Big Talk About Breast Reconstruction

Authored By Lisa Cassileth MD, FACS

Recently the Cosmetic Surgery Times wrote a wonderful and insightful article about the successful Reddit AUA (ask us anything) hosted by our own Lisa B. Cassileth, M.D., FACS, and Kelly Killeen, M.D.
In this interview following their lively and popular Reddit Q&A (over 2,100 comments), Dr. Cassileth and Dr. Killeen discuss why women should “expect more” with mastectomies and breast reconstruction, including sparing their nipples and avoiding devastating scarring.
Check out the entire article:

Big Talk About Breast Reconstruction

by Randy Dotinga, Cosmetic Surgery Times
A pair of Beverly Hills plastic surgeons has a simple message for women with breast cancer who seek mastectomies and reconstruction: Expect more. Lisa B. Cassileth, M.D., FACS, and her partner Kelly Killeen, M.D., tell their breast reconstruction patients that it’s often possible to spare their nipples and avoid devastating scarring. It’s all thanks, they say, to their partnerships with top breast surgeons and a strong focus on aesthetics.
“Women often feel they can’t be naked after a mastectomy, that they feel asexual: ‘I’ve had this happen to me and I’ll move on, but I’ll never be able to be naked again or have anyone see me naked again,’” says Dr. Cassileth, the clinical chief of the Division of Plastic Surgery at Cedars-Sinai Medical Center and an assistant clinical professor at UCLA.
The reality, she believes, is the exact opposite. In fact, women can often even get the breasts they always wanted.
Dr. Cassileth puts it this way when she talks to breast cancer patients: “Sorry to be so superficial, but my job is to make you hot.”
In July, the two surgeons became a hit on the Internet bulletin board Reddit when they took part in an AUA — Ask Us Anything — titled “We are two female Beverly Hills plastic surgeons, sick of seeing crappy breast reconstruction — huge scars, no nipples, ugly results. There are better options!” Their discussion drew more than 2,100 comments.
Cosmetic Surgery Times reached out to the surgeons and asked them to describe their approach to mastectomy and breast reconstruction.
Q: What does the public misunderstand about breast reconstruction after breast cancer?
Dr. Cassileth: The reality is that women have no idea about it. Maybe their mothers or someone they know had a mastectomy, but it’s a taboo subject. You may never be told that you have this big cut across your chest. Then they look online, and the pictures can be really horrific. These women come into my office, and they’re shell-shocked. They just want to get this done.
Q: How have surgeons typically looked at the nipple in mastectomies and reconstructions?
Dr. Killeen: Traditionally, cancer surgeons considered the nipple to be part of the breast tissue, and it was removed. In fact, the nipple can be safely left behind in most patients. This leads to superior cosmetic outcomes, and women feel psychologically better keeping their nipple. Unfortunately, a lot of the country has been slow to adopt this as the standard of care.
Q: Why do you think nipple-sparing surgeries are so uncommon?
Dr. Cassileth: The majority of surgeons I’ve worked with don’t know how to do that. That’s why I’ve reversed the flow so we only work with breast surgeons who are fabulous.
Q: So you choose the breast surgeon instead of a breast surgeon choosing you?
Dr. Cassileth: I’m driving the consult back to the general surgeon, not the other way around. I’m first, and they’re second.
Q: What does your approach mean for the risk of mastectomy flap necrosis, a common complication of breast reconstruction?
Dr. Cassileth: The published complication rate is 15%. I’ve seen an average of 30% among surgeons, and one surgeon reached 55%. They want to do a good job, but they’re not fully aware, it doesn’t hit them like it hits us. All we care about is the aesthetic. When we choose the general surgeon, we keep statistics on every single one of our patients. We’re under 1%. I had one surgeon get up to 2%, and I said this will never happen again.
Q: You perform breast reconstruction at the same time as the mastectomy instead of separating the procedures. What does that accomplish?
Dr. Killeen: Traditionally, a lot of surgeons don’t pay as much attention to creating a perfect pocket. They don’t think they have to get it right the first time, since can be fixed when the patient comes back to get an implant later.
When you get the implant in on the first go, you have to treat that reconstruction with respect. You aren’t coming back another time.
Q: In the Reddit Q&A, you mention something surprising about how many men deal with the breast reconstruction of their loved ones. Can you tell that story?
Dr. Cassileth: When you give a man an implant to hold, they close their eyes and massage it: What does that feel like? I like it when they do that. They’re really committing. They’re fully committed that this will be their wife’s boob.
Q: How can men support the women in their lives when they undergo these procedures?
Dr. Cassileth: The woman’s facing this idea that they’ll somehow be maimed or damaged. They’re inhibited by the idea that their husbands are judging them. If the husband weighs in too heavily, even if he’s trying to be helpful, women will often take that as a criticism of themselves. They’ll feel more nervous and insecure about their reconstruction. Men who say “I love you, I don’t care about what you look like” — even if they’re lying — help women to feel unconditional love.

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