Plastic surgical reconstruction extends the capabilities of surgical and radiation therapy for cancer patients. Resection defects that are large, involve functional structures, aesthetically sensitive areas, and/or are at increased risk for wound healing complications are successfully reconstructed with a wide variety of techniques. Cancer and the complications of cancer treatment can involve virtually any area of the body, and to address every potential circumstance, the breadth of oncologic reconstruction must be extensive. A multidisciplinary team approach is the optimal method of cancer treatment, and plastic surgical reconstruction has become a critical component of that treatment, with the ability to restore form and function to the involved areas.
It is with great pleasure that I have the opportunity to reflect on the article by Drs. Hasen, Few, and Fine, who nicely summarize some of the commonly performed oncologic reconstructive procedures. The authors are to be commended for their succinct and simplified overview of the complex decision-making and execution involved in oncologic reconstruction.
Choosing a Procedure
Decisions about breast reconstruction should be individualized, based on input from both the surgeon and patient. It is crucial that there be open and accurate communication with the medical oncologist, breast surgeon, and radiation therapist, who will influence the potential reconstructive options and ultimate procedure selected.
As stated in the article, tissue expander/implant reconstruction can be used for patients who are uncertain of the type of reconstruction they desire. This option is the least invasive, reversible, maintains the shape of the breast skin envelope, does not involve surgery outside the breast area, and usually can be converted to an alternative type of reconstruction in the future, if desired. Although this strategy "burns no bridges," I would strongly emphasize the benefit of choosing and performing the reconstructive option best suited for the patient as the primary procedure, to reduce the potential need for additional operative procedures.
Every attempt should be made to educate the patient about each available option, providing a detailed comparison of the risks, complications, expected outcomes, and recovery considerations. Additional sources of information that have been helpful include written literature, diagrams, photographs, videos, and discussions with patients who have undergone each procedure (ie, those who have had positive and negative experiences).
I am much more reluctant than the authors to use tissue expander/implant reconstruction in patients who have had or will receive chest-wall irradiation, particularly if an autologous tissue reconstructive option is available. The functional and aesthetic outcome is often compromised and, as mentioned, the complication rates are considerably higher.