Dr. Robert Goldwyn

This is a classic! It has been posted at the TRAM/LATISSIMUS DORSI FLAP LIBRARY at the Silicone Survivors Website, article #12; the following is a rare insight into honesty from the editor of the Plastic Surgery Journal himself.

HOW GOOD ARE OUR BREAST RECONSTRUCTIONS?
Plastic Surgery Journal, September 1990, Editor: Robert M. Goldwyn, M.D.

I have attended and participated in numerous courses, conferences, meeting, symposia, and grand rounds on breast reconstruction, yet I still do not know what my colleagues are getting for results. I know what mine are; I wish they were better. So do many of my patients, and I suspect that other plastic surgeons also have heard similar complaints from their patients. That almost every woman is grateful for our efforts may be true, but to what degree we have met their expectations, voiced or silent, is difficult to assess.

At the time of the Dreyfus trial at the turn of the century in France, Emile Zola angrily defended Dreyfus with his famous “j’accuse” (“I accuse”). What follows is my own version relative to breast reconstruction.

I know that many of my rectus abdominis flaps look unnatural; that a few older patients, when followed for more than 5 years, have developed hernias; that flap necrosis is seldom a problem with midabdominal rectus abdominis myocutaneous flap, but some of my colleagues locally who have tried the low rectus have dead flaps (they blame themselves for not knowing how to do it correctly, for being on the wrong part of the “learning curve”); that many of my patients whose breasts have been rebuilt with expanders have results that are considerably worse than those shown in articles published in this Journal (the breasts look artificial, spherical, and are abnormally firm even when the final implant is polyurethane-covered, textured, or the usual soft gel); that I now hear from those who were ecstatic about the unilateral rectus flap that they are now using a bilateral pedicle in many instances because it is “safer” and yet I have never heard them state in print or in public (except for a private conversation) their complications with the former method; that at every national meeting I encounter new enthusiasm for a new implant or expander whose clinical trial, if there has been one, is notable for the plethora of impressions and the dearth of data; and that many who champion the virtues of a new implant have a financial interest in it, which per se does not invalidate their claims but should raise our index of scrutiny.

With regard to breast reconstruction, we have been feverishly, even desperately, jumping from one procedure to another, from one implant to another, in the futile hope that perfection is just a breast away. Such behavior can only mean that our results are not as good as some of our colleagues tell us they are. Why do they not state so in print?

As our readers know, we have a Follow-Up section, which is underutilized, not because I fail to ask authors for a later report on procedures they have introduced or advocated, but because most of them are reluctant to admit that what they had once thought was true no longer is. Pride before truth, a sorry sequence for physicians who have supposedly been exposed to the scientific method.

How jarring reality can be I learned many years ago when I gave a talk at grand rounds on breast reconstruction. I mentioned that I had been surprised that a few patients were not satisfied with their new breast. After the lecture, a psychiatrist whom I know well and respect highly said to me privately, “I am surprised that you are surprised. Some of those results are really not good.”

After the sting subsided, I realized that he was correct, that I had been blinded by my own handiwork – taking too much pride in the fact that I could make something from nothing, but not letting myself see that the something was not everything. To my credit, at least, I had shown a complete range of results, although admittedly I had not realized it and had not interpreted them properly. This is why any series of patients must be evaluated by someone else who can be objective – not one’s employee, resident, or mother.

For too long we have been fruitlessly repeating history, performing operations whose results even the originator sometimes knows are less than claimed. We are like the musician who plays yesterday’s tunes thinking that they are today’s hits – playing them off key. Is it too much to ask that we honestly share information with our colleagues so that we can provide our patients with a realistic idea of what result they will likely obtain from a particular method of breast reconstruction?

Even though I am a clinical surgeon doing breast reconstructions regularly, I remain confused about what I anticipate when I perform a procedure relative to the information that I have received at meetings and even in this Journal I edit. While I am not the world’s best surgeon, I do not believe I am the worst and if I, after 27 years of practice, find my average results below what I think an average result should be, I question whether I or anyone else has ever received an honest disclosure of the full range of surgical outcomes from the various methods of breast reconstruction.

I want to know the average result. I want to see consecutive patients with consecutive results. I want more than selected results, skewed to improve the surgeon’s image at the expense of everyone else, most particularly the patients whom we have to treat. It has now become fashionable to show a complication and even a poor result, but we still have enormous blur when it comes to knowing what happens in the middle part of the distribution curve. This type of result remains an elusive entity that we cloak in secrecy or circumlocution.

For the woman who has had the agonizing disclosure that she has breast cancer and now faces a bewildering choice of treatment, we have imposed a choice in reconstruction that is no less bewildering, but compared with the treatment of breast cancer, is less factual. The surgeon is also bewildered, but he or she will not admit this when presenting a list of alternatives to the patient who hopefully will participate in choosing a particular type of breast reconstruction. When the surgeon sees the patient postoperatively, and if he or she is willing to admit that the result is less than what it should be, usually there is self-recrimination. Perhaps this is justified, but too often, I suspect, this would be the same result that authors of papers on that particular method usually obtained, although they have not stated so in their articles or in their self-aggrandizing presentations at meetings.

These pages are open to the manuscripts (obviously, they have to be reviewed) that will show consecutive, not selected patients. Because I am a realist or perhaps a cynic about human nature, I would insist that the cases be notarized to be certain that they are truly consecutive and they be duly photographed at the same distance with the same views, particularly from the front – not twisting the patient to the side to lessen the obvious asymmetry. I would also want to see the postreconstructive defect at the time of mastectomy if the reconstruction had been done immediately. Some surgeons perform what my colleagues in general surgery here in Boston (maybe we are too conservative or radical) would consider a “cosmetic mastectomy” with only minimal removal of skin. Under these circumstances, using an implant alone or in conjunction with an expander is certainly easier than if a large amount of skin has been removed.

While I have no desire to be the Grand Inquisitor, and I certainly have enough to do, I might even be willing, on occasion, to travel to someone’s office or clinic to examine the entire series of patients that he or she is going to report in order to be certain that the results in the raw are the same as those in print. I realize that this type of activity is not the usual job description of an editor. However, I am very concerned that our Journal has published and is likely to continue to publish articles that are half-truths (or half-lies) because of the understandable human tendency of putting one’s better foot forward – will not enhance the series or the reputation of the author, so the author believes – incorrectly, in my opinion.

Leaving out patients whose results will not enhance the series has no more validity than and is equally deceptive as not reporting in an experiment an animal that may have died or whose flap might have failed. A result is a result, and I and every reader of this Journal want all the results. I confess to being a surgical disbeliever, but I would welcome conversion by facts.

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