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.

Myths and Misconceptions about Preserving Sensation after Mastectomy

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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

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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'

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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

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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

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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

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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

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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.

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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.?

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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

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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

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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

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Breast Cancer Advocate Reveals Why BioZorb Was Right for Her

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Dr. Anne Peled Implant Reconstruction

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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

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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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Dr. Anne Peled on ABC

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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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Dr. Anne Peled In the Columbian

Dr. Anne Peled's story has been featured in the Columbian.  Please follow the link to read the well-written article by @MarissaHarshman.  

http://www.columbian.com/news/2018/jan/22/breast-cancer-surgeon-diagnosed-with-breast-cancer-advocates-oncoplastic-surgery/

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Dr. Anne Peled on ABC

Dr. Peled's story was featured on ABC 7 in the story Bay Area surgeon views breast cancer treatment from new angle.  Watch and read the whole story here to get more information on Dr. Peled's treatment and how her recovery is progressing.

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Dr. Anne Peled in WellAndGood.com

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Anne Peled MD BreastCancer Surgery

Dr. Peled was featured in the story titled "How this one bra could make a difference for breast cancer survivors, according to a cancer surgeon", where she discussed her experiences on both sides of Breast Cancer, as a surgeon that has helped hundreds of patients and as a patient who beat Breast Cancer.  Read the article here to learn more about Dr. Peled's story and the Athleta bra.

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Dr. Peled In Medium

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Dr Anne Peled In Medium

Dr. Peled was interviewed by Yitzi Weiner for his article “I’d Love To Take A Movement Like #Ilooklikeasurgeon One Step Further” With Dr. Anne Peled for Authority magazine.

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WHAT I LEARNED FROM SURVIVING THE CANCER I TREAT AS A SURGEON

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No woman can fully comprehend how breast cancer can affect her life until she experiences it personally. As a breast cancer specialist who is also a breast cancer survivor, I can certainly attest to the gap between understanding the disease and battling it firsthand. Unfortunately, I've also found personally and in my practice that a huge repercussion of surgery — emotional and psychological trauma — is chronically overlooked.

While survival is paramount, few consider the emotional impact that accompanies the visible scarring from breast cancer treatment. Many women who undergo breast cancer surgery never fully come to terms with their physical appearance, often having daily reminders of their surgery every time they look in the mirror. The emotional trauma related to incision scars can severely impact a woman's mental health, her feelings of attractiveness and self-confidence, and sexual intimacy and relationships.

A staggering 12 percent of women in the United States will be diagnosed with breast cancer in their lifetime. Although oncologic outcomes from breast cancer treatment continue to improve, the prospect of an altered body image after surgery can be frightening, even with the cancer threat taken away.

I speak from experience, both on a professional and personal level. As a breast cancer and breast reconstruction surgeon, my goal has always been to provide guidance and education about options to help women make the best choice for themselves. I feel so grateful to get to play a role in my patient's lives as they're making these decisions, but definitely never thought I'd be considering these options for myself.

However, in December 2017, following a biopsy of a lump I'd felt on a routine self-check that hadn't gone away, I found myself completely unexpectedly in the role of a breast cancer patient after finding out the lump was invasive breast cancer.

Fortunately, I had caught the cancer early and it was Stage I. I opted for an oncoplastic surgery that would allow for cancer removal and breast reconstruction in the same surgery, so I could wake up cancer-free and also be happy with how I looked, without the daily reminder of what I'd been through.

I'm so glad I made the choice to seek out surgeons who not only cared that my cancer was treated but also how I felt about myself moving forward and the psychological impact of the surgery. Too many women who undergo breast cancer surgery live with the painful reminder of their disease their entire lives, and I so appreciated that they wanted to do everything they could to help me feel and look like myself again.

Successful breast cancer surgery should allow survivors to move past their cancer, and scars play a big role in a woman's ability to do this. Certainly, every woman is different and for some women, even very visible scars can be seen as symbols of victory and strength. But for others, they can be an obstacle, a source of shame, or a painful or disfiguring reminder of their cancer. According to one study, nearly two-thirds of women feel self-conscious about their breast cancer surgery scars, which can have a wide-reaching negative impact on many facets of their lives. I feel so grateful that my scars are well-hidden and my reconstruction was done in a way so that I don't look like I ever had cancer surgery. I know this has a huge impact on allowing me to forget most days that I even had breast cancer.

Surgeons have the responsibility to educate women with breast cancer about scar-minimizing surgery options. The safest, most cost-effective, and patient-centered approach is to thoughtfully and cosmetically place scars and offer breast reconstruction when needed or desired at the time of the initial cancer surgery. This is essential to allow women to move past being breast cancer patients and instead become breast cancer survivors.

When I got diagnosed with breast cancer, I felt so fortunate to have access to exceptional care through my professional connections and the help of my family- my mom, dad, and sister are all breast cancer medical and radiation oncologists. One of the best memories from after my diagnosis was the day I got testing back that showed my cancer was low risk and I wouldn't need chemotherapy: my parents were visiting and I knew when we celebrated with champagne that they truly felt the same relief that I did.

As a physician who does breast cancer and breast reconstruction surgery and research, I was very aware of all my treatment options. But many patients aren't as lucky: one in three survivors say they didn't know about all the surgical options available or even what to expect in terms of scars or breast appearance after surgery, which really limits a woman's ability to feel good about her treatment choice. Recent advances in breast cancer surgery mean that women can have lumpectomies or mastectomies through hidden scars and reconstruction of the cancer site at the same time, which allows them to look the same or sometimes better than they did before surgery.

Dr. Anne Peled is a board-certified plastic surgeon in California who specializes in breast, reconstructive, reduction, and cosmetic surgery. She is uniquely trained as both a plastic surgeon and a breast surgeon and is recognized as a Hidden Scar trained surgeon.

The views expressed in this article are the author's own.​​​​​

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#TeamPeled Study on Sensation Preservation after Mastectomy and Implant Reconstruction Published in “Plastic and Reconstructive Surgery – Global Open”

unnamed #TeamPeled Study on Sensation Preservation after Mastectomy and Implant Reconstruction Published in “Plastic and Reconstructive Surgery – Global Open”

 

We are excited to have the results from our combined work on nerve grafting and preservation at the time of nipple-sparing mastectomy and implant reconstruction published in the open access arm of the largest international plastic surgery journal. The study describes our combined work to improve sensation for women who go through mastectomies and implant reconstruction for breast cancer or breast cancer risk-reduction. While other plastic surgeons have previously published studies looking at nerve grafting for breast reconstruction sensation with free flaps using women’s abdominal tissue for reconstruction, this is the first published study doing nerve grafting for women having implant reconstruction. This is important because many women either are not good candidates for flap reconstruction or would prefer not to have the additional recovery and surgical site required for flap reconstruction. Additionally, not all reconstructive surgeons routinely perform flap reconstruction, and thus the vast majority of women who have breast reconstruction have implants used.

Our study included both women having nipple-sparing mastectomies for cancer treatment and women having prophylactic mastectomies for genetic mutations or strong family history. We found that with carefully preserving breast skin nerves and doing nerve grafting to the nipples, most of the women in our study had close to complete return of breast skin sensation and feeling in their nipples after surgery.

To Read Full Article Click Here

For more information on this novel procedure, please contact our office at:
TEL: 1-415-923-3011
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

ANNEPELEDMD.COM

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Considering a breast reduction?

breast-reduction Considering a breast reduction?

 

A breast reduction, also known as a reduction mammaplasty, is a surgery where breast tissue and skin are removed to reduce the size of the breasts while also re-shaping and lifting them. This surgery can not only help to alleviate some of the symptoms associated with large breasts such as back, neck, and breast pain, but also lead to a more youthful looking breast shape and size. •

Most women who seek a breast reduction usually have a few things in common. The following issues are often described by women who might benefit from breast reduction surgery:   

        • You feel as if your breasts are too large or disproportional to your body frame 

  • • Your breasts are heavy and pendulous and your areola and/or nipples point downwards or seem much lower on your chest than you would like

  • • You have disproportionate breast sizes, where one breast is much larger than the other breast

  • • You have neck, back, upper shoulder, or breast pain secondary to your large or heavy breasts

  • • You have chronic skin infections/irritation to the skin underneath your breasts

  • • You find it difficult to exercise due to your large breast size (or feel the need to wear multiple sports bras to give you the support while exercising) or have trouble finding clothes or bras that fit you

If these symptoms resonate with you, the first step in seeing if you are a good candidate would be to either discuss this with your primary care provider or find a board-certified plastic surgeon in your area and set up a consultation.  At that visit, your plastic surgeon will determine if it would be safe and appropriate to recommend a breast reduction for you.  If it is, your plastic surgeon will then send your consultation note documenting how much breast tissue he/she thinks would be removed during your surgery to get you to the size you'd like to be and clinical photographs to your insurance company for insurance authorization. For the most part, when women have significant disruptions in activities of daily living as a result of their large and heavy breasts, insurance companies will cover this surgery, though every company is different.

Once you have decided to proceed with breast reduction surgery, your surgeon will discuss the best options for you in terms of incision and technique for the surgery. We like to show patients 3D simulations of what they might look like after a breast reduction using their own photographs, which helps women have a clear sense of what their goals are.

The surgery itself typically takes from three to four hours, is done under general anesthesia (where you are put to sleep with medicine) and it is almost always outpatient surgery (meaning that you get to go home the same day of your surgery). Women tend to do very well after this surgery and may be uncomfortable for the first 24-48 hours, but usually have good pain control with ibuprofen and potentially some stronger pain medication for breakthrough pain if needed in the first week or so.

Recovery after the surgery varies on a multitude of factors, but in general, one week off work or school is expected. Your surgeon will likely have you wear a sports bra for quite some time before transitioning to a regular bra (without underwire for the first three to six months). It is normal to feel like your breasts are heavy and tight – this is from swelling; however, it may take several months for your breasts to settle in and complete healing takes about one year. Most women feel like they can return to normal life activities within two weeks after surgery and are back to full exercise by 4 to 6 weeks.

 

Breast reduction surgery can be truly life-changing for many women, which is why it’s one of our favorite surgeries to offer! Please contact our office with any additional questions to help decide if breast reduction surgery could be helpful for you.

To Learn More Visit http://www.annepeledmd.com/

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Breast surgeon becomes breast cancer survivor

bc Breast surgeon becomes breast cancer survivor

In a touching interview, breast surgeon Dr. Anne Peled opens about her personal experience as a breast cancer survivor

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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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Outcomes Utilizing Inspira Implants in Primary Aesthetic and Reconstructive Surgery

Outcomes Utilizing Inspira Implants in Primary Aesthetic and Reconstructive Surgery

I recently had an article published in Plastic and Reconstructive Surgery  about using silicone implants for breast reconstruction and breast augmentation.  One of my favorite parts about being a plastic surgeon is getting to use and learn about new technology, which is why I was excited to talk about the latest advances in silicone breast implants for this article. With the most recent generation of silicone implants (“gummy” implants), the silicone is more cohesive, which means that the silicone stays together better, with less concern that the silicone will rupture and potentially spread. It also means that they hold their shape and projection better when placed in the breast, which is particularly important for breast reconstruction when the breast tissue is no longer there to provide shape. One misconception about “gummy” implants is that they are very firm, but actually they can feel fairly soft and natural in the body, even with the increased “gumminess”! 

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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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