Hi! I am Dr. Lisa Cassileth, board-certified plastic surgeon in Beverly Hills, Chief of Plastics at Cedars-Sinai, 13 years in private practice. My partner, Dr. Kelly Killeen, and I specialize in breast cancer reconstruction, and we are so frustrated with the bad-looking results we see. The traditional process is painful, requires multiple surgeries, and gives unattractive outcomes. We are working to change the “standard of care” for breast reconstruction, because women deserve better. We want women to know that newer, better options exist. Ask us anything!

Proof: http://imgur.com/q0Q1Uxn /u/CassilethMD http://www.drcassileth.com/about/dr-lisa-cassileth/ /u/KellyKilleenMD http://www.drcassileth.com/about/dr-kelly-killeen/

It’s hard to say goodbye, leaving so many excellent questions unanswered!

Thank you so much to the Reddit community for your (mostly) thoughtful, heartfelt questions. This was so much fun and we look forward to doing it again soon!

Comments: 2205 • Responses: 33  • Date: 

muckman67021030 karma

As a male that had a bilateral reduction (gynecomastia) that is very uneven, wavy, and somewhat folded over... oh and missing a nipple on the left side. What is my recourse? Get a lawyer, ask for compensation to a better surgeon to repair? Live with the outcome that is worse than the issue I lived for 20 years that I was very self concious about?

CassilethMD1146 karma

This completely sucks. I've had good luck with these just resmoothing the skin with a combination lipo and excision. You've got to get the fatty spots out as it weighs down the skin and makes it wrinkle and fold weird, and sometimes I fat graft the thin spots as well as areas overresected can stick to the muscle and that looks weird. It's a bad problem, but it is fixable, and you may get your insurance to pay for it especially is you have a real deformity.

propofalling892 karma

Anesthesiologist here - what is your anesthesia team like? Hospital or specialty same day center? Do your patients ever receive a paravertebral block for post op pain as has been the trend for breast reconstruction in recent years?

CassilethMD618 karma

Hi doctor. Speciality center same day, Exparel in the field (LOVE it it's a pain gamechanger for us), discharge to aftercare center for 2-3 days. The Exparel is more of a field block with intercostals added as the surgeons perform it on the field looking directly at the anatomy.

Pinksockathon889 karma

Serious Question: my wife has two different size breasts. More so than the average women. She is a small C cup on one size and a larger DD on the other. We have talked with a few surgeons and never left the consultation with a good feeling about the possible outcomes. What has your expirence been in similar situations? You are welcome to answer here or PM. Thank you in advance!

CassilethMD1749 karma

Love your question. I have a very different philosophy than pretty much everybody else. I think that breasts should always have the same amount of fatty tissue and the same amount of implant. II have three tools, reduction (removes breast tissue), implants, and fat grafting (adds fatty natural tissue). So, if she would like a large C let's say, reduce the DD down and augment both sides with the same implant. Usually need a small lift on the DD side. Or if she wants a DD on both, you can fat graft the C side, possibly reduce the DD side, and augment them both? Get it? It's a little complex, but at the end of any procedure the breast should be the same, essentially. Never augment asymmetrically as they always get exaggerated over time and is inherently the wring answer.

Gl0riousGr0uch712 karma

Here is an immature one, Do you gals every play with your own products?

Like squeezing, bouncing or jiggling in order to ensure you have quality implants?

CassilethMD2299 karma

The implants feel pretty good. My favorite thing is when the husbands/boyfriends check the implant out they always close their eyes. Hilarious.

voedselpakket640 karma

Could you share one of your most positive experiences helping a patient?

CassilethMD2789 karma

Absolutely... recently one of my young breast cancer patient got married. One year prior, she was diagnosed with breast cancer, and initially she was told she would have long scars, no nipples, and would be lucky to look good in clothes at all. We of course did a nipple sparing mastectomy and she has no visible scars. She sent our office her wedding photos of her in a strapless dress? How fabulous to allow this young woman to move on with her life, and sorry to be superficial, to be HOT after having breast cancer!!!!

Sythus254 karma

A day or two on reddit there was an article about utilizing fat stem cells for breast augmentation. What do you know about this, how does it differ from fat transplant, and how does that differ from silicon, which is your preference?

CassilethMD397 karma

You can actually sort the fat aspirate from liposuction to get more stem cells out of it. The process can take an hour, where after completion, the machine gives you a more pure stem cell derivitave. It has a higher yield supposedly once put in the breast, but it's most worth it with radiated fields and bad scars. You lose a lot of the fat when you concentrate it, as well, so for skinny girls this is not an option. The perfect augmentation with stem cells would be a fat hipped lower body girl that need a lot of boob boost and didn't mind the extra lipo.

Didsota209 karma

Did you have anything done yourselves?

CassilethMD658 karma

An old babe like me? Of course. I had some seriously hanging eye skin (thanks MOM!) that I had fixed at 40, and of course we are always doing lasers and fillers (grow up in florida with a lot of coppertone oil and pay the price!) I coolsculpted off my mommy tummy and that was awesome can barely tell I have three kids. It's the proverbial candy store, got be careful never to cross over to the weird!

fuckingoff163 karma

Do you only do cancer related reconstructions or do you also repair botched enhancements as well?

What are the principal challenges you face other than managing expectations?

CassilethMD385 karma

Much of our work is revisions and botched augmentations etc. Many of our patients have had 10 or more surgeries :( Capsular contracture, asymmetry, boobs in the armpits, one hard boob, bad scars, one up one down, weird implant fluid squirting out the nipples, ruptured silicone, you name it. The reconstructive aspect has really helped with the cosmetic work, and vice versa.


Hi there! What was the worst botched surgery that you have seen? Have you ever had to turn someone away?

CassilethMD694 karma

This is going to sound awful, but I so so love bad problems from prior surgery. It's like a great opportunity to really do some great things. Last week I had stacked implants, capsular contractures with the ones on top of the muscle, the ones under the muscle had fallen into the armpits, ruptured silicone, and the nipples put too high looking straight up at the top of the boob. When I removed the capsule it was full of free silicone and old black ooze that I think must be from old congealed blood from the last surgery. So much fun to fix that... !!! I know I'm weird!

Neurocadence114 karma

In the 90's I had implants to help after a large fatty tumor was removed. 2 more children and many lbs. later I am actually too large now at DD. I have looked at reduction but I really do not like the keyhole and worry about loss of sensation. Are there options to the keyhole and can sensation be preserved?

CassilethMD198 karma

OK, so you have big boobs with implant in, and don't like lift scars. We've been doing a lot of lollipop only lifts, or circumareolar...it depends on how droopy you are of course. We've also been doing a lot of fat grafting the top of the breast during reductions to give a nice big full look to the top of the breast with these surgeries to make it even better. Another trick is that we leave all the nerves intact from the breast for sensation, it's called "medial pedicle" for the plastic surgery savvy. The old technique, called "inferior pedicle", we never use as sensation is cut to 50%. No thank you. ;)

boobieaficionado110 karma

My girlfriend's sister was diagnosed with breast cancer earlier this year. She's about 75% through with her chemo treatments, and starting to consider her cosmetic options. What general recommendations would you have for a mid-40s African-American woman considering reconstructive plastic surgery after breast cancer?

CassilethMD239 karma

OK, this is a big deal. Breast cancer patients right now really need to advocate for themselves to get a mastectomy that has a short scar and spares the nipples. If she has very droopy or very big boobs, then she may not be a candidate nipple sparing (anything over a DD, or nipples that hang straight down). She has a little time to reasearch if she is in neoadjuvant chemotherapy, and remember, don't take no for an answer!!!! Find a great team that will cater to HER as the patient, and don't always trust the system to do the right thing!!! We are always willing to help out if she wants to contact us, use the [email protected] email.

fuckingoff105 karma

When you see a topless celebrity who's had an enhancement, do you ever critique to your SO or each other?

CassilethMD359 karma

I love one of the HBO series and have been bummed about my favorite character's weird boobs and then she came to me to fix them... I practically fell over myself to do the surgery. High pressure for celebs the poor things are constantly scrutinized!!!! Ok poor things nothing but it's a lot of pressure

LukeCrane31 karma

What is the strangest request that you have had from a client?

CassilethMD132 karma

OK, I had a patient that had an extra set of nipples that were functional, and wanted the breast tissue around it to be bigger, so it looked like a set of four. Does that seem strange?

IKingJeremy30 karma

I imagine this is stressful work.

What are the biggest challenges in your field of work, and what do you find the most stressful?

Also, what do you find the most rewarding?

CassilethMD66 karma

We put a lot of pressure on ourselves to get each case as perfect as possible. It's an imperfect world, though, for example, if a patient has had many surgeries, there may be breast skin stuck directly to the implant capsule, it makes it tough to look perfect and may require two surgeries. The most rewarding is doing surgeries that we create that no one else does... and having happy patients say "why doesn't everybody else do this?" Hell ya!

ennmac27 karma

You say no nipples - surely you must be joking?

CassilethMD56 karma

Clearly you have no idea that mastectomy USUALLY means removing your nipples! One of our big motivators is doing mastectomies sparing all the skin and leaving the nipples in place. It makes all the difference in the world in terms in great looking boobs, and there is no increase in cancer risk. http://www.drcassileth.com/before-afters/breast-gallery/one-stage-breast-reconstruction-after-mastectomy/

Nattylight_Murica21 karma

Have you ever seen the movie Breast Men? If so, did you find it entertaining or a frustrating representation of the industry?

CassilethMD60 karma

OF course I have, that's why I picked this field!! no not really. I doubt I would stare at hot boobs and get myself killed (sorry if this is a spoiler). There's so much crazy hype in plastic surgery (dr 90210, botched, the swan,...) because it's so much about what's sexy and how we relate to it. It's actually feels great to be more of a voice of reason in a crazy world clamoring for unrealistic things.

haleandheartless15 karma

I would like to get surgery for gynecomastia overseas because it's too expensive in America. What do you recommend I do?

CassilethMD60 karma

Really? Our experience is that insurance often covers the procedure. Always do the technique using a VASER as it really cuts out the breast tissue, a scar at the nipple and under the armpit only. This is not the time to skimp my man. You need your chest to look good not like a lumpy bag of golf balls.

absecon14 karma

Is it reasonable to get a breast lift after children? Will the skin just age and go back to droopy?

CassilethMD24 karma

Of course it's reasonable. Wait til you are done with kids. If you are just a little droopy, a circumareolar lift (scar only at areolar) with a round of fat grafting is my absolute favorite, because you don't have to commit to having implants forever and ot pops the volume up jus the right amount. :)

kittykittysnarfsnarf13 karma

No nipples?

CassilethMD64 karma

It's pretty surprising that mastectomies take the nipple. The usual mastectomy makes a horizontal scar across the patient's chest, removing the nipple and an ellipse of normal skin. The nipple sparing mastectomy should be done through an incision under the breast, the "inframmary crease". It's hard to find a team that does this, because most team won't do it. Why? It's harder. They can kill off the skin, called mastectomy flap necrosis, in 30% of cases. It takes longer. Our team has a less than 1% flap necrosis rate we've worked years to be as good as possible, because we really believe this is the better way.

totosmaster12 karma

Thank you for doing this AMA. Do you have a recommended list of doctors who perform similar types of breast surgeries in the United States?

CassilethMD24 karma

I'm currently making a list, because not everyone wants to come to LA for surgery (although why not I say?). I've identified a few other teams, but it's tough. You need the right mastectomy surgeon (ie willing to do nipple sparing) and the right plastic surgeon (ie willing to do direct to implant). These surgeons exist as part of high volume teams. For now, you have to do the groundwork, and if you find anyone great please let us know.

Fraidycat_kitty11 karma

How do you ladies feel about final implants before radiation?

CassilethMD27 karma

Great questions. For years that was taboo. I LOVE putting the implants in before radiation, because operating in a radiated field is higher risk, then you avoid that risk. IF you know you need radiation, make sure your initial plastic surgeon uses acellular dermal matrix in your breast reconstruction (marketing under alloderm or FlexHD). It will drop your risk of capsular contracture down to less than half what it would be.

burnsie039 karma

Hi. My friend has always had very large breasts. They have always caused her discomfort and because of them, she regularly has to visit a chiropractor. She is interested in breast reduction surgery, but the negatives (to her) vastly out weigh the improvements that having the surgery would have on her life. The horror stories are scary enough, but the stories about loss of sensation, scarring, pain, etc that happen even when the surgery is successful, are pretty terrifying. My question to you is whether or not she should get the surgery? In your experiences, do the positives out weigh the negatives?

CassilethMD17 karma

These are our happiest patients, the breast reductions. It's an immediate weight off, literally. The new techniques improve sensation and take the tension off the scars so they look better, and we rarely use the anchor anymore (just lollipop scar) and add to it upper pole fat grafting and some other tricks that make it better. Also get the fat off the armpits at the same time... nice. It's scary, we get it.

ITradeBaconFutures9 karma

Two questions: do you counsel couples if one person feels the other's breasts need some enhancements, just to help make the decision based on facts?

Secondly, and this is for the /r/wallstreetbets crowd, how much is a typical procedure and what does that get the clients/patients? A lot of our guys hit it big in the market, and I think a few were talking about getting some surgery for their partners.

CassilethMD14 karma

Hmm. This is tough because any surgery that a woman gets "for a man" can end in disaster. If she wants the surgery, and you are just the sugar daddy, then at least try to shut up in the consult and say things like "honey, I think you are perfect just the way you are!" or maybe "you did mention a DD, I'm just being supportive here of course". Otherwise you are looking at comments post-op like "you did this to me" "pay to have these removed it's all your fault" etc. Manhattan is high price, you are looking at a minimum of 10K for someone of quality for standard silicone breast aug.

Fraidycat_kitty3 karma

How do patients pay for your work?

CassilethMD3 karma

For breast reconstruction and other reconstructive procedures, health insurance usually covers some or all of the cost. For totally elective, cosmetic procedures (like breast augmentation for example), insurance will not cover it, but we do offer financing through CareCredit. Learn more at http://www.drcassileth.com/new-patients/consultation/

DontGiveaFuckistan3 karma

ok so my girlfriend went from an A/B cup to a medium sized C cup. she received silicone implants via a small incision under the breast.

So it's been approximately 9 months since the procedure and the first 3 months the breasts implants were very, very firm, almost hardlike, now they have soften up a bit.

my question is, when is an approximate time that the final softness or hardness settling in is finally finished? and recently we have felt 1 small hard bump on each breast coming from the natural breast tissue, obviously you cant diagnosis from a simple text, but how common is having small hard bumps form after breast implants?

also, final question, she now sort of regrets getting the implants as seeing that they didn't make her "happy" with her body image, which I tell her women go to the gym to have her current body, anyways, so now she is afraid to sleep to long on them and is afraid they will pop, is it ever so likely that she could pop her implants via her own body weight?

CassilethMD9 karma

Ok there is a lot here. - implants can take up to a year to soften up. exercise is good for them. I don't really believe in massage but it can help with the intial relaxation. - they won't pop. I routinely roll over these things with my chair to illustrate how hardy they are. - the hard spots may be her breast tissue getting pushed forward. These should be checked out. But it also may be that she has early capsular contracture and she is getting some folding of her implant, which feels like a poking fold or a knuckle, and is most common around the edges. - my advice is to completely enjoy her body and see what happens. What fun is having breast implants and a hot body if she doesn't enjoy it? This often happens to women as they get hung up on the details and forget to show off what they have. If it doesn't improve by a year, then follow up with her PS or go for a consult.

BackWaterBackWash2 karma

Do you work on a lot of porn stars?

CassilethMD3 karma

Always back to the porn. These poor ladies... held to an impossible standard, giant implants, low body fat, it's tough for them. Surgeons had been "stacking" implants (bad idea as the stack falls over eventually). Best option is to make a strong breast pocket using a sheeting called dermal matrix and use a big implant. Then you can't even tell they are fake. No, not really, you can!!!! But they look good!

scribblefrog1 karma

What is the worst breast reconstruction you have seen, and how did you improve it?

CassilethMD1 karma

This is a sad question. I saw a patient that had an mastectomy and the skin died, the doctor had tried a tissue expander that was removed, then she needed radiation, It was literally hardened skin tacked directly to the ribs. This is so unnecessary and wrong and angers me beyond belief. In her case, we had to do a tissue flap to put some normal back in there, and a second surgery to fat graft to even it out.

WhiteRastaJ1 karma

Do you have a preference for specific procedures, such as DIEP or TRAM flaps, etc? And why or why not?

CassilethMD1 karma

DIEPS are great flaps and use abdominal fat normally removed in a tummy tuck to reconstruct a breast, spares the muscle. Best for unilateral mastectomy in a patient with some abdominal hang. TRAM is the same thing but takes out one of your rectus muscles (ie half of your six pack) and is a bit old school (ie don't do it if you value being able to sit up).

Patches671 karma

NO NIPPLES?!? Seriously? This is a thing.? OMG. That sounds so horrible. What's going on?

CassilethMD1 karma

From ancient times, (like 1980) they have been doing mastectomy with a wide removal of skin and the nipple. OVer the last few decades, mastectomy surgeons have been allowing more skin to be spared (called skin sparing technique) and let the plastic surgeon come in and do some time of reconstruction, but it's still near impossible to find a surgeon to spare the nipple in a mastectomy. It's teaching an old dog new tricks, asking these oncologic surgeons to perform a nipple sparing mastectomy, which is technically more difficult. Listen, don't take no for an answer, ladies! Patients feel bad when they are diagnosed with cancer and forget to advocate for themselves but that is THE MOST IMPORTANT TIME to do exactly that! Only with the patients insist on a better technique will the standard of care improve. OK, I'm ranting now. But you get me.

robbieeeeee1 karma

Hi Doctors!

I work at a gentlemen's club in Australia and a lot of the more mature aged girls don't want implants but want to be fuller above the nipple if that makes sense, a more youthful looking breast in their words. They definitely aren't sagging for most of them but the fatty tissue has moved below the nipple and they've researched breast lifts but the result is not what they're after. Any thoughts or recommendations I could pass onto them?

CassilethMD1 karma

I see you are a connoisseur of breasts so you will appreciate the answer. 100-200cc of fat graft placed on the upper pole of the breast (the top part) will make it pop again, take the fat from a area you wouldn't mind liposuctioned. Fast recovery, some bruise for a couple weeks, no breast incision.

brainchasm1 karma

Left field question:

My SO has very small breasts (can't hold a pencil under them, etc) and normal to small diameter, very erect nipples. She loves her nips, but wants bigger breasts...is there a specific route she should go, as far as surgical "style"? She's afraid to lose sensitivity or reactivity.

In tandem, she's been considering surgery as a way to get rid of some of the mom-bod she's carrying after three kids...anything new in that arena? Anything that won't keep her flat on her back for a month while she heals?

CassilethMD3 karma

IF she has a little extra fat, she can do conservative lipo, use it for low volume fat grafting to augment the breast, just a body touch up. Easy to do and easy to recover and a huge mommy boost :)


How often do you guys see women with oddly shaped breasts?(i.e. one is larger than the other) And how common is this? Curious as my mom is a plastic surgeon with like 22 years of practice.

CassilethMD1 karma

I would say that it is more common to have breast asymmetry that not. Some special cases, like constricted and tuberous breasts, paitents come in at a young age saying they "look droopy" or "have big areolae" but really they have a congenital abnormality. Ask your mom I'm sure she will say the same :)