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All TopicsForum: Radiation Therapy - Before, During and After → Topic: Fat Graft Transfer and the Radiated Breast

Topic: Fat Graft Transfer and the Radiated Breast

Forum: Radiation Therapy - Before, During and After — What to expect from treatment and ways to cope with side effects.

Posted on: Dec 3, 2009 02:47PM, edited Mar 1, 2014 02:11AM by whippetmom

whippetmom wrote:

I started this thread in 2009, and since that time, further data has been published regarding the efficacy of utilizing stem-cell enriched fat graft transfer in previously irradiated breast tissue. 

Since links are often malfunctioning, I am posting the most recent information, so that you can easily cut and paste and print out to take to your plastic surgeons.

Print out these articles:

http://www.ncbi.nlm.nih.gov/pubmed/21987041

http://www.ncbi.nlm.nih.gov/pubmed/23158103

http://www.plasticsurgery.org/News-and-Resources/Technique-Provides-New-Option-for-Breast-Reconstruction-after-Radiation-Therapy.html

Autologous Fat Grafting in Secondary Breast Reconstruction

Losken, Albert MD; Pinell, Ximena A. MD; Sikoro, Katherine MD; Yezhelyev, Maksym V. MD; Anderson, Erica MD; Carlson, Grant W. MD

Abstract

Autologous fat grafting has become a common technique for revisional breast surgery. The purpose of this series is to review our experience with fat grafting for the correction of acquired breast deformities. A retrospective review was performed on 107 patients with a history of breast cancer between 1996 and 2010, who had autologous fat grafting at the time of secondary breast reconstruction. The indications were for improvement in contour, shape, and volume of the breast following transverse rectus abdominis myocutaneous (TRAM) flap reconstruction (n = 55), latissimus dorsi with or without implant (n = 20), implant reconstruction (n = 20), and breast conservation therapy deformity (n = 12). The average volume of injection was 40 mL (range, 5-150 mL), the most common location being upper and medial quadrants. Fat was harvested mainly from the abdomen, thighs, and flanks. Complications occurred in 11% of the patients, and included fat necrosis, erythema, keloid scarring, and pain. Complications were higher when performed with implant reconstructions. Repeat fat injection was performed in 25% (n = 27/107), which increased with the length of follow-up. Patients with a history of radiation therapy had an increased incidence of repeat injections (36% vs. 18%). Patients with >6 months follow-up reported an improvement of about 83%. Autologous fat grafting is a safe and effective tool for secondary breast reconstruction. It is helpful in all types of reconstructions to improve contour, volume, and overall breast shape and symmetry. Repeat injections are often required and this is more common in patients with longer follow-up and in those with a history of radiation therapy. The popularity of this approach in reconstructive breast surgery will likely continue to increase.

© 2011 Lippincott Williams & Wilkins, Inc.

Fat Grafting and Breast Reconstruction with Implant:  Another Option for the Irradiated Breast Cancer Patients.

Salgarello M, Visconti G, Barone-Adesi L.

Source

Assistant Professor, Department of Plastic and Reconstructive Surgery, Catholic University of "Sacro Cuore" - University Hospital "A. Gemelli" - Largo A. Gemelli 8, 00168 Rome, Italy; Resident in-training, Department of Plastic and Reconstructive Surgery, Catholic University of "Sacro Cuore" - University Hospital "A. Gemelli"- Largo A. Gemelli 8, 00168 Rome, Italy; Consultant Plastic Surgeon - Breast Unit - Catholic University of "Sacro Cuore" - University Hospital "A. Gemelli" - Largo Gemelli 8, 00168 Rome, Italy.

Abstract

BACKGROUND:

In postmastectomy radiated patients, autologous tissue reconstruction is preferred over the implant one, because the latter is associated with a higher rate of postoperative complications. However, autologous tissue reconstruction is not always feasible and is sometimes refused by the patient. A challenge also arises in breast-conserving surgery patients, seeking breast augmentation with implant. In this paper, the authors present a further reconstructive option for irradiated breast cancer patients, consisting of fat grafting followed by implant placement.

PATIENTS AND METHODS:

The authors retrospectively reviewed sixteen cases of irradiated breasts treated with fat grafting and subsequent alloplastic reconstruction/breast augmentation. The evaluation methods were clinical and photography-based assessments. The BREAST-Q was used to quantify patient satisfaction.

RESULTS:

Sixteen patients, with a pre-treatment LENT-SOMA score of 1 and 2, underwent two to three fat graftings to achieve a LENT-SOMA score of 0. The placement of the breast implant had been performed in a separate stage at least three months after the last grafting session. The average follow-up was 15 months. The reconstructive outcomes were graded from excellent to good in 93.7 percent of patients. Patient satisfaction was marked high to very high. There were no short-term complications. A Baker grade 1 capsule contracture was found in all patients.

CONCLUSION:

The authors' experience shows that breast fat grafting followed by implant placement may represent a feasible reconstructive option in high selected patients with irradiated breasts. Fat grafting seems to reduce the radiation-induced complications in implants. Larger studies with a longer follow-up are needed.

PMID:
21987041
[PubMed - as supplied by publisher]

Lauren Greenfield, MD's blog [a California plastic surgeon]

http://www.laurengreenbergmd.com/uncategorized/breast-reconstruction-after-breast-cancer-using-fat-grafts/

As you can see, there are numerous studies which have been performed to substantiate that fat graft transfer [even to a breast where the implant is already in place] can change the integrity of the radiated skin.  It can soften the skin and apparently can also reduce a higher grade capsular contracture which otherwise might require surgical intervention, to a Grade 1 which would require no intervention.  Fat grafting is also a method by which symmetry to the irradiated breast can be made to more closely match the non-irradiated breast.

MASSAGING DURING EXPANSION 

From an interview by D r. Weiss here on bc.org

Maurice Nahabedian Yes. Also, in patients who've had radiation to implants (expanders) I recommend an aggressive massaging protocol to help maintain the soft consistency of the reconstructed breast.
Marisa Weiss, M.D. Can you explain what you mean by this massage protocol?
Maurice Nahabedian I recommend they use some sort of a moisturizing lotion and massage the breast two to three times a day to retain the moisture and also to help control the amount of scar tissue that forms around the implant/expander.
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Dec 4, 2009 09:49AM wabiwoman wrote:

Wow Deborah,

Your generosity abounds -- thanks for filling us RAD girls in on this.  I'm going to print out a copy of your email and the article and bring it to my doc when I have my pre-op prior to my exchange in January.

You rock!

Geena

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Jan 28, 2010 04:31PM whippetmom wrote:

Bumping

DISCLAIMER! I am not a physician or medical profesional. The information provided is my own personal opinion. You must discuss every aspect of your reconstruction with your plastic surgeon. Dx 10/15/2008, IDC, 1cm, Stage IA, Grade 2, 0/1 nodes, ER+/PR+, HER2-
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Dec 28, 2010 04:11AM chillipadi wrote:

Thanks for this post Deborah. My onco said that reconstruction will not be possible after radiation, so I'm glad to know that she's wrong. I may need skin-grafting during masectomy, though, as the tumors are large and cover my whole breast. I wonder if this will make reconstruction difficult?

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Dec 28, 2010 06:04AM mom3band1g wrote:

OH thank you!  I was just talking to my ps's PA about fat grafting.  Right now  I look like someone split  cantaloup and attached each side to my chest.  Not pretty.  The PA was saying that fat grafting could help soften the look.  My rads side is tight as a drum.....off to look at the links you posted.

thanks!

lumpectomy 2/10/10 bi-lat mx 3/25/10 rads completed 7/10! Dx 1/19/2010, DCIS, 6cm+, Stage 0, Grade 3, ER+/PR+
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Apr 28, 2011 11:22AM kareenie wrote:

Deborah's link above to the Results of the ASPS Fat Graft Task force doesn't work any more but this one does:

http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/guiding-principles/Current-Applications-and-Safety-of-Autologous-Fat.pdf

ILC 1994 & 2009, Endometrial CA 2005, DES dau, Chemo, Rads, MX, ALND, PMX, LE, Fatgrafting recon.
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Apr 28, 2011 12:35PM kareenie wrote:

and

http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/guiding-principles/ASPS-Fat-Transfer-Graft-Guiding-Principles.pdf

ILC 1994 & 2009, Endometrial CA 2005, DES dau, Chemo, Rads, MX, ALND, PMX, LE, Fatgrafting recon.
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Apr 28, 2011 12:36PM kareenie wrote:

oops it didn't post as a link

http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/guiding-principles/ASPS-Fat-Transfer-Graft-Guiding-Principles.pdf

ILC 1994 & 2009, Endometrial CA 2005, DES dau, Chemo, Rads, MX, ALND, PMX, LE, Fatgrafting recon.
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Apr 29, 2011 03:53PM StephDeg wrote:

excellent information - My radiation oncologist was basically trying to talk me out of implants because of the capsulation thing- she says 50% + have problems after radiation...

so I had assumed i would have to go with transflap surgery- I already have tissue expanders in- this looks like another option.

p.s. anyone who has had implants after radiation care to comment?

Dx 4/1/2010, IDC, 2cm, Stage IIIA, 2/11 nodes, ER+/PR-, HER2+
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Aug 5, 2011 03:21PM whippetmom wrote:

Bump

DISCLAIMER! I am not a physician or medical profesional. The information provided is my own personal opinion. You must discuss every aspect of your reconstruction with your plastic surgeon. Dx 10/15/2008, IDC, 1cm, Stage IA, Grade 2, 0/1 nodes, ER+/PR+, HER2-
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Aug 10, 2011 02:03PM whippetmom wrote:

A new article....out this month....

http://journals.lww.com/plasreconsurg/Abstract/2011/08000/Human_Fat_Grafting_Alleviates_Radiation_Skin.6.aspx

DUH??? 

DISCLAIMER! I am not a physician or medical profesional. The information provided is my own personal opinion. You must discuss every aspect of your reconstruction with your plastic surgeon. Dx 10/15/2008, IDC, 1cm, Stage IA, Grade 2, 0/1 nodes, ER+/PR+, HER2-
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Aug 10, 2011 02:35PM , edited Aug 10, 2011 02:36PM by geewhiz

I finished radiation in July 2010 and had fatgrafting in January and skin and implants seem to be fine!

Dx 10/2/2009, IDC, 2cm, Stage IIIA, Grade 2, 8/13 nodes, ER+/PR+, HER2+
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Aug 10, 2011 03:51PM whippetmom wrote:

geewhiz:  Tell us about your skin.  Is it softer, a different texture, and did your PS inject the fat in various areas on the mound or just in the scar region?  I'm so glad it has all been successful for you!

DISCLAIMER! I am not a physician or medical profesional. The information provided is my own personal opinion. You must discuss every aspect of your reconstruction with your plastic surgeon. Dx 10/15/2008, IDC, 1cm, Stage IA, Grade 2, 0/1 nodes, ER+/PR+, HER2-
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Aug 10, 2011 04:47PM geewhiz wrote:

I am blonde, fair and freckled. Rads left me with sheets of skin peeled off that came back brown and tight.
I had followed the recommendation of being fully expanded and exchanged prior to rads. I was very nervous, and honestly only recently have calmed down about it. The rads side is now the same color as the other breast. It had been brown. The implant is not as mobile or squishy as the other side, but my first ps had that one side lifted higher to overcompensate. Now I don't think that was necessary.
The fat was injected all around the breastbone and breast. Looked like a pincushion!!! I thought I was done, and was ready to get nipples...but now, 7 months post fat graft....I might do it again to even things out more. I have a bony chest area that I would like to see more fat on. So, I can't believe I am saying this, but I might actually take another stab at it.
And yes...Dr Khouri was my ps. His caring and enthusiasm has probably been the most positive experience I have had through the cancer journey.

Dx 10/2/2009, IDC, 2cm, Stage IIIA, Grade 2, 8/13 nodes, ER+/PR+, HER2+
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Aug 10, 2011 10:09PM whippetmom wrote:

geewhiz:  I am so glad that this worked for you.  I thought you might have gone to Dr. Khouri.  Wish other plastic surgeons would get on the bandwagon....

DISCLAIMER! I am not a physician or medical profesional. The information provided is my own personal opinion. You must discuss every aspect of your reconstruction with your plastic surgeon. Dx 10/15/2008, IDC, 1cm, Stage IA, Grade 2, 0/1 nodes, ER+/PR+, HER2-
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Aug 11, 2011 04:08PM tedwilliams wrote:

After my first fat grafting there has been a big change in my radiated breast. The color has gone from brownish to pink and the skin has softened. Just had the second grafting and my PS injected more fat along the scar at the bottom of what was my breast and along adhesions to the chest wall.

I really appreciate the references provided.

Jana

Dx 6/16/2009, IDC, 2cm, Stage IIIA, 1/19 nodes, ER+/PR+, HER2- Hormonal Therapy 01/01/2010 Surgery 05/10/2010 Reconstruction of my right breast: DIEP flap Surgery 12/02/2009 Mastectomy of one or both breasts: Mastectomy of my right breast; Lymph node removal (also called dissection): Underarm (axillary) lymph node removal (also called dissection) , Lymph node removal (also called dissection) on my right side Surgery 05/11/2013 Reconstruction of my right breast: IGAP flap Surgery 09/02/2014 Reconstruction of my right breast: Latissimus dorsi flap Surgery 08/08/2010 Reconstruction of my right breast: DIEP flap Radiation Therapy 01/09/2010 Partial-breast radiation: 3-D conformal external beam radiation (also called 3DCRT) Chemotherapy 07/01/2009 AC + T (Taxol): Adriamycin and Cytoxan, plus Taxol
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Aug 11, 2011 06:44PM whippetmom wrote:

Jana:  Keep us posted on the changes after this second procedure. 

DISCLAIMER! I am not a physician or medical profesional. The information provided is my own personal opinion. You must discuss every aspect of your reconstruction with your plastic surgeon. Dx 10/15/2008, IDC, 1cm, Stage IA, Grade 2, 0/1 nodes, ER+/PR+, HER2-
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Aug 13, 2011 03:10PM whippetmom wrote:

Physician at MD Anderson in Houston using fat graft transfer for treatment of radiation damaged skin...

"ASPS member Elisabeth Beahm, MD, professor of surgery at the University of Texas (Houston) MD Anderson Cancer Center:....she has seen startlingly good results from stem cell therapy employed to repair skin damaged by radiation treatment."

DISCLAIMER! I am not a physician or medical profesional. The information provided is my own personal opinion. You must discuss every aspect of your reconstruction with your plastic surgeon. Dx 10/15/2008, IDC, 1cm, Stage IA, Grade 2, 0/1 nodes, ER+/PR+, HER2-
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Aug 13, 2011 05:13PM Estepp wrote:

very interesting.

my skin is not damaged though.... but someday... if I ever have insurance without the deductible... I might try this... for other reasons.

Thank you my sweet sister! I am sending you a PM

We are the Ta Ta Sisterhood! Her2+ BC is what I had.... and yes sisters.. I had lymph node involvement...Plus Radiation AND Implant only Reconstruction. DX 6/25/08
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Aug 13, 2011 05:23PM mrsnjband wrote:

I was thinking that I would prefer fat grafting to help the rad breast  than an implant.  I know the rad side will not look like the non- rad breast after my bi-lateral DIEP.  She has talked about fat grafts after the initial surgery.  Thanks for all the info! NJ

Norma June, Bi-lateral MX 2008, Bi-lateral DIEP 2011 Dx 1/10/2008, IBC, <1cm, Stage IIIB, ER-/PR-, HER2- Surgery 07/09/2008 Mastectomy of one or both breasts: Mastectomy of my right breast; Lymph node removal (also called dissection): Lymph node removal (also called dissection) on my right side ; Prophylactic (also called preventive) mastectomy of one or both breasts : Prophylactic (also called preventive) mastectomy of my left breast Surgery 08/14/2011 Reconstruction of my right breast: DIEP flap Surgery 12/11/2011 Reconstruction of my left breast Surgery 08/14/2011 Reconstruction of my left breast: DIEP flap Radiation Therapy 08/10/2008 Chemotherapy 01/24/2008 AC: Adriamycin and Cytoxan Chemotherapy 05/28/2008 Taxotere (chemical name: docetaxel) Chemotherapy 03/09/2008 Taxol (chemical name: paclitaxel)
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Aug 13, 2011 05:35PM geewhiz wrote:

Estepp, I promised you pictures. I took some prior to the grafting and was quite sad and shocked by how dark the skin looked after rads in the picture. Then I could never figure out how to get them sent, and wound up deleting them. Things look much better now, still not perfect, but I am grateful for what I have. I will figure out how to get them to you!

Dx 10/2/2009, IDC, 2cm, Stage IIIA, Grade 2, 8/13 nodes, ER+/PR+, HER2+
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Sep 12, 2011 08:49PM kittycat wrote:

Interesting info.  This is my new obsession!  I had surgery to correct my capsular contracture after radiation.  I had bmx on my first bc diagnosis.  When I got dx the 2nd time, I had to do chemo and rads!  Bummer!  My right side really tightened up.  My PS thought doing a capsulelotemy and Alloderm would help it.  It is an improvement, but the breast is still hard and about an inch higher than the left (non radiated) one.  When I had my BMX, my left dropped a little more than my right (like half and inch at most).  My PS wasn't too worried about it.  He figured it would drop into place.  I had more scar tissue on the right side because of the biopsies.  While we were closely watching my foob, I found bc again.  :(

Anyway, I see my PS this Friday.  I'm going to check out the articles and ask him about fat grafting.  He wants me to do lots of massage and some light exercise (walking).  He does fat grafting, so we will see what he says.  :)

2 time survivor of triple negative BC, postiive for BRCA1 gene mutation! 9 surgeries, 5 months of chemo and 6 weeks of radiation. Dx 6/17/2009, DCIS, <1cm, Stage 0, Grade 2, 0/0 nodes, ER-/PR-, HER2- Dx 4/30/2010, IDC, <1cm, Stage I, Grade 3, 0/10 nodes, ER-/PR-, HER2- Radiation Therapy 11/15/2010 Chemotherapy 06/16/2010 AC + T (Taxol): Adriamycin and Cytoxan, plus Taxol
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Sep 14, 2011 11:54AM beacher4209 wrote:

glad i found this thread !

Dx 10/15/2010, DCIS, 2cm, Stage 0, Grade 3, 0/3 nodes, ER-/PR-
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Oct 17, 2011 10:18AM , edited Oct 17, 2011 10:20AM by rockstar22

I see that you had TE and implants prior to radiation. I had a BMX on 8/30/11 with immediated recon. I have the TEs in and then found out I need radiation due to poor margins. My PS wants to finish with expansion and put the implants in before radiation. I had a hard time finding info to back this up, seemed he was the only one who did it this way. Can you please elaborate more on your experience and how you are feeling. Did your PS give you the option to do rads first and then implants? How did you make that decision? Any info would be helpful. thanks!

Dx 7/21/2011, IDC, 4cm, Stage I, Grade 2, 0/2 nodes, ER+/PR+, HER2-
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Oct 17, 2011 10:58AM roseamy wrote:

Hi,

I had mx followed by rads I did have very bad radiation burn which left the chest muscle (as my surgeon said) like concrete.

15 months later I had an ld flap with implant done, then to fill in a couple of dips I had fat grafting, this not only softened the area and improved the cosmetic look but it also improved the radiotherapied skin.

I have since had this done again and the feel of the muscle and skin is again improved. THe surgeon has said this has improved the capsular contracture I have and I have noticed an improvement in the look of the surface of the skin, prior to this it was very thin and firm.

He did say to me when I saw him last that he fully expects to be removing implants from Ladies like me and replacing them with fat grafts (c cup) in about 5 to 10 years time, but at the moment the rate a which they could remove and treat the stem cells from the fat collected would take too long but things are moving rapidly in this area of reconsrution.

I am in England by the way.

Rose 

Dx 9/30/2008, ILC, 5cm, Stage IIIB, Grade 2, 0/4 nodes, ER+/PR+, HER2+
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Oct 17, 2011 12:07PM whippetmom wrote:

Rose: Thank you for sharing this.  I wish that fat graft transfer was performed more of a matter of course with every rads patient, where possible, to improve the cosmetic outcome.  Addressing capsular contracture is yet another potential benefit of this process.

DISCLAIMER! I am not a physician or medical profesional. The information provided is my own personal opinion. You must discuss every aspect of your reconstruction with your plastic surgeon. Dx 10/15/2008, IDC, 1cm, Stage IA, Grade 2, 0/1 nodes, ER+/PR+, HER2-
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Nov 8, 2011 02:03PM Sunone wrote:

Whippetmon, I was wondering if you would share which So Cal Kaiser and PS you have talked to about the fat grafing for radiated breast, PM would be ok if you prefer. I just saw a PS at Kaiser last night and he does not seem to want to have anything to do with my previously radiated breast, except maybe for a latflap - I had lump and rads for DCIS in the left breast two years ago and now have it again on the right side, one of my options per the BS is mx or even bmx or to do lumpectomy and rads again. Went to see the PS last night to discuss this and was not too happy with the limited options for the previous rad side,  I would really be interested in talking to a PS within Kaiser that works more with radiated breasts and fat grafting.

Dx 10/2011, DCIS, <1cm, Stage 0, Grade 2, 0/0 nodes, ER+ Dx 1/24/2014, DCIS, <1cm, Stage 0, Grade 1 Dx 2/12/2014, DCIS, <1cm, Stage 0, Grade 3 Dx 8/10/2009, DCIS, <1cm, Stage 0, Grade 3, 0/3 nodes, ER-/PR- Surgery 09/08/2009 Lumpectomy in one or both breasts: Lumpectomy in my left breast; Lymph node removal (also called dissection): Sentinel lymph node removal (also called dissection) , Lymph node removal (also called dissection) on my left side Surgery 12/02/2011 Lumpectomy in one or both breasts: Lumpectomy in my right breast Surgery 04/11/2014 Mastectomy of one or both breasts: Mastectomy of my left breast, Mastectomy of my right breast; Lymph node removal (also called dissection): Sentinel lymph node removal (also called dissection) , Lymph node removal (also called dissection) on my right side ; Reconstruction of my left breast: DIEP flap; Reconstruction of my right breast: DIEP flap Radiation Therapy 10/19/2009
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Nov 8, 2011 10:29PM whippetmom wrote:

Sunone:  Yes, Gregory Scott, MD - Kaiser Permanente in San Diego.  He is a wonderful physician!  I will PM you!

DISCLAIMER! I am not a physician or medical profesional. The information provided is my own personal opinion. You must discuss every aspect of your reconstruction with your plastic surgeon. Dx 10/15/2008, IDC, 1cm, Stage IA, Grade 2, 0/1 nodes, ER+/PR+, HER2-
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Nov 20, 2011 09:07AM dancetrancer wrote:

Thought you all might find this radio interview with Dr's Khouri, Coleman, and Khoobehi interesting!

www.voiceamerica.com/episode/5...

I saved my hair with cold caps! TCH: 4/10 - 6/13/12; 33 rads; BMX w/fat grafting; DX: 7/29/11 @ age 43: Stage 1A on L (3 mm IDC w/ 6 cm DCIS, Gr 2 ER/PR+, HER2+) 0/3 nodes; Stage 0 on R (2 mm DCIS). IDC missed on L by first 3 paths; see bio.
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Nov 20, 2011 07:38PM , edited Nov 20, 2011 07:50PM by whippetmom

Try this link:

http://www.voiceamerica.com/episode/57715/fat-transfer-the-skinny-on-fat

Kamran Khoobehi, MD is the one who speaks most about the use of fat graft transfer with post-radiation patients.  His portion is around the middle of the session.  Dr. Khoobehi is near New Orleans, LA....

http://www.khoobehi.com/

DISCLAIMER! I am not a physician or medical profesional. The information provided is my own personal opinion. You must discuss every aspect of your reconstruction with your plastic surgeon. Dx 10/15/2008, IDC, 1cm, Stage IA, Grade 2, 0/1 nodes, ER+/PR+, HER2-
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Nov 20, 2011 07:50PM whippetmom wrote:

Thank you dancetrancer!

DISCLAIMER! I am not a physician or medical profesional. The information provided is my own personal opinion. You must discuss every aspect of your reconstruction with your plastic surgeon. Dx 10/15/2008, IDC, 1cm, Stage IA, Grade 2, 0/1 nodes, ER+/PR+, HER2-

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