As we explored women’s breast reconstruction options and shared powerfully personal stories from the RealSelf community over the past few weeks, we wondered just how much techniques and technology had recently improved. So we asked Dr. Anne Peled, a board-certified plastic surgeon in San Francisco who’s on the cutting edge of reconstructive and breast cancer surgery and education.

We learned that surgical techniques and implants have improved so much—even in just the past 3–5 years—that some women who had breast reconstruction just few years earlier are opting for revision reconstruction, and they’re genuinely happier with their results.

Here’s why Dr. Peled is more optimistic than ever about the care women facing cancer and reconstruction are getting, and what the future holds.




RealSelf: What do women facing breast cancer need to know about reconstruction, that they may not know yet?

Dr. Peled: One of the things women tend to be surprised by is that breast reconstruction is a covered insurance benefit, by law. It’s covered for both women who’ve just had breast surgery, and for women who, for whatever reason, had breast surgery in the past and didn’t have reconstruction at the time. They don’t always know it’s an option even 15 or 20 years down the road, and their options are better now.

The spectrum of breast reconstruction is bigger than most women realize. One of the things I try to talk a lot about is lumpectomy reconstruction. The majority of women with breast cancer in this country are having lumpectomies for their breast cancer surgery, but they don’t know there are good reconstruction options for lumpectomies too—everything from filling in a divet, so they aren’t reminded that they had cancer, to making your breasts look better than before. Even a breast reduction or lift falls into that reconstruction category, in this context. Sometimes women think they want to have mastectomies, but when they hear that they could have a lumpectomy combined with a breast lift, they realize that might be a better choice for them.

I always recommend that women try to go, if they can, to a place with a dedicated breast team, with a fellowship-trained or specialized breast surgeon, who either does their own breast reconstruction or has a plastic surgeon there who does it. So women can make sure they’re getting access to and information about all their options.

Sometimes, surgeons don’t do certain kinds of reconstruction, don’t have them in their toolbox, so they might not even present them as an option.


RealSelf: What about women who have had reconstruction and aren’t thrilled with their outcome? How common is it for them to get revisions, and is that still covered by insurance?

Dr. Peled: Fortunately it is. It’s really nice for women to know that reconstruction changes are covered, and that reconstructive technology now is better than ever. I mean, just think about the difference between older silicone implants that we were worried would leak and now we’ve got beautiful gummy cohesive gel implants. These new implants are also great for augmentation, but there’s even more of a need for better implants in reconstruction where we don’t have as much soft tissue coverage.

We hope that we get these things right the first time, but outcomes after breast reconstruction can be unpredictable, especially if you have radiation or other unexpected changes from your breast cancer treatment. Reconstruction is much less predictable than standard breast augmentation. It’s important that women realize we can’t always predict outcomes. But if you’re unhappy, we can do better. And our technologies and techniques keep changing.

We used to always put our implants under the muscle. But now, all of my patients have above-the-muscle, pre-pectoral reconstruction with Alloderm support. And I’m so happy with the outcomes that I’m now switching some of my prior patients who had their breast reconstructions under the muscle before I started doing pre-pectoral reconstruction. Several of them are beyond thrilled with their results after they switch, both functionally and aesthetically. They’re some of my happiest patients.

One of my patients recently, someone else had done her below-the-muscle reconstruction. She was unhappy with the fact that when she flexed her muscles, her implants moved; we call that a “hyper animation deformity.” So she went to see her original plastic surgeon, who’s still doing below-the-muscle reconstruction, which is fine, since that’s his technique and one he’s comfortable with and does safely. But he didn’t think of offering her an implant site change (to over-the-muscle), because that’s not what he does.

When she came to see me, and I offered her that, she said, “Why didn’t my plastic surgeon suggest it?” I told her, “That’s just not in his toolbox.” I did it for her, and she’s one of my happiest patients.


RealSelf: How much have you seen technology and techniques change, just over the past five years?

Dr. Peled: The last five years have been huge. We have microsurgery for autologous (flap) reconstructions, which can allow for muscle-saving reconstructions like DIEPs (a type of flap surgery that uses your lower stomach skin and fat to reconstruct your breast.) We’ve been doing DIEPs for longer than five years, but now surgeons are doing DIEPs more aesthetically. We’re making the abdominal contour better, shaping the breast better. A lot of people are combining flaps with implants. Sometimes DIEP flaps can’t always give you the best projection alone, so it’s a nice combo.

Also, our fat grafting has gotten so much better. So sometimes if I’m doing flap reconstruction, I will fat graft my flaps to help with upper pole or central breast fullness, or help make them look more natural in matching the other side. I use fat grafting in most of my implant reconstructions too, and sometimes after lumpectomy.  All of that has gotten better.

Even in the last few years, the switch to pre-pectoral (above-the-muscle) reconstruction and better implant technology has been huge.

I now feel more comfortable offering women revisions, because I actually know I can do better. I feel very confident.

One of my favorite patients just came in for follow-up, I had done her surgery three years ago. She had been radiated in the past and her below-the-muscle reconstruction is just not great. And I love that she came in, and I could say “We’re switching in better implants, above the muscle.” We’ll also do some fat grafting, and she should have a better result than what I could offer her three years ago.


RealSelf: How have you seen nipple reconstruction evolving?

Dr. Peled: The biggest change is that many women are able to keep their nipples now with nipple-sparing mastectomies. We’ve seen major changes in the breast surgery world over recent years and most of us are really expanding the indications for nipple-sparing mastectomies. At this point, nearly 100 percent of my patients have nipple-sparing mastectomies.

We all know that we don’t have great nipple reconstruction options yet. The projection doesn’t stay very well. So for women who don’t keep their nipples, I’ve been so happy with 3D nipple tattooing. They look beautiful. I sometimes cannot get over the results.


RealSelf: That’s fantastic. What about lymph node transplants, for women who have lost lymph nodes in their mastectomy? Do you see that improving as well?

Dr. Peled: I do. There are more and more studies coming out showing that lymph node transfers work.  Some of the microsurgeons who do a lot of flap breast reconstruction are doing lymph node transfers in combination with flaps.

In my mind, that’s what you want. People who are very skilled at microsurgery anyway or already in there doing a flap. And then you have the lymph node transfer as a side benefit.

Those centers that are doing a lot of them are feeling like they’re getting better outcomes.

But the real answer to lymphoedema (a swelling of the arm that can happen when lymph nodes are removed) is what we’re doing on the breast surgery side. All of us are really trying to be more mindful of how many lymph nodes we’re taking. We have bigger studies that show if you do chemo upfront and shrink down your tumors, even if you had lymph node involvement, you don’t have to do a full lymph node dissection. So I think we’re tackling the problem on both sides.


RealSelf: Could you tell us about the Hidden Scar technique for breast cancer surgery? How widespread is it?

Dr. Peled: In just the past five years, the American Society of Breast Surgeons has started actively pushing courses and research on Hidden Scar surgeries. Breast surgeons are starting to think more about the aesthetics of lumpectomies and mastectomies, which leads to better outcomes.  

Before then, if you were highly trained and breast surgery-specialized and knew how to do nipple-sparing mastectomies, maybe you were trying to hide your scar somewhere, or make an aesthetic scar.

But the reality is that not all centers have breast surgery fellowship-trained surgeons and older surgical training really focused on just taking the tumor out, without thinking as much about aesthetic scars.

That’s why I’ve been so excited to see this push to get surgeons better trained in techniques like Hidden Scar. When we teach the beginner course, the first thing we teach is just doing a better job in placing your incisions, in making a better scar.

We focus so much, as we should, on survival and how great cancer treatment is now. But if you leave people with a scar that reminds them every day that they had cancer, we haven’t fully supported their survivorship.


Dr. Anne Peled is a board-certified plastic surgeon practicing aesthetic, reconstructive, and breast oncologic surgery in San Francisco.

Considering breast reconstruction? Learn more about your options and see powerful stories from the RealSelf community.