Volume 135, Number 3 • Letters Kim Turner, M.D.
Correspondence to Dr. Orgill Brigham and Women’s Hospital 75 Francis Street Boston, Mass. 02115
Departments of Anesthesiology and Perioperative Medicine Queen’s University Kingston, Ontario, Canada Correspondence to Dr. Davidson Department of Surgery Division of Plastic Surgery Queen’s University Kingston, Ontario K7L 2V7, Canada [email protected]
disclosure The authors have no financial interest in any of the products, devices, or drugs mentioned in this communication.
disclosure The authors have no financial interest in any of the products, devices, or drugs mentioned in this communication. REFERENCE 1. Cawthorn TR, Phelan R, Davidson JS, Turner KE. Retrospective analysis of perioperative ketorolac and postoperative bleeding in reduction mammoplasty. Can J Anaesth. 2012;59:466–472.
reference 1. Cawthorn TR, Phelan R, Davidson JS, Turner KE. Retrospective analysis of perioperative ketorolac and postoperative bleeding in reduction mammoplasty. Can J Anaesth. 2012;59:466–472.
Reply: Ketorolac Does Not Increase Postoperative Bleeding: A Meta-Analysis of Randomized Controlled Trials Sir:
We would like to thank Drs. Davidson and Turner for their comments regarding our article entitled “Ketorolac Does Not Increase Postoperative Bleeding: A Meta-Analysis of Randomized Controlled Trials.” It appears that they have published their data in the Canadian Journal of Anaesthesiology.1 Our article focused on a review of prospective, double-blind, randomized studies. As a retrospective study, although provocative, their study was not of a high enough level of evidence for us to include in our review. They do bring up the important point of understanding the risk-to-benefit issues when considering the use of drugs in the perioperative period. The question of performing elective operations on patients with either antiplatelet or anticoagulant therapies will likely become more of an issue in the future. Certainly, our report does not definitely answer the question about whether using ketorolac in breast reduction is appropriate. It simply shows where the available evidence is today and highlights where we have gaps in our knowledge. For breast reduction surgery, surgeons will have to use the available published evidence combined with their own experience and evaluation of individual patients to make this decision. Carefully performed prospective, blinded, randomized studies will ultimately need to be performed to provide more definitive guidance. DOI: 10.1097/PRS.0000000000001078
Ryan M. Gobble, M.D. Dennis P. Orgill, M.D., Ph.D. Brigham and Women’s Hospital Boston, Mass. [email protected]
“Plastic Surgery” … Beware Sir: t was with great interest that we read your Editorial entitled “‘Plastic Surgery’ … Beware.”1 Your opening line resonated with us, as these are concepts that are common to all surgical disciplines, but none more so than modern-day breast surgery. The past 10 years have seen enormous changes in the way that breast disease is managed. Multidisciplinary teams are now the norm in Australia, many parts of Europe, and indeed in the United States, where once some scorned them as unnecessary and considered them a waste of time. Clinician-performed bedside ultrasound is now commonplace; however, at its inception, breast surgeons rarely found support for its use from their radiologic colleagues, who feared that referrals for this procedure would dry up. This did not occur. Any discussion of oncoplastic surgery universally seems to put many plastic surgeons on the defensive. Claims about breast surgeons not being properly or rigorously trained are made, as are statements along the line of “unless you can offer a full range of reconstructive options including free flaps, you should not be offering or performing any breast reconstructive procedures.” These historic attitudes serve only to foster the old silo mentality that comes with self-interest and turf protection. Breast surgeons in my experience only adopt “plastic surgery” techniques for the betterment of their patients. This is often driven by the fact that it is rare for plastic surgery services to be so well staffed that a plastic surgeon can be on “standby” for every breast cancer operation to “reconstruct” the necessary defect that follows a cancer excision—whether it is a lumpectomy or a mastectomy. If you subscribe to the construct that only a plastic surgeon is capable of repairing a defect in a breast following wide excision, or that only a plastic surgeon can be trained to perform implant-based reconstruction, you also have to believe that it is acceptable to leave the majority of breast cancer patients with aesthetically unappealing results, which is not the standard to which any modern breast surgeon would aspire. The most
I
649e
Plastic and Reconstructive Surgery • March 2015 logical solution is to train breast surgeons to understand breast aesthetics, to understand not only the complexities of breast oncology but also the principles of tissue rearrangement and breast reconstruction. Sadly, it is uncommon that plastic surgeons become involved in adaptive mammaplasty operations, and in fact there is no loss of patient referrals to the plastic surgeon; rather, there is simply a gain to the patient. In summary, oncoplastic surgery is here to stay. Plastic surgeons should embrace this major step forward because it improves patient outcomes. There will always be a role for plastic surgeons that have an interest in breast reconstruction. There will always be cases that are best treated by a two-team approach. Plastic surgeons should look for opportunities to work collaboratively with their breast specialist colleagues, not against them; as you point out in your Editorial, plastic surgeons do not dictate breast cancer referral patterns. DOI: 10.1097/PRS.0000000000001059
James French, F.R.A.C.S. Elisabeth Elder, Ph.D., F.R.A.C.S. Pouri Moradi, F.R.A.C.S.(Plast.) Westmead Breast Cancer Institute Westmead, New South Wales, Australia Correspondence to Dr. French Westmead Breast Cancer Institute P.O. Box 143 Westmead, New South Wales 2112, Australia [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCE 1. Nahabedian MY. “Plastic surgery”… beware. Plast Reconstr Surg. 2014;133:965–966.
Reply: “Plastic Surgery”… Beware Sir:
Thank you for your comments with regard to the Editorial entitled, “‘Plastic Surgery’ … Beware.”1 Your insights and experience are greatly appreciated. As in Australia, multidiciplinary breast centers have become common in the United States. I agree that the advancements in breast surgery have been beneficial to patients in terms of quality and convenience. I agree that oncoplastic breast surgery has improved patient outcomes and satisfaction and is here to stay. I agree that collaboration among surgeons, physicians, and members of the health care team will further enhance all of these positive attributes. I disagree that plastic surgeons foster the old silo mentality because of self-interest and turf protection. I disagree that only a plastic surgeon can repair a breast defect and I emphatically disagree that plastic
650e
surgeons feel it is acceptable to leave the majority of breast cancer patients with an aesthetically unappealing result. Most breast defects following lumpectomy are small and uncomplicated, and do not require closure by a plastic surgeon. However, larger breast defects following partial or total mastectomy are more complicated and should be repaired by a plastic surgeon. In their response, it is stated that the most logical solution is to train breast surgeons to better understand breast aesthetics and principles of tissue rearrangement and reconstruction. They also state that it is “sadly uncommon for plastic surgeons to become involved in adaptive mammaplasty operations.” I was very intrigued by this statement because the strict definition of adaptation is the process of change by which an organism or species becomes better suited to its environment. I agree that adaptation is necessary in our ever-changing health care milieu. That said, I wonder what driving forces are perpetuating the type of adaptation being promoted in this reply. Is it purely about what is best for the patient? Because if it is, why is it considered adaptive for plastic surgeons that have been performing advanced breast reconstruction for the past 30 years to step aside and allow a non–plastic surgeon to perform it. Why is it considered maladaptive for breast and plastic surgeons to operate sequentially in the setting of complex partial and total mastectomy to provide patients with the highest standards of quality and care? Plastic surgeons are specifically trained to repair and reconstruct soft-tissue defects and to appropriately manage any complication that may occur. The ability to perform a particular operation requires that one has the ability to manage any complication that may arise from that operation. In the reply, it is stated that there will always be a role for plastic surgeons interested in breast reconstruction. Does the new concept of adaptive mammaplasty redefine the role of the plastic surgeon to perform only microvascular breast reconstruction and to be “on-call” and assist the breast surgeon when needed? Perhaps this is the case in Australia and much of Europe, but in the United States, a healthy collaborative relationship between breast and plastic surgeons still exists, and patient outcomes and satisfaction scores are higher than ever. DOI: 10.1097/PRS.0000000000001081
Maurice Y. Nahabedian, M.D.
Department of Plastic Surgery Georgetown University 3800 Reservoir Road NW Washington, D.C., 20007 [email protected]
DISCLOSURE The author has no relevant conflicts to disclose with regard to this communication. REFERENCE 1. Nahabedian MY. “Plastic surgery” … beware. Plast Reconstr Surg. 2014;33:965–966.
Correspondence to Dr. Orgill Brigham and Women’s Hospital 75 Francis Street Boston, Mass. 02115
Departments of Anesthesiology and Perioperative Medicine Queen’s University Kingston, Ontario, Canada Correspondence to Dr. Davidson Department of Surgery Division of Plastic Surgery Queen’s University Kingston, Ontario K7L 2V7, Canada [email protected]
disclosure The authors have no financial interest in any of the products, devices, or drugs mentioned in this communication.
disclosure The authors have no financial interest in any of the products, devices, or drugs mentioned in this communication. REFERENCE 1. Cawthorn TR, Phelan R, Davidson JS, Turner KE. Retrospective analysis of perioperative ketorolac and postoperative bleeding in reduction mammoplasty. Can J Anaesth. 2012;59:466–472.
reference 1. Cawthorn TR, Phelan R, Davidson JS, Turner KE. Retrospective analysis of perioperative ketorolac and postoperative bleeding in reduction mammoplasty. Can J Anaesth. 2012;59:466–472.
Reply: Ketorolac Does Not Increase Postoperative Bleeding: A Meta-Analysis of Randomized Controlled Trials Sir:
We would like to thank Drs. Davidson and Turner for their comments regarding our article entitled “Ketorolac Does Not Increase Postoperative Bleeding: A Meta-Analysis of Randomized Controlled Trials.” It appears that they have published their data in the Canadian Journal of Anaesthesiology.1 Our article focused on a review of prospective, double-blind, randomized studies. As a retrospective study, although provocative, their study was not of a high enough level of evidence for us to include in our review. They do bring up the important point of understanding the risk-to-benefit issues when considering the use of drugs in the perioperative period. The question of performing elective operations on patients with either antiplatelet or anticoagulant therapies will likely become more of an issue in the future. Certainly, our report does not definitely answer the question about whether using ketorolac in breast reduction is appropriate. It simply shows where the available evidence is today and highlights where we have gaps in our knowledge. For breast reduction surgery, surgeons will have to use the available published evidence combined with their own experience and evaluation of individual patients to make this decision. Carefully performed prospective, blinded, randomized studies will ultimately need to be performed to provide more definitive guidance. DOI: 10.1097/PRS.0000000000001078
Ryan M. Gobble, M.D. Dennis P. Orgill, M.D., Ph.D. Brigham and Women’s Hospital Boston, Mass. [email protected]
“Plastic Surgery” … Beware Sir: t was with great interest that we read your Editorial entitled “‘Plastic Surgery’ … Beware.”1 Your opening line resonated with us, as these are concepts that are common to all surgical disciplines, but none more so than modern-day breast surgery. The past 10 years have seen enormous changes in the way that breast disease is managed. Multidisciplinary teams are now the norm in Australia, many parts of Europe, and indeed in the United States, where once some scorned them as unnecessary and considered them a waste of time. Clinician-performed bedside ultrasound is now commonplace; however, at its inception, breast surgeons rarely found support for its use from their radiologic colleagues, who feared that referrals for this procedure would dry up. This did not occur. Any discussion of oncoplastic surgery universally seems to put many plastic surgeons on the defensive. Claims about breast surgeons not being properly or rigorously trained are made, as are statements along the line of “unless you can offer a full range of reconstructive options including free flaps, you should not be offering or performing any breast reconstructive procedures.” These historic attitudes serve only to foster the old silo mentality that comes with self-interest and turf protection. Breast surgeons in my experience only adopt “plastic surgery” techniques for the betterment of their patients. This is often driven by the fact that it is rare for plastic surgery services to be so well staffed that a plastic surgeon can be on “standby” for every breast cancer operation to “reconstruct” the necessary defect that follows a cancer excision—whether it is a lumpectomy or a mastectomy. If you subscribe to the construct that only a plastic surgeon is capable of repairing a defect in a breast following wide excision, or that only a plastic surgeon can be trained to perform implant-based reconstruction, you also have to believe that it is acceptable to leave the majority of breast cancer patients with aesthetically unappealing results, which is not the standard to which any modern breast surgeon would aspire. The most
I
649e
Plastic and Reconstructive Surgery • March 2015 logical solution is to train breast surgeons to understand breast aesthetics, to understand not only the complexities of breast oncology but also the principles of tissue rearrangement and breast reconstruction. Sadly, it is uncommon that plastic surgeons become involved in adaptive mammaplasty operations, and in fact there is no loss of patient referrals to the plastic surgeon; rather, there is simply a gain to the patient. In summary, oncoplastic surgery is here to stay. Plastic surgeons should embrace this major step forward because it improves patient outcomes. There will always be a role for plastic surgeons that have an interest in breast reconstruction. There will always be cases that are best treated by a two-team approach. Plastic surgeons should look for opportunities to work collaboratively with their breast specialist colleagues, not against them; as you point out in your Editorial, plastic surgeons do not dictate breast cancer referral patterns. DOI: 10.1097/PRS.0000000000001059
James French, F.R.A.C.S. Elisabeth Elder, Ph.D., F.R.A.C.S. Pouri Moradi, F.R.A.C.S.(Plast.) Westmead Breast Cancer Institute Westmead, New South Wales, Australia Correspondence to Dr. French Westmead Breast Cancer Institute P.O. Box 143 Westmead, New South Wales 2112, Australia [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCE 1. Nahabedian MY. “Plastic surgery”… beware. Plast Reconstr Surg. 2014;133:965–966.
Reply: “Plastic Surgery”… Beware Sir:
Thank you for your comments with regard to the Editorial entitled, “‘Plastic Surgery’ … Beware.”1 Your insights and experience are greatly appreciated. As in Australia, multidiciplinary breast centers have become common in the United States. I agree that the advancements in breast surgery have been beneficial to patients in terms of quality and convenience. I agree that oncoplastic breast surgery has improved patient outcomes and satisfaction and is here to stay. I agree that collaboration among surgeons, physicians, and members of the health care team will further enhance all of these positive attributes. I disagree that plastic surgeons foster the old silo mentality because of self-interest and turf protection. I disagree that only a plastic surgeon can repair a breast defect and I emphatically disagree that plastic
650e
surgeons feel it is acceptable to leave the majority of breast cancer patients with an aesthetically unappealing result. Most breast defects following lumpectomy are small and uncomplicated, and do not require closure by a plastic surgeon. However, larger breast defects following partial or total mastectomy are more complicated and should be repaired by a plastic surgeon. In their response, it is stated that the most logical solution is to train breast surgeons to better understand breast aesthetics and principles of tissue rearrangement and reconstruction. They also state that it is “sadly uncommon for plastic surgeons to become involved in adaptive mammaplasty operations.” I was very intrigued by this statement because the strict definition of adaptation is the process of change by which an organism or species becomes better suited to its environment. I agree that adaptation is necessary in our ever-changing health care milieu. That said, I wonder what driving forces are perpetuating the type of adaptation being promoted in this reply. Is it purely about what is best for the patient? Because if it is, why is it considered adaptive for plastic surgeons that have been performing advanced breast reconstruction for the past 30 years to step aside and allow a non–plastic surgeon to perform it. Why is it considered maladaptive for breast and plastic surgeons to operate sequentially in the setting of complex partial and total mastectomy to provide patients with the highest standards of quality and care? Plastic surgeons are specifically trained to repair and reconstruct soft-tissue defects and to appropriately manage any complication that may occur. The ability to perform a particular operation requires that one has the ability to manage any complication that may arise from that operation. In the reply, it is stated that there will always be a role for plastic surgeons interested in breast reconstruction. Does the new concept of adaptive mammaplasty redefine the role of the plastic surgeon to perform only microvascular breast reconstruction and to be “on-call” and assist the breast surgeon when needed? Perhaps this is the case in Australia and much of Europe, but in the United States, a healthy collaborative relationship between breast and plastic surgeons still exists, and patient outcomes and satisfaction scores are higher than ever. DOI: 10.1097/PRS.0000000000001081
Maurice Y. Nahabedian, M.D.
Department of Plastic Surgery Georgetown University 3800 Reservoir Road NW Washington, D.C., 20007 [email protected]
DISCLOSURE The author has no relevant conflicts to disclose with regard to this communication. REFERENCE 1. Nahabedian MY. “Plastic surgery” … beware. Plast Reconstr Surg. 2014;33:965–966.
