Latest / HKB Uncut | A Cosmetic Surgery Podcast / 26. My Breast Implants Don’t Feel Like Me Anymore… Now What? | Breast Implant Revision Surgery with Dr. Wu

Transcript

26. My Breast Implants Don’t Feel Like Me Anymore… Now What? | Breast Implant Revision Surgery with Dr. Wu · HKB Uncut | A Cosmetic Surgery Podcast

• 0:00
  SPEAKER_01: I actually had one of these cases today.
• 0:02
  SPEAKER_01: They're like adamant that they had saline this size.
• 0:04
  SPEAKER_01: And sure enough, it wasn't that size, and it wasn't saline.
• 0:08
  SPEAKER_02: And it was in a different pocket.
• 0:09
  SPEAKER_01: And I mean, I I found different manufacturers in each pocket.
• 0:13
  SPEAKER_01: I found different pockets on each side.
• 0:15
  SPEAKER_01: I found different sizes.
• 0:17
  SPEAKER_01: I even found two implants before in one pocket.
• 0:20
  SPEAKER_00: Wow.
• 0:25
  SPEAKER_01: Welcome to HKB Uncut, the health, knowledge, and beauty podcast.
• 0:29
  SPEAKER_03: On this show, we unpack the newest techniques and trends in cosmetic surgery, how to tune out the social media noise to make empowered decisions about your appearance and what you need to know before you book a procedure.
• 0:39
  SPEAKER_03: I'm Dr.
• 0:40
  SPEAKER_03: Bill Cortesis.
• 0:41
  SPEAKER_03: And I'm Gorov Bahardi.
• 0:43
  SPEAKER_03: We are board-certified plastic surgeons and co-founders of HKB Cosmetic Surgery, an award-winning practice with 11 locations across six states.
• 0:51
  SPEAKER_01: In other words, when it comes to aesthetics and cosmetic surgery, we've pretty much seen it all, and we want to share our knowledge and unique approach to aesthetics and beauty with you.
• 1:00
  SPEAKER_01: Whether you're interested in cosmetic surgery for yourself or want to separate fact from fiction in the plastic surgery world, we hope you'll tune in each week.
• 1:18
  SPEAKER_03: Today we're going to be talking about breast implant revision.
• 1:22
  SPEAKER_03: And I know it's something you know a lot about because we've been on um uh speaking um engagements with you where we're on a lot of panels talking about this specific topic.
• 1:31
  SPEAKER_03: So we're excited to talk about it.
• 1:32
  SPEAKER_03: Let's get into it, Cindy.
• 1:34
  SPEAKER_03: What why do patients need to have a breast implant revision?
• 1:37
  SPEAKER_03: What's what are the top reasons?
• 1:38
  SPEAKER_00: Thank you for allowing me to be on the podcast.
• 1:40
  SPEAKER_00: Really excited to do this episode with you.
• 1:42
  SPEAKER_00: Um but yes, I've been seeing more patients with uh needs for breast revision.
• 1:47
  SPEAKER_00: And the top things that I'm seeing right now are women who want to have their implants out altogether or to downsize, because as you know, the aesthetic now is to have smaller breasts.
• 1:58
  SPEAKER_00: I'm sure you've heard about the ballerina breasts, and that's really a focus on a more smaller uh breast size and shape.
• 2:05
  SPEAKER_00: And so women who've had implants that are large and they were placed maybe like 10, 15, 20 years ago, no longer want that aesthetic.
• 2:12
  SPEAKER_00: You know, they might be older, more active, kids are out of the house.
• 2:16
  SPEAKER_00: So I see patients who want to be smaller, and that either means removing the implants altogether or going down in size.
• 2:23
  SPEAKER_00: And when you do that, there is some skin that's going to sag.
• 2:27
  SPEAKER_00: And so oftentimes women need a lift at the same time.
• 2:30
  SPEAKER_00: Um, there are women who, when you want to take the implants out, they want to really kind of give some volume back, they don't want to be completely flat.
• 2:39
  SPEAKER_00: Uh, so some of these women want to have fat grafting, they want that natural tissue, they want to have some shaping after the implant comes out.
• 2:47
  SPEAKER_00: So that's the most common implant revision patient I'm seeing, the patients who want to have the implants removed altogether or downsize.
• 2:54
  SPEAKER_01: Well, you know, when when patients come in and you know they're talking to you about having implants in place, and I know this is a question I get asked all the time is when do I have to have a revision?
• 3:06
  SPEAKER_01: You know, what's the length of time that my current implants are gonna last?
• 3:10
  SPEAKER_01: So you have somebody coming in for their original surgery, they're already thinking about their second operation because we all talk to them about that.
• 3:16
  SPEAKER_01: We were like, hey, this is not a lifetime product.
• 3:18
  SPEAKER_01: Yeah, you're gonna ultimately need to have a second surgery.
• 3:22
  SPEAKER_01: So, what do you tell patients when that time frame is and what to look for?
• 3:26
  SPEAKER_00: Yeah, that's a great question.
• 3:28
  SPEAKER_00: Very commonly I get asked that, and with the current implants now that are cohesive, they're made to last longer than the 10 um years that people normally are associated with silicone implants.
• 3:40
  SPEAKER_00: And so I tell them with the current generation of implants, I've seen women who've had their implants for 10 or 15 years and really no issue at that point.
• 3:50
  SPEAKER_00: And so I tell women, yes, they're not lifelong devices, but they are so much better made these days that they can last longer than 10 years.
• 3:58
  SPEAKER_00: So I will tell them if at 10 years, 12 years, 15 years, they look good, you're happy with them, there's no problem with them, you can continue to uh have that same set of implants.
• 4:09
  SPEAKER_00: But at some point, let's have a discussion to swap them out because the swapping out procedure can be pretty straightforward.
• 4:17
  SPEAKER_00: And so we want to do that before there potentially may be a problem.
• 4:21
  SPEAKER_00: And so problems like that could be rupture or capsule contracture, but most of the time women are doing just great with their silicone implants, and at some point when it's convenient for her to have a discussion about when to swap out the implants.
• 4:36
  SPEAKER_03: All right, so you got a lady who's got um prior breast implants.
• 4:40
  SPEAKER_03: Let's say she had saline implants, they are they were pretty decent sized, they seem that they've lost volume now, and also they're in her armpits and there's rippling.
• 4:49
  SPEAKER_03: How do you approach this patient?
• 4:50
  SPEAKER_03: What are the tools and tricks that you have to get her a result that she's gonna like and it's into a point where it's not gonna look so obvious and not be in the wrong place?
• 5:01
  SPEAKER_00: Yeah, this is something that can happen with saline implants, and it's because the saline implants um have saline in them, and that to and fro motion can result in that implant going to the side into her armpit.
• 5:13
  SPEAKER_00: And also sometimes with implants placed under the muscle, that can happen.
• 5:16
  SPEAKER_00: So, really, what you see is that you have some volume loss, the implants, she may come in saying, My implants are in my armpit when I lay down, and nobody wants that.
• 5:25
  SPEAKER_00: So, really, what we can do is a couple of things.
• 5:27
  SPEAKER_00: We can either stick with the saline implant, but for better shape, I think a silicone implant is better equipped to give you that volume, to give you that structure.
• 5:37
  SPEAKER_00: So swapping out from a saline to silicone implant can be helpful to really give you a more natural upper pole appearance.
• 5:46
  SPEAKER_00: Um, and the other thing too is you want to be thinking, okay, why are her implants to the side?
• 5:51
  SPEAKER_00: And I'm automatically thinking, I need to support that pocket with something other than her own tissue.
• 5:57
  SPEAKER_00: And so I'm thinking of maybe doing an internal bra, which is another word for doing mesh to reinforce and support that implant and get it towards the middle out of her armpit, and so where she has more cleavage, where everybody wants it in the middle and on top.
• 6:13
  SPEAKER_00: So there are a few things we need to look at, you know, the implant pocket, and then maybe the uh size of her nipple.
• 6:20
  SPEAKER_00: Maybe she's had some nipple sagging, maybe the bottom part of her breast has started to droop.
• 6:24
  SPEAKER_00: So this might be a patient where we do an implant exchange and a lift to really balance the volume of the breast on the top of the nipple versus on the bottom.
• 6:34
  SPEAKER_01: Are you always doing an implant exchange?
• 6:36
  SPEAKER_01: You know, I know my approach, but somebody's coming in for a revision case.
• 6:40
  SPEAKER_01: Is it always going to be an implant revision where you're taking out that old implant and putting in a new one?
• 6:46
  SPEAKER_01: Is there ever a case where you don't?
• 6:48
  SPEAKER_00: Yes, there is a case when you don't.
• 6:50
  SPEAKER_00: And if the implants are not really old, if they're like 10 years or less and she's happy with it, nothing's wrong with the implant.
• 6:58
  SPEAKER_00: I think doing just pocket modification with capsulorophy um or capsulectomy if needed, and then replacing with the same implant.
• 7:06
  SPEAKER_00: But if it's getting around the 10-year mark and it's been, you know, around that time frame or even a little longer, it's an opportunity to give her um a set of implants that's going to last another 10, 15, 20 years.
• 7:18
  SPEAKER_00: So I think it really depends on the age of the implant and what the patient prefers.
• 7:23
  SPEAKER_03: You know, one of these things too, I'll be honest, sometimes when I think about that, what a patient's gonna think, I always go back to thinking about what would I want?
• 7:30
  SPEAKER_03: What would I want from my wife or mom?
• 7:32
  SPEAKER_03: And I I mean, I don't know about you all, but I tell them, listen, I know you've had these in for five years, but like this is an opportunity to exchange these.
• 7:37
  SPEAKER_03: If we're gonna take them out, expose them to the environment.
• 7:40
  SPEAKER_03: I'm a I'm a little bit of a proponent of like, I think you should probably get new devices.
• 7:44
  SPEAKER_03: Nothing wrong with replacing them.
• 7:45
  SPEAKER_03: That's the one thing I want to clearly say.
• 7:47
  SPEAKER_03: There's nothing wrong.
• 7:47
  SPEAKER_03: I think we all agree with that, with using the same ones I'm saying.
• 7:51
  SPEAKER_03: But I want to know out of you you three or you two, you know, would you put the same one back in?
• 7:56
  SPEAKER_01: I would say you uniformly, I I exchange them all.
• 7:59
  SPEAKER_00: Yeah.
• 7:59
  SPEAKER_01: Yeah, at the at this point, if they're if they're gonna have a secondary surgery, you know, we're we're gonna exchange them and put something new in.
• 8:06
  SPEAKER_01: I mean, most of the time, as you would imagine, people change the w their lifestyle, they change the their their wishes and desires and what they want.
• 8:14
  SPEAKER_01: It it's rarely do I hear somebody say, I actually love them, I want to stay the same size, I just want new ones.
• 8:20
  SPEAKER_01: Now, will I get that?
• 8:21
  SPEAKER_01: Yes, but it's rare.
• 8:23
  SPEAKER_01: Most of the time it's I'm not happy with the shape, size, or position, right?
• 8:27
  SPEAKER_01: And I want something of that changed.
• 8:30
  SPEAKER_01: And so for me, it's like I put people in two categories.
• 8:33
  SPEAKER_01: Is it an aesthetic issue that we need to take care of, or is it do they have an actual true, you know, complication from the surgery?
• 8:41
  SPEAKER_01: And which, you know, obviously we're gonna take care of the aesthetic side um with every surgery we do, but is there a true complication that we need to fix at the same time, right?
• 8:49
  SPEAKER_01: Do they have capsule contracture, do they have malposition, um, do they have breastosis?
• 8:54
  SPEAKER_01: Um, and and we need to kind of decipher between those two issues when when doing this.
• 9:00
  SPEAKER_00: Um Yeah, and I agree with you, it just depends on what the reason is.
• 9:03
  SPEAKER_00: And you know, my preference, and I I will say this to patients, my preference is to swap out the implants because this is another opportunity to get 10, 15, 20 years out of them.
• 9:13
  SPEAKER_00: There's some patients who are either cost conscious and want to keep the same implant, or you know, there's some other circumstance, they're very rare, but like you, I want to put a completely clean implant, no touch technique, you know, just give her another decade or more of the implant without complication.
• 9:33
  SPEAKER_01: So a lot of our listeners, you know, have implants and they're trying to decipher, you know, when to come in for follow-ups.
• 9:39
  SPEAKER_01: You know, what are the your approach to appropriate follow-up for patients who have implants in place and how do they know if they have a problem going on?
• 9:48
  SPEAKER_00: Well, I kind of like to see my patients often.
• 9:51
  SPEAKER_00: So after a year, I tell them, look, everything's great, but I still want to see you.
• 9:55
  SPEAKER_00: I want to make sure the implant's in good position.
• 9:58
  SPEAKER_00: I'll do a breast exam so she'll get a breast exam for me, and then also her primary care physician or OB Gyne.
• 10:04
  SPEAKER_00: And then I want to see how the scar is progressing, you know, and so this is a way for me to keep track of my patients.
• 10:10
  SPEAKER_00: Um, and so really I want to see them, and I also tell her if you're older than 40, continue with your self-breast exams and your yearly mammograms, and that will really help survey not only your breast tissue, but your implant.
• 10:22
  SPEAKER_00: And so I keep in close contact with my patients, and really when you usually when patients have a problem, they know it.
• 10:29
  SPEAKER_00: So they come in and they say to me, something feels different, Dr.
• 10:33
  SPEAKER_00: Wu.
• 10:33
  SPEAKER_00: It's not a pain, it just my breast feels different, or my implant looks like it's in a different position.
• 10:39
  SPEAKER_00: You know, it's sometimes really subtle and they can't quite put their finger on it, but they know.
• 10:43
  SPEAKER_00: And then sometimes it's really dramatic.
• 10:45
  SPEAKER_00: For example, if you have a saline implant and you wake up, it's deflated, you know right away.
• 10:50
  SPEAKER_00: And it can be subtle if you have a you know rupture with a silicone implant, and they they these patients and they say, you know, I have a little change in my breastfeel, or maybe there's a little bit of pain, but it can be subtle.
• 11:01
  SPEAKER_00: But if there's a change, I ask my patients to come in, I'll do an exam, and then we can do some imaging if indicated.
• 11:08
  SPEAKER_00: So, really, and this is why it's really important to do self-breast exam so you know your baseline every single month, you know, and that way if there's a change, you can detect it and come on in.
• 11:20
  SPEAKER_03: You know, one of the things we we all do a lot of um secondary, tertiary cases, and I don't know about you all, but I want to uh get get a thought from each of you kind of what's your preference?
• 11:32
  SPEAKER_03: So you have a patient who comes in, they have a need for uh adjustment.
• 11:37
  SPEAKER_03: And sometimes in these adjustments, you can have a big old pocket that you're trying to downsize somebody to, or you're having capsule contracture, or you're having lateral displacement.
• 11:46
  SPEAKER_03: How often are you all, what are you all doing in the pockets?
• 11:49
  SPEAKER_03: Are you using the pocket you have, are you tightening the pocket you have, you adding mesh in the pocket you have, or you're creating a new pocket or creating a neo pocket?
• 11:56
  SPEAKER_03: There's a lot of terms that are out there.
• 11:58
  SPEAKER_03: So how do you approach it, Cindy?
• 12:01
  SPEAKER_00: Yeah, so there are many different things you can do with revision breast surgery.
• 12:05
  SPEAKER_00: So I try to break it down to patients in three parts.
• 12:08
  SPEAKER_00: So what to do with the implant, what to do with the capsule, and then what to do with the breast tissue, because it can be very complex with lots of combinations.
• 12:15
  SPEAKER_00: So, you know, if the patient, for example, has a rupture and a capsular contracture, grade four, you know, there it's graded on a one to four scale, four is the hardest.
• 12:24
  SPEAKER_00: Then we need to remove the implant and remove the capsule.
• 12:28
  SPEAKER_00: You know, sometimes it's a partial, most of the time it's a total capsulectomy.
• 12:32
  SPEAKER_00: So, you know, that is something that we need to address because there's an issue that we need to fix.
• 12:37
  SPEAKER_00: So that's the implant.
• 12:39
  SPEAKER_00: Um, if there is a capsule contraction, and let's say they're submuscular, you could either do the capsulectomy, the submuscular plane, and do a neo pocket, or you could change sites from under the muscle to over the muscle.
• 12:52
  SPEAKER_00: And the thought process behind changing sites is that you know you're in a new clean virgin pocket without any bacteria in it, because we think that capsulture happens because of biofilm and seeding of bacteria.
• 13:05
  SPEAKER_00: So sometimes you can do above the muscle.
• 13:09
  SPEAKER_00: However, I found that going under the muscle and reinforcing it with mesh is my preference just because I think that going above the muscle, especially if you're removing, replacing, even with a smaller implant, that breast tissue has thinned out most of the time and lost some soft tissue support.
• 13:27
  SPEAKER_00: So I'd rather not put weight in the subglandular plane and keep it in the submuscular plane so that you have more support.
• 13:35
  SPEAKER_00: And oftentimes, if I'm doing a capsulectomy, I will have to do soft tissue support.
• 13:40
  SPEAKER_00: So that's my approach to doing capsulectomy.
• 13:45
  SPEAKER_00: If they have a lot of tissue in the subglandular plane, I think that's a better candidate for a plane change with the implant.
• 13:52
  SPEAKER_00: And then, you know, oftentimes we need to do a lift because, like you said, when you do a capsulectomy or revision, you lose pocket control, and you need to uh conform and kind of shape the breast tissue around the implant.
• 14:03
  SPEAKER_00: Um, but I'd be interested in knowing what, Bill, you do with these complex cases.
• 14:08
  SPEAKER_01: Yeah, we see we we see a lot of it.
• 14:11
  SPEAKER_01: And you know, it's amazing in breast surgery, there's so many different approaches, and not one approach is right or wrong.
• 14:16
  SPEAKER_01: It's kind of surgeon preference and what you feel.
• 14:19
  SPEAKER_01: Like I appreciate all everything you said, but my preference always is to do a site change if I can.
• 14:24
  SPEAKER_01: And um, that would always, you know, if you're submuscular, go to sub subfascial or subglandular, if you're subglandular or subfascial, go to submuscular.
• 14:33
  SPEAKER_01: I like to start afresh, you know, brand new pocket.
• 14:36
  SPEAKER_01: It's like it nobody's ever been there before, and I can create the the pocket and the look that I'm going for.
• 14:42
  SPEAKER_01: So that's always my preference.
• 14:44
  SPEAKER_01: And if somebody, if I'm going from submuscular to on top of the muscle and they lack that soft tissue support, then I'll add mesh product to give me that soft tissue support.
• 14:53
  SPEAKER_01: Or if I have to remove the capsule because it's what I refer to as pathologic, where it is not supposed to be there, I need support, then I'll add mesh in that submuscular pocket, you know, if I'm making that conversion.
• 15:07
  SPEAKER_01: So it's really dependent whether or not they have breastosis if I do a lift or not.
• 15:13
  SPEAKER_01: But in my hands, I like to start afresh.
• 15:15
  SPEAKER_01: If somebody has malposition, which means their implant is not in the right pocket where it needs to be, or they have a capsule contraction where things are really firm and hard, I'm like, let me get out of that old nasty pocket, let me start afresh, let me go to brand new, and then to your point though, I do address every one of those points you made, but it's like, all right, I'm starting afresh with a brand new pocket, and then I say, Hey, do I need soft tissue support or do I need to do a lift at the same time?
• 15:43
  SPEAKER_01: And I'm not opposed to doing fat grafting at the same time.
• 15:47
  SPEAKER_01: You know, you know, we when we do these difficult revision breast cases, I tell myself, all right, what we have all these tools that we have in our bag that we can use.
• 15:57
  SPEAKER_01: What do I need to do to give this patient the ideal outcome that they want?
• 16:01
  SPEAKER_01: And, you know, we have to fix the problems that they have going on.
• 16:04
  SPEAKER_01: But the other part of this is what is the aesthetic outcome that they're looking for?
• 16:09
  SPEAKER_01: Some people want to be bigger, some people want to be smaller, some people want to no implants at all.
• 16:14
  SPEAKER_01: So we have all these options, and it's got to give them the best aesthetic outcome based on their desired goals.
• 16:21
  SPEAKER_03: Yeah, and then one thing that one thing that I say is really important, that's more important now more than ever, is we're trying to really delineate.
• 16:28
  SPEAKER_03: Now, obviously, you want to get a great result, right volume, right position, all that stuff.
• 16:34
  SPEAKER_03: But also, women are much more keen and aware of like their activity level.
• 16:38
  SPEAKER_03: And women do not like most people don't really want or or have really symptomatic animation, and even a little bit of animation bothers women now.
• 16:46
  SPEAKER_03: So I just have a a large, large segment of my revisionary breast cases, almost all of them are sight changes now.
• 16:54
  SPEAKER_03: Um, where because we're they want to get rid of the animation, they want to get rid of the lateral displacement, they want to be smaller, some of them want to be bigger, you want to have a soft result, and then may want may need a massive extra.
• 17:03
  SPEAKER_03: So we're combining multiple modalities to achieve an outcome.
• 17:07
  SPEAKER_03: I do think that there is important concepts of like, you know, all of us have refined our surgical techniques, you know, and how we're doing things.
• 17:14
  SPEAKER_03: We're still incorporating that fascia to kind of keep have some extra coverage, and um you're eliminating that animation.
• 17:22
  SPEAKER_03: And I think I'm I've been surprised how much how much people actually do care about it.
• 17:25
  SPEAKER_03: There's some that really don't, but it's a small segment.
• 17:27
  SPEAKER_03: Most of them do not want their breasts to like move like crazy when you flex, and and that changes with time.
• 17:33
  SPEAKER_03: So I think one of the reasons why I'm doing more side changes is because of that.
• 17:36
  SPEAKER_03: But nothing not knocking the subpectoral pocket.
• 17:39
  SPEAKER_03: I think it's a phenomenal place, and like you know, we all gotta make decisions based on patients' anatomy and their goals.
• 17:45
  SPEAKER_03: So, like you know, you you guys, I'm sure you guys know of some surgeons where like you know, they're like subfascial every time or submuscular every time.
• 17:52
  SPEAKER_03: And I think we can't be like that.
• 17:54
  SPEAKER_01: I think our criteria have expanded a little bit too, with the fact that some of these newer devices and newer implants have have allowed us to be able to use that pocket a little bit more versus where we had before because of the fill ratios that we had with those old implants, you could see rippling and wrinkling a little bit more.
• 18:12
  SPEAKER_01: Now, with some of these newer devices, we don't have to have as thick of a coverage to go on top of the muscle.
• 18:19
  SPEAKER_01: So I think that has helped tremendously, right?
• 18:22
  SPEAKER_01: In a lot of these cases.
• 18:24
  SPEAKER_03: When people have revisionary uh breast surgery, Cindy, is it worse than the primary?
• 18:30
  SPEAKER_03: Is it easier?
• 18:31
  SPEAKER_03: Is it harder?
• 18:32
  SPEAKER_03: How would you how would you describe that to the patients?
• 18:34
  SPEAKER_00: Well, it's definitely more complex than the primary surgery, um, I think by far, just because so many things have happened.
• 18:42
  SPEAKER_00: You know, there's time that affects the soft tissue, uh, the skin laxity, and as well as the implant.
• 18:48
  SPEAKER_00: And, you know, there are things that can um go wrong with the implant.
• 18:52
  SPEAKER_00: So it can there there can be malposition, like we talked about, which needs to be corrected, capsular contracture, which needs to be addressed, you know, and like possibly um a rupture.
• 19:03
  SPEAKER_00: And so all those things you have to address individually with your revisionary plan.
• 19:09
  SPEAKER_00: And so I think that you really have to have a detailed conversation with patients and address those issues.
• 19:14
  SPEAKER_00: And that becomes more complex because with the primary surgery, you know, you have virgin tissue, you have tissue that's never been touched by surgery before, and you can really focus on okay, creating the perfect pocket that fits her anatomy.
• 19:30
  SPEAKER_00: So, you know, whether or not you're just doing an implant or an implant a lift, that's kind of your first chance, right?
• 19:36
  SPEAKER_00: This is the first surgery she's had.
• 19:39
  SPEAKER_00: But when you have revision surgery, you likely are not the surgeon who did the initial surgery.
• 19:45
  SPEAKER_00: I mean, I'm seeing patients from surgeons who, you know, in other states, they moved to North Carolina and now they're needing a revision.
• 19:53
  SPEAKER_00: And so you don't really know what's going on unless you get the operative note.
• 19:57
  SPEAKER_00: And sometimes you can't get that information.
• 19:59
  SPEAKER_00: So you're doing your best to understand what the patient has, their issue, based on their anatomy and their exam.
• 20:07
  SPEAKER_00: And I like to plan in these cases because if I don't have the op known and I don't know exactly what happened, you know, the the way I do it, I will have several sizes of implants just so I know that I have options and also know that I have mesh at my disposal and things like fat grafting.
• 20:26
  SPEAKER_00: And then the other thing too is you have to plan to stage these procedures sometimes because you know, you're doing a lot to the breast uh when you're doing a breast revision, and so that blood supply can be compromised.
• 20:38
  SPEAKER_00: And so I always talk to patients if I think that blood supplies could be an issue, we might have to stage your fat grafting.
• 20:44
  SPEAKER_00: So, for example, if they're doing a capsulectomy and a lift, and then uh we might be doing an exchange, that's when I would say, okay, look, we've already been doing a lot, we plan to do a lot to your breast.
• 20:57
  SPEAKER_00: I think fat grafting would be a good adjunct for you, but let's save it once your breast has recovered from this initial surgery.
• 21:04
  SPEAKER_00: And so, you know, these are some of the discussions that I have with my patients because it's a complex issue.
• 21:10
  SPEAKER_01: Yeah, how often are we all surprised when we go into surgery anticipating one thing because we were told from the patient this is what they had.
• 21:18
  SPEAKER_01: I actually had one of these cases today.
• 21:20
  SPEAKER_01: They're like adamant that they had saline this size, and sure enough, it wasn't that size, and it wasn't saline.
• 21:26
  SPEAKER_02: And it was in a different pocket.
• 21:28
  SPEAKER_01: And I mean, I I found different manufacturers in each pocket.
• 21:32
  SPEAKER_01: I found different pockets on each side, I found different sizes.
• 21:35
  SPEAKER_01: I even found two implants before in one pocket.
• 21:39
  SPEAKER_00: Wow.
• 21:39
  SPEAKER_01: So my running joke, it's like Christmas.
• 21:41
  SPEAKER_01: You don't know what you're gonna get until you open up and see what you got.
• 21:44
  SPEAKER_01: Um, so it it you have to be prepared to your point, right?
• 21:48
  SPEAKER_01: Of of what can happen.
• 21:50
  SPEAKER_01: And you have to have these discussions with with patients.
• 21:53
  SPEAKER_01: You know, despite it being a little bit more challenging of a procedure, from a recovery standpoint, secondary surgery is Actually, easier.
• 22:00
  SPEAKER_01: I always like to tell patients, yes, challenging for the surgeon, much easier for the patient, right?
• 22:06
  SPEAKER_01: They've already gone through their initial recovery, and the second time around, it's like a walk in the part for them.
• 22:11
  SPEAKER_01: So it, you know, it is a benefit to the patient.
• 22:13
  SPEAKER_00: Yeah, absolutely.
• 22:15
  SPEAKER_03: One thing that happens in revisionary breast surgery, and then you when patients come in, is that sometimes they don't need the implant.
• 22:21
  SPEAKER_03: Sometimes they've gone through menopause or they've had kids, and there's a lot more parenchyma or aka breast tissue there, and there are other options.
• 22:30
  SPEAKER_03: So why don't you all tell us a little bit about kind of your approach on all right does it what do you do when a patient really doesn't need an implant, or how do you walk them through that and what surgery do you do for them?
• 22:40
  SPEAKER_00: So if the patient has saline implants, I get really excited because that means this is an opportunity for us to find out exactly how much breast tissue she has now because we can deflate the saline implant.
• 22:53
  SPEAKER_00: And so people come in in the consultation, I propose deflation because it helps them to get in touch with how much breast volume they actually have now versus 20 years ago.
• 23:03
  SPEAKER_00: Um, and it also allows us to basically see what the breast shape looks like, so where the nipple is, how the breast skin looks.
• 23:12
  SPEAKER_00: And I tell them that's an advantage for me as a plastic surgeon because if we're doing a lift, I know what the baseline is without the implant clouding the picture, and then I can mark your mastopexy or breast lift incisions that much more accurately.
• 23:25
  SPEAKER_00: And I have pictures to show patients that have had saline implants, I deflate them and it under it uncovers this underlying nipple asymmetry.
• 23:34
  SPEAKER_00: And then when we wait, that actually levels out and equalizes.
• 23:37
  SPEAKER_00: And so your breast undergoes this elastic breast recoil phenomenon, as you probably have all seen in like a month, but that happens because we can deflate saline implants to have patients get in touch with how much parenchyma they have.
• 23:50
  SPEAKER_00: And chances are most of the time, women, you know, after childbirth, pregnancy, breastfeeding, they have more parenchyma.
• 23:58
  SPEAKER_00: And so they're pleasantly surprised when we deflate them and they say, Oh, I actually like the volume that I have, you know, I'm bigger than the A-cup that I was 20 years ago.
• 24:06
  SPEAKER_00: So in these women, we just need to remove the implant and do the lift.
• 24:09
  SPEAKER_00: And so that can save them that extra additional part of the procedure because they have enough of their own breast parenchyma.
• 24:16
  SPEAKER_00: So I'd be curious to know, Bill, you know, what your approach is with patients like this who have enough breast tissue.
• 24:23
  SPEAKER_01: Yeah, you know, in my hands, I really try to figure out the look they're going for.
• 24:28
  SPEAKER_01: And I do this through photos and having them show me kind of their their ideal outcome.
• 24:35
  SPEAKER_01: Try to explain it as best as possible.
• 24:37
  SPEAKER_01: And then I ask them why they got implants in in the first place, because that really kind of helps elicit where they were, where their headspace was at that time and where they are currently.
• 24:47
  SPEAKER_01: And it's amazing.
• 24:48
  SPEAKER_01: A lot of the individuals they come in, they're like, I want to downsize, I want to be smaller.
• 24:53
  SPEAKER_01: I don't want to be as busty as I am, and I want to be natural.
• 24:58
  SPEAKER_01: If I hear those words, I'm like, and they have enough breast tissue, I'm like, hey, let's get rid of your implants.
• 25:03
  SPEAKER_01: Because if we keep your implants or even downsize, you're gonna end up being bigger than you ultimately want to be.
• 25:11
  SPEAKER_01: And we know we have these patients sometimes, right?
• 25:13
  SPEAKER_01: That we have this dichotomy of, hey, are you gonna be more unhappy if you're bigger than you want to be, but have the shape that you want, or would you rather be the size you want, not the shape you want?
• 25:25
  SPEAKER_01: So, like again, the patients that really want that fullness up top, we can't achieve it without having an implant, but they not may not be able to have the the size that they ultimately want.
• 25:35
  SPEAKER_01: So these are honest discussions we as surgeons have to have with folks.
• 25:39
  SPEAKER_01: But trust me, if they say, I want to be natural, I don't care to have all that fullness up top, and they have enough of their own breast tissue, heck yeah, that's an implant removal all day long.
• 25:49
  SPEAKER_01: But I think the most difficult cases are the patients that are like, hey, doc, I want to be five cup sizes smaller than I am, but I still want to be perky and round, and they have a ton of breast tissue.
• 26:01
  SPEAKER_01: Like sometimes we can't get them both the look and the volume that they want.
• 26:06
  SPEAKER_01: Um, and I think those are very difficult cases.
• 26:09
  SPEAKER_01: How do you approach that, G, and in terms of patients that that there's gonna be a compromise one way or the other?
• 26:16
  SPEAKER_03: Yeah, you know, I think that um the first is you know to tell them that, all right, we're gonna get you there, but I want you to know that you're you're signing up for a secondary intervention where we're gonna get you, like we're gonna get you way smaller, we're gonna downsize you, we're gonna debulk your soft tissue envelope, we're gonna tighten things up, and then at some point we're gonna get that implant out and you know go again and may have to fat craft you.
• 26:38
  SPEAKER_03: Like the problem is those larger implants that were in there have done, they've changed the architecture of the breasts, they've thinned out the parenchyma, and so they there's some fundamental changes that have to be adjusted for.
• 26:48
  SPEAKER_03: But truthfully, usually what happens is patients' um aesthetic, like their aesthetic goals change.
• 26:54
  SPEAKER_03: Initially they want this big round full, and then they want kind of less of a uh obvious thing, something they can turn on and turn off, and then as they progress through, a lot of people want to be a little bit more natural.
• 27:02
  SPEAKER_03: So I think that it sort of depends.
• 27:04
  SPEAKER_03: I think the one patient you're talking about is a tough one, you know, and so I think typically you're having to, you're having to do, you're actually having to do like three things.
• 27:11
  SPEAKER_03: So in those patients, I'm using a small device, a little bit of fat grafting, and some and some mastopexy.
• 27:16
  SPEAKER_03: One thing I wanted to add though is when a patient, I ask a patient when we're in this, is like, hey, you know, are you good with you know potentially another surgery in the future?
• 27:24
  SPEAKER_03: And when they say, I want to be done, well then the answer is simple.
• 27:27
  SPEAKER_03: Implants out, do all the other secondary adjuncts that you need to do, and hopefully close that chapter for them.
• 27:33
  SPEAKER_03: Because I think it's it's our duty to like make sure to lead patients in the right direction.
• 27:36
  SPEAKER_01: Are they ever really done though?
• 27:38
  SPEAKER_01: Like again, so to that point, I hear you.
• 27:41
  SPEAKER_01: That tells me they want their implants out, right?
• 27:43
  SPEAKER_01: You know, let's let's because the key here, and I think we all do this and we tell our patients if you go to the implant route, you're gonna have maintenance.
• 27:51
  SPEAKER_01: There's maintenance associated with your implants.
• 27:54
  SPEAKER_01: You get them out, there's no more maintenance.
• 27:56
  SPEAKER_01: But theoretically, you could have more surgery, right?
• 28:00
  SPEAKER_03: If if it's like you know, we were talking about face, you know, um, you know, aesthetics.
• 28:04
  SPEAKER_03: If you want to maintain a certain look, you gotta do things, you gotta maintain it, you gotta enhance it, you gotta add to it.
• 28:10
  SPEAKER_03: Same kind of thing with the breast.
• 28:12
  SPEAKER_03: But if a patient's like, I just don't want to have to have surgery again, then I think that's chucking the implants, right?
• 28:18
  SPEAKER_03: 100%.
• 28:19
  SPEAKER_00: I totally agree.
• 28:20
  SPEAKER_00: Yeah, I totally agree.
• 28:21
  SPEAKER_00: When I hear that, then I say, all right, we're done with implants, because that means that you don't have to worry about the surveillance.
• 28:28
  SPEAKER_00: But like you said, there might be additional surgery that is needed.
• 28:32
  SPEAKER_00: And so some people want a little bit of volume replaced.
• 28:35
  SPEAKER_00: And so that might be a good patient to do fat crafting.
• 28:38
  SPEAKER_00: Or you know what, we can't fight time and gravity, and so later down the road, she might need a lift or even a revision lift if she's already had one.
• 28:47
  SPEAKER_00: You know, she might gain weight and get larger, her breasts become larger, in which case we might need to do a reduction.
• 28:54
  SPEAKER_00: So I think it doesn't a hundred percent preclude an additional surgery.
• 28:59
  SPEAKER_00: However, it decreases the chance significantly if you just remove the implants altogether.
• 29:04
  SPEAKER_01: A lot of our patients answer the question for us because they want them out because of uh breast implant illness.
• 29:10
  SPEAKER_03: Yeah, or or or autoimmune issues, inflammatory issues.
• 29:14
  SPEAKER_01: And so they come in specifically saying, I'm over them, I'm ready to get them out, let's go ahead and go down this road of of getting them out.
• 29:21
  SPEAKER_03: Um, breast implant fatigue is what we talk about, that you know, where they just they're just done.
• 29:27
  SPEAKER_03: And like you said, they they kind of come in and we sort of know what's what to do with that.
• 29:31
  SPEAKER_03: And it's not necessarily a bad thing, you know, like you it's like a it's a new chapter and it's like different, and it's like a lot of things people get the the effect, the mileage out of what of what they got, but they're just that's right.
• 29:42
  SPEAKER_03: It's like how many people keep the same car forever?
• 29:45
  SPEAKER_03: I mean, I know it's not the same exact analogy, but you think about it, like I go through a lot of cars, but that's a little different story.
• 29:50
  SPEAKER_01: Well, let's put ourselves in the patient's shoes, knowing what we know.
• 29:54
  SPEAKER_01: What should patients come in and tell us physicians and plastic surgeons when they're coming in for a breast revision case?
• 30:03
  SPEAKER_01: What are things you want to know right away and things that they should start thinking about?
• 30:07
  SPEAKER_00: Well, I want to know as much as I can about their breast surgery history.
• 30:11
  SPEAKER_00: So I love it when patients come in, at least with their implant card, and then I have some patients who are super organized, they have their op notes.
• 30:18
  SPEAKER_00: So, as much information for me is very helpful because I can know what to expect and then how to plan for the revision.
• 30:25
  SPEAKER_00: So if you have that information, great.
• 30:27
  SPEAKER_00: If you don't, a lot of people move and they lose their implant information.
• 30:30
  SPEAKER_00: That's okay.
• 30:31
  SPEAKER_00: I'll do your measurements and then do some imaging so that we can figure out what you need if you need an implant replacement.
• 30:39
  SPEAKER_00: So uh information and also a mammogram.
• 30:42
  SPEAKER_00: You know, we need to know whether your breast tissue is okay before we undergo another surgery.
• 30:47
  SPEAKER_00: So having a yearly mammogram is really important.
• 30:50
  SPEAKER_00: And then telling us what you really want.
• 30:53
  SPEAKER_00: So, like you said, there are patients who the the patients who want their implants out, they'll say, Okay, I want my implants out undone.
• 31:01
  SPEAKER_00: Um, or they'll come in and say, you know, I want less volume, but I want it to be natural, in which case that signals to me that they may not want the implant and they may want some fat grafting to replace it.
• 31:14
  SPEAKER_00: Um or they'll say, Look, I like this rounded look up here.
• 31:17
  SPEAKER_00: I just want to be smaller and perfectier.
• 31:19
  SPEAKER_00: So that might be a patient where we do an exchange and do a lift.
• 31:23
  SPEAKER_00: So, really, you know, the information is really, really helpful.
• 31:26
  SPEAKER_00: I think that's um going to tell your surgeon a lot of information about what you have had and then where you want to go is where you'll you'll say these things like, I want a smaller implant, I want to have a lift, I want to just have fat grafting.
• 31:41
  SPEAKER_00: So it's a combination of these things that will help me figure out where we need to go with uh your implant revision surgery.
• 31:50
  SPEAKER_01: You know, the other beautiful thing, I I love that.
• 31:52
  SPEAKER_01: I you know, that that's exactly what we want.
• 31:55
  SPEAKER_01: We want to know where they came from and where they ultimately want to go.
• 31:58
  SPEAKER_01: And the more pictures we have, the better it ultimately is.
• 32:01
  SPEAKER_01: And one of the real reasons we want to know what their manufacturer was or what implants they have is there's warranties associated with a lot of these implants, right?
• 32:10
  SPEAKER_01: And so, like if if some of their problems that they have currently are covered under their warranty, then they could have some financial uh benefits to them, you know, going into this next generation or this next surgery for them.
• 32:25
  SPEAKER_01: Right.
• 32:25
  SPEAKER_03: You know, uh in a from a simpleton standpoint, I kind of simp similar to what Dr.
• 32:29
  SPEAKER_03: Wu was saying, what you were saying, I I I want to know what they like, what they don't like, and then the others what they do from a from an actual career standpoint or what they do at home, and then what their physical activity levels are too.
• 32:42
  SPEAKER_03: Because it it's something interestingly that now is I think helping me really figure out you know the plan to make for patients.
• 32:48
  SPEAKER_03: So we we have to take into consideration their lifestyle and kind of and and what they do for a living because all those things have an impact.
• 32:56
  SPEAKER_03: People did not realize in the past, like when you were getting a procedure that maybe it could, you know, potentially affect your, you know, to a micro extent, a little bit of your strength or your shoulder girdle and all this stuff.
• 33:07
  SPEAKER_03: You know, under the muscles totally fine, but some people don't really like that.
• 33:10
  SPEAKER_03: And so I think it's it's important to think about these other considerations of not just an aesthetic goal, but also like functionally what patients do, how it could impact them, and um taking it all into consideration.
• 33:24
  SPEAKER_01: And follow up with your surgeon, you said it best, Cindy, it's like you know, ha come back frequently to see your doc.
• 33:30
  SPEAKER_01: You know, make sure everything's okay, make sure your aesthetic goals haven't changed.
• 33:34
  SPEAKER_01: We're here for every patient, right?
• 33:36
  SPEAKER_01: And we want to be able to help them throughout their journey of their their lifespan.
• 33:40
  SPEAKER_03: Well, this was awesome, Dr.
• 33:42
  SPEAKER_03: Wu.
• 33:42
  SPEAKER_03: You're an incredible surgeon and a great person to talk to.
• 33:45
  SPEAKER_03: Um, we're gonna conclude this episode.
• 33:47
  SPEAKER_03: And if um any of our viewers have any questions about um revisionary uh breast surgery, to please um uh message us on our platforms and we'll be glad to answer them and get um Dr.
• 33:57
  SPEAKER_03: Wu to chime in as well.
• 33:59
  SPEAKER_01: We'll look forward to having you on the show again to talk about future topics.
• 34:03
  SPEAKER_00: Yeah, thank you so much for having me on your podcast.
• 34:06
  SPEAKER_00: It's been great.
• 34:07
  SPEAKER_00: So thank you.
• 34:11
  SPEAKER_01: Thank you for listening to HKB Uncut.
• 34:13
  SPEAKER_01: If you enjoyed this episode, please subscribe to us on Apple, Spotify, or YouTube.
• 34:18
  SPEAKER_03: To book a surgery consultation or med spa appointment with our team, visit our website at hkbsurgery.com or head to the links in our show notes.