Introduction

Over 1.2 million cases of breast carcinoma in women occur worldwide annually [1–3]. Breast carcinoma is the most frequently diagnosed malignancy in women worldwide [1–3]. Twenty-two percent of new cancer cases in women are due to breast carcinoma [1–4]. The lifetime probability of a woman developing breast carcinoma worldwide is as high as one in eight [1–4]. Death rates from breast carcinoma have steadily decreased in women since 1990 [4]. This decrease is due to a combination of earlier detection and improved treatment. Approximately half of those patients who require surgery for breast cancer will be referred for postoperative radiotherapy. After a steady decline, mastectomy rates have increased in recent years [5]. Fewer than 20 percent of eligible women undergo breast reconstruction after treatment for breast carcinoma [2, 6].

There is a growing interest in understanding the surgical treatment decision-making process for patients with breast cancer [7, 8]. Many prospective randomised trials have shown equivalent survival after breast-conserving surgery and radiation and after mastectomy for women with stage I and II breast carcinoma [9–12]. In spite of this, mastectomy remains a common treatment for women with both invasive and intraductal carcinoma [13, 14]. It has been proposed that the large variation in patterns of surgical treatment is evidence of failure to involve female patients in the decision-making process for surgical therapy [7, 8, 15]. However, work examining the surgical treatment decision-making process for women with breast carcinoma suggests that greater patient involvement in the decision-making process is associated with higher rates of mastectomy [12]. All else being equal, the option of breast reconstruction may make mastectomy more appealing to women who strongly value breast preservation [8].

Women who decide to undergo breast reconstruction are exceptional, they have greater fortitude than others who suffer from the same deformities but dare not face an operation. They may even have made their decision alone, without support from their families or even doctors. For those women undergoing mastectomy, significant advances in reconstruction techniques provide several options for breast reconstruction [16]. These women go through a maze of decisions to whether they will opt for breast conservation or will choose a mastectomy with reconstruction. Patients rely on surgeons for guidance and often ask the surgeon which option they would choose, if they were the patient. When faced with these complex management problems, it is would be interesting to see how female reconstructive surgeons would deal with their own potential reconstructions. Studies have been done for patient satisfaction regarding their method of reconstruction, but no studies have been done as to surgeons’ preferences regarding type of reconstruction [17–24]. For the surgeon, reconstructive breast surgery always a challenge as it is demanding surgery in which perfect results are never achieved and little is known about surgeons’ perceptions regarding the decision-making process for reconstructive breast surgery. The aim of this study was to explore the opinions of female plastic surgeons regarding breast reconstruction, if they themselves required breast reconstruction after surgical ablation of a breast carcinoma.

Materials and methods

A questionnaire was developed for this study to inquire about female doctors preferences for breast reconstruction, if they were to be diagnosed with breast carcinoma. Female plastic and reconstructive surgeons were polled by face-to-face questionnaire by the author to the methods of breast cancer treatment and reconstruction they would opt for if they were diagnosed with 2 cm invasive breast carcinoma. These surgeons were approached at six international congresses from 2007–2010.

Results

107 female plastic and reconstructive surgeons were surveyed. The majority stated that they would opt for mastectomy ± reconstruction (75%) rather than undergo breast conserving surgery and radiation (21%) (Fig. 1). Most (95%) of those choosing a mastectomy would opt for reconstruction (Fig. 1).

Fig. 1
figure 1

Choice of treatment if they were diagnosed with a 2 cm invasive breast carcinoma

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For their reconstruction choices, 50% of those surveyed would choose a deep inferior epigastric artery perforator (DIEP) flap or transverse rectus abdominis musculocutaneous (TRAM) reconstruction flap reconstruction (38% DIEP: 12% TRAM) (Fig. 2). 26% would choose tissue expansion with implant (Fig. 2). Only 19% would opt for a latissimus dorsi flap if all methods of reconstruction were available to them (Fig. 2). Interestingly, 4% of the female surgeons would not want a reconstruction (Fig. 2).

Fig. 2
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Choice of reconstruction

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For the women choosing tissue expansion with implant reconstruction 64% would choose a silicone implant, 9% would choose a saline implant while 27% felt either type of implant would be acceptable (Fig. 3). For women choosing latissimus dorsi flap with implant reconstruction, 69% would choose a silicone implant, 13% would choose a saline implant while 19% felt either type of implant would be acceptable (Fig. 4).

Fig. 3
figure 3

Choice of implant with tissue expansion

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Fig. 4
figure 4

Choice of implant with latissimus dorsi flap

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Discussion

A patient’s overall satisfaction with a particular procedure stems from the combination of the events they experience in the preoperative, perioperative, and postoperative recovery periods and the final aesthetic outcome. Furthermore, there are few areas of medicine so dependent on ensuring our female patients are happy and satisfied with their choices as plastic and reconstructive surgery.

As mentioned in the introduction, multiple prospective randomized trials have demonstrated that survival after breast-conserving surgery and radiation is equal to survival after mastectomy for females with stages I and II breast cancer [9–12], yet mastectomy remains a widespread treatment for females with both invasive and intraductal carcinoma [13, 14]. There is little question that a female surgeons would be highly involved in her decision-making process for both treatment and reconstruction and it has been demonstrated that the more a female with breast carcinoma is involved in the decision-making process, the higher the rate of mastectomy [7, 8]. Female surgeons without clinical contraindications to breast conserving surgery may still favour mastectomy over breast conserving surgery because of concerns about cancer recurrence or fear of radiation [21, 25]. It has been demonstrated that patients with higher levels of education with early stage disease (stage I or II) who had a discussion about reconstruction were more than four times more likely to receive a mastectomy when compared with those who did not [7, 8]. Ensuring that patients are appropriately and adequately informed ensures that they can make a rational decision about their treatment and sits well with medical and governmental recommendations.

The significant advances in breast reconstruction techniques have provided several options for breast reconstruction and patients can choose what they feel is the right option for them [7, 8]. A good decision can only be made if the patient has been given all of the information [7, 8]. Female plastic and reconstructive surgeons should have all this information and may better perhaps understand the true perception of a particular procedure. By experiencing and understanding what their patients have experienced and perceived, a female plastic and reconstructive surgeon is likely to be properly and well informed about her breast cancer therapy and reconstruction choices, her expectations of the entire process, potential postoperative complications and her final outcomes.

Autologous breast reconstruction, particularly with abdominal flaps was the most popular form of reconstruction amongst the population studied and the use of abdominal tissue has been described as the “gold standard” in breast reconstruction [26]. It is interesting that over a quarter of female plastic and reconstructive surgeons with their knowledge and experience with various reconstructive methods used for breast reconstruction would choose tissue expander reconstruction; this may be due to its ease and speed compared to autologous breast reconstruction.

Silicone gel implants were a more popular implant choice than saline-filled implants with our female surgeons, primarily because they produce a natural-feeling breast and are particularly effective for women with minimal breast tissue [16].

Although these results offer some insight into current thinking amongst this group of clinicians, it is important to recognise the limitations of this study in order to take these findings in context. The questions asked were purely hypothetical and may not necessarily relate to what decisions would be taken in reality. Opinion may reflect a bias as some methods are more commonly performed in a particular department, geographical area or personal experience. The options chosen may also be biased by the female surgeon considering their suitability for the various options, for example, if they considered that they were too slim for a DIEP/TRAM they may have chosen another option. However, female plastic and reconstructive surgeons offer an exclusive insight into surgical outcomes following breast cancer therapy and reconstruction. 75% of the female plastic surgeons stated that they would opt for mastectomy over breast conservation surgery. Although the use of autologous abdominal tissue has been described as the “gold standard,” it is worthy of note that only 48% of female plastic and reconstructive surgeons with their expertise and understanding of the range of reconstructive methods used for breast reconstruction would select autologous breast reconstruction with abdominal tissue.

The complete postablative reconstruction approach should offer alternatives to breast conserving surgery [27]. Skin sparing mastectomy with autologous reconstruction is one way to avoid radiotherapy in some patients and is an alternative to breast conservation [20, 21]. This approach is often appropriate for women, especially for younger patients, with DCIS or invasive cancer without lymph node involvement and has both low morbidity and high levels of patient satisfaction [20, 21]. The absence of lymph node involvement is often the basis for avoiding radiotherapy, an integral part of the local modality in breast conserving therapy [21–23]. This N0 staging of an invasive cancer serves as a plausible rationale to discuss with the patient in the context of her preference for either skin sparing mastectomy and immediate or, in some cases, implant reconstruction to avoid a 6-week protocol of radiotherapy and a more complex follow-up imaging protocol for the treated breast. Currently, no randomized data are available comparing breast conserving surgery with skin sparing mastectomy and autologous reconstruction.

Effective management of women with breast cancer requires a complete understanding of the various options throughout the entire treatment process [7, 8, 24]. Female plastic and reconstructive surgeons have thorough understanding of these options. Breast surgery is evolving and becoming more complex, but the goal remains the same: maximize local control and minimize poor cosmetic results. Surgery of the breast and lymph nodes has become advanced and comprehensive, ranging from well designed partial ablations to mastectomy and reconstruction. In addition, breast conserving surgery has been shown to be as effective as the more radical resections in terms of overall survival [9–12]. Female plastic and reconstructive surgeons have comprehensive knowledge of both oncology and cosmesis and understand the entire process from planning to reconstruction. One complicating factor to any breast conserving therapy is the addition of postoperative irradiation as breast tissue is left in situ [9–12]. Radiotherapy is not a negligible therapeutic modality and must be balanced with its side effects and long-term sequelae [3, 28]. Skin sparing mastectomy with reconstruction is a surgical option that can avoid the use of radiotherapy [9–12], but when compared with breast conserving surgery and radiotherapy, mastectomy and reconstruction is also not without significant risks and complications. [3, 17–25, 28, 29].

This study suggests that due to their clinical experiences, female plastic and reconstructive surgeons have knowledge as to outcomes and consequences of breast cancer treatment and reconstruction and their choices do not always adhere to current guidelines. The challenge for breast cancer therapy in the future will be to produce collaborative long-term trials and datasets large enough to demonstrate beyond doubt maximal oncological safety whilst minimising cosmetic impact by a combination of ablative and reconstructive techniques. In addition, the underlying paradigm of informed breast cancer treatment decision-making may need to change to include mastectomy with the option of reconstruction, for patients who express a preference for treatment with mastectomy.