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The “Oncoplastic” Movement Among General Breast Surgeons: Will Plastic Surgery Lose the Turf War Over Breast Reconstruction?
Jennifer McGrath, BS, Theresa Wang, MD, Brynn Wolff, MD, Brian Czerniecki, MD, Liza C. Wu, MD.
University of Pennsylvania, Philadelphia, PA, USA.
BACKGROUND: 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 of low reimbursements, 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: An anonymous 29 question web-based survey was distributed by email to all current breast fellows in U.S. accredited oncologic breast surgery fellowship programs. They were asked about their background general surgical training 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 completed survey. Statistical significance was determined using the Fisher exact test.
RESULTS: Sixteen of 46 recipients completed the survey (35%). A majority of respondents were trained at large, academic centers (68.8%) and all fellowship institutions had access to plastic surgeons for breast reconstruction. 87.5% spent time on a plastic surgery service, most commonly two to four weeks duration. All respondents were exposed to breast reconstructive procedures, including mobilization and rearrangement of tissue (87.5%), immediate prosthetic reconstruction (68.8%), tissue expansion (93.8%), contralateral balancing procedures (81.3%), pedicled flap reconstruction (81.3%), and free flap reconstruction (62.5%); however case number tended to be low. Fifty percent of 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 25% of respondents feel adequately trained in reconstructive procedures. Surgical competency was not significantly correlated with intent to perform reconstructive procedures (75% vs 71.4%, p=0.5692). More than half of respondents said that it does not matter whether a plastic or general surgeon performs breast reconstruction as long as they were adequately trained to do so.
CONCLUSIONS: 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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