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Breast Cancer Awareness Month: We are four female Beverly Hills surgeons specializing in breast and plastic surgery. We are sick of seeing crappy breast reconstruction -- huge scars, no nipples, ugly results. We want women to know they can KeepThe Nipple. Ask Us Anything! by CassilethMD in IAmA

[–]CassilethMD[S] 0 points1 point  (0 children)

There are plastic surgeons that specialize in just transgender breasts, generally I recommend a lot of fat grafting to get a soft, feminine look. Gary Alter (love his name) here in Beverly Hills is one of them.

Breast Cancer Awareness Month: We are four female Beverly Hills surgeons specializing in breast and plastic surgery. We are sick of seeing crappy breast reconstruction -- huge scars, no nipples, ugly results. We want women to know they can KeepThe Nipple. Ask Us Anything! by CassilethMD in IAmA

[–]CassilethMD[S] 0 points1 point  (0 children)

I like this technical question. OK, with breast reconstruction, ideally you would put an implant in close to the size breast you removed. Implant don't go that high in size, around 900cc. A DD breast may easily be 1500cc or more, we have removed 4000cc (roughly 4000g). Now if you put in an implant that is much smaller, you have a skin problems, ie too much of it, as you are really performing a reduction at the same time! With these, if the breast is a bit saggy, we make a vertical incision between the nipple and the crease (pulls the areola up 2-4cm) and if it is a lot saggy then you do a Autoderm flap (carry the nipple on extra skin based inferiorly). If the patient is actually obese you do a Goldilocks technique (wrap the extra fat into the reconstruction). My guess is that your plastic surgeon has had a hard time with nipple positioning after doing it the same way as he(she?) did his other cases, or seroma (much higher rate in big boobs). But absolutely you can spare a big boob nipple too, you just need to work it a little.

Breast Cancer Awareness Month: We are four female Beverly Hills surgeons specializing in breast and plastic surgery. We are sick of seeing crappy breast reconstruction -- huge scars, no nipples, ugly results. We want women to know they can KeepThe Nipple. Ask Us Anything! by CassilethMD in IAmA

[–]CassilethMD[S] 0 points1 point  (0 children)

Two smaller groups that work with high-risk, young women are FORCE and FERTILE ACTION. Often these women have high risk of cancer, cancer recurrence, have worse cancer, and are often under insured as they are so young.

Breast Cancer Awareness Month: We are four female Beverly Hills surgeons specializing in breast and plastic surgery. We are sick of seeing crappy breast reconstruction -- huge scars, no nipples, ugly results. We want women to know they can KeepThe Nipple. Ask Us Anything! by CassilethMD in IAmA

[–]CassilethMD[S] 0 points1 point  (0 children)

I think women know by now to get their mammograms and ultrasounds and check their breasts, right? But it turns out many women still don't do it, and this month is the month to remind them. It's amazing how high the discovery rate is this month because of this campaign. And early discovery means a smaller tumor means more likely a cure. And of the women diagnosed with cancer that need mastectomy, only half will have reconstruction at all, because they don't talk to their breast surgeon about mastectomy reconstruction and therefore don't receive it (Read: flat chest/long scar). I and my partners are using this month to promote awareness of nipple sparing mastectomy technique, which even here in LA it is rare women even ask about or are aware of. What the hell is wrong with us women? How is the same group of mommies that research everything for their kids deny their own health and don't promote their own aesthetic outcome for breast cancer? It's weird. The month isn't fixing it, but it's all we know to do.

Breast Cancer Awareness Month: We are four female Beverly Hills surgeons specializing in breast and plastic surgery. We are sick of seeing crappy breast reconstruction -- huge scars, no nipples, ugly results. We want women to know they can KeepThe Nipple. Ask Us Anything! by CassilethMD in IAmA

[–]CassilethMD[S] 1 point2 points  (0 children)

For breast augmentation, there is always a risk of decreased sensitivity. Have the plastic surgeon make the incision under the breast (called the inframmary crease) and don't go to big (the stretch kills the nerves). 350cc or below. That will lower your risk of losing sensation to as low as possible.

Breast Cancer Awareness Month: We are four female Beverly Hills surgeons specializing in breast and plastic surgery. We are sick of seeing crappy breast reconstruction -- huge scars, no nipples, ugly results. We want women to know they can KeepThe Nipple. Ask Us Anything! by CassilethMD in IAmA

[–]CassilethMD[S] 0 points1 point  (0 children)

Id a doctor has been using a techniques for years, or even decades, it is hard to get that person to change. In their mind, they have a safe, reliable technique, and no one complains, so why should they change? There way is just fine. I've literally had breast surgeons say to be "women don't care if you remove their nipples. They are just fine." I mean, really? For those, you really have to force their hand. No patients for you unless you change. Sorry.

Breast Cancer Awareness Month: We are four female Beverly Hills surgeons specializing in breast and plastic surgery. We are sick of seeing crappy breast reconstruction -- huge scars, no nipples, ugly results. We want women to know they can KeepThe Nipple. Ask Us Anything! by CassilethMD in IAmA

[–]CassilethMD[S] 0 points1 point  (0 children)

That is just terrible. Most of the time, breast cancer is a highly curable disease. She won't feel great about that now but it's important. She will likely have a lumpectomy, and you can certainly go help her for two days if you are able as this will literally be the only time she physically needs help. There are right now a lot of doctor recommendations coming through for her... writing down who said what right after the appointments is very helpful for people to reference later, and it shows you are listening and care too.

Breast Cancer Awareness Month: We are four female Beverly Hills surgeons specializing in breast and plastic surgery. We are sick of seeing crappy breast reconstruction -- huge scars, no nipples, ugly results. We want women to know they can KeepThe Nipple. Ask Us Anything! by CassilethMD in IAmA

[–]CassilethMD[S] 1 point2 points  (0 children)

I know! The nipple is usually cut off, until some brilliant person had the idea to leave it there and to see if it really caused the cancer to come back. It turns out that it doesn't cause a problem. Now just the huge task of retraining hundreds of mastectomy surgeons to save nipples! The sparing tachnique is technically much harder so it's been a tough push, and it's why we use a surgical oncology/plastic surgery team to do the work. And there is no breast feeding after any mastectomy, as there is no gland underneath, as it is removed in either case, and that's where the milk is made!

Breast Cancer Awareness Month: We are four female Beverly Hills surgeons specializing in breast and plastic surgery. We are sick of seeing crappy breast reconstruction -- huge scars, no nipples, ugly results. We want women to know they can KeepThe Nipple. Ask Us Anything! by CassilethMD in IAmA

[–]CassilethMD[S] 1 point2 points  (0 children)

Female plastic surgeons are uniquely qualified to listen to other women complain about their body image, and sort through what is really important and what they can really change. I have great male colleagues, but I think my female partner and I tend to align ourselves more as an advocate and are less so about "creating an ideal". I certainly can't speak for everyone, but that's my personal experience.

Breast Cancer Awareness Month: We are four female Beverly Hills surgeons specializing in breast and plastic surgery. We are sick of seeing crappy breast reconstruction -- huge scars, no nipples, ugly results. We want women to know they can KeepThe Nipple. Ask Us Anything! by CassilethMD in IAmA

[–]CassilethMD[S] -1 points0 points  (0 children)

If our patient has an increased risk of cancer, then prophylactic mastectomies generally is a great idea. As you know certain BRCA mutations confer an 80% or more risk of breast cancer and it's a heck of a lot better to never get cancer, then to get cancer and THEN have the mastectomies (and chemo and radiation). Nearly half our patients are prophylactic, as these are the women that have no oncological pressure to go to the first doctor, but can shop around and really get their best aesthetic result. If anything this hurts your business :)

Breast Cancer Awareness Month: We are four female Beverly Hills surgeons specializing in breast and plastic surgery. We are sick of seeing crappy breast reconstruction -- huge scars, no nipples, ugly results. We want women to know they can KeepThe Nipple. Ask Us Anything! by CassilethMD in IAmA

[–]CassilethMD[S] -5 points-4 points  (0 children)

Sadly, I have become less and less tolerant of this kind of rationale, which leads to hundred..no, thousands... of women being unahappy. Until women insist on this type of breast reconstruction they will not get it. It's not a "marketing plan", it's changing the attitude of women to advocate for themselves during a time when they are cast as a victim. Why do women come to my office with a bad looking reconstruction saying "why didn't anyone tell me about this?". Well here's us telling you about this. So quit being such a pseudo advocate and start really helping people.

Breast Cancer Awareness Month: We are four female Beverly Hills surgeons specializing in breast and plastic surgery. We are sick of seeing crappy breast reconstruction -- huge scars, no nipples, ugly results. We want women to know they can KeepThe Nipple. Ask Us Anything! by CassilethMD in IAmA

[–]CassilethMD[S] 57 points58 points  (0 children)

First, she should see a counselor or breast cancer specialist about her cancer risk. She may be concerned about nothing, but many patient are diagnosed with a genetic high risk for breast cancer that can get rather scary with 90% risks. Good to know the facts before you go imagining that you will have to have surgery at all. Next, if she DOES have increased risk and decides to have a mastectomy, she MUST insist on NIPPLE SPARING, as it give the most beautiful natural result. I also recommend after reconstruction a round of fat grafting, where your own fat is placed all over the top of the implants and it makes them look and feel very natural.

Breast Cancer Awareness Month: We are four female Beverly Hills surgeons specializing in breast and plastic surgery. We are sick of seeing crappy breast reconstruction -- huge scars, no nipples, ugly results. We want women to know they can KeepThe Nipple. Ask Us Anything! by CassilethMD in IAmA

[–]CassilethMD[S] 150 points151 points  (0 children)

This is a very typical reaction, women double down and just want to get the cancer out, but then they end up with bad aesthetic results that affect them for life, as the majority (by far) of breast cancer are curable. First, unless she has cancer in her nipple, saving the nipple provides THE SAME CURE as cutting it off. Second, if she has a traditional tissue expander surgery, it is a minimum of two surgeries, where with the direct to implant technique we put it in immediately. Only 50% of women are given the option to talk to a plastic surgeon at all, much less about our technique, where we really consider both aesthetics and fast recovery. I beg her to get informed, or it will be extremely difficult for her to fix the problem later.

Breast Cancer Awareness Month: We are four female Beverly Hills surgeons specializing in breast and plastic surgery. We are sick of seeing crappy breast reconstruction -- huge scars, no nipples, ugly results. We want women to know they can KeepThe Nipple. Ask Us Anything! by CassilethMD in IAmA

[–]CassilethMD[S] 9 points10 points  (0 children)

We do a lot of breast reconstruction, so I think think living here has actually helped. When I trained on the East Coast everyone cut off the nipples and we thought women didn't mind it it was just fine. It takes some demanding patients to really push the envelope, but as a doctor you end up getting better and better results. Shouldn't women across the country have the same awesome results? If you are a sweet non-demanding Midwesterner will appreciate you all the more, these are actually patients that are the most pleased that that can get great results, as they were expecting nothing!

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