DOI: 10.1097/PRS.0b013e3181cb6284

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Issn Print: 0032-1052

Publication Date: 2010/06/01


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Maurice Y. Nahabedian

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Author Information: drnahabedian@aol.com

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I read with interest the commentary entitled “Oncoplastic Surgery in a Pre-Paradigm Era: A Brazilian Perspective in an American Problem.”1 It is assumed that this was prepared in response to our editorial entitled “Oncoplastic Breast Surgery: Past, Present, and Future Implications in the United States.”2 The editorial attempted to point out the trends in breast surgery and the roles of ablative and reconstructive surgeons. We recognize that in other countries, the paradigms have already shifted and the roles of the specialists have already changed. We acknowledge that paradigm shifts in the United States are evolving and the roles of breast specialists may be changing. Dr. Urban has provided his perspective on this “American problem.”
In formulating my response, I wish to focus principally on the United States because, as the title of the commentary suggests, this is primarily an American problem. The implication that Dr. Urban has conveyed is that plastic surgeons in the United States should adapt to these paradigm shifts because it is in the best interests of the patient. It is claimed that many plastic surgeons in the rural United States are not available or not interested in performing breast reconstruction and therefore the reconstruction should be performed by the breast specialist. Dr. Urban attempts to further support his position by stating that most women in the United States do not undergo breast reconstruction. I assume his implication is that plastic surgeons are not interested and not available, and not because of factors related to the cancer or patient or the lack of an appropriate referral.
Frankly, I am puzzled by these assertions based on the expectations of plastic surgeons and of women with breast cancer. In my travels across rural and urban America, I have lectured many plastic surgeons and presented to numerous women's organizations on topics related to reconstructive and oncoplastic breast surgery. I can assure Dr. Urban that there are many plastic surgeons in virtually all cities across America that are willing and interested in performing reconstructive and oncoplastic breast surgery, and that the expectations of women with breast cancer are significantly greater now than they were 5 to 10 years ago. Plastic surgeons are able to more predictably and reproducibly create a breast with natural volume, contour, and positional symmetry, and women are very aware of this fact.
In contrast, I have also attended several oncoplastic symposia that are filled with breast surgeons from cities throughout the United States. Ironically, the audience is not composed entirely of those breast surgeons who live in rural America and are frustrated by a lack of plastic surgical support. They are filled to a large degree with breast surgeons from urban America, in which plastic surgical assistance is readily available. It is interesting that they wish to learn about and perform techniques related to plastic surgery of the breast even in circumstances in which plastic surgeons are readily available. I do not know why plastic surgeons in Brazil are unavailable to assist with breast reconstruction. I do not understand the socioeconomic climate, the procedural reimbursement, or the practice patterns responsible for those trends. However, I do know that there are plastic surgeons in almost every city within the United States who are willing to assist with breast reconstruction.
It is clear that some breast surgeons feel that reconstructive plastic surgery of the breast is a simple process.3 I agree that some methods, such as described in the class 1 group, are simple and should be performed by all breast surgeons. Delivery of these procedures by the breast surgeon will certainly benefit our patients.
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