To dispel the first and most common misunderstanding, the nipple/areola is not removed.  Although the incision scars give this impression.  The fact is that the nipple areolar complex remains attached to the “pedicle” or the breast tissue remaining after everything else has been removed.  The most common method of breast reduction has been the “inferior pedicle” technique.  This means that the breast tissue is removed from the lateral, superior and medial aspects of the breast.  Or if one thinks about it as a clock, from about 7:00 to 5:00.  The remaining pedicle is the tissue between 5:00 and 7:00 up to the center of the clock.  This center is where the nipple areolar complex is.

There are a few issues I take with this technique.  First, the blood supply is limited so large reductions cannot be done.  Second, it removes the breast tissue in the upper part, or superior pole, of the breast which can lead to a flattened area between the collar bone and the nipple.  And finally a breast reduction also lifts the breast but this technique tries to push the breast up.  Since breast tissue is like gelatin that doesn’t work that well.  Don’t get me wrong.  Most surgeons use this technique and get good outcomes but I think there is a better technique.

I prefer a “superomedial” pedicle technique.  Although this was first introduced in the 1950′s it never caught on for unknown reasons.  However, around 10 years ago Dr. Elizabeth Hall-Findlay, of Canada, reintroduced the technique.  In this technique the breast tissue that is removed is the breast tissue that bothers women.  The tissue is removed from about the 4:00 position, around the bottom of the breast to the 11:00 position.

I think this is a better technique for several reasons.  First, as I said the tissue that bothers women with large breasts the most is removed.  Second, the pedicle or remaining breast tissue has fantastic blood supply so even the largest reduction is possible.  And finally the breast is supported from above like a suspension bridge-which works well for breast tissue.

So if you’re looking for a better breast reduction in the Washington DC area, call my assistant Katie to schedule your consultation.

Basically all cancers, whether breast, brain or blood, start when a single cell’s DNA gets a mutation or is damaged.  This means that a normal gene, that produces a protein that goes on to provide a certain function, becomes abnormal.  This abnormal gene produces an abnormal protein.  Now our cells are really smart and there are other proteins that detect abnormal genes and remove them or even signal for the entire cell to be destroyed.  However, it’s often these removing genes, known as tumor suppressor genes,  that are abnormal.  This prevents the cell from removing the other abnormal genes or proteins.  When the cell divides the abnormal gene is passed on to the next cell.  Both cells divide again passing along the abnormal gene and so on and so on.  This is very basic so all you molecular biologists just relax.

The problem is that it’s usually not the same abnormal gene in each patient.  So although the end result may be the same, e.g. invasive breast cancer, the starting point is different.  Some cancers have virtually the same starting point.  This is the premise behind “silver bullet” research.  These therapies aim to exactly target the cells with the abnormal protein while leaving all other cells alone.  This is the goal of all researchers for all diseases-find the “silver bullet.”

What Lance Liotta and Emanuel Petricoin are doing at George Mason University is unique.  They are determining what the initial abnormal protein is for each patient with metastatic breast cancer.  Then they will figure out which of the many drug therapies best attacks those specific cells.  It’s analogous to using a smart bomb vs carpet bombing.  Although, in theory, there will still be some collateral damage it will be significantly less if all works as suspected.

What really struck me with this research is that Liotta and Petricoin get “it.”  They understand that we need to continue the fight even when the cancer is metastatic.  In fact, we need to step up our attack on the disease.  So often metastatic cancer patients are written off for dead.  Why?  Just remember, Lance Armstrong was a metastatic cancer patient.  By all rights he shouldn’t even be alive.  And yet not only did he survive but went on to win the Tour de France 7 times!!  And why did he survive?  It was the research behind the treatment that made things possible.

We’ll continue to track the progress of Liotta and Petricoin and let you know how their study goes.  Let’s keep our fingers crossed.

As I’ve said, I’m the youngest of four.  The “baby” of the family is the end of reproductive life of the mother.  So my theory is that the youngest gets spoiled because the mother sees this and wants to hold onto her vitality.  No matter what the reason I was the envy/irritation of my siblings – a true “black sheep.”

There are four years between each of my siblings, except for my sister and me — there’s 13 months.  Dad never wanted two children in college at the same time.  Remember I told you he was an engineer (very logical people).  I was unplanned, yes, but often the best things are.  (The great thing about having a blog is that you can stroke your own ego).   According to Dalton Conley, author of ‘The Pecking Order: Which Siblings Succeed and Why, the youngest tends to be the most creative and can be very charming (I like this) — even manipulative (not so much).

Famous youngests include:  Cameron Diaz, Jim Carrey, Drew Carey, Rosie O’Donnell, Eddie Murphy and Billy Crystal so I’m in good company (well maybe except for Rosie).  Whether you are the youngest or know one, you can probably appreciate the pervasive power the youngest child possesses.

Like most boys I hated school.  So I really enjoyed anything but school.  I was always the “busy” child.  My grandmother on my mother’s side disliked me immensely because of this.  (No shock to any one who read the last post.)  I  did the usual things: baseball (which I wasn’t good at),  soccer (the same) and scouting (where I did actually get my Eagle Scout).  But mostly it was the theater that I loved.  I doubt I was any good at it but it was my mother’s main interest as well so I kept doing it.   This connected us during my childhood.  It’s interesting because the first play I ever did was the Princess and the Frog which is in theaters as a movie now.   By the time I turned 16, I had performed in numerous plays and musicals even a paid part at a dinner theater.  So as a junior in high school, I had to decide on my future.

Academics was definitely not my forte (just what you want to hear your surgeon say); more on this later.  I grew up in a lower-mid/middle class town, in Delaware, that was forever carried by a steel company that died a slow painful death and took the town with it.   The high school system reflected this.  In addition, the state decided that busing suburban kids into the worst schools of Wilmington, DE and vice versa would create racial harmony, but it actually created racial riots and a lousy school system.  Forcing love-of-thy neighbor never works.  So although I gleaned from my father that college was a necessity, it wasn’t for me and fortunately mom and dad supported my desire to do New York theater…

Man this one was boring, wasn’t it?  Now it gets interesting.

—-

Catch up with Part 1 and Part 2

In the mid-1960′s the modified radical mastectomy came into existence. This surgery involved removal of everything that the radial mastectomy did except the pectoralis major muscle.  As minimal as it may seem this was a huge surgical advance and allowed for much better reconstructive possibilities.  This surgery was the standard of care well into the 1990′s.  But in the late 70′s and 80′s innovative surgeons introduced the skin-sparing mastectomy that removed the nipple areola complex and used a much smaller incision.

Finally, in the mid-1980′s the nipple sparing mastectomy was introduced.  However, as with many procedures the indications for its use had to be determined and therefore it was not widely used.  Finally we have understanding and indications for its use.

The nipple sparing mastectomy is the greatest advance in breast cancer surgery.  We have gone from removing everything associated with the breast and chest wall to only the breast tissue.  This leaves the nipple areola complex, an excellent breast skin envelope and all of the muscles of the chest wall.   In addition it may or may not be combined with a sentinel lymph node dissection.   The incision for the nipple sparing mastectomy can be as short as 6cm, hidden in the inferolateral inframammary fold or breast crease (see the picture).  This incision is only one centimeter longer than an incision used for a primary silicone breast augmentation!  With this surgery an immediate breast reconstruction may be done with an acellular dermal matrix and tissue expander or permanent breast implant.  I do not use a permanent breast implant in this setting because the final result will never be as good as a two-stage procedure using an expander first followed several months later by exchange to the permanent implant.

So why don’t we always do this fantastic surgery?  The reason is tied to anatomy.  Invasive ductal breast cancer means that the cancer has started in the milk duct of the breast and has spread through the duct into the surrounding tissue.  All ducts are connected to the nipple so theoretically there could be cancer cells in the nipple.  Remember this is only theory.  Therefore current dictum (and lack of tort reform) states that all of the breast tissue and the nipple areolar complex should be removed to remove any possibility of recurrence.  Therefore the current indications for nipple sparing mastectomy are really limited to DCIS (ductal carcinoma in situ), prophylactic mastectomy or non-cancerous breast disease.  DCIS is cancer that has not mutated enough to become invasive through the milk duct wall.  Given time it will.

Ten years ago DCIS was not considered cancer, but since we now know that if given time it becomes invasive cancer, then by definition it must be cancer (just not invasive).  Other researchers and surgeons believe that the nipple sparing mastectomy should be considered even for patients with invasive cancers of less then 2cm in size, located at least 2.5cm from the areola (see indications).  While this remains to be determined what is important is that we have outstanding surgeons like Dr. Virginia Chiantella, of Reston VA that are on the forefront of breast cancer surgery.  Few surgeons can perform a thorough and complete mastectomy through such a small incision.  It is this level of understanding, skill and caring that allows plastic surgeons like me to give patients, like our 31 year old, breasts that are imperceptible from normal breasts.

Just to clarify, young women typically have very dense breast tissue.  This is why mammograms aren’t done in younger women; it’s very difficult to see any pathology or disease through the dense tissue.  If there are any concerns, an ultrasound is the first test performed.

The ultrasound was performed and read by a radiologist as normal.  Fortunately, this radiology group uses two radiologists as a sort of checks and balances system.  The second radiologist, either due to experience or intuition, suggested that the patient get a mammogram for clarification.  The mammogram confirmed the doctor’s suspicions, something irregular, was there. Our patient was then referred to a breast surgeon, Dr. Virginia Chiantella.  Dr. Chiantella (can-tell-a) is well-trained and performs outstanding breast surgery.

Now just take a minute.  Think about the whirl-wind that this woman was undergoing.  She was living a normal, happy, suburban life one day and in a very short period of time she’s going to see a surgeon for a potential cancer.

Just take a moment and put yourself in that position.

There aren’t enough adjectives to describe the feelings that would go through your mind and body.  But our patient is tough. Tough, like so many other women in this situation, because she has to be-children don’t understand when mom is sick.  And the thought of your own children having to grow up without you will drive any parent to do what is necessary.

Dr. Virginia Chiantella MD FACS, is incredibly talented, smart and caring.  She performed a needle biopsy on our patient.  This involves using a needle to take an actual piece of breast tissue.  The pathologist determined that the this tissue contained cancer, DCIS (Ductal Carcinoma In-Situ).  Now when I was a resident physician DCIS wasn’t considered “cancer” but over the course of time and multiple studies we know that this is the first stage of invasive breast cancer.  In addition, because of her young age and an extensive family history of breast cancer, gene testing was suggested.

Gene testing looks for damaged BRCA 1 and BRCA 2 genes.  These genes are in the class of tumor suppressor genes.  What they do is produce proteins that go out and repair DNA that has been damaged.  Like a power company fixing a power line-they either repair it or replace it. Damaged DNA, if not fixed or removed, will proliferate as the cell it is contained in multiplies.  There are lots of these gene in our DNA that protect us from cancer and other diseases.  The problem is that these genes, like any gene, can become damaged and not able to perform their duties.  When this happens cancer occurs.  When these damaged genes are present they can increase the possibility of breast cancer as well as other cancers AND be passed onto offspring in their damaged state.  Our patient got tested and her results indicated….

Mom grew up the daughter of a teacher/homemaker and an industrial engineer whose specialty was time management.  My grandparents were cold Germanics who ran their lives to the second and raised children to be the same.  My mother went to Syracuse University for fine arts (it was this or Home Ec. believe it or not).  She and my dad started dating in high school and got married immediately after graduation.  Ah, life in the 50′s.

My parents “wedding” story explains a lot.  Mom and dad decided to elope.   My guess is that dad had no money, mom and grandma would have killed each other and they were born in the depression so my grandfather wouldn’t pay for something that had no return on investment.  So mom and dad were driving to the courthouse and stopped at a red light.  My mother turned to my father and said, “You never asked me to marry you!”  Dad said, “Will you marry me?”  Mom replied “Yes. Light’s green.”  Do you feel the love?

During my childhood my mother and I had a close relationship which was fostered by my participation in theater (she also did a lot of community theater).  As early as age seven or eight mom had me trying out for small parts in various community theater productions.  Now don’t misunderstand this, my mother was no “stage mother.”   She was simply finding me an activity that I enjoyed and would keep me occupied for a few hours a week, I think.  And I enjoyed performing eventually getting paid parts.  But mom has a strong narcissistic personality trait that leaves little room for anyone else.

Our relationship was very good until… can you guess?  Anyone?  Yes, I got married.  Apparently this did not fit into mom’s vision for me?  Who knows, but what I do know is that the criticisms and complaints began in earnest and haven’t ceased.  But I will give credit where credit is due.  When my ballet career (yes you’ll hear of this later) was ended in a severe accident my mother, with her infinite wisdom said, “You never finish anything.”  Ah, okay?!  Yes, she saw the end of her vicarious life but that statement has driven me in every endeavor since.

I don’t begrudge my mother; she’s a product of her upbringing.  People can change if they choose to; as I have.  My father has worked very hard to show that he cares about my family, especially my children, and all of his children.  We all have that person in our lives that we hope will change.  Never give up on them.  You never know when change may come.

Many physicians take great care to never discuss their personal lives with patients.  And while it’s true that there must always be a professional doctor-patient relationship that doesn’t mean that we physicians can’t be human and interact with patients on a more personal level at times; I love swapping stories about children with my patients.  This is especially important with cosmetic patients.

As many of you know, my approach to patients is first educating them on the available options then working together to create the ultimate aesthetic outcome.  As part of this process, I like to know who the patient really is.  And I’ve found that without a more personal understanding of my patient it’s more challenging to determine exactly who they are and what they desire.  But maybe it should be a two-way street.  My webwife, Eva, and I were talking and we thought that maybe we should level the playing field and let my patients know who I am.  Well here goes.  If you have insomnia you can thank me later.

I was born a poor….

Okay, sorry for the only Steve Martin line, I know.

I am “the baby” of my family (this explains a lot, you’ll see).  My father, a retired chemical engineer from the oil industry has been married to my mother, a graduate of Syracuse University in fine art (remember this later), for 50-something years, God help them both.  They have four children all but one in engineering or business.

Then there’s me – the one.  The baby of the family is well known to be extroverted, spoiled, the entertainer, type A, blah, blah blah.  Is that me? Okay, ya got me.  But I’m only a product of my upbringing and I suspect a mother who was living somewhat vicariously through me.

I honestly think my mother wanted fame and fortune but she married the wrong guy for that.  My father is a very smart, hard working, minimally exciting only child who was the first in his family to go to college.  My grandfather died when my dad was only 18 so with a very small loan (interest bearing) from my grandmother and the work-study engineering program at Drexel University dad made it happen.

But I have to give my parents huge credit because they’ve lived through things I never had too.  My father’s first job in 1956 paid $100/month.  Their rent was $80/month.  Anyone who can stretch $20/month with a newborn is pretty impressive.

Of course, the apartment they lived in was more likely on the condemned list than Better Homes and Gardens.  In fact, things were so bad that my father would put the legs of my brother’s crib in cans and fill the cans with kerosene just to keep the cockroaches out of the crib.  Yeah, I get the willies just thinking about it too.   But my parents were industrious and really exemplify the saying “you make your own success.”

Still awake?  It’s later.

Then there’s my mother….

For instance one patient went in for a lower eyelid lift and ended up with extensive scars across her temples.  Another paid for liposuction of one area yet the liposuction was performed on other areas as well with devastating results.  My colleague also recounted several patients he had seen with similar tales.  And we came to the same question – how can they get away with it?

The idea of the informed consent came about because of this exact thing.  Years ago surgeons were viewed as authoritarians so patients asked few questions and accepted whatever was performed.  The problem was that patients weren’t always emotionally ready for the outcome.  But times have changed and medicine as evolved.  Today there are basic rules for informed consent that center around explaining the risks and benefits of each procedure.  But for me and the 99% of other conscientious surgeons this only forms the basics of consent.

My approach to each and every patient is education.  This means describing in complete detail the procedure to be performed, from incision to closure.  Every reasonable risk and complication is spelled out in a bound booklet.  So my patients aren’t surprised after surgery.  This isn’t to say there are “gray” areas.  For me these “gray” areas consist of things like: slightly more dissection or a few more stitches needed to get the surgery perfect.  This is opposed to these arrogant surgeons who feel they can do whatever they want, for what ever purpose.  Perhaps they realize during surgery that what they planned wasn’t right, extensive enough or what they thought the outcome would be.  Whatever the reason it’s wrong to perform surgery, in a non-emergent or urgent way, without the consent of the patient or family!

As surgeons we have an obligation to educate our patients so they understand, well, what to expect.   Unexpected things can and do happen during surgery but these should still be within the realm of the planned surgery.   I pride myself on being forthcoming and the surgeon you choose should as well.

The leading theories for implant rupture include….

1. Aging of the implant elastomer shell
2. Excessive handling or stressing the implant during surgery
3. Excessive stress on the implant due to trauma or intense physical activity
4. Over filling or under filling of the implants.

The underlying result of all these theories is damage to the silicone elastomer shell resulting in microscopic fractures or areas of weakness leading to failure.  So the question is, do you really know when the implant will fail?  Unfortunately it might be within 5 years of placement or never.

So what happens when a breast implant fails?

If a saline breast implant fails it’s usually pretty obvious.  If the implant develops a catastrophic failure then the implant will fail like a tire blow out.  And it’s inevitable that this will occur when you’re getting ready to go out for a dinner party or the like.  Occasionally the implant will develop a small leak that is only obvious after it has been leaking for several days and the volume decreases enough to appreciate.  In either case it’s important to make an appointment with your plastic surgeon as soon as possible to avoid having to wear extra padding in the bra.

If a silicone breast implant ruptures you’ll never know it.  The reason is that the capsule that develops around the breast implant will contain the silicone gel.  In the older style implants some of the silicone oils could migrate through this capsule.  However, silicone is inert and this oil did not result in any disease or disorder (contrary to popular claims made by the media).  Today the cohesive gel implants that we use have silicone that does not migrate and thus are even safer than the previous implants.  And if you have any concerns, the “gummy bear” implant should ease your mind.

If the saline breast implants rupture, then the breast implant repair process is simple.   The old implants are removed and new implants of equal size are inserted.  The surgery should be performed within a few weeks of rupture to prevent contracture of the pocket.  If a breast lift or other procedure is necessary, that can be discussed with your surgeon.  If a silicone breast implant ruptures it’s a sticky, gooey mess.  The capsule and implant should be removed together if possible, but that is often impossible and removal of the old silicone can become tedious.  Once all of the silicone gel is removed the new implants – silicone or saline -  can be put in place.

While it may be stressful, don’t worry when your implant ruptures.  There’s time to correct the situation and return your breasts to their previous state.  Call Dr. Hess at 703.752.6608 and he’ll help you regain the appearance you desire.

This series was put together so that perhaps more patients and surgeons will appreciate the numerous areas that must to be considered before choosing the correct breast implants.   Determining the correct implant must be a collaborative effort between patient and physician.  Use your surgeon as a guide. Use his or her knowledge, sizers, and experience – but trust the knowledge you have and your own personal desires to make decisions.