The Impact of a Single Dual-Trained Surgeon in the Management of Mastectomy and Reconstruction

Abstract

Background: Oncoplastic breast surgery is typically performed using a two-surgeon, two-team approach. The authors present their experience with patients undergoing mastectomy and immediate reconstruction performed by a single, dual-trained breast surgical oncologist and plastic and reconstructive microsurgeon. Methods: Patients who underwent mastectomy and/or immediate reconstruction performed by the senior author between 2015 and 2019 were divided into single-surgeon or dual-surgeon cohorts, and matched by age, body mass index, reconstruction type, and cancer stage. Results: The authors included 158 patients in their analysis (single-surgeon, n = 45; dual-surgeon, n = 113). Single-surgeon patients underwent surgery 13.2 days earlier than dual-surgeon patients (p < 0.01), and required significantly fewer preoperative (1.9 versus 3.4; p < 0.01) and postoperative visits (6.8 versus 10.7; p < 0.01). Operative duration was comparable (single-surgeon, 245 minutes; dual-surgeon, 245 minutes; p = 0.99). The authors found no significant difference in surgical-site infection, seroma, hematoma, abdominal donor-site healing, or flap and prosthesis loss between the groups. The authors did find that dual-surgeon patients had a significantly higher rate of mastectomy flap necrosis (20 percent versus 4 percent; p = 0.01), which held true on logistic regression when controlling for other variables. BREAST-Q data demonstrated that single-surgeon patients had significantly higher overall scores (p = 0.04), and were significantly more satisfied with their outcomes, surgeon, and the information provided (p = 0.03, p = 0.03, and p = 0.01, respectively). Conclusions: The single-surgeon approach has the potential to decrease patient burden by requiring fewer preoperative and postoperative visits without compromising surgical outcomes or oncologic safety. Further investigation is warranted into the financial implications and patient outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Plastic surgery market share of breast reconstructive procedures: An analysis of two nationwide databases

“…Historically, the United States has utilized a two-surgeon model in which general surgeons, typically with fellowship training in breast surgery and/or surgical oncology, perform the ablative breast procedure (lumpectomy or mastectomy) and plastic surgeons perform the reconstruction. 8,9 This contrasts with the single-surgeon model that is common in Europe, in which one surgeon trained in both surgical oncology and plastic surgery performs both tumor resection and reconstruction. [9][10][11] American breast surgical oncologists have increasingly voiced interest in learning reconstructive techniques, 10 thus raising the possibility that breast reconstruction in the United States may be shifting more towards this latter model.…”

“…Considering these changes, there is a potential opportunity for surgeons without formal plastic surgical training to perform an increasing share of breast reconstructive procedures. Historically, the United States has utilized a two‐surgeon model in which general surgeons, typically with fellowship training in breast surgery and/or surgical oncology, perform the ablative breast procedure (lumpectomy or mastectomy) and plastic surgeons perform the reconstruction 8,9 . This contrasts with the single‐surgeon model that is common in Europe, in which one surgeon trained in both surgical oncology and plastic surgery performs both tumor resection and reconstruction 9–11 .…”

Patterns of breast reconstruction and the influence of a surgical multidisciplinary clinic

“…14,16 Similarly, combined multidisciplinary clinics allow patients timely access to multiple consultations, reducing waiting times and improving patient compliance with treatment by lowering the barrier to their access. [17][18][19] We therefore established Alfred Health multidisciplinary breast surgical clinic, staffed by both the breast and plastic surgeons in 2016. Prior to this, patients would initially be seen by the breast surgical team.…”

“…This is important as the array of treatment options and their order of sequencing expands 14,16 . Similarly, combined multidisciplinary clinics allow patients timely access to multiple consultations, reducing waiting times and improving patient compliance with treatment by lowering the barrier to their access 17–19 …”

Discussion: The Impact of a Single Dual-Trained Surgeon in the Management of Mastectomy and Reconstruction

“…T his article by Piper et al examines the feasibility and outcomes of a single surgeon performing the role of breast surgeon and reconstructive surgeon. 1 This paradigm of a single surgeon performing a mastectomy followed by immediate reconstruction is not uncommon in Europe. However, in the United States, a dual-surgeon model commonly uses an oncologic breast surgeon for the mastectomy and a plastic and reconstructive surgeon for the reconstruction.…”