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Surgery: A Creative Surgical Approach

      for Breast Cancer Patients

      by Gail S. Lebovic, MA, MD, FACS

      For Additional Information visit: www.ASBD.org

      The term Oncoplastic Surgery describes an evolution within the field of breast surgery that was started in the late 1980s by a few pioneering surgeons. Concerned with the disfiguring surgeries commonly associated with breast cancer removal, these individuals sought a more creative surgical solution. Basically, the idea behind Oncoplastic Surgery is to combine the principles of surgical oncology (cancer removal) with techniques from plastic and reconstructive surgery. In this way, the surgeon plans the cancer-removing portion of the operation while keeping in mind the aesthetic outcome, and utilizing techniques to improve the appearance of the breast(s) afterwards. Oncoplastic Surgery does not describe a particular surgical procedure; it represents a comprehensive approach to surgical planning intended to achieve:

      1.Wide surgical margins free of tumor

      2.Reduced risk for local recurrence

      3.Optimized cosmetic outcome by preserving more skin

      4.Breast volume reduction for patients with large breasts and breast cancer

      5.In general, fewer surgical procedures overall

      6.Prophylactic removal of the breast tissue with reconstruction for patients at high/serious risk of breast cancer (i.e., genetic)

      Studies have demonstrated that the Oncoplastic approach adds to the oncologic safety of breast-conserving treatment, and ultimately better cosmetic outcomes following breast cancer surgery. This occurs because a larger volume of breast tissue can be excised and wider surgical margins free of tumor can be obtained. Oncoplastic techniques can be utilized routinely, and they are especially useful in specific cases such as removal of large tumors, when standard breast-conserving approaches have a high probability of leaving positive margins behind. By obtaining a “cleaner” margin, the associated risk of local recurrence can be diminished without creating an unacceptable deformity of the breast.

      A preoperative assessment includes a discussion regarding the cancer, but will also include the details of methods of breast reconstruction and whether surgery is needed on the opposite breast such as reduction, lift, or augmentation in order to achieve breast symmetry.

      Over the past several decades, techniques for breast reconstruction have undergone dramatic improvements. With the advent and integration of breast implants, tissue expanders and new methods for natural tissue flap reconstructions, there have been dramatic improvements in the appearance of reconstructed breasts. However, even though plastic and reconstructive surgery has seen and achieved great success, recent studies reveal that most women undergoing mastectomy (as many as 80%) are not having breast reconstruction. Unfortunately, fewer and fewer surgeons are committed to this highly specialized area leaving far too many women with little or no option for reconstruction.

      This phenomenon has stimulated a tremendous interest in the field of Oncoplastic Surgery, with many breast surgeons seeking additional training in order to offer full and comprehensive management to their patients. Since there are many various clinical practice settings within the United States, sometimes surgeons will work as a team, and in other situations, a single surgeon may have the skills to perform both the cancer surgery and the reconstruction as well.

      As mentioned, in some cases the primary surgeon may not take on the additional responsibility of performing the breast reconstruction; however, if the surgeon has an intimate knowledge of the various techniques, the risks, benefits, and timing of each type of reconstruction, this can help the patient take a more active role in planning the overall surgical approach. This allows for integration of all aspects of the surgery. In many cases, immediate breast reconstruction can at least be started at the time of mastectomy with placement of an implant, expander, or flap. This ultimately helps the patient emotionally through the loss of the breast, and in most cases, decreases the number of surgical procedures the patient ultimately needs to undergo.

      In this manner, the field of Oncoplastic Surgery will help surgeons learn and apply creative surgical solutions that simultaneously improve oncologic outcome and surgical cosmesis. These techniques are broadly applicable to all patients undergoing breast surgery, and it is most likely that university training programs will soon offer specialty training for surgeons in Oncoplastic Surgery. The American Society of Breast Disease has dedicated significant resources to teach surgeons these unique skills in a unique annual program called the “School of Oncoplastic Surgery.”

      Dr. Lebovic is Past President of the ASBD, and founder of the School of Oncoplastic Surgery.

      Once inside the bathroom, I had to strip naked and put on the white elasticized stockings and a gown that opened at the back. I placed my underwear, jeans, sweater, socks, and shoes in a paper bag with my name on it. I walked to my gurney with the bag in my hands and gave it to Paul for safekeeping. Reality set in. At that point, I told myself, “You just have to do this. You'll cry about it later. Now, you must stay positive and visualize a positive outcome.” I had to do this to save my life. And, it felt like I was doing it rather well. Grace carried me.

      Men to the Rescue

      Before the surgery, I asked my female surgeon to request a female operating team. I wanted the sacrifice of my left breast to be a women's ritual. It felt like a private female thing. When I received a telephone call the evening before surgery from a male anesthesiologist, I was upset. While I was not rude to him, the conversation lasted two minutes. I told him not to over medicate me, and I would see him in the morning. The disappointment hit. I felt weighed down because my ritual was not being honored by the “powers that be.”

      I reminded myself: “You believe in the divine right order of things, so you really need to let this negative attitude go.” I had to get past my sense of dread. The inner turmoil lasted a few hours, and I finally fell asleep surrendering to the inevitable. When I met the anesthesiologist the next morning in his funny green shower cap, he seemed quite harmless. He was tall, blonde and had bulging muscles on his thin frame. I liked him in spite of myself. He appeared centered and calm like someone who meditated as well as lifted weights. He exuded confidence. I gave him a slight smile, as a truce offering between us. He passed the test of a painless IV insertion.

      My female team took another hit when a short, dark-haired, body-builder type man walked over to introduce himself and offer his assistance as my surgical nurse. I was too preoccupied with staying positive to have an emotional reaction to him. I did not have the time or luxury to get tense and upset. I wanted the energy to stay high and positive so the surgery would be flawless. (I believe that our attitude affects outcomes.) My job was to remain centered and calm while I waited to go under my surgeon's knife. The nurse appeared gentle in spite of his strong masculine appearance, and he spoke to me with genuine concern. Instead of females, I attracted two muscular men who were gentle and caring. I began to get the picture. I was in the best of hands regardless of the demise of my ritual. I got what I needed, instead of what I wanted.

      I did manage to become slightly agitated when Paul could not find the healing mantra tape I wanted to hear before being wheeled into surgery. I quickly settled on my second choice—Triple Mantra, designed to eliminate negativity and prevent accidents. As I began listening to the trance inducing sounds, my body relaxed. I was able to transcend the voices, smells, and activity in the room. Within five minutes of focusing inward my surgeon showed up. She was all smiles and positive about the surgery. She looked like a little happy pixie, so I am thinking, “How bad could this be?” I reminded her not to take too many lymph nodes because I was going to do something systemic to heal my body. My plan was to treat my body as though the lymph nodes were positive no matter what they actually found. Plus, I had heard horror stories of women suffering without their lymph nodes, and I did not want to become one of them. It was time to go. It all seemed so rushed. I forgot to tell her to keep my breasts small with the two implants she would be inserting.

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