Breast Implant Removal Breakdown

Dr. G (00:02):
You are listening to another episode of All the B's with me, Dr. G and my scrub tech Bri. Alright, welcome back to another episode of All the B's. Good morning, Bri.

Bri (00:13):
Good morning. Happy Friday.

Dr. G (00:15):
Yeah, exactly. So today on the podcast we're going to talk about breast implant removal. It's a little controversial, but it's also very common in a popular procedure that I do in this office. But at first we have some goss to discuss.

Bri (00:32):
Got to go over the gossip.

Dr. G (00:34):
I think the article we looked at and what we have been discussing in the OR this week has been The Perfect Couple's, Nicole Kidman. Right?

Bri (00:43):
I think we ask every patient, have you watched The Perfect Couple? And everyone's like, I'm on the last episode, don't tell me. I was like, I Okay.

Dr. G (00:52):
That's right. We couldn't discuss it. We did do some procedures under local anesthesia this week, and we always recommend shows for patients to watch while they're recovering. And that has been number one on our list lately.

Bri (01:06):
Yes, it was so good. I love Nicole Kidman. She looks amazing.

Dr. G (01:12):
She does look great. And I think the Daily Mail article was referencing her, I think the word was visage, which is a fancy way of saying face.

Bri (01:21):
Don't love that.

Dr. G (01:23):
She looks great. She's 57. I was thinking about this article this morning and I was remembering how she was married to Tom Cruise at some point, which seems,

Bri (01:33):
I didn't even know that.

Dr. G (01:34):
So wild to me because he also recently has made headlines for reverse aging. But yeah, she looks fantastic. The article is all about what "tweakments" she might've had. I'm like, I probably,

Bri (01:51):
But she looks good, like face, neck, chest. I feel like when people do skincare regimens, they forget about their neck and their chest, and you can just tell she is just perfect all the way down. There has to be some, she's doing some juicing or collagen or body lasers.

Dr. G (02:11):
Well, I will say that she's, yeah, her whole body, maybe it's body makeup. Yeah. Because there is no telltale freckling around the chest. She is Australian and they do take sunscreen very, very, very seriously.

Bri (02:26):
Don't forget your neck, ladies and gents.

Dr. G (02:29):
Yes. Neck and chest for sure. I mean, if I had to guess, I would say she's had more than a tweakment. I'm going to go with a deep plain facelift, a very good one that basically has made her look more youthful because you can only go so far with filler fat transfer, Botox, laser non-invasive, I mean, there's so many things and I'm sure she does all of those things to keep her skin looking healthy. But that jawline man.

Bri (03:02):
I know. Little too perfect.

Dr. G (03:05):
She has no bad angles. My guess is

Bri (03:09):
She's smooth.

Dr. G (03:10):
Yeah, I do love that in The Perfect Couple, she gets to channel her Big Little Lies also the whole, I'm going to wear monochromatic looks. I'm going to be drinking a glass of wine with a cashmere cardigan in a beautiful home.

Bri (03:29):
Such a vibe. It gives me such Hamptons.

Dr. G (03:32):
Yeah. Yeah. The Hamptons vibe was strong in the show. I did read a little bit about it and critics were like, either it's really good or this is the worst thing ever. And I'm like, well, you can't take it at face value. It's supposed to be campy. Right? Come on.

Bri (03:51):
Right. And wasn't it a book, right, a book?

Dr. G (03:55):
Yes it was a book first. So was Big Little Lies actually. So I mean maybe that's her jam right now.

Bri (04:00):
Okay, next article.

Dr. G (04:02):
Okay, so moving on to actual

Bri (04:04):
Interesting one about the Mormon Wives star who got a labiaplasty.

Dr. G (04:12):
I have not watched the Secret Lives of Mormon Wives, but it is all over my social media.

Bri (04:17):
I just feel like nobody should get shunned for this. I mean, this is such a common procedure. People just don't talk about it. And I would like to see a lot of other people, it gets uncomfortable down there. You're wearing tight clothing, you're working out. I think there's a lot of other factors just besides, oh I want it to look pretty, of course a huge one, but come on, let the girl have whatever kind of designer vagina she wants.

Dr. G (04:47):
Right. She's an adult. Also, the argument is that the series could be wrecking havoc on impressionable teenagers. What teenagers are watching the secret lives of Mormon wives? I just want to know.

Bri (05:00):
They're on YouTube and TikTok all day.

Dr. G (05:02):
Yeah, nobody is. They're not watching that. And so sure they're on social media all day long, which is influencing their opinion about how things should look. But this is not the nail in the coffin, so to speak.

Bri (05:17):
Right. And out of all the other plastic surgery surgeries that are out there, is everyone else getting shunned for implants or tummy tucks? Like no.

Dr. G (05:31):
Right. Yeah, no, I know. So this lady in her vulva la resistance. Okay. Good for you. I don't know. I think you're a right to do what you want with your body and yes, everything is on the spectrum of normal. However you can decide to make things better if you want, if it's bothering you.

Bri (05:55):
Yeah, exactly. I don't know about that picture though.

Dr. G (05:58):
I know pretty much every surgery we do is enhancing something that was normal. So it's interesting that everyone gives props to Nicole Kidman for looking amazing when she most likely had surgery, but this woman has a procedure and everyone's jumping on her because it's the vagina.

Bri (06:15):
I know. Okay. Women in plastic surgery are like men in going to the gym, so don't want to hear it.

Dr. G (06:26):
That's right. Alright. Alright. So let's talk about breast implant removal. How about that?

Bri (06:32):
Let's get to it.

Dr. G (06:33):
There were so many headlines about breast implant removal that I feel like we had to cut some of them out, honestly. Yes, it's a topic that gets bantered about in the media. I would say it's definitely trending high to have implants removed or to have your breasts reduced on our breast reduction podcast that we talked about. But yeah, there was a great people article about 26 stars who removed or regretted their breast implants. How many of these people do you actually know, Bri, that you recognize?

Bri (07:09):
Ashley Tisdale, Chrissy Tegan, Kourtney Kardashian.

Dr. G (07:14):
I feel like those are all, yeah, reasonable.

Bri (07:18):
Danica Patrick, don't know who she is.

Dr. G (07:21):
She's a race car driver that doesn't race cars anymore, but just will not stop being in the media.

Bri (07:30):
So what are your thoughts on implant removal?

Dr. G (07:35):
Well, like many things, I think it's your right to choose what you want to do. If you want to have implants put in and you're a reasonable candidate and it's a safe operation, go for it. If you no longer want your implants in and you want them removed, then again it's your right to say, I want these out and what I'm going to do about it. Oh, I love Ayesha Curry.

Bri (07:58):
Me too.

Dr. G (07:59):
So I think there have been, it's definitely on the rise and I think I've met patients who say I went back to my original surgeon and I asked to have my implants removed and they said no, which I think is bizarre. But

Bri (08:13):
Can you do that?

Dr. G (08:14):
I mean, you can say no. I can say no if somebody asks for something insane or something that I don't think is appropriate for them or I think is unhealthy. But I think if you have some reasonable expectations and you really have a good reason for removing your implants, then you should be allowed to remove 'em. It was your choice to put 'em in, it can be your choice to take 'em out. So I think there's multitude of reasons like Heidi Montag who had hers removed. Do you know who that is, Bri?

Bri (08:43):
I do. I watched The Hills.

Dr. G (08:44):
Oh, okay. Alright. You never know.

(08:47):
I know who a lot of people are.

(08:50):
Well, some of these people are just a little bit older and since I'm only five years older than you.

Bri (08:57):
I'm young?

Dr. G (08:57):
Yes. You're such a baby.

Bri (08:59):
Did you say at least five?

Dr. G (09:01):
Yes, at least five. I'm hoping that doesn't get edited out.

Bri (09:05):
I won't comment. I don't want to get fired today. Just kidding.

Dr. G (09:09):
So anyway, Heidi Montag, she made the news back when she was peak 15 minutes of fame for having so much plastic surgery, including that rhinoplasty, that's pretty obvious.

Bri (09:21):
She gives me Farrah Abraham vibes from 16 and Pregnant. I don't know if that's mean, but.

Dr. G (09:28):
I don't know.

Bri (09:28):
If you've seen her lately.

Dr. G (09:30):
That's what she looks like.

Bri (09:30):
No judgment, love plastic surgery, but she has overdone it.

Dr. G (09:35):
And Heidi talked about it. I think she talked about having implants, then she went bigger and now she's gone full circle. Right. She's downsized, but I feel like she had extremely large implants. So one of the reasons some of these women are having them removed is because they had large implants in the first place, which if the larger the implant you put in, the more likely that you're going to have issues over time. If you put an 800 cc implant in, that implant is going to stretch your tissues out. It's going to pull down on your breast tissue. It could cause upper back and neck pain. If over time you gain weight and add breast tissue to what you started with, then your breasts are even larger and heavier. And then now you have these giant implants dragging everything else down. So your options are to downsize or because actresses are kind of extreme sometime just take 'em out.

Bri (10:36):
I mean, we took out 700 cc implants under local the other day and I weighed them afterwards and they were three pounds, which doesn't sound like a lot, but imagine carrying a three pound weight on your chest for years. It hurts. It is not comfortable. All these people, she was like, it is so crazy. She's like, one side, it's empty, I'm free. And the other one, she's like, it's still so heavy.

Dr. G (11:01):
I know she could tell as we had removed the right implant out and then on the left side still was in. And when we moved to the other side since she was awake for the procedure, it was like, oh, I can immediately tell the difference. My right side feels so much less pressure. Yeah, I can't believe actually all of these people have their implants removed. It's kind of wild, the scrolling through this list. So I think we're going to talk about SZA a later because she had her implants in and then out in rapid fashion. She had, well, we can talk about her now. She had another reason to do it right. She had what sounds like and gets lost in translation in the article is that she had fibrocystic disease, so her mom had breast cancer. She's probably at an increased risk for breast cancer.

(11:51):
So she's getting maybe mammograms or some sort of imaging on a regular basis. They're putting little clips in to monitor certain areas. And so having really fibrous breasts and that risk factor can make it difficult to look for or screen for breast cancer. She had implants placed and then she's still having to go through all this screening either with mammograms or ultrasounds or whatever. It's not clear in the article. And so since it was just making life difficult, she just had them removed. I don't even think they were in for eight months and she took 'em out. So I don't know.

Bri (12:33):
So would you put implants in on a patient with an increased risk for breast cancer? Do you think she knew about this prior to getting her implants in and she was just like, eh?

Dr. G (12:43):
I think she says that she was like, eh, I didn't really think it through, I just wanted it, it was sort of an impulse situation. I don't know, I think studies have shown that implants don't increase your risk for breast cancer. That's asked and answered. And one of the things is generally speaking, but not over time, women who have implants tend to be more proactive in screening for breast cancer or more diligent about getting the mammogram or the MRI or the ultrasound. So the implant itself isn't causing breast cancer. You should be able to do a mammogram and do a displacement technique and still be able to see all your breast tissue. So it should not, it's not in the way of diagnosing breast cancer. If the implant is subpectoral, meaning under the muscle, then it's a little bit even easier to displace the implant during a mammogram. For someone like CZA who has, if she really does have a high risk, then she probably meets the criteria for MRIs. In which case if you think a mammogram's uncomfortable, you have to lay face down on the MRI table and your breasts hang out of it and then they do the MRI. So that just seems weird, but whatever.

Bri (13:59):
Interesting.

Dr. G (14:00):
But again, technology is advanced so much that you can do a pretty good screening that way for patients who are at high risk. So those options are all there. So I feel like it's a little disingenuous to say she had them removed to cancer risk. However, if you're constantly getting breast biopsies, meaning they're like using a needle to locate a certain area that looks concerning and then they're taking a little piece of tissue and you're always having procedures on your breast and those implants are sitting there potentially to get ruptured, or you might have a complication from the breast biopsy and a bleed and all the then maybe, yeah, don't add implants on top of that. Makes the breast surgeon sometimes a little nervous. They don't want to hit the implant and you're always getting monitored. Maybe you don't want the implants. I would say though, in terms of breast enhancement, she's a terrible candidate for a fat transfer to her breasts because if you do really have this fibrous tissue and unclear studies that can't determine what's what for breast cancer and you add fat into the mix, I'd probably not recommend that. You can't take that back. You can take the implants out pretty easy and I like doing fat transfer to the breast. But yeah, in her, they put it in her booty, which is probably the best place for it, as you would say.

Bri (15:20):
Amen. So to vaguely touch, I know a little bit in this article they were saying that prophylactic implant removal for textured implants is not necessary. People that say that they have symptoms from implants. What are your thoughts on getting them removed?

Dr. G (15:41):
I think it's important that if you feel like you have breast implants and they're making you sick, that you are again entitled to have them removed. However, you should be evaluated by primary care and whatever other subspecialties to make sure we're not missing something else. There is no test for breast implant illness. I can't draw a lab or run you through a study. But the symptoms of breast implant illness are very vague and can be attributed to a lot of things. So you would hate for somebody to be like, I'm fatigued all the time and I have these rashes and I have brain fog and I'm cold or hot, or I'm losing weight or my hair is falling out, or any of these symptoms and you just take the implants out and you miss a thyroid cancer or a rheumatoid arthritis or lupus or something else that is a systemic process that goes undiagnosed.

(16:44):
So that's super important to make sure that everything is not attributed to your breast implants and you really have to rule out the other things first and treat that otherwise we're doing our patients a disservice. Because again, I can't validate that the implants are making you sick. So a lot of times it's the last thing on the list. I've done all these tests and nothing is working and I don't feel better, so take 'em out. The larger studies that have come out, most women, so somewhere between 60 and 80% of women who feel that their symptoms are attributable to breast implant illness don't have any other major systemic diseases will feel better after removing them. So it could be a foreign body reaction, we don't know. So if it makes you feel better, great. If it doesn't make you feel better, I think that's where things start to go a little crazy.

(17:40):
You could argue that for some of these patients, it wasn't their breast implants. Some percentage just statistically speaking are not going to get because it was never their breast implants. It's something else. Unfortunately in some of the groups of breast implant illness, that's the wrong answer. You can't have explant regret. There are Facebook groups who advocate for breast implant removal pretty strongly and have strong opinions about it. And most things on social media, if you have a differing opinion, you get shut down or shut out of the group. So now there's another group of women who've, like you mentioned, had their implants removed and are not happy about it and wish they hadn't done it and don't feel better. And so they have their own group and so then it becomes an echo chamber. What bothers me is when the patients who do regret having their implants out ask for validation, are there other people out there like this? Some of the people who are strong BII advocates will tell them, well, it's because you still have capsule leftover, or you have mold toxins, or you need to do a cleanse or, you know what I mean? It's not.

Bri (18:58):
Oh yeah.

Dr. G (18:59):
You just can't let it go. No, maybe it wasn't, like did it ever occur to you? It wasn't the implants? That has to be an option. And there are some groups who it's never an option. It's something else. The surgery wasn't done properly or you didn't drink enough water or whatever the hell it is, you need to take these supplements. It just never ends. So that's kind of where I deviate from, there's nothing that's a hundred percent solution for anything ever, ever.

Bri (19:27):
So touching on the capsule a little bit, is the capsule something you take out with every implant? Is it what the patient wants? How do you decipher if all the capsule comes out if it doesn't?

Dr. G (19:44):
Right. So that is another controversial topic. So anytime you put an implant in, because sometimes I talk to my patients who are there for their implants to be removed for lifestyle changes or they're just tired of them or it's ruptured or whatever, and I start talking about their options for capsulectomy and they're like, backup, what's a capsule? Right?

Bri (20:08):
Yeah.

Dr. G (20:08):
Or the husband's like, wait, what are we talking about now?

Bri (20:12):
Are we still talking about her breasts?

Dr. G (20:14):
What's a capsule? So anytime you put in a foreign body, your body will form a capsule around it. So that's kind of like a scar tissue. It's a foreign body reaction. So if you have a pacemaker in your chest, when they insert that pacemaker, it forms a capsule around it. When you put the implant in, it forms a capsule. In some patients that capsule is super thin and mobile and you don't know what's there. You've seen them where it's like one cell layer, I call it moonbeams, right?

Bri (20:47):
So thin. So thin.

Dr. G (20:50):
So thin, it's practically non-existent. In other patients, that capsule can get thicker and then that's when it becomes a problem. We call it capsular contracture, meaning that the capsule gets thickened and hard and starts to distort the implant. It can happen for no reason or it can happen because the implant is ruptured. And so that's inciting a little bit of irritation. It can happen just over time, radiation, which most patients aren't having, but if you radiate that breast, you will 99% of the time get a capsular contracture. It's known to be at an increased risk with smokers, although weirdly, sometimes one side gets cap con and the other doesn't. And then we think that there might be some things at the onset of surgery that's like a low, low, low level of biofilm that creates a cap con later. That being said, so every implant has a capsule, I can take the implant out and leave the capsule as long as the implant's not ruptured and the capsule is nice and thin and filmy, because since it's your own tissue, your body will reabsorb that capsule over time.

(21:57):
If the capsule is thickened, I can take some of the capsule out, the thickened part out just so it's less burden for your body to break down cuz it's not doing anything. And then there's patients who feel really strongly that their symptoms are not going to get better unless you take the entire capsule out. And I tell patients, if they come to me asking for that, that's their choice. If you are going to lie awake at night wondering if you're not feeling better because you didn't choose to have your entire capsule removed, then by all means have it removed. The studies show, overwhelmingly, that it doesn't matter whether you take out all of the capsule, part of the capsule or none of the capsule. Women who have symptoms of breast implant illness prior to having their implants removed will all feel better. But again, the groups that advocate for breast implant illness just feel like the study is discredited, even though it was a grant funded study and was really, really, really well done. So again, I know people hate when I say science.

Bri (23:07):
But that's all we have to go on these days.

Dr. G (23:09):
Yeah. Sometimes it's science, so the science doesn't show that the type of capsulectomy matters. You will still feel better. I mean, I always liken it to breast cancer. If you have a small breast cancer, your options are a lumpectomy, just remove that cancer and then radiate the breast. Or you can do a total mastectomy, just take the whole breast off and avoid the radiation perhaps. So those are two completely different ways of addressing breast cancer. Again, if you're the type of person who's like, I want the whole breast removed, I do not want to deal with this. Actually take the other breast while you're there and do a reconstruction. That's your choice. If you're like, I actually like my breast and I want to keep it so you can take the cancer out and then radiate it, and I'll just go with that.

(23:58):
Also your choice. Those are both equal survival rates. So if you're going to lie awake at night because you just did the lumpectomy and radiation, then do the mastectomy. If you're not, then do the lumpectomy and radiation. It just depends. So this is the same thing, if you feel strongly that having your whole capsule out is going to make you feel better, then we can do that. But if you're like, I don't know what you're talking about, then I usually advocate just a partial capsulectomy unless you're doing it under local anesthesia in which I'm not taking any capsule out.

Bri (24:34):
Just the implant.

Dr. G (24:35):
Just the implant. And why would we do that? And the recovery is so much faster, right?

Bri (24:41):
So easy.

Dr. G (24:42):
Yeah.

Bri (24:43):
They walk out of there, they feel great. Local, we have done a ton of implant removals under straight local. A lot of patients do not like going under anesthesia. I know we've said that before, but the fact that you can just go in there and get them done way easier than they were put in.

Dr. G (25:02):
Right. And drive your little

Bri (25:04):
Drive yourself home.

Dr. G (25:05):
Right. Can you tell us what straight local means? It's not heteronormative, it's. The difference between,

Bri (25:13):
I'm going to pretend like I know what heteronormative is.

Dr. G (25:16):
It's just funny.

Bri (25:17):
But.

Dr. G (25:18):
Every time I think of straight local, just in today's day and age, and maybe it's because we're in Southern California, I'm like, why does the local have a gender preference?

Bri (25:34):
Oh, oh, oh, okay. Yeah. I mean it can be any kind of local you want. It doesn't have to be straight, but we essentially just go in, we put a little bit of numbing cream on, it sits for 10, 15 minutes, however long, and then she injects a little mix of local, not straight. It's a little mix of lidocaine and Marcaine, with a little bit of epi, and that's just so the patient doesn't feel any of it. And it does wonders. Patients do so good.

Dr. G (26:06):
Yeah.

Bri (26:06):
It's pretty easy.

Dr. G (26:08):
So in our parlance, straight local is that. We also offer doing it with an oral sedative. So that is fine with us. It takes the edge off if you're nervous about being in the operating room and being totally awake. And we like doing that as well, you just need a ride home. So I think people understand if they have a ride home, just take the margarita in a pill form and then you can relax.

Bri (26:32):
And you don't have to hear us talking about our Daily Mail in the OR.

Dr. G (26:37):
Right. We're just chit chat. I think we did, these are the patients that we've been chitchatting with about Nicole Kidman and The Perfect Couple.

Bri (26:45):
Yes. We did a whole procedure on Nicole Kidman's ear lobes.

Dr. G (26:50):
That's right. Yes.

Bri (26:52):
I can't unsee them. She's absolutely beautiful, love her. But once you look at them, you can't unsee them. So we segued real deep on that one, but.

Dr. G (27:03):
I know I think it's easier for the patients if they've had the margarita. I tell them, they're going to be a little dumber after the local procedure having talked to us.

Bri (27:11):
Exactly. But it's fine.

Dr. G (27:15):
Yeah. So if you want any of the capsule removed, then obviously you need to be under general anesthesia. And then yeah, so we have the collaborative community issues consensus statement on breast implant capsulectomy definitions and management by the ASPS and the Aesthetic Society. Again, it's pretty clear that en bloc is not a requirement or impacts your ability to heal afterwards, but people feel strongly about having it done. So if you choose to have en bloc procedure, just know that the incision often needs to be a lot. Are you pulling up? She's pulling up

Bri (27:55):
The ear lobes.Thank you. So everybody can see what I was talking about because

Dr. G (28:01):
They're just large.

Bri (28:02):
I mean for all the work that we presume that she may have done. The ear lobes, I love that she's confident with your ear lobes. I love that she owns it, but I would've had those trimmed a long time ago.

Dr. G (28:17):
Yeah, we digress.

Bri (28:18):
Someone else has to comment so I don't sound like such a rude person.

Dr. G (28:24):
But the ear lobes are insane and you could easily fix that. That's so fixable.

Bri (28:30):
Under straight local.

Dr. G (28:32):
That's right. Under straight local, no margaritas required. No scar in a visible location.

Bri (28:38):
No.

Dr. G (28:39):
Slam dunk.

Bri (28:40):
But yes, I feel like at the end of the day, it is your body, with the whole breast implant illness. It's your body. And I feel like every doctor is there to just essentially guide you. As coming from a patient myself, the doctor is there to guide you on the best possible options, but you should never feel pressured into doing something you don't want to do or not doing something you don't want to do.

Dr. G (29:02):
Right. So I will reserve my right to recommend taking out the whole capsule when somebody has a textured implant, and that leads to breast implant associated lymphoma, which is a whole other issue. So that is a real diagnosis of cancer. We know it's related to a breast implant. It's overwhelmingly been associated with textured implants. So I feel like it's reasonable to remove your textured implants if you want to reduce the risk of this very rare cancer. And there have been isolated incidents of patients developing B-I-A-A-L-C-L who had smooth implants in place. But when you look back at their records, they had had textured implants prior or textured expander prior. So the thought is that that laid the groundwork for the cancer. And then despite having a smooth implant later, you were already creating whatever instigator it was to create this rare cancer, which is treatable with an en bloc capsulectomy and removal of the implant. So if you have textured implants, it is reasonable. Again, the science is not amazing because it's such a low incidence to recommend getting all the capsule out, even if you're not putting in new implants, just to take that risk, not off the table. Again, nothing is a hundred percent, but greatly reduce the risk in my opinion. And again, I talk to patients about that. The problem is that how many patients would you say, how many out of 10 implant patients would you say actually know what's in there?

Bri (30:53):
I would be generous to give one or two.

Dr. G (30:56):
Right.

Bri (30:57):
Nobody knows what's inside their body. Absolutely no idea.

Dr. G (31:01):
Nope.

Bri (31:02):
Yeah, sorry girl.

Dr. G (31:02):
Patients are routinely confused about what type of implant they have. I love mean we've had a handful of patients that had their implants put in other countries. I'm like, you're absolutely killing me. Right?

Bri (31:15):
Yes.

Dr. G (31:15):
So we've taken implants out from Thailand, from Europe, from Columbia. I mean, we're internationally, internationally known. I'm like Thailand, a hundred percent those are going to be textured just because textured implants are way more popular outside of the us. So just FYI. But yeah, people don't know what size it is. I want to go back in a time machine and kill all the people, all the plastic surgeons 20 or 30 years ago who didn't discuss ccs and just told people We're going to take you from an A to a C. So they were like, yeah, it was an A and I got a C cup implant. That means nothing.

Bri (31:55):
Right?

Dr. G (31:56):
Did he get a 300 cc implant, a 500 cc implant? But I think back then that was the conversation you had. You said, I'm going to take you from a cup to a C cup, and then you put whatever you wanted in. I guess, I don't know. Those surgeries are older than when I was practicing. Now I'm like, Hey, we're going to do a 325. This is the profile. This is the type of implant, this is the plan. This is what we're putting in. Here's your implant card. They'll still probably forget, but at least we know at the beginning what we're doing.

Bri (32:26):
Right?

Dr. G (32:27):
Yeah. I think it's, again, some patients I think never knew and some patients have forgotten or they can't find the card, so they really don't know what's in there. And I would like to also, my call to action on this is to complain to mentor because their catalog listing of implants, so when you look at an implant catalog, it lists usually for Allergan, let's say it's an SRM 325. So that tells you it's a smooth, responsive, moderate profile, 325. So some reason in Mentors world, which is one of the major implant manufacturers, all the catalog numbers start with 350, and then it's a dash, and then maybe it's a seven, and then 325 would be your actual implant size, and then there's a letter,

Bri (33:21):
Or everyone thinks they have 350s.

Dr. G (33:23):
Yeah. So that's a problem. I think in a single day I saw two patients that had mentor implants. They both said, oh yeah, I have 350 ccs. I was like, oh, you have your card. It was a banner day because they both had their cards. And when you look, you can see that they're looking at those first three numbers, which are not actually the size of their implant, and you have to look at either the next three numbers or the last three numbers, depending on the style, blah, blah, blah. So both patients thought they had 350 cc implants in, one had 275 cc implants in, and the other had 475 cc implants in. So again, I like to know what they have so you can make an educated guess about how much volume they're going to have afterwards. Certainly if you're actually exchanging the implants and going upward down in size, you kind of don't want to know what's in there. But a lot of times we're just CSI-ing it and figuring it out on the fly.

Bri (34:18):
Yep.

Dr. G (34:19):
The most common question I would say that patients ask when they're getting their implants removed is what is it going to look like? So that's a different story if I'm removing 200 cc implants or 800 cc implants. So if I can get that ballpark from you, I can give you a little bit more information about what they might look like.

Bri (34:41):
Then you have options to decide if you want to lift or fat transfer or you just straight want them out.

Dr. G (34:47):
That's right. Saline implants can be ruptured if you really want to know. So my patients with saline implants, and not everybody takes me up on it, can have their implants deflated in clinic. So one, we can take out the fluid that's in there and count it. So if they don't know what's in there, we can pull 400 ccs out or whatever it is until you, well, you had 400 cc implants, and then two, they get a sneak peek at what it would look like if they just had the implants out.

Bri (35:17):
So you would recommend having that done prior to the procedure?

Dr. G (35:21):
Yes. I usually tell patients you can do that at least two weeks up to four to six weeks before the procedure, if that's something that you are on the fence about, in terms of what you want to do. I think it's helpful. Silicone implants, obviously you don't have that option. You just have to,

Bri (35:38):
Don't do that.

Dr. G (35:40):
No, it's been done.

Bri (35:42):
I'm sure. I'm sure. How far prior would you recommend somebody get their saline implants deflated prior to a procedure?

Dr. G (35:50):
I would say ideally four to six weeks, but most often, and I think in our patient population, we do it two weeks. I just tell 'em, you can do it whenever. I just would have surgery date at least on the books, because if you're very thin and that implant is deflated, the shell of the implant is still in there and sometimes you can feel it, it wrinkles up and it pokes you and it's annoying. So you don't want to deflate them and then have that happen and be stuck with them for three months like that. I mean, you'll live, but it's just annoying. Now. I have deflated implants for patients who are planning to walk around with them deflated for even longer in specific circumstances. I had a patient who had one was already deflated, but she was trying to get pregnant, so we just deflated the other one, and then she'll circle back around when she's done having kids.

Bri (36:41):
And I've read a couple articles that say that if they are deflated, you can find your true IMF crease. So if you decide to do a lifter some sort, you can actually, your breast goes kind of back to its natural position.

Dr. G (36:56):
That is correct. So yeah, when you put an implant in, it definitely lowers your inframammary crease, so that under boob line on your chest, it stretches that out. And usually when you remove the implant, it comes back up a little bit. It just depends. I mean, yeah, you could see where that crease is. I've had patients where the incision is obviously where they made the new crease. So when you take the implant out and your breast springs back to the old crease, now the incision's on your chest wall, which kind of sucks, but there's nothing you can do about it. And I don't make a new incision at the new crease. I just go through the old incision. Then in that case, I think, oh, well then maybe peri areolar is the way to go because you can make an incision if they've already had a peri areolar incision, go in there, get the implant out, and then the IMF gets to do what it wants to do.

(37:48):
The lady that we took the saline implants out under local had that, and you could see her inframammary crease kind of find itself, find it some proper home, but without the pressure of the implants. But that incision actually is often fraught with weird, dense and issues where the lower part of the areola tethers down or just looks funny. If it looks funny at the beginning, already looks a little weird, it tends no matter what I do to look really great afterwards and it can kind of dent in at that position as well. So there is no perfect solution. And then last week I believe we took out implants from someone who had had them done through an axillary incision, which I have to then pick something else. I done it once where I took out

Bri (38:36):
That's still a thing?

Dr. G (38:38):
Yeah.

Bri (38:38):
Does anybody even still do that incision?

Dr. G (38:40):
There's somebody locally in San Diego who offers that incision. It's just any kind of revision work is going to have to be done through a separate incision. So I don't think it's as popular as it used to be.

Bri (38:51):
So after you get your implants out, what can you do to make them look as best as possible with all that extra space from what their implant has been?

Dr. G (39:02):
Great. So when we talk about implant removal, I say you can take 'em out. You can take 'em out and do a lift. You can take 'em out and do a fat transfer or you can take 'em out, do a lift and a fat transfer. Now, some surgeons don't like doing fat transfer at the type of implant removal. I don't mind doing it. It depends. Everything always depends, right? It depends on, I think the most important thing is what's your implant to breast tissue ratio? Are you all implant and no breast tissue? Are you 50/50? Are you the awesome patient that has 200 CC implants in and D breasts so you're not even going to miss them? I see less and less of those patients. Sometimes those are patients in their sixties, they've gained 50 pounds over the last 20 years, and so they're not going to miss their implants at all. Those are very rare. Again, Southern California is full of teeny tiny people. So my 60-year-old patients, I think and older are skin over implant. They're just so tiny, right?

Bri (40:05):
And some of them are so incredibly hard. They're like little dinosaur eggs. I don't know how else to explain it. Yeah, the ruptured encapsulated implant, yes. Some of them you take out and it's calcified.

Dr. G (40:21):
So those are the most challenging, I think. And those patients actually, I've started to stage and I just had someone recently where I was like, I cannot, I have to take them out and then let your tissues recover because you're literally skin over this hard ruptured implant, and then we can figure out what's the next best step. So the most challenging are the dinosaur eggs, the ruptured implants that have been sitting there for 20 years. And the ladies who have super large implants and started with Type A breasts and they have size a breasts and they still have size A breasts stretched out over that implant. So those are the most challenging. I tell patients that when you take the implants out, shockingly your nipples don't fall to the ground. People are super worried about that. So if your nipples are staring at the wall or the mirror, they're not going to fall when we take them out.

(41:19):
So the reason to do a mastopexy are either to raise the nipple areolar complex or to reshape the breast. So for some patients, if their nipple is in good position, then we're just doing it to reshape the breast tissue that's been stretched out for patients whose nipples falling off their implants that so-called waterfall deformity where the implants are staying high, but the breast tissue has aged and fallen off the breast, then I strongly recommend doing a lift when you take 'em out, because they're also not magically going to come up. The nipples going to sort of fall backwards. So wherever it is it is. And then fat transfer is usually an effort to restore volume, so we can put fat in to restore volume. Again, if you have a 200 cc implant, it's a little easier to put 200 ccs of fat in than 800 ccs. And then it also depends on the patient. If you have no fat, kind of hard to, I can usually scrounge around, but every once in a while someone challenges me on that. I think the lady we saw had a BMI of 16.

Bri (42:20):
So tiny.

Dr. G (42:21):
Literally, that's when you're like, I need someone to donate fat for this because there's no way.

Bri (42:26):
That's when you have to look into purchasing the fat.

Dr. G (42:29):
That's right. Fat in a syringe.

Bri (42:31):
Exactly. But we still found some.

Dr. G (42:35):
Yeah, we have done

Bri (42:38):
Done patients where we've definitely put in some work.

Dr. G (42:40):
To get the fat, for sure. Yeah.

Bri (42:44):
And by work it's her lipo. I'm I'm there for moral support. Yeah, faster you can do it.

Dr. G (42:52):
You're doing a good job. Yeah. So I think it's important to know these are all the options. And so that for that reason, our consults for these procedures are generally a little bit lengthy. And for people who are open books and have no idea what they want to do or even aren't sure if they want to replace the implants, I usually do a two time consult. So we talk about all the options, and then when you start to think about it, narrow it down, okay, I think I'm going to do this and a lift, or I think I'm going to exchange it, or I think I'm going to do, then we can have a more refined conversation about what that surgical plan is. So it is a lot to take on, and I think most patients have a lot of questions truly related to what's it going to look like when I remove these. So I think it's important that they have a good sense of why they're doing it and what it's going to look like afterwards and kind of what the long-term effects are.

Bri (43:46):
Right. Because everyone's different. So

Dr. G (43:49):
Yep. We're all snowflakes or thumbprints or whatever. I dunno.

Bri (43:53):
And to touch back on the capsules, just to smidge, what do you, sending off the capsules, what do you do with them? Do you send them? Do you toss? I know we send them to pathology.

Dr. G (44:03):
Right. So if there's a history of textured implants, I like to send them to pathology, to look for abnormal cells to rule out any B-I-A-A-L-C-L. Again, it's low. If you have a suspicion of having that prior to having your implants out, which is a completely different subset of patients than you need a thorough workup prior to. So if you have a fluid collection around your implant or mass or something, that's a completely different pathway. But if you have totally normal implants, they happen to be textured and we're taking out the capsule, it's usually a good idea to send them to pathology, just to look at cytology and make sure there's no abnormal cells. If you have smooth implants and we're taking out your capsule because you want to, then it's dealer's choice whether you want to have the pathologist look at that tissue or not. And some people do and some people don't. Again, are you going to be able to sleep at night if you know I took that out and I sent it to pathology or didn't send it to pathology, obviously I have sent it when I see something concerning or abnormal, and that's happened usually with the older ruptured implants where I'm like, this looks weird. We're sending this. If I find anything in breast surgery that looks abnormal or weird, we're going to send it to pathology and make sure.

Bri (45:13):
Awesome. We love that. So who is a good candidate for local, awake local implant removal, and who is a good candidate for general anesthesia?

Dr. G (45:26):
I think if you are confident that you just want your implants removed and you want a quick recovery, then you're a good candidate to have them removed under local anesthesia. If you're kind of a nervous Nelly or you're anxious about the procedure and you don't tolerate dental appointments, then you probably want to do that under generally anesthesia. Certainly if you want any capsule work or a lift or a fat transfer, then you need to be under general anesthesia for that procedure.

Bri (45:54):
And what's the recovery for those that go under general anesthesia or have other work done along with getting their implants removed?

Dr. G (46:01):
If you're having implant removal with capsulectomy lift or fat transfer, I tell patients two weeks of taking it easy, not raising your heart rate or blood pressure, and then generally another two weeks where you can start to increase your activity level. But no heavy lifting, no push pulling, no pushups, CrossFit, any of the other crazy things we do down here in San Diego. But you can walk to your heart's content, no Peloton if you're pushing on the, no soul cycle, there's so many things, but yeah. And then at four to six weeks, you're generally free to go back to your life.

Bri (46:36):
Daily activities.

Dr. G (46:39):
All right. I think mean you've asked some good questions. I did do a IG live once where we talked about implant removal with my friend Dr. Greer, and someone trolled me and said, what would you know? You don't have implants.

Bri (46:51):
You're like, thanks.

Dr. G (46:54):
For the record

Bri (46:55):
All natural.

Dr. G (46:58):
I actually do have implants, and there are those annoying Mentor ones, but I know they're not three fifties.

Bri (47:05):
Well, I have implants and they're unfortunately going to be with me till I die because I'm one of those patients that had A boobs that stuck these massive implants in. So these will be in my casket. Just bones and implants.

Dr. G (47:21):
And hair.

Bri (47:22):
And hair.

Dr. G (47:23):
Maybe the lashes.

Bri (47:25):
Exactly. Maybe my front teeth.

Dr. G (47:31):
Alright, I think we can wrap it up based on that. Thanks for listening. If you have questions or need information or you want to argue with me about breast implant removal, please reach out. Check the show notes for links. You can send us a DM on Instagram @RestoreSDPlastics, or you can hit us up on YouTube. So thanks so much for listening to this podcast, and we'll talk to you later. 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 Podcast, Spotify, or wherever you like to listen to podcasts.