Breasts: Normal, Medically Worrisome and Things to be Corrected

Breasts come in all shapes and sizes and there is infinite variety in the human experience. Beyond their physiological function of providing nourishment for babies, however, breasts occupy a unique place in the cultural ether and many women wonder and worry about whether or not they deviate from ‘normal’. “Unfortunately, we are often bombarded by an air-brushed, unrealistic image of what constitutes the normal breast”, says Dr. Constance M. Chen, plastic surgeon and breast reconstructive specialist. “Even as young women mature and become comfortable with their own unique physical characteristics, there are any number of variations that may trigger questions about what is normal, what is medically worrisome, and what can be ‘corrected”.

There is no normal breast size or shape. Nor is there a normal nipple size or color. Nipples and the areolae that surrounds them might be large or small, pale or dark, might match skin tone or might not. Small bumps on the areola are lubricating glands and are completely normal. “Chances are that whatever is causing concern is a completely normal variation”, says Dr. Chen. “Here are some common variations in normal breasts along with recommendations on when to see a doctor”.

Breasts that don’t match: Very few women have perfectly symmetrical breasts. One breast may be larger, shaped differently, or positioned differently than the other. Differences in size up to 20% are normal and are particularly common in teenagers whose breasts may develop at different rates. Hormonal changes associated with ovulation, pregnancy, and breastfeeding that cause changes in breast size may also cause asymmetry. Breasts that differ by more than a cup size and asymmetry unrelated to pregnancy that develop suddenly overnight, however, should be evaluated by a doctor to rule out a medical problem.

Hair on or around the nipples: “Human beings have hair all over their bodies”, says Dr. Chen. “Sometimes human hair is thin and clear and sometimes it’s thicker and darker. It is quite common for women to have darker visible hair around their nipples”. A few hairs is nothing to worry about but denser growth might be indicative of a hormonal imbalance or other issue. The best way to avoid infection when removing hair around the nipples is with small scissors.

Inverted nipples lie flat against the areola or turn inward instead of protruding. They occur in either one or both breasts and may be present from birth or develop later in life. “As many as 10% of women may have one or both nipples inverted”, says Dr. Chen. “They are not generally a cause for concern and require treatment only if they interfere with breastfeeding, if there is an underlying medical condition that must be addressed, or to satisfy aesthetic preferences”. There are several treatment options for inverted nipples, most of them temporary; surgery is the only permanent treatment. Sudden changes, however, may indicate problems that should be evaluated by a physician.

An extra nipple, also called a supernumerary nipple, occurs in 3-5% of people, both men and women, and seldom needs to be removed for any but cosmetic reasons. It may go undetected, mistaken for a mole, and if it occurs alone, it can be removed in a simple procedure much like removing a mole. If it occurs with underlying breast tissue, it should be monitored for changes as the breasts are and removal is much like a mastectomy.

“While these variations are mostly common and benign, there are changes in the breasts that do require examination”, says Dr. Chen. “While being conscientious about regular mammograms and self-exams checking for lumps, women should also be alert to anything out of the ordinary that persists beyond a menstrual cycle. In particular, there are indications that require medical evaluation”.

• Discharge from the nipples: Fluid can commonly be expressed from the nipples of pre-menopausal women, particularly those who have given birth or nursed a baby in the last year or two, but spontaneous discharge, particularly if bloody or yellow, should prompt a visit to a doctor.
• Skin changes: The skin on the breasts can be affected by common skin conditions like eczema and psoriasis, and from irritation by clothing or other contact, but some skin changes might have a more serious cause. These include ulceration, scaliness, crusting, dimpling, and redness that is not from an identifiable source.
• Nipple inversion that occurs suddenly in an adult could be a sign of trouble.

Dr. Chen reminds us that the soft tissue that we think of as a breast is actually a mammary gland, a complex system of fat cells and ducts that produce milk and deliver it to a nursing infant via the nipple. “Breasts are remarkable”, she says. “They fulfill vital functions, undergo changes at different times in a woman’s life, and are as variable as every other part of the human anatomy. Most of these variations are completely normal but any woman with a question shouldn’t hesitate to discuss her concerns with her doctor”.

About Dr. Constance M. Chen

Constance M. Chen, MD, is a board-certified plastic surgeon in New York City with special expertise in the use of innovative natural techniques to optimize medical and cosmetic outcomes for women undergoing breast reconstruction. She is Clinical Assistant Professor of Surgery (Plastic Surgery) at Weill Cornell Medical College and Clinical Assistant Professor of Surgery (Plastic Surgery) at Tulane University School of Medicine.

Dr. Chen is frequently invited to lecture nationally and internationally on new advancements in breast reconstruction and the surgical treatment of lymphedema. She is the author of three books, five book chapters, and fifty journal articles. She has also won numerous awards for her work in plastic and reconstructive surgery at the local, regional, and national levels.

Dr. Chen has developed a reputation in the community for the personalized attention that she devotes to her patients. She is committed to aesthetic restoration of the breast and body, and enjoys helping her patients achieve overall well-being. At the end of the day, there is nothing more important to her than the joy she hopes to bring to her patients’ lives. Come into the beautiful world of Dr. Constance M. Chen.

Board-Certified Plastic Surgeon Dr. Constance M Chen on Why Breast Implants are Removed

Over 400,000 women in the United States receive breast implants each year. Three quarters receive breast implants for cosmetic breast augmentation, while the other one quarter receive breast implants to reconstruct a breast lost to cancer. According to the implant manufacturers, about 50% of women with breast implants undergo another surgery to revise, replace, or remove their breast implants within 7 years. Since breast implant problems are common, on October 27, 2021, FDA strengthened breast implant risk communication to help those considering breast implants make informed decisions.

According to the implant manufacturers, about 50% of women with breast implants undergo another surgery to revise, replace, or remove their breast implants within 7 years.

For starters, the FDA now requires a black box warning on all breast implants to let people know that they are not considered lifetime devices and carry risks. In addition, patients are required by law to initial and sign an extensive patient decision checklist that outlines many potential risks and complications, including Breast Implant Illness and Breast Implant Associated Anaplastic Large Cell Lymphoma. There are also updated silicone gel-filled breast implant screening recommendations, device descriptions with a list of specific materials used to make breast implants, and a patient device card. Finally, the FDA released updated information on the status of breast implant manufacturer post-approval studies.

Board-certified plastic surgeon and breast reconstruction specialist Dr. Constance M. Chen comments that there are many medical and cosmetic reasons that women have implants removed. “In some cases the implants basically fail and must be removed for the health of the woman. In other cases, women realize that they don’t have to live with implants that are not comfortable for them. For example, women with cosmetic breast implants sometimes reach a new stage in their lives in which they no longer feel that breast implants fit their lifestyle anymore.”

Breast implants don’t last forever

Implants aren’t expected to last forever. Most implants have a ten-year warranty although many are removed before the warranty period is over. The risks only increase with time.

Implants are foreign material, and as such, they elicit a natural response in which the body creates a barrier of scar tissue around the implant to wall it off and protect any foreign substance from penetrating other parts of the body. In some cases this barrier, or capsule, is soft, flimsy and not noticeable. In other cases the scar tissue around the implant can become hard and painful. This uncomfortable condition, known as capsular contracture, is among the most common reasons for implant removal. Other common problems include rupture, where the saline solution or silicone gel that fills the implant leaks into the surrounding tissues; infection, caused by bacteria becoming rooted in the implant; and rippling, in which the skin over the implant appears irregular.

What’s in ‘vogue’ changes

The allure of the full-breasted figure of the 1950s has given way today to a more natural, athletic and healthy look. Some women find that large, augmented breasts are heavy and unwieldy to manage. “In some cases, women who are unhappy with their implants have them replaced with smaller implants,” says Dr. Chen, “and others revert to their own natural breasts. The aesthetic outcome depends on several factors, including how long the implants were in place. Sometimes a breast lift (or mastoplexy) or fat-grafting procedure may be needed to create attractive breasts”.

In addition to facing medical complications, some women find that their implants look distorted and unnatural, feel hard and uncomfortable, or that they’ve lost all sensation in the breast. “In some cases, the solution is to remove the implant and the entire surrounding capsule and to repair the muscle and skin around it,” says Dr. Chen. “Thankfully, there are ways for women to address problems with breast implants whether it is discomfort or a disappointing aesthetic look. Women today have many options for improving the appearance of their breasts. Sometimes simply removing the implants is the first step”.

About Dr. Constance M. Chen

Constance M. Chen, MD, is a board-certified plastic surgeon in New York City with special expertise in the use of innovative natural techniques to optimize medical and cosmetic outcomes for women undergoing breast reconstruction. She is Clinical Assistant Professor of Surgery (Plastic Surgery) at Weill Cornell Medical College and Clinical Assistant Professor of Surgery (Plastic Surgery) at Tulane University School of Medicine.

Dr. Chen is frequently invited to lecture nationally and internationally on new advancements in breast reconstruction and the surgical treatment of lymphedema. She is the author of three books, five book chapters, and fifty journal articles. She has also won numerous awards for her work in plastic and reconstructive surgery at the local, regional, and national levels.

Dr. Chen has developed a reputation in the community for the personalized attention that she devotes to her patients. She is committed to aesthetic restoration of the breast and body, and enjoys helping her patients achieve overall well-being. At the end of the day, there is nothing more important to her than the joy she hopes to bring to her patients’ lives. Come into the beautiful world of Dr. Constance M. Chen.

Post Mastectomy Breast Reconstruction Basics: Understanding Your Options

Plastic surgeon and breast reconstruction specialist Dr. Constance Chen offers practical tips on breast reconstruction.

Breast reconstruction has come a long way. Although breast cancer was known to the ancient Egyptians as far back as 1600 B.C., it was not until the 18th century that it was understood to be a localized disease whose spread could be contained by isolating and removing the affected cells, and it was not until a hundred years later that pioneering work was done on what we know today as mastectomy.

Early practitioners of surgical breast removal did not believe in reconstruction. They feared that any intrusion at the surgical site could adversely affect the progression of the disease or hide a recurrence. So while the first attempts at reconstruction were made in the 1890s, it was not until the mid-20th century when radical surgery gave way to equally effective but less aggressive treatments that interest in breast reconstruction soared. Today, women have many options for breast reconstruction and every woman can make an educated decision about what is best for her.

Dr. Constance Chen, plastic surgeon

There are two types of breast reconstruction and multiple options for each: implant-based breast reconstruction and natural tissue breast reconstruction, also known as “autologous reconstruction.” Either type can be performed immediately, or months or even years after the mastectomy. For the best results, most breast reconstructions will require more than one procedure. Many factors will influence a woman’s decision on the best option for her. Chief among them are her general medical and genetic history, the size, location, and characteristics of her tumor, her treatment plan, and her aesthetic expectations. “An initial consultation with her surgeon will help a woman sort through her options,” says Dr. Chen, “but it is important for her to start with a general understanding of the basics of breast reconstruction.”

Reconstruction with implants

The introduction of silicone implants in the 1960s signaled the beginning of the modern era of breast reconstruction. Implant insertion used to be delayed until after the mastectomy had healed but now is often done in a single surgery at the time of the mastectomy. Usually, a temporary device called a tissue expander is placed on the chest wall and gradually filled with saline solution until the tissue has expanded enough to hold the permanent implant. Today, breast implants are either filled with saline or silicone, and the outer shell is either smooth or textured. The silicone gel has also become more cohesive over time so that there are now different types of silicone gel implants with different degrees of firmness.

“Implants have continued to improve and many women are happy with them,” says Dr. Chen, “but patients should be aware that implants are not expected to last a lifetime. In the United States, all breast implants have a ten-year warranty but complications such as pain, infection, hardening, and rupture lead many implants to be removed well before that. Some women find that their breasts feel hard and look unnatural, or that they’ve lost all feeling in the breast, or that their breasts are distorted and asymmetrical.” According to the implant manufacturers, at least half of breast implants need another operation within 7 years. Many women who suffer complications or are unhappy with implants ultimately have them removed and opt for reconstruction with their own tissue.

Reconstruction with your own tissue

The gold standard in breast reconstruction today is surgery that creates a breast from a woman’s own tissue, a procedure, known as “autologous reconstruction.” Natural tissue breast reconstruction creates a breast that is soft, warm, and when combined with nipple-sparing mastectomies can be barely distinguishable from a woman’s own breast. Unlike implant-based reconstruction, a restored breast made of her own tissue reacts just like any other part of her body, expanding or contracting with weight gain or loss, for example. When nerve reconstruction is added, the reconstructed breast may be sensitive to touch. Autologous reconstruction produces the best aesthetic result and the highest level of patient satisfaction but it should be noted that it requires more complex surgery and a longer recovery than reconstruction with implants.

Autologous tissue breast reconstruction uses tissue from a donor site in the patient’s own body to create the new breast. This type of reconstruction has been done for decades but new advances have made it unnecessary to sacrifice muscle from the donor site which reduces recovery time and enables a woman to maintain muscle strength. In this new type of reconstruction, known as “perforator flaps,” microsurgical techniques are used to carefully separate muscle from the fat and skin that will form the new breast. “Perforator flap reconstruction can use tissue from several donor sites,” says Dr. Chen. “Most often, tissue is taken from the abdomen, but for thin women or women who have had a previous tummy tuck, it may be more appropriate to use tissue from the upper inner thigh.”

Nipple and areola reconstruction

Changes in mastectomy itself have also facilitated improved restoration results. Surgery that spares skin and the nipple-areola complex enhances the surgeon’s ability to create a breast much like the woman’s own. If there are cancer cells in or near the nipple and it cannot be saved, the nipple-areola complex can be reconstructed later using skin from the breast or from another part of the body. Three-dimensional tattooing is also an effective option that creates a realistic illusion of a nipple.

Nerve restoration

During a mastectomy, the nerves that provide feeling to the breast and nipple are severed, causing loss of sensation in the remaining skin whether the woman undergoes reconstruction or not. With certain types of autologous reconstruction, however, it is now possible to reconnect blood vessels and nerves and have them grow through the transferred tissue to reach the skin and significantly improve the return of sensation. “This is the next frontier in breast restoration,” says Dr. Chen. “By microsurgically reconnecting nerves that are cut and restoring sensation to the breast, we can not only create a soft, warm breast that looks and feels natural to others but one that feels like her own breast to the woman herself.”

“The evolution of restorative techniques over the last several decades has been remarkable,” Dr. Chen concludes. “What makes a woman feel ‘whole’ again after mastectomy is an individual matter but we will continue to pursue solutions that enable her to regain not just her health but her confidence and sense of self”.

About Dr. Constance M. Chen

Constance M. Chen, MD, is a board-certified plastic surgeon in New York City with special expertise in the use of innovative natural techniques to optimize medical and cosmetic outcomes for women undergoing breast reconstruction. She is Clinical Assistant Professor of Surgery (Plastic Surgery) at Weill Cornell Medical College and Clinical Assistant Professor of Surgery (Plastic Surgery) at Tulane University School of Medicine.

Dr. Chen is frequently invited to lecture nationally and internationally on new advancements in breast reconstruction and the surgical treatment of lymphedema. She is the author of three books, five book chapters, and fifty journal articles. She has also won numerous awards for her work in plastic and reconstructive surgery at the local, regional, and national levels.

Dr. Chen has developed a reputation in the community for the personalized attention that she devotes to her patients. She is committed to aesthetic restoration of the breast and body, and enjoys helping her patients achieve overall well-being. At the end of the day, there is nothing more important to her than the joy she hopes to bring to her patients’ lives. Come into the beautiful world of Dr. Constance M. Chen.

Plastic Surgeon and Breast Reconstruction Specialist Dr. Constance M Chen Offers Tips on Improving Post Mastectomy Breast Reconstruction Results

When secondary breast reconstruction is necessary. Breast reconstruction should be thought of as a process rather than a single procedure. Most mastectomies will not be identical, and it is unusual for the initial breast reconstruction to have perfect symmetry. Usually, breast reconstruction requires multiple stages to obtain the ideal results.

The objective of breast reconstruction after mastectomy is to create a natural breast with the shape, symmetry and softness of the original. In most patients, modifications are needed after the initial surgery to accomplish that goal. Women should know that with a customized plan and advanced surgical techniques, we can often improve shape, size, and symmetry after the initial breast reconstruction to help a woman’s breasts look better and feel more normal.

Dr. Constance M. Chen, plastic surgeon

In most cases, the best aesthetic outcomes are achieved with natural tissue. There is a principle in plastic surgery to ‘replace like with like’. On the operating room table, the actual breast tissue looks and feels like regular fat – breast tissue and fatty tissue look and feel the same. As a result, when it is feasible to use a woman’s own fat to recreate the breast, the reconstructed breast will feel very much like the original – sometimes it is almost identical.

Women should know that even if they had reconstruction with breast implants that the implants can be removed and replaced with natural tissue. While many women with implant-based breast reconstruction are happy with the results, some women who have undergone breast reconstruction with implants feel uncomfortable because breast implants are usually placed underneath the muscle. In these cases the subpectoral breast implants can cause rigidity and trouble with breathing, and a hyper-animation deformity can also result in which the patient’s breasts move up and down when she flexes her pectoralis muscle.

In our experience, many women are surprised when their breast implants are removed and replaced with natural tissue. They commonly report feeling much more comfortable and they are pleased that their new breasts feel and look normal.

Dr. Constance M. Chen, plastic surgeon

Breast reconstruction problems can also arise due to asymmetry. Breasts should look like sisters if not twins, and it’s best when at least they look like they belong to the same family. It is easiest to obtain symmetry with bilateral reconstruction, in which the incisions from the mastectomy and reconstruction method are the same. However, in cases where only one breast has undergone a mastectomy with breast reconstruction it may be necessary to perform additional procedures on the other breast to achieve symmetry. Fortunately, the 1998 Women’s Health and Cancer Rights Act requires all health insurance companies to cover all stages of breast reconstruction and any complications from all stages of mastectomy or breast reconstruction, and symmetry procedures on the opposite breast are also covered. A woman’s right to breast reconstruction at any stage is protected by federal law and many state laws.

Refining and improving breast reconstruction

One common type of secondary breast reconstruction procedure is fat grafting, in which fat is collected from another part of the body through tiny incisions via liposuction. The extracted fat is processed to remove impurities, and then the fat graft is transferred by injections into the breast. This process is used to make the breast larger or to correct contour deformities by sculpting and filling in small areas to improve breast size, shape, and symmetry.

Another common secondary breast reconstruction is called mastopexy or breast lift. Here the goal is to improve the look and/or evenness of the reconstructed breasts. Reconstructed breasts are usually perkier, particularly after implant-based breast reconstruction. If only one breast has undergone mastectomy and breast reconstruction, a mastopexy may be needed on the unaffected breast to match the reconstructed breast. A breast lift will remove excess skin and raise the nipple-areola complex so that the breast sits higher on the chest wall. A breast lift will not significantly alter the size of the breast.

Finally, in some cases the breast size may need to be modified with a breast reduction or a breast augmentation. A breast reduction is similar to a breast lift, except breast tissue is removed along with the breast skin to make the breast smaller. A breast augmentation may be performed with fat grafting or a breast implant.

Any of these procedures can also be implemented on the reconstructed breast(s).

Additional procedures to achieve symmetry are almost always needed for women who have undergone a unilateral (single-sided) mastectomy and breast reconstruction with a breast implant. On the other hand, the best aesthetic outcomes are from bilateral (double-sided) nipple-sparing mastectomies with immediate natural tissue breast reconstruction. When all the breast skin has been preserved and the breast reconstruction is performed with natural tissue at the same time as the mastectomy, it can be nearly impossible to tell that a woman has had a mastectomy.

“Too many women have experienced the devastating upset of a cancer diagnosis and subsequent treatment only to have added disappointment of an unsatisfactory reconstruction outcome,” says Dr. Chen. “Correcting a poor or uncomfortable reconstruction can be the last step in restoring a woman’s physical and emotional health and improving her quality of life.” Even women who have not had the gold standard in mastectomy and breast reconstruction from the beginning can undergo secondary breast reconstruction to improve their initial results.

About Dr. Constance M. Chen

Constance M. Chen, MD, is a board-certified plastic surgeon in New York City with special expertise in the use of innovative natural techniques to optimize medical and cosmetic outcomes for women undergoing breast reconstruction. She is Clinical Assistant Professor of Surgery (Plastic Surgery) at Weill Cornell Medical College and Clinical Assistant Professor of Surgery (Plastic Surgery) at Tulane University School of Medicine.

Dr. Chen is frequently invited to lecture nationally and internationally on new advancements in breast reconstruction and the surgical treatment of lymphedema. She is the author of three books, five book chapters, and fifty journal articles. She has also won numerous awards for her work in plastic and reconstructive surgery at the local, regional, and national levels.

Dr. Chen has developed a reputation in the community for the personalized attention that she devotes to her patients. She is committed to aesthetic restoration of the breast and body, and enjoys helping her patients achieve overall well-being. At the end of the day, there is nothing more important to her than the joy she hopes to bring to her patients’ lives. Come into the beautiful world of Dr. Constance M. Chen.

Understanding the Benefits of Short-scar Breast Reduction

Breast Reconstruction Specialist Dr. Constance M. Chen Provides Tips for Women Considering Breast Reduction Surgery.

Many women with large and heavy breasts experience significant discomfort including back, neck, and shoulder pain, challenges finding clothes that fit, and a feeling of self-consciousness about their bodies. Some report rashes under their breasts, stares and unwanted attention, and find that large breasts can also make vigorous physical activity difficult. Breast reduction surgery, or reduction mammoplasty, helps deal with these problems and helps many women feel more comfortable in their own bodies.

In a reduction mammoplasty, breast tissue and breast skin is removed and the nipple-areola complex is repositioned higher on the chest wall, creating a smaller and more youthful breast.

Dr. Constance M. Chen, plastic surgeon

A traditional reduction mammoplasty is performed with an incision that results in an “anchor scar,” which involves three discrete scars. One incision is made around the border of the areola, the second extends down vertically from the areola to the inframammary fold, and the third is a long horizontal incision along the bottom of the breast at the inframammary fold. Dr. Chen explains that “the horizontal scar sometimes can extend beyond a bathing suit or bra and be visible. This same scar is also susceptible to complications while healing and can become wider or hypertrophic (raised).” This is where a short-scar or limited-scar reduction can be advantageous. That’s because it eliminates the horizontal scar,” adds Dr. Chen.

Short-scar reduction uses what we call a ‘lollipop incision’ – around the areola and down to the inframammary fold. “In this case, the horizontal scar is eliminated,” says Dr. Chen. The best technique for each woman is determined by the breast surgeon depending on the size and shape of the patients’ breasts and by the amount of reduction desired.

In most cases, patients who undergo a breast reduction will leave the hospital the same day, with overnight stays rare. The recommended recovery at home is typically 10-14 days before returning to work and several additional weeks before returning to a fully active lifestyle.

Dr. Chen says that “a breast reduction can be performed on healthy women after the breasts are fully developed. She reiterates that “short-scar breast reduction minimizes scarring on the breast after surgery. With advances in breast reduction surgeries, women today don’t have to tolerate the discomfort and emotional distress of large breasts that are out of proportion to their bodies so that they can be more comfortable in their own skin.”

About Dr. Constance M. Chen

Constance M. Chen, MD, is a board-certified plastic surgeon in New York City with special expertise in the use of innovative natural techniques to optimize medical and cosmetic outcomes for women undergoing breast reconstruction. She is Clinical Assistant Professor of Surgery (Plastic Surgery) at Weill Cornell Medical College and Clinical Assistant Professor of Surgery (Plastic Surgery) at Tulane University School of Medicine.

Dr. Chen is frequently invited to lecture nationally and internationally on new advancements in breast reconstruction and the surgical treatment of lymphedema. She is the author of three books, five book chapters, and fifty journal articles. She has also won numerous awards for her work in plastic and reconstructive surgery at the local, regional, and national levels.

Dr. Chen has developed a reputation in the community for the personalized attention that she devotes to her patients. She is committed to aesthetic restoration of the breast and body, and enjoys helping her patients achieve overall well-being. At the end of the day, there is nothing more important to her than the joy she hopes to bring to her patients’ lives. Come into the beautiful world of Dr. Constance M. Chen.

Pros and Cons of immediate versus delayed post-mastectomy breast reconstruction

A new breast cancer diagnosis is emotionally challenging, and it becomes even more difficult when women must also make decisions about treatment during a stressful time. In the case of a woman who will have a mastectomy, the difficulty can be even more overwhelming due to the variety of options available and the choices she must make about if, when and how to have breast reconstruction.

According to Constance M. Chen a board-certified plastic surgeon and breast reconstruction specialist, “there are two types of breast reconstruction, breast implants and natural tissue breast reconstruction that uses the body’s own tissue, also known as autologous tissue breast reconstruction.” And with each scenario, there are multiple options. One time-sensitive consideration is whether to have the reconstruction performed immediately in the same surgery as the mastectomy, or delayed by months or even years after the mastectomy. Dr. Chen details the considerations of immediate versus delayed post-mastectomy reconstruction.

Immediate Reconstruction

One of the primary advantages of immediate reconstruction is blunting the emotional suffering from losing one or both breasts. “For many women, waking up from a mastectomy and seeing that she still has breasts is very positive”. Immediate reconstruction that conserves the nipple, areola, and skin is the highest standard in breast reconstruction. Nipple-sparing mastectomy preserves the entire skin envelope, which makes it possible to preserve the breast shape. Thus, regardless of the type of reconstruction, whether implants or natural tissue, the resulting breast shape will always be best after nipple-sparing mastectomy. When performed with natural tissue, the reconstructed breast has the added benefit of being soft, warm and alive, and it is also possible to reconnect nerves to restore feeling.

One drawback of immediate reconstruction is that the hospitalization and recovery time may be longer than with a mastectomy alone with breast reconstruction. Moreover, for women with advanced disease who need immediate chemotherapy, immediate reconstruction may delay treatment until after healing is complete.

Delayed Reconstruction

Delaying reconstruction sometimes shortens the recovery time after a mastectomy. If a patient has a high-grade tumor or advanced disease, she may elect to delay reconstruction so that she can start her chemotherapy or radiation therapy sooner. With both implants or with the woman’s own tissue – breast reconstruction can be performed after healing from the mastectomy is complete and after chemotherapy and radiation therapies, if those are required.

The biggest drawback to delaying reconstruction is the need for another surgery at a later date, and the potential for an inferior aesthetic result. This is particularly true if the patient has not undergone nipple-sparing mastectomy, and/or if the patient needed radiation therapy. Without nipple-sparing mastectomy, a significant amount of breast skin may have been removed, which permanently deforms the breast by changing the shape and flattening it. Radiation therapy also alters the remaining breast skin and tissue so that it does not stretch and heal normally. Without nipple-sparing mastectomy, the skin will need to be stretched with a tissue expander if using breast implants. With natural tissue breast reconstruction, skin from the patient’s donor site can make up for the lost skin, but it may appear as a patch. In these cases, there will likely be a need for additional follow-up procedures to improve the overall cosmetic result.

One of the biggest considerations driving the timing of reconstruction is whether the woman will need radiation therapy after her mastectomy. “Radiation therapy always automatically unfavorably affects the aesthetics of any breast reconstruction,” says Dr. Chen. “But if a woman wants autologous tissue reconstruction, she may be advised to postpone placing the natural tissue until her radiation is completed.” In these cases, the patient can undergo a delayed immediate reconstruction, in which a tissue expander is placed at the time of mastectomy to save the breast skin, and then the natural tissue reconstruction is performed after the radiation is completed.

The Takeaway

According to Dr. Chen, “women have the best aesthetic result and the most sustained level of satisfaction with nipple-sparing mastectomy and natural tissue breast reconstruction. Autologous tissue reconstruction produces a soft, natural breast that looks and feels like the breast lost to mastectomy. Most breast surgeons are reluctant to perform nipple-sparing mastectomy without immediate breast reconstruction, because of the deflated appearance of the breast skin. Whether immediate or delayed, however, preservation of the nipple-areola complex and all of the breast skin sets the foundation for the best possible breast reconstruction”.

“There are pros and cons to immediate and delayed reconstruction, and each woman must consider personal and medical reasons for choosing the best course of action for them. Breast reconstruction is an integral piece of managing breast cancer,” says Dr. Chen. “We’ve made amazing developments in our ability to reconstruct a breast that closely resembles the breast lost to mastectomy. Today more than ever we can offer women a wide range of options to fit their medical needs and personal preferences, including the choice of when to have reconstruction. Each breast cancer patient has unique needs and we can help her get the best care that is ideal for her”.

About Dr. Constance M. Chen

Constance M. Chen, MD, is a board-certified plastic surgeon in New York City with special expertise in the use of innovative natural techniques to optimize medical and cosmetic outcomes for women undergoing breast reconstruction. She is Clinical Assistant Professor of Surgery (Plastic Surgery) at Weill Cornell Medical College and Clinical Assistant Professor of Surgery (Plastic Surgery) at Tulane University School of Medicine.

Dr. Chen is frequently invited to lecture nationally and internationally on new advancements in breast reconstruction and the surgical treatment of lymphedema. She is the author of three books, five book chapters, and fifty journal articles. She has also won numerous awards for her work in plastic and reconstructive surgery at the local, regional, and national levels.

Dr. Chen has developed a reputation in the community for the personalized attention that she devotes to her patients. She is committed to aesthetic restoration of the breast and body, and enjoys helping her patients achieve overall well-being. At the end of the day, there is nothing more important to her than the joy she hopes to bring to her patients’ lives. Come into the beautiful world of Dr. Constance M. Chen.

Breast Reconstruction Specialist Dr. Constance M. Chen offers practical tips to help manage expectations for women recovering from breast surgery

Hundreds of thousands of women undergo breast surgery every year. Whether these procedures are reconstructive, cosmetic, or therapeutic, surgery itself is traumatic to the body. “The body’s reaction to surgery depends on many factors,” says plastic surgeon and breast reconstruction specialist Dr. Constance M. Chen.

Most important are the patient’s overall health, type and location of the surgery, and the aftereffects of anesthesia. Before surgery, each woman should discuss with her surgeon both the expected effects of the procedure she will undergo and the individual factors that might affect her recovery. Knowing what to expect and preparing for her recuperation will help ease her return to normal activities.

Dr. Constance M. Chen,  plastic surgeon and breast reconstruction specialist

Reconstructive breast surgery replaces a breast lost to mastectomy or rebuilds one disfigured by breast-conserving surgery such as lumpectomy. Breast reconstruction may be via implants or via a woman’s own tissue from another part of her body – often the abdomen – to fashion a soft, warm, natural breast much like the one she lost. Recreating a breast after lumpectomy depends on the degree of deformity and might range from implants to some sort of natural tissue breast reconstruction such as fat grafting or flap reconstruction. Cosmetic breast surgery includes breast augmentation with implants, breast reduction, and mastopexy, or breast lift. Therapeutic breast procedures include cancer surgeries such as mastectomy, lumpectomy, and biopsy as well as surgery for other conditions such as a breast abscess.

After surgery…
Dr. Chen points out that surgery induces some common and predictable responses at the surgical site and throughout the body. She offers some suggestions on what to expect in the days and weeks on the road to recovery.

Immediately after waking from anesthesia, you will be groggy. Some women experience post-operative nausea and/or vomiting that usually wears off in a couple of hours or days. If you are not staying overnight in the hospital, you will need a ride home.

Surgical drains may be in place after mastectomy or reconstructive surgery and will be removed either in the hospital or in the doctor’s office a week or so after discharge. You will be instructed before leaving the hospital on how to manage the drains and how to keep them secure and discreet.

Pain is most likely in the first few days and your doctor may prescribe medication to control pain. After that, over-the-counter painkillers generally suffice.

Post-surgical swelling is common along with bleeding and bruising at the surgical site and swelling may be apparent elsewhere. Your surgeon will advise on dressings and whether or not ice and elevation are appropriate.

Easing into light daily activity will be easier after a couple of weeks and some women can resume a desk job. Over the next few weeks, soreness and swelling will diminish and by six-to-eight weeks, most women are fully recovered and can resume regular activity.

Promoting healing…
Dr. Chen emphasizes the importance of following your doctor’s instructions while recovering and offers tips to make you as comfortable as possible and promote healing.

• Wear loose, comfortable clothing that slips on easily and closes in the front. Zippered closures are often easiest to avoid fumbling with buttons. Avoid restrictive clothing and anything that requires you to lift your arms over your head.
• Your surgeon will discuss whether and when to wear a bra and whether you should wear a compression garment at first to reduce swelling or avoid compression to keep the tissue alive. When you’re ready for a regular bra, look for one that is made of soft, breathable fabric and closes in the front. Avoid underwire bras that dig into your skin. Consider a post-surgical camisole that has pockets to hold drains.
• Try sleeping in a recliner or lying on your back with pillows under your knees.
• Don’t lift, carry, or push anything heavy – including a child – in the first few weeks after surgery.
• Eat a nutrient-rich, well-balanced diet rich in lean protein to repair damaged tissue; iron, found in liver and green leafy vegetables, to replenish red blood cells; fluids from 6-8 glasses of water a day to reduce swelling; and fiber from beans and grains to stimulate a gastrointestinal system made sluggish by anesthesia. Get energy from food rather than supplements.
• Avoid all products that contain nicotine – including cigarettes, patches, gum, chewing tobacco, and lozenges. Nicotine inhibits the body’s ability to heal.
• Get moving! The body gets debilitated quickly. Even gentle stretching is helpful to stimulate the muscle fibers and overcome stiffness. After the immediate healing period, exercise also gets your heart rate up so that the blood is moving and your lungs fill with oxygen.

“Your doctor will let you know when various activities are safe after surgery, such as driving,” says Dr. Chen. “But remember that every patient reacts differently and estimated time frames don’t apply to everyone. Our goal is to ensure that every woman understands her treatment and recovery as well as possible. It’s vital to her physical and emotional healing that patients have comprehensive, accurate information about what to expect.”

About Dr. Constance M. Chen

Constance M. Chen, MD, is a board-certified plastic surgeon in New York City with special expertise in the use of innovative natural techniques to optimize medical and cosmetic outcomes for women undergoing breast reconstruction. She is Clinical Assistant Professor of Surgery (Plastic Surgery) at Weill Cornell Medical College and Clinical Assistant Professor of Surgery (Plastic Surgery) at Tulane University School of Medicine.

Dr. Chen is frequently invited to lecture nationally and internationally on new advancements in breast reconstruction and the surgical treatment of lymphedema. She is the author of three books, five book chapters, and fifty journal articles. She has also won numerous awards for her work in plastic and reconstructive surgery at the local, regional, and national levels.

Dr. Chen has developed a reputation in the community for the personalized attention that she devotes to her patients. She is committed to aesthetic restoration of the breast and body, and enjoys helping her patients achieve overall well-being. At the end of the day, there is nothing more important to her than the joy she hopes to bring to her patients’ lives. Come into the beautiful world of Dr. Constance M. Chen.

Plastic Surgeon and Breast Reconstruction Specialist Dr. Constance Chen Offers Practical Tips about Inverted Nipples

Inverted nipples are a common and normal variation in nipple shape. Also called retracted nipples, inverted nipples turn inward toward the breast instead of protruding. They occur in either one or both breasts, in both men and women, and may be congenital – present from birth – or may develop later in life.

As many as 10% of women may have one or both nipples inverted. Inverted nipples are not generally a cause for concern and require treatment only if they interfere with breastfeeding, if there is an underlying medical condition that must be addressed, or to satisfy aesthetic preferences.

Dr. Constance M. Chen, Breast specialist and plastic surgeon

Nipple inversion may be permanent or temporary, with the nipples fluctuating between inverted and erect. Some women experience inversion during pregnancy even if their nipples weren’t inverted before. While nipple sensitivity varies from person to person, inverted nipples are not ordinarily less sensitive to stimulation than erect nipples.

There are different grades of nipple inversion that may help determine whether it will interfere with breastfeeding or if treatment is needed. At the lowest level of inversion, the nipple can be easily pulled out and may remain protruding for some time. At a moderate level, the nipple can be pulled out, but will retract when released. With the most severely inverted nipples, it may be difficult or impossible to pull the nipple out. The higher the level of inversion, the more likely breastfeeding is to be difficult or impossible.

Breastfeeding is often problem-free with inverted nipples by having the baby latch onto the entire areola. Also, inverted nipples sometimes protrude naturally during pregnancy and breastfeeding or can be made to protrude by stimulation. Devices such as a ‘nipple shield’ that helps the baby latch on or a ‘breast shield’ that helps the nipple protrude may be helpful.

There are several treatment options for inverted nipples, most of them temporary and all of which should be discussed with a doctor to determine the best solution for each individual. There are home exercises for drawing the nipple out as well as suction devices that achieve a similar result in some cases. Inverted nipples can also be surgically corrected.

“Surgical options try to preserve the milk ducts to enable breastfeeding, but sometimes the milk ducts will be divided. When the milk ducts are disrupted to correct an inverted nipple, future breastfeeding may be difficult or even impossible”, says Dr. Chen. In either case, the procedure, generally performed under local anesthesia, involves a very small incision under the nipple through which a fine instrument is used to detach the fibers and duct(s) that are holding the nipple in an inverted position. A suture placed beneath the nipple then keeps it in position.

While inverted nipples aren’t generally medically troublesome, particularly when present since birth or when occurring gradually, over several years, there are indications that require medical attention. Nipples that had been protruding but flatten or turn inward suddenly or in a short period of time should be brought to the attention of a doctor. Other symptoms that require medical examination include discharge, a lump or swelling of the nipple, dimpling or thickening of the skin, and redness or pain.

“Inverted nipples are one of the many normal variations in the breast”, says Dr. Chen. “Depending on the degree of inversion, they may be easily manipulated to enable breastfeeding and they may be made to protrude for some period of time. When they cause distress for any reason, surgical correction is usually minimally invasive. As with many such procedures, correction can have a positive effect on a woman’s physical and emotional well-being”.

About Dr. Constance M. Chen

Constance M. Chen, MD, is a board-certified plastic surgeon in New York City with special expertise in the use of innovative natural techniques to optimize medical and cosmetic outcomes for women undergoing breast reconstruction. She is Clinical Assistant Professor of Surgery (Plastic Surgery) at Weill Cornell Medical College and Clinical Assistant Professor of Surgery (Plastic Surgery) at Tulane University School of Medicine.

Dr. Chen is frequently invited to lecture nationally and internationally on new advancements in breast reconstruction and the surgical treatment of lymphedema. She is the author of three books, five book chapters, and fifty journal articles. She has also won numerous awards for her work in plastic and reconstructive surgery at the local, regional, and national levels.

Dr. Chen has developed a reputation in the community for the personalized attention that she devotes to her patients. She is committed to aesthetic restoration of the breast and body, and enjoys helping her patients achieve overall well-being. At the end of the day, there is nothing more important to her than the joy she hopes to bring to her patients’ lives. Come into the beautiful world of Dr. Constance M. Chen.

Arm Lift: Help for Stubborn and Unsightly Under Arm Sagging

Arms had their moment in early 2009 when Michelle Obama posed for her first official photograph as first lady in a sleeveless black dress. While some style critics carped that the look was too informal or out of season with the February weather, many women all over the world envied Obama’s toned arms and wanted to know how they could achieve similar muscle definition. Workout and diet recommendations proliferated as millions of women went to work on their arms. Plastic surgeon Dr. Constance M. Chen remembers what happened next.

Women didn’t just head to the gym. Some found that weight loss and exercise didn’t achieve the results they wanted and headed to their doctors’ offices to inquire about a surgical fix for sagging upper arms.

Dr. Constance M. Chen

As we age, the skin on the upper arms loses elasticity and droops. Fluctuations in weight and heredity also contribute to this effect. While exercise can strengthen the arms and improve muscle tone, it cannot correct skin that has lost elasticity. An arm lift, or brachioplasty, can reshape the upper arm by removing excess skin and fat from the underside of the upper arm from armpit to elbow. The problem is that excess skin resection can leave unsightly scars, while liposuction alone can worsen the problem of loose sagging skin if the woman does not have enough skin elasticity.

As we age, the skin on the upper arms loses elasticity and droops. Fluctuations in weight and heredity also contribute to this effect. While exercise can strengthen the arms and improve muscle tone, it cannot correct skin that has lost elasticity. An arm lift, or brachioplasty, can reshape the upper arm by removing excess skin and fat from the underside of the upper arm from armpit to elbow. The problem is that excess skin resection can leave unsightly scars, while liposuction alone can worsen the problem of loose sagging skin if the woman does not have enough skin elasticity. Good candidates for an arm lift are healthy, non-smoking adults of any age who are not significantly overweight and whose weight is stable.

As with any cosmetic procedure, it is important that those considering surgery have realistic expectations, The smoother, tighter contours produced by an arm lift are relatively permanent as long as weight and general fitness are maintained though there may be some loss of firmness over time as the body continues to age. Scars from an arm lift can be significant, however, so patients need to be sure that they would like to trade an improved arm shape for a visible scar.

Dr. Constance M. Chen

The procedure may be performed in the hospital or on an out-patient basis, under local or general anesthesia. The number and extent of incisions are dependent on the amount of skin to be removed; they may be on the inside or back of the arm and will be placed to minimize the visibility of scars. A short-scar brachioplasty limits the scar to the armpit, but passit also is not as effective for resecting a large amount of loose sagging upper arm skin. Fat may be removed directly or treated with liposuction. Underlying supportive tissue is tightened and smoothed, then skin is replaced over the reshaped arm and secured with stitches. Physical and athletic activity will be limited for several weeks following surgery. Risks associated with an arm lift are those of any surgery, such as bleeding, infection, or adverse reaction to anesthesia, as well as temporary changes in skin sensation.

“As with any cosmetic procedure, the driving motivation and expectations for results are unique to each individual,” says Dr. Chen. “For those committed to maintaining a healthy regimen of fitness and weight control, an arm lift can solve a nagging problem that is otherwise resistant to change. Patients need to think carefully about the scars, however. Our goal is always to help people have the bodies they want and to improve their physical and emotional well-being.”

About Dr. Constance M. Chen

Constance M. Chen, MD, is a board-certified plastic surgeon in New York City with special expertise in the use of innovative natural techniques to optimize medical and cosmetic outcomes for women undergoing breast reconstruction. She is Clinical Assistant Professor of Surgery (Plastic Surgery) at Weill Cornell Medical College and Clinical Assistant Professor of Surgery (Plastic Surgery) at Tulane University School of Medicine.

Dr. Chen is frequently invited to lecture nationally and internationally on new advancements in breast reconstruction and the surgical treatment of lymphedema. She is the author of three books, five book chapters, and fifty journal articles. She has also won numerous awards for her work in plastic and reconstructive surgery at the local, regional, and national levels.

Dr. Chen has developed a reputation in the community for the personalized attention that she devotes to her patients. She is committed to aesthetic restoration of the breast and body, and enjoys helping her patients achieve overall well-being. At the end of the day, there is nothing more important to her than the joy she hopes to bring to her patients’ lives. Come into the beautiful world of Dr. Constance M. Chen.

One Size Doesn’t Fit All: Finding the Right Bra for Every Breast Shape

No two breasts are alike. For many women, even her own two natural breasts may not quite match. It is normal to have breasts that are different sizes and even different shapes. Breasts come in many different shapes, all of them completely normal, but important to be aware of when shopping for a bra.

A properly fitted bra is important for all women, not just large-breasted women who suffer discomfort in their necks and backs when their bras don’t support them adequately. Every woman will be more comfortable and less restrained in her physical activity if she is wearing a properly fitted bra.

Dr. Constance M. Chen, Breast specialist and plastic surgeon

Breast shape is determined primarily by genetics, but influenced by several additional factors, weight chief among them. The breast tissue that isn’t made up of milk ducts is largely composed of fat cells that increase and decrease as weight is gained and lost, potentially changing the shape as well as the size of the breast. Other factors are the hormonal changes that accompany pregnancy and breastfeeding and the changes that are a natural consequence of aging as skin loses elasticity and as the composition of breast tissue changes to a higher concentration of fat, which is more prone to sagging. Most women find that the shape of their breasts changes more than once over the course of their lifetimes and with that change comes the realization that it may be time to retire the bra style worn for decades and get fitted for a new one.

Any catalog of breast shapes is only an approximation, Just as every woman is unique, her breast shape cannot be expected to conform to a picture or description. However, even having a general idea of the one or two shapes that match you best can make all the difference in making sure you get a bra that fits. These descriptions of breast shapes aren’t comprehensive but most women – with the aid of a mirror – should be able to get an idea of which ones come closest to her own.

Dr. Constance M. Chen, Breast specialist and plastic surgeon

Round breasts appear to be equally full at the top and bottom of the breast. Not many women have well-rounded breasts, but many bras are designed for this presumed shape and account for lots of poor fit. Tear drop breasts are also rounded but fuller at the bottom than at the top. Women who have lost weight may find that their breasts now reflect this shape as they have less roundness at the top.

• Bell breasts are also fuller at the bottom, but narrower at the top and less rounded than tear drops.
• East west breasts have nipples that point outward, away from each other.
• Side set breasts have a wide space between them; close set breasts have very little space between them.
• Slender breasts are narrow and long and have nipples that point downward.
• Athletic breasts tend to be wide-set and more muscular with less breast tissue, correlating with an athletic body that is muscular with little fat.
• Conical breasts are cone-shaped rather than round and are more common in small-breasted women.
• Asymmetric breasts may have differences in size or shape.
• Relaxed breasts have looser tissue and nipples that point downward, similar to slenders, but generally fuller; they are more common later in life.

“Many women wear a bra that does not fit properly, which can lead to discomfort,” says Dr. Chen. “The best way to be properly fitted for a bra is in a specialized shop with experienced bra fitters. But with or without expert help, understanding the shape of your breasts will help you get the right fit. When a bra fits properly, there will be no gapping and no overflow in the cups, the straps won’t slip or dig into your shoulders, and you should be able to slip two fingers under the band in the back. Remember that the shape of your breasts will affect which bra is right for you”.

About Dr. Constance M. Chen

Constance M. Chen, MD, is a board-certified plastic surgeon in New York City with special expertise in the use of innovative natural techniques to optimize medical and cosmetic outcomes for women undergoing breast reconstruction. She is Clinical Assistant Professor of Surgery (Plastic Surgery) at Weill Cornell Medical College and Clinical Assistant Professor of Surgery (Plastic Surgery) at Tulane University School of Medicine.

Dr. Chen is frequently invited to lecture nationally and internationally on new advancements in breast reconstruction and the surgical treatment of lymphedema. She is the author of three books, five book chapters, and fifty journal articles. She has also won numerous awards for her work in plastic and reconstructive surgery at the local, regional, and national levels.

Dr. Chen has developed a reputation in the community for the personalized attention that she devotes to her patients. She is committed to aesthetic restoration of the breast and body, and enjoys helping her patients achieve overall well-being. At the end of the day, there is nothing more important to her than the joy she hopes to bring to her patients’ lives. Come into the beautiful world of Dr. Constance M. Chen.