Immediate reconstruction, performed at the time of the original cancer surgery, can decrease overall healing time and time away from work. Exposure to anesthesia is cut down by eliminating an additional surgery. And there is the psychological benefit of waking up after cancer surgery with two breasts, not one.

But immediate reconstruction is not for everyone. Some patients can’t handle the added emotional stress and just want the cancer out. Some will need radiation, which can damage a reconstruction. Some don’t think missing the breast will bother them, but find out that it does. And unfortunately, a significant number of women do not know that breast reconstruction is possible, and only discover it after their mastectomies.

The timing of breast reconstruction needs to be discussed with your cancer surgeon, oncologist, radiation doctor and your plastic surgeon. But first and most importantly, you, the patient, need to know what your options are.

First there are the fixed costs, like, for instance, the current price of breast implants. Variability in cost depends in part on volume of use, so a high volume facility may be able to negotiate a price as low as $350.00 per implant, where a low volume facility pays $450.00.  Other fixed costs depend on geography. Rent in New York City, for example, is much higher than it is in Pittsfield Massachusetts.

Then there is the cost of employing health care workers.  The professionals chosen to participate in a procedure greatly influence its cost.  If only a medical assistant and a surgeon are working, the cost will be small, compared to a full OR staff including a nurse, OR tech and anesthesiologist.  These costs are clearly related to quality and safety.

Costs most consumers are unaware of can account for the greatest variability:  Hospitals cost about 10 times what Ambulatory Surgery Centers (ASC’s) cost, although both are subject to similar regulatory bodies and require similar staffing.  ASC’s have been proven to be as safe or safer than hospitals, and are much more comfortable.

Finally, the price a surgeon sets for a service is sometimes elevated to imply a better product, akin to a luxury item wearing a high price to make it appear luxurious.  This “luxury” effect is particularly rampant in places like Manhattan.

If cost is as important to you as safety, think high-volume ASC, away from a big city, with a well-trained reputable surgeon who is not trying to impress you with astronomical fees.

We can improve the appearance of a partial mastectomy defect. Plastic surgeons can be involved during the initial cancer surgery to prevent a problem, or after the surgery to correct one.  Using breast reduction techniques to reshape the lumpectomy side is called Oncoplastic Surgery.  It is combined with a standard reduction on the other side for symmetry.

Oncoplastic techniques are only appropriate for large breasts.  For smaller breasts,  several other methods can be used to improve outcomes. Tissue flaps from the flanks, back or abdomen can be moved to fill in hollows or provide new skin. Fat transfers, using fat obtained by liposuction from another part of the body, can be injected into the breast to replace lost tissue.

If you are unhappy about the look of your lumpectomy or if you want to prevent a problem, consider contacting a plastic surgeon.  We can help.

What’s the difference between the procedures? Both a mini and full use an incision starting in the hair in front of the top of the ear. The incision uses the architecture of the ear to hide the scar and then can end at the earlobe or go completely behind the ear into the hair again. The difference is in the amount of muscle manipulated. For a mini facelift the muscles are tightened around the ear suturing to the base of the skull and the cheekbone areas. With a full facelift the muscle tightening extends to under the chin, the front of the neck and even can be tightened in the temple region.

In order to tighten the muscles the skin must be freed creating a larger area to heal and bruise. So when you hear of a facelift with minimal bruising and short healing times, that’s a mini facelift. A full facelift usually comes with a full two weeks of bruising and swelling. Besides increased healing times, the cost is usually 30-50 % higher for the full facelift.

Excessively large breasts can cause pain in the upper and lower back, neck and shoulders. Well fitted bras can be difficult to find and their straps can cause shoulder grooving. The folds under and between the breasts can develop hard to treat rashes from retained moisture. Large breasts can make exercising impossible, leading to weight gain and other health problems.

So to decrease these symptoms insurance companies cover breast reduction if a significant reduction in weight can be achieved. How much depends on your height, weight and the insurance company. For example, Blue Cross/ Blue Shield of Massachusetts requires 325 grams of tissue be removed from each breast in a woman of normal weight and height between 5’2” and 5’4”. That translates to about 2/3 of a pound, which will bring a DD cup to about a C cup.

Why suffer any longer? Come in for a consult. Breast Reduction is usually done as an outpatient with little post-operative discomfort and limited time off from work. Why don’t you take a little weight off your chest?

When there is a cut through the skin, the skin needs to heal. To heal, it needs to lay down new collagen, which is never as organized as the collagen you are born with. Disorganized, heaped up collagen is the definition of a scar.

So what do plastic surgeons do to avoid scars? Well, we either try not to cut through the skin or do it in such a way as to minimize the scar. We often use lasers to avoid a full thickness injury to the skin, thus  avoiding scar formation.  Some topical treatments like chemical peels, laser resurfacing or dermabrasion, can alter the skin, but, because they don’t cut through it, rarely cause scarring.

What if a cut through the skin is necessary or is the result of an accident?  First and foremost, we handle the skin as delicately as possible taking care not to unnecessarily damage tissues. We try to preserve vital blood supply and repair muscle as well, and close the wound or incision with no tension on the skin for the best possible healing.

Secondly, we place the incision where it will be as unnoticeable as possible.  The incision for a facelift, for example, uses the architecture of the ear to hide the scar, hugging the edges of normal anatomy and taking advantage of shadows. We also use the natural lines of the face, what we call the relaxed tension lines—like crows feet–to blend scars in.

Lastly we can change the direction and placement of scars with local skin flaps like z-plasties. A z-plasty can change a straight line scar that creases the skin to a zig-zag that acts like an accordion stretching over the area. Using local flaps, we can borrow from nearby areas with skin to spare and bring it to areas that need it to soften a scar.

And if the scar can’t be moved or hidden or surgically improved? That’s when we use pulsed dye lasers to decrease redness, or dermabrasion to sand down raised scars. Sometimes we use steroid injections to decrease itching and inflammation or topical silastic dressings to flatten scars.

The bottom line: If you have surgery, you are going to have scars.  There’s no real way around it.  It’s up to the plastic surgeon to make them as subtle as possible.

When patients ask why is it called “plastic” surgery, I usually reply, “We had plastic before plastic had plastic.”  The term plastic means to mold, and is from the Greek word plastikos. It was first used to describe a specialty of surgery in 1837.

The first plastic, on the other hand, was made by Alexander Parkes in 1855 by mixing cellulose and nitric acid to produce Parkesine, more commonly known as Celluloid. Leo Hendrik Baekeland invented the first synthetic plastic, Bakelite, in 1907.

My favorite definition of plastic surgery was written Gaspare Tagliacozzi in 1597:

“We restore, repair, and make whole those parts…which fortune has taken away, not so much that they may delight the eye, but that they may buoy up the spirit and help the mind of the afflicted.” 

Gaspare Tagliacozzi (1545-1599) devised a nasal reconstruction using the tissues of the inner arm, now referred to as “The Italian Method.” This method has essentially been replaced by a technique devised by an Indian surgeon named Sushruta Samhita over 2000 years ago. Sushruta’s original operation used skin from the forehead and blood vessels to make a new nose.

Today plastic surgery encompasses cosmetic surgery, reconstructive surgery after cancer and accidents, microsurgery, craniofacial surgery to fix birth defects like cleft lips, and branches of transplant surgery. And sometimes, plastic surgeons actually do put plastic things—plastic-like implants, anyway—into their patients.

Different amounts of breast skin are removed depending on how far the nipple needs to move and how much extra skin there is. The nipple stays attached to the milk gland, and both move upwards as a unit.  If a minor lift is needed, the nipple moves a small distance and the skin closure is only around the areola. The skin removed around the areola looks like a donut, so this is referred to as a donut mastopexy.  If a major lift is necessary, the place where the nipple was needs to be closed separately, and a vertical scar is left below the newly moved nipple and areola. This larger lift is called a vertical mastopexy.

When there is severe drooping such as after massive weight loss, the breast needs to be reshaped. In this case the operation is the same as a breast reduction, but no breast tissue is removed. All the breast tissue can be reshaped and repositioned  with  a Wise pattern lift often called an“anchor” operation. In the “anchor” operation the scar starts around the areola, then is connected to a vertical scar that extends to the inframammary fold and continues in the fold under the breast. So you see, this pattern is in the shape of an anchor. Although this operation does involve more conspicuous scars, all the breast’s components can be improved from nipple position and skin envelope to breast gland position and shape.

Why would a nipple be below the fold? All breasts sag with time, and the larger they are, the lower they fall. Some breasts start off that way.  A tubular breast, for example, is shaped like an inverted triangle with the nipple at the bottom, pointing downwards. And some breasts are just naturally big.  With age, they sag too.

Sometimes the nipple is above the fold but the breast still looks very droopy. That condition is called pseudoptosis or false droop and is caused by deflation of the breast, not drooping. Pseudoptosis is a good reason to have a breast augmentation to replace the lost volume. It’s common for this breast augmentation candidate to have had much larger breasts, either with pregnancy or obesity, that appear fallen with the loss of the extra weight.

Read my other blogs on breast augmentation for more information.

The two most common complications of breast implants, rupture and capsule formation, are influenced by which type of implant you choose. The appearance and feel of the implants are also affected by implant type.

Implant manufacturers have a lot of faith in their products these days and provide free lifetime replacements if an implants ruptures. But detection of rupture is affected by which type of implant you choose. Your body is 70% saline.  When saline implants rupture, the salt water simply goes into your bloodstream and is absorbed, leaving behind an empty plastic bag.

Silicone, however, cannot be absorbed your body, so when silicone implants rupture the leaking material causes inflammation in the surrounding tissues. This inflammation can be a more reliable indicator of silicone rupture than imaging studies such as MRI or ultrasound.

Another potential complication with silicone implants is thickened capsule formation. After a breast augmentation, the surrounding tissues react to the implant.  The body sometimes reacts more strongly to silicone than to saline, causing a thicker capsule to develop around the implant.  The thicker capsule can move the implant or cause pain, requiring additional surgery.

So why bother with silicone implants? Because they look and feel more like natural breast tissue than saline implants.  Silicone gel is more cohesive than saline, decreasing the appearance of rippling. The gel is also more viscous than saline and feels more like natural breast tissue.

You can’t choose the implant type in a vacuum.  Pocket placement and the need for a possible breast lift will impact your choice. Please read my other blogs on breast augmentation.