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Deconstructive Reconstruction

Fri, 10/29/2010 - 6:07am
Interview by Amanda Hankel, editor

Oncoplastic breast conservation surgery combines breast cancer surgery with plastic surgery techniques to offer breast cancer patients an option that rids them of their cancer while providing a better cosmetic result.

October 29, 2010

Dr. Melvin Silverstein is a renowned oncoplastic surgeon, Clinical Professor of Surgery at the University of Southern California Keck School of Medicine and Director of the Hoag Breast Program at Hoag Hospital. Currently, lumpectomy and partial mastectomy are the norms in breast cancer surgery and often result in breast deformity.

Dr. Melvin Silverstein is a renowned oncoplastic surgeon, Clinical Professor of Surgery at the University of Southern California Keck School of Medicine and Director of the Hoag Breast Program at Hoag Hospital. Currently, lumpectomy and partial mastectomy are the norms in breast cancer surgery and often result in breast deformity. However, surgical advances, using oncoplastic breast conservation surgery, can provide patients with complete excision of their tumor as well as a beautifully-shaped breast. Dr. Silverstein was one of the first to incorporate plastic surgery into breast cancer operations more than 20 years ago. Surgical Products spoke with him recently to learn more about this novel procedure.

Surgical Products: Can you explain how you developed oncoplastic breast conservation surgery and what this procedure entails?

Dr. Silverstein: I have practiced oncoplastic breast conservation surgery for 27 years. I built the first breast center in the United States [in Van Nuys, CA] in 1979. The Van Nuys Breast Center was truly multidisciplinary and had all the different disciplines there at one time. There were two plastic surgeons. In 1983, it became apparent to me that I could more widely remove a cancer by using some of the things that plastic surgeons routinely did cosmetically.

So, we invented a series of different operations, based on breast reduction, that could be used to take out a cancer from any part of the breast. The operations widely excised the cancer while making the breast smaller and rounder.

In 2003, I started teaching a course about oncoplastic breast surgery at the American Society of Breast Surgeons Annual Meeting. 400 to 500 people came to the first course because nobody knew anything about these new techniques. It just wasn’t a major topic in this country. Now, I’d say for the last five to six years, it’s become an enormously important topic and many surgeons are interested in it.  

Oncoplastic surgery – "onco" meaning tumor – is a combination of two different sets of surgical skills and techniques. It combines the oncologic techniques, which tend to be destructive, with plastic techniques, which are reconstructive. So we combined oncologic and plastic surgery to create a win-win situation.

I always ask my breast fellows to think: ‘how can you get this cancer out, and at the same time, make this breast look as good as when you started or even better?’

Surgical Products: How does this differ from traditional methods of breast cancer surgery, such as lumpectomy or partial mastectomy?

Dr. Silverstein: Typically, a lumpectomy or partial mastectomy takes no skin and makes no attempt to re-shape the breast. All it attempts to do is take the cancer out with a rim of normal tissue. A side effect of standard excision, in probably 25 percent of cases, is a negative change in the size or shape of that breast. So, it actually looks worse than when you began. Whereas oncoplastic surgery takes the tumor out, but also re-sizes and re-shapes the breast so it looks as good as or better than when the surgeon started.

Surgical Products: Are there certain patients who are better candidates for this procedure?

Dr. Silverstein: It’s available to most patients. However, if you have a very small breast, it doesn’t work as well. The bigger the breast, the better oncoplastic surgery works. In a patient who needs a reduction or a breast lift or a little reshaping, this is really the ideal procedure.

Surgical Products: Are there any increased risks associated with this oncoplastic breast conservation surgery?

Dr. Silverstein: It’s the normal risks that accompany any surgery – hemorrhage, infection and so on. There certainly is going to be a change in size and shape and it’s possible the patient may not like the new size and shape. However, those are pretty much the standard risks of any breast surgery, even a regular lumpectomy or partial mastectomy. If you’re doing a reduction, there is always a risk of losing sensation to the nipple-areolar complex and a small possibility that part or all of the nipple-areola complex may die. Overall, though, the risks are minor and acceptable with a great potential benefit.

Surgical Products: How come this procedure didn’t take hold until recently?

Dr. Silverstein: Nobody ever taught young surgeons that it is important how the breast looks when you’re done with a breast cancer surgery. During training for the entire 1900s, teachers never said, ‘It’s important that the breast look good when you’re done.’ All they said was, ‘It’s important that you get the cancer out.’ So there was never any pressure to make it look good, and when it didn’t look good, a surgeon would say to the patient, ‘Look, we got your cancer out, be happy.’

It wasn’t until we really grabbed a hold of the philosophy that the appearance of the breast after breast cancer surgery is important that this technique really took off. I travel around the country and a lot of people have told me they’re doing it. It’s ultimately up to the surgeon.

Some of these techniques require additional training. All surgeons who train in general surgery are not ready to come out and become oncoplastic surgeons. The additional training required has probably slowed universal acceptance.

The University of Southern California in association with Hoag Memorial Hospital runs a fellowship in breast surgery. The main goal of that fellowship is to teach oncoplastic surgery. The easiest way for a practicing general surgeon to learn these techniques is to do these cases with a plastic surgeon. The best cases for them to do are reduction mammoplasties. A general surgeon should get a plastic surgeon to help him/her take out a cancer using a reduction. That’s the best way to learn – on the job.

Surgical Products: Can you discuss some of the effects this procedure has on patients post-operatively?

Dr. Silverstein: They feel better about their appearance and they have more confidence because they look better. It’s pretty exciting to get your cancer out and look better rather than get your cancer out and look worse.

The recovery time is identical to whatever the plastic surgery procedure is. So, for example, if I do a simple lumpectomy, I can do that procedure in an hour in the OR. Whereas, if I do a lumpectomy using reduction, it might take three hours. There would be somewhat more pain associated with it because there is a lot more work done on both sides than with just a simple lumpectomy. So, there is a little more pain associated with oncoplastic surgery and a little more recuperation time, but a far better cosmetic result. That’s the tradeoff.

Surgical Products: What do you see for the future in terms of oncoplastic surgery’s role in breast cancer surgery?

Dr. Silverstein: First, I see more and more surgeons getting on board and doing this. Secondly, I see more breast fellowship training programs adopting this and structuring the programs with large segments of plastic surgery so breast surgeons learn these techniques. The breast surgeon ought to know about both breast cancer surgery and breast plastic surgery. That is very important.

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