In current study, we reported the preliminary outcome of 451 breast reconstructions performed by one ORBS, who initially was a BS and received international oncoplastic and reconstructive breast surgery training program. The preliminary results showed that the clinical outcome was acceptable, and there was no total flap failure in autologous breast reconstructions. The implant failure rate was 1.4%, which was low compared to around 8% implant failure rate reported in a meta-analysis of breast cancer patients with IBR[16]. We observed a high patient-reported satisfaction rate (Figure 2a), with 95% of the study population reporting being satisfied (good: 41.1%; excellent: 53.9%) which is comparable with an earlier study published by Roberson et al[15]. Moreover, an earlier report by He et al[13] also demonstrated that having breast surgeon specialists performed IBRs doesn’t seem to negatively affect outcome. Additionally, we found that ORBS also had positive impacts on rate of breast reconstructions (Figure 3a, Table 4).
IBR with implant have been employed as a mainstream option of breast reconstructions after early breast cancer treatment [13, 17-19], and implant failure is an important quality-indicator for the performance of reconstructive surgeon[16]. According to literature review meta-analyses results, around 8% of breast cancer patients with IBR suffered from implants loss[16]. Another study, in which breast reconstructions were performed by breast surgeons, showed a 4.9% (11/223) of implant extrusion rate due to infection[15]. The 1.4% (5/361) implant failure rate from the ORBS in the current study is low and acceptable. Factors predisposing to implant loss had been reported, radiotherapy, uncontrolled infection, obesity, and ptosis breasts were important risk factors[15, 16]. Whenever patients with the above mentioned risk factors are indicated for IBR, autologous breast reconstruction would be a safe alternative[17-19].
A qualified ORBS should be able to provide immediate or delayed breast reconstructions, which include implant types and/or autologous breast reconstructions[3, 9, 15]. Other than 361 implant insertions, our breast reconstructions program by ORBS also performed 94 autologous flap breast reconstructions (76 TRAM flap, 18 LD flap, Figure 1, Table 1, 3), laparoscopically harvested omentum flap, and other local flaps for partial breast reconstructions or repair of soft tissue defects. Compared with BS, who did not receive oncoplastic reconstructive breast training and provided only implant type breast reconstructions, a trained ORBS was able to provide more diversity of breast reconstruction services and in the same time, demonstrated a similar level of competency to PS (SLL) at the same year-of-service for breast reconstructions without microsurgeries (Table 3). Usually ORBS do not receive formal micro-surgery related trainings, therefore whenever the breast reconstructions involving the use of microsurgery techniques, consultation with PS, who experienced with microsurgeries, is recommended.
The impact of cases accumulation to the performance of an ORBS was rarely reported. We found that the operation time decreased, and implant failure rate dropped from 4% to 1% during study period after more cases experience accumulated (Figure 2b, c). From CUSUM plot, about 58 procedures were required for an ORBS to be familiar with the procedures of mastectomy and IGBR (Table 2, and Figure 2f), and the operation time together with blood loss were significantly decreased after initial learning phase. The patients’ reported satisfaction rate also increased steadily when more breast reconstructions performed by ORBS (Figure 2). These results supported that a BS after formally ORBS training could perform breast reconstructions and provided high quality services after adequate cases experience accumulated.
Breast reconstruction is traditionally going from breast cancer operation performed by BS (or general surgeon) then breast reconstruction part performed by PS[1, 12] (Figure 3b). This system had the advantage of different surgeons perform the best part of their work, however, some disadvantages remained unsolved[1]. For example, if the breast surgeons do not refer patients for breast reconstructions (as shown in Figure 3a), then patients may not have the chance to have breast-reconstruction consultations or operations provided by PS[20-22]. Sometimes, the BS or at the hospital just do not have adequate PS to perform the breast reconstructions[21-25]. These were some of the reasons that breast reconstructions rate remained low (around 10-25%) around the world today[9, 21, 23, 26].
At our institute, and I believed some other hospitals in the world[1, 7, 9, 12, 13, 15], now adopted the two tracts system, which allowed both the traditional two-team system (BS performed breast cancer operations then PS do the breast reconstructions) or the ORBS system (ORBS or dual-trained surgeons[12] do the mastectomies and reconstructions, Figure 3b). Patients could be referred from BS to PS for breast reconstructions or BS could work with ORBS doing breast reconstructions. ORBS (or dual-trained surgeon[12]) are capable of carrying out breast cancer operations and breast reconstructions. Herrick et al.[12] had shown that patients received dual-train surgeons’ services (mastectomy and reconstruction) required fewer doctor visit, and have significant socioeconomic and psychological benefits. In some cases, when breast reconstructions involving micro-surgeries, ORBS could work with PS for breast reconstructions.
The concept of ORBS, which originated in early 2000 in UK and Europe, was aimed to incorporate aesthetics and plastic technique into breast cancer operations, and to promote breast reconstructions[1-3, 5, 6]. In our multivariate analysis for factors predisposing breast reconstruction (Table 4), younger age (OR=0.92), breast MRI (OR=3.74), NSM (OR:7.40), ORBS (OR:1.84), and high-volume surgeon (OR:6.96) were important factors. Our findings supported that ORBS could increase breast reconstruction rate, and confirmed that the primary breast surgeons played import roles[20-22, 27, 28]. High volume surgeon (defined as cases larger than 100 per year) and ORBS were important contributing factors affected patients receiving breast reconstructions (Table 4, Figure 3a).
This study is limited due to its single institutional study without multi-centers’ data to confirm the hypothesis that breast surgeons after adequate training could be transformed to ORBS and perform breast reconstructions with adequacy. As each BS received different surgical training and had quite different practice behaviors. The experience and results derived from current study might not be applied to other surgeons, hospitals or regions in the world. More studies and reports from other ORBS were needed to consolidate this concept. The questionnaire, which had been used and published in our previous studies[29-32], we used at current report was different from the common used questionnaire like “BREAST-Q”[14], and might not be so comprehensive and well adopted. Based on our experiences, a surgeon to be trained as an ORBS should be a certified breast surgeon, who is familiar with conventional breast cancer operations and treatment. Furthermore, he/she should receive reconstructive breast surgeries training in a high volume (≥100 cases per year) reconstructive breast surgeries centers with adequate training duration (≥ 6 months).
In conclusion, we demonstrated that a breast surgeon after adequate training could become an ORBS and perform breast reconstructions with adequacy. Following more cases’ experience accumulations, the performance of ORBS increased gradually in term of decreasing operation time, less implants loss, and increased patients’ reported satisfactions. In complimentary to traditional BS to PS pathways, ORBS could increase breast reconstructions, which were remained under-performed in the world.