Latest / Alabama The Beautiful: The Eastern Shore Cosmetic Surgery Podcast / The Truth About Breast Implant Removal
Transcript
- Announcer (00:02): You are listening to Alabama the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis. Kirstin (00:08): Hey Dr. Koehler. Dr. Koehler (00:10): Hey Kirstin. Kirstin (00:12): Guess what I have for you today. Dr. Koehler (00:14): What do you have for me today? Kirstin (00:15): Today I have a vocabulary question. Dr. Koehler (00:19): Okay. Kirstin (00:20): Related to breast implant removal. Dr. Koehler (00:24): Okay. Kirstin (00:24): You want to talk about that? Dr. Koehler (00:25): Sure, let's talk about it. Kirstin (00:26): Oh yeah. Dr. Koehler (00:27): We do a lot of them. Kirstin (00:28): Yeah, that's what you're kind of known for on our little corner of the Eastern Shore, specifically for what is called or used to be called the en bloc. Dr. Koehler (00:39): Yeah. Alright, well, let me give you a little bit of history here. So I'm going to start off by saying that we see a lot of people that come in and they specifically request what they call an en bloc capsulectomy. And I don't think patients really don't know what that means. They just know that that's what they've heard on social media or these help groups and that's what they know to ask for because that's what they think will give them the best possible outcome. And this is, I feel unfortunately, because I don't really know the history of who was first starting using that term, but I feel pretty strongly it just kind of came out of the social media world. But it is a medical term, but this is what people read online and how doctors speak can be very different. And even though we're both kind of talking about same kinds of things, it's got different meaning. Dr. Koehler (01:31): So let me try to be a little more specific in what I'm telling you here. So when doctors refer to an en bloc procedure, the term en bloc really refers to cancer surgery where we're taking out a cancer and then we're going to remove a layer of healthy tissue around that cancer. And that's the en bloc. Part of it is taking out the disease and adjacent tissue to hopefully get all of this out. And people who have breast implant illness, they're requesting what's called an en bloc capsulectomy. Now what they're referring to is to take out the whole capsule in one intact piece with the implant inside of it. Dr. Koehler (02:18): The reason for that, and the reason that people who are calling or requesting that is they have this concern that first of all they want all the capsule out because they could be potential bacteria, fungus, heavy metals from the shell of the implant, all these things that potentially they're worried about that are causing their illness. So they want it all out. That's the first thing. And they want it all intact because in case there's any fluid or anything inside of that capsule, they don't want that to enter their body as well. And they just want the whole thing out in one complete piece. So the patients are referring to that as an en bloc capsulectomy, but really it's just a complete capsulectomy that's intact, so a complete intact total capsulectomy. Or some people just say a total intact capsulectomy, but it's not en bloc because we're not taking the muscle with us, we're not taking the periosteum off the ribs, we're not going after all that other stuff. Dr. Koehler (03:14): So the medical community, because of all the awareness that there has been in regards to this, is trying to change the verbiage that the public is using because it's not correct. So this is where the medical people are just trying to say to the non-medical people, yes, we hear what you're saying, but can we make this correction in the verbiage because it's not like we're not talking about the same thing. So that's really where that is. So patients really are requesting a total intact capsulectomy. We're going to keep hearing en bloc probably for, and when people ask me that, if I do an en bloc capsulectomy, my answers can be yes, I do. I know what they're referring to, it's a total intact capsulectomy. So anyhow, the other types of capsulectomy would be, so you have a total intact capsulectomy and then you have just a complete capsulectomy. Dr. Koehler (04:05): What does that mean? Well, it's the exact same thing as a total intact capsulectomy except for it may not be taken in one piece. So you've taken the whole capsule, it's a complete capsulectomy, but it's just maybe we had to take it out in two pieces, but it's all out. And then there's what's called a partial capsulectomy where you just sort of take out part of the capsule. So maybe there's part of it that looks really healthy and we can talk more about why you would want to leave it, but maybe it's against really, against the ribs and it's right next to, like we don't want to get into the lungs, and so we're going to leave that little bit of capsule. So we didn't take it all, so it would be if we left a little bit behind, then it would be a partial capsulectomy. So those are the three main things. Kirstin (04:46): So why did this clarification get made? Dr. Koehler (04:50): Well, I mean, I think the main reason is that we are not dealing with cancer. It's a cancer term. And I mean indirectly, I mean, the only thing that would be considered if you were removing the capsule for let's say an Anaplastic Large Cell Lymphoma, and you're removing that, and you might be even removing maybe some healthy surrounding tissue. So with that cancer removal, yes, that term would be, I think a more appropriate term. But it's a cancer term for a non-cancer surgery. So that's why we're trying to correct it. That's all. Kirstin (05:22): What are some reasons that a patient might come to you wanting their implants removed? Dr. Koehler (05:26): We get a lot of different reasons. I've had some sweet ladies come in and they're just like, I love these when I was younger, but I'm older now and I don't need 'em and they're heavy and I want 'em out. Some people, they were a different point in their life. They wanted bigger breasts when they were younger, and now they're like, yeah, my back hurts. I'm tired. I don't want 'em anymore. Or I don't want to have to keep replacing them. So just like I'm ready to get 'em out for good. There can be a lot of reasons that people want them out. But in terms of breast implant illness, people are coming because they feel that their health has been impacted by having implants in their body. And so they want them out for that reason with the hope that they will have their symptoms improved. Kirstin (06:15): How common is this request? Are there tons of people coming to you for this surgery? Dr. Koehler (06:20): I mean, we see quite a few people for it. I don't know if the word tons is the right number, but I mean, we do see quite a few people with this request. The really hard part is, and I see a lot of these patients, and I try to just give them facts and tell 'em, I mean, sometimes people say, well, do you believe in it? And I'm like, well, it's not even really whether I believe in it or not. You're coming to me because you want these out and for these reasons. And if I feel like it's appropriate that we do that, I mean I'm happy to do it. But I do believe that there's certainly the possibility that having something foreign in your body could result in an altered immune response. So yes, I do believe in it. That's the short answer. But I also think that this is a very complex problem that we don't fully understand. Dr. Koehler (07:10): And so this is where the hard part of the discussion comes in. Not a matter of you think your implants might be making you sick, and I could go, oh yeah, they could, but we don't know because there's not a test. And that's where we really are struggling. And so until we can really come up with a way to diagnose and say, Hey, this is the diagnostic criteria for breast implant illness. We're kind of just, it's what we call a diagnosis of exclusion, which means once you've sort of checked for every other possibility, and if everything else came back, it's not lupus, it's not this, it's not that. Well, the only thing that we haven't checked for is maybe it's this breast implant illness. So let's take those out. Okay. So that's what we typically are telling people is, I mean, unless you just want 'em out, but even if you do want 'em out, there's this discussion of how aggressive a treatment do you want to have. Dr. Koehler (08:04): So typically if we're saying, Hey, we want to do a complete total intact capsulectomy, and we want to do all this, are you sure that this is the problem? And so that's a little bit of the struggle that we face because the symptoms that people come in with is very broad. So if you look at some of the top symptoms that people have, there are a few that seem to be more common, but they're also common with a lot of other diseases. So it's like fatigue, brain fog, joint pain, muscle pain, hair loss, and there's a whole constellation of symptoms. And these symptoms are also seen with other things like fibromyalgia or multiple chemical sensitivity or other diseases that we do have diagnostic, I mean saying they're difficult diagnosis to make as well. But the point is that it's not a, oh, if you have four of these and two of those, and one of this, we can say definitively, you have breast implant illness and we just don't have that. Dr. Koehler (09:05): So that's the tricky part, and that's where the discussion comes in. And yeah, I think the only time I just really want to have a good feel for the discussion is that it's not that we don't want to take your implants out, but a lot of these women who are coming in to get them out, they got their implants for a reason in the first place, and most of these women, they had no breast tissue to begin with. And so this is where the challenge is, is that what we don't want to do is say, yep, I can help you. We take your implants out, and by the way, now you're not any better. And on top of that, you really don't like how you look and you're depressed because of that. And that's not what we want to do. So that's why we just want to make sure we have a good dialogue as far as the reasons why you're doing it, what you've checked into doing, have you looked at these other possibilities? Dr. Koehler (09:52): And it's not like we don't want to believe you, that's not the case. It is more difficult than you think to make that with certainty. And yes, lots of people that we treat get a lot better. Now, whether that can be psychological, sometimes that can be play a role too, because some people are dealing with tremendous amounts of anxiety and depression because they feel like these implants are causing all these problems. And real or not, our brain is saying it's real. And so sometimes just the relief of getting that removed can cause a tremendous improvement. And even if you say, oh, it was in your head, but they're better, it doesn't matter if it was in your head, they're better. So it was a positive result. So anyhow, that's kind of just sort of the scratching the surface of breast implant illness. Kirstin (10:38): Well, I think that's a lot of the reason that you have such a good reputation surrounding breast implant illness in these total intact capsulectomies for patients, because you do have that real true conversation with them beforehand during consultation. You get down to it and make sure this is exactly what they want to do before surgery and before y'all make that decision together. So I think here, I respect you for that because you do have a great relationship with patients because of that. Dr. Koehler (11:04): Well, I mean, ultimately at the end of the day, it's like, yeah, I get paid to do the surgery. I could just tell every person, yes, we can do it. But that is not the goal is to make sure that they are making an educated decision and the right decision. And the thing that I find a little bit frustrating with social media, and it's nothing, so this is not directed at any one person or anything, but it's no different than, okay, you and I, let's say you're my sister, my much younger sister. Kirstin (11:36): That's right. Dr. Koehler (11:37): Yeah, no, and you say, oh, you know what? I've been checking my blood pressure and my blood pressure is really high. And I go, oh yeah, I have high blood pressure too. My doctor wrote me this. Here, let me give you my bottle of pills. Why don't you take this? This is good for your blood pressure. Now you know what? It may be totally fine, but that dose may be incorrect for you, and it may not even be the best first choice for your particular circumstances because I'm not a doctor, well, I am a doctor. Kirstin (12:05): Not a cardiologist. Dr. Koehler (12:06): No, but the point is that that's what happens. Sometimes family members and friends go, oh, this made my pain better. You should try this. Or I got better, I had my implants out, I'm so much better. You should get your implants out. That's probably what it is. And we make these sort of assumptions and jump to conclusions. And so just because one person wasn't feeling good and they got their implants out, and then they tell the world on social media, I mean, I'm happy for them, but we sometimes have people that come in and they're like, they think, I mean, they read that on social media and they're like, well, it has to be this because all these people were saying this. And again, I'm not saying that it's not, but that's not necessarily the best way to go about making those decisions. You factor that in, but you have to get medical advice, make sure that there's not other things going on. And when you check all those boxes and you get to the end of the list, you're like, okay, well, it looks like this is what I need to proceed with. And you want to make sure that you do that so that you don't have regrets. Kirstin (13:06): Alright, tell me about ALCL. Dr. Koehler (13:09): So ALCL is called Anaplastic Large Cell Lymphoma. And it's a type of a low grade cancer, a lymphoma that people that we sort of discovered, it's related to patients having a certain type of implant and it's a textured implant. And those implants have been taken off the market. And just to make sure that people understand, although this is a serious thing, it's typically a slow growing. It's not typically any kind of an aggressive type of a tumor and it's treatable, but it was associated with patients who had this particular type of textured implant. And the recommendation from the FDA was like the company had to send out a letter to let everybody know if you got this implant, you got a letter. And that letter was to say that, Hey, you've got one of our textured implants and it's been associated with this rare type of lymphoma, and we're just making you aware. Dr. Koehler (14:10): Now, they were not recommending people go and get their implants out and their capsules out just because they had that implant. They were saying, pay attention. And if you ever get one of the signs of people having Anaplastic Large Cell Lymphoma is getting what's called a late forming seroma, which is when you start building up fluid around an implant and your breast starts getting bigger. So that's kind of one of their cardinal signs of Anaplastic Large Cell Lymphoma. But basically they just said, Hey, monitor your breasts and see your doctor if there's any concern. But they weren't recommending everybody go get their implants and capsules out. And it was, let me just say that this was such a rare tumor that was being diagnosed, and now it's become much more prevalent. But mainly because I think doctors are aware of it. I don't think that people even realize that. Dr. Koehler (15:00): I mean, people had these seromas and I think doctors were just taking the capsules out and the implants out, and they didn't even, they just thought, oh, it's a seroma. They didn't know that even it was associated with a lymphoma. And so anyhow, I have actually had one patient, I didn't put her implants in. She had them done many years ago. And I diagnosed this patient, this has been almost 15 years ago now, and I had just read probably, I don't know, six months earlier about these early reports of this rare type of lymphoma. And she came in and she had this one-sided breast swelling. And I was like, oh, I read an article about that. I'm going to send the fluid off. And I sent it off, and lo and behold, she was one of these people. And just to put it in perspective so people understand how rare this was, this was 15 years ago, even now, it's still a rare type of lymphoma. Dr. Koehler (15:53): I sent her, she wanted to go to see a specialist. I sent her to this breast specialist and she asked him, well, how many of these have you treated? And he said, well, none. And she's like, okay. She came back to me, goes, okay, that guy's not a specialist. I mean, he says he's never treated one. And I'm like, okay, well, she said, I'm going to MD Anderson. And I said, okay, well tell me what they tell you. So she goes to MD Anderson, they said, oh, we want to enroll you in a study. We're doing a study on this. And she's like, okay, well, how many people are in the study right now? Well, you're going to be the first. And she's like, what? So anyhow, if MD Anderson and you're like, oh boy, what are some of the first people in this study? Now, this was 15 years ago, but the point is that it was not really common. Anyhow, it's treatable. Don't, it's sort of a separate discussion for another day. But I would say that it's people do get capsulectomies for that, and that's where you could use the term en bloc. Kirstin (16:47): Alright, well, let's talk about how you'll look after a capsulectomy and be realistic about people's bodies and what recommendations you would give after an explant. Dr. Koehler (17:00): Well, that's where the exam comes into play. And so if I see a patient and I'm like, are you really sure you want to do this? And we start talking about that, that is typically the reason I'm having that discussion about is this really the route you want to go? Is sometimes on the exam I'm like, gosh, this patient has no breast issue and I know that when we take this out, it's going to be pretty alarming difference, and I am hopeful they're going to be okay with how it looks. But you just know, first of all, and let me back up and say something. If you were an aup and you got implants, and then let's say 10 years later you got them removed, don't expect to still be an aup. You might be less than an aup because the pressure of an implant can cause some atrophy of the overlying breast tissue. Dr. Koehler (17:51): It can cause some resorption around the rib cage. So basically you're not going to look like you did. It's not like you're going back to the way you looked like before and you're going to have some skin that's been stretched out because of having an implant. So it's not like, oh, you take it out, you go back to exactly how you looked like before. I mean, it's going to potentially look less than ideal. So in people who don't have a lot of breast tissue, I just want to make sure that we're on the right page because I do know that there can be some aesthetic concerns. If somebody's got plenty of their own breast tissue, or I shouldn't say plenty, if they just have enough of their own breast tissue, I usually am not concerned we'll be able to get a decent result, typically. And sometimes it requires a lift. Dr. Koehler (18:30): And let me just say this, there's a lot of misconceptions about what a lift does and does not do. First of all, for everybody out there, I don't even like to call it a breast lift. I'd rather say it's a de sagging procedure or a nipple relocation procedure, because that's really more accurately what we're doing. Where if your nipple position is too low, we're trying to move, we don't cut your nipple off, it stays attached to breast tissue, but we're moving it to the ideal location, and then we're getting rid of any sagging tissue underneath. That's what we're doing. But it doesn't push your breast up higher on your chest wall. It doesn't give you any more fullness up top. It really doesn't do any of those things. That's what an implant typically provides. So sometimes people think, well, if I get my implants out, and sometimes they come in and their nipple position is perfect, and they're like, I want to lift. Dr. Koehler (19:16): I'm like, well, you don't need a lift. Well, I want one. I'm like, why do you want lift? Because I'm getting my implants out. I just want them lifted at the same time. I'm like, okay, well, this is where we are not on the same page because if your nipple's already in the ideal location, I can't move it any higher. It won't look right. And so there's nothing to lift. And that's where, again, if we're talking about nipple position, that's really what the lift is doing is moving the nipple to the right location and getting rid of sagging skin. So sometimes, yes, even with a more ideal nipple position, you still might want to do a lift to just get rid of some of the, gather up some of the sagging skin. But sometimes you might want to just take the implant out, see where things settle, and maybe you can get away without a lift mean that's where you got to talk to your doctor about. Dr. Koehler (20:00): But the only other thing that I would add is that there is this relief that I can get my implants out and I'll just go ahead and fat graft them and I'll get my breasts enlarged with fat. And yes, although fat grafting to the breast is now an approved procedure, which many years ago it was considered malpractice to fat graft in the breast. And the reason it was considered malpractice is because of when you'd inject fat from where you liposuction it into the breast, it could cause cyst formation, it can cause calcifications, and it can cause all these sort of abnormalities that'll appear on a mammogram. And then people start having to get biopsies. And really it's just artifact from having fat grafting. Now different when you put fat in your butt, you're not getting a mammogram or you're not getting a butta gram, you're not getting it imaged, and so that's not anything. But when people are doing surveillance exams for breast cancer, all these things that are showing up that are abnormal can result in problems. So that's the first thing. But we've kind of overcome that because we have MRIs and better imaging and people are just, they've decided that, you know what? It's okay to fat graft a breast fine, but that doesn't mean those things still don't happen. The other thing is that if fat grafting was a really good and worked, why are we even putting implants in? Doctors would be like, you'd have people go, oh, I just want breast use my own fat, and I want something that's permanent. It's my own body that I'm not going to have. I mean, that would be great, but we don't do it and we don't recommend it because unfortunately we know that the fat that takes is not going to be predictable. Dr. Koehler (21:36): So people, they're like, I want to be this size. Well, you might need to get fat grafted three four times to get to that size. I mean, who knows? Or you might even do it three, four times and still not be where you want to be. And then you have all the potential problems with fat graft to the breast. So although fat grafting is typically done as in conjunction with or as part of a breast procedure, like you're getting implants, but maybe we're also fat grafting some areas to help with the cleavage or some other things, that's where you can do fat grafting as a procedure by itself, it's not ideal. And so just because you get your implants out, it's not a simple thing to just say, okay, well go ahead and fat graft me. Then there's the obvious thing, which is like, well, you got to have enough fat to put in there too. So sometimes we have people that are just too thin that even if we wanted to fat graft, it's just too hard to get enough decent fat to do it. Kirstin (22:26): We can talk all day about breast fat grafting. Dr. Koehler (22:29): Yes, all day. Kirstin (22:30): People will talk all day on social media about it. Dr. Koehler (22:33): Oh, really? Kirstin (22:33): Yeah, it's a thing. Okay. So for capsulectomy, what is the recovery like or what could somebody expect for post-surgery? Dr. Koehler (22:44): I mean, it's usually not a terrible recovery. Now if the implants are under the muscle, it's definitely a much bigger recovery. If they're above the muscle, it's actually not that painful. It's a pretty quick recovery under the muscle is a different, because we've got the muscle above the implant and your chest wall below, and we have to get all that capsule out. And the muscle is a much more vascular structure, so it oozes a little bit. So we definitely have to put a drain in afterwards. So you're going to have a drain tube typically for a week. Also because this implant has been under the muscle, the muscle has been lifted up. Well, now we got to reattach that muscle. We're going to tack that muscle back down to the chest wall. We're going to suture it back down. When we do that, there's some discomfort that's associated with that. Dr. Koehler (23:29): And because we're reattaching your chest muscle to your rib cage, we don't want you doing any heavy lifting. You got to be careful for the first four to six weeks because muscle doesn't hold suture really well. And if you overdo it, it's just going to pull right through. The muscle will just tear right through that suture. Pain wise, I'd say for explant people off pain medicine in a week, maybe a little bit more than that, and then pretty much driving a car, regular daily activities, all that stuff after a week. But you really can't do the heavy strenuous lifting, working out, stuff like that for six weeks. Kirstin (24:04): So we talked about the power of social media and BII websites and things like that. So are there other ways that women research and communicate about this surgery that's different than other, if somebody was coming in wanting a tummy tuck or just a straightforward breast augmentation? Are there other communities for people who want an explant or are considering that they may have BII? Dr. Koehler (24:30): Yes. It's called the nail salon or the hairdresser. Kirstin (24:36): That's true, actually. No, but for real. You had a patient that told me that story one time that she was like, oh, I think I have this going on. And the lady that was doing her hair was like, oh my God, you have BII. And then she came to you. Dr. Koehler (24:53): Well, there you go. Kirstin (24:54): Yeah, Dr. Koehler (24:54): Hairdresser. Kirstin (24:55): That's a true story. Dr. Koehler (24:56): Yeah, I mean, I just want to say I don't think that it's bad that awareness comes from any source, social media or otherwise. I mean, there are benefits, and again, sometimes people wouldn't even consider that to even be like, they wouldn't even thought, oh, could this even be an issue because they weren't aware. I think the problem just is, like I mentioned, it's no different than a family member saying, oh, well, I had those same symptoms. This was my problem, you obviously have the same problem I do, and maybe not because there's a lot of diseases that have similar symptoms and different reasons. And I'm going to share one other story that I share with my patients all the time, and I just think this is a good kind of put it all into perspective. So I have a patient, and she's a real sweet girl, and she had lupus and she said she wanted breast implants. Dr. Koehler (25:48): And she said, well, Dr. Koehler, I mean, can I get breast implants? I said, well, you can. And then we talked about all of the issues of, Hey, some people feel like autoimmune diseases are caused or from implants. And so then there was the discussion, well, could it make it worse? Would it change? Anyhow, we had this long discussion. She said, well, I really would like to get implants. She doesn't have any breast issues. So fine, we did her implants and she got silicone implants. And by the way, that's another thing. It's silicone or saline, same difference, but maybe we can talk about that in a minute. But anyhow, so she gets her implants, has lupus, gets her implants, and guess what? Nothing changes. So medicine stays the same, her lupus doesn't, I mean, her illness has not changed. And then several years go by still doing great, but she comes in with a friend of hers for a consult, and her friend thinks she's got BII, and her friend wants her implants out. Dr. Koehler (26:46): So we had this big discussion, and the girl that had lupus at the end of the consult looks at me and she says, well, Dr. Koehler, I will say one thing. If I had got my implants and then got lupus, I totally would've blamed the lupus on the breast implants. And I said, I understand. Yes. And that is something that just sort of struck home, even though that's sort of the things we talk about. I mean, here we are, I mean, here's a patient that had autoimmune disease, and it's like, but if she got her implants like a month, a year, two years before, and then she got this, she would've, our brains want to do that? We want to say it's got Kirstin (27:26): Gotta blame something. Dr. Koehler (27:27): Yeah, you got cancer. Well, what caused the cancer? It's not just bad genes, right? There had to be something, an environmental exposure, maybe something in the water, your school, your business. I mean, just that's the human nature is that we want to have a reason for why that happened. And so that's where the tricky part of BII comes in. Because you could see how you would've jumped to that conclusion, and that would've been definitely one where it would've been like, oh, man, well, she was healthy and then she got implants and now she's got lupus. I mean, yeah, get those implants out. So anyhow, that's just something to think about. And then I did mention the one thing people say, well, our saline or silicone, does it matter? In my experience, I did a survey of all my patients, hundreds of people that I've taken breast implants out on, and it's 50/50. Half of the people, they have saline implants, half of them have silicone. And that's kind of consistent with what I'm hearing from other people in other studies. And it really should be that way anyhow, because if you think about it, the outside part of the implant, the silicone is solid silicone, whether it's saline or silicone, it's just what's on the inside is different. Kirstin (28:37): I have one right here. Dr. Koehler (28:38): Yeah, Kirstin (28:39): This is what you're talking about, right? Dr. Koehler (28:41): Yeah. Kirstin (28:41): This little. Dr. Koehler (28:42): Yeah. Well, the outer part. Yeah, the shell. So it's like m and m's chocolate or peanut butter, but it's just the outer part is still chocolate. Kirstin (28:50): True. Dr. Koehler (28:51): Yeah. So anyhow, the point is you can't take out a silicone and swap the saline and think you're going to be, if you really believe that the silicone is the problem. They both have silicone. Kirstin (29:03): Yep. Do you have a guess on the number of these explant surgeries that you've completed? Dr. Koehler (29:09): No. I can't off the top of my head, but I know I want to say that we were doing about 60 a year, so I mean more than one a week, which I mean a fair number, which I want to talk to my colleagues. That's certainly more than a lot of people do. Kirstin (29:26): All right. Anything else you want to talk about regarding total impact? Dr. Koehler (29:31): No, I just want to say one other thing is that if you do come in for a consult for something like this, recognize that when I talk to you about what is maybe recommended treatment and stuff like that, my recommendations are based off of medical studies. Now, you may choose to ignore the study, but my recommendations are based off of medical studies. And so back to my original early comment, which is well do I believe in it? Yeah, I believe that it's quite possible, but I don't necessarily think it's to the level that some people may think it is. So for instance, I tell people, aspirin sold over the counter, but you can die from anaphylactic shock from an aspirin. Okay, it's got potential dangers, but still sold over the counter. So my point is that, yes, there can be real risks, but if it's a small portion, if it was really significant, I do feel strongly like these wouldn't even be available for breast reconstruction. Dr. Koehler (30:27): We'd be like, these need to come off the market, and that's not been the case. So I would say overall, I think breast implants are safe. Do they affect some women? Yes. Yes, I think that that is possible, and hopefully we'll be able to really narrow that down and be able to identify by testing. The other thing is that in a lot of these clinical studies, the clinical studies currently, they're saying currently do not support a total intact capsulectomy. In fact, the same percentage of women seem to get better with just a partial. So the only reason I say that is that there's a lot of weight put into, Hey, my doctor needs to take this out in one complete intact piece. And the clinical data currently is suggesting that that may not entirely be true. So I mean, I'm going to honor my patients' wishes if they want the whole thing taken out, we're going to take it all out. Dr. Koehler (31:18): I certainly try to take it out in one piece. Sometimes we have to take it out in more than one piece, but most of the time we get it out in one piece. But the good news, and the reason I share that with people is that you shouldn't be putting your like, oh, I didn't get better because my doctor didn't get it all out in one piece. That's not really what the data shows. So that's good news. I know a lot of people on all of these sites, they think that, I dunno know, I'm not sure what the altered reason for sharing that with patients would be, but to me, it's good news. Dr. Koehler (31:52): It means that you don't have to stress about, oh my gosh, if a little piece was left behind, I'm no longer going to get better and that's just not the case. And my other little analogy that I sometimes use, which some people may not like, but so some people have nickel allergies, and so if you get earrings and they've got nickel in them and your ears get all red and inflamed because you're allergic, i.e. an altered immune response to a foreign substance nickel. How do we treat that? Well, we take the earrings out, but we don't cut your ear lobes off. Kirstin (32:27): Sure. Dr. Koehler (32:27): Alright. I'm not saying that could there still be nickel against the skin surface? Maybe, but your body generally has capacity to overcome. Dr. Koehler (32:40): You could do a more aggressive treatment and cut the piercings out as well as take the earring out. But if you get rid of this source, which is the silicone, take the implant out, which is the problem, hopefully the body is able to do all that. And more studies are needed. We're still waiting on all the information. So just realize this is a work in progress. And I think ultimately the doctors that do a lot of this work, I mean, what we really want to be able to do is to tell people with certainty what the best treatment is. And unfortunately, we can't do that right now because we are still in a little bit of a learning stage as far as figuring out who's the best candidate and what's the best treatment. So I would end it on that. Kirstin (33:23): All right. Well, do you have a burning question for Dr. Koehler or me? We'd love to hear you on AlabamatheBeautifulPodcast.com. Thanks Dr. Koehler. Dr. Koehler (33:34): Thanks, Kristin. Kirstin (33:35): Go back to making Alabama beautiful. Dr. Koehler (33:37): Alright. Announcer (33:37): Got a question for Dr. Koehler?Leave us a voicemail at AlabamatheBeautifulPodcast.com. Dr. James Koehler is a cosmetic surgeon practicing in Fairhope, Alabama. To learn more about Dr. Koehler and Eastern Shore Cosmetic Surgery, go to easternshorecosmeticsurgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, Apple Podcast, Spotify, or wherever you'd like to listen to podcasts. Follow us on Instagram @EasternShoreCosmeticSurgery,. Alabama the Beautiful is a production of The Axis, theaxis.io.