MedicalWe are two female Beverly Hills plastic surgeons, sick of seeing crappy breast reconstruction -- huge scars, no nipples, ugly results. There are better options! AUA
Jul 11th 2016 by CassilethMD • 17 Questions • 3681 Points
Hi! I am Dr. Lisa Cassileth, board-certified plastic surgeon in Beverly Hills, Chief of Plastics at Cedars-Sinai, 13 years in private practice. My partner, Dr. Kelly Killeen, and I specialize in breast cancer reconstruction, and we are so frustrated with the bad-looking results we see. The traditional process is painful, requires multiple surgeries, and gives unattractive outcomes. We are working to change the “standard of care” for breast reconstruction, because women deserve better. We want women to know that newer, better options exist. Ask us anything!
It’s hard to say goodbye, leaving so many excellent questions unanswered!
Thank you so much to the Reddit community for your (mostly) thoughtful, heartfelt questions. This was so much fun and we look forward to doing it again soon!
Serious Question: my wife has two different size breasts. More so than the average women. She is a small C cup on one size and a larger DD on the other. We have talked with a few surgeons and never left the consultation with a good feeling about the possible outcomes. What has your expirence been in similar situations? You are welcome to answer here or PM. Thank you in advance!
Love your question. I have a very different philosophy than pretty much everybody else. I think that breasts should always have the same amount of fatty tissue and the same amount of implant. II have three tools, reduction (removes breast tissue), implants, and fat grafting (adds fatty natural tissue). So, if she would like a large C let's say, reduce the DD down and augment both sides with the same implant. Usually need a small lift on the DD side. Or if she wants a DD on both, you can fat graft the C side, possibly reduce the DD side, and augment them both? Get it? It's a little complex, but at the end of any procedure the breast should be the same, essentially. Never augment asymmetrically as they always get exaggerated over time and is inherently the wring answer.
Hi there! What was the worst botched surgery that you have seen? Have you ever had to turn someone away?
This is going to sound awful, but I so so love bad problems from prior surgery. It's like a great opportunity to really do some great things. Last week I had stacked implants, capsular contractures with the ones on top of the muscle, the ones under the muscle had fallen into the armpits, ruptured silicone, and the nipples put too high looking straight up at the top of the boob. When I removed the capsule it was full of free silicone and old black ooze that I think must be from old congealed blood from the last surgery. So much fun to fix that... !!! I know I'm weird!
An old babe like me? Of course. I had some seriously hanging eye skin (thanks MOM!) that I had fixed at 40, and of course we are always doing lasers and fillers (grow up in florida with a lot of coppertone oil and pay the price!) I coolsculpted off my mommy tummy and that was awesome can barely tell I have three kids. It's the proverbial candy store, got be careful never to cross over to the weird!
As a male that had a bilateral reduction (gynecomastia) that is very uneven, wavy, and somewhat folded over... oh and missing a nipple on the left side. What is my recourse? Get a lawyer, ask for compensation to a better surgeon to repair? Live with the outcome that is worse than the issue I lived for 20 years that I was very self concious about?
This completely sucks. I've had good luck with these just resmoothing the skin with a combination lipo and excision. You've got to get the fatty spots out as it weighs down the skin and makes it wrinkle and fold weird, and sometimes I fat graft the thin spots as well as areas overresected can stick to the muscle and that looks weird. It's a bad problem, but it is fixable, and you may get your insurance to pay for it especially is you have a real deformity.
Could you share one of your most positive experiences helping a patient?
Absolutely... recently one of my young breast cancer patient got married. One year prior, she was diagnosed with breast cancer, and initially she was told she would have long scars, no nipples, and would be lucky to look good in clothes at all. We of course did a nipple sparing mastectomy and she has no visible scars. She sent our office her wedding photos of her in a strapless dress? How fabulous to allow this young woman to move on with her life, and sorry to be superficial, to be HOT after having breast cancer!!!!
A day or two on reddit there was an article about utilizing fat stem cells for breast augmentation. What do you know about this, how does it differ from fat transplant, and how does that differ from silicon, which is your preference?
You can actually sort the fat aspirate from liposuction to get more stem cells out of it. The process can take an hour, where after completion, the machine gives you a more pure stem cell derivitave. It has a higher yield supposedly once put in the breast, but it's most worth it with radiated fields and bad scars. You lose a lot of the fat when you concentrate it, as well, so for skinny girls this is not an option. The perfect augmentation with stem cells would be a fat hipped lower body girl that need a lot of boob boost and didn't mind the extra lipo.
Do you only do cancer related reconstructions or do you also repair botched enhancements as well?
What are the principal challenges you face other than managing expectations?
Much of our work is revisions and botched augmentations etc. Many of our patients have had 10 or more surgeries :( Capsular contracture, asymmetry, boobs in the armpits, one hard boob, bad scars, one up one down, weird implant fluid squirting out the nipples, ruptured silicone, you name it. The reconstructive aspect has really helped with the cosmetic work, and vice versa.
Anesthesiologist here - what is your anesthesia team like? Hospital or specialty same day center? Do your patients ever receive a paravertebral block for post op pain as has been the trend for breast reconstruction in recent years?
Hi doctor. Speciality center same day, Exparel in the field (LOVE it it's a pain gamechanger for us), discharge to aftercare center for 2-3 days. The Exparel is more of a field block with intercostals added as the surgeons perform it on the field looking directly at the anatomy.
Here is an immature one, Do you gals every play with your own products?
Like squeezing, bouncing or jiggling in order to ensure you have quality implants?
The implants feel pretty good. My favorite thing is when the husbands/boyfriends check the implant out they always close their eyes. Hilarious.
When you see a topless celebrity who's had an enhancement, do you ever critique to your SO or each other?
I love one of the HBO series and have been bummed about my favorite character's weird boobs and then she came to me to fix them... I practically fell over myself to do the surgery. High pressure for celebs the poor things are constantly scrutinized!!!! Ok poor things nothing but it's a lot of pressure
Have you ever seen the movie Breast Men? If so, did you find it entertaining or a frustrating representation of the industry?
OF course I have, that's why I picked this field!! no not really. I doubt I would stare at hot boobs and get myself killed (sorry if this is a spoiler). There's so much crazy hype in plastic surgery (dr 90210, botched, the swan,...) because it's so much about what's sexy and how we relate to it. It's actually feels great to be more of a voice of reason in a crazy world clamoring for unrealistic things.
My girlfriend's sister was diagnosed with breast cancer earlier this year. She's about 75% through with her chemo treatments, and starting to consider her cosmetic options. What general recommendations would you have for a mid-40s African-American woman considering reconstructive plastic surgery after breast cancer?
OK, this is a big deal. Breast cancer patients right now really need to advocate for themselves to get a mastectomy that has a short scar and spares the nipples. If she has very droopy or very big boobs, then she may not be a candidate nipple sparing (anything over a DD, or nipples that hang straight down). She has a little time to reasearch if she is in neoadjuvant chemotherapy, and remember, don't take no for an answer!!!! Find a great team that will cater to HER as the patient, and don't always trust the system to do the right thing!!! We are always willing to help out if she wants to contact us, use the [email protected] email.
Thank you for doing this AMA. Do you have a recommended list of doctors who perform similar types of breast surgeries in the United States?
I'm currently making a list, because not everyone wants to come to LA for surgery (although why not I say?). I've identified a few other teams, but it's tough. You need the right mastectomy surgeon (ie willing to do nipple sparing) and the right plastic surgeon (ie willing to do direct to implant). These surgeons exist as part of high volume teams. For now, you have to do the groundwork, and if you find anyone great please let us know.
I would like to get surgery for gynecomastia overseas because it's too expensive in America. What do you recommend I do?
Really? Our experience is that insurance often covers the procedure. Always do the technique using a VASER as it really cuts out the breast tissue, a scar at the nipple and under the armpit only. This is not the time to skimp my man. You need your chest to look good not like a lumpy bag of golf balls.
It's pretty surprising that mastectomies take the nipple. The usual mastectomy makes a horizontal scar across the patient's chest, removing the nipple and an ellipse of normal skin. The nipple sparing mastectomy should be done through an incision under the breast, the "inframmary crease". It's hard to find a team that does this, because most team won't do it. Why? It's harder. They can kill off the skin, called mastectomy flap necrosis, in 30% of cases. It takes longer. Our team has a less than 1% flap necrosis rate we've worked years to be as good as possible, because we really believe this is the better way.
How do you ladies feel about final implants before radiation?
Great questions. For years that was taboo. I LOVE putting the implants in before radiation, because operating in a radiated field is higher risk, then you avoid that risk. IF you know you need radiation, make sure your initial plastic surgeon uses acellular dermal matrix in your breast reconstruction (marketing under alloderm or FlexHD). It will drop your risk of capsular contracture down to less than half what it would be.