DOI: 10.1097/01.prs.0000264563.48652.a6
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PMID: 17572589
Issn Print: 0032-1052
Publication Date: 2007/07/01
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Excerpt
It is an honor that the Viewpoint entitled “Caution Note on the Use of the Internal Mammary Artery in Breast Reconstruction” (Plast. Reconstr. Surg. 117: 1653, 2006) has aroused the interest of Dr. Nahabedian (Plast. Reconstr. Surg. 119: 425, 2007). I am in unqualified agreement with Dr. Nahabedian regarding his comprehensive and thoughtful considerations on breast surgical oncology and reconstructive microsurgery. It is the obligation of clinicians to make careful, thoughtful appraisals, especially of topics of controversy, and to provide balanced advice to patients regarding the most effective treatment.
In the New York registry of almost 60,000 risk-matched patients, those patients who received coronary artery bypass grafting rather than percutaneous coronary intervention had a highly significant absolute reduction in their mortality rate of around 35 percent at 3 years and a seven-fold reduction in the need for further intervention.1 Similar evidence in favor of coronary artery bypass grafting has also been reported from the Cleveland Clinic,2 and the effects are further magnified in diabetic patients.3 An editorial accompanying the New York registry article pointed out that the survival benefit of coronary artery bypass grafting is because, as the bypass graft is placed to the midcoronary vessel, surgery not only deals with the culprit lesion, which can be of any complexity, but also has a protective effect against further culprit lesions. It is true that the rate of coronary artery bypass grafting is decreasing, but our aim was to instill an element of “thought” into the plastic surgical community that a non–life-threatening reconstructive procedure such as breast reconstruction and its use of the internal mammary artery, which is widely accepted to be the best conduit for coronary revascularization, could affect the potential survival benefit of a future coronary artery bypass graft. However, we are in agreement that at this point its use is justified.
So what is the best way to ensure that the patient has at least access to balanced advice regarding best treatment? I agree with Dr. Nahabedian that this can only be achieved by the patient being advised by a multidisciplinary team, including a plastic surgeon who practices evidence-based medicine. Ensuring that patients are appropriately and adequately informed ensures that they can make a rational decision about their treatment and sits well with medical and governmental recommendations to that effect.
