specialty of surgeons receives the extent of formal breast aesthetic and reconstructive training as that in our field. Given the current healthcare economic climate, there is constant pressure to increase operative volume and bottom line. There is a recent trend among general and breast surgeons towards performing not only the extirpative but also the reconstructive portion of the surgery; trainees in U.S. breast fellowships are now formally exposed to breast reconstruction with dedicated time on plastic surgery services. This poses a threat to our clinical territory that may eventually displace plastic surgeons from the breast reconstructive process. The goal of this study was to examine this breast reconstruction exposure and its resultant effects through surveying general surgery breast fellows in training.
METHODS: A 29 question web-based survey was distributed by email to current breast fellows in U.S. accredited oncologic breast surgery fellowship programs. They were asked about their background surgical and current fellowship training with a focus on breast reconstruction exposure. They were further asked about their practice plans and comfort level of performing breast reconstruction procedures. Entries were anonymously logged in a web-based database upon submission of the survey. Statistical significance was determined using the Fisher exact test.
RESULTS: Twenty-one of 39 current fellows completed the survey (54%). The majority of respondents were trained at large, academic centers (70%) and all fellowship institutions had access to plastic surgeons for breast reconstruction. Over 80% of respondents spent time on a plastic surgery service, most commonly two to four weeks in duration. All respondents were exposed to breast reconstructive procedures. Almost all had surgical experience with tissue expansion (95.2%), mobilization and rearrangement of tissue (90.5%), immediate prosthetic reconstruction (61.9%), contralateral balancing procedures (85.7%), pedicled flap reconstruction (71.4%), and free flap reconstruction (61.9%). Thirty-eight percent of breast fellows plan to perform reconstructive procedures when entering practice; this typically was limited to mobilization of remaining tissue, contralateral balancing mastopexy, and reduction mammoplasty. However, only 23% of respondents feel adequately trained in reconstructive procedures. Surgical competency was not significantly correlated with intent to perform reconstructive procedures (p=0.1333). To more than half of respondents it did not matter whether a plastic or general surgeon performed the breast reconstruction as long as they were adequately trained to do so.
CONCLUSION: Like the field has seen with many cosmetic and reconstructive procedures, if not protected, plastics surgeons may eventually share clinical ground with other specialties. As a field we need to bring awareness to general breast surgeons as well as plastic surgeons that we remain the best trained in breast reconstruction to provide the highest standard of care to breast cancer patients. Beyond offering the full spectrum of reconstructive options, we must make ourselves available as part of a multidisciplinary team in all types of breast cancer care. It would be a detriment to our field to lose breast reconstruction to other specialties.
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