The only way a patient can access gold-standard breast reconstruction is by consulting a Specialist Plastic Surgeon. No other specialty is able to offer all forms of breast reconstruction.
Many of my colleague Breast Surgeons are very well equipped to offer their patients the best in cancer care. Equally, many Breast Surgeons perform immediate implant-based breast reconstruction, either on their own or in conjunction with a Plastic Surgeon. The problem can arise when a patient is told that (perhaps due to an anticipated need for radiotherapy or tumour characteristics, or even the patient’s breast size/shape) she is not able to have an immediate implant-based reconstruction. The reason this can be a problem, is that whilst the patient may not be a candidate for implant-based techniques, she may be a perfectly good candidate for a free flap reconstruction. DIEP flap reconstructions (and other microsurgical options) requires a referral to a Plastic Surgeon. Seems simple enough, right?
Every day, I am seeing women who have never been offered the opportunity for a consultation with a Plastic Surgeon, and who have had a total mastectomy without any form of reconstruction, even if there may have been options available.
So why would a woman not be offered a consultation with a Plastic Surgeon in this context?
I can’t answer this question. Fortunately, there are some wonderful Breast Surgeons who embrace the collaborative nature of treating breast cancer, who want the best for their patients and who will seek an opinion. I have spoken before about the truly dismal rates of immediate reconstruction in Australia, and one of the drivers of this I think is the fact that many patients have never been offered all of the available options.
I think the issue is this: if you have breast cancer, if you have been told that you need to have your breast removed, then you have every right to request a referral to a Plastic Surgeon. You certainly have the right to be offered ALL appropriate forms of reconstruction.
“Whilst it is still said that the need for radiotherapy is a contraindication to immediate breast reconstruction, the evidence is mounting that this is not (always) true.”
Advanced reconstructive techniques including “delayed-immediate reconstruction” (where an expander is placed immediately, expanded to full volume and then deflated to allow for radiotherapy before being re-expanded and then replaced with a DIEP flap), and even irradiating an immediate DIEP flap reconstruction followed by autologous fat grafting, are yielding excellent results for women without leaving them for a long period of time without a breast of any form. Whilst there remain cases where immediate reconstruction simply isn’t appropriate, I do believe that standard arguments for not reconstructing the breast are becoming less and less relevant. This is a rapidly changing space in breast reconstruction and I hope that our colleagues in Australia can embrace these evolving concepts.
To get the best outcomes (oncologically, functionally, psychologically and aesthetically), patients often need the skills and resources of more than one surgeon. Exercise your right to ask questions and seek opinions.