Expert Commentary: Peter Geldner, M.D. 12/16/09

Posted by Admin on December 16, 2009

The guiding principles of breast cancer have always been to treat the disease first and offer the hope of restoring the body image second. There has never been serious deviation from this standard. The cancer surgeon must do what they feel that they need and what they can prove that they need.  Bizarre incisions and overly aggressive breast ablation has no place in the concept of evidence-based medicine.  Likewise, inadequate excision can never be tolerated just because it makes reconstruction easier.

We must abide by some simple guidelines.  First, the procedures must be performed by two separate specialists, each focusing on their goals, irrespective of the other's procedure.  The cancer surgeon must not do the reconstruction and the reconstructive surgeon cannot do the cancer operation.  They must remain unbiased and dispassionate.  Second, it is the responsibility of the cancer surgeon to do what is necessary to allow cure, and no more. 

The days of routine expanded radical mastectomies is over. The plastic surgeon must do what is necessary to reconstruct the patient, and no less.  Opting for the easiest technique is not the answer.  A complex reconstruction may take many hours and provide scant insurance reimbursement, but, it still may be the thing to do.  The goal is to restore the patient's body, not finish early.  Fourth, no-one should take themselves too seriously.

 A prophylactic mastectomy, especially if it's bilateral does not require the same dissection as an invasive tumor.  If the cancer surgeon can spare the skin excision to facilitate reconstruction in such a case, then they should.  Fifth, the reconstructive surgeons must live by an old principle:  there isn't a hole made by a general surgeon that I can't fill.

The patient has the expectation of a chance at cure.  We can't throw that away.  The cancer surgeon has to be let free to do what they must.  Plastic surgeons like myself have to hone our skills to restore form, no matter the defect.

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