Latest / Alabama The Beautiful: The Eastern Shore Cosmetic Surgery Podcast / One Size Does Not Fit All: Finding the Perfect Breast Implant Size
Transcript
- Announcer (00:02): You are listening to Alabama the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis. Kirstin (00:13): Hey Dr. Koehler. Dr. Koehler (00:15): Hey Kirstin. What you got today? Kirstin (00:17): Okay, well I had to tell you this. This is huge. Are you ready? Dr. Koehler (00:22): I'm ready. Kirstin (00:22): We got our first voicemail. We got a caller. Dr. Koehler (00:26): Alright. Kirstin (00:27): Okay. So that means we get to do a caller Q and Q. Dr. Koehler (00:32): Alright. Kirstin (00:33): So but we need a few more calls to do that first. Dr. Koehler (00:36): Oh, okay. Kirstin (00:37): So if you're listening and you have a question for Dr. Koehler, this is your sign to go to Alabama the Beautiful podcast.com and ask your question. Otherwise, I'm just going to have to make some up and change my voice and we don't want any of that. Dr. Koehler (00:52): Yeah. Looking forward to some questions. Kirstin (00:54): Yeah. Okay. You ready? Dr. Koehler (00:57): I'm ready. What are we talking about? Kirstin (00:58): Well, you just went to the AACS or the American Academy of Cosmetic Surgery annual scientific meeting. Dr. Koehler (01:06): Yes. Kirstin (01:07): Where was it? Dr. Koehler (01:08): It was in New Orleans this year. Kirstin (01:10): Was so fun. Dr. Koehler (01:11): Yeah, it was good. I mean, I didn't really get out a whole lot, but I mean. Kirstin (01:17): Did you go to Bourbon Street? Dr. Koehler (01:18): No, I did not go to Bourbon Street. Kirstin (01:20): What? Dr. Koehler (01:21): Yeah. No, I don't want to get knifed. I think I'm good. Kirstin (01:25): Did you come back with any little pearls? Dr. Koehler (01:28): Yeah, I mean lots of little things. I mean the meetings always, I get some stuff from going to lectures and then some stuff just from talking to colleagues. So I mean they always come away with something. Kirstin (01:39): What did you teach this year? Dr. Koehler (01:42): We did a Brazilian Butt Lift safety class. That was in the pre-meeting, so that was just sort of reviewing the new guidelines or new recommendations for using ultrasound and teaching people how to do a BBL safely with ultrasound, I should say. So that was good. That was in the pre-conference and then in the conference gave several talks and then moderated some sessions, so it was good. Kirstin (02:06): Yeah. I always like to go listen to you. Dr. Koehler (02:11): uh-huh. Kirstin (02:11): I mean I hear you talk every day, but. Dr. Koehler (02:14): Thanks for the support. Kirstin (02:17): Alright, so we're going to talk about breast augmentations. Dr. Koehler (02:21): Okay. Kirstin (02:23): Is that your favorite? Dr. Koehler (02:24): I mean, yeah, we enjoy doing breast augs. It's a big part of our practice. Kirstin (02:28): That's my favorite. So I am noticing that breast implant sizes are starting to trend down. Are you seeing that too? Dr. Koehler (02:37): Maybe a little bit. I think that tends to be a little bit regional. I think people in the northeast tend to go with smaller implants than in the south. People in the south tend to go with a little bit bigger implants and it's just so very dependent. I'm always having to, when I'm going through before and after pictures in a consultation, always have to say to the patient, I'm like, look, I'm going to show you just different examples. I understand these may be bigger than what you like or smaller than what you like. They're just examples everybody. It's like artwork. People have their own tastes. Some people like 'em big, some people like 'em small, it doesn't matter. We have 'em in all the sizes, so we can do whatever you like in that regard. But I don't know, we still put in some bigger implants, but maybe as a whole they're a little bit more conservative than maybe 10 years ago. Kirstin (03:28): What's the first question that most women have when they come and ask you about breast augmentations? Dr. Koehler (03:35): The first question, I don't know. I mean, I think the good thing about doing consultations now compared to maybe when I first was in practice is that people come to the consultations much more educated. So they've already done a lot of research, so their major questions they probably already have got the answers to. They might just want to hear my take on it. So I can't say that there's one universal question that this is the question that I get most commonly because it's just very different. Kirstin (04:02): Well, I feel like with Facebook groups and Google, I mean people get a lot of questions answered before they come in here and hopefully it's good information, but. Dr. Koehler (04:11): Yeah, I mean I think you got to be careful where you get your information from, but I mean at least even if it's, it may not be all correct information, but it's better than no information and then they might bring it up and then we can have a discussion because sometimes people are like, oh, I heard it's best to put your implants above the muscle. I'm like, well, where we are, everybody's getting their implants under the muscle and there's a discussion there obviously to be had. There's pros and cons to each, but anyhow, people come with some preconceived notions. Some of them are correct and some of them are not. Kirstin (04:42): Yeah. So anybody can get breast implants at any age, but is there a typical age when you see women getting their first breast implants? Dr. Koehler (04:51): Well, let's back up. They can't all get it at any age. Kirstin (04:56): Oh. Well. Dr. Koehler (04:58): I mean the FDA recommendation is for saline implants, you need to be 18 years of age and older, and if you're getting silicone, you've got to be 22 years of age and older. Don't, I have no idea why they chose 22. You can go to war and you can smoke cigarettes and all that kind of stuff. You can drink, but you can't get breast implants until you're 22 if you want silicone. But that's the FDA recommendation. It doesn't mean there are cases where we will do augmentation on younger patients for when they have maybe significant asymmetries or things that they don't have any breast tissue and as long as mom and dad and everybody's all on board and we're doing it just for the right reasons, we're not trying to put in huge implants, we're just trying to help this person out. There are some select cases where we go under that age, but typically those are the ages. And if you do implants, let's say you do silicone on somebody that's 21 years old, it's off label. It's not illegal, it's off label. The patients need to that, but generally as a whole we try to stick to that. Kirstin (06:01): Okay. Is there a way to know what size or shape will look good before you come in and have your consult? Dr. Koehler (06:08): Before the consult? Yeah, there's little things that people try. If you get online online, they'll say, oh, you can fill up a bag with rice and stick that in your bra and you can add and subtract rice until you get the size you want. And then that can kind of help determine the size of implant you want. I don't know how accurate it is, but maybe it can be useful for people who are trying to figure it out. I've certainly tried a lot of different things over the years. There's been a lot of different imaging systems. I've purchased a couple over the years and although they are fun for the patient, there was one that you could put on virtual reality glasses and we'd take a picture and then it was like they were looking at themselves in the mirror and we could put with the software, we could pick an implant and it would automatically change the size of their breasts and they could see it in the virtual reality. But the truth of the matter is it wasn't very accurate. It was kind of neat for them to see the difference and it's kind of fun, but it's not real. The best sizing I find is when I actually put sizers in the bra and we have some discussion and we go through a process of how we do the sizing and we try to get that to the desired size of the patient through that method. Kirstin (07:18): Well, speaking of sizing, how big can someone go? Dr. Koehler (07:22): There's a lot of factors that go into that. So it depends on how tight your breast tissues are. It depends on the distance between your nipple and your crease, and there's just a lot of factors like tissue factors that come into play. So sometimes if a person wants a really big implant, we might say, look, this is as big as we can safely go at this point in time. Let your tissues expand, we'll reevaluate and if you want to go bigger, we can do that. Sometimes you can't go from flat chested to big implant if you've had several kids and the tissues are a little looser and they've been stretched out already, and maybe we can go a little bigger. And that just depends on the comfort level of your doctor and again, your anatomy. So it's not two patients are never the same, everybody's different and we treat 'em on a case by case basis. So the only thing I would say is when people are looking at larger sized implants, they need to also understand the complications go up with big implants. If you go with bigger implants and you don't have good tissues, the implants can bottom out, then you can get implant exposures. There's just things that can happen. Obviously we want to find something that fits your frame, but large implants is kind of almost a separate discussion. So I gotta have the hands-on, see the patient, see what their tissues are like, and then kind of guide them from there. Kirstin (08:54): So Dr. Koehler, does anybody ever come to you and say, I'm positive I want this size, this is the size I want because my best friend got that and I know it looks great on her? Dr. Koehler (09:05): Yeah, actually I hear that really, really commonly. And it's something that we have to always educate people on because the size of the implant, there's a lot of factors that come into choosing the size and the same size implant on two different people can look very, very different. And that's why there's a process that we go through. For instance, some people have a broad chest and their friend may have a narrow chest, and so the implant that their friend has may be much narrower and that would not look good on the friend who has the broader chest and she'd have a big gap in her cleavage if we didn't fill out the width of her breast. The implants come in multiple styles and sizes and these are, I think it's good if you show, you say, this is my friend, this is what she has, I like the way this looks. Dr. Koehler (09:56): That's okay, but they shouldn't come in going, she has 300 ccs, so I want 300 ccs because she may be very disappointed unless she's built just like her friend and then maybe that would be okay. But people are very different. I often show pictures in my consultation. I have a picture, I show two different women the same height and weight, same size implant, and they look completely different because their chests are different. And so it's not like the first patient, she says, oh, I want to look like this other girl. She'll never look like that other girl because her chest and nipple position and all that stuff is not the same. So we got to take those factors into account and I think it would be helpful if people say, well, this is how my friends' breasts look. Maybe we can say that's realistic or not based off of that. Kirstin (10:41): Yeah. So speaking of pictures, do you encourage people to bring wish pictures with them or is that something that helps or doesn't help? Dr. Koehler (10:51): It helps in the sense that if they're showing me pictures of things that I just know are not achievable on their frame, I can at least look at them and go, I know this is what you'd like and it looks good in your mind that this is what you want it to look like, but I may not be able to achieve that because your body is built differently. So one thing I always encourage people when they're looking at before and after pictures is try to pick people that look similar to you that their nipple position is similar, their chest width dissimilar, and you can kind of get an idea looking at pictures online, people that look similar to you, but if you just look at the after pictures, your body's not a piece of clay. We can't just go, oh, that's what you like. We're going to mold it to that. Dr. Koehler (11:33): The key with breast implant surgery is well picking the right size of implant and the right style of implant for the patient, but really surgically there's just one thing that we have to do and that's place it centered underneath the nipple in the right location, and we can't really do anything else like that. We can go with a wider implant to give more fullness up top, more cleavage, but then you also more side boot because the implant always has to be centered on the nipple. And so nipple position, chest shape, ribcage shape, all these things factor in to what we're going to be able to achieve. Kirstin (12:03): Do you ever get celebrity pictures as goal pictures? Dr. Koehler (12:08): We get some all kinds of pictures sometimes, I'm like, where'd you get that one from? That's an interesting picture. Kirstin (12:13): <laugh> Dr. Koehler (12:14): But no, truthfully, I mean most people, they bring in reasonable pictures, but occasionally we'll have people that I'm like, yeah, this lady doesn't look anything like you and it's okay. Again, when they bring those, I mean it's actually good because we can have that discussion. What would be worse is if they didn't show me and we kind of go through the sizing and they think in their mind they're going to end up with that result. And if their body's just not shaped that way, then they're going to be disappointed. Kirstin (12:41): So is there anything that prevents somebody anatomically or health-wise or any other reason that prevents anybody from being a good candidate for breast augmentation? Dr. Koehler (12:49): Well, yeah, I mean if your health's not good, I mean it's elective surgery, so I mean that's true of any elective cosmetic procedure. So that would be a for sure off the table. There can be some difficult situations like people who have significant rib deformities. It's not that they can't get implants, but that opens up a very different discussion. If your ribs really cave in or they slope way back, that's a much more complex breast augmentation and expectations definitely need to be set. And there can be problems with doing those types of patients specific to their anatomy. If people have already preexisting autoimmune diseases, sometimes that's just a discussion to be had because of there are some people out there that feel that having a breast implant can aggravate or maybe even create autoimmune issues that's not been shown, but there's certainly that thought out there. And so if a person already has autoimmune condition, that would be a discussion that the doctor would want to have with the patient before putting implants in. Kirstin (13:50): Is there a certain brand that you prefer or does it matter? Dr. Koehler (13:54): There's really two main companies in the US. There's more than two companies, but there's two main companies and I've used both of their implants and I can tell you that I would feel comfortable using either brand on any family member, staff, whatever. I think there are some pros and cons to both of the company's implants, but there's not a perfect implant. If there was a perfect implant, we would definitely be using it. Kirstin (14:25): Do you still do much saline or is it mostly just gel now? Dr. Koehler (14:29): We still do saline, mostly silicone. I think most people prefer the feel of the silicone compared to the saline. The shell of both of the implants is solid silicone, so it's the same on whether you do a saline or a silicone, but it's kind of what's on the inside. The chocolate or peanut butter. Kirstin (14:48): It's what's on the inside that counts. Dr. Koehler (14:51): But the thing about saline, and for people who are worriers, they may want to choose a saline implant because people worry about leaking and if a saline implant leaks, it just goes flat and it usually goes flat pretty quickly. You wake up one morning and you're like, what happened to my breast? And it's deflated. Your body will reabsorb it. It's filled with IV fluid, salt water, and so if it gets into your body, it's not a big deal, you'll just pee that water away. But a silicone implant on the other hand, it's not going to go flat. And in fact, you probably could walk around for sometimes years not even knowing you have a ruptured implant. So for people who are unwilling to do imaging of their breasts or are just worried about walking around with a ruptured implant, they may choose a saline implant. However, there are some patients that come in that may want a saline implant that are not good candidates for saline implants. So if they have very thin tissues and there's not good tissue coverage, then we're going to recommend a silicone. But if you've got good tissue coverage, you can pretty much choose whatever you like. It's whatever flavor you like. Kirstin (16:00): Whatever flavor you like. Okay. Let's talk about placement. Well, we kind of did a little bit and you said in this area of the country, we're going to find below the muscle implants. Do you ever do trans umbilical or see that in your colleagues? Dr. Koehler (16:16): Yeah, the tuba. I don't do the tuba. If you're doing well, I mean you can do silicone. You saw the meeting, there were some people doing silicone through the belly button. To me, it doesn't make sense. I don't do that and I don't do it frequently. I've done it before. It's definitely a technique that I think there's a little niche market for that. I know I have some friends that they do a lot of tubas, but they have a lot of patients coming specifically because they do that. I think if you call around, there's a lot of offices that most people aren't doing tubas. It definitely, it's a different technique. You go through the belly button, you have to create these big, big, but you have to create these tunnels through the abdomen to get underneath the muscle and put them in. It's a long way to travel to put an implant in. Dr. Koehler (17:00): I think in my world, that's just not an approach that I like to do and I just don't do them. I think for those people that want it, I would just seek out somebody who really does a lot of tubas because that's not something, you want somebody who only does a handful of those a year. You want somebody who does those all the time. It's a very technique sensitive. The reality of it is, yes, you have a scar inside of your belly button, but when you come back to have to get them replaced, especially if you need any kind of internal work on the pocket, you're going to get another incision. So you're going to end up with an incision under the breast, around the nipple, something like that. But might for the first set, maybe that's okay, you want to avoid the scar, but just realize that down the road you might need to have that incision. Kirstin (17:46): I didn't know that was a thing. I worked here for a while and did not know that was a technique. And I saw a video on Instagram. I don't know if I can say the doctor's name because I saw 'em at the meeting, but then I had a dream that my implants fell. They fell down my rib cage and into my leg, and I had to scoop them back up and put 'em where they belong. Dr. Koehler (18:08): Well, that happens more commonly than you'd think, so. I'm just kidding. No, I mean people who do that technique and do it well, I mean, they do a great job, I have to say. But it's a technique that you have to do often. Kirstin (18:21): Yeah. Okay. So is there something special you do to get a natural result for somebody? Dr. Koehler (18:27): Yes. I mean, I think a lot of getting a natural result is, again, picking a size that's appropriate for the chest. And then as long as the implants don't get contracted or something like that, they should look very natural. Kirstin (18:41): How long does a straightforward rest augmentation take, or how long will the patient be under anesthesia? Dr. Koehler (18:49): Well, I mean, the procedure itself takes less than an hour, but we usually tell people an hour. But it is really more than that because there's meeting with anesthesia and we do our photos in the morning, we do our markings, they meet with anesthesia, then they go to sleep, then we've got to inject, and then we re-prep. And so the whole process in surgery is it's under an hour, but we say about an hour, then they go to recovery, and then they're going to be in recovery for maybe 45 minutes or so. Kirstin (19:15): And you said inject because you do lidocaine, right? Dr. Koehler (19:20): Well, I think everybody does lidocaine, but we do. Kirstin (19:23): Okay, that's what I was going to ask. Dr. Koehler (19:24): Yeah, I mean, we inject along our, so we prep the breast and we inject along the incision lines, and then we'll do some nerve blocks, and then we will re-prep and then we'll do the surgery. Kirstin (19:36): Then you'd be feeling good. Okay. So afterwards, say the patient is not a mother yet, and then she decides she wants to have kids one day, what will happen to the implants? Or could she breastfeed if she chose? Dr. Koehler (19:49): So technically, yes, she should be able to breastfeed, especially if the implants are under the muscle. But depending on the studies you read, there was one study on breast reduction surgery that I used to, I talked to patients about when they have to have a breast reduction and they want to talk about will they be able to breastfeed. And in that study, the control group, about a third of the women couldn't breastfeed and they had no surgery. So first of all, I don't know if it's necessarily 30% in the general population, but it's certainly not zero. So there's a percentage of people that even if they didn't have implants, are not going to be able to breastfeed for many reasons. So to say that it was caused by your implant is like, well, that's anybody's guess really. Maybe, could it affect? Maybe. But sometimes I think an implant actually can help some people because it pushes the breast tissue forward and maybe it can make it easier for the baby to latch on. Dr. Koehler (20:43): But as far as the breast tissue itself, the implant's under the muscle, it's not affected. Yes, there could be some ducts that were cut through in the process depending on the approach that was done to do the surgery, but really you should still be able to breastfeed. But what will happen afterwards, anybody's guess? So it depends on a number of things. Women who come in and get a breast augmentation but really don't have hardly any of their own breast tissue, and they have a child, whether they breastfeed or not, a lot of times their breasts do pretty well. Really, the ones that are going to be problematic are the ones that were probably going to have a problem whether they had an implant or not. So let's say they already started off as a small C cup and they got implants. Well, if they have a child and their breasts getting engorged, they've already got a lot of their own breast tissue. Dr. Koehler (21:32): And when that gets engorged and gets stretched out, gravity wins and all that. Breast tissue starts to sag and the implants not dropped down. The implant will be in the same position. It was likely that it's not going to move, but the breast tissue starts to sag over the top of the implant, and so then you get this snoopy nose kind of look. And so that's what can happen. Again, more likely to happen when women who have more breast tissue before they have a child, but you don't know, some people do well after having kids and they don't need anything, but there's a lot of people that end up needing a lift. And again, they would've probably needed a lift if they didn't have an implant. Kirstin (22:10): What do scars look like? Dr. Koehler (22:13): Well, it looks like red and then it gets faded with time. That's what a scar look like. <laugh> Kirstin (22:18): Where are they? Dr. Koehler (22:21): It depends. So there's different approaches. You can go through the armpit, you can go through an incision around the nipple or you can go underneath the breast. Probably my preferred approach is to go underneath the breast. You can certainly go through the armpit, but again, if you need to do additional work on the pocket, let's say at a later time, like let's say five years down the road, we've got to reposition the implant, we might have to do some internal suturing. That's not something that you can easily do through an armpit incision. So typically the incision around the nipple or under the breast is the best access to do that kind of revision work. So that's kind of the preferred technique. But for 10 years, I did almost all my implants through the armpit. It's not something that I am very familiar with, but I think over the years I've kind of transitioned to the inframammary incision underneath. Dr. Koehler (23:09): It's patient preference. I'm not a huge fan of going through the nipple just because you do have to cut through a lot of the duct, the breast tissue to get down to the muscle. And we do know that there's bacteria that lives in our bodies. It's in the duct of your breast, and you don't want that to get on the surface of the implant. It doesn't cause infection, but it can cause what's called a biofilm where you get bacteria on that surface and then that can result in the body forming excessive scar tissue, and that can tighten up around the implant and it causes capsule contracture. So capsule contracture is one of the problem things with implants, you don't know who it's going to happen to, and it can happen three months, six months after surgery, or it could happen 15 years later. So you just don't know. But it's a cumulative risk. Certainly bacteria does play a role, and that's why I don't like going through the nipple approach. Kirstin (24:06): How big are your typical scars? Dr. Koehler (24:09): Well, for saline, it's typically around a three centimeter incision. And for silicone it's a little bigger. It's about four centimeters. But then again, with silicone, the implants are prefilled, so the doctor can show you this is the implant size and the bigger the implant, you might need to use a slightly larger incision depending. But nowadays, we have those little funnels that you can use to put implants in. It makes it a lot easier to put the bigger implants in through a smaller incision. So anyhow, about three centimeters for saline, four for silicone, that's about standard. Kirstin (24:40): How long does it normally take the incisions to heal? Dr. Koehler (24:43): Well, I mean, most people are looking pretty good in four to six weeks, but I always tell people it takes six months to a year for incisions to fully heal. And everybody's different. Some people, when you see 'em at six months, it's a pencil line, you don't really see hardly anything. And other people can have redness and it takes longer. But time is a good healer. We certainly have things in the office that we can use for patients to help with scarring. There's scar creams that we recommend. There's a lot of over the counter stuff too. And then we have lasers and microneedling and all kinds of other stuff that we can use to assist with scarring. We don't routinely across the board, recommend that to every patient because not every patient needs that, but it's available. Kirstin (25:25): So how do the patients take care of their incisions once they're home? Dr. Koehler (25:30): Well, first, for the first week, they've got dressings on and there's nothing to do, so they just shower pat dry, don't do anything. When we take the dressings off at a week, then my nurses will talk to them about putting antibiotic ointment on the incision, usually for a couple of weeks. And after a couple of weeks, once we make sure there's not any redness and the incision's a little bit more matured, then we can start scar cream. And so usually scar cream has started about two or three weeks after surgery. Not right away, it's just keep it clean. Antibiotic ointment for the first couple of weeks, and then scar cream. Kirstin (26:07): Okay. Are there things that patients can do or do we send people home with anything to make them a little more comfortable at home? Dr. Koehler (26:13): Well, yeah, there's medications and stuff that we give people, but really we're using less narcotic. There are some other medicines that we're giving at surgery that kind of seem to help people out, and we try to transition people into anti-inflammatories like ibuprofen and stuff after a week, for sure. And most people are doing pretty good in about four or five days, maybe not a hundred percent, but they could be functional. They're not in bed, and it's not that bad a surgery as far as pain goes, it's actually most people do very well. But as far as healing goes, yeah, I mean, there's not anything specific that we send people home with. I mean, we talk to 'em about making sure their nutrition is good, that they're not smoking. I mean, you can do breast augmentation on a smoker, but I can tell you, you can pick people who are healing poorly. It's almost always a smoker. I hate to say that, but it's true. I mean, they tend to spit sutures. Their incision lines don't look as good. So if you can quit, that's going to help heal. Kirstin (27:12): Yeah. Okay. Everybody always wants to know when do I look good, feel good, and when can I do stuff? Dr. Koehler (27:18): Well, I mean, a lot of people really look pretty good in a week, but the implants are still going to be sitting a little high. So usually by four to six weeks, they're going to be settled. And so if you had, I don't know, an event or something, I'd say four to six weeks, you should be looking pretty darn good at that point. There's typically not very much bruising. Occasionally, sometimes people have a little bit of bruising, but most of the time there's not any bruising but feel good. I don't know. I mean, it's different. I mean, have some people in a week, they feel great, but we wouldn't let them do heavy lifting exercise, stuff like that for six weeks. So you might feel good in a week or two. But as far as really getting back to the gym, we have people that are dying to get back and at four weeks they're like, really? They feel very good and they think they should be able to go and do it. And could they? Yes. But I mean, we don't want to push it. You just had an elective surgery, you paid a lot of money for it. You don't want to wreck it. I mean, can you wait two more weeks and then you're good to go? Kirstin (28:15): Yeah. Okay. When will a patient need to have their implants replaced? Dr. Koehler (28:20): Well, that's a tough question. Only from the standpoint of with silicone, let's start with silicone. With silicone people, with the older style of implants, people, you say, well, you got to get 'em changed every 10 years. Every 10 years, no matter what change. And I certainly think that that's not a bad idea. Is it a hundred percent necessary? I dunno. I wouldn't say that's true. I've certainly taken out implants, the old variety, the ones that are not considered, they were out Corning that were taken off the market in the late eighties, early nineties, but I've had removed some of those and the implants are perfectly intact and fine. Now, that's not typical after 35 plus years, but we've seen that. But for sure, if you're not going to replace them at 10 years, you certainly need to be getting imaging done to check to make sure they're not ruptured. Okay. If they are ruptured, you want to replace them so they're not permanent devices. And I will say the one good thing is the companies now have lifetime warranties against leakage on these implants. So just because the lifetime warranty is there, doesn't mean you should keep, they're not lifetime devices. Kirstin (29:31): Okay. So I've seen on Instagram, some Miami surgeons and even some local surgeons here Dr. Koehler (29:42): Dance? Kirstin (29:42): in our area, not dance, well, they do dance, but they're offering some crazy deals on breast augmentations. So is that something that somebody should look out for? Is that dangerous or is that a good? Dr. Koehler (29:58): No, I would say, I don't know. I sometimes think you get what you pay for, so just remember that. I mean the aftercare and all that kind of stuff. But sometimes people do offer specials and they can be really good. So I wouldn't sit there and say, oh, just because somebody's price is less, it's a less service. But I mean, do your research. That's all I would say. I mean, that's just all there is to it. Kirstin (30:25): Well, speaking of doing research, how do I find a good surgeon? Dr. Koehler (30:30): Well, my phone number is (251) 929-7850. Kirstin (30:37): Yeah. Dr. Koehler (30:37): No, but we're good. Kirstin (30:38): We are good. You are good. Dr. Koehler (30:40): Anyhow, I think talking to friends who've had surgery with the doctor and had a good experience. That's good. Definitely online reviews. I mean, have they been around for a long time? Have they been in the area? I mean, most of the time if doctor's been in the area for a good period of time, there's enough people that know about the doctor's reputation if they're good or not. If you're in the medical community, I guess we sometimes have a little bit of an inside scoop. I always say, talk to anesthesia people. They've worked with a lot of the doctors, and even though they don't do the surgery, they kind of get a feel. They know the doctors that are doing good work. I mean, they just know because their surgeries go smooth, the patients aren't coming back. I mean, that kind of thing. So I don't know. Dr. Koehler (31:25): But if you go and see that they only have two before and after pictures and you only liked one of 'em, maybe that's not a doctor for you. If somebody's got lots of pictures and you're like, well, I didn't like all of them, and you're not going to like all of 'em, just go ahead and tell you that. If you go to a doctor's website and you say, I liked every one of his pictures. Well, I mean, I'll just tell you, I look at some of my own work and I'm like, oh, I like this one better than this one. We always strive for perfection, but hitting it every time is just impossible. But the vast body of the work that you're looking at, you should be like, yeah, I like that. And if you do, then that's a good sign. Kirstin (32:03): Can patients get financing? Dr. Koehler (32:06): Yes. There's different options of financing that we offer, and I'm sure other people do as well. Kirstin (32:13): Yes, and our website has all those financing options and the ability to go ahead and apply straight from the website, eastern shore plastic surgery.com. Dr. Koehler (32:23): Okay. Kirstin (32:24): Alright. On our next episode, we're going to talk about how long your implants will last and what you can expect when it's time for removal or replacement. Before we go, if you have a burning question for me or Dr. Koehler, don't forget to go to our podcast website at Alabama the Beautiful podcast.com. Our call in episode will be coming up very soon and we want to hear from you. So call and leave your message. Thank you, Dr. Koehler. Dr. Koehler (32:50): You're welcome. Kirstin (32:51): Go back to making Alabama beautiful. Announcer (32:55): Got a question for Dr. Koehler. Leave us a voicemail at Alabama the Beautiful podcast.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 eastern shore cosmetic surgery.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 like to listen to podcasts. Follow us on Instagram at Eastern Shore Cosmetic Surgery. Alabama the Beautiful is a production of The Axis, T-H-E-A-X-I-S. io.