SURGEON INTERVIEW #1: MEET DR. ASHLEY AMALFI
[this post was created in partnership with Mentor Breast Implants]
I just finished my FIRST interview with plastic surgeon Dr. Amalfi and I think this may be my first time NOT crying during a doctors appointment **happy tears!!**
I am so grateful that because I am a #MentorAmbassador they introduced me to and I was able to meet with Dr. Amalfi!
I don’t know what it is about going to my BRCA/Mastectomy doctors appointments that just make me SO emotional but I end up crying almost every time.
This experience with Dr. Amalfi couldn’t have been farther from those past experiences. Dr. Amalfi is like the cool older sister we all wish we had. She is so smart, she is so down to earth, she is funny, compassionate and understanding, she empowers you and she is also absolutely beautiful on the inside and out. She made me feel so comfortable, I couldn’t be more grateful.
A little bit about Dr. Amalfi:
● She specializes in breast reconstruction and revision surgeries
● She is based in Rochester, NY (full info for her practice below!)
● She is a leader in the field of Plastic Surgery, she is highly involved in the American Society for Plastic Surgeons
● She dedicates her time to a variety of committees including: Co-chairing the Women in Plastic Surgery Steering Committee, Young Plastic Surgeons Steering Committee, Co-chairing the Social Media Subcommittee and the Section Editor for YPS Column of Plastic Surgery News Editorial.
Before my consultation with Dr. Amalfi, I sent over some photos of my reconstruction and let her know what my current complaints are.
[ CLICK HERE TO READ THE REASONS I WANT TO HAVE A REVISION SURGERY ]
We then set up a consultation over IG Live where I was able to ask her questions and get insight and information from her about my upcoming revision surgery.
My hope with doing my consultations LIVE on IG is that it will help empower you to know that you have options and provide more access to information that can be difficult to find. More on this here.
[ If you missed the IG LIve you can watch it here on IGTV!! ]
I would like to point out that with any medical/surgical treatment, individual results may vary. Only a surgeon can determine whether reconstruction is an appropriate course of treatment for you and you should always consult with your medical team before making any decisions.
LET’S GET STARTED….!!
PAIGE: BASED OFF OF MY CURRENT COMPLAINTS WHAT I HOPE TO FIX WITH MY REVISION SURGERY - FOR EXAMPLE, I WOULD LIKE MY IMPLANTS TO SIT CLOSER TOGETHER SO I DON’T HAVE THE INDENTS OR POCKETS, I DON’T WANT THEM TO MOVE INTO MY ARMPITS WHEN I RUN OR LAY DOWN (TO THE POINT WHERE WHEN I WORKOUT I GET BRUISES ON THE SIDES OF MY FOOBS), AND FIX MY CURRENT BACK PAIN - WHAT RECOMMENDATIONS DO YOU HAVE?
DR. AMALFI: “Those are all reasonable concerns and those are reasons why I see patients for revision reconstruction all the time. Let’s start off by talking about where your implants are placed - they are Under The Muscle - well three years ago, I pretty much mostly put implants under the muscle, too. So this way of doing pre-pec surgeries is fairly new. This hopefully gives you an idea how much this field is constantly changing and evolving - in a good way! I think most surgeons would have done what was done in your surgery at that time because that is what we did. The reasons we put implants under the muscle is because it adds padding and thickness and after the mastectomy, there isn't much fat there, so by putting the implants under the muscle we are hoping that it adds that padding and support there and provides another layer of coverage. The downsides of having your implants placed under the muscle are that it does tend to cause animation deformity and movement of the implants from that pocket. That implant is getting squished - like how you see a bodybuilder flex their pecs - you can probably do that!”
PAIGE: OH YEAH - I CAN GIVE GEORGE OF THE JUNGLE OR THE ROCK A RUN FOR THEIR MONEY! HAHAH
DR. AMALFI: “This is often what patients do not like about their implants placed UTM, is that they reach for something and their foob moves - which not only feels and looks uncomfortable but can also be embarrassing and it hurts. What happens over time is that it keeps squeezing the implant down and out down and out and what happens is that it smooshes the implant over and towards your armpits because everytime you flex your pec it pushes pressure down and out and that’s what your implants are doing, they are moving down and out. The reasons your implants move and slide are because you have smooth round implants - which are what are most commonly used for implant safety reasons - but they don’t stick in place the same way textured implants do. The symptoms and complaints you are having are most likely because your implants are placed under the muscle.”
PAIGE: CAN YOU EXPLAIN IN DEPTH WHAT TYPE OF SURGERY THIS WOULD REQUIRE?
DR. AMALFI: “So changing from UTM to OTM in a first surgery versus doing it now is a little bit different. You already have a pocket under the muscle, so we will have to start over and create a new pocket on top of your muscle. The nice thing about changing the plane, is that we are able to create a more natural shape. It is kind of like starting over with your pocket. Right now, under the muscle, you have this big stretched out pocket. So if I change your plane and move your implants to over the muscle, I am able to create a new pocket for you that will fit the exact size of implants that you want. So we have more control this time around and if you like the size that you currently have, I recommend going down a little because when you are UTM your muscle is smooshing your implant a little bit so it actually looks a little smaller than it actually is. If I put that same size implant on top of your muscle, it would feel really big to you. When I do implant reconstruction, I always show my patients all of the implants and allow them to touch the and play with them and feel them. I ask them to tell me a good idea of how they want to look and then I order a range of implants and then I choose something within the range that you are looking for while making sure it really harmonizes with your chest. Sometimes, depending on the quality and strength of your skin, you may need to have expanders placed after the plane change and then have your implants placed, but we would determine that during surgery. This is very uncommon, but I like to give my patients the full range of possibilities so that way you are fully prepared and you have heard it from your doctor so it's not a total curve ball. This is why it is so important to build a good relationship with your doctor so you feel confident that they know what you want and you can trust them.
There are a couple of things that we want to think about:
1. How much tissue do you have?
2. How much does the animation bother you?
3. Do you like your size? Projection? Width?
4. Are you unhappy with any rippling?
5. Do you want a natural upper slope to your breast or do you like the prominent look of the upper implant? 6. When having a revision, you open up a pandora's box to complications and you could end up with a complication that causes us to remove the implants.
Please make sure this is something you are willing to risk to achieve a better result with your revision. When you are on top of the muscle, you have less padding and you no longer have that layer of muscle. So I tell patients that it’s kind of a trade off.
WHEN YOU ARE UTM YOU HAVE:
CONS:
● Animation deformity
● Movement
● Discomfort
● Muscle disruption
PROS:
● Really well padded
● Gives you a natural upper slope
WHEN YOU HAVE OTM:
CONS:
● You are going to see more rippling
PROS:
● Less painful surgery
● Restores natural anatomy
● No animation deformity
● Patients state it “feels” more normal and like a part of their body
PAIGE: DO YOU THINK I WILL NEED FAT GRAFTING? WILL THIS BE DONE DURING THE REVISION SURGERY OR AFTER?
DR. AMALFI: “The way to counteract the rippling is through fat grafting. This is typically a two-step process. Initial revision reconstruction, where we change your plane and place your implants OTM we would be able to add some fat in then and then we would do a second stage where we would just do fat grafting and add in another layer. So yes, I would recommend fat grafting for you.
WHAT ARE THE RISKS OF CAPSULAR CONTRACTURE?
DR. AMALFI: Capsular Contracture is the formation of a "capsule" of scar tissue around an implant, and is a normal part of the healing process. The body automatically reacts to any foreign object it detects within it and attempts to isolate said object by creating a barrier of scar tissue around it. In the case of breast implants, this is usually a good thing – the capsule helps to keep the breast implants in place, preventing slippage. In some patients, however, this capsule of scar tissue becomes unusually hard and starts to contract around the implant. This can lead to both aesthetic problems and, in extreme cases, pain in the breasts. Research shows that about one in six breast augmentation patients experience some degree of capsular contracture, though not all cases present with obvious symptoms.
PAIGE: WHAT DO YOU LOVE ABOUT MENTOR IMPLANTS?
DR. AMALFI: “I love mentor implants and J&J as a company. They are so empowering and the things they are doing for patient education and public awareness and the true dedication that the have behind the safety of their brand is unparalleled and I love their implants, they are freakin awesome. They are squishy but also the perfect amount. They aren't too soft or too hard. They also have the variety that I need from teeny tiny implants to larger implants and more projecting implants.
PAIGE: WHICH MENTOR BREAST IMPLANT DO YOU THINK IS BEST FOR ME AND THIS SURGERY? WHY?
DR. AMALFI: “I would use the MemoryGel Xtra because they are the extra filling and there is extra good stuff inside and because of that, it ripples less because it is so filled. So these are ideal for OTM. But what I love is that while they are so full, they aren't too hard. They still feel soft and it is just a great feeling implant and the variety is amazing.”
PAIGE: ROUGHLY HOW LONG IS THIS SURGERY?
DR. AMALFI: “Almost all revision surgeries I book for about two and a half hours. Fat grafting takes about 30 minutes and I like to give myself about an hour per breast. Sometimes its more and sometimes its a lot less. I always tell families, if it takes me an hour - I wasn’t rushing! And if it takes me three hours, nothing is wrong, I am just being meticulous. It’s not a huge operation and I would do this as an out-patient surgery. You typically wouldn’t have to spend the night in the hospital.
PAIGE: WILL I NEED DRAINS AGAIN?
DR. AMALFI: “I would say yes. I almost always use drains because it is the safe thing to do. I know that most patients hate them but fortunately they almost always come out quicker than they did for the initial mastectomy, because it’s just less surgery. Usually it’s just one per side. If I am doing minimal pocket work I do not use drains, but for most revision patients we are making more changes and this requires drainage.
PAIGE: CAN YOU USE THE SAME DRAIN SITE AS BEFORE? ARE YOU ABLE TO DO THIS SURGERY USING THE SAME SCAR / INCISION POINT AS MY MASTECTOMY?
DR. AMALFI: “Yes to both. I always try to use the same incision points as long as they are in line and in the area that I need them. The only time I wouldn’t is if there was an infection. Because you have a scar in your inframammary fold, so I can use that scar for this surgery. If you didn’t have your scars there, I generally would use the mammary fold for a revision surgery and you would then have a scar there. Even if a patient had a skin sparing mastectomy and have their scars across the front of their chest, I never use those scars because what I have found is that every time you cut out that scar, the front of the breast gets tighter and flatter every time and that’s the part of the breast that you want to project out the most and think when its reopened it makes it look worse in my opinion”
PAIGE: CAN YOU MAKE MY SCARS ANY SMALLER - AS IN SHORTER?
DR. AMALFI: “There is no way to make them shorter, though sometimes we can cut out scars and make new ones, but I would have to see it in person.”
PAIGE: IS THERE AN EXTRA RISK OF NIPPLE NECROSIS DURING A REVISION SURGERY?
DR. AMALFI: “Nipples make everything more complicated haha! Everytime you are re-creating a pocket you really risk injuring the skin in general - with the nipple being the most vulnerable part. It is not a MAJOR concern but it is always a risk. Something that is also a risk is nipple malposition but there is a pretty low risk.
PAIGE: IS THERE A WAY TO PROTECT AGAINST THIS?
DR. AMALFI: There is nothing you can do as a patient. As a surgeon, there are tips and tricks in the OR we can do to redirect nipple position. Sometimes I place patients in a sticky dressing to help the nipples stick down in an ideal location. This tape can cause some irritation to the skin but is really worth the help it provides to redirect nipple position.
PAIGE: HOW LONG IS THE RECOVERY AND ARE THE RESTRICTIONS THE SAME AS THE MASTECTOMY?
DR. AMALFI: “It is pretty similar. It is generally six weeks until you are back to doing what you want to do. The first three weeks are critical to be low-key: no lifting anything heavy and nothing that will raise your blood pressure or heart rate. After three weeks you can start walking, doing lower body activity, and slowly start to increase your activity and use your body as a guide. Dont overdo it. At six weeks you can be back to a normal baseline. You will still have little aches and pains but those will start to decrease over time. Something really critical here is that Muscle hurts - putting something under the muscle is really painful. So one of the great things about pre-pectoral reconstruction is that you don't have that. You really are just stretching skin and since you already don't have much sensation, it is a much more comfortable recovery. So a lot of times when we do pre-pectoral right out of the gate, patients just go home after surgery they don't even spend the night, because they don't have that same stretching pain of their pec that those have when they go under the muscle.
PAIGE: DO YOU ASK YOUR PATIENTS TO WEAR A BRA AFTER SURGERY?
DR. AMALFI: “This is a personal question and if you ask 20 plastic surgeons, you would probably get 20 completely different answers. I LOVE bras! I think they are so important for support, especially after surgery, for at least eight weeks.
PAIGE: IN GENERAL, HOW OFTEN ARE PEOPLE SATISFIED AFTER ONE REVISION SURGERY?
DR. AMALFI: “My revision patients are my happiest patients and it is my favorite thing to do because people know what they want. Typically, before a mastectomy you barely know what breast reconstruction even means. All you know is your original breast and you don't know what to expect or what questions to ask. So people who choose to have revisions have lived with their foobs, they know exactly what they like and don't like and what they want and because they have lived with something they are unhappy with and if we are able to make that even somewhat better, they are so grateful. Not even because of how they look but because you stop thinking about it and it no longer consumes you. I often hear patients say, “I just feel so good because I am not thinking about it anymore.”
PAIGE: WHAT ARE THE TYPICAL COMPLICATIONS TO A REVISION BREAST RECONSTRUCTION?
DR. AMALFI: All the same complications are possible with revision surgery as with the original operation. Risks to the skin and tissue include scarring, delayed healing, infection, need for implant removal, and asymmetry. Implant risks include rupture, malposition, capsular contracture, rippling and implant palpability, need for revision surgeries, and the potential for ALCL or systemic systems. We will go over the complete risk profile during your preoperative appointment with our nurse practitioners to make sure you understand those risks and dont have any questions about your surgery.
PAIGE: IF YOU ARE THINKING OF HAVING A REVISION SURGERY, DR. AMALFI WOULD LIKE YOU TO KNOW…
DR. AMALFI: “Asking a lot of WHY - you should be presented with options and if they are giving you a black and white answer, feel empowered to ask WHY. Don’t be afraid to ask your surgeon, “why are you putting my implant under the muscle? Why aren’t you using an ADM? Why do I not need to wear a bra?” Because this will help you better understand and make more informed decisions about the things that are happening because sometimes there aren’t a lot of choices but the more you ask the more you know and the more empowered you feel when making these decisions.
Thank you to Mentor for partnering with me this year to create content like this. [ #MentorAmbassador ]This information should be used as a tool to better understand what YOUR options are and to feel empowered when you talk to your doctor to ask the right questions, understand the procedures and the benefits and drawbacks. At the end of the day, it is YOUR body and it is YOUR choice. Knowledge is power and you should always feel empowered to take charge of your health and ask for what YOU want.
To discuss if this surgery may be helpful for you, please call Dr. Amalfi at (585) 244-1000 or visit her website: https://www.quatela.com/about-us/dr-amalfi/