Anne Peled | Breast, Plastic, and Reconstructive Surgery Blog

Dr. Anne Peled is a breast, plastic, and reconstructive surgeon practicing in San Francisco. She is also an educator and innovator of novel breast surgery techniques and a breast cancer survivor.

Nipple-Sparing Mastectomy: Key Considerations and Options 

Nipple-sparing mastectomy (NSM) is the latest evolution in mastectomy techniques. With this approach, the entire breast skin envelope, including the nipple and areola skin, are preserved, while all the breast tissue is removed as part of the surgery. By saving the nipple and areola skin, the outside of the breasts look similar to how they did before surgery, especially when combined with immediate breast reconstruction. Studies looking at how women feel after nipple-sparing mastectomy have shown a significant benefit from keeping the nipple and areola, plus this can allow for a more natural-looking result after surgery. 

Who is a candidate for nipple-sparing mastectomy?

As time has gone on and longer follow-up on the safety of NSM is available, we are finding that nearly everyone can be a candidate.  Whether or not someone is a candidate primarily depends on two factors: 1) the location of the cancer, and 2) the breast size and shape. People with cancer in the nipple itself or directly underneath the nipple are not recommended to have procedures that spare the nipple, though sometimes chemotherapy can be used before surgery to shrink the tumor and see if NSM may then be possible. For women with large breasts or a long distance from the top of their breasts to their nipples, NSM can be challenging and has been associated with higher rates of complications, including skin and nipple healing problems. However, a great option in this scenario is to do an initial breast reduction or breast lift (which can be combined with a lumpectomy for women with breast cancer) to get the nipples in better position and reduce the amount of breast tissue and breast skin. This makes NSM when done as a second surgery much safer, and also improves breast reconstruction outcomes.

Is it safe for people with BRCA mutations and other hereditary cancer syndromes?

Yes! Risk-reducing/prophylactic mastectomies can dramatically lower the chance of getting breast cancer for someone who has a BRCA or other high risk genetic mutation. Bilateral mastectomies can also reduce the chance of cancer coming back in the breast or getting a new breast cancer for people with genetic mutations who have already been diagnosed with breast cancer. Although there are some misconceptions that nipple-sparing mastectomy is not a good option for people with BRCA mutations, multiple large studies have shown that it is safe, with extremely low rates of new or recurrent cancers developing in the nipple.

What type of incisions are typically used?

The goal with choosing an incision for NSM is to be able to do the mastectomy safely while also hiding the scar as much as possible.  The most common incisions for NSM are inframammary fold (underneath the breast), peri-areolar (around part of the areola), lateral (from the side of the areola out towards the side of the breast), and inferior vertical (from the bottom of the areola down towards the bottom of the breast). These breast incisions tend to heal well, with scars fading out over time, typically in the first six months to a year.

Common incisions:

 

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What kind of reconstruction can be done with nipple-sparing mastectomy?

All types of reconstruction can be performed with NSM, including implant-based and flap reconstruction. In some cases, this is best done as a staged reconstruction, with a temporary implant (tissue expander) placed at the time of NSM followed by a later surgery to switch out the expander for a permanent implant or a flap reconstruction. Some people may choose not to have reconstruction initially or ever, but still want to keep their nipples, in which case NSM can also be done without reconstruction. 

Is there sensation in the nipples after surgery?

With most nipple-sparing mastectomies, the nerves that go to the nipple are cut during the surgery, which causes numbness of the nipple (and usually the rest of the breast skin) after surgery. Some people may have sensation come back to parts of the breast skin and nipple over time, but it is hard to predict when or if this will happen. Some newer techniques, however, focus on looking for and preserving the nerves to the nipple to help improve nipple and breast skin sensation after mastectomy. There are also newer reconstructive surgeries where the nerves are reconstructed with nerve grafts during implant or flap reconstruction so that the sensation can come back more quickly and in a more consistent way. Research on options for preserving or restoring sensation after breast cancer and breast cancer risk-reduction surgeries continues to grow as the importance of maintaining sensation has been better appreciated.

 

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What To Expect From Your Virtual Visit with Dr. Anne Peled

 

There are a number of reasons that a virtual consultation or follow-up might be the best way for you to meet with our providers, and we are excited to connect with you in this way. We’ve put together the information below on what to expect with your virtual visit – please reach out to our office at This email address is being protected from spambots. You need JavaScript enabled to view it. for any additional questions or to schedule a visit!

What types of consultations are appropriate for a video visit?

We’ve found that really any type of issue that we would discuss with patients in our office works for virtual consultations as well. In our practice, this includes breast cancer surgery, oncoplastic surgery, prophylactic mastectomy, sensation-preserving mastectomy, breast reconstruction, breast reduction/lift, breast augmentation, abdominoplasty, and liposuction, among others.  Additionally, video visits work well for follow-up visits for patients who have already had their surgery and are unable to easily come into the office for follow-up.

What should I expect before, during, and after my video visit?

Once you have scheduled your video visit, our patient coordinator Alyssa will get you set up to fill out online medical history forms and upload photographs (when appropriate) to our HIPAA secure telemedicine portal. We may also need to obtain medical records prior to your consultation, depending on the reason for your visit.

At the time of your video consultation, you will receive a text or email (based on your preferred method of contact) for a link to our secure video portal to start your consultation. You will have 10 minutes to click the link and your visit will automatically start. We suggest choosing "email" for a computer with a webcam or "phone number" if you prefer to use your cell phone as your video device for your appointment.

Our virtual consultations are typically set up for 30 to 45 minutes, and often last the entire time, depending on the discussion.  During your consultation, Dr. Peled will review your history and the clinical information provided, as well as your goals for any potential surgical procedure. She will discuss potential surgical options and review the anticipated procedure details, recovery, and outcomes.  You will have time to ask any questions you have about the procedure and the next steps and Dr. Peled will make sure all of your questions and concerns are addressed before the completion of the consultation.

After the consultation, depending on the conversation you had with Dr. Peled and the surgical procedure you may be planning, our office will follow-up with you on the next steps. We can also connect you with patients in our practice who have already been through a similar procedure to help you with decision-making and know what to expect.  For out-of-town patients, we have a number of resources on traveling for surgery from out of town and what that entails. When you have confirmed you’d like to move forward with an in-person consultation or schedule surgery, we will send you all the information on hotels and other accommodations, how long you should plan on staying, and additional details on your surgical procedure.


If you have any medical questions after your video consultation, please feel free to reach out to our practice PA, Nicole Daoud, at This email address is being protected from spambots. You need JavaScript enabled to view it. She will also be in touch with additional information regarding the pre-operative and post-operative process if you decide to proceed with surgery.  For any scheduling or non-medical questions, please e-mail Alyssa at This email address is being protected from spambots. You need JavaScript enabled to view it. or you can call the office at (415) 923-3011.  We look forward to welcoming you to our practice!

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Coping During COVID

With news about the novel Coronavirus changing, with what seems like every minute, our anxiety levels around the world are flying high. When it comes to change, getting a diagnosis, not understanding the disease or how it may or may not affect you or your loved ones, it’s difficult to know how to cope with it. While quarantining at home with loved ones, by yourself, or the varying living situations, know that we are all in this together and you are not alone in how you feel.

Here are a few tips from experts on how to cope with resiliency at home:

  • Perspective. Use reliable sources like the CDC, NIH and reputable news sources. Having an understanding on the latest from leading experts can ground us in knowing how the world is coping and surviving. Seeing change happen as COVID-19 is more understood and having a clear understanding reduces anxiety and provides hope as things evolve and curves start to flatten.

  • Balance. Limit the time you scope out articles online or watching news. Try to have a routine or schedule to give you more leverage on staying grounded and engaged in a lifestyle that encourages resiliency and an equilibrium between the new, work-home life.
  • Feeling alone, together. Here is an article from the director at Office of Work/Life by the Harvard Gazette on how the world is coping with the new and changing tele-meeting world.

  • Self-care. Stress and anxiety during this time is normal and expected. Practicing mindfulness, stress reduction techniques, and good physical hygiene can help with decreasing stress and anxiety. Being kind to your mind and body while having realistic expectations with oneself is paramount during an unprecedented time in our history. It’s okay to not know how to manage stress levels well. But making small strides towards tiny goals can help with feeling less stuck and provides a sense of control.

  • Understanding Our Emotions. Here is an article from the Harvard Business Review on grief. Understanding our emotions during this time can give us better insight in how to deal with them. And if you’re more attune to Podcasts, here is one with David Kessler and one of my favorites, Brené Brown on coping and grief.

    Dr. Peled is a huge proponent of boosting immunity as it relates to not only your overall health but especially important to your breast health. These core ideas are no different than how we can best take care of ourselves during COVID. She always recommends:

  • Rainbow Diet. The more varying and brighter the colors, the better! Try adding foods you’re not used to by adding squash, peppers or sweet potatoes. Some experts say that eating poorly isn’t an abundance of the “bad food,” rather, a lack of “good food” that has lasting health effects and increases cellular damage. Eating a mostly plant-based diet feeds your body and cells the micronutrients it needs in order to fight infections, heal after surgery and provide cellular longevity. 

  • Also, limiting foods high in sodium, added sugars and saturated fats have healthful benefits for our body and brain. If you are still making safe trips to the grocery store, as natural as it is to want to go for the boxed and long-lasting shelf life boxed items, try to limit the number of processed foods that are in your cart when possible. 

  • Choosing simple and healthy recipes like those from Bloom & Bundle can help make the stresses of a new home-life easier. You can double many recipes and freeze the leftovers that can last for 3-6 months with ease.

  • Got kids? Have them get involved with helping in the kitchen, teaching them about where produce comes from or what family they belong to can increase their own interest in healthy eating. Making it fun is key and giving them age-appropriate jobs in the kitchen gives them agency while having them feel like a true member of the quarantine team!

  • (Before changing your diet, always make sure to discuss this with our office, your medical oncologist and/or primary care providers, as some food items may be restricted with certain medications or metabolic disorders.)

  • Exercise Regularly. Try to aim for 30 minutes of an elevated heart rate, daily. But be kind to yourself. Any exercise, whether performed in your living room, garage or (quarantined approved) outdoor space, count! However, increase as tolerated. If you haven’t been exercising regularly, start slow and listen to your body, but keep a journal, tag a virtual buddy or ask for support from your family members, friends or community to help keep you on track to hitting your goals! Don’t know where to begin? PopSugar is a free app you can download on your phone or access right from your computer and will be linked to YouTube for at-home HIIT, yoga and bodyweight workouts right in the comfort of your own home. No workout equipment required to participate! 

  • Limit Alcohol. As it pertains to breast health for women, less than four alcoholic beverages a week are recommended. This also helps boost immunity, lowers your risk for infection and increases the rate of healing.

  • Hydrate... Hydrate. Increasing your water intake is crucial for healing before and after surgery when fighting infections or generally staying healthy. As a baseline, sources recommend half your body weight, in ounces, daily. So, if you weigh 150 pounds, 75 ounces of water is the recommendation. (That is three of the large, SMART water bottles). 50 Shades of Avocado have some healthy recipes to doctor up water if you don’t particularly like that H20 taste.

  • Sleep. As anxieties run high and no clear answers to questions we have about duration and lack of normalcy, this is much easier said than done. Restorative sleep is paramount for a boosted immune system and healthy coping mechanisms. Good sleep hygiene involves dimming lights in your house one to two hours prior to the time before wanting to be bed. Also, limiting TV and screen time (iPads, Kindles, cell phones, etc.) can also help in maintaining the natural release of your body’s melatonin. Still having difficulty falling or staying asleep? You can also try natural supplements like Kava root tea (no more than five cups per day), Valerian root tinctures or capsules or melatonin to help get you rest. Safely check out your local grocer like Sprouts, WholeFoods or even Trader Joes for these natural remedies. Always talk to our office or your primary care provider before starting these regimens as they can interact with medicines you might be currently taking.

    You are not alone, even if you are physically or geographically isolated from your support, community or loved ones. Our office is also here for you and during this unrivaled time, as we are still working from home, making telemedicine phone calls and although rarely, coming into the office, to ensure our patients are well taken care of.

    Remember that even though we are physical distancing, being social and connecting with those we love is crucial during this time. Wash your hands, know your local ordinances before venturing out and please, stay safe.

    We are thinking of you.

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Myths and Misconceptions about Preserving Sensation after Mastectomy

Since our recent feature in a media story on sensation-preserving mastectomies (https://www.bbc.com/news/health-51534636), we’ve found that there are a number of misconceptions about the approach and, more generally, on sensation after mastectomies.  Here are some of the most frequent misconceptions we’ve seen and the myths debunked:

1) Without careful and thoughtful preservation of nerves during mastectomy, sensation is likely to return on its own if you just give it enough time 

Although there is still a lot more research to be done related to sensation after mastectomy, the studies that have been done show unacceptably low rates of return of chest/nipple sensation, with studies consistently showing that the majority of women do not ever regain even sensation to light touch throughout their breasts (let alone any pleasurable sensation). Because of the variable nerve anatomy in the breasts, there are some women who may get lucky and have sensation return over time without active preservation of nerves during surgery, but most women will not.

2) Sensation-preserving mastectomies are only possible for women having prophylactic mastectomies, as the technique may compromise cancer outcomes for women having mastectomies for breast cancer treatment

Sensation preservation does not depend on the reason for the mastectomy. The goal with any mastectomy, whether for cancer treatment or for breast cancer risk reduction, is to remove all visible breast tissue. While there may be rare circumstances with mastectomies for breast cancer where a small amount of skin may need to be removed or nipple-sparing mastectomy may not be possible based on the tumor location, for the most part, the mastectomies are the same. Nerve preservation during mastectomy is possible when the nerves run in the fatty tissue layer beneath the skin, which can be saved during mastectomies done for either reason. If the nerves do not have favorable anatomy for preservation (meaning they run straight through the breast and do not stay in the fatty tissue layer), then they will need to be cut and repaired (with nerve grafting) regardless of the reason for the mastectomy.

3) Nerve reconstruction can only be done with flaps, not with implants

Nerve reconstruction done at the time of breast reconstruction to improve sensation after mastectomy is a fairly new concept, both with flaps and with implants. A growing number of centers in the US offer nerve reconstruction at the time of flap reconstruction, typically with DIEP flaps through a technique called Resensation® (https://www.resensation.com/). But there are a handful of groups who are taking some of the principles from nerve reconstruction with flaps and successfully applying them to breast reconstruction with implants, an important advance as over 80% of reconstructions done in this country are done with implants. Ideally, both flap and implant reconstructions would involve both a nerve-preserving and a nerve-reconstruction component to give women the best chance of preserving sensation.

Sarafina Nance                

Anne Peled, MD               

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Breast and nipple sensation preserving mastectomy

One of the most common operations performed for the treatment of breast cancer is a complete mastectomy, which involves removal of all of the breast tissue.  Mastectomy approaches have evolved over time and many women are now able to safely have nipple-sparing mastectomies in the hands of well-trained breast surgeons.  When combined with immediate breast reconstruction, women can have outcomes where their breasts look the same, or even better, than they did before their mastectomy. However, despite the significantly improved cosmetic outcomes in breast reconstruction with these techniques, most women don’t realize that they will have little if any, sensation in their breast skin or nipple skin after surgery.

Because of the way the nerves to the breast skin and nipple travel through the breast tissue, traditional mastectomies tend to cut through these nerves, which leads to breast skin and nipple numbness for many women, or even sometimes, painful sensations at the cut nerve ends.  To try to prevent this numbness or pain, our team (Dr. Anne Peled, breast oncology and reconstructive surgeon, and Dr. Ziv Peled, peripheral nerve and plastic surgeon) have been doing sensation-preserving mastectomies, where we either carefully preserve the nerves during nipple-sparing mastectomies and/or do nerve grafting if nerves cannot be preserved safely.  We have already done a number of these mastectomies combined with immediate implant reconstruction and most women are telling us that their breasts feel almost the same or exactly the same as they did before surgery!

We are so excited to be able to offer this innovative new approach for women considering mastectomy for breast cancer treatment or breast cancer prevention.  Please contact us at 415-923-3011 to learn more.

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BBC News: 'I have sensation in my breasts again'

When Sarafina Nance found out she had a very strong chance of getting breast cancer, she decided to have a preventative double mastectomy followed by reconstruction. The surgery would dramatically reduce the risk, but she would likely lose feeling in her chest. The 26-year-old was "fully prepared" to be numb, until pioneering surgery changed her life.

The first time Sarafina was screened for breast cancer, doctors found something worrying.

She already knew she had inherited the BRCA2 gene from her father, after he was diagnosed with advanced prostate cancer and she had genetic testing.

The gene increases the risk of developing a number of cancers - including breast cancer; Sarafina, who lives in California, was told she'd need twice-yearly screening.

But after her first MRI scan, doctors ordered a biopsy.

"Waiting for the results, I was completely debilitated," Sarafina says.

"I remember calling my dad, asking him what happens if we both have cancer. What if I die?"

The mass was benign, but Sarafina realised she didn't want to go through repeated scans.

Still in her mid-20s, she decided to have a preventative double mastectomy with reconstruction. She would have all her breast tissue removed and implants would create new breasts.

 
Sarafina Nance recovering in a hospital bedImage copyrightSARAFINA NANCE
Image captionSince having her mastectomy, Sarafina has felt a 'sense of peace'

Typically, mastectomy with reconstruction is offered to two groups: those with a cancer diagnosis, and those who have a high genetic tendency to developing breast cancer who choose to undergo preventative operations.

Dr Emma Pennery, clinical director at UK charity Breast Cancer Now, says that there is a distinction between the procedures that may be offered to women like Sarafina, and those who have already developed breast cancer. It's of the utmost importance that the cancer is properly treated.

"Breast cancer cells can exist in the area behind the nipple or behind the areola, so you have to be safe to get all the cancer out," Dr Pennery says, adding that ongoing cancer treatment plans may affect the method of reconstruction.

'You don't feel hugs'

Sarafina is an astronomy PhD student at the University of California, Berkeley, and when she started researching her surgical options, her science background kicked in.

"It was very difficult to know what I should be doing," she says.

"Women who have mastectomies and reconstruction can lose feeling in their breasts and that can mean you don't feel hugs, or you don't feel waves crashing into you if you're in the ocean."

Dr Pennery says the surgeons she's worked with will try to minimise any side effects for women having preventative mastectomies.

"The ease of removing breasts and reconstructing the breasts does vary an awful lot on things like the size of the breast, the size of the nipple and areola and also how central it is, which can be affected, putting it bluntly, by how droopy one is," she says.

With implant reconstruction, it's "quite likely" a woman will lose sensation afterwards, she says.

"In order to do the mastectomy and reconstruction, the surgeon cuts through some of the nerves that supply the area and that's what leads to the numbness."

A study from the Royal Marsden in London, published in 2016, found that "breast sensibility is significantly impaired following mastectomy and reconstruction" but noted the majority of women go on to recover some light touch sensation.

"Sensory changes post-reconstruction have largely been overlooked in the past, but can be crucially important in a woman's quality of life and affect how she accepts her reconstruction," says Ms Ayesha Khan, a consultant oncoplastic breast surgeon and one of the study's authors.

"Novel techniques to better preserve sensation post-reconstruction are in evolution and likely to be something women could benefit from in the future."

Anne PeledImage copyrightHANDOUT
Image captionDr Peled focuses on improving surgical outcomes for mastectomy and reconstruction patients

After weeks of research, Sarafina found Dr Anne Peled, who is based in California and trained in both breast cancer and reconstructive/plastic surgery.

Dr Peled is also a breast cancer survivor.

"When I had my own diagnosis," Dr Peled says, "I had a really, really difficult time making a choice, because I felt like it was so daunting to consider at age 37, having no sensation in my chest for the rest of my life."

She opted for an alternative surgery and is now working with her husband, a nerve specialist, on finding new approaches to preserve sensation.

Dr Peled performed a mastectomy and then a reconstruction with implants on Sarafina at the end of 2019.

Sarafina's first emotion when she woke up from the anaesthetic was relief, and her recovery has been going well.

"I now have sensation in my whole right side and three-quarters of my left side and it's coming back more and more every day," she says.

Dr Peled performing surgeryI

Sarafina is now using social media to raise awareness of preventative mastectomies and reconstruction, studying for her PhD and applying to train as an astronaut.

It's been a challenging time for her family, especially her father, who is still having treatment for his own cancer.

"He was very sad that I have the [genetic] mutation, I have to undergo this and face things that I think he wishes I'd never have to face," Sarafina says.

"But I think he's really proud and very relieved that everything went so well and that I feel 100% like myself."

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Getting Diagnosed with the Disease You Treat

When I was first diagnosed with breast cancer two years ago, it felt like getting diagnosed with something I treat every day was, for the most part, a huge help. I had access to quick reading of my pathology and radiology results by physicians I knew well and trusted, expert advice on my care was just a text or an email away, and I hand-picked an amazing team of caring and talented clinicians who really listened to me and what I wanted. Coupled with the fact that both of my parents and sister are also breast cancer providers (two radiation oncologists and a medical oncologist), I felt incredibly grateful for the amazing care and support I received throughout my treatment.

Settling back into my post-treatment life, though, has been a journey full of surprises and challenges. It’s not easy being surrounded on a daily basis by the same disease I just experienced first-hand. One set of challenges — talking with patients about their own breast cancer diagnoses and treatment — I expected. But the other — figuring out if and how my own breast cancer history plays a role in professional meetings with colleagues — I didn’t.

On the patient side, I’ve found that the biggest challenge is if, when, and how to disclose my breast cancer history to my patients. I think as physicians we all struggle with the balance between wanting to connect with patients (particularly if it’s a situation we have personal experience with) and also making sure that it’s “not about us.” We always want our patients to feel that the focus is on them — their specific issues and concerns. In my practice, especially, I feel I need to be even more sensitive, as many women already feel inundated by all of the unsolicited advice they get from well-meaning family members and friends who’ve experienced breast cancer. I understand that my treatment choices and course may be different than my patients’, so I try to be selective about sharing my own story. I do not want to take anything away from any patient’s own unique breast cancer journey. 

It’s definitely still a work in progress, but I’ve found that sharing my story can be helpful for particular populations. The challenges and decision-making around breast cancer can be very different, for example, when you’re young (I was 37 when I was diagnosed); peer support can be especially important for younger patients. 

I’d like to think I now have “insider tips” on how to get through breast cancer care, from the best way to take care of your skin during radiation, to the right stretches to do after healing from surgery, to managing side effects of hormone-blocking therapy. Many of my patients who know about my diagnosis will reach out to ask me questions about my experience as they go through their treatment, and I love the way this connects me to them in a totally different way.

Addressing my breast cancer history with colleagues has been more complicated. Whether at Tumor Board, research meetings, advisory boards, or patient education sessions, there’s not a week that goes by in which I’m not in a situation where colleagues are talking about a clinical issue that directly impacted (or continues to impact) my life and health. When the discussion about recommendations for patient management gets highly focused on numbers and small differences in outcomes data — and therefore seems to lose sight of the potential negative quality-of-life impact for women — the “patient” part of me activates. I start to feel like I should speak out and advocate for survivorship issues on behalf of my fellow breast cancer survivors. These moments can be emotional for me, especially when it comes to patient decision-making. I’ve learned that it’s helpful to transfer these feelings to the “surgeon” part of me, which allows me to use my emotional responses to make productive, patient-focused suggestions in my role as a breast surgeon without bringing up my own history. I wonder sometimes, though, if it might not actually be more effective for my colleagues to hear the patient perspective in these conversations. It is, after all, a unique voice that I can offer beyond my clinical or research perspectives.

As I settle into my dual and simultaneous roles, breast cancer surgeon and breast cancer survivor, I like to hope that I’ll more seamlessly balance these parts of myself, both with my patients and with my colleagues. I suspect that my comfort with intertwining my survivor story with my professional life will grow and evolve over time, much the way I see my patients evolve after their cancer treatment and figure out their own post-cancer journeys. For now, I take it one interaction at a time, trusting my instinct about sharing in each situation, and basking in the moments of truly shared understanding when they happen.

Dr. Anne Peled is a breast, plastic, and reconstructive surgeon practicing in San Francisco. She is also an educator and innovator of novel breast surgery techniques and a breast cancer survivor.

Illustration by Jennifer Bogartz

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Rippling and Flipping Implant Questions Answered

 

There are many mysteries and misconceptions around breast implants, but two of the most common questions that have been coming up lately in my practice are rippling and flipping. 

Rippling

Rippling describes seeing the folds of the implant through the overlying mastectomy skin (in reconstruction) or breast tissue (in augmentation). It can happen with either saline or silicone implants, though it tends to be more pronounced with saline implants. More cohesive/”gummier” implants are less likely to ripple because they hold their shape better in the body and are firmer, so the implant folds are less prominent. Although rippling is talked about more frequently in discussions of over-the-muscle reconstruction, it can happen with either over-the-muscle or under-the-muscle reconstruction.

When rippling occurs, several different approaches may help improve it. Switching out implants to more cohesive implants can work well. Sometimes, implants may also need to be exchanged for larger ones to help fill out the skin envelope better, which can reduce the appearance of rippling. Putting in a biologic mesh that will help stabilize the implant and/or add a little thickness to the tissues can also help. And finally, fat grafting may also be an effective option for some women to help camouflage the rippling by adding volume to the tissue over the areas of rippling.  

Flipping

Implant flipping (or malrotation) is often thought of as a potential complication of shaped/teardrop implants, occurring when the pocket was too large for the implants, giving them room to rotate clockwise or counter-clockwise, thus distorting the breast shape. More commonly, now, though, is the issue of front-to-back flipping, which happens most frequently with larger, higher-profile/projecting gummy implants. The basic thought is that the implants are essentially top-heavy, and in certain positions (typically when women are lying on their sides sleeping), the pocket opens up in such a way that the implant has room to flip over on itself. This complication is usually instantly apparent to women because the back/flat part of the implant is now facing forwards. When this happens, it gives the breast a flattened appearance with loss of roundness, seen particularly in the top part of the breast. The edges of the implant may also be more prominent or even visible.

Since gummier implants can be very helpful for minimizing rippling and helping with breast shape (particularly in reconstruction), the trade-off of potential intermittent implant flipping may be worth it in some cases. When implant flipping does occur, it can usually be fairly easily flipped back by women themselves, typically by leaning forward and making space for the implant in the pocket to allow for manual flipping back into place. 

If flipping is occurring frequently and becoming bothersome, revision with pocket correction and possible implant exchange may be needed to fix the issue.

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I Am 26 & Getting A Double Mastectomy | Truth Told | Refinery29




This week on Truth Told, we follow Sarafina, a 26 year old woman preparing to undergo a double mastectomy. She bravely shares her journey and reasoning for electing this preventative surgery with us. Watch this episode to fully understand her decision!

ABOUT SERIES Truth Told is an educational and investigative series designed to overcome the misinformation surrounding present day social issues. Our hosts delve into facts through interacting with the individuals on the street who are taking a stance on the matter and consulting with the experts in the field.

ABOUT REFINERY29 Refinery29 is a modern woman's destination for how to live a stylish, well-rounded life. http://refinery29.com/

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Male breast cancer: traditionally under-diagnosed and under-researched, but hopefully that's changing

Male breast cancer: traditionally under-diagnosed and under-researched, but hopefully that's changing

For several reasons, including potential social stigma and a significantly smaller number of patients, breast cancer in men has never had anywhere close to the awareness and research commitment that's seen for women affected by breast cancer. An article in the New York Times (https://www.nytimes.com/2019/09/09/health/breast-cancer-men.html) in September 2019 highlighted these disparities in research and clinical studies, reporting on recent FDA guidelines encouraging increased participation by men in breast cancer trials. However, with the announcement in October 2019 that Mathew Knowles, Beyonce's father, was being treated for breast cancer, there has been an increased focus in the media on male breast cancer. With this increased awareness will hopefully come many of the benefits seen with awareness around breast cancer in women, including men with breast masses seeking more timely medical attention and more research support for male breast cancer.

Among the many misconceptions around breast cancer in men is that presentation and treatment are the same as for women. While there are some similarities, there are many differences, primarily related to the fact that men do not receive screening mammograms and have an increased chance of having a genetic cause for their breast cancer. To address some of these issues, I was fortunate enough to sit down to discuss male breast cancer with Robert Warren, MD, MBA, and professor of medicine and co-director of the Betty Lou Ourisman Breast Health Center at Georgetown (he also happens to be my dad!).

Here's our interview on presentation and evaluation of breast cancer in men, treatment options, and the importance of genetic testing after diagnosis:

Dr. Anne Peled: What are some common presenting symptoms of male breast cancer?

Dr. Robert Warren: The most common symptom is a mass in the breast, followed by breast pain. Men may also notice changes in their skin or nipple appearance.

AP: What should men do if they feel a mass in one of their breasts?

RW: They should first see their primary care provider for a clinical exam. Based on findings, their providers may recommend breast imaging and/or referral to a breast surgeon.

AP: Is breast imaging for men who have a breast mass the same as for women?

RW: Similar to women, men with a breast mass are typically recommended to have both a mammogram and an ultrasound. Solid breast masses in men have a characteristic appearance on both imaging studies, which would prompt a biopsy if the masses looked at all suspicious.

AP: When men get breast cancer, do they do as well as women if appropriately treated?

RW: In the past, it was thought outcomes after male breast cancers were the same. However, more recent studies have shown that outcomes may be worse in men than women, which is likely related to the fact that men are often diagnosed at later stages because they are not getting regular screening like women. Men with breast masses may not get them evaluated as quickly, which can lead to late diagnoses and potentially larger masses and lymph node involvement. Still, in general, when caught early, men diagnosed with breast cancer have overall very good outcomes.

AP: What is the usual treatment for breast cancer in men?

RW: Breast cancer surgery for men usually involves mastectomy and lymph node biopsy. Some men may be candidates for skin-sparing or nipple-sparing mastectomy. Radiation may be recommended after mastectomy but is not typically needed. Male breast cancer is even more likely than breast cancer in women to be hormone receptor-positive, so nearly all men receive a hormone-blocking medication called tamoxifen after surgery. Some men may be recommended to have chemotherapy, which is decided based on tumor factors and genomic testing results similar to how it is determined in women.

AP: If men are diagnosed with breast cancer, should they and other family members undergo genetic testing?

RW: Yes, all men diagnosed with breast cancer should have a genetic evaluation, as men with breast cancer have an increased chance of gene mutations such as BRCA2 mutations. Depending on testing results, other family members may be recommended to have testing as well.

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What Breast Cancer Survivors Should Know About The FDA's Proposed Breast Implant Warnings

 

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October 23, 2019

On Wednesday, the FDA asked manufacturers and medical professionals to better inform women about the potential hazards of breast implants. The federal agency has approved saline and silicone gel implants for augmenting breast sizebreast cancer reconstruction, correcting developmental defects, and to “improve: the result of a previous surgery, but implants are not without risks.

“The Food and Drug Administration and the major plastic surgery societies are all working together to do further research more closely looking into implant risks, which will help future patients receiving implants know they’re getting the safest approaches and technologies,” says Anne Peled, MD, a board-certified plastic surgeon practicing aesthetic, reconstructive, and breast oncologic surgery in San Francisco. Although the FDA’s recommendation won’t yet be formally implemented, Dr. Peled says it’s worthy of the attention of doctors, manufacturers, and, most of all, survivors.

In rare cases, people who receive implants may wind up with a form of lymphoma called breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), or a full-body condition called breast implant illness (though this hasn’t been well-studied yet), says Dr. Peled. “More common risks of implants include hardening over time, which is called capsular contracture; infection; rupture or deflation; and malpositioning,” she says. The FDA adds that the longer you’ve had implants, the more likely you are to experience complications.

If you’ve received implants already, Dr. Peled says the FDA news should prompt you to pay attention to the signs and signals your body relays to you.  “Anyone who has had breast implants placed for breast augmentation or reconstruction should see their surgeon once a year to check on their implants. Sooner than that if they develop any new breast signs or symptoms such as swelling, pain, masses, or change in the shape of their breasts,” she says.

Furthermore, if you’re a breast cancer survivor who’s considering reconstructive options, remember that you have choices. “There are a number of reconstructive options available for women who have had both lumpectomy and mastectomy and these can be done not only at the time of breast cancer surgery, but also any time after treatment is complete,” says Dr. Peled. Take the time to speak with your doctor to weigh the pros and cons of the many implants on the market before making whatever decision feels right to you and your body.

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Breast Numbness After Surgery Is Too Common. This Surgeon Is Changing That.

 

October 22, 2019

In this op-ed, Dr. Anne Peled, MD, a board-certified plastic surgeon practicing aesthetic, reconstructive, and breast cancer surgery in San Francisco, discusses how the prospect of breast numbness after a mastectomy can prevent patients from seeking this life-saving treatment — and how there are new techniques to help preserve sensation.

One out of every eight women and about one out of every 800 men in the U.S. will develop breast cancer in their lifetime, according to thePicture1 National Cancer Institute. Many people diagnosed with breast cancer opt for a mastectomy, as will many people who know they are at high risk for breast cancer in the future due to their family history or genetic mutations and want to reduce this risk. And while mastectomy is a life-saving measure, few people talk about the after-effects, especially the psychological ones. Through my work as a breast cancer and reconstruction surgeon, as well as having gone through breast cancer treatment personally, the one thing I continue to be struck by is how a mastectomy can negatively affect a person’s sense of self and relationship to their body — and how there are new treatment options to minimize these effects.

At the time of a breast cancer diagnosis, considering treatment options can be very overwhelming. The initial, understandable urge for many people is to just “get the cancer out,” without as much consideration for the potential impact that the treatments may have on them later. Fortunately, we have come a long way in providing many different treatment options for patients. Many breast cancer patients are now offered newer breast reconstruction options and nipple-sparing mastectomy (NSM) approaches, and while these procedures provide excellent aesthetic outcomes, they also unfortunately come with a major downside: loss of breast and chest sensation.

Most people making the decisions around mastectomy don’t realize that the procedure will leave them with little, if any, sensation in their breast or nipple skin after surgery. In one 2018 study, only 2% of women gained full sensation in their breasts after a mastectomy. While this fact is sometimes discussed during surgical consultation, many people are surprised to find out that they have lost sensation after surgery, and are then even more shocked to find out it’s often permanent.

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It’s difficult to be numb in any part of your body, but breasts may play a big part in a person’s life, from intimacy with their partner, to their sense of femininity. Studies of people who have undergone breast cancer treatment show a significant decline in overall sexual health, with specific studies looking at women who have undergone mastectomy showing it to be associated with a sense of disfigurement and conflict between sense of self and body. I've heard patients voice hesitation or fear about undergoing a life-saving mastectomy because they are concerned about permanently losing feeling in their breasts, and question how that will affect them for the rest of their lives.

When I was diagnosed with breast cancer at age 37 in December 2017, it came as such a huge shock on so many levels, especially as a surgeon who spends every day treating the same disease I’d just been diagnosed with. Once I started thinking about my treatment options, I realized that the thought of losing sensation after a mastectomy, especially so young, played a large role in my decision-making around what type of surgery I chose. I ultimately chose to have a lumpectomy, which is when the tumor is removed with clean tissue around it but the rest of the breast is left intact, primarily to avoid facing a lifetime of chest numbness and the many ways that would impact my life. Fortunately, I had the choice of either lumpectomy or mastectomy based on the size and type of cancer I had, but for many people, mastectomy is the only option. This is especially the case for people with genetic mutations that significantly increase their future breast cancer risk, who are strongly recommended to consider having mastectomies.

From this experience, my husband, Dr. Ziv Peled, who is a peripheral nerve and plastic surgeon, and I began to discuss ways in which we could prevent people undergoing mastectomy from losing sensation after the surgery. We developed a new technique for preserving sensation during mastectomy and implant reconstruction that combines the latest advances in breast oncologic, reconstructive, and peripheral nerve surgery. This procedure introduces the concept of nerve preservation and grafting for restoration of sensation following immediate implant breast reconstruction as a viable option for breast cancer patients.

We have been so excited to see our patients keeping their sensation after mastectomy and implant reconstruction, making it a much more attractive option for people who have been diagnosed with cancer and those who are considering preventive mastectomies, or “previvors.” We hope that as more and more people become aware of the prospect of numbness they will likely face after a mastectomy, breast cancer patients and previvors will seek out the option of sensation-preserving mastectomies, encouraging more surgeons to become trained in these techniques.

We should continue to raise awareness about breast cancer and support these patients who have battled this disease through fundraising, events, and research support. However, it’s equally important to understand the potential long-term impact breast cancer treatment can have on patients. While loss of sensation can be truly daunting, evolving options can help patients move past their breast cancer and continue to thrive.

Studies referenced:

Chirappapha, P., Srichan, P., Lertsithichai, P., Thaweepworadej, P., Sukarayothin, T., Leesombatpaiboon, M., … Kongdan, Y. (2017). Nipple-Areola Complex sensation after nipple sparing mastectomy. The Breast, 32. doi: 10.1016/s0960-9776(17)30390-9

Oberguggenberger, A., Martini, C., Huber, N., Fallowfield, L., Hubalek, M., Daniaux, M., … Meraner, V. (2017). Self-reported sexual health: Breast cancer survivors compared to women from the general population – an observational study. BMC Cancer, 17(1). doi: 10.1186/s12885-017-3580-2

Sun, L., Ang, E., Ang, W. H. D., & Lopez, V. (2017). Losing the breast: A meta-synthesis of the impact in women breast cancer survivors. Psycho-Oncology, 27(2), 376–385. doi: 10.1002/pon.4460

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What is A P.A.?

In this video Anne Peled and Nicole Daoud discuss what it means to be a P.A. in 2019.

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Breast and Ovarian Cancer Week

Do you know somebody who has had breast, ovarian or any other hereditary cancers? September 29th - October 5th is Hereditary Breast and Ovarian Cancer (HBOC) week and the entire month of October is Breast Cancer Awareness Month. It’s a good time to remind ourselves what these weeks and month are about and to talk to your family members, friends and healthcare providers about their story and your own history.

In 2010, HBOC made its debut with the goal of raising awareness about hereditary cancers. As we move into Breast Cancer Awareness Month, we are recognizing men and women and all those affected by hereditary breast, ovarian and related cancers including those with BRCA mutations, survivors, previvors, family and friends of those who have been affected by breast, ovarian and related cancer and those with strong family histories of cancer.

Millions of people carry inherited mutations or have strong family history of cancers, but don’t know their individual risk. In some families, breast and ovarian cancer have a predominance to develop and these cancers usually affect woman and men much younger than the average age of diagnosis and some individuals may develop different types of cancers - this is known as HBOC.

Most often, HBOC is caused by inherited gene mutations in the BRCA1 or BRCA2 genes, as well as others. Some families have HBOC based on the predominance of cancer history in their family without a detected gene variant or mutation. Breast and ovarian cancer are very high in women and men with these inherited gene mutations and individuals with strong family history, those of Ashkenazi Jewish descent, and/or family members with HBOC should talk to their healthcare provider about possible genetic counseling to help estimate their lifetime risk of developing these types of cancers. With more knowledge comes more informed decision making and this can guide the discussion with your healthcare provider, gynecologist, breast or plastic surgeon or anyone else involved in your healthcare about what screening tools, guidelines and recommendations that might be right for you and your family. For some women, these recommendations may include increased screening and surveillance, while for others they may include considering prophylactic breast or ovarian surgery.

Know your risk and know what options are available to you. Some resources to find out more are:

cancer.org, HBOC, The Breasties, National Breast Cancer Organization, Anne Peled, MD

Join us throughout the month of October as we celebrate and raise awareness surrounding all those affected by breast, ovarian and related cancers!

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Dr Anne Peled Discusses Breast Cancer Surgery in San Francisco

Dr. Peled was featured on ABC News 7 in San Francisco speaking about performing breast cancer surgery on a breast cancer activist in San Francisco. She discussed the procedure and how a new device called a Biozorb is helping to make a target for radiologists in follow-up procedures. Dr. Peled is on the cutting-edge for breast cancer treatment in San Francisco.
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Breast Cancer Advocate Reveals Why BioZorb Was Right for Her

Breast Cancer Advocate Reveals Why BioZorb Was Right for Her

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Dr. Anne Peled Implant Reconstruction

Dr. Anne Peled explains the different types of breast implants used in breast implant surgery. Learn more or contact Dr. Peled about breast reconstruction or enhancement surgery today at https://annepeledmd.com
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Dr Anne Peled Interviewed About Breast Cancer Awareness Month KTVU FOX2

Dr Anne Peled Interviewed About Breast Cancer Awareness Month KTVU FOX2
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Breast Cancer Surgeon Is 'Shocked' to Learn She Has Breast Cancer — and Then Becomes a Survivor

"I kept reminding myself, 'Remember what you tell your patients,' " Dr. Anne Peled tells PEOPLE

By Wendy Grossman Kantor 
July 26, 2019 01:53 PM
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GENE COHEN PHOTOGRAPHY

In November 2017, Dr. Anne Peled of San Francisco was taking a shower and doing the monthly self-exam she encourages her patients to do when she felt a lump in her right breast. The now-38-year-old board-certified plastic and breast surgeon told herself it was probably nothing. After all, she’s a super-fit pescatarian, tri-athlete and distance runner, and she has no family history of breast cancer.

But that lump didn’t go away.

On Dec. 7, 2017, she had a biopsy. The next morning, Dr. Peled was preparing to perform a double mastectomy and implant reconstruction on a patient when her phone rang.

“I was getting ready to put on my gloves,” she tells PEOPLE. But she saw her pathologist was calling and answered the phone. “I was sure she was going to tell me it was a cyst and I was going to go on with my day.” 

Instead, the pathologist told the breast cancer surgeon that she had breast cancer herself.

“I was so shocked,” says Dr. Peled. “There were no words. Literally, I tell women breast cancer diagnoses multiple times a week. What I tell all my patients is: ‘This is very treatable. Most breast cancer nowadays — not all — is very curable.’ I kept reminding myself, ‘Remember what you tell your patients.'”

It was a Friday when she received her diagnosis. She immediately began assembling her team. That afternoon she had a breast ultrasound. On Monday, she had a breast MRI.

Dr. Peled’s the type of mom who makes M&M pancakes and regularly piles her three kids and two yellow labs, Kahlua and Clementine, into the car and drives them to the beach or on a hike. “I make my kids go on adventures,” she says. In April, they stayed in a treehouse in Costa Rica.

Husband and wife Dr. Anne Peled and Dr. Ziv Peled, operating on a mutual patient
 
DR. ANNE PELED

But after she was diagnosed with breast cancer, Dr. Peled decided not to tell her young children she had cancer. Her now-8-year-old son Simon, and now-5-year-old twin daughters, Charlotte and Eveline, have friends whose grandparents died of cancer, and she didn’t want them to worry.

Her parents stayed with the children. She scheduled her surgery in Vancouver, Washington, with a surgical team she trusted and would give her the type of hidden-scar surgery she performs herself.

A week later, she came home, told the kids mommy couldn’t lift them because she had “an ouchie,” went back to work and signed up for a 10K.

“By the time I came home, I felt great. And my kids didn’t have any idea that anything had happened,” she says. “In many ways, I look better than how I started, which is pretty amazing.”

The day she learned she didn’t need chemotherapy, she and her husband, fellow surgeon Ziv Peled, toasted with champagne.

“I got really lucky,” she says. “After that first scary phone call, every other piece of information I had after that was great news.”

Dr. Anne Peled with her husband, Dr. Ziv Peled
 
DR. ANNE PELED

Dr. Peled wore her running clothes to her radiation treatments and ran afterwards every day.

“It would clear the space in my head,” she says. “We have really good data that shows that exercise decreases recurrence. I take hormone-blocking pills and I exercise. I think of this as part of my treatment.”

She finished radiation in March and ran the 10K the following month.

Dr. Peled worked with Athleta to design their second https://athleta.gap.com/browse/product.do?pid=869609#pdp-page-content" Empower Bra. She is an incredibly strong and inspirational woman and we are honored to have been able to work with her,” says Casey Schumacher, Athleta’s senior director of design. “Dr. Anne Peled brought invaluable insight, given both her personal and professional experience with breast cancer and reconstruction surgery.” 

Post-cancer bra shopping was something Dr. Peled hadn’t thought too deeply about until she had to do it for herself, she says. Some bras rub where incisions are. “And a lot of women have mobility restrictions, so options of zippers and clasps are important,” she says. “And the fabric — when you get radiation, your skin gets sunburned when you’re healing. So you don’t want the fabric to chafe or rub.”

Once a month, Dr. Peled travels the country to train other surgeons in the type of hidden-scar surgery technique she had herself, because she wants other women to have the “amazing care” that she had. She talks about the technique on social media and invites surgeons to come to her practice to watch and learn the technique.

“Many women don’t realize that not all lumpectomies are the same. A lot of times, there are big scars right over where the cancer was. And then they get closed without reshaping the breast,” she says. “Women get these holes in the breast where your tissue caves in — and that can be pretty disfiguring for women. You wake up in the morning and get out of the shower and you’re reminded every day.”

Dr. Peled wants women to know their options before they have breast cancer surgery.

“I feel lucky to have this job,” she tells PEOPLE. “In so many ways, it’s so scary. It’s so much more filled with hope than it used to be. Our treatments get better and better.

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Dr. Peled in Medium - Cancerversary

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Dr. Peled shared her Cancerversary story on //medium.com/@annepeledmd/cancerversary-946a5480c51b" target="_blank" rel="noopener" style="box-sizing: border-box; background-color: transparent; color: rgb(47, 47, 47); text-decoration: none !important; transition: all 0.5s ease 0s;">Medium and with Kevin M.D. 

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