Dr. Lisa Cassileth of Beverly Hills is committed to making the process of reconstruction following breast cancer surgery just a little less traumatic, painful and drawn out. The board-certified plastic surgeon has created the Cassileth One-Stage Breast Reconstruction technique, whereby she reconstructs breasts at the time of mastectomy in one single surgery. This approach significantly cuts down on recovery time, risk, pain and mental anguish, and is particularly appreciated by woman undergoing elective mastectomy due to the BRCA gene. The innovative technique was recently published in the August 2012 Annals of Plastic Surgery. Traditional reconstruction requires months of using tissue expanders to stretch the chest muscles to make room for breast implants. With the one-step approach, women wake up from their mastectomy with intact breasts and minimal or no scarring.
Who is a candidate for one-stage breast reconstruction?
Almost every breast cancer patient, including those who are BRCA positive, is a candidate for one-stage breast reconstruction. It makes it particularly easy to give a patient new breasts that are similar in size, shape, and position to her existing breasts. And if you want your breasts to be a bit bigger or a little smaller than they were, then that also can be achieved in one-stage. One-stage breast reconstruction requires a skin-sparing or nipple-sparing mastectomy, so patients who have cancer that involves the skin would not be good candidates, as some of the existing breast skin will be removed during the mastectomy. For that kind of patient, tissue expanders can be used, so that breast implants can be placed later.
How is it that you can avoid using tissue expanders for this surgery?
Many breast surgeons remove breast skin during the mastectomy. The point of tissue expanders is to stretch the remaining skin to give coverage to the new breast implants, which are inserted in a second surgery later. With one-stage breast reconstruction, the mastectomy surgeon does not remove any skin—this is called a skin-sparing or nipple-sparing mastectomy. The skin is still there; only the breast tissue is removed, leaving full coverage available for the breast implants.
What sort of medical team do you work with to perform one-stage breast reconstruction? Do you perform mastectomies?
The most critical partner is the surgical oncologist, who will perform the mastectomy. The surgical oncologist should be a specialist in breast cancer. She or he must be able to safely excise the breast tissue and perform a skin-sparing mastectomy, all through a small incision in order to set the stage for the plastic surgeon to provide the best possible final results.
If a patient needs radiation and/or chemotherapy after surgery, can they still have one-stage breast reconstruction?
Many of my patients require chemotherapy after surgery, and it is typically not a problem. As with any breast surgery, you can’t start the chemotherapy until you are fully healed. Radiation treatment can be a problem with both tissue expanders and breast implants. The problem is not that the implant or the tissue expander is radiated, the problem is that the tissue itself gets radiated. Tissue, when radiated, will become fibrotic, meaning it forms excess, fibrous connective tissue, which can cause something called capsular contracture. This is the formation of tough scar tissue around an implant, which can occur after radiation with either a tissue expander or implant.
In my vast experience with one-stage reconstruction, I have found that one-stage patients who receive radiation treatment actually do better than those who have radiation after tissue expander placement. Expanding the tissue after radiation can cause an inflammatory process and increase the chances of capsular contracture. There are some tricks I use to help alleviate this problem—fat grafting with stem cells to allow for the tissue to heal, for example.
The acellular dermal matrix I use to create an internal bra during one-stage breast reconstruction also appears to have some protective effect. Surgeons are finding this to be the case more and more, and are beginning to use it more frequently, even with tissue expander reconstruction, and even to treat capsular contracture in cosmetic breast augmentation patients.
So this protection against some of the effects of radiation has been a nice side benefit of one-stage, and I have no hesitation to perform one-stage on patients who will receive radiation in most cases.
What are the three questions a patient should always ask before breast reconstruction?
Let me give some overall advice first: be vain. Of course, most patients are focused on their very survival when they come to their breast reconstruction consultation. They are fearful and worried. They don’t want to admit to being concerned about the way they will look.
I tell my patients to choose this moment to be as vain as they possibly can. Just because a woman has breast cancer does not mean that she should not demand the results she desires for her breast reconstruction. She must at this moment assume that her oncologist and oncologic surgeon will banish her cancer, so she can turn her attention to what will be her body’s appearance for the rest of her life.
Here are the three questions I would recommend asking:
- What type of breast reconstruction do you recommend for me? Is one-stage an option? Have you done this type of reconstruction before and where are the results? Will I be able to get the breast size, shape, and position I want with this procedure?
- What is the risk of mastectomy necrosis? (This is death of skin, nipple, or areola tissue following a mastectomy.) How have you handled that in the past?
- How many revisions do you generally need to perform after this type of surgery? Do you think I will need any?
In addition to breast reconstruction, what other plastic surgery procedures do you specialize in?
I specialize mainly in breast procedures: revision of breast reconstruction, revision of breast augmentation, removal of implants, and correction of asymmetry, to name a few. The cosmetic breast procedures that I do are an advantage to my work in reconstruction and vice versa, because I am always pushing to get the best cosmetic results safely. Because I specialize in both cosmetic and reconstructive surgery, the range of my tools—techniques that I have learned, honed, and developed—is much broader.