Should a plastic surgeon perform mastectomy?

Question

Narrowing down choices for PS for prophylactic mastectomy. I figured the PS could suggest a breast surgeon he/she likes to work with. The highly reputed PS I'm considering using wants to perform mastectomy. He says even the best breast surgeons cut into the fat. I'm open to this because I know this surgeon is a perfectionist however it concerns me because a PS is not trained in oncological surgery and the whole point of this surgery is to reduce chances of developing breast cancer.

Ziyad Hammoudeh, MD · Answer

Thank you for your question.  Choosing the surgeon you feel most comfortable performing your prophylactic mastectomy is certainly an important personal decision.  As someone who has trained in both general surgery and plastic surgery and practices in the LA area, both mastectomy and breast reconstruction are within my scope of practice.  However, I believe that a multidisciplinary approach in which the breast surgeon focuses mainly on the mastectomy and the plastic surgeon focuses mainly on the reconstruction is preferable; such teamwork leads to a strong collaborative working relationship and great communication between specialties with excellent outcomes.  In general, focused attention to a particular discipline of surgery through great training in residency/fellowship and repetitive operative experience in practice leads to superior results.  The follow-up care you receive from an oncologic standpoint and reconstructive standpoint will also differ, and you will most likely want a specialist dedicated to each.  Amazing outcomes can be achieved now days with nipple sparing mastectomies through the inframammary fold and immediate reconstruction!  I hope this helps guide you in making your decision.
Best regards,
Ziyad Hammoudeh, MD

Leslie Memsic, MD, FACS · Answer

HI. Generally mastectomy and reconstruction is performed by a team consisting of a general surgeon/breast specialist and a plastic surgeon. The breast surgeon should be trained to remove all the breast tissue (or at least 97-99%) and leave healthy skin flaps and nipple. The plastic surgeon reconstructs the breast. Certainly there are plastic surgeons capable of mastectomy AND reconstruction, but this is not the norm. There are also breast surgeons (oncoplastic trained) who can remove the breasts and reconstruct the patient.This is also not the norm.  I would consult both specialists, insist on seeing pictures and discussing their complication rate. I am sure you will find the team that works for you. Good luck and take care.

Heather Richardson, MD, FACS · Answer

I am a general surgeon who performs mastectomy surgeries in the LA area. My nipple survival rate for the past 5+ years is 100%. I relocated here from Atlanta and I was very surprised at the increased need for wound care, hyperbaric oxygen, and the number of plastic surgeons unwilling to perform one stage reconstructions and - even worse- doctors preparing their patients for expecting nipple and skin death by regularly suggesting to otherwise healthy patients that they would need an additional surgery to increase blood flow called a "nipple delay". I agree that there is a general misconception among many mastectomy surgeons in this area that stripping healthy fat and healthy blood supply to the skin and nipple somehow will make the patient healthier. It won't. I sympathize with your plastic surgeon that he/she hasn't found a good general/oncological surgeon to partner with yet, but there is an important need to be able to perform the mastectomy consistently, removing the cancer causing breast tissue, and without bias to a cosmetic outcome. It may be (slightly) less important for a prophylactic case, but your PS needs someone who can address cancer producing tissue and also follow up with post operative screening to make sure your healthy tissue stays that way. Tell your PS to reach out to Heme Onc or Rad onc doctors in your area to ask them what mastectomy surgeons have the best out comes with the healthiest nipples and flaps- maybe they need to find new surgeons who will respect the need to keep the healthy skin blood flow alive while removing the breast tissue. It's easy- we do it all the time!

Robert Whitfield, MD · Answer

It is most appropriate for the Plastic Surgeon to work in concert with the Breast Surgeon.  Your oncologic care should be and is best handle by the breast surgeon and oncology providers.  I can perform a mastectomy as I am fully trained in general surgery and plastic surgery but I don't of the reasons above.

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Should a plastic surgeon perform mastectomy?

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