Bigger or Smaller? The Real Reasons Women Get Breast Implant Revision

Dr. G (00:02):
You are listening to another episode of All the B's with me, Dr. G and my scrub tech Bri. Okay, we're back. Welcome back to All the B's. It's myself, Dr. Gallus and Brianna. Hi Bri.

Bri (00:23):
Good afternoon. Hello.

Dr. G (00:25):
Today we're going to talk about breast implant revision for when you have implants, but you need a redo, but first we're going to skip past the miserable ending of the White Lotus and talk about some celebrity gossip.

Bri (00:43):
That was just so terrible. White Lotus really did us dirty this season, but we can, like I said, I'll keep my opinions to myself, but we can just, yeah,

Dr. G (00:54):
It's not worth it. So this actually came up in the OR. This guy in New York City was doing an illegal butt implant removal or something and then gave the patient lidocaine toxicity, so local anesthetic toxicity and I think she's still in the hospital or might be in a coma.

Bri (01:15):
I just want to say was that his house at the beginning of that video? Because the fact that anybody would go there that looked like, ugh.

Dr. G (01:25):
Right, so a makeshift medical office, i.e. your house.

Bri (01:34):
Look at that house. Okay. If you guys are just listening and not watching, please look at the house so you can understand. So was this guy a doctor?

Dr. G (01:43):
No.

Bri (01:45):
Okay, just clarifying.

Dr. G (01:47):
Was he anything on. I don't think so. It's not even like a nurse or an MA or respiratory therapist.

Bri (01:57):
People need dual incomes these days, so it's like let's do after hours clinic in our basement.

Dr. G (02:02):
And how is he even getting the lidocaine?

Bri (02:06):
Who knows if it was even lidocaine.

Dr. G (02:09):
Right? I mean she went into cardiac arrest, which is a side effect of lidocaine toxicity. I guess if you, I don't know. It's a mess.

Bri (02:18):
Someone needs their intra lipids.

Dr. G (02:19):
Right? Expensive to have but worth it. We're just talking about things that you can have if somebody is to have signs of local anesthetic toxicity, i.e. too much or it got infiltrated somewhere where it gave them too much at one time and one of the things you can do is give them IV intra lipids. But I'm going to guess at this dude's house, probably not unless they're under the couch. What the hell?

Bri (02:48):
I want to see where he was like, I need more information. I want to see where he was performing this procedure.

Dr. G (02:54):
Oh, the actual bedroom?

Bri (02:56):
Yeah. I want to see what kind of setup he had it.

Dr. G (02:59):
It's sad. Yeah. Yes, it's terrible.

Bri (03:04):
Did she pay for this procedure?

Dr. G (03:06):
I don't know. I'll just say please go to a licensed facility where you can confirm that the person doing whatever it is is actually licensed to do so. I don't understand. Okay. He was trying to make a run for it, get a ticket to go back to Columbia. Good for you.

Bri (03:28):
Speaking of getting caught, you know who got caught? The doctor that tried to kill his wife in the Hawaii. This is a follow-up from our previous podcast. He did get caught.

Dr. G (03:38):
Oh, was he the one who tried to push her? I forget.

Bri (03:40):
Yeah, the anesthesiologist who tried to kill his wife by pushing her off a cliff and injected her with some unknown substance that God knows what, but he got caught.

Dr. G (03:53):
Good.

Bri (03:54):
Yeah, so you always get caught. I guess my after hours clinic, I'm going to have to close.

Dr. G (04:02):
Yes, put that on pause. You can set those business plans aside. Okay. All right. Moving on. What is our next little piece of gossip? This one we'll touch on briefly because it's a Reddit thread, but some Colombian singer revealed that she couldn't have sex for two years because she unknowingly was given the husband stitch, spelled wrong, after she gave birth, but that's what you expect on Reddit Also, I don't think English is her first language, but I think she's referring to after you deliver and you have an app episiotomy or a tear in the vagina, they will close that up and sometimes it's called the husband stitch when they put another extra stitch in there to make your vagina a little bit tighter. It's kind of obnoxious on so many levels.

Bri (04:55):
But how would you have to put it so tight where you cannot? I just.

Dr. G (04:59):
So I think what happens is there are some muscles in that area and I think you can have spasms or scar tissue that make it then uncomfortable and so until the scar tissue relaxes, which we know scars can remodel for one to two years, or if you have some sort of pelvic floor muscle spasm ends up relaxing, then it could be painful to have intercourse.

Bri (05:24):
Oh, I see now, and I quote, it benefited him because of course it's delicious when it's tight. I know I gave birth, but he also got a reward. Okay, next. I'm going to get fired from this podcast pretty soon.

Dr. G (05:46):
I know, I don't know what is prompting her to talk about it now, but I do think it goes back to, because Brooke Shields mentioned this in her book, it just goes back to informed consent, and I feel like if you're going to have something done, just be clear on what's being done or hopefully you trust your provider. I don't think it's as common as it's you think it is.

Bri (06:10):
But nowadays that would just be a lawsuit waiting to happen.

Dr. G (06:14):
Yeah, I think people would be very unhappy if they had pelvic floor dysfunction or dyspareunia, which is pain with intercourse after delivery and I feel like they would come back at you for that.

Bri (06:28):
I also love the analogy when you try on a shoe and it finally goes in, are we comparing a shoe hole to a vagina?

Dr. G (06:36):
Does she mention that?

Bri (06:38):
Yeah.

Dr. G (06:38):
At the very end. I mean you just take the shoe to Nordstrom and have 'em stretch it out.

Bri (06:44):
Exactly. Exactly.

Dr. G (06:48):
Okay. All right. Moving on. This one's kind of sad because this guy is actually a certified oculoplastics surgeon, so that means somebody who did a legitimate medical school, legitimate residency in ophthalmology and then went on to do another year of oculoplastic surgery and has been practicing for a long time, but it seems like these patients are not going well.

Bri (07:22):
What happened there?

Dr. G (07:24):
I don't know because her facial nerve is out and if you strictly are doing eyeball surgery, you're nowhere near the main branch of the facial nerve, which would affect her smile and her face. There's one little branch that's going to be around the eye that you are responsible for if that's your domain, oculoplastics, but I don't know if he was doing facelifts or?

Bri (07:51):
It looks like an upper bleph and a brow lift. I mean her eyebrows are so high.

Dr. G (07:58):
She can't close her eyes.

Bri (08:00):
Anchored those babies up.

Dr. G (08:03):
But see how her mouth is distorted too. That's a facial nerve injury on that right side it looks like. Anyway, like I said, the guy had legitimate credentials but then has all these terrible outcomes. This patient said she had previous surgery before having surgery with him, so who knows when the undated photo was taken and that she had some sort of congenital nerve problem or some other issue prior to having surgery with him. But I cannot say that he made any kind of improvement there. She looks horrible.

Bri (08:40):
Dunno what happened. Stuck in eyes. That's just insane. And he's allowed to keep, he's being sued by 10 patients.

Dr. G (08:47):
Yeah, I don't really know what's going on there. I don't think he has hospital credentials anymore. He has this bad scarring on these patients. But again, why are we in the lower face if you're oculoplastics, their big selling point is they only do the eyeball. So we just had a oculoplastic surgeon practice, he was operating in our OR on Monday and he literally did the upper lids and the lower lids and then left and the other surgeon did the facelift. That's all he is supposed to do. See? So he said among those suing or somebody said he nicked a vessel in her neck. Why are you in the neck? So my guess is that this guy has moved on outside of his little eyeball training. I don't know why because there's plenty of eyeballs to do.

Bri (09:36):
I mean that stitch has to be so, he just didn't take out any skin. I mean I don't even know what's happening there, but it gives me Dr. Death vibes.

Dr. G (09:45):
Yeah, actually I just looked up Oculus plastic surgery and he does facelifts neck lifts, so buckle fat removal.

Bri (09:55):
That's terrible.

Dr. G (09:56):
So I just think that's not what he was trained to do and it is not going well. That sucks because you want to do your research.

Bri (10:09):
Right, and I mean half my job in surgery, when we are doing facelifts, is making sure that when they're using anything in the face that there's no twitching. That's a

Dr. G (10:20):
Rght. No nerve injuries.

Bri (10:24):
That's so sad. He should not be allowed to continue practicing.

Dr. G (10:29):
I know. I don't know what it takes. I mean he's being sued but I just don't, don't know what they're doing in Georgia. And then speaking of non-physician related terrible outcomes, let's talk about fashion fans slam trendy summer dresses amid complaints. They only look great if you have fake breasts. So I think they're referring to backless dresses or dresses that show every dress has no back or you can't wear a bra with it. I mean I think there's a whole small industry of boob tape and pasties and all kinds of things that you can do.

Bri (11:19):
I mean I'm all for body

Dr. G (11:20):
Get on Amazon

Bri (11:21):
Positivity. This may be an unpopular opinion, but dresses just do fit better if you got fake boobs, they just do. You got some good side boob, you got some cleavage, but I mean if you are buying those kind of dresses that are showing all that and you got small boobs, maybe just convert to a different dress that's more flattering for your figure.

Dr. G (11:44):
Or I mean I think sometimes that lady has small boobs in the photo. I think it's fine to wear that dress with small breasts. I think maybe people who have larger breasts or sagging breasts or I get, it's hard to find something that's going to support your breasts, so you either have to have small breasts or fake ones I guess that are lifted.

Bri (12:10):
But I feel like everyone has fake boobs. People are just making dresses for fake boobs, for bigger boobed people.

Dr. G (12:20):
So let's see, trendy celebrity beloved brands like reformation are offering backless dresses, which a much smaller selection of bra friendly options. So if you have large breasts, I mean it's hard to find clothes. That's one of the reasons we do breast reductions.

Bri (12:40):
Right. Yeah. Can't be too big, can't be too small.

Dr. G (12:45):
Right. I don't know if you need support, you're tired of wearing double D or larger bras which are more expensive or you need to wear two sports bras or you're always wearing a sports bra. Those are all common complaints from patients that have large breasts. That's not changing I don't think. If you scroll down there's a, yeah and San Diego fashion person who comments on why the stylist, Cynthia Kennedy says it's trend plus cost saving measures.

Bri (13:17):
Less fabric, fewer sewing steps.

Dr. G (13:20):
Yeah.

Bri (13:20):
Lower price.

Dr. G (13:22):
So fast fashion can make money basically, but it's skipping structural features to save time and money. So I feel like

Bri (13:34):
Then you've just got to go and spend more money.

Dr. G (13:37):
Yeah.

Bri (13:37):
Spend more money to get a dress that's got more support, more sewing, more fabric.

Dr. G (13:45):
Different style. I think no one's going to be happy. I feel like when I had small breasts I hated anything strapless because nothing would hold it up and you just look flat. So there's lots of things that,

Bri (14:01):
Well, you could just come here and get fake boobs.

Dr. G (14:04):
Not ideal or get your boobs reduced. We love the bra free summer from our breast reduction patients. That's what they're interested in.

Bri (14:11):
Yes.

Dr. G (14:12):
So there are things you can change. You can either change the clothing or you can change your breasts. Lots of options or you can just wait for the fashion to change again. It's just because it's summertime and it's vacation ready.

Bri (14:26):
Whatever makes you feel good. It's all about what you feel.

Dr. G (14:31):
Yeah. Okay. Speaking of what makes you feel good? Poor Ben Affleck?

Bri (14:42):
I don't know what makes him feel good at this point. It has to just be drugs.

Dr. G (14:46):
Lorazepam.

Bri (14:46):
Lorazepam.

Dr. G (14:49):
I don't know. I don't know. I'm

Bri (14:53):
He really is just a handsome guy though. Despite him in all the memes, he's still a good looking guy.

Dr. G (15:00):
It's so weird when he's,

Bri (15:03):
He dyed his beard.

Dr. G (15:03):
And his hair and it looks weird. It's almost too dark for him. You have all the resources at your fingertips and you cut in subtly removed the gray a little bit at a time?

Bri (15:19):
No, he had to go full force. He's post divorce. I don't know how many marriages he's on but he's divorced again to a different Jen. He's got a midlife crisis it and buy a sports car, date someone 18. I don't know.

Dr. G (15:35):
Oh lord. Yeah, I don't love it. I think if you scroll down, I think I like him better with salt and pepper hair but he looks good otherwise.

Bri (15:42):
His be definitely needs a little more gray hair in it for sure.

Dr. G (15:47):
Yeah, it just doesn't look natural. It looks weird but whatever. Also if you dye your beard isn't that incredibly hard to maintain.

Bri (15:57):
So Eric dyed his beard when we first started dating. Sorry Eric and he was always dyeing his hair

Dr. G (16:04):
Under the bus. Under the bus.

Bri (16:06):
Love you. He was dying it every week and I was like, no, we just got to let this grow. We like the salt and pepper, we like the gray but it was a lot of work to do and I'm like, I swear we would go out and he'd be like, put it on beard dye. I was like, what are you doing?

Dr. G (16:21):
Yeah, because facial hair grows so fast. It just seems like maintenance wise that would be insane.

Bri (16:29):
Absolute pain in the butt.

Dr. G (16:30):
I mean if you're doing it for a movie, sure, but for the day to day and the mustache and all this stuff. Does he have somebody come in and do that for him every week? Wild.

Bri (16:41):
He has to.

Dr. G (16:42):
I'm glad he is out and about. He otherwise looks good. He looks not tired or haggard or I don't know. He looks like he's holding up. Yeah,

Bri (16:54):
He does look like he has a very smooth forehead though.

Dr. G (16:57):
I know. Good. Good for him.

Bri (16:59):
He's doing his self-care. His self-care girly era. Go Ben, go.

Dr. G (17:07):
Oh my god. He's on his hair journey right now.

Bri (17:11):
His hair and skin. I bet he even quit smoking.

Dr. G (17:15):
I wouldn't go that far but it would be a good move for him. Healthy.

Bri (17:19):
Just don't show us your back tattoo.

Dr. G (17:21):
Yeah. Get that removed.

Bri (17:23):
That's where we draw the line. That was sad.

Dr. G (17:28):
Okay. Alright, let's talk about breast implants and replacing them. Let's talk about why someone might want to replace them. There's a bazillion reasons you might want to replace them. There's a whole other set of reasons why you might want to just remove them and get off what I call the implant train like you're done, you want 'em out, you don't want to look back. Although I will say sometimes you do look back and then come back a couple years later and want them back in. We see that. Common reasons for exchanging your implants are you want to change the size, that's the most common reason.

Bri (18:04):
Boob greed is a real thing.

Dr. G (18:07):
Sometimes you they'll want to go smaller sometimes.

Bri (18:09):
Yes, yes. But sometimes people get 'em in and they're like, wait, I should have gone bigger.

Dr. G (18:16):
Yeah, I feel like that was a trend maybe 10 years ago.

Bri (18:21):
I think it's coming back.

Dr. G (18:22):
Then they come back and get 'em bigger now. I just try, I think now the technology is good enough that we can really get you a sense of what you're going to look like and so you're going to know, you can make a decision about what size you really want and then if you want to go bigger, I guess that's fine, but I feel like there's an appropriate range of size that is going to fit your frame, your body, your height. You don't really want 600 cc implants if you're four 11, it's just not going to go well, I don't think. But size change, that's the one thing we spend the most time trying to figure out when someone comes in for breast augmentation. Once you have your implants in though and you've had 'em in for a while, then I feel like you are pretty well educated into what size you really want to be.

(19:12):
So people will want to be a little bit bigger, a little bit smaller or stay the same. So that's one reason. The other reason to get 'em exchanged is rupture, which I think we have a selling sunset person who talks about her ruptured implants and once she found out that her implants were ruptured, what she did next. So if you have saline implants, you don't need a detective to know they're ruptured because it deflates so you have an automatic, hey one breast is deflated. Oh, her breast surgeon's, Joe Hadid. That's cute. Her 15-year-old implants were ruptured after a full body scan. I'm not exactly sure what that is.

Bri (19:55):
That's very popular. Everyone is doing, it's all over Instagram. I forgot what it's called, but they're going and it's preventative health. They're going in to check out and see everything going on in their body.

Dr. G (20:07):
Okay.

Bri (20:08):
Yeah, I would not want to do that. I'd be like, let it simmer. I don't want to know.

Dr. G (20:15):
Right. Anyway, so she learned her implants had ruptured. They were 15 years old. I'm assuming they're silicon because she didn't know until she had a study. So usually you should be surveying your implants. Almost no one does it every three to five years with MRI or high resolution ultrasound to look for what we call silent rupture. Generally it gets picked up on something else like a mammogram or you think you have an issue and it turns out that your implant is ruptured. Certainly 10 years your risk of having ruptured implants goes up. But here they talk about it, they might be uneven or the shape and size might change or nothing. A lot of times nothing happens. So

Bri (21:01):
I just grab mine every couple years and see if there are any squishier. I just do this self test. Don't do that.

Dr. G (21:10):
That is not precise. Anyway, so if the rupture's caught early, then the gel stays within the gel capsule and it's a pretty straightforward exchange. So we will take out the implant, make sure the pocket is super, super clean and put in a new implant and then that's when you can decide whether you want a same size, larger or smaller. So implants can fail. It's a mechanical failure when they rupture, but the current type of implants we use have a pretty thick gel on the inside, so it's a gummy bear type implant. You can just exchange them without too much fuss. Now if you let them sit there with a rupture and that shell continues to fall apart with time and the silicone starts to leak out, then you can start to see a reaction by the surrounding tissue and that leads to capsular contracture, which becomes harder to fix later. And that's usually our patients who have had them in the 30 plus years category and probably did start to rupture at 15 or 20 years and then really were in denial about it just kind of blew it off. So those are our patients with dinosaur eggs, these hard contracted implants that we know are ruptured. The probably number two reason is what we call capsular contracture, which is related usually to an implant rupture or implant rupture as a reason to do a breast implant revision. And it's doable.

Bri (22:46):
Definitely we do it all the time.

Dr. G (22:47):
You know what we appreciate is if you know what's in there.

Bri (22:49):
Which most people do not know what is inside their body.

Dr. G (22:55):
So for all the agony that breast augmentation patients have with exactly what size am I going to do a 345 cc or a 365 or I'm going to do a 330 cc and then 10 years later when you come into my office and you need an exchange and I'm like, so what's in there? And you're like, Hmm, I have C breasts.

Bri (23:17):
Yeah, I have no idea.

Dr. G (23:18):
Okay, are they silicone? I don't know. Are they under the muscle? I don't know. Do you know what profile? No. Nope. Okay, but I want to be the same size, which is fine. We'll figure it out. So what we end up doing is taking the implant out in the OR and then the newer implants have the size printed on the back of them with a serial number. The older implants might not, those are from the seventies and eighties or they're ruptured and we can't find a number on the back anyway. If we don't have information we can weigh the implant and then 250 cc implant generally weighs 250 grams. So we get a ballpark size. So if you say, Hey, I don't know what's in here, I need them exchanged and I want the same size, and we just guess order a shit ton of implants to have around because we don't know. We sometimes try to use the vectra to help narrow down what size we think they're going to be and then we get in there and when we see what it is and we ship all the implants back that we didn't use and put the same size in. It's helpful to know what the profile of the implant is, but a lot of times I can finesse that as well. Most patients are in one of two profiles, but Azella loves it when I order 80 implants for a case.

(24:45):
So a lot of times I'll see you at the consult and we'll talk about how you don't know what implants you are and you're like, I might've had the card somewhere in the garage. And if you do find it, we love it when you call back and say, Hey, this is what I got, but if you don't, no big deal. We'll figure it out.

Bri (25:03):
See, I threw up all over my implant card on my way home from getting surgery, but I know what's in here.

Dr. G (25:11):
Take a picture. Oh my god.

Bri (25:12):
I know what's in here.

Dr. G (25:12):
Yeah. The problem is you can go back to your original surgeon and find out what's in there, but a lot of times they're not obligated to keep your information for more than seven years and they just ditch it. Or your person is, how do you say, an English retired or dead or something. I don't know. They're no longer around.

Bri (25:31):
My favorite is when we go in and they're not only ruptured but they're also textured and you have no idea.

Dr. G (25:37):
You did it in Thailand or Greece or

Bri (25:41):
Yeah, exactly.

Dr. G (25:43):
Bulgaria or something.

Bri (25:44):
Yeah,

Dr. G (25:45):
That's right. That's fine. We should have our own separate CSI of implants. Right.

Bri (25:50):
I feel like I'd be really good at it. I think so.

Dr. G (25:54):
We take a stab at what's in there. We guess.

Bri (25:57):
I actually am usually pretty, the last couple times I've guessed I was almost to the exact number.

Dr. G (26:04):
Yes, I agree. Except we get the really old implants have weird sizes. Right. There's the 233 CC McGann. Why? What did the three ccs add? So wild.

Bri (26:20):
Exactly.

Dr. G (26:20):
Although it helps us, if we see 233 or something like that, then we know what implant brand that is because only one brand was doing that. Everybody else just went with even numbers like either zeros or fives.

Bri (26:33):
They just wanted to be different.

Dr. G (26:36):
So unfair. Okay, so we've covered the ruptured implant sometimes want to downsize or upsize. Okay. Jesse James Decker. I plan to downsize boob implants according to Bri, this has never happens, but it does.

Bri (26:56):
It doesn't.

Dr. G (26:58):
What's the first thing you think of when someone wants to downsize their implants, what are they going to need? Almost always. Sorry.

Bri (27:06):
A lift.

Dr. G (27:07):
Yeah. I was like this is not,

Bri (27:08):
I hope that was right.

Dr. G (27:09):
Yeah. Not a hard question.

Bri (27:11):
What am I thinking about right now?

Dr. G (27:13):
Your diet Coke. Yeah, she's going to go down to a smaller size. She is a country singer. I swear I was thinking of somebody else, but fourth child, your breasts are going to go through some changes and then you have to decide am I going to go same size or smaller size or add a lift, which is probably what she ends up doing. And she did a Q and A with fans and somebody asked her if she was considering removing her implants altogether. Troll.

Bri (27:45):
Why would you ask that?

Dr. G (27:47):
I don't know. I don't know why you're talking about your breast implant surgery on Instagram live or whatever she was sharing on. So I dunno, scroll down. Let's see what she said. Hell no. I'm just going to get smaller implants. It's hard to go from giant implants to nothing. I feel like it can be done and some of my patients love it, but a lot of patients are not really ready to go from large implants to nothing. They are softened up from breastfeeding i.e., they're sagging. She probably just needs a lift and downsizing implants, not a big deal.

Bri (28:32):
I just feel like if the overall satisfaction rate is so much better, if you're going to downsize your boobs, if you get a lift, it's the people that don't want to lift. That's why I think the saline implants are great when you do take them out is that you can drain them first and then they see what their breast is going to look like. You had one patient that was like, oh, I'm not getting a lift, not getting a lift, but I want my implants out. And then she got it drained and she was like, oh my god, you have to do a lift and changed her mind last minute after she saw what it looks like. Right.

Dr. G (29:05):
Yeah. I feel like having saline implants is great for that because you can kind of see, it definitely shows whether you really mentally are prepared to not have implants or whether or not you're going to need a lift. I think for most patients, depending on where your nipple position is, so if your nipples are kind of centered on the most projecting part of your breast or if you have your arms down by your side and your nipples are staring straight into the mirror and or are at the level of the midpoint of your arm, those are the sort of things I look for. If they're below that or they're pointing down to the floor, then you're going to need a lift no matter what. Even if I take 'em out and put new ones in, nothing's changing about your nipple position. So that generally requires a lift and that can happen over time.

(29:57):
Definitely after pregnancies and breastfeeding, weight changes, aging, gravity, all of those things are going to, if you didn't even ever have a breast augmentation, your breasts are not going to look the same as they did when you were 22, if you're now 42. So understanding that, but I do think patients, I do see a lot of patients who are like, I don't want the scars from a lift. So just exchange it and if you are okay with your nipple position as they are, then you'll be okay with it afterwards. But it isn't the ideal result. So I think she's probably ,Jessie James Decker's probably due for an exchange, probably because she needs a lift and if you're already going in for a lift and they've been in for 15 years, you might as well just deal with it now, because you don't want to do a lift, leave the implants in place and then find out one's ruptured two years from now and then have to go back in and exchange.

(30:52):
And if you're considering exchanging it, are you going to downsize the implants or upsize or now you can have that decision point. Her implants are probably under the muscle. Most people did 'em that way. Can you move them when you redo your implants? Absolutely. I would say most commonly we're going from over the muscle to under the muscle. If you're operating for capsular contracture, that's the treatment plan. You could change from under the muscle to over the muscle, which I know is kind of trendy right now to go under the breast tissue only or a subfascial breast augmentation. I'm still not on that bandwagon. I feel like it just doesn't hold up over time. You see the implant outline in the upper half of your breast. It's really noticeable. A lot of times if this is your second surgery, you're going to need mesh and then you're definitely going to need mesh if you're going subfascial after already being under the muscle.

(31:47):
So for lots of reasons, the only patients that I keep under just the breast tissue are ones that are already under the breast tissue and we're trying to minimize their recovery time or there's not a real great reason to switch to under the muscle. When I'm doing breast revision surgery, I feel like just recently I went in and one implant was under the muscle and one wasn't. I did not do the original surgery. You never know what's going to be in there. That's kind of the fun of revision surgery. Even if you think or you have the implant card, sometimes there's a little surprise in there for you.

Bri (32:23):
Does it happen more if it's under over the muscle?

Dr. G (32:26):
So historically it's associated with being over the muscle. So sub glandular breast implants. The other thing that it's associated with is peri areolar incision. So the incision where you go in through the bottom half of the nipple or the bottom half of the areola has a slightly higher risk of cap con, which was really popular 15 years ago. Now a lot of people don't do it. Smoking's associated with capsular contracture, so I tend not to operate on smokers, especially for that because if you don't stop smoking, I can't guarantee that I'm going to improve anything.

Bri (33:02):
That and labiaplasty. Don't smoke.

Dr. G (33:04):
Don't smoke in anything. Don't even get me started. So you're coming back for breast implant revision. Speaking of the peri areolar incision, are we going to use the same incision? Probably. So the three most common incisions are around the areola, underneath the breast, so in the breast crease, and then my probably least favorite, is in the axilla or in the underarm. And then there's

Bri (33:30):
Chicken nuggie.

Dr. G (33:30):
Yeah, there's a fourth location that is through the belly button, which should only be named to remind people not to do that. It's a terrible idea. It's the so-called tuba. You're never doing any breast revision surgery through that incision or through the underarm again, just FYI. So that's a one and done.

Bri (33:51):
I can even envision how that would happen through the belly button.

Dr. G (33:55):
It's really dumb. It's a dumb idea I didn't touch on. But there was somebody in town or I think he is still in town who practices that way and did a bunch of those. So I see those patients every once in a while. So now you need a second breast surgery and there's no way I can go back in through the belly button. It's not possible. So we have to make a new incision, but most of all of the time I'll go through your old incision. Not usually in the habit of creating a new one. Even if it's in the areola. I will use your lift incision obviously if that's what needs to happen. It doesn't matter if you go bigger or smaller, honestly, we can work around both. Let's look at this Bravo, Ashley Darby and see she did an implant swap and see what that was all about. She's feeling about her new boobs after doing an implant swap. Including what she named her breasts.

Bri (34:52):
Oh, I didn't know we named breasts. I knew we named cars and stuff.

Dr. G (34:56):
Yeah, I know my car has a name, but my breasts don't.

Bri (35:00):
Demi and Diamond. Okay.

Dr. G (35:05):
They each have a name.

Bri (35:08):
I dunno how I feel about this. Okay.

Dr. G (35:15):
So she lemme see here, got a breast augmentation. It looks like she had the surgery after her two sons were born. So was it a primary breast augmentation or was it?

Bri (35:31):
Also she said if she got any, she was told if she had any sort of a, she would not be able to breastfeed, which I feel like nowadays, isn't that a common misconception that you can still breastfeed with an aug?

Dr. G (35:42):
Yes, that is a lie. Oh, so she said an implant swap instead of a lift that I'd be fine. Oh, she didn't think she would be able to breastfeed if she did an implant swap and a lift. I'm just going to say also a lie, but she probably just misunderstood. If I knew somebody was going to have two kids, I would not tell them to get a lift and then have the two kids. That does seem dumb. Not because of the breastfeeding. You should still be able to try to breastfeed. Maybe you have decreased milk production, you might not be able to breastfeed. There's no guarantee, but you're going to change the shape of your breasts when you get pregnant and then breastfeed. So why go through the process of having a lift and that it's like coming in and saying you want to augmentation lift, but you're also planning to lose 50 pounds in the next three months. Well, don't do that. So just wait until you're at a stable weight and then you can see where your breasts end up, how big they are, how much lifting they need, those sorts of things. I mean as per usual, you don't want to get your medical advice from real housewives

Bri (37:01):
From Demi and Diamond.

Dr. G (37:03):
I'm sure the Bravo network is credible but not as advice. It's just, it's funny how people just interpret things so she didn't implant swap. There she is with Demi and Diamond, they look great.

Bri (37:15):
Yeah.

Dr. G (37:16):
But yeah, you want to be at a stable place when you decide to do a lift if that's something you need.

Bri (37:21):
Definitely.

Dr. G (37:22):
That halter dress is something else.

Bri (37:26):
It fits Demi and Diamond though.

Dr. G (37:31):
Yeah, that's interesting.

Bri (37:33):
Yeah,

Dr. G (37:33):
I mean maybe we're just oblivious to the trend of naming your breasts.

Bri (37:39):
I'm going to name mine, I'm going to have to think about that. I'll get back to you on the next episode.

Dr. G (37:44):
Same.

Bri (37:44):
Snoo. Just kidding.

Dr. G (37:48):
Yeah, we'll have to contemplate. If you have any suggestions for what we should name our breasts. Please, by all means.

Bri (37:54):
Yes. Please shoot us a message. I would love to know.

Dr. G (37:58):
We need something clever.

Bri (37:59):
Yeah, mine deserve a name after all the surgery they've been through.

Dr. G (38:06):
Alright, so what haven't we talked about when we're talking about breast revision surgery, what have we missed?

Bri (38:13):
Okay. Are there any actual signs besides maybe calcified rock, solid tits on your chest?

Dr. G (38:22):
Yeah, I mean if you think one's feeling firmer than the other and it's not moving around as much, that's usually capsular contracture. If you gained or lost a lot of weight and if you've breastfed or maybe had 10 pregnancies and you feel like your breasts aren't matching your implants anymore for whatever reason, either the implant stayed high and your breasts are falling off the implant or your implants have fallen and your breasts are still up on your chest. Or a lot of times implants will fall out laterally. So that's another form of malposition. Those are all indications for revision. So the implants up in your armpit or out falls down to the side of your chest wall when you lay down or what we call bottomed out. So malposition is another reason for doing an implant revision. Now we usually use mesh, so like an internal bra, which we've talked about before to kind of support the revision while you're healing.

Bri (39:18):
And is that used mainly in revision augs because it's not a primary aug?

Dr. G (39:23):
No, I would only consider using it in a primary augmentation. If the patient was a weight loss patient or had very thin tissues and needed, you could just tell that they were going to need extra support and that's, like I said, it's usually weight loss related.

Bri (39:38):
Do you still recommend, is there a recommendation for getting your implants replaced every 10 years or is it?

Dr. G (39:46):
I think you should be screening your implants on the regular basis. I know none of us do that, but that would be something to consider. You do not need to get them removed at 10 years. The cutoff though is if they're ruptured, most implant companies will replace the implants for free if they're ruptured for the lifetime of the implant. But the warranty starts to run out at 10 years for other issues. So if you have a problem, don't wait until you're 11 years out to deal with it because you'll have less support from the implant company than if you had done it at nine years. But at 10 years, if you're not having any issues, leave them alone.

Bri (40:23):
Just let it be. Let it be. Now if you say you don't want implants, can you still have a fat transfer after you get an implant removal?

Dr. G (40:32):
Yes. I mean I think the hardest part about doing a fat transfer when you're taking implants out has to do with the amount of breast tissue left behind. So what I have to work with fat transfer. So if you had a breasts, a type A cup breast and then double D implants, I can only do a fat transfer into the A cup breast. So I can only put a hundred ccs, maybe a fat in there. If you had D breasts with an A implant, so you have plenty of breast tissue and a teeny tiny implant in there, then I can put tons of fat in there. I have something to graft into. But even in the patients that I have that have 800 CC implants in, we usually get a little bit of fat in there. That skin is so stretched and thinned out after having a giant implant in place. And I do do it at the same time.

Bri (41:25):
As far as when you take an implant out, I know a common question is about what happens with my capsule.

Dr. G (41:32):
So it just depends. I mean the capsule is going to disappear on its own if it's otherwise normal. So a type one capsule is a normal capsule. It's super thin, like translucent, one cell layer thin. So when you take the implant out, that capsule is just going to break down nothing there no foreign body to make the capsule. Your body will just break it down. If you have a thickened capsule or areas of thickening, then I'll remove that. If you have a textured implants, I like to remove the capsule because of the risk of ALCL down the road. That's a rare form of cancer. If you have a patient request where you want the capsule removed, I'll also remove the capsule. Those are all the reasons. So textured, ruptured dinosaur egg slash calcified tissue and patient request are the reasons I take out capsule.

Bri (42:27):
So it doesn't need to always be removed?

Dr. G (42:29):
No, we have patients that have their implants removed under local anesthesia. I don't do a breast augmentation under local anesthesia. That's a little rough, but I can take 'em out under a local.

Bri (42:40):
Just like birthing a baby.

Dr. G (42:43):
Yeah, because you make a tiny little incision and you just push that implant out.

Bri (42:49):
Give it a little pressure.

Dr. G (42:49):
And we're done.

Bri (42:52):
Good to go. So is having a breast revision more complicated?

Dr. G (42:55):
Than having the first augmentation? Absolutely. So there's so many other factors you have to consider. We're usually, very rarely does someone have a perfectly held up augmentation and we're just exchanging them for the same size implants. For what reason would we be doing that? Maybe a rupture non-detectable just got picked up on an MRI or something. So almost always we're either addressing the capsule, we're addressing the positioning of the implant, we're adding mesh, we're doing a size change, we're adding a lift. So for all those reasons, primary augmentation is much more simple and revision augmentation generally takes longer and is more expensive. So the second go round is you can plan on that. And I tell people who are getting breast augmentation, they're not lifetime devices, you're going to have another surgery down the road mentally and financially prepare for that at some point.

Bri (43:56):
Do you think the recovery is the same?

Dr. G (43:59):
It depends. I think it's almost, it depends. I was going to say, a lot of times revision surgery is harder because we're doing a bunch of work inside with repositioning the pocket, but you don't have that initial expansion. So if you had, as long as you're staying in the same range or whatever, you're not going to feel, even if you go from 400 to 600 ccs, you've already gone from zero to 400 ccs that first time. So that pressure and expansion of the tissues, you don't have that kind of pain again. So you won't have that kind of pain. A lot of times my revision patients are surprised that they don't have those issues, but they'll be like really hurts right here, internally. I'm like, yeah, I closed off that pocket. There's a bunch of sutures in there that will eventually dissolve, but for the time being, they're keeping your implant where we want it and it's going to tug a little.

Bri (44:57):
Don't be like me and feel like you can go do things and then pop your suture.

Dr. G (45:01):
Oh god. The worst.

Bri (45:02):
I did it like day three. I heard it.

Dr. G (45:05):
Yeah, you really have to be careful. The recovery time is about the same four to six weeks, but it's usually a solid six weeks of not doing anything after revision surgery. So no chest stuff.

Bri (45:15):
Just take that time.

Dr. G (45:17):
No Pilates, no,

Bri (45:18):
No Pilates,

Dr. G (45:19):
Yoga, no bench pressing, none of that.

Bri (45:23):
No.

Dr. G (45:24):
But yeah.

Bri (45:24):
Skydiving.

Dr. G (45:27):
If you have questions or want to learn more about breast revision surgery, please reach out to us. Call the office. Ava will walk you through it and we can set you up with a consultation.

Bri (45:40):
Or if you just want to name our boobs.

Dr. G (45:42):
Yeah, if you want to name our boobs, like subscribe and place something in the comments.

Bri (45:51):
Oh.

Dr. G (45:51):
Oh my God.

Bri (45:53):
It's like our stripper names.

Dr. G (45:55):
I know. There should be some sort of algorithm for a naming. You know how it's like

Bri (45:58):
Hundred percent.

Dr. G (45:58):
The first letter of the last street, and those are the names of your boobs, like your porn name.

Bri (46:07):
Exactly.

Dr. G (46:08):
We'll have to come up with that.

Bri (46:09):
Yeah.

Dr. G (46:09):
Okay. Well help us out with that little project and we'll catch you later.

Bri (46:17):
The B's re back.

Dr. G (46:23):
No. Alright. We're going to wrap it up. Okay.

Bri (46:27):
Okay, I'm done.

Dr. G (46:32):
If you're listening today and have questions, need info about scheduling, financing, reviews, or photos, check out the show notes for links. Restore SD Plastic Surgery is located in La Jolla, California. To learn more about us, go to restoresdplasticsurgery.com or follow us on Instagram @ restoreSDplasticsurgery. If you enjoyed this episode, please share it and subscribe to All the B's on YouTube, Apple Podcasts, Spotify, or wherever you like to listen to podcasts.