March 10, 2022

Deconstructing Kristen’s Breast Reconstruction with Plastic Surgeon Dr. Salvatore Pacella (Part 2)

Deconstructing Kristen’s Breast Reconstruction with Plastic Surgeon Dr. Salvatore Pacella (Part 2)

In part 2 of our conversation with plastic surgeon Dr. Salvatore Pacella, we go behind the doors of the operating room to understand how the team functions and learn some surprising things about surgery.

Looking back on Kristen’s extraordinary pain in the hours following surgery, we get real answers about how and why her pain was so extreme and what could have been done differently.

Dr. Pacella walks us through what to expect during the exchange surgery and subsequent nipple reconstruction coming up soon.

In part 2 of our conversation with plastic surgeon Dr. Salvatore Pacella, we go behind the doors of the operating room to understand how the team functions and learn some surprising things about surgery.

Looking back on Kristen’s extraordinary pain in the hours following surgery, we get real answers about how and why her pain was so extreme and what could have been done differently.

Dr. Pacella walks us through what to expect during the exchange surgery and subsequent nipple reconstruction coming up soon.


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Listen to Dr. Pacella’s podcast, Three Plastic Surgeons and a Microphone:

Meet Kristen’s doctors: surgical oncologist Dr. Louis Rivera, hematologist and oncologist Dr. Sonia Ali, plastic surgeon Dr. Salvatore Pacella, and radiation oncologists Dr. Anuradha Koka and Dr. Kenneth T. Shimizu.

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About Breast Cancer Stories

Breast Cancer Stories follows Kristen Vengler, a 56 year old single empty nester in San Diego, from her diagnosis of hormone positive breast cancer through chemotherapy, mastectomy & breast reconstruction, radiation, and whatever happens after that.

In 2020, Kristen moved from Austin to San Diego to be near family and start her life over after a life-shattering workplace trauma. A few months later she had that terrifying moment in the shower we all hope we never have.

From her breast cancer diagnosis, through chemotherapy, breast reconstruction, and radiation, we experience each new milestone as it happens. This podcast is about what happens when you have breast cancer, told in real time.

Support the show by sharing online, writing a review, or donating at

Host and Executive Producer: Eva Sheie
Co-Host: Kristen Vengler
Editor and Audio Engineer: Daniel Croeser
Theme Music: Them Highs and Lows, Bird of Figment
Production Assistant: Mary Ellen Clarkson
Cover Art Designer: Shawn Hiatt

Breast Cancer Stories is a production of The Axis.


Special Guest: Salvatore J. Pacella, MD.


Eva Sheie (00:05): ... and we're back for part two of our interview with Dr. Sal Pacella, Kristen's plastic surgeon. If you missed part one, he really gave us a high-level look at the multi-stage strategy. On today's episode, we're headed into the OR or the actual surgery and what happened behind those doors. As you know, this is a story about what happens when you have breast cancer told in real-time.

Eva Sheie (00:32): I want to bring us back to the actual surgery because it's still fresh in my mind from our most recent episode. We were talking about recovery, and I actually got through that episode and I was shell-shocked. Now, I don't remember the conversation, but listening to it again, I remember feeling so much anxiety over some of the things that happened to you in that one. The first thing that struck me was that you were in there with Dr. Rivera together for a very, very long period of time.

Eva Sheie (01:03): Are you helping each other or are you taking turns or... I mean, I just like knowing how stuff works. So what does it look like in the OR when you're doing this?

Salvatore Pacella (01:12): We're not necessarily in there together for very long. The reason being is he needs his space and time to do what he needs to do, and I need mine afterwards. The other important thing is that many people don't realize is it's really actually two separate operations. So what I mean by that is I don't want to mix any of my surgery with his surgery for the risk of contamination of cancer. So we actually have two separate tables, two separate setups.

Salvatore Pacella (01:43): Once the mastectomy is done, we actually put a sterile piece of tape on the incision. We take all of the drapes down. We get rid of them. We get rid of everything that was used in the cancer operation. We re-prep and drape you with clean towels, clean, sterile stuff, and then restart the operation that way. You're not obviously waking up, but we're cleaning all of sort of the cancer world out of the room and bringing everything that's clean and sterile after that.

Salvatore Pacella (02:12): I think that's a very important thing to do because, not only for the risk of infection, but the risk of, let's say, there was a random cancer cell sitting around. We don't want to somehow reimplant that into the chest wall or the breast. So that's the reason why we separate the two.

Kristen (02:27): That's so cool. I had no idea you guys did that.

Eva Sheie (02:29): I didn't either. Do you have different teams or the same team?

Salvatore Pacella (02:35): Pretty much the same team. So the techs that I work with are the same techs that he works with. So that person will pivot over to my side of things. One other thing you may not know is sterility is a huge, huge concept in breast reconstruction because, obviously, one of the most devastating things that can happen is an expander getting infected. It's not 0% of the time that happens.

Salvatore Pacella (03:01): I would say, if you look at the literature across the country, about 10 to 15% of the time, patients can get a real serious infection after breast reconstruction. So we take infection exceptionally seriously. So once I start my procedure, we actually lock the door of the operating room so that no one is coming in and out. The act of opening the operating room door... If you look at actually the literature, they've looked at studying what causes infection in the operating room.

Salvatore Pacella (03:31): One of the big things that they found is what matters is the amount of people coming in and out of the operating room. So we actually close the door. We lock it. We put a big red chain across the door that says don't enter until we're finished. If we need equipment, the nurses call and send the equipment through a pass-through process. So it is taken exceptionally seriously. The consequence is we have an exceptionally low infection rate at Scripps. I would say less than about 2% of the time.

Eva Sheie (04:02): The next thing that happened when we re-listened was we were really struck by how much pain she was in. So do you want to tell that story of just what happened?

Kristen (04:12): Me? Oh, yeah. Well, let me go back. We talked a little bit about this in the episode. When I had my son, I'd had two epidurals and could still feel him. Now, granted he was almost 10 pounds, but-

Eva Sheie (04:22): I still think it was his personality that you were feeling.

Kristen (04:24): Probably. He's 24. I haven't had a lot of surgeries, and so I don't know if it's something in my body or what, but I woke up in just incredible pain, and they'd given me as much medication as they could.

Eva Sheie (04:40): We know this is probably not in your lane, but we were just curious.

Salvatore Pacella (04:43): No, no, no. It's exceptionally important, and I'm glad you brought that up because I do have a few comments on this. Again, this goes back to what we were talking about, the difference between cosmetic and reconstructive surgery. Why isn't this just a breast augmentation? The reason is is it can be very, very, very painful. That's one discussion I have with patients at the pre-op appointment is just how much to prepare for the fact that this can be painful, and I will tell you that we have a huge bell curve of patients.

Salvatore Pacella (05:12): Some patients are in very little pain. A lot of patients are kind of in modest pain. Some patients are in an exceptional amount of pain, and we don't really have a very good understanding about, going in, who is going to have more pain than others. Now, what do we do to help prevent pain afterwards or to help mitigate the pain? So number one is the anesthesiologist that we work with, they all understand that this is a very painful operation, and so many times what we do after the patient's asleep is we series of blocks of the chest wall with a specialized device.

Salvatore Pacella (05:48): They use an ultrasound to block specific nerves that go up and down the chest, and so that's a standard that we do for everybody. Those blocks are usually very successful, but sometimes the medication just doesn't trickle to the right nerve or muscle. In addition, during the operation, I'm always injecting some additional local anesthesia around the site to cover whatever the block may not have covered. So in addition to that, we oftentimes use a combination after surgery of a narcotic medication that's given IV and a very intense nonsteroidal medication called Toradol afterwards.

Salvatore Pacella (06:30): The Toradol, we don't necessarily want to start until the next day after surgery because Toradol can sometimes have a risk of bleeding associated with it. So the combination of doing those blocks in the surgery and using the heavier narcotic medication that you self deliver with a... It's called a PCA pump., Usually that can take a good chunk of the pain away. But one of the things I tell my patients, and hopefully it's a good strategy to think about is, obviously we don't want anybody to be 10 out of 10 pain, but it's not quite feasible to be zero out of 10 pain.

Salvatore Pacella (07:06): So we sort of have to shoot for the range of three to five. That's probably a good place to be. Unfortunately, I wish I could get rid of everybody's pain. It's just not possible but... All of the medications that are given for pain have some sort of side effect. So, for example, all of the narcotic medications will cause nausea. They'll cause constipation. They can make patients feel crazy and loopy, and so we try to minimize that as much as we can but still not have patients screaming in pain.

Salvatore Pacella (07:38): What that means is sometimes right after surgery, we have an idea of where the blocks are working, and you've been given a big dose of narcotic pain medication during the surgery, and so after surgery, sometimes patients wake up in a bit of pain that we have to kind of manage a little bit differently, but my intention is, hopefully, that's very short-lived for just a few hours.

Kristen (08:01): It was. I remember waking up, just tears streaming down my face, and again, after thinking about when I had my son, how my body responded to the epidurals, I wasn't surprised after we looked at that. You and I went over a couple different times about what to expect. There would be the pain pump and all of that. That was my best friend.

Salvatore Pacella (08:23): Yes.

Kristen (08:23): With the pain. The Toradol was fantastic.

Salvatore Pacella (08:27): Trust me, I'm very tuned into this issue. I've had multiple orthopedic problems and surgeries throughout my life. I was an athlete, rugby player and I've had multiple knee surgeries, and believe me, I am no stranger to pain whatsoever. So I am not somebody that is just like, "Tough it out. Go deal with it." Believe me, if we had the technology to take away people's pain, I would do it in a heartbeat. Now, Kristen, I have a couple questions for you.

Salvatore Pacella (08:55): Obviously, what you've been through has been very traumatic and taxing on your life, and I would say now that you're kind of getting towards the last part of this process, how do you see this affecting you the rest of your life, say, in five, 10 years, and what are the things that have changed about your life from this process?

Kristen (09:16): A lot has changed. First of all, Eva's husband always called me Pollyanna as a teacher. I'm always able to see the good, able to see the half full, and throughout this podcast, we've talked a little bit about that. I will say that I don't know that I would've changed this in having cancer. No one wants cancer. I'm a different person. I understand myself a whole lot better. I've had to dig really deep into myself to find my strength and to really kind of realize that I don't have control over a lot.

Kristen (09:49): I'm a more raw Kristen than I was before. I don't have a lot of fear about cancer recurrence, but I know it's a real possibility.

Eva Sheie (10:02): I've noticed that, I said this to you the other day, she's become an absolute professional at drawing boundaries and not allowing people to give her any kind of shit for anything.

Salvatore Pacella (10:15): Good for you.

Eva Sheie (10:16): No one walks on her.

Kristen (10:17): It's true, and I have also changed the people that I allow in my life. The only people I have deep respect, unconditional love for, and vice versa are allowed, and there's no reason for anything else. I think that I really respect my body for what it's taking me through. I'm not so worried about fitting in that one pair of jeans anymore. Something that you told me has been so valuable because I'm a big picture person. And you reminded me, several times, that chunking is important to the point where like the night before surgery, I hadn't even thought about getting up the next day.

Kristen (10:56): When Eva and I were having a conversation, I actually went through it with her while we were talking, and really just compartmentalizing, and chunking, and getting to that next piece as opposed to seeing, "In 10 years, what if I have brain cancer or something like that?" I don't look at it in that way. I look at it as living my best life. You don't know this about me, Dr. Pacella, but I was born in San Diego and I was out here in Austin for 26 years.

Kristen (11:21): It was only 11 months before I found my cancer. I had moved back to San Diego and to North County, and so I've just decided that I'm staying in San Diego. I'm going to enjoy the weather there. I enjoy the people that are out there, and that's my long-term plan. I'm not sure if I answer a question, but as far as my body goes, that's been the hardest thing for me to wrap my head around is I feel like my body has aged and my mind has aged 10 years in the past year from the different treatments that I've had.

Kristen (11:55): I'm hoping that that changes over time, as time goes on, and as we finish our work, and I am exercising more, and I'm feeling more like myself. I have some pretty serious neuropathy going on and I have some plantar fasciitis in my feet. It's difficult to walk sometimes. I trip over myself, and my brain is not as... I, I can't put my... See? I'm doing it right now. I can't put words together or sentences together as complexly as I used to be able to.

Salvatore Pacella (12:25): Right. Right.

Kristen (12:26): So I look at this as a weird, necessary journey in my life in order for me to be who I am today. I mean, I cry a lot. I have a lot of sadness about it. There haven't been a lot of things in my life that have been tough like a divorce, or a loss of a loved one, or cancer, where there hasn't been an opportunity for me to directly help or affect someone else in a positive way, and so I'm looking at this as that kind of thing.

Eva Sheie (12:57): Pollyanna.

Kristen (13:00): It's hard. I still... When I get out of the shower and I see the scars, or I had long hair forever and I see my short hair or when I saw my bald head, "Gosh, I have cancer or I have had cancer." And my mom had ovarian cancer. When I was in my twenties is when she had it. So I've spent a lot of my life trying to avoid getting cancer, and maybe a roundabout way of answering the question. But I still don't believe I have breast cancer as we're sitting here in a podcast called Breast Cancer Stories and I'm talking to my reconstruction surgeon... I mean, I still don't believe it.

Salvatore Pacella (13:37): I think by doing what you're doing with this podcast and psychologically preparing yourself, I think that you're giving back to those that come after you. I think it's really, really helpful information.

Eva Sheie (13:51): We've heard that. We have two really distinct audiences. One is, of course, obviously people who are going through it. But what we didn't expect is the families and the friends of people who are going through it have been writing to us and saying, "This is so helpful because we have not been able to have these conversations in our family." And I have thought about that a lot. The person who has cancer may not want to repeat what's happening over, and over, and over to all the people who need to know, and so that's been a nice surprise and a silver lining to doing this.

Kristen (14:31): I have a quick question, Dr. Pacella. Can you explain the exchange surgery, how that goes? I know it's an outpatient thing, which is awesome, but can you explain the technicality of that?

Salvatore Pacella (14:41): Yes. So not a very long procedure, not a very painful procedure compared to what you've been through, and basically, what we would do is we remove both expanders and we would put in a new set of implants, and the process of choosing the implant, you and I will go over and have a discussion about the various sizes and what's feasible, and then I'll usually have a series of implants there. We use actually sizers too. So I can't tell you exactly what size I'm going to use on one side versus another.

Salvatore Pacella (15:12): I usually sit you up during the operation. Your arms are kind of strapped on the sides. We sort of look at you sitting up and determine exactly what size, and many times on the radiated side, we use a slightly larger implant compared to the opposite side, which may not be as thin. I imagine during our surgery, I'm going to have to reconfigure a little bit of skin on the left side to make a match, and then you'll have a series of drains afterwards. Very similar to what you had before.

Salvatore Pacella (15:38): But in general, I think the pain is a fraction of what you've been through. So it's a much nicer experience.

Kristen (15:47): Got it.

Eva Sheie (15:47): Are those implants different from cosmetic implants, or are they exactly the same?

Salvatore Pacella (15:51): Same type of implants with the exception of the implants come in various profiles, and in the cosmetic world, because there's a breast already there, we usually use a lesser projected implant. In a reconstructive surgery, we'll probably use the highest projection implant. It's called an ultra high-profile implant.

Kristen (16:11): Okay. Silly question. Do you take the saline out of this expander when you take it out?

Salvatore Pacella (16:16): Yes. In an effort to do it through a smaller incision, we manually deflate the expander and then basically fold up the expander to bring it out.

Kristen (16:26): That's awesome. I wouldn't want to watch it on myself.

Eva Sheie (16:30): Now, you also have a podcast, and it's called-

Salvatore Pacella (16:33): I do. Yes.

Eva Sheie (16:34): ... Three Plastic Surgeons and a Microphone. Very funny.

Salvatore Pacella (16:36): That's right.

Eva Sheie (16:36): Now do you guys usually say, "Wikki, wikki, wikki." After you-

Salvatore Pacella (16:40): No, but we should. We should.

Eva Sheie (16:41): Okay. Well, there's my contribution. I've watched a bunch of your episodes with Dr. Jejurikar and Dr. Rhee. How do you guys know each other and what made you decide to do a podcast together?

Salvatore Pacella (16:52): So those gents are two of my really good friends from residency at the University of Michigan. They're both a couple years ahead of me, and so we've been in touch throughout the years and we see each other at meetings here and there, and we were chatting one time and they had an idea to get together and do a podcast. It was a great idea because it's a chance for us to catch up, have some coffee on a Sunday morning, talk about interesting cases and plastic surgery.

Salvatore Pacella (17:19): What's wonderful about it is I think we each bring a unique perspective to the topic. I'm in California. Sammy J. is in Texas. Sammy Rhee is in New Jersey, New York area, and so we all have different slates of patients, different things we do, and it just really gels very well. It's really become something I look forward to during the week.

Eva Sheie (17:43): I've found you on YouTube. Is that where you prefer people to watch, on YouTube, or is there somewhere else that you send?

Salvatore Pacella (17:49): So we're on YouTube. We're also on Spotify too, which is just the audio.

Eva Sheie (17:53): It's more fun to watch you.

Salvatore Pacella (17:55): Yeah. That's right, and the fun thing is we do a lot of teasing of each other, and it's just kind of fun because, fortunately, moving out to California from the Midwest or from New York, I hate to say this about Californians, but they're very soft. They don't like to be teased very much. So coming from back East, it's like that's a side of affection when you're teasing each other. So it's just been fun to reconnect.

Eva Sheie (18:23): So on our way out, and I promise you that I would ask you this at the beginning. Just give us your usual bio. So if someone's listening today and they want to come to you either for cosmetic or for any other reason, tell us about yourself and your background, and then we'll let you get on with your Sunday.

Salvatore Pacella (18:40): Sure, sure. My title is I'm the Division Head of Plastic and Reconstructive Surgery at Scripps Clinic in San Diego and also at Scripps MD Anderson Cancer Center. My practice is both cosmetic and reconstructive surgery. I'm board-certified in plastic surgery, and I'm double fellowship-trained in cosmetic surgery, cosmetic surgery of the breast and cosmetic surgery of the face and the eyelids. I do a tremendous amount of cancer reconstruction, both for skin and breast cancer work.

Salvatore Pacella (19:12): I very much believe in advancing the specialty, and so one of the things I take great pride in is teaching and educating on a national and international level. In fact, just this past year, I was invited to about six talks around the country. I've been invited, internationally, to speak in Melbourne, Australia, Toronto, South America. So I do a lot of professional society work through the three major societies in plastic surgery, the American Society for Plastic Surgery, the Aesthetic society, and the International Society for Aesthetic Plastic Surgery.

Eva Sheie (19:48): So you like to go to school and you like to teach.

Salvatore Pacella (19:53): That's right.

Kristen (19:54): That's why we get along.

Salvatore Pacella (19:57): That's right, and I kind of leave you with this. At the University of Michigan, there was a huge pedigree of surgeons. Some of the pioneers of surgery in the 20th century have been graduates or attendings at Michigan, and there was kind of a phrase that we lived by there, and it was called standing on the shoulders of giants. And so many patients come in and say, "Well, gosh, you did this operation and took a piece of tissue for my forehead and rebuilt my nose, and gosh, you're so special."

Salvatore Pacella (20:29): My answer to that is many smarter people and more insightful people have come up with these operations. We have had the benefit of studying them, and using them and tweaking them. But this didn't start with us. This is standing on the shoulders of giants, and that's a major reason why I believe in teaching, and innovation, and giving back to the specialty is for that reason.

Eva Sheie (20:52): Seems like it came with a lot of humility, too, which is also rare in the plastic surgeons. Thank you so much for spending time with us this morning. We're so grate-

Salvatore Pacella (21:03): Oh, wonderful. It was an absolute pleasure.

Kristen (21:05): And Happy New Year.

Salvatore Pacella (21:07): Thank you. You too, and enjoy 2022.

Kristen (21:09): Oh, yeah.

Salvatore Pacella (21:10): It's better than 2021.

Kristen (21:11): Yes.

Eva Sheie (21:11): How could it not be?

Salvatore Pacella (21:12): Cheers to that.

Eva Sheie (21:13): Quite a year. Absolutely. Cheers. Thanks for listening to Breast Cancer Stories. There's a link in the show notes with all of the resources mentioned on this episode and more info about how you can donate. If you're facing a breast cancer diagnosis and you want to tell your story on the podcast, send an email to

Eva Sheie (21:42): I'm Eva Sheie, your host and executive producer. Production support for the show comes from Mary Ellen Clarkson, and our engineer is Daniel Croeser. Breast Cancer Stories is a production of The Axis,