Anne Peled Plastic Surgery

Based in San Francisco, Dr. Anne Peled is a surgeon, an educator, a researcher, a mother, an athlete, and a breast cancer survivor. Just a few years into starting her own thriving breast cancer and plastic surgery practice, Anne was diagnosed with breast cancer herself, which gives her the unusual perspective of both the expert and the patient. This has also only strengthened her dedication to provide the most empathic and personal care for her patients, to research and innovate the most cutting edge techniques and practices for breast cancer surgery and reconstruction, and to educate her peers and the public on the best care and prevention for breast cancer and breast health.

Why Use Genetic Testing For Breast Cancer Detection

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Dr. Peled explains how women need to use Genetic Testing to determine if they are at risk for breast cancer in her new video.

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Wondering about Textured Breast Implants?

Textured Implants

After recent increased concerns around breast implant safety, which prompted an FDA hearing in March 2019 focused on this issue, certain types of breast implants and tissue expanders with textured surfaces have now been taken off the market.

Here’s some information that may help you sort through your breast implant-related questions and be able to make an informed decision about options.

Does this decision affect all breast implants?

No, this is specifically regarding textured implants and expanders (not smooth ones) from only one of the implant manufacturers, Allergan. Both saline and silicone implants come in smooth and textured surfaces, but the vast majority of implants placed in the United States are smooth.

What is the concern with textured implants?

The main concern and the reason these implants have been taken off the market has to do with a rare type of lymphoma that has been linked to breast implants with textured surfaces. Depending on the implant type, rates of this type of lymphoma (called BI-ALCL) range from 1 in 3,000 to 1 in 30,000. Although there have unfortunately been a small number of deaths from this lymphoma, it is usually very treatable when identified early.

Is removal of already placed textured implants being recommended?

No, right now there is not a recommendation from any government agency or plastic surgery society to remove textured implants (even ones from Allergan, which have the highest rates of lymphoma with their textured implants). However, patients with any type of implants, textured or smooth, should follow-up with their plastic surgeon (or another board-certified plastic surgeon) for a check of their implants every year or sooner if they develop any new pain, swelling, or change in appearance or feel of their implants.

If you have had breast implants placed already by Dr. Peled, please feel free to contact our office at 415-923-3011 with any questions about your implant type or the safety of your implants, and visit annepeledmd.com to learn more.

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What To Expect After Breast Cancer Surgery

What To Expect After Breast Cancer Surgery

In the midst of processing everything after finding out you have breast cancer, thinking about what to expect after surgery can easily get lost. While everyone’s recovery is a little different, and it’s always best to check with your surgeon about their specific recommendations, here’s an overview of common breast cancer procedures to give you a sense of what they might be like:

Lumpectomy

This is usually done as an outpatient surgery, often under lighter anesthesia. Typically recovery is about a week, with return to sfull activity within two weeks. If a lymph node biopsy is done at the same time, I often recommend not lifting the arm on that side completely overhead for 2 weeks, as well as working with a physical therapist after surgery to help with stretching and strengthening exercises. No special bras are needed after this surgery, though soft bras that don’t rub are helpful to use during radiation if you need radiation.

Breast lift/reduction for lumpectomy reconstruction

When combined with lumpectomy, breast reductions or lifts are still typically done as outpatient surgeries, though sometimes an overnight stay is recommended. Most surgeons do not use drains, but some may use them and recommend they stay in for a few days or longer. Recovery is usually around two weeks, with light exercise encouraged by the end of the first week and a return to full activity usually by four weeks. Physical therapy is helpful for recovery and to help with swelling. A soft bra that zips or clasps in the front that provides some compression should be worn full-time for 2 weeks, and then during the day for another 2 weeks. I recommend avoiding underwire bras for 3 months to decrease the chance of irritation at incision sites.

Mastectomy (with or without reconstruction)

The expectations for after this surgery really depend on whether or not reconstruction is done and the type of reconstruction. Surgery typically entails at least an overnight stay, though it may be more like 3 or 4 days if flap reconstruction is done. Drains are used and usually stay in place for 10 to 14 days depending on the type of reconstruction. Once drains are out, I recommend physical therapy to help with chest opening exercises and strengthening.  Return to activity varies, but is usually from two to six weeks depending on reconstruction. Similar to breast reductions, a soft bra that zips or clasps in the front can be helpful for the first few months to provide support and a little compression. Underwire bras should be avoided for 3 months.

To learn more about Lumpectomy, Breast Lifts/Reconstructions and Mastectomies, visit annepeledmd.com today to make an appointment to talk with Anne.

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#AskDrAnne Anne Peled, M.D. Answers Your Breast Cancer Surgery Questions April 19, 2019

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Anne Peled, M.D. answered many patients' questions about Breast Cancer Surgery and Breast Health on April 19, 2019.  We collected the questions below so you can watch the video and find answers to all of these questions at the times listed below:

2:20 How many women who choose to save their nipples end up getting cancer anyway, either if they have mastectomies for prophylactic or for cancer reasons?
3:25 Some surgeons are worried about the risk of necrosis after nipple sparing mastectomies, meaning that nipples might have healing problems or that some of the nipple tissue might not survive. How likely is this?
4:15 What should I expect from a recovery standpoint, after prophylactic mastectomies or mastectomies for cancer?
7:00 If I have large breasts, a small frame and a limited ability to use my own tissue, what are my reconstruction options?
8:20 Can gummy implants deflate?
10:05 How do I choose implant size?
11:30 Have you ever seen redness at the incision site, where the wound isn't infected?
12:50 How soon can I travel after breast reconstruction surgery?

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Breast Implant Safety: Updates and Resources

Wondering about the safety of your breast implants_.jpg

Concerns about the safety of breast implants have been all over the news lately, but the information presented is often confusing and can lead to more questions than answers. In order to really understand all of the information, it’s important to know some basics about breast implants (which many women are unfortunately not well-informed about before having implants placed!).

First, here are the main features of breast implants that impact their safety and outcomes:

Saline Versus Silicone

Breast implants can be filled with either silicone or saline, though both have a silicone shell on the outside of whichever fill type they have inside the shell. There are potential benefits and downsides to both- the most commonly described advantages of silicone are that they feel more natural and have less rippling, while some women prefer saline because of the ease of identifying rupture if it happens and greater overall peace of mind with saline implants.

Textured Versus Smooth

The surface texture of an implant refers to properties of the silicone shell and basically comes in two types, “textured” (which has a rough surface that acts like Velcro with the surrounding tissue) and “smooth” (which has a completely flat surface that doesn’t interact with the surrounding tissue in a significant way).

The major benefit of textured implants is that the “Velcro effect” can hold implants in place better, which can allow surgeons to use shaped (“teardrop”) implants without worrying that they’ll rotate in the wrong orientation in the implant pocket, and also that the breast shape after augmentation or reconstruction with implants may be stable for a longer time because of the contact between the tissue and the implant.

Implant companies have different “levels” of texturing, which are designed to optimize patient outcomes but also appear to impact the risk of a rare form of lymphoma called Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL- see below for more information).

Round Versus Shaped

Implants come in two different shapes, round and shaped (also known as “teardrop”). Round implants can have smooth or textured surfaces, while shaped implants need to have a textured surface to prevent the rotation issue described above.

Prior to finding out about the link between implant texture and BIA-ALCL (see below for more information), decisions around implant shape were entirely related to patient goals for their breast/reconstructed breast appearance, but now concerns around texturing have led many surgeons to recommend smooth implants exclusively, and thus fewer shaped implants are being used (at least in the U.S.) 

Within the different implant shapes there are also different levels of projection and implant width and height, which also impact the overall look to the breast after augmentation or reconstruction, but don’t impact the safety profile.

Implant manufacturer 

There are a small number of breast implant manufacturers in the U.S., and all have different proprietary processes for how they make their implants, which can affect their long-term outcomes as well as potential risks from the implants. All of the implant companies collect data on outcomes with their own implants, but there are really not any great studies comparing different implant types to each other.

Surgeons usually have specific reasons for using a particular implant type, and some many use more than one type, so it’s good to ask why your surgeon prefers one type over the other and how they make their choices.

After you have breast implants placed, you should receive an implant card that contains all of the information listed above (although depending on the manufacturer or age of your implants, you may have to look up your implant type to find out about the shape and texturing). If you don’t still have the card (or never received one), your plastic surgeon’s office should be able to give you a copy.

Next, here’s what we know and don’t know about breast implant safety and BIA-ALCL as of this publication date (April 2019):

  • The risk of getting lymphoma following breast implant placement for cosmetic or reconstructive reasons is very low. Reported lifetime risk in the U.S. for women with textured implants ranges from 1 in 3,800 to 1 in 30,000. Hundreds of thousands of breast implants are placed every year, but to-date only 457 unique cases have been reported to the FDA.

  • BIA-ALCL can be treated and cured when discovered early. The typical signs of BIA-ALCL are late swelling in the breast around the implant (usually 2 or more years after surgery) or a mass in the breast near the implant. If these kinds of symptoms occur, women should be evaluated by their plastic surgeon as soon as possible. Depending on the findings, patients may require imaging of their breast and a possible biopsy or drainage procedure. Once BIA-ALCL has been diagnosed, women will need to undergo surgery to remove the implant and the surrounding capsule as well as any breast masses. Surgery alone is very effective for treating the lymphoma in most patients, though some patients will need chemotherapy or radiation therapy if the disease is more advanced. Death from BIA-ALCL is extremely rare (17 cases reported worldwide) and all occurred after significant delay in diagnosis and treatment and without getting appropriate targeted therapy.

  • Plastic surgery organizations, implant manufacturers, and the FDA are working together to collect more information to better understand BI-ALCL and learn how to prevent it in the future. The American Society of Plastic Surgeons and the American Society for Aesthetic Plastic Surgery, as well as implant manufacturers, have been actively working in conjunction with the FDA (including a recent two-day hearing) to track all cases of BIA-ALCL and collecting as much clinical information as possible to try to determine the specific risk factors for BIA-ALCL and the safest implant options for women. Research is also being done to investigate genetic and other patient factors that may make patients more susceptible to developing BIA-ALCL if they do have breast implants.

  • There have not been any recommendations from any plastic surgery organization or the FDA for asymptomatic women who currently have breast implants to have them removed. The current recommendations for monitoring implants include regular imaging (current guidelines recommend MRI, but this may be changed to ultrasound) and routine follow-up with your plastic surgeon. I recommend yearly follow-up for all of my patients with breast implants, with earlier follow-up if any new breast symptoms such as pain, swelling, change in breast appearance, breast masses, or implant firmness develop.

Finally, here are some resources by topic that can help as you’re making decisions about implants or wondering about the risks of implants if you already have them:

BIA-ALCL

https://www.plasticsurgery.org/for-medical-professionals/health-policy/bia-alcl-physician-resources

https://www.plasticsurgery.org/documents/Health-Policy/ALCL/ALCL-Brochure-Trifold.pdf

https://www.mdanderson.org/cancer-types/implant-associated-anaplastic-large-cell-lymphoma.html

FDA Recommendations

https://www.fda.gov/medicaldevices/productsandmedicalprocedures/implantsandprosthetics/breastimplants/ucm239995.htm

Implant Manufacturer Data

https://www.natrelle.com/reconstruction

https://sientra.com/breast-implants

https://www.breastimplantsbymentor.com/breast-implants/

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Expanding Patient-Reported Outcomes Tools after Nipple-Sparing Mastectomy

Nipple Sparing Mastectomy

I’m honored to have recently had a paper published in Plastic and Reconstructive Surgery  focused on patient-reported outcomes after nipple-sparing mastectomy and breast reconstruction. Over the past decade, plastic surgeons have realized the importance of not just reporting on complication rates after surgical procedures, but also specifically focusing on how patients feel about their surgery, or “patient-reported outcomes”. For this study I was lucky enough to collaborate with some experts in the field of patient-reported outcomes, including Dr. Andrea Pusic, who is the lead developer of a patient-reported outcomes tool called the BREAST-Q. The BREAST-Q has become widely adopted in breast surgery research and is thought of as the gold standard for assessing patient-reported outcomes after a variety of breast surgery procedures.

Prior to our research study, the BREAST-Q hadn’t yet included questions specifically related to nipple-sparing mastectomy (NSM) in regards to NSM scars, nipple sensation, or nipple appearance. The goal of our study was to speak to women who had undergone NSM and immediate reconstruction, as well as health care providers treating women after NSM, to come up with and validate survey questions that could help to better understand how women feel about these outcomes. Following the validation of these questions in our study, the questions can now be incorporated into the BREAST-Q to help surgeons improve their techniques and get women better outcomes.

As my husband Dr. Ziv Peled and I move forward with our innovations in mastectomy and reconstruction techniques to allow women to have breast and nipple sensation after NSM and implant reconstruction, we’re excited to have better patient-reported outcomes tools like the more comprehensive BREAST-Q survey to help us really understand our results and continue to innovate further.

For more information on Nipple Sparing Mastectomy and Breast Cancer Surgery, visit www.annepeledmd.com or call our office at 415-923-3011 to make an appointment.

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#AskDrAnne Anne Peled, M.D. Answers Your Breast Cancer Surgery Questions

Ask Dr Anne

Anne Peled, M.D. answered many patients' questions about Breast Cancer Surgery and Breast Health on March 27, 2019.  We collected the questions below so you can watch the video and find answers to all of these questions at the times listed below:

0:49 Over the muscle or under the muscle reconstruction: can you muscle be too thin for over the muscle reconstruction?
1:42 Is over the muscle less safe from a cancer perspective?
2:35 What are the downside for going over the muscle?
3:47 Under the muscle: can it cause chronic neck and back pain and does this get better when you switch this?
5:06 What is your opinion about the implant illness we keep seeing articles about?
6:23 For over the muscle reconstruction, how do you choose between expanders or implants?
7:29 What are some of the factors to consider with nipple-sparing mastectomy and how can sensation be preserved?
9:24 Who is a candidate for a nipple-sparing mastectomy?
11:11 What should I expect during recovery from these procedures (over the muscle implants, nipple-sparing mastectomy)?
13:20 What exercises do you recommend to help recovery?
14:48 Is breast reconstruction covered by insurance?
16:08 How safe are implants?

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6TH ANNUAL BRAVE DAY SAN FRANCISCO

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ANNE PELED, M.D. JOINS BRAVE COALITION FOUNDATION IN CELEBRATING THE 6TH ANNUAL BRAVE DAY, EDUCATING AND ADVOCATING FOR BREAST CANCER RECONSTRUCTIVE RIGHTS

[SAN FRANCISCO, CA] March 21, 2019 Breast Restoration AdVocacy and Education (BRAVE) Coalition Foundation is recognizing their 6th annual “Brave Day” nationally this year.  Brave seeks to empower women through educating them of their rights to reconstruction when diagnosed with Breast Cancer. BRAVE is about restoring the whole woman after the diagnosis, and is one of few charities that focuses on “after the diagnosis.”  

March 21st is National Breast “Restoration” Day - a day that we encourage everyone to spread the word that women have the right to reconstruction after breast cancer treatment. Although 1 in 8 women will be diagnosed with breast cancer, only 30% of those diagnosed know their federally mandated right to reconstruction. In order for breast cancer survivors to thrive, BRAVE Coalition promotes that all survivors should be empowered with education and resources to give them the choice and opportunity to experience life beyond cancer as her whole self, however she defines it.

BRAVE Day will be celebrated nationally at multiple locations across the United States.

"At the time BRAVE was founded, there wasn’t a nonprofit that focused attention on breast restoration also referred to as reconstruction,” says Christine Grogan, MHA/EMHL, Founder “BRAVE was started to help women know of their options after breast cancer removal so there could be a positive focus during the next phase of their journey.  We call it “restoration” since the end result is women restored to their best self, however they choose.”  

About BRAVE Coalition Foundation
The Breast Restoration AdVocacy and Education (BRAVE) Coalition Foundation, a 501(c)3 nonprofit, was founded in 2013 by Christine Grogan, industry leader in breast restoration rights awareness, to promote education and awareness of resources for breast cancer survivors regarding breast reconstruction options.

To find out how to get involved with BRAVE, www.bravecoalition.org

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Considering Prophylactic Mastectomy? How to Help Make the Best Decision for Yourself

 Considering Prophylactic Mastectomy How to Help Make the Best Decision for Yourself

Finding out you’re at increased risk for future breast cancer due to your family history or a genetic mutation (or both), can be really overwhelming. Here are some steps that may help you come up with a plan that feels right to you and lets you feel more in control of your health and body.

First, a genetic counselor and/or high-risk breast specialist can help you really understand your risk of breast cancer and any other cancers that you might have to think about. They can talk to you about screening and prevention plans, which could range from more frequent imaging studies and exams to considering taking hormone-blocking medication or prophylactic mastectomy.

Knowing what your surveillance plan looks like can help you make a decision about if and when you want to think about having prophylactic mastectomies.

Next, if at all possible, find a surgeon who specializes in breast surgery and routinely does mastectomies.  Nearly all women having prophylactic mastectomies are candidates for nipple-sparing mastectomies if they would like to save their nipples, which has been shown in multiple studies to be safe in women at high risk for breast cancer due to family history or genetic mutations.

Depending on your breast shape, size, and goals, nipple-sparing mastectomy might involve an initial breast reduction or lift to make NSM safe at the next surgery. Your breast surgeon can also help connect you to a plastic surgeon if you’re considering breast reconstruction. Keep in mind that there are many different techniques for different types of reconstruction, so take your time asking potential plastic surgeons about the trade-offs of the different procedures and feel free to get multiple opinions if needed to help you feel most informed.

I find one of the most helpful things for making the decision around prophylactic mastectomies is talking with other women who have gone through it. In our office, we are lucky enough to have prior patients who are willing to speak with women considering mastectomy about their experiences, which we offer to coordinate for all of our new patients.

We try to match them with other women who may have similar health or personal situations that could play a role in their recovery - we think of it like a buddy system! There are also some great groups that have fostered communities of women sharing and supporting women through their journey- a couple of our favorites are The Breasties and FORCE.

We’d be happy to see you in the office or via Skype call if you’d like to learn more as you’re considering your options. Please contact us at (415)923-3011 or ..">This email address is being protected from spambots. You need JavaScript enabled to view it..

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Getting the Best Breast Cancer Surgery Results

Getting the Best Breast Cancer Surgery Results

One of the most rewarding parts of my job is educating other surgeons and patients on new and exciting techniques in breast cancer and breast reconstruction surgery. I love interacting with surgeons who are truly passionate about learning new approaches to help their patients get better outcomes, and with patients who want to know all of their options to make the best decisions. I often hear from women, though, that they didn’t know what to ask their surgeons to make sure they were getting access to the most innovative, patient-centered care and that they regretted not getting second opinions or researching more before having their surgery. 

Given the psychological and emotional issues that understandably come up when thinking about having breast cancer or reconstruction surgery, women deserve to have a surgeon who is really focused on getting them the best outcome that minimizes the negative impact on their bodies, both short- and long-term, and is least disruptive to their sense of self and body image. Here are a few suggestions to help make sure you’re getting this kind of patient-focused breast surgical care:

1) Ask about where your scars will be. Lumpectomies and mastectomies can often be done in ways where the scars are hidden so you don’t have a constant reminder of your breast cancer or breast surgery.

2) Ask to see before and after pictures of other women who’ve had a similar surgery to what you’re planning. This can help show you where scars will be and what they’ll look like and give you a realistic sense of how you might look after surgery. It also helps you evaluate your surgeon’s results and lets you compare outcomes between surgeons.

3) Consider a second opinion. Different surgeons have different skills and it can be useful to hear more than one recommendation as you’re making your decision. It can also just be helpful to have information presented multiple times so that you really understand your options.

4) Ask if you can speak with other women in the surgeon’s practice who have had the same surgery that you’re considering. This will help you learn more about what to expect and how patients feel about their results. Keep in mind, though, that every woman’s experience is different, so add what you hear from other women who’ve been through it to information from your surgeon and other resources to help you make the best decision.

For more information or to make an appointment to see Dr. Peled, visit annepeledmd.com or call us at 415-923-3011.

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Dr. Peled Interviewed in Paige Previvor!

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I was interviewed last week for the article "Choosing Between Over or Under the Muscle" by Paige More over at paigeprevivor.com.  Paige asked me a variety of questions, ranging from my experiences as a survivor of breast cancer to my opinion on Over the Muscle and Under the Muscle breast reconstruction techniques.

Paige had a double mastectomy 2 years ago at 24 and has been blogging at https://paigeprevivor.com about her experiences and sharing her story to help other women who may need help or have questions about breast cancer and breast cancer surgery, including our topic, whether to go over or under the muscle for implant breast reconstruction.  She is also co-founder of the amazing group The Breasties, which supports young women affected by breast or ovarian cancer.

Our interview covers all sorts of different questions about breast reconstruction, from recovery to screening. If you have any questions about implant reconstruction or switching from under the muscle to over the muscle, give us a call to schedule an appointment to learn more!

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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.

Learn More Sensation preservation NSM

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Moving Beyond Breast Cancer: Making Room for Revision Surgery

Moving Beyond Breast Cancer: Making Room for Revision Surgery

I’m currently only weeks away from my one year “cancerversary” from being diagnosed with Stage I breast cancer at age 37 and am finding myself taken back to where I was last year in getting ready to be on the “other side of the scalpel” as I prepare for reconstruction revision surgery. In some ways, this feels similar, in terms of the worry about complications, how my recovery’s going to go, and the impact it will have on my family, work, and exercise routines. But in so many other ways, this time is different, and complicated in ways I never expected, despite having performed so many breast reconstruction revision surgeries myself as a plastic surgeon.

While my first surgery was overwhelming because of all of the cancer unknowns, like whether or not my lymph nodes were involved and if I’d need chemotherapy, this time feels “elective”, which brings a new set of emotions with it. When I reassure my patients that their initial or revision breast reconstruction surgery will be covered by insurance because it’s not their choice to have breast cancer or a gene putting them at high risk for breast cancer, I like to think it gives them permission to truly accept the surgery as reconstructive, and not cosmetic (which it of course isn’t). And even though I completely believe this for myself as well, somehow it still leaves me wondering if going through surgery again is something I really “need” to do. I’m cancer-free and honestly have a pretty fantastic result thanks to my amazing surgical team, which makes me question if I should just ignore the subtle divots and asymmetries left from my cancer treatment instead of going through another surgery? Is it worth it to put myself and my family through another recovery when I’m truly grateful every day to feel so healthy and am completely settled back into all of my pre-cancer exercise and work routines?

And then, in the midst of all of this doubt, I remember what I promise my patients, which is that I will do everything I can to get them back to feeling and looking like themselves after surgery as quickly and smoothly as possible so that they’re not reminded every day when they look in the mirror that they had cancer. I think about how happy it makes me when one of my patients says that they can barely remember which side they had cancer on because they’ve healed so well or that they like their breasts even more than they did before their cancer surgery thanks to their oncoplastic breast reconstruction. And it reminds me that I too deserve to look in the mirror every day without a reminder of cancer and to head into my revision surgery with the permission to look as healthy and cancer-free as I feel.

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Understanding Your Breast Cancer Care Team

Understanding your breast cancer care team

Finding out you have breast cancer can be overwhelming on so many levels. In the midst of all of the initial appointments, it can be difficult to understand which providers you need to see and how each one is involved in your care.

Here are some of the breast cancer providers who may be a part of your breast cancer care team (everyone’s situation is a little different, so you may not need all of them):

Radiologist

For many women, a radiologist is the first doctor they meet with, usually to review an abnormal mammogram or ultrasound and to perform a breast needle biopsy. Depending on your follow-up plan, radiologists will likely be a part of your ongoing care after your breast cancer treatment as well, continuing to evaluate any follow-up mammograms, ultrasounds, or MRIs you may have.  

Nurse Navigator

Not all centers have nurse navigators, but in the ones that do, they play a huge role in helping women get through finding out about their diagnosis and coordinating their care. Nurse navigators will often set up appointments for patients to meet with a surgeon or a medical oncologist and provide information on important resources and support services.

Breast Surgeon

Meeting with a breast surgeon is usually your first appointment after finding out you have breast cancer. Your breast surgeon will talk to you about surgical options and discuss any other tests you might need before surgery. After surgery, they will review your pathology results with you and the next steps in treatment.

Plastic Surgeon

All women diagnosed with breast cancer should get the opportunity to meet with a plastic surgeon to discuss their reconstructive options.  Some breast surgeons may be able to do some types of reconstruction (such as lumpectomy reconstruction) on their own and some women may choose not to have reconstruction, but hearing about the options can help you make the most informed choices.

Medical Oncologist

Most women with invasive cancer and some women with non-invasive cancer/pre-cancer will see a medical oncologist as part of their treatment. Medical oncologists prescribe pills and IV-medications (such as immunotherapy or chemotherapy) to treat breast cancers or prevent them from coming back after they’ve been removed.

Radiation Oncologist

Radiation oncologists typically meet with women after their breast cancer surgery to discuss using targeted radiation to help prevent breast cancer from coming back after surgery. Most women having lumpectomies will be recommended to see a radiation oncologist, while only some women having mastectomies will be recommended to have a radiation oncology visit.

Pathologist

Although you likely won’t ever meet a pathologist during your breast cancer treatment, pathologists play an important role in your care.  They review the tissue taken during your breast biopsy and breast surgery to determine specific details about your breast cancer, which helps determine your breast cancer treatment.

Genetic Counselor

Depending on your family history, as well as your personal history and age when you’re diagnosed, you may be recommended to see a genetic counselor.  Genetic counselors will review your history and may talk to you about undergoing testing to check for a genetic cause for your breast cancer.

Primary Care Provider/Gynecologist 

Your primary care provider, whether an internist or gynecologist or other provider, is an important part of your breast cancer team.  They may help you to get in to see breast cancer specialists when you’re first diagnosed.  They will also be involved in following you after you finish your treatment, which may include doing breast exams or ordering follow-up imaging tests.

Support Services

There are many other care providers who may be a part of your team, including physical therapists, nutritionists, social workers, and psychologists, among others.  All of these providers will help get you through your treatment as smoothly and healthily as possible and may play an important role during and after your breast cancer journey.

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Exercising after Plastic Surgery: 5 Tips for Healing Safely and Smoothly

Exercising after Plastic Surgery 5 Tips for Healing Safely and Smoothly

One of the most frequent questions I get asked when I speak to patients about recovering after surgery is when they can exercise again. I love having active and healthy patients and strongly encourage exercise before and after surgery, but always spend a lot of time going over an exercise timeline to make sure it’s done safely. While you should ask your surgeon what his/her protocol is for exercising after surgery, here’s what I recommend:

1. Think of getting ready for surgery like training for a race or athletic event. The better shape you are going into surgery, the better shape you’ll be coming out of it. Having more muscle mass before surgery can help speed up the time it takes for swelling to go away afterwards. And for certain procedures, such as tummy tucks, strengthening your core muscles before surgery can make it easier to get back into core exercises once you’re able to do them again after surgery.

2. Figure out what kind of special exercise gear you’re going to need for exercising after surgery and buy it before surgery so you’re ready. Depending on what type of surgery you’re having, you may be recommended to have compression garments or wear special types of bras. If you have whatever your surgeon has recommended at home in advance, as soon as you get the green light to exercise, you’ll be ready to start.

3. Consider re-starting your exercise program with the help of a physical therapist or personal trainer. Even if you’ve carefully reviewed your exercise plan with your plastic surgeon, it can still often be helpful to enlist the help of an exercise professional for when you re-start. They may notice alignment or technique issues that they can point out to you to help your exercise be safer, or may be able to give you specific stretching or strengthening exercises based on the type of surgery you had. I personally refer almost all of my patients to physical therapy after surgery and many of them feel like they end up even stronger than they started thanks to their physical therapy.

4. Listen to your body. It seems obvious, but you know your body best. If a certain exercise is painful, or just doesn’t feel right, stop and ask your surgeon or physical therapist/personal trainer about it and make sure you’re not negatively impacting your surgical healing. Also, if you notice any concerning changes in your incisions or surgery site, contact your plastic surgeon to check in.

5. Set goals, but be flexible with your schedule and yourself. On a personal level, exercise is an incredibly important part of my life, both physically and psychologically, and I couldn’t wait to go back to it as soon as possible after my own surgery. I think for people who are used to being active, setting goals for yourself about getting back into your exercise program can make you feel better about and more in control of your recovery. But just remember that if you do have to slow things down because healing takes longer than expected or something doesn’t feel great, try to just accept it as part of taking care of yourself and being safe, rather than as a major setback- you’ll get back on track to your goals before you know it!

To discuss your surgical options or make an appointment, visit www.annepeledmd.com or call the office at 415-923-3011.  Our goal is to provide a personalized, thoughtful approach to care that comprehensively addresses all of the components needed to optimize your surgical outcome and your experience through the process.

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Considering Prophylactic Mastectomy? Knowing Your Options Can Help You Get the Best Outcome

Prophylactic Mastectomy

Prophylactic Mastectomy is a surgical procedure that removes one or both breasts in order to lower the potential for breast cancer development in women at higher breast cancer risk.  The surgery can significantly reduce the risk for women carrying the BRCA1 or BRCA 2 gene mutation or other gene mutations, as well as women with a strong history of breast cancer in their family. 

Prophylactic mastectomy can nearly always be done as a nipple-sparing mastectomy, which gives women the psychological and visible benefit of preserving their own nipples.  It also saves them from having to have additional procedures in the future for nipple reconstruction.

Depending on a woman’s goals, breast reconstruction can be done as either a one-stage or a two-stage procedure with either implants or using their own tissue.  Newer techniques for implant reconstruction include one-stage, above-the-muscle reconstruction, which allows women to avoid having a tissue expander and helps them recover more quickly.  Flap procedures such as DIEP flap reconstruction preserve a woman’s abdominal muscles, again helping them recover more quickly with fewer long-term issues.

To discuss your surgical options or make an appointment, visit www.annepeledmd.com or call the office at 415-923-3011.  Our goal is to provide a personalized, thoughtful approach to care that comprehensively addresses all of the components needed to optimize your surgical outcome and your experience through the process.

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Dr. Peled Profiled in the CSPS New Member Spotlight

Dr. Peled has been chosen to be profiled in this month's California Society of Plastic Surgeons New Member Spotlight, with an interview discussing the best thing about being a plastic surgeon, her favorite procedure to perform, what she couldn't operate without, her first social media check in the morning, her favorite hobby, and the best part of what next weekend will be.  It's a great profile!

You can read the profile on the California Society of Plastic Surgeons' site at https://californiaplasticsurgeons.org/csps-new-member-spotlight/ and learn some more about Dr. Anne Peled, the leader in breast cancer surgery, breast reconstruction surgery, and all mastectomy and reconstructive surgeries, including nipple-sparing reconstruction and immediate pre-pectoral implant reconstruction, two procedures that help women make quicker recoveries and wake up looking as good or better than when they underwent the surgery.

CSPS NEW MEMBER SPOTLIGHT

In 2018, the CSPS welcomed 10 New CSPS Active Members.  We are excited to highlight our newest members of the CSPS – this week, we are pleased to shine the spotlight on:

Dr. Anne Peled

The best thing about being a Plastic Surgeon is: The challenge and immense satisfaction of doing something truly and often immediately transformative for patients, whether it’s reconstructive or aesthetic surgery.  I love the “unveiling” at the initial post-operative visit, when patients get to see their results for the first time- it’s by far one of my favorite parts of being a plastic surgeon.

My favorite procedure to perform is:  Nipple-sparing mastectomy and immediate pre-pectoral implant reconstruction- I love being able to offer a procedure where women with breast cancer or at high risk for breast cancer wake up from having mastectomies looking essentially the same, or even better, than they did when they started.

I couldn’t operate without my:  Fun socks or hot pink OR glasses.  As much fun as it is to have a job where you get to go to work basically in pajamas, on my OR days I like to wear something in bright colors too- my patients often make comments about my socks when I’m in doing their markings before surgery.

Dr. Peled in the OR wearing her hot pink OR glasses.

The first social media outlet I check every morning is: Instagram. I keep a fairly small number of friends and family and some lifestyle/fitness sites (like Athleta and Self Magazine) that I follow, so I don’t get overwhelmed looking through them. I love starting my day with little photographic glimpses into everyone’s lives mixed in with style inspiration and fitness routines!

My favorite hobby is: Anything that gets me outside being active- running, triathlons, stand-up paddling boarding, hiking.  Even 30 minutes helps me clear my head from the day and gets me feeling great for the next one.

Dr. Anne Peled along with her husband, Dr. Ziv Peled (also a CSPS member)

The best part of next weekend will be: Taking my family to Legoland (in Carlsbad, CA) – all 3 of my kids (7 year-old son and 4 year-old twin daughters) have been asking me and my husband pretty much every week when we can go back since our last visit there!

The Peled family enjoying some quality time at Lego Land!

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21st Century Breast Reconstruction: Less Invasive, Better Outcomes

I recently saw a woman in my office who had been diagnosed with breast cancer over 30 years ago, at age 37.  At that time, she had undergone a simple mastectomy without reconstruction, a major lymph node dissection, and chemotherapy for what sounded like a small, very treatable, Stage I cancer.   Since that time, as would be expected, her non-cancer breast had gotten larger and dropped over time, and as a result of the major asymmetry between the two sides of her chest, she had mostly been wearing hoodies or loose-fitted patterned sweaters for years to try to hide her chest.  She had also developed neck and shoulder pain as a result of the lopsided-ness of her chest and found that even trying to wear a mastectomy bra and prosthesis wouldn’t fix her asymmetry in clothes and her pain.  She had been living like this for 30 years, without knowing her asymmetry could be significantly improved with an insurance-covered reconstructive surgery.

I was so struck by how things had changed over 30 years between her treatment and mine after my recent breast cancer diagnosis at the same age she had been.  With a small, Stage I cancer, women like me have the option of avoiding major lymph node surgery and can instead have just a few lymph nodes removed, saving them from potential complications such as long-term arm weakness or swelling. With the development of genomic tumor testing, women can get information tailored specifically to them that can help them make informed decisions as to whether or not they would benefit from invasive treatments such as chemotherapy.

And finally, on the reconstructive side, there have been so many advances that truly improve how women look, feel, and recover after breast cancer surgery.  Most women now have the less invasive option of breast-conserving surgery, which can be combined with a number of different reconstructive techniques (“oncoplastic surgery”) that avoid future divots at the lumpectomy sites and can in some cases lift or reduce the breasts in a way that makes them look even better than before surgery.   For women having mastectomies, they can now often have nipple-sparing mastectomies, giving them the psychological and aesthetic benefit of keeping the external appearance of their breasts.  When combined with less invasive types of reconstruction such as over-the-muscle (“pre-pectoral”) implant reconstruction, women can be back to their normal lives in a matter of weeks with natural looking breasts.

For all of us who treat women with breast cancer, or have had breast cancer ourselves, we’re so fortunate to benefit from the advances of the past 30 years and to eagerly await the advances coming in the next 30.

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Pre-Pectoral Breast Reconstruction

Switching to pre-pectoral (“over-the-muscle”) breast reconstruction: how to fix chest wall hyperanimation

Up until the last few years, most women who had implant reconstruction after mastectomy typically had their implants placed under their chest wall muscles.  Now, however, we know that women can get great reconstruction results with implants placed over the chest wall and covered with a soft tissue supportive matrix such as AllodermÒ.  The benefits of this approach are more natural looking results, less chest wall pain, and most importantly, complete elimination of “hyperanimation deformity”, which is the appearance of the muscle and implant moving up with chest movement that many women with implants under the muscle experience.

For women who have hyperanimation after implant reconstruction below the muscle, here are some answers to help you think about how best to fix it:

How does switching to pre-pectoral reconstruction help with hyperanimation?

Switching the implant from under- to over-the-muscle involves freeing up the chest wall muscle from the overlying breast skin and sewing it back in place to its normal position on the chest wall.  By doing this, when the chest wall contracts, it is no longer visible because the implant and the soft tissue supportive matrix are now sitting underneath the breast skin and in front of the chest wall muscle. Studies show that 100% of women who have their implant switched to the over-the-muscle position have their hyperanimation fixed.

What is the recovery like after the surgery?

Because the new implants are placed over the muscle, women have little discomfort from the surgery and can go home the same day.  Typically drains are placed during the surgery and removed around 10 days to two weeks.  Once the drains are out, women are free to go back to most of their normal activities and can be back to full exercising by four weeks after surgery.

Is this surgery covered by insurance?

Because this is a reconstructive surgery, insurance companies are required to cover the procedure.

What are the potential downsides to switching to over-the-muscle reconstruction?

When implants are placed over the muscle, they can sometimes be more visible or easier to feel in the upper part of the breast, depending on how much soft tissue coverage women have in that area following their mastectomy.  A good way of addressing this is to do fat grafting at the time of the surgery, where fat is transferred from one part of the body (usually the abdomen or thighs) and then placed into the breast to help camouflage the edge of the implant.

To discuss if this surgery may be helpful for you, please call Dr. Peled at 415-923-3011 or e-mail at This email address is being protected from spambots. You need JavaScript enabled to view it..

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When a Breast Cancer Surgeon Gets Breast Cancer: Being on the Other Side of the Scalpel

Six weeks ago, I was diagnosed with invasive breast cancer.

 

As a breast cancer and breast plastic surgeon, I see women all the time who are in the exact same place I’ve been since receiving the phone call from the pathologist.  Shocked and terrified by the news, overwhelmed by what this is going to mean for their life in both the short- and the long-term, waiting for results from what seems like endless tests that could significantly change their treatment options. When talking about my practice, I would tell people that my goal was to provide the kind of personalized, high-touch care that I would want to have if I were in my patients’ position - I never imagined I’d actually be needing that kind of care myself, though. 

So far the journey has been, and I know will continue to be, an unpredictable course of emotional highs and lows, buoyed by great testing news one day only to be followed by an evening where I can’t stop tearing up every time I hug my three young kids.  I really never understood until now that the discussion I have with my patients about surgical choices for breast cancer in so many ways isn’t about choices at all; it’s really about picking what seems like the better of two non-ideal options for a disease you certainly didn’t choose to get and that will be a part of you in some way for the rest of your life.  

I truly believe these options can get better, that we can come up with new techniques and technologies that continue to give women great cancer outcomes but do an even better job at minimizing the impact on their previously scheduled, pre-cancer lives.  Approaches that don’t take away from their feelings of self; leave them feeling as close to “normal” as possible; allow them to maintain their jobs, family life, exercise routines, and personal relationships without compromise following surgery.   As I’ve struggled with my own surgical “choices” over the past six weeks, I know that these better options can’t come soon enough.  

As I write this, I am days away from having a lumpectomy, sentinel lymph node biopsy and oncoplastic breast reconstruction. As a surgeon, in many ways this part of my treatment feels the most predictable, as it is mostly reassuring (though also at times terrifying) to know exactly what all the steps of my procedure will be, a replica of an operation I’ve done many times.  But I’ve been struck in the past weeks by how every time I pick up the scalpel to start an operation, I have a brief moment of the recognition that I’m soon going to be on the other side of the scalpel, in an unfamiliar and vulnerable position completely in the hands of my (fortunately amazing) surgical team.  I was humbled before by all of the patients who put a similar trust in me to be their surgeon, but now truly understanding what it’s like to be entirely in someone else’s hands, especially in the midst of all of the anxiety after being diagnosed with cancer, has transformed that feeling into sheer gratitude. So as I head into my own surgery, I take that deep feeling of gratitude with me - gratitude for the women who trust me to do operations to cure their breast cancer, for the surgeons who are going to cure me of mine, for the family and friends who have shown me more love than I ever could have imagined, and for the sparkling hope I hold so strongly in my heart that we are one day going to completely transform breast cancer care.

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