Oncoplastic Breast Recon

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Stare Decisis

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Will oncoplastic breast surgeons displace plastic surgeons performing breast reconstructive surgery? In talking to a general surgery resident she was fairly confident that in the next decade most of the breast reconstruction cases will be performed by general surgeons with a oncoplastic fellowship. Is this actually a possibility or legitimate concern?

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Will oncoplastic breast surgeons displace plastic surgeons performing breast reconstructive surgery? In talking to a general surgery resident she was fairly confident that in the next decade most of the breast reconstruction cases will be performed by general surgeons with a oncoplastic fellowship. Is this actually a possibility or legitimate concern?

She is not correct, at least not from the standpoint of ASBS.

Most oncoplastic training programs for general/breast surgeons are not training to place tissue expanders, implants, nipple reconstruction, etc. These are simply training surgeons how to do tissue advancement flaps/rearrangement. The point of these training program is not to replace the plastic surgeon who has years of training in reconstructive techniques but rather for providing a better cosmetic outcome for the breast conservation patient.

Currently many hospitals will not allow breast surgeons to do reconstruction and malpractice insurance providers require a different policy if you any plastics. However, that could change if the training changes or there is a need (ie, local policies about who can do what depend on local needs, requirements).

I think that while many of us do oncoplastic techniques in select patients there is still a role for the plastic surgeons which cannot be replaced by an "oncoplastic fellowship" (I know of only 1 aesthetic breast fellowship in the US which is open to general surgeons; there are some in the UK. Italy and France); most of these fellowships are simply weekend courses.
 
I think Kim would have some more valuable inight, but there are some practical reasons why I don't think we'll see much happen with this

1) a surgeon will be doing long,complex procedures with high complication rates at 50 cents on the dollar (due to mulitple procedure discounting with insurance billing). As reconstructive procedures pay worse then the resection procedures (when you account for increased complexity, decreased productivity and aftercare), I can't imagine this will ever make much financial sense

2) Oncology procedures of the breast (generally speaking) are short,simple, and predictable. Reconstructive procedures are often long, complex, idiosyncratic, and prone to reoperations. The aftercare for reconstructive patients is orders of magnitude more complex then the aftercare by a general surgeon for breast CA. As most specialty breast oncology types are trying to focus and limit their practice, adding reconstructive procedures destroys that model in terms of complexity.

3) the skill set for a lot of reconstructive procedures is the sum of a lot of highly specialized techniques that just wouldn't be able to be incorporated well in a breast-onc fellowship. It would be far,far easier to start with a trained plastic surgeron and work backwards towards a combined breast onc-reonstructive practice then vice-versa

4) the efficiency of a breast-onc practice model (like derm) relies on focused expertise and throughput of patients. Things that disrupt that undercut the financial sustainability of the model.
 
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I think Kim would have some more valuable inight, but there are some practical reasons why I don't think we'll see much happen with this

1) a surgeon will be doing long,complex procedures with high complication rates at 50 cents on the dollar (due to mulitple procedure discounting with insurance billing). As reconstructive procedures pay worse then the resection procedures (when you account for increased complexity, decreased productivity and aftercare), I can't imagine this will ever make much financial sense

2) Oncology procedures of the breast (generally speaking) are short,simple, and predictable. Reconstructive procedures are often long, complex, idiosyncratic, and prone to reoperations. The aftercare for reconstructive patients is orders of magnitude more complex then the aftercare by a general surgeon for breast CA. As most specialty breast oncology types are trying to focus and limit their practice, adding reconstructive procedures destroys that model in terms of complexity.

3) the skill set for a lot of reconstructive procedures is the sum of a lot of highly specialized techniques that just wouldn't be able to be incorporated well in a breast-onc fellowship. It would be far,far easier to start with a trained plastic surgeron and work backwards towards a combined breast onc-reonstructive practice then vice-versa

4) the efficiency of a breast-onc practice model (like derm) relies on focused expertise and throughput of patients. Things that disrupt that undercut the financial sustainability of the model.


Dr. Oliver or WS,

With all due respect to general surgeons if the mastectomy pays better then why do the plastic surgeons relegate this to GS and only do the reconstruction. At my institution most of the breast recon. guys just complain about the flaps left by the general surgeon anyway. Is this just one of those "political" things?
 
Dr. Oliver or WS,

With all due respect to general surgeons if the mastectomy pays better then why do the plastic surgeons relegate this to GS and only do the reconstruction. At my institution most of the breast recon. guys just complain about the flaps left by the general surgeon anyway. Is this just one of those "political" things?

Actually, I know some plastic surgeons who are fine with doing prophylactic mastectomies themselves. That's probably the easiest thing that breast GS do. But few if any plastic surgeons have the knowledge or interest in staging, BCT, image-guided stuff etcetera that is the real area of specialization for breast oncs.

And while I wish WS's opinion was universal, there is a reason that "the powers that be" of plastic surgery are highly concerned about this (and they are, look in this month's PRS or the talks at ASPS or other big meetings about the "oncoplastics" bogeyman). In Europe, the one-stop-shopping oncoplastic surgeon is often the primary model, so there's evidence it can be done safely. The reimbursement for recon sucks and it's inconvenient to schedule around whenever the GS happens to finish the onc part of the case, so interest in doing it has declined which leads GS to claim that they can't get plastics to do it and need to train their own, and it becomes a big cycle. I really don't know where the future is going, just throwing the devil's advocate out there.
 
Actually, I know some plastic surgeons who are fine with doing prophylactic mastectomies themselves. That's probably the easiest thing that breast GS do. But few if any plastic surgeons have the knowledge or interest in staging, BCT, image-guided stuff etcetera that is the real area of specialization for breast oncs..

Most of us from the plastics side would rather do the prophylactic mastectomy ourselves as you can have more control over the reconstruction considerations and do things (difficult nipple transpositions, simultaneous mastopexies,, etc..) you would not trust to do when someone else does the mastectomy. None of the surgical procedures for breast CA, be it mastectomy or partial (BCT), are too difficult technically. Image guided biopsy (ultrasound, stereotactic, or MRI) is pretty simple to learn. Staging is pretty cookbook. Some treatment plans do require a great deal of thought that have to be individualized (which I appreciate more and more in a multidisciplinary breast cancer clinic I participate) in. What a dedicated general or breast onc surgeon offers is a very narrow focus that makes throughput very efficient and having a dedicated office infrastructure to handle the needs of those patients. That is a HUGE difference in creating a sustainable practice model on a narrow focus like breast disease


there is a reason that "the powers that be" of plastic surgery are highly concerned about this...The reimbursement for recon sucks and it's inconvenient to schedule around whenever the GS happens to finish the onc part of the case, so interest in doing it has declined which leads GS to claim that they can't get plastics to do it and need to train their own, and it becomes a big cycle.

The idea that in most metro areas you can't find a plastic surgeon to do breast reconstruction has been shown to be demonstrably false when this has been studied. In some areas (NYC metro area for ex.) you may run into issues with insurance participation (lots of out of network surgeons there), but that's a economic issue rather then an abscence of providers available to do surgery. The bigger discrepency from the literature is that relatively few women diagnosed with breast CA get referred for reconstruction. I think the bigger concern of ASPS on this issue is not that breast oncologists start doing 12 hour free flaps, but that you suddenly get "mission creep" into ancillary and cosmetic breast surgery by these providers
 
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