FAQs

The definition of breast reconstruction has expanded over the last twenty years. In the past, breast reconstruction was defined as a re-creation of the breast mound with natural tissue or an implant. At this moment, breast reconstruction can also include reconstruction of partial defects of the breast with local tissue flaps or tissue grafts or reconstruction of the entire breast mound with tissue or implants. More on this later. For the sake of simplicity, think of breast reconstruction as the return to a near normal-appearing soft breast mound.

Approximately 12% of women in the United States will be affected by the diagnosis of invasive breast cancer. There are about 275,000 cases of invasive breast cancer diagnosed per year in the United States; there are about 48,000 cases of non-invasive breast cancer diagnosed per year in the U.S. The majority of these women will be treated with breast conservation therapy and not a complete mastectomy. In other words, in the breast diagnosed with invasive breast cancer, only the tumor will be removed with a margin of normal tissue. The majority of the breast will be conserved. The patient may be further treated with various types of chemotherapy/ immunotherapy and/or radiation. The goal of breast conservation therapy is self-explanatory-preservation of the breast mound.

Unfortunately, in some cases, breast conservation is just not possible. It could be that the tumor is too large, or that the tumor is spread out [multifocal], or even because the tumor may be a recurrence from previous cancer. In cases like these, it is deemed too risky or unreasonable to try to conserve the breast. At that point, the team may recommend a mastectomy not only for safety’s sake but also because it may make the most sense in preparation for a breast reconstructive surgery.

A mastectomy involves the removal of the breast tissue by the oncologic breast surgeon. In the majority of cases, the areola-nipple complex is removed as part of the surgery. Yet, oncologic breast surgery is also evolving. There is an accepted procedure known as a nipple-sparing mastectomy. A patient must meet certain criteria to undergo this procedure but the patient gets the benefit of keeping her native areola and nipple.

A breast surgeon is usually a person who has trained in general surgery and may or may not have pursued an oncology breast fellowship. Plastic and Reconstructive Surgeons who have also completed training in general surgery (like Dr. Heffel and Dr. Kordestani) also sometimes perform mastectomies as they are well experienced in all types of breast surgery.

A mastectomy entails the removal of the breast mound and usually the nipple-areola complex.  In this way, a complete mastectomy significantly reduces the chance of breast cancer recurrence. The chance of recurrence never goes to zero but it is dramatically reduced. Breast surveillance is still mandated. Along with mastectomy, radiation therapy is often used as an adjunct to decrease the possibility of local recurrence.

The short answer is NO.

No one has to get breast reconstruction. In fact, breast reconstruction is purely elective. However, by law *, women who undergo breast cancer treatment or a mastectomy have to be made aware that a breast reconstruction is an option. Health insurance plans, Medicare, and Medicaid are legally obligated to cover breast reconstruction.

That being said, many women opt not to have breast reconstruction. Some defer on breast reconstruction because of their age. Others defer simply because they wish to avoid more breast surgery. But there is a segment of the mastectomy population that decides to not go forward with surgery simply because they are not well informed. The surgical/oncological groups are doing their utmost to make up for this deficiency. Nearly ALL WOMEN are candidates for some type of breast reconstruction. The exact type of reconstruction depends on the patient’s history, their presentation, their cancer diagnosis, and the reconstructive team involved.

*In 2015, the American Congress passed the Breast Cancer Patient Education Act. President Barak Obama signed the bill into law on December 18, 2015, legally requiring patients with breast cancer be offered plastic surgery consultations and information about breast reconstructive options prior to oncologic surgery. The American Society of Plastic Surgeons (ASPS) was active in promoting these ideas to become bills and eventually laws.

The United States Congress passed a bill mandating that health insurance companies cover breast reconstruction and President William J. Clinton signed the bill into law effective in 1999. Therefore, if a woman has health insurance, Medicare, or Medicaid, then breast reconstruction of whatever type should be covered.

Loss of sensation.

A mastectomy involves the removal of breast tissue. Nerve fibers do pass through that breast tissue to the skin of the chest wall. When a complete mastectomy is performed, the sensory nerves that travel through the breast are surgically removed as part of the procedure. As a result, the skin over the chest becomes numb [insensate]. This loss of sensation is pretty much permanent. Microsurgeons are working on reversing the loss of sensation by attempting to connect sensory nerves in flaps to sensory nerves remaining in the chest. This effort looks promising, but it is not yet standard practice.

One of the primary complaints by women who have undergone a mastectomy is the loss of sensation at the chest. There are reports of women burning the skin of the chest with an iron or bruising the chest because of the lack of feeling. When we see a patient in consultation before their mastectomy, we attempt to inform them of this expected outcome ahead of the surgery.

Traditional breast reconstruction was developed by Plastic and Reconstructive Surgeons to create as normal an appearing breast as possible. When you ponder that concept, you must admit it is a lofty goal. Reconstructive surgeons were actually trying to figure out how to construct some semblance of an organ after it had been completely removed. These goals and concepts derived from the core history of Plastic and Reconstructive Surgery which has always had the objective of “creating form and function.”

There are several options for breast reconstruction and the reconstructive surgeons at The Associates A Plastic Surgery Group will go over in detail each of the possible options. Below we will discuss breast reconstruction with your own tissue which is termed autologous breast reconstruction. Below we will also discuss implant-based breast reconstruction which is the reconstruction of the breast mound with tissue expanders and/or implants.

First, however, we will discuss the timing of breast reconstruction.

What Is Delayed Breast Reconstruction?

Delayed breast reconstruction is defined as the creation of the breast mound at a time after the mastectomy. That time maybe a few weeks or several years. Some women have presented to us several years after a mastectomy and have the desire to undergo breast reconstruction. In this situation, they would undergo delayed breast reconstruction. This reconstruction procedure would probably require the initial placement of a tissue expander followed by tissue expansion and then reconstruction with one or a combination of various reconstruction methods.

What Is a Tissue Expander?

A tissue expander is basically an empty silicone balloon that is intermittently filled with sterile saltwater by the Plastic and Reconstructive Surgeon.  The tissue expander is placed under the chest skin in a sterile fashion. The surgical site is allowed to heal. Once the site is safely healed the surgeon will start to expand the device by accessing a fill port on the tissue expander.  The tissue expander when completely filled somewhat resembles the shape of a breast. We use this device to recruit skin with which to work and also to create a space for an eventually reconstructed breast.

What Is Delayed-Immediate Breast Reconstruction?

This technique was first implemented by Plastic and Reconstructive Surgeons at Houston’s M.D. Anderson Cancer Center. Sometimes, it is unclear prior to the mastectomy whether the patient will be treated with external beam radiation therapy (See the heading External Beam Radiation Therapy). In this situation, the reconstructive surgeon would place a tissue expander as a “babysitter” implant device. The tissue expander most likely will be inflated at the time as the mastectomy with additional expansion carried out later in the clinic. The goal in delayed-immediate breast reconstruction is to expand the skin envelope to the final predetermined volume prior to radiation therapy and to preserve some skin with which to work later.

Answer: Both.

External beam radiation therapy is a double-edged sword. It has the benefit of decreasing the chance of local recurrence of the tumor. Radiation therapy also causes normal tissue damage and eventual scar formation.

Think of it this way. Radiation is basically energy directed at the breast/ chest wall. The radiation energy induces damage in cells, especially cells that are dividing relatively rapidly such as cancer cells. As a result, cancer cells are more prone to radiation damage and are consequently destroyed. Normal healthy cells are destroyed also, just not as frequently as cancer cells. In short, external beam radiation therapy does cause collateral damage.

You can understand this concept if you imagine what happens to your hair when you expose it to energy-like heat from a curling wand.  If you direct the heat at the hair it ends up softening somewhat. If you direct lots of heat at the hair, the hair ends up contracting and eventually burning. Radiation conceptually does the same thing.  It has the beneficial effect of destroying cancer cells. It has the detrimental effect of delivering energy to the normal tissue in the breast. The end result of this delivered energy directed at normal tissue is inflammation of the tissue of the chest wall and eventually the formation of scar tissue. So, some type of scar tissue is generated at the chest wall everywhere radiation is delivered.

If you happen to undergo external beam radiation therapy, your radiation oncologist should discuss the risks and benefits of this therapy with you. Some patients tolerate radiation therapy quite well. Some patients develop irritation of the exposed skin termed radiation dermatitis. Some patients can develop radiation-induced ulcers/skin wounds. When the radiation dermatitis is severe the therapy is occasionally put on temporary hold.

To Plastic and Reconstructive Surgeons, the skin is very precious because that tissue is something we manipulate in reconstructive surgery. Surgeons, and especially Plastic and Reconstructive Surgeons, do not like to work with scar tissue. Scar tissue is described as being fibrotic. Sometimes it is as hard as a piece of wood. It neither moves well nor stretches like normal skin. Imagine if the whole left chest has been radiated. Some degree of fibrosis is now present in the left chest. Reconstructing a left breast from tissue that is fibrotic is difficult, to say the least. For this reason, in delayed-immediate breast reconstruction, the surgeon will place a tissue expander at the chest in order to preserve at least some of the skin envelope even if it becomes fibrotic. Trying to expand that left chest wall skin with an expander once it is fibrotic would prove difficult and really not possible. If the left chest wall skin is expanded prior to commencing the radiation, the expansion works and then the reconstructive surgeon has at least some precious, though fibrotic, skin with which to work.

The benefit of using tissue [skin] that is outside of the radiation field might now be obvious. Plastic and Reconstructive Surgeons have the ability to bring tissue distant from the radiation field, the abdomen for example, and use that healthy and soft tissue for breast reconstruction. That kind of tissue is very pliable and makes the construction of a breast mound much easier.

Nearly everyone who has a post-mastectomy defect or a post-partial mastectomy defect is a candidate for some type of breast reconstruction. There are so many available techniques for breast reconstruction that the probability of finding a method of reconstruction is fairly good.

A few patients will meet the criteria for all types of breast reconstruction. A few patients will be limited to one type of breast reconstruction. The take-home point here is that your experienced Plastic and Reconstructive Surgeon can likely find some means of reconstructing the breast. Obviously, a person with breast cancer would like to be a candidate for all available options for breast reconstruction. While that situation may be present sometimes, it is not present all the time. An example of some fictional patients should help.

Jane Doe is a 42-year-old woman who was diagnosed with non-invasive right breast cancer and will undergo a right mastectomy. No radiation therapy is anticipated. She desires immediate breast reconstruction following a planned right mastectomy. She stands 5 feet 7 inches tall and weighs 180 pounds. Her cup size is C-D. She has some extra tissue in the lower abdomen due to weight gain. She takes no medications and has no allergies. She can run 3 miles on her Stairmaster without chest pain or shortness of breath. She has never had any major surgery.

Is this patient a candidate for breast reconstruction?

Absolutely.

What are her options for breast reconstruction?

She is a candidate for all options: implant-based reconstruction, reconstruction with a pedicle flap, reconstruction with a pedicle flap + implant, reconstruction with a free flap, reconstruction with fat grafting. The objective of the patient and the surgeon is to find the right operation for this patient. In our humble opinion, if only one breast is to be reconstructed, the best option for this patient would be reconstruction with a free abdominal flap. While implant-based reconstruction is an option, it is our opinion that an implant just cannot match the look and feel and lifespan of real tissue. She is healthy and she will tolerate a 6–8-hour operation under general anesthesia. We would advise a procedure known as a DIEP flap.

Jane Buck is a 67-year-old woman who was diagnosed with multifocal non-invasive right breast cancer and will undergo a right mastectomy. No radiation is anticipated. She desires immediate breast reconstruction following the mastectomy. She stands 5 feet 7 inches tall and weighs 195 pounds. Her cup size is C. She has some redundant tissue in the lower abdomen. She takes medications to control her diabetes, high blood pressure, and COPD. She still smokes cigarettes. She gets tired after walking up one flight of stairs and can almost walk one block on a flat surface. She has had one angioplasty procedure 2 years ago.

Is this patient a candidate for breast reconstruction?

Absolutely.

What are her options for breast reconstruction?

They are limited because she is not the healthiest of patients. She has coronary artery disease, already; never mind the risk factors of diabetes and high blood pressure. She cannot walk very far without feeling stressed.

This patient is not a candidate for any operation that might take 6-8 hours under general anesthesia. She is probably a candidate for implant-based reconstruction, short operations that take 90 minutes. Because of her health status, she may not get the optimal breast reconstruction result.

When your Plastic and Reconstructive Surgeon uses your own tissue for purposes of reconstruction, that technique is referred to as Autologous Reconstruction.

When your Plastic and Reconstructive Surgeon uses your own tissue for purposes of reconstruction, that technique is referred to as Autologous Reconstruction.

There are several autologous reconstruction techniques available and more might be on the way.

1. Reconstruction of the breast with a deep inferior epigastric artery perforator flap. This flap uses extra abdominal tissue from the lower abdomen for breast reconstruction.
2. Reconstruction of the breast with a superficial inferior epigastric artery perforator flap. This flap uses extra abdominal tissue from the lower abdomen for the reconstruction of the breast.
3. Reconstruction of the breast with a superior gluteal artery perforator flap. This flap uses buttock tissue for the reconstruction of the breast.
4. Reconstruction of the breast with an inferior gluteal artery perforator flap. This flap also uses buttock tissue for the reconstruction of the breast.
5. Reconstruction of the breast with a profound artery perforator flap [a good choice for small breasts in thin women]. This flap uses tissue from the upper inner and posterior thigh for the reconstruction of the Breast.
6. Reconstruction of the breast with a Transverse Upper Gracilis flap (#5 is a better choice, in our opinion).
7. Reconstruction of the breast with a lateral thigh perforator flap. This flap uses the lateral thigh tissue for the reconstruction of the breast.
8. Reconstruction of the breast with a pedicled transverse rectus abdominis myocutaneous Flap [TRAM flap}. This flap uses tissue of the lower abdomen for breast reconstruction. The downside of this flap is that unlike the DIEP flap, it harvests the complete rectus abdominal muscle. In our opinion, the DIEP flap is a better option because the muscle is preserved and the blood supply is more robust.
9. Reconstruction of the breasts with a pedicled latissimus dorsi myocutaneous flap. This flap uses tissue of the posterior thorax or back for the reconstruction of the breast. This flap might be an excellent choice for some patients. This flap can be combined with an implant and other materials.
10. Reconstruction of a partial mastectomy defect with a latissimus dorsi perforator flap. This flap is useful for local breast reconstructions. It utilizes skin and fat only and preserves muscle tissue.

Take-home point: Several options for autologous breast reconstruction exist. Autologous reconstruction can be tailored to the patient. For example, some patients may have no extra lower abdominal tissue or they may not want any scar on their abdomen. In these situations, the Plastic and Reconstructive Surgeon can elect to perform reconstruction with a profound artery perforator flap or one of the other perforator flaps listed above.

A perforator flap is a flap of tissue that contains skin, subcutaneous tissue (fat), and blood vessels only. The harvested blood vessels perforate the muscle and are not harvested with the muscle.  In days gone by, we Plastic and Reconstructive Surgeons would harvest the flap with skin, subcutaneous tissue, muscle tissue, and blood vessels. The perforator flap does not harvest muscle and therefore preserves muscle tissue and its function.

Take-home point: The muscle is preserved with a perforator flap. The vessels perforate the muscle. Fine dissection through the muscle preserves the muscle and frees the vessels.

The DIEP Flap

DIEP is an abbreviation for the deep inferior epigastric artery perforator flap. It is one of the most common autologous flaps in use for breast reconstruction. Plastic and Reconstructive Surgeons term it the gold-standard of breast reconstruction.

At the abdomen, the preserved muscle is the rectus abdominis muscle. This muscle is the one that allows you to perform sit-ups or flex the chest towards the hips or do a leg lift exercise. It can give the “six-pack appearance.” It is an important muscle. Each person has two muscles, one to the left of the midline abdomen and one to the right of the midline abdomen. In the past, harvesting one of these muscles for breast reconstruction did not create too much of a deficit at the abdomen because the remaining muscle, the one not harvested, would compensate for the loss of the other muscle. If both muscles are harvested for breast reconstruction, the 2-muscle deficit creates a more noticeable physical defect and leads to laxity of the anterior abdominal wall.

Take-home point:  The DIEP flap preserves the rectus abdominus muscle, the abdominal six-pack muscle.

When a DIEP is harvested for breast reconstruction, only the skin, subcutaneous tissue, and vessels are collected. The muscle is left behind attached to the anterior abdominal wall. Less muscle harvest equals more muscle function. When 2 DIEP flaps are harvested, both muscles are preserved which means the better overall function of the anterior abdominal wall musculature. This result should seem logical and intuitive.

When the DIEP flap is used for breast reconstruction, it is used as a free flap. Microsurgery is required to attach the artery and vein of the flap to an artery and vein in the chest. Typically, we attach the blood vessels of the flap to the internal mammary artery and vein using a surgical microscope and extremely fine suture, and a device called a coupler.

The DIEP flap procedure for breast reconstruction is a complex procedure that requires a team consisting of two surgeons, 2 technicians, an instrument technician, and a circulating nurse, minimum. Two surgeons cooperate during the harvest of the flap and also during the microsurgical portion of the procedure. It is a multi-step procedure that requires time and attention to detail.

Once the flap is harvested from the abdomen, the flap is transferred to the chest. At the chest, the blood vessels from the flap are connected to blood vessels in the chest, typically the internal mammary artery and vein. The flap is then tailored to fit the chest, a procedure called insetting of the flap. As the flap is being positioned on the chest wall, one of the surgeons proceeds to close the abdominal donor site. Closure of the abdominal donor site is much like the closure of an abdominoplasty surgery site. However, it is important to understand that the resulting surgical scar from a DIEP flap is typically located higher on the anterior abdominal wall. An abdominoplasty procedure is a cosmetic surgery procedure while a DIEP Flap is a reconstructive surgery procedure. There is a difference.

Once the flap is inset on the chest wall and satisfactory blood flow is confirmed, and once the abdominal donor site is closed, the procedure is largely complete. The patient is typically admitted to the recovery room and then a special unit familiar with flap reconstructive surgery. The procedure itself takes about 5- six hours but recognize that there is also a time in the operating room spent prepping the patient for surgery, putting the patient to sleep, positioning the patient, applying dressings to the patient at the end of the procedure, and transporting the patient. When all is said and done, the procedure is more on the order of 8 to 12 hours. After the recovery room, the patient goes to a floor room and is monitored. When all goes well, the patient is usually discharged to home with special instructions on post-operative day number three. The length of stay in the hospital is now approaching 2.5 days which is remarkable.

Take-Home Points:

1. Breast reconstruction is a completely elective procedure.
   1. Every woman who must undergo a mastectomy or partial mastectomy should be informed that there are options for reconstruction. Some women do not pursue reconstruction.
   2. Partial mastectomies can create defects that could benefit from reconstruction. These reconstructions are often missed because some medical professionals do not realize that they can in fact be fixed. We at The Associates A Plastic Surgery Group do understand how to perform local perforator flaps for partial mastectomy defects.
2. Several options for breast reconstruction are available.
   1. We at The Associates A Plastic Surgery Group perform ALL the types of breast reconstruction noted in this article. Why are perforator flaps so common at places like Johns Hopkins University Hospital, Duke University Hospital, MD Anderson Cancer Center, UCLA Hospital, and other major cancer centers? The answer has to do with long-term results, long-term costs, and quality of life issues.
3. The Plastic and Reconstructive Surgeon should tailor the operation to the patient’s medical and physiologic status.
   1. Free flap breast reconstruction with a perforator flap is state-of-the-art breast reconstruction. Some women will not be candidates for this type of reconstruction. Many wills.
   2. Great results can be achieved with a flap and an implant and ancillary procedures.
4. Implant-based reconstruction can provide great results in the case of bilateral mastectomies without any radiation. It should not be surprising to find out that if identical mastectomies are carried out and if identical implants are placed, identical breast size will be the result. In select candidates, bilateral reconstruction with implants can provide a very symmetric and aesthetically pleasing result.

You should be aware that breast implants are not without their own set of problems and they do not last forever. If you are thinking about implant-based reconstruction, The Associate’s A Plastic Surgery Group will discuss the pluses and minuses of implant-based reconstruction with you.

We understand that the diagnosis of breast cancer is psychologically traumatic for the patient and also for those who care about the patient.

At the first consultation, we have found that too much information is overwhelming and really goes in one ear and out the other. Most patients have more important issues circulating in their minds other than what type of flap or implant is available for reconstruction.

At the first visit, we generally get to know the patient. We discuss the reconstruction pathway in very broad terms just to get the patient started thinking about reconstruction. Generally speaking, the earlier breast reconstruction is started, the easier it tends to be for patients and reconstructive surgeons. In addition to presenting some very broad information to the newly diagnosed breast cancer patient, we collect important information such as who the breast surgeon might be, who has been chosen as the oncologist, who the primary care doctor might be. We collect pathology information if it is available. We review past medical history and past surgical procedures, especially those on the breast and abdomen. We perform a routine physical exam, perform breast measurements and take photographs. And then we schedule a second visit.

We have resources in the clinic that we loan out to patients so that they may fully understand their options for reconstruction.

Often we physicians are accused of being too rational and scientific when we encounter a patient. [Breast cancer = mastectomy = reconstruction] We surgeons often do not discuss how the diagnosis of breast cancer affects the patient and the family.  Patients are encouraged to discuss how they feel about the diagnosis. Other important issues may be going on in the life of the patient. These other issues could affect the reconstruction in ways that only become apparent once reconstruction is started.  A patient may feel overwhelmed by the diagnosis of breast cancer. We ask the patient to remember that breast reconstruction can be delayed if the diagnosis is overwhelming.  Treatment of breast cancer should not be delayed.

An angiogram is a study performed in the radiology department. It is a way of mapping and photographing the blood vessels in the body. In advance of a microsurgery procedure, it is useful to know where the blood vessels are located and if the blood vessels are even where they are expected to be. The angiogram allows the microsurgeon to identify the dominant vessels in the flap and we can actually mark the location on the skin with the use of a hand-held doppler device. CT angiograms use radio-opaque intravenous dye and a scanner. An MR angiogram uses a magnetically sensitive dye and a scanner. We always use one or the other type of angiogram depending on the flap we plan to use for reconstruction.

Nicotine-containing products such as cigarettes, vaping products, and nicotine gum need to be discontinued well before the mastectomy and any reconstructive surgery. Cigarettes contain many toxins in addition to nicotine. We do know a great deal about nicotine and it is quite harmful to small blood vessels as it makes them much smaller in diameter or closes them off completely.

Smoking of nicotine-containing products should stop 4 weeks prior to surgery and hopefully never recommence.

Answer: Tamoxifen.

If you are taking Tamoxifen as part of your adjuvant therapy for hormone-positive breast cancer, please inform us. Tamoxifen is known to affect the very small vessels in a flap and we generally recommend stopping this medication 4 weeks prior to surgery and re-starting the medication about 7-14 days after reconstruction. This potential complication has been recognized since 2012 and as a result, newer generation aromatase inhibitors have replaced tamoxifen. Medications such as anastrozole [Arimidex™] and letrozole [Femara™] [estrogen production inhibitors] do not adversely affect microsurgery flaps, as far as we know. We will discuss this issue with you and your oncologist.

When we review your medical history and what dietary supplements you might take, we will identify other medications which we might want to stop.

Answer: 6 months to 12months.

Studies have clearly demonstrated that a delay period should exist between the end of radiation therapy and microsurgical reconstruction. Radiation adversely affects deeper structures in the chest, notably blood vessels. If microsurgery occurs too soon after radiation therapy has finished, microsurgeons have noted that the complications from microsurgery are increased. Radiation irritates the target vessels in the chest and the vessels become easy to tear.

That’s a fair question.  Unfortunately, there are no two patients that are exactly the same. That being said, many patients tend to need the same types of procedures.

Most patients are candidates for post gastric bypass procedures once they have effectively recovered from their original gastric surgery.  To be a candidate, you must be at least one year out from your gastric procedure AND you need to be stable and plateaued with your weight.  We do not want to take you to surgery if your weight is still going up and down.  We really want to plan for your surgery when your weight is stable.  If you think it through, that just makes the most sense.

Most often the gastric bypass team has coordinators that work with us to get you ready and to get you to us.  We interact with these coordinators to get you “optimized” in preparation for the evaluation.  I have to be clear here.  It is OK for you to show up 6 months after your gastric procedure to be educated about the different possible procedures—It is NOT OK for you to undergo the procedures until one year has passed AND you have plateaued.  We really do not want to operate on you and then you lose another 20-30 pounds and be forced to undergo the procedures again.  That would be very unkind to you and would be incredibly costly.

Planning goes a long way.  We are here to help.  So let’s chat.  Again, one step at a time.  First, lose weight and be happy and comfortable.  Then, come and see us.

That’s a very interesting question.  Most patients actually do not know the differences.  The older gastric bypass operations were actually mal-absorptive procedures.  That means that the anatomy of a patient was physically altered so that the absorptive surfaces of the GI tract were actually bypassed.  In other words, the place in your gut that would be absorbing food would be bypassed.  If you cannot absorb food, then you cannot gain weight.  These operations unfortunately were plagued with physiological problems, along with dumping syndromes since so much volume was being lost.

As opposed to the older bypass procedures, the newer procedures like the gastric sleeve, actually, mechanically make the stomach smaller.  By making the stomach smaller, you have less space to be able to collect food.  Less space translates into less food, and therefore less chance for absorption.  In this way, the effect is not so much physiologic as it is mechanical.  The stomach can only expand a bit to accommodate the food bolus over time and so the patient literally starts to lose weight.  This procedure has been found to be incredibly effective in weight loss.  The patients also have been found to be more ready to undergo additional procedures.  Along with this, their weight loss has been shown to last longer and be more permanent.

Most often, after massive weight loss, patients end up losing a tremendous amount of fat and body “filler.”  With this in mind, many complain that their body seems to genuinely just deflate.  That is understandable.  But that leaves many with lots of skin excess.  This affects the torso, and central trunk area most.  It also affects the medial thighs, the arms, and the breast areas.  So it is often these areas that are most concerning in regards to the residual effects of massive weight loss.

The trunk and torso are the most common areas that seem to be affected.  Most patients present with lots of extra skin here.  To address this excess skin, there are a few operations that can be considered.  The first is an abdominoplasty or a “tummy tuck.” This tends to address the vertical excess that affects most patients.  The operation resects the skin in the anterior trunk or abdomen.  The loose tissues in the mid aspect of the abdomen are also plicated/brought together.  The abdominoplasty is a good solid procedure and has lots of benefits.  It gets rid of the excess skin in the lower abdomen and it allows a better contour and appreciation of the anterior trunk.  Unfortunately, it is not necessarily the right answer for everyone.  For some patients, the excess skin can be impressive.  It not only affects the anterior trunk, but it also affects the flanks and the back.  In these patients, a traditional abdominoplasty may not be the ideal answer.  In patients with a tremendous amount of skin, even after an abdominoplasty, the patient is often left with residual excess skin at the flanks and in the back.  Most often, these patients return a year or two later dissatisfied with the procedure and its cosmetic results.  This is because they underwent the wrong procedure.  In patients that have a tremendous excess of skin in all of these areas, the belt lipectomy or a circumferential lipectomy is a far better choice.

A circumferential lipectomy or a belt lipectomy is like a tummy tuck that goes all the way around the body.  In this way, the procedure removes all the excess skin from the anterior trunk, the flanks, and the posterior trunk.  It allows the lateral thighs to also be elevated and supported AND it pulls the buttocks area and hind region upwards.  For many patients who have excess skin all the way around, this is the more appropriate/ideal surgical intervention.  In this way, the excess skin from ALL areas of the trunk is removed, not just the front.  This procedure has been tried and is effective and is the one that should be advocated for these types of patients.

Along with a circumferential lipectomy, other procedures are often advocated.  Again, please remember, not every procedure has to be done on every person.  It all depends on the patient and what they want addressed.  Some may want everything addressed; Some may only want the arms or the thighs addressed.  It depends solely on you and what you think will make you happy.  Again, that being said, many patients return after a belt lipectomy and want their arms or their thighs addressed.

A medial thigh lift is another common procedure performed.  It allows us to resect all of the extra skin in the medial thigh area and then to bring the tissues together and give the medial thigh a much-deserved final contour that fits with the rest of the body.  We sometimes use liposuction/lipocontouring as an adjunct.  We NEVER consider lipocontouring by itself in the medial thighs.  Since the medial thigh tissues and skin are so thin and lax, if you simply use liposuction here, the tissues will simply fall apart.  You literally have done nothing except make the tissues and the overall contour look worse.  For this reason, we advocate BOTH skin and fat resection here.  We believe you need to be more aggressive here to end up with a good result.  Again, the liposuction can be used as an adjunct or in addition to the actual skin resection but it cannot and should not be used as the only intervention. Moreover, we use the laser Harmonic scalpel to minimize the swelling.  This makes the incision less problematic and allows the tissues to heal faster.

Along with the medial thigh lift, many patients ask for a brachioplasty or a surgery for their arms.  Those patients that have endured massive weight loss present with a concern about their arm excess skin or what many refer to as “my bat wings.”  This excess skin seems to hang in the arm area and is always a reminder of their previous self.  To address this, we advocate resecting the skin and recontouring the underlying tissues to give the patient a very nice contour.  Again, as with the medial thighs, lipo-contouring can be used as an adjunct.  However, the skin and fatty resection is essential to give the needed final contour.  Without it, the operation seems half finished.  Also, our experience has shown that the use of the harmonic or “laser scalpel” minimizes post-operative swelling and post operative scar formation and scar hypertrophy.

The breasts are the next most often seen procedure.  With massive weight loss, the breasts suffer a great deal of volume loss.  When patients present after their gastric bypass procedure, they often are less bothered by their breasts since unlike the arms, they are not as exposed.  However, in time, the focus does return to them.  To address the laxity of the breasts, we often recommend a breast augmentation along with a vertical or an anchor type of breast lift. The implants allow us to give the breast volume while the lift allows us to resect the lower breast tissue/skin that is simply hanging down and is unsightly.  Often additional adjustments in suture lines are needed to get the breasts to their final form.  These additional adjustments are often done in the office as opposed to in the operating room.

I believe everyone is a good candidate.  It just depends on what you wish to undergo.  Once you have plateaued in your weight, you need to sit and look at yourself and see what you would like improved.  We can then sit with you and look at the options and see what would be best for you.  Again, remember, no two people are the same.  The plan has to be individualized to you.  You have to have realistic expectations.  Then, we have to sit with you and plan what makes the most sense for you.

Good question.   As I mentioned above, you are always welcome and see us whenever you wish.  This is so that we can meet and make plans.  I would suggest/recommend that you come at the earliest, about 6 months after your gastric surgery.  We can then take the time to educate you in person about the multiple possible procedures.  Does that mean you will need all of them? No.  It simply means that we will educate you about all of them.  Then when a year has passed and you have maximized your weight loss AND your weight has plateaued, then we can seriously sit down and plan what makes sense for your body and what you wish to get.  By doing this, you have control over the situation.  Our job is to help you—Our job is not to take over the control.

The most common procedures that apply to the abdomen or the skin excess of the abdomen and trunk are the abdominoplasty procedure, the belt lipectomy procedure and the fleur-de-lys midline addition to the abdominoplasty procedure.  There are other procedures that can be done like the reverse abdominoplasty or the lateral truncal abdominoplasty.  However, these are not as commonly performed.  For most patients, after undergoing gastric surgery and having seen massive weight loss, one of the three procedures I mentioned earlier is most common.

I have already discussed the abdominoplasty and the belt lipectomy procedure at length.  I have not explained the fleur-de-lys midline abdominoplasty.  I will do that now.

The Fleur De Lys (FDL) midline addition to the traditional abdominoplasty is a wonderful procedure that adds much to the original abdominoplasty.  In the more traditional abdominoplasty, the lower abdominal tissues are resected.  This is to address the most often seen “vertical” excess.  This is the tissue that drapes poorly in the lower abdomen and can be resected giving a better overall contour.  In some patients, however, this is not enough.  In some patients, they not only have vertical excess, they are also hampered by “horizontal” excess.  In these patients, a traditional abdominoplasty does a POOR job of a final result.  In these patients, if they undergo a traditional abdominoplasty, they are often left with excess tissues in the midline/core area.  This is easily seen when you can pinch a large amount of extra skin in the mid abdomen, AFTER an abdominoplasty.  In these patients, a fleur-de-lys midline incision allows us the luxury of resecting the extra midline tissues.  This does require a midline incision in addition to the traditional transverse incision.  Using this midline incision, we can resect a tremendous amount of excess skin that would otherwise be left behind.  In some cases, as much as 6-8 inches of extra skin is resected.  That is 6-8 inches of extra skin that would otherwise just sit there and hang.  It is an interesting visual.  Again, this is not indicated for every patient—But it needs to be considered for every patient.

A brachioplasty or plastic surgery for the arms is an effective intervention for patients after massive weight loss.  In many cases, patients do well and have only this as a detractor since their arms are not hidden.

A brachioplasty allows us to resect the excess skin, or as some call it their “bat wings.”  We often resect the skin and the underlying tissues, using the harmonic laser scalpel.  This allows us the ability to minimize the scar and maximize the recovery. Patients that undergo a resection with a laser scalpel tend to have minimal post-operative swelling and tend to recover extremely fast.

There are multiple procedures that apply to the breasts.  The real important thing here is to see what the patient really wants—What is their expectation?  In patients that undergo massive weight loss, the breast tissue often involutes.  This leaves the tissues both lax and empty.  To address this most effectively, we often recommend that patients undergo BOTH a breast augmentation and a lift.  The breast augmentation gives us the ability to put in an implant that gives the patient the FILL that they are missing.  The lift procedure gives us the ability to put the breast tissue back to where it should be to fit the implant and also to give the patient a nice perky new look.  In most cases, there is lots of skin resection.  This is necessary to again make sure that the breast fits the implant and there is not too much skin left over.  If you do not take the skin and simply place an implant, there will be a mismatch of the outside skin and the inside filler.  This would be considered a poor result and so is not recommended.

In some cases, a lift will do just fine.  In other cases, an augmentation does well.  Again, it all depends on the patient’s anatomy and on their expectations and hopes.  Our job is to see what you have and see what you want.  Our task is to get you there in a safe and directed fashion.

The face and neck areas often shrink back after gastric bypass surgery and are not areas of focus for skin resection procedures.  In a handful of cases, there is some skin excess and that can be addressed with a myriad of different interventions.

For the neck, a neck lift is a possibility.  With this procedure, we tend to bring the muscles of the neck together to get a very nice contoured base at the muscle.  The overlying skin is then stretched to the sides.  The excess skin is resected, leaving behind a nicely contoured look.

Similar to the neck, the face can be addressed with a facelift to resect the extra skin.  The face though is different from the neck.  The face can and in some cases is well addressed simply by injecting fat into the hollowed out areas.  As the bypass procedure has shown, the excess fatty resorption leaves the face hollowed.  This can be addressed by filling the face to correct for the hollowing, AND/OR by resecting the excess skin.  Skin resection of the face by itself is the more older version of the intervention.

This set of possible procedures (fat grafting, neck lift, mid face lift, full face lift) needs to be much more fine-tuned to the patient.  This is a new and exciting area of plastic surgery since before our only option was simply skin resection.  Now with the advent of more purified fat grafting techniques, we can do much more here than previously known.  Again, the exact procedure depends on the patient, their wishes and wants and their expectations.

That is a great question.  Most procedures take time.  When we are dealing with massive weight loss, and lots of hours of skin resection, we at times are dealing with 7, 8, 9 or ten hours of surgery.  These extended times can put a tremendous burden on the patient, and on the surgical team.  For this reason, we have worked out methods of mixing and matching types of procedures to allow the patient to plan, safely and effectively for their final end product.  For example, if a patient wants to have their breasts, their arms and their legs done, we suggest and recommend completing their breasts first.  We would then have them do their arms and their medial thighs in a second combined, “staged” procedure.  This allows us the patient to undergo the surgery in a shorter time, making it safer for them.  It also allows them time to recover and heal more effectively. Again, this is something that is assessed on case-by-case scenario.

As for safety, the surgical team and the anesthesia team completing the procedures are the best at what they do.  For this same exact reason, if they believe that a procedure or a grouping of procedures places the patient at undue risk, they will have a discussion with the patient to change the procedure or to mix and match the procedure in a different way to ensure the highest safety and the least risk.

All of our procedures are completed in the hospital setting.  We provide the best surgical team.  However, without the most effective anesthesia or the most capable nursing, the patient would still be at risk for an adverse outcome.  We currently advocate completing our procedures in the main hospital system, where we can use the full breath of the anesthesia team and the best nursing recovery teams available in the region.

That is another great question.  YES.  YOU CAN FINANCE YOUR PROCEDURE.  Each and every one of the local banks has new medical financing tools.  They are very willing to work with you to get your procedures completed.  Since each and every one of them comes out with new deals, I cannot serially recite them here.  The best way to proceed is to come in and meet with us first.  Once we have decided what you need and you agree, we can then have the patient coordinators sit with you and make plans.  They would be the best to approach in regards to details about financing.  They also know of the discounts that may apply to you.  For example, we have discounts for police, and law enforcements.  We also have discounts for medical professionals and health care alliance members.  The hospital system in turn has additional discounts for nurses and medical professionals.  These can all help to make your overall bill less burdensome.  How and in what way they may apply to you depend on your specific situation.  Again, the coordinators are your best bet here.

That’s a great question.  Breast Implant Illnesses (BIIs) are a poorly defined set of symptoms that seem to bother some patients after undergoing breast augmentation/implantation.  These symptoms range from headaches, to coughs, to flu like symptoms, to body aches to constant fatigue.  Also, the symptoms have been noted to occur at times years after the implantation.  Unfortunately, even though there is a significant amount of chatter about Breast Implant Illnesses or BIIs, there have been no scientific studies that have shown convincingly that BII actually exists.  This is not to say that we do not believe the patient or the patient’s symptoms.  However, in many cases, the symptoms do not translate into any lab values that are irregular.  For this reason, it is hard to say what Breast Implant Illnesses truly are.

In my own experience, it has been a situation where one in 30 or 40 patients comes back years later and notes that she thinks that she may be having problems due to her implants.  We sit and go through all her symptoms.  We see and make sure she has no other physical problems that may be confounding the picture.  We then get labs done on her.  In most cases, the labs are completely normal.  This is where we are faced with a problem.  If the labs are completely normal, what are we treating?  At this point, we sit down with the patient and really have a heart-to-heart conversation.  In some cases, the patients are adamant that they wish to have the implants removed.  We believe in the team concept and are here to help the patient.  In those cases, we help the patient and get the implants out.  In more than ½ the cases where we remove the implants, we have noticed that the symptoms do not change—So the implant was not at fault.  However, the patient is often simply much less anxious and therefore we have served our purpose.  In other cases where the symptoms persist, we then work with the patient’s internist to see what else may be going on.

Again, even though Breast Implant Illnesses (BII) has a name, there is no specific diagnosis or specific exact set of symptoms.  Therefore, quite a few symptoms can be seen or noted.  I have heard patients complain of headaches, body aches, rashes, swelling, pain, numbness, burning sensation, coughs, flu like symptoms, muscle aches, joint pain, neck pain, back pain, fatigue, and an overall body listlessness.  As you can see, that is quite a few different things.  You can literally diagnose a dozen diseases with those symptoms.  So, what exactly is it? We don’t know.  However, it is true that some women after breast implantation have expressed concerns about these symptoms.  Have I seen them? Yes.  Do I see them often? No.  If we did, we would stop implanting breast implants into women.  By numbers, I probably have heard of symptoms in as few as 1 patient in 30 to 40 patients.  The biggest problem is that the disease problem is poorly defined and that there is no specific test to say that a patient definitively has the problem.

Great question.  Without an easily recognizable way of deducing a problem such as BII, we rely on simple physical exam.  For example, if you have an implant rupture, and you had a saline implant, you breast would start to deflate.  That is easily seen.  If you have capsular contraction, well then, the implant and the surrounding tissue would start to get hard.  This is easily noted and is most often picked up by the patient.  Often, the patient comes in and says that something feels different.  We examine the patient and note that YES, they are right, and the implant is in fact getting harder.  We then treat the patient accordingly.  This may require further examination or further testing with an MRI.  But again, this is easily recognizable and there are treatment protocols to follow.

So, most problems with implants are not as nebulous as BII.  Most are found by the patient or the plastic surgeon and most are in fact treatable. 

Breast implant illnesses are poorly defined so there are no great tests for them.  There are several tests that can be run to see if the patient is in a “reactive” state.  This would be tests like an erythrocyte sedimentation test (ESR) or a white blood count with a shift (WBC).  These tests in some cases may show a slight elevation.  But again, in some cases they may be normal.

Unlike breast implant illnesses, other problems with breasts can be easily found out with diagnostic tests.  As for an implant rupture with saline implants, a physical examination or an ultrasound will do.  With silicone implants, an MRI would be the gold standard.  With capsular contraction, again, a physical examination and an MRI would help diagnose the problem.

That is a great question and often a source of great anxiety. 

BIA-ALCL is Breast Implant Associated Acute Large Cell Lymphoma.  In other words, it is a cancer that is associated with breast implants.

In the last 5 to 10 years, the many plastic surgery societies around the world began to notice that in some patients, after undergoing breast implantation, there was a phenomenon of unexplained tissue swelling. In most cases, this swelling would happen often years after the breast implant placement.  The patient would present with a history of sudden swelling of the implant with a fluid collection.  This fluid collection would then be identified by ultrasound.  It would then be aspirated and would show cancer cells.  This was incredibly unusual.  In researching these cases, it became obvious that almost all these cases were related to textured implants.  Textured implants are a type of breast implant that were often used in breast reconstruction.  They are textured to help the shape of the breast look more natural.  It turns out that in some cases, the body of the patient reacts to the shape and texture of the implant and causes the local tissue to have a cancer response.  This then results in the sudden fluid development and the swelling around an implant.

A good question and a fair query.  As opposed to BIIs, BIA-ALCL has a fairly clear presentation.  So, if you have breast implants AND you suddenly have swelling around your implants over a course of a few days or weeks, it is recommended that you seek the advice of your surgeon.  If your surgeon has retired or is no longer practicing, the American Society of Plastic Surgeons can recommend someone in your local area.  Also, you can simply use one of the search engines on your computer to search for your closest plastic surgeon.  It would be prudent to go to see he or she so that your anxiety and concerns can be addressed.

Once you meet the plastic surgeon, you can get their help to go forward regarding further testing to make sure that you do not have BIA-ALCL.

In cases of patients that are in fact diagnosed with BIA-ALCL, an EN-BLOCK resection or Explantation is recommended.  This surgery is different from a regular breast implant removal in two ways.  First, the effort will be to remove the implant in its natural state.  The implant is NOT deflated or overtly manipulated.  The focus is to get the implant removed with all its local tissues still attached.  In this way, it is reasoned that the cancer and all the reactive tissue components are being removed together, out of your body.  The second is that once the implant and the tissues are removed, the effort will be to look around and remove whatever reactive tissue or capsule that may be still in place. Again, the effort is to remove everything that the implant has touched or has influenced.  In the more customary implant removal, the implant is simply removed, and parts of the shell are removed.  There is no need to remove all the shell since in some cases the surgical removal may damage some of the muscle or some of the local tissues and may cause more problems down the line.

A fair question.  The professional fee/cost is usually about 4200 to 4500$.  This is slightly more than a breast augmentation.  Of course, the focus is different and is much more on making sure that all the components of the affected tissues and the implants are removed.  This is much more meticulous and therefore more time consuming.

Also, since we are chatting about costs, we should also speak about insurance and warranties here.  Nowadays, the implant warranties supplied by the companies tend to be comprehensive.  In cases with capsular contraction, the companies now have inclusive policies that pay for the implant removal and some part of the surgery.  For BII, there is some ambiguity.  As for BIA-ALCL, there is no ambiguity.  Since this is a cancer, both the insurance company and the implant company are very much involved and do their best to help the patient.  That is refreshing and rare.

Another great question.  That all depends on what we have decided is your diagnosis.  If we are dealing with a case of capsular contraction, no.  If we are dealing with BIIs, probably not.  But unfortunately, due to the ambiguity of BII, it depends.  As for BIA-ALCL, you may need further testing depending on what we find in surgery.  Often, several MRIs will be needed as your response to the medications and your treatment course is gauged.  Again, I must point out, with BIA-ALCL, most of your costs will be covered by the insurance companies and the implant companies.

After your implants are removed, our job as the plastic surgeon and your surgeon is to make sure that you recover effectively and have a cosmetic result that is satisfactory to you.  Often, we see you at least once a week for the first few weeks until we are comfortable with your healing, and we do not forecast any problems.  In cases with BII, we will most likely follow you with your primary doctor or your rheumatologist to make sure that your symptoms subside. In cases with BIA-ALCL, we will follow you along with the oncologists for the next several years to ensure that you are symptom free.

That’s a great question.  The focus of any type of breast surgery is to make the breasts better or in the case of reconstructive surgery is to make the breasts as “normal” and as “symmetric” as possible.  The focus here is the same.  We will remove the implants and the associated involved tissues and focus on trying to make the breasts look very normal and natural and above all symmetric.

To make that happen, in some cases, we will have to plan for a breast lift.  In this procedure, when the implants are removed and the volume is now lost, we will have to change to breast contour to put the nipple areolar complexes in the right place.  In many cases if not most, this will involve a resection of some of the extra skin and a repositioning of the location of the nipple areolar complex.  The reconstruction may also involve the re-suturing of the muscle of the chest back into their original position, prior to undergoing the breast augmentation process.  In this way, we re-establish the natural contour of the breasts before the augmentation process and then simply do the lift or the recontouring from there.

Absolutely.  Our focus and our effort will be to minimize the damage to your body and your overall body form.  If in fact we can save you a scar or give you one less incision, we will definitely do that.  Our focus is to recalibrate your body, after the implant removal with a focus on a “natural” look and a “symmetric” look.

BBL stands for Brazilian Butt-Lift.

The procedure involves harvesting your excess fat and transferring it to the buttocks to augment the projection of the buttocks. Dr. Heffel and Dr. Kordestani collect the fat by performing liposuction of multiple areas around your body. Typically, patients store excess fat around the abdomen, at their waist, the flanks, the inner thighs, and the back. Please remember everyone is different.  Typically, between two and three areas are used as harvest sites for liposuction and contouring.  More sites are used if more fat is needed.  The liposuctioned/harvested fat is collected under sterile conditions, prepared, and then systematically injected into the buttocks area to accentuate the contour.    

The way to a successful BBL can be somewhat complicated.  There are PRE-OP and POST-OP protocols that help with a successful surgery.   If you are really looking and considering a BBL, we ask and encourage you to find us and to seek our advice.  Our team along with Drs. Heffel and Kordestani would be more than happy to share their experience with you.

No.

The BBL procedure is considered a cosmetic/elective procedure and is not covered by most health insurance programs/products.

The procedure is done either in a surgery center or in a hospital operating room. Both Dr. Heffel and Dr. Kordestani use the hospital and the hospital-affiliated surgery center.  They feel that the hospital or the surgical center setting gives them more ability to get a better result.

Yes.

In most cases, to complete the most appropriate operation with the most amount of fat grafting, the patient needs to be asleep.  This alleviates any angst the patient may have.  Also, should there be a need to access more fat areas to get more fat graft, a general anesthesia setting gives the surgeons the most amount of flexibility to give the patient the best result.

It depends on you.

Everyone is different but more than likely you will be up and walking the day of surgery. You will feel fairly sore the day of surgery and the day after the procedure–It will feel as if you did a strenuous workout or as if you went on a 10-mile hike over and down steep hills.

Right after the procedure you will be in some sort of wrap.  Within the first two weeks, depending on the extent of your swelling, you will be placed into a compression garment which is a surgical girdle that will act as compression at the areas where you had liposuction. It is critical to wear this garment as it helps prevent the development of isolated fluid pockets in the suctioned areas.  

It depends on you and your body.

The cost is proportionate to the number of areas that undergo liposuction. What does that mean? If you undergo liposuction of the abdomen and waist only, then the cost will be less than if you undergo liposuction of the abdomen, waist, outer thighs, and back. The more time the procedure takes, the more costly the procedure will be. Once the doctors see you and have an idea of what you wish to get done, they can give you a fairly accurate estimate.  Please speak to our team members so that you know the exact cost of the procedure before scheduling the case.

Yes

Every major surgical procedure has recognized complications.  BBL is no different.  However, with any well known team, the task is not to focus on the complications but to focus on how to minimize the complications.  Drs. Heffel and Kordestani have extensive experience with this procedure and can help to plan out your surgical procedure weeks before and can help to minimize any chance of any post-operative complications.  A good surgical plan can do much to minimize any possible complications. 

Here is a list of potential complications of which you should be aware. During your consultation, we ask and encourage you to ask Dr. Heffel or Dr.  Kordestani about these possible complications.  In lieu of that, please feel free to contact the office and ask any of the team members.    

• Anesthetic risks
• Bruising
• Change in skin sensation
• Damage to deeper structures  
• Deep vein thrombosis
• Pulmonary Embolism
• Pulmonary complications such as fluid overload
• Infection
• Irregular contours or asymmetries  
• Irregular skin pigmentation
• Persistent swelling or an isolated fluid collection [seroma]
• Poor wound healing
• Rippling or loose skin/ failure of skin contraction

Hopefully, none of these complications occur. However, should one occur, you should ask yourself, “Am I prepared to potentially deal with a complication?” That is a genuine and real question.

If a complication does occur, the team at The Associates will be available and with you throughout the recovery period.  We have a wealth of experience and will do our best to recruit others to help in getting you appropriately recovered.  Having over twenty years of experience each, Drs. Heffel and Kordestani will work with you to ensure your proper recovery from any of these complications.