#10: What to Know About Breast Augmentation

You are listening to The Natural Plastic Surgeon Podcast. I'm Dr. Daniel Barrett, Board-Certified Plastic and Reconstructive Surgeon located right here in Beverly Hills. I specialize in cosmetic surgery of the face, nose, breast and body. This podcast is dedicated to those deciding if plastic surgery is right for them and revealing all the latest beauty secrets. New episodes premiering every Monday at 10 am. Let’s get started.

On this episode of The Natural Plastic Surgeon…

Dr. Barrett:...is this a board-certified plastic surgeon, okay, by the American Board of Plastic Surgery, there's a big difference there. There's other boards that are out there. Some are fictional, they don't exist. Some are made up like the American Board of Cosmetic Surgeons that was made for people that never were board-certified by the American Board of Plastic Surgery. Not the same caliber. To get board-certified by the American Board of Plastic Surgery you had to go to medical school, you had to go to a qualified residency, then you have to take lots of tests…

Dr. Barrett:...have asymmetry. If you have any breast asymmetry, sizing is a must. Because sometimes people have a 25 cc difference, sometimes people have a 50 cc difference, and you will only be able to get that right in the operating room.

Dr. Barrett:...bottoming out happened. There's no studies on bottoming out but there should be. That's where implants drop below and they, they fall exactly where they came in, right? If you put an implant from the bottom, guess where it wants to go, it wants to go out the way that it came.

01:25 ALL ABOUT BREAST AUGMENTATION

Dr. Barrett: Hey everyone, you're watching and listening to The Natural Plastic Surgeon Podcast. I've got a special episode for you guys today. Today we're going to talk all about breast augmentation. And the things you need to know, we're actually going to, we're going to pack it all in. We're doing a solo episode just so I can get all the pertinent information. So you guys are in luck, get excited. You're going to get a lot of information coming at you really fast. Okay?

So I get a lot of questions about breast augmentation. As you know, I’m Dr. Barrett, I'm a board-certified plastic surgeon here in Beverly Hills and I specialize in breast, body, face and nose plastic surgery. More importantly, I do about six to nine breast operations every week. And so I get a lot of people coming in, I get a lot of people writing in, or calling in, asking about breast augmentation. What do they need to know? What do you need to know? And so I wanted to do this episode to kind of go all…to go into it so that you guys know exactly what you need to know, before starting your journey. If you're considering it, or if you decide is not for you. That's fine, too.

02:30 WHERE TO START YOUR RESEARCH

So one of the questions I get is, where do I start with my research? How do I start this process? Well, there's a lot of information out there on the Internet, and there is a lot of good information, there's a lot of bad information. And so what I suggest is to look up a board-certified plastic surgeon, find someone who does a lot of breast surgery, okay, someone who does at least one or two breast operations every week. They have before and afters so that you can actually look at the results. Look at the quality of the results. Does that speak to you in terms of what you're thinking of in terms of your goals?

03:18 ARE THEY BOARD-CERTIFIED?

So at the base of your research pyramid, it should be: Is this a board-certified plastic surgeon, okay. By the American Board of Plastic Surgery, there's a big difference there. There's other boards that are out there. Some are fictional, they don't exist. Some are made up, like the American Board of Cosmetic Surgeons that was made for people that never were board-certified by the American Board of Plastic Surgery, not the same caliber. To get board-certified with the American Board of Plastic Surgery you had to go to medical school, you had to go to a qualified residency, then you have to take lots of tests and you have to submit surgeries that you've done. So it's a very detailed process, and it really selects the best of the best. So starting right there. That's the base of your research.

Next thing, find out more about these particular surgeons. Find someone local if you can. If there's nobody local, find someone who has a visiting program so that you can come and visit the plastic surgeon, get everything taken care of, and they're still a resource for you when you go back home. We have the, we have that set up here in our office with virtual consultations. And we have a lot of out-of-town patients that come here from all across the world.

04:15 DO THEY HAVE BEFORE AND AFTER PHOTOS?

Next thing you want to do is, like I said, look at those before and afters. Do the results really speak to you? Is this a look that you're trying to achieve? Are the results really big and fake looking? Is that what you want? Or are you looking for more natural-looking results? So those are the things you want to kind of look at. Lastly, I would look at reviews. Here in Los Angeles, Yelp reviews are really important. They're really big. You can't make them up. They're very strict, unfortunately, about their review guidelines. So if there's a review up there, there's no way it's coming down. So even our practice we get, we get bogus reviews, we get some real ones. And it's a great way to really hear what other people are saying. I don't know how it isn't the other parts of the country, different, Yelp is not as big in other places. But there's other sites like Healthgrades, RealSelf, Google...all those reviews you want to, you want to listen to and pay attention.

And guess what, you can also reach out to those people that wrote reviews. And you can ask them. Hey, is this, did you really write this review? Is this really your story? Can you tell me a little bit about more Dr., Dr. Barrett, whoever, or Dr. So and So.

And then I would call. Call the office. By the way, backing up now, you can also check out their Instagram profile. What do they do on social media? Not every doctor does social media. I do a lot of social media because I want to be transparent. So I put it all out there. So viewer discretion advised, okay. So if you do check it out, be mindful that I will be showing graphic details of surgeries, just so you can see exactly what's involved. I want all my patients to be fully informed about surgical decision-making process. So you're going to see everything there. So you've done your Yelp research, or your Google ugh sorry, you've done your review research. You've done your social media research.

05:58 CALL THE OFFICE

Now call the office. Do you get a warm person on the phone that answered? Or do you get an automated response? That's gonna be your first clue as to whether or not this is going to be a place you want to go get surgery done on your body, okay? You want a place that's going to be there for you in case you have complications, that's easy to schedule, that doesn't make you wait and that's friendly and can provide valuable information on the phone. So that's something that we always try to do. So that's where I would start.

06:30 NATURAL-LOOKING BREAST AUGMENTATION

Next question is, how, how do you get natural-looking breast augmentation results? So I mentioned to you guys, that's, that's one of my core philosophies in my practice. I'm from Virginia, have an organic garden in my backyard, I have a beehive. I'm really into natural-looking things, form and function. I never want to make somebody look fake or unnatural that they couldn't have been born that way. I think there's natural versions of bigger that we can achieve through breast augmentation with implants or with fat transfer. My goal is to make it look like you haven't had surgery. Get you the results you want but make, make it look like you haven't had surgery.

So how do I do that? Well, there's a lot of things that I do. The main thing I spend most of my time on is pocket placement. Getting that implant partially underneath the muscle in a, kind of, you know, the pectoralis muscle is when you do push-ups, whatnot. And so if you are to place the implant partially underneath that muscle...so actually maybe we’ll show you on the side. Implant partially underneath the muscle creates more of a teardrop shape versus that fake and rounded look with an implant above the muscle. I call that the $5,000 Vegas Special. You see it on the billboard on the way to Vegas, and you see it at the pool parties, the results there. That very fake and rounded look on the top. You definitely want that submuscular placement. Alright, so that's step one. That's where I spend about 65 to 70% of my operation is getting that perfect pocket placement.

07:55 INCISION CLOSURE AND SIZE CHOICE

Next, I spend a lot of time on my closure. I closed in five layers, which is insane. It's super OCD. But what we found is that when you were able to bring all of those layers precisely back together, you get much less scarring. Okay?

And lastly is size choice, okay? There's a lot of things that go into, to determining size we'll get to later in this, but you want to pick the size that's customized for your body. You want a surgeon that sizes you in the operating room with sizers. It's like trying on a pair of shoes before you buy ‘em. Yes, you can buy online, but you don't want to commit to buying that until you actually try ‘em on. Okay.

So that's how you get natural-looking breasts, that's how I get natural, that’s some of the main components of how I get natural-looking breast results. Because again, my biggest fear, and this is, is the truth, is that I don't want any of my patients to go to the pool party or go to the beach, or be with their family, friends and family and someone's like, oh, she's had a breast augmentation. Okay. And I feel like a failure. So that's, that's how I designed the whole operation. Okay, next question.

09:00 NIPPLE SENSITIVITY

Will breast augmentation affect nipple sensation? I actually had this cons...I had this question today. I had about eight consults for breast surgery today. And that's a great question. Because nipple sensitivity is very important. It's very important for arousal, just general well being and so forth. If you understand the anatomy of nipple sensation, you can understand the answer to this question. The nerves for nipple sensation, they come from the spine, right? All of our nerves come from our brain, they go down behind our spine and they wrap around our chest, and they poke out a muscle called the serratus anterior. That's a muscle that is, is kind of like those, those, like, that ripped, if you ever see those people, that ripped look right underneath the armpit. Those, kind of looks like three or four little cords there. That's a serratus anterior muscle and the, and the nerves for the nipple sensation, most of them wrap around and they percolate through that muscle into the pectoralis and then right directly underneath the areola.

So, the way that people lose nipple sensation is when surgeons do lateral dissection of the pocket. That is they create a pocket and they dissect too far to the lateral aspect. It's a great way to speed up your operation. Because you can make a room for a quick, quick implant, very large implant by doing that, and it's something that I never do. Because if you go inside and you look in there, you can see those nerves popping up through the muscle and you have to protect them. That's why my loss of nipple sensitivity is very rare. I can count on one hand how many times I’ve, I have had patients lose nipple sensitivity. And these are patients that typically go very large or they’re revision type procedures where there's a lot of work that needs to be done.

So it has actually nothing to do with incision placement. Whether you go periareolar, inframammary, or transaxillary. Transaxillary has the highest risk of loss of nipple sensation because, guess what, you're taking an implant, you're going through the armpit, and you're directly going across where those nerves travel. Right?

So that's why I typically avoid the transaxillary. I can do it. That's why I avoid the transaxillary incision. And I stick to the periareolar or inframammary incision, which you can see in this friendly diagram here. Okay?

So that's nipple sensation. So most people, they don't lose it. But I will tell you this, if you were worried...if nipple sensitivity is the most important thing to you in the world, do not do breast surgery, okay? Because nobody can guarantee that you will keep your nipple sensitivity. In fact, most of my patients, they actually get a hypersensitivity for a while as things heal, and then it goes back down to normal. But, again, you know, this is one of those things that can happen with surgery. So, if it is the most important thing to you, it's very important to you, don't consider breast surgery. Okay, there's pros and cons to everything.

11:55 IMPLANT SIZE

Now how do I determine size? I, I mentioned that briefly. Sizing is, is one of the most challenging things that I do, that I get to do for patients. And it's one of the most difficult things to do right. A lot of us have heard horror stories about...I went to this doctor, I woke up, and I had DD breasts. Or I had, like, 450 cc high-profile implants...I just wanted a B cup. And I feel like those are all true stories. And sadly that happens because there is a disconnect of when the patient talks to the doctor and the doctor is not listening. Or the patient's not clear on their goals and there's a loss of communication. You absolutely have to establish clearly what your goals are. If you don't, if you don't communicate that clearly, you're not going to be certain about what you’re, what your ultimate size is going to be.

The way that I like to do it in my office is a result of tried and tested ways that I've, have kind of evolved over time. When I first opened my practice, I would start to, I started using sizers in the exam rooms. I had patients put their bras on, I would put the sizers in the bra and be, like, okay, 325 looks like it's going to be right for you, go to surgery, put it in. Most of the time it worked, I'd say 80%, 85% of the time, it was kind of in line with what they wanted. But about 15%, 10 to 15% of the time we’d put it in, and I'm like, oh, that's kind of it's kind of too small compared to what we were talking about. And I didn't like that.

So I, I started getting away from that. I've tried computer animation, 3D animation with dedicated photography to simulate breast sizing results with a, there's a, there's a program out there that does that. And that was about the same rate.

And lastly, the third, the third way in which I do now exclusively, is I size patients in the operating room with sizers. So it all starts with the consultation. I get a really good sense of what your goals are. What are you expecting? We do talk about bra sizing, but it’s objective, right? Victoria Secret is different than JCPenney, it's different than Neiman Marcus. So there's no, there's no golden bra sitting in the British Museum, right? They have a kilo, they have a pound, or whatever they have they, actually they're on, they're not on metric. They have, they have the golden pound or whatever it is. And there's no universal guidelines when it comes to bra sizing.

And that's why it's, it's so difficult to talk in terms of bra sizing. I, we, we all get a sense for what a C cup, what a D cup is, and that's why I do talk about it a little bit. But I try to get the conversation away from that. I try to get it to photographs. What are some photos of sizes that you like?

Let's check out ratios of breast width versus shoulder width. Do you want the breast to stick out a little bit outside the chest wall, a lot? You want a lot of sideboob or do you want just a little bit you want to be completely, completely within the chest frame. Okay. Those are some concepts that you have to kind of internalize for what you want for yourself. Because if you can't find photos that really speak to you in terms of what your goals are, how do you expect your surgeon to match it?

Okay, so you, you have to do some soul searching: what do I really want? And I get a lot of patients, they're like, you know what, I, I was told that I should go bigger. And I was like, well, what does that mean? Because there's, there's a point where it's too big. So it's just like, fine. You know what, screw that. Screw that advice because I think it sucks. Spend the time, do your soul searching, do a lot of searching on one day, sleep on it, go back to your top three picks of that previous day. Look at it again. Do one more day, look at it again. You're about to undergo surgery on your body for implants that are gonna last about 10 years. So you want to make sure that you get this right and that you're really happy with it.

It's tough because how do we know what decision to make? I promise all my patients I keep them within natural-looking results. Okay. We do measurements in the office and measurements are important. One of which is we do is called the base width measurement, one of many. And if you measure your chest width right here, okay...I have my tape measure with me, that's that noise. My, my base width is about 17 centimeters. Okay?

So 17 centimeters...I need an implant that's about 17 centimeters wide, in a diameter. So if you were to actually measure the diameter of an implant like this one, for example, is about 13, this implant would be too small for me, okay. One day it’d be over here, the other day it’d be off on the other side. So we need to find an implant that's within a centimeter of whatever your base width is. And that's typically about a 200 cc range. Okay, so that puts us in the ballpark of what you need. And then the remainder we take care of with your photos and sizing in the operating room. So let's take that 325, let's put it in. Your measurements say that you're you know, 325. We think, you know, you kind of want to be in the mid-range in terms of photos. Let's put it in there. Let's see exactly how it looks.

Because sometimes you think you're a size seven in a shoe. You go to the store and you're, you're not, you’re like a seven and a half, right. So shoes you could throw away right, but breast implants? You need another operation if you're not happy with the size. So that's why it's even more important that you do your soul searching on this, your meditation, whatever it is, you know? Figure it out. Because if you find those photos that really speak to you, it makes this process way more effective. And I found it to be the most successful way of getting people the, exactly the size that they want. And that's really important to me. It's not what I think. I customize every, every operation based on my patients and I will make sure that it looks natural. I'm not gonna do something that distorts the natural body or anatomy. But, but there's, there's a range that I can go. I can go on the smaller side or and I can go, I tell people I can go on the bigger side. So it's important to do that, that soul searching, that sizing.

17:45 BREAST ASYMMETRY

And then if you have asymmetry, if you have any breast asymmetry, sizing is a must. Because sometimes people have a 25 cc difference. Sometimes people have a 50 cc difference. And you will only be able to get that right in the operating room.

And sometimes you have breast asymmetry but then there's ribcage elevation is different. And what you think might be a different size, you put in the same size it actually looks better. So, if you see my operations on my social media, DrDanielBarrett.com you will see how I do that sizing on every single operation. It is the most critical part of making sure we get the right size.

18:20 IMPLANT OPTIONS

Okay, so what implant options are there? So I have all these implants out here with me. I'm here in my operating room, on the operating room table that I do a lot of my surgeries...and I've got textured implants, I've got smooth implants, I've got saline implants...and let's talk about each one of them.

Okay, so first decision you want to make is whether you want to go silicone or saline. Silicone is cohesive gel, now. It's called gummy bear. They're all gummy bear. So if you were to cut it, the gel doesn't run off the table and into your body or wherever else. Okay, they're cohesive. They're like gummy bears. They don't rupture very much. They're pretty high-quality devices. And exposed cohesive gel silicone is minimally problematic for your body, okay? So even if there is a rupture is not a huge deal, okay? Your body typically walls it off, and in my opinion these implants are extremely safe. I wouldn't hesitate to use one on a family member, okay.

19:15 SALINE IMPLANTS

You have saline. Saline is, is another option. They are filled with saline and they feel more like water balloons. They don't feel as natural. They don't feel like breast tissue. They have rippling on the sides. If they rupture you know right away. Saline is not really toxic if it leaks into your body at all, but the shell is actually made of silicone. So I get, I don't really see the advantages in terms of using the saline implants other than cost and keeping the incision maybe just a tiny bit smaller. Saline implants typically are a little less expensive. But if you're about to get surgery on your body, why not spend a little extra and get the better looking implant and the more natural-looking implant?  Because saline is, is not, is not the solution there.

So it's been a while since I used saline implants. I just don't think there's any adv...advantages to it. And most of my patients that come here are not bargain, bargain hunters. There's two things you don't want to bargain shop for: parachutes and plastic surgery. Okay guys, so let's put, let's put saline aside.

20:20 SILICONE IMPLANTS

Now, when it comes to silicone implants, we have textured, we have smooth implants. There's been a lot of…I have a whole episode talking about textured implants and the incidence of anaplastic large cell lymphoma. The risk of that in Mentor implants--textured--is about one in 86,000. There's a recall with Allergan textured implants. It’s one in 3,000 risk of anaplastic large cell lymphoma. That's a rare lymphoma that can happen due to bacterial contamination on the textured implants that develops inflammation over time. If you want more information on that, check out my podcast with Dr. Chopra, where we talk all about that, okay? What applications we use textured implants for are for lifts, very heavy lifts, or revisions, okay. The main reason why is because the texture of the implant is very grippy. It stays where you put it. It's great for really challenging cases where you need stability of the implant in the pocket. Okay, and I do get some of these pretty gnarly cases where we, we pray for that stability, right? And we've had several, several people here discussing that, that we've used textured implants. Okay, so you can check out their stories...

21:30 LAURYN EVARTS HAS TEXTURED IMPLANTS

Skinny Confidential, Lauryn Evarts, is very publicly known and she, she had textured implants for that reason. Because she needed stability of her breast pocket after bottoming out, okay? And again, your chances of getting struck by lightning in your lifetime is about one in 3,000. Your chance of getting anaplastic large cell lymphoma, which is treatable by the way, is one in 86,000. Okay, so you have to put those statistics in mind.

21:53 SMOOTH IMPLANTS

Okay, now when it comes to smooth implants, there is shaped implants and there are… Actually, there are shaped implants and there are round implants, whether or not they're smooth or textured. Shaped implants, they're called teardrop implants, because they look like a teardrop. All right. And I first started using these when they first came out, and I thought they were great, but they rotate, okay? When they rotate, they cause problems. They have about a 30% rotation rate. And even if they are textured, and they tend to be firmer, and you tend to lose cleavage in the middle, so I really only felt that the applications for these are for women who have had mastectomies. I don't see the advantages of using these in primary breast augmentation. They were really hot for a while, for...a couple years ago, people thought oh, it must be better because it's shaped like a breast. Well, in reality, it ends up causing more problems, it ends up looking more pronounced on the bottom. Kind of like a boomerang on the bottom and...wasn't very natural. So I kind of stopped using those for primary augmentations. What I do typically, use mostly for primary augmentations is smooth, round implants.

Okay, so let's get textured off the table. Okay, so we're not doing a lift. We're not doing revisions. We're not doing shaped implants because you didn't have a mastectomy. All right? So now we have smooth, round silicone implants. What are the options there? Well, there's two companies, there's three companies out right now, that make implants. There is Mentor and Allergan and there's Sientra. I like to use Mentor implants because I think they have the best warranty. They have a smooth, very soft, pliable texture. They tend to feel a little bit softer than Allergan implants. But all three of those companies are actually really good. And so I don't think you're gonna go wrong.

Where I do like to make a decision though is about the profile of implants. So there's high-profile implants, there's moderate-profile implants, and there's low-profile implants. I don't actually, I, I barely ever use a low-profile. I've used a couple of them and they looked like pancakes...I, I stopped using them because I wasn't doing anybody any favors with a low-profile implant. So I’ve mainly gone from…I mainly actually just use moderate-profile plus for my augmentations because it tends to look more natural.

24:06 IMPLANT PROJECTION

What is projection? What is profile? Profile is the amount of projection for width, right? So think of, like, you know, a skyscraper as a high project...high-profile implant, right? That's very tall, but very narrow. And then think of a moderate-profile implant is kinda like a pyramid, right? Big wide base, some projection, some height. And I like to use, like I said, I like to use moderate-profile for most of my augmentations for a, for a lot of reasons. Because what I found is that using high-profile implants, creates a big gap in the middle, a big cleavage gap. Yes, you get that really nice projection, but that tends to look fake, right? So we don't really want that, we don't want that fake look.

And the other thing is, if you understand physics, force per unit area, how much pressure is going on per square centimeter in the bottom part of this implant? It's much higher on high-profile implant versus a moderate-profile implant has this kind of smooth, gradual hammock on the bottom that evenly distributes that pressure. Okay, so you get much less malposition with moderate-profile implants versus high-profile implants. High-profile implants tend to fall off to the side a lot more, and they don't stay in place.

My biggest revision rate for other people's plastic surgery augmentations are high-profile implants with the inframammary incision, right? Because you’ve just made an incision right where you need that support mechanism of the breast and you put a high-profile cannon right on top of that incision. And guess what, it's going to hammer that incision that opening over two to three years, it'll start to drop, it'll bottom out. How do you know you’re bottomed out? The implant drops and your nipple points to the sky.

Okay, so I, I could actually do a whole episode on implant options, but those are the main things that I like to talk about during the consultation. But we can certainly talk about it more. We'll save that for another episode.

26:00 INCISION TYPE

Now...another question we get...what affects the nipple sensation in terms of incisions? So we talked about that, we talked about the anatomy. There's no difference in periareolar incision and inframammary incision. However, there is a loss, higher loss of nipple sensitivity with the transaxillary incision. You have to just understand the anatomy for, for why that works.

What incision should I use? Now, this is a very hotly debated topic. Okay. There are four main types of incisions. So transaxillary, periareolar incision, inframammary incision and periumbilical incision. Okay. Periumbilical can only used, be used with a saline implant that's why I virtually we never do that. The other three can be used with saline or silicone. Transaxillary is through the armpit, periareolar is on the bottom border of the areola, which is right next to the nipple and inframammary is at the breast crease, okay? The most...in terms of...let's go through the pros and cons of each.

26:55 TRANSAXILLARY INCISION

Transaxillary incision, one of the most noticeable incisions because you can see it if you raise your arm up. It tends to scar badly because the armpit doesn't heal very well. There's a chance for contamination through the armpit. It's not the cleanest place, it's really even hard to get clean during surgery. The implant, if you remember this, the implant likes to come out the way you put it in, right? So if you go through the armpit and you come in laterally, guess where it wants to go over time as you heal? Laterally, right? So you get the most amount of lateral displacement with transaxillary implants. Takes a really good surgeon to do transaxillary augmentations well. Because you have to do everything, all your whole pocket dissection, through the armpit, through an awkward angle, all, all through a tiny little incision. So it can be done. It's just really, really challenging and I see a lot of complications from it. And I do a lot of revisions from transaxillary, okay? So it's not one I recommend.

27:50 INFRAMAMMARY INCISION

Now, let's talk about the next one: inframammary incision. That's an incision that goes on the bottom part of the breast crease, and is probably the most common incision used. In fact, when I first started my practice, I used that exclusively because I felt like it would reduce my risk of capsular contracture. And I thought the incision was, was concealable and it would heal well. Well, welcome to Los Angeles, where there's no, there's very, I mean, there's all types of people here. You know, Fitzpatrick skin types, all types, right? So Fitzpatrick types, one, are, these are the redheads or the Swedish people. They have light skin and blonde hair. And guess what, it doesn't matter really where you make their incision, they're going to heal fine, no matter, no matter what. Majority of my patients have Fitzpatrick two, three, four and five, right? So they are going to have much more noticeable scarring. So if you're going to make an inframammary incision, you have to counsel them and let them know that if they were to wear a bra or bikini, you're going to be able to see that line on the bottom part of the breast.

Okay so, it is not very concealable. Now there has been some studies that show that there's a decreased risk of capsular contracture with inframammary incision. Capsular contracture is a very important thing to understand. We'll get that, and to, get into that in a minute in one of these other questions. It's basically scar tissue formation that can happen around the breast implant that happens due to contamination, and so forth.

So capsular contracture is a big thing that we're trying to prevent with, with all the things that we're doing in surgery. So what I noticed when I started doing the inframammary incision is that scars were way noticeable. Patients weren't happy with it. Bottoming out happened, there's no studies on bottoming out but there should be. That's where implants drop low and they, they fall exactly where they came in, right. If you put an implant from the bottom, guess where it wants to go, wants to go out the way that it came. Okay, so I started studying the periareolar incision, and, and now I use that, I recommend that the most. And again, nobody wants any of these incisions, I'm happy to do them, and I can do them well. But I think the one that has the most advantages is the periareolar.

So how did I address the capsular contracture question? Because there was a significantly higher percentage of capsular contracture with periareolar...

30:10 KELLER FUNNEL

...possibly due to contamination from the breast glandular tissue or the ducts getting on the implants somehow. Well, I was the first person in Beverly Hills to start using the Keller Funnel. You want to make sure any doctor that's doing your breast augmentation is using some kind of funnel device. A funnel protects the implant as it goes into the breast pocket. I do no-touch technique. I irrigate with an antibiotic solution. I get meticulous hemostasis. All these things that help reduce capsular contracture rate.

30:35 CAPSULAR CONTRACTURE

So nationwide, the capsular contracture rate for breast augmentation is about 20%. So one in, I'm sorry, it's about one in 20. So about 5%, Okay? Right now my rate going through periareolar is about one in 100. So I've effectively been able to use periareolar incision, decrease my bottoming out rate, decrease my noticeability of scarring and decrease capsular contracture rate, right? So that's why I recommend the periareolar incision because you have to be completely naked in order to see that incision.

And guess what? Chest wall tissue is not designed to handle trauma, right, your nipple and your areola is much more designed to handle trauma for breastfeeding, right? So it heals predictably better. There's a natural color border that happens in the border the areola with the rest of the breast tissue. That makes it the perfect, perfect concealable location for an augmentation. Okay, I've never had a nipple or areola that was too small to do it. A lot of surgeons like to still do that inframammary incision because they believe that capsular contracture reduction and my hat’s off to them. That's totally fine. I think that's very noble. But, you know, my patients here in Los Angeles with different skin types, it isn't the best concealable option for them and that bottoming out rate is just unacceptable. There should be zero percent of that happening.

So, great, great question. Oh, the other thing. The other sneaky thing about the inframammary incision is that it's faster to do. So surgeons get really easy to, used to doing that inframammary incision because it's super fast to do that augmentation. It's much harder to go through that border of the areola to get that perfect pocket placement, okay? But I do it because I think I get better results from it, and happier patients. All right, good. I feel like I could talk about, all day about incision.

And, but that's, those are some things I talk about during my, my consultation. And, but every, every surgeon is different. And again, if you're going with a board-certified plastic surgeon that does a lot of this and has really good pictures and before and afters, go with what they recommend, okay, but that's just how I do things.

Alright, so, I do want to talk a little bit about capsular contracture because I just briefly mentioned it. Again, it's that scar tissue that forms around the implant. We don't really fully understand why...we have a feeling that it has to do with contamination. But there's some people that, there's probably no contamination that still get capsular contracture. There's some people that are higher risk for it, we don't fully understand it yet. We're definitely studying it. I do about six different things to prevent capsular contracture during my operations. I use the funnel technique and no-touch technique, I change gloves, I get meticulous hemostasis, I irrigate three times with triple antibiotic solution, I re-prep the area with Betadine so that I don't, in case something falls from the air, lands on the access site, that there is very, very little chance of getting contamination during my operations.

33:35 TREATMENT OF CAPSULAR CONTRACTURE

So, what happens if you get capsular contracture? Well, you can treat it medically with a medication called Singular or Accolade. These are, these are basically...they're not antihistamines, but they are kind of allergy medications. They're leukotriene inhibitors that act selectively on certain pathways. So what they found is people that were taking it for their allergies, notices that, noticed that their...if they had capsular contracture that they just didn't want to treat--reduced. So that's where we like, hey, just a heads up, my capture contracture went away.

So that's how we discovered about these medications. So if one of my patients gets capsular contracture, I start them on the Singular or the Accolade to get a reduction of that. And a lot of times that works. If it doesn't, then you need to go back to surgery to get a complete capsulectomy and start over. Now, one of the reasons...

34:25 IMPLANT PLACEMENT

...one of the questions I get is should I go above or below the muscle? Going below the muscle is, by far, one of the best routes to go. Because it looks way more natural for that teardrop look that we just previously talked about. And it also reduces your risk of capsular contracture. The drawback of going underneath the muscle is you get a slight bit of animation deformity when you flex your muscles and that's normal. But most women get used to that and they just, they don't end up, I mean, most women are not out there flexing their pectoralis muscle. It's just not something you would do anyway.

So they kind of get used to that so that they understand what triggers that animation. And then they, they don't do that and they relax, that motion. But hands down their breasts look 10 times better, 10 times more natural than if you were to go above the muscle. There's a few instances where above the muscle makes sense. But most of the time for primary augmentation, you want to go partially underneath the muscle and the dual-plane technique. That's pretty well known at this point.

Now, what is the chance of getting capsular contracture? I told you this nationwide is one in 20, my rate is about one in 100. I'm actively studying this to try to make it zero. I want to make it zero, folks, I don't want people to get capsular contracture. It's the biggest number one complication that I have in my practice, that most plastic surgeons have in their practice. And it should be, we really are trying to eradicate it. Any good plastic surgeon should be doing all of the published things that are out there to help reduce it--funnel, irrigation, changing gloves, all that good stuff. And those are great questions to ask at your consultation.

35:55 BREASTFEEDING

Okay, so breastfeeding. Breastfeeding is a very popular question that I get. Women who are younger, they haven't had kids yet, or they want to have more kids...they're like, does it affect my ability to breastfeed? Now there's, there's a bunch of studies out there about breastfeeding ability. It's important to understand that some women can't breastfeed no matter what you do...and...whether you have implants or not. Some women who've never had implants had difficulty breastfeeding, and they just can't. So women who have had implants and can't breastfeed, they sometimes blame the implants for causing them not to be able to breastfeed. When you actually break down the statistics, and you look at it, breastfeeding ability, statistically, when it was, it was narrowed down, is shown to affect breastfeeding ability anywhere between seven and 15%. And it's important to know anatomically, the implant is sitting underneath the muscle, right? The glandular tissue is above the muscle. So when you, when you think about it anatomically, the implant is farther away from the glandular tissue. A lot of people are worried about is there, is there going to be silicone in my breast milk?

They actually did a study on that too. They found more silicone in women without implants--in their breast milk--than silicone in women with implants. Isn’t that crazy? So it just, it goes to show you that the silicone doesn't really bleed. The old ones way back in the day, 30-40 years ago, did. They had a high bleed-rate, but the newer implants, the studies, the studies do not show that you're actually leaking out silicone or anything like that to potentially contaminate breast milk. So I have no, I have no problems with, with women breastfeeding with implants as long as they’re recent implants and they're not old and they're not ruptured, okay?

So, what…let’s see. One more thing I wanted to tell you about breastfeeding, is...same thing with nipple sensitivity. If breastfeeding is the most important thing to you in the world, it's very important, don't do breast surgery, okay? Because, yes, there is a statistical significance of seven to 15% of women report difficulty breastfeeding with implants, okay? So it's very important that you, you weigh that risk. It doesn't prevent you most, most of the time, but if it's a really important thing for you to do. Don't do breast surgery. Okay?

38:14 IMPLANT PLACEMENT

Now my route for, for placing implants is very protective of the glandular tissue, I kind of skate around it when I make my incision. I'm not going behind the areola, I’m not going behind the nipple ducts. Breastfeeding is very important to my family. And that's the last thing I want to do is set my patients up for higher risk of difficulty breastfeeding. So anatomically, my surgical route I try to avoid all the glandular tissue. Okay, but I can only tell you statistics nationwide. I don't have statistics on my own patients and their ability to breastfeed. I just don't have the numbers. Okay? All right. Moving on.

38:45 IMPLANT EXCHANGE

When should I have my implants exchanged? We recommend 10 years, okay? Rupture rate stays pretty baseline until about 10 years and then it goes up exponentially. It’s like driving on tires that are meant for 50,000 miles but you're driving on 55,000 miles or 60,000 miles, okay? You probably can get away with it but you don't want to risk it.

39:05 IMPLANTS AND BREAST SAGGING

Will my implants make my breasts sag over time? Yes and no. Statistically speaking, if you go up to 400 cc's, they don't really create a problem with sagging until you go over 400 cc's and then complications for breast sagginess start to develop, okay? So, my recommendation is I try to keep people 400 cc's or lower because the statistics say that over 400 cc's you start to run into problems with that. I mean it may make sense. Implants are not very heavy, but at a certain size, they are going to have an impact, especially if you're smaller framed. You want to keep within natural portions of your body, keep within that one centimeter of your base width so that you avoid excessive weight on your breasts over time.

39:50 IMPLANTS AND CANCER

Do breast implants cause cancer? The answer to that is no. It does not cause breast cancer. This has been well studied. There's been plenty of people that are trying to badmouth implants over the past 50 years, okay? And everybody wants to demonize them because of vanity and whatnot, and to each his own, but what they've never been able to show, and trust me they've tried, do implants cause breast cancer? No, they don't. Sadly, women, one in six women get breast cancer for all kinds of reasons, but none of which are because of implants--silicone or saline. The one thing they did find was that association with anaplastic large cell lymphoma, which is not breast cancer. It is a lymphoma of the lymphatic system. It’s a can, a cancer of the lymphatic system that develops because of textured implants. And again, that risk is very, very low--one in 3,000 for the Allergan bio cell implants which are recalled now, and one in 86,000 for Mentor siltex implants. They're completely safe otherwise.

So I actually had a couple, couple questions from a consult today. And she was asking about breast implant illness. And I have a whole podcast with Dr. Chopra about breast implant illness. And I go into more detail about that. So breast implant illness, I think is a real thing, I think it's pretty rare. Majority, 99% of the population are perfectly fine with implants, they don't have any problems. And implants are life-changing and game-changers for a lot of women and confidence boosters. So there's, there's more to be done on breast implant illness. Check out my podcast with Dr. Ritu Chopra, where we dive into it more where we're actually trying to look and get statistics on breast implant illness.

There is a lot of websites out there that talk about breast implant illness and these are women that have real symptoms and real concerns, and it's definitely valid. But you have to understand this is a small fraction of people that get breast implants, it’s not everybody.

41:39 FAT TRANSFER

Other options besides breast implants are fat grafting, okay? You can do liposuction in one area and then transfer the fat to the breast, instead of an implant. The problem with that is fat’s unpredictable. It waxes and wanes with body weight, and how much fat takes is totally variable. Okay, so we lose anywhere from 30 to 50% of the fat that we transfer to breasts. And, at most, I get about a half cup size improvement typically with breast fat transfer. My home runs I get about a full cup size, but those are rare. So I, I have to caution people that if you really want to do the fat transfer route it might take more than one, or two, or three fat grafting sessions to get you to that size that you want. And if you're not looking for that, an implant is a perfectly good option. Okay?

42:25 CHRONIC INFLAMMATION

Does having implants create chronic inflammation? Again, if they're contaminated, if you have a low-grade infection in there, that's why we do all this stuff to prevent, to have sterility…probably not. But again this is, this goes back to the breast implant illness question and we're actually trying to, to dive into further. For the majority of people, no. When we do surgeries to swap them out their, their capsules are paper thin. There's no reactivity going on locally in the breast tissue.

42:50 IS SALINE SAFER THAN SILICONE?

Is saline safer than silicone? Again, not, not necessarily, right? Because that shell of that saline implant is silicone. So what are you really saving yourself? Yeah, if it ruptures, you just get saline in your body, you're not going to get that cohesive gel. But that cohesive gel is much more cohesive than before, so, so that it doesn't actually run through your body. So it, it's much more localized if, if you were to get a rupture.

43:18 RECOVERY PERIOD

What is the recovery period like? Well, I tell people for breast augmentation, it's about three days of solid downtime. Probably want to take a week off from work depending on what you want to do. No heavy lifting for six weeks. My exercise regimen for after breast augmentation is as follows: walking right away, I want you walking those first two weeks, getting the blood moving, circulation. But not getting your heart pumping to the point where you're out of breath. Okay, that happens at two weeks. You can start to do cardio, you can start to do exercise that starts to pump, pump your heart at two weeks. At four weeks, you can do jogging where it's a bouncing movements, and at six weeks, you can get back to heavy lifting and lifting things and using upper body workouts, yoga, pilates and stuff like that. That's my, that's my recovery protocol. Now everybody's different. So I tell people to use their body as a guide. If something hurts, don't push through it, just let it heal, take a day or two off and then get back to it.

44:12 CRAZY REACTIONS TO THE SURGERY

Okay...has anyone had a crazy reaction to the surgery? Anesthesia is extremely safe, okay? You're more likely to be struck by lightning than have a problem with anesthesia. I think the risks are like one in a million for a major adverse outcome for anesthesia, like death or major debilitation. So you're more likely to get in a plane crash, car crash on your way to consultation versus getting any problem with anesthesia. It's extremely safe. The monitoring we do here in ambulatory surgery center, fully-accredited surgery center, board-certified plastic surgeons is the same level, if not more, of what you would get in a hospital. Okay, so we don't cut corners when it comes to safety. We've got a perfect, perfect safety rating. And you want to find out does your surgeon operates in an ambulatory surgery center? Or do they try to do this in their office?

If they try to do this in their office under local, chances are they're not board-certified. I don't know any board-certified surgeon that tries to do this under local. It is just a way too painful of operation to try to do under local. These people are kind of scams and watch out for them. Make sure that they're doing it in fully-accredited surgery centers using general anesthesia. It's really the safest and most comfortable way to go.

45:17 CRAZY REACTION TO IMPLANTS

Has anyone had a crazy reaction to the implant itself? No. These implants are mostly inert. You know, if you think about the hip and joint replacements that people get in their bodies, there's way more toxic stuff out there that's, that's going on. Implants are pretty inert substances...products that are proven safe by the FDA. Countless, countless studies, okay?

45:36 MOST COMMON COMPLICATIONS

What are some of the most common complications for breast implants? We talked about the number one is capsular contracture, okay? That's, for me, it's, like, it's about 1%. Just underneath that I've got hematomas. So patients that do heavy lifting or push-ups right after...or handstands. I had a patient, this is crazy...She did a handstand literally the, the same day of her breast surgery. Got a bleeder--a hematoma. If that happens it’s no big deal. It's all self contained, right? But you have to go back to surgery to get that blood out.

Okay, get the blood out, stop the bleeder, put the implant back in. It’s a double surgery. So you basically want to make sure you follow your guidelines. It can also happen without any particular rationale. If your heart rate goes up, or there's just something that wasn't bleeding during surgery and then started bleeding afterwards. It's a known complication. Infection is also a possibility. You want to make sure your surgeon gives you perioperative antibiotics. But infection can happen. Knock on wood, I've never had it. I've never had a full-on, blown breast implant infection. I’ve had some local superficial stuff. Bad scarring can happen--depends on your skin type. If you're a natural keloid former we gotta do certain things to make sure that you don't heal with thick scars or keloids. And implant rupture can happen. It's pretty rare, right at the time of surgery, but it, but it can happen. And I’m trying to think else...wound breakdown and seroma can also happen. Those are, those are much less common...less common, especially with breast augmentation.

47:05 WHAT IS THE PROCEDURE LIKE?

What is the procedure like? Well, you show up, we try to make the process as painless as possible. Not only am I trying to perfect the surgery, you're trying to make, the process here very smooth and effective. And that's why I say when you're finding that surgeon, make sure you talk to a real live person on the phone. You want to come in, you don't want to wait for your appointments too long. Literally, within 15 minutes we try to get everybody in here.

I try to treat everybody how I would want to be treated and that's how I designed this whole practice for people. So we're not wasting anybody's time. Okay, you come in the day of surgery, you get into a gown, you pee on a stick, make sure you're not pregnant. By this point, you've already had your labs done. You've been through, you know, we've talked about photos, and we've, we've done a consult and everything like that. And I do some markings in the preoperative area that help guide me during the operation. We go over your photos again, we go over everything else again, post- and pre-op instructions. Repetition is key. Then you meet with the anesthesiologist and you, kind of, go over the anesthesia plan. We bring you back to the operating room, which is right here where I'm sitting.

And ...obviously, we do a terminal clean after we do these podcasts here. But you come in, you relax, we give you, start an IV, and literally once we get the IV, you are comfortable. And by the way, our anesthesiologists use numbing medicine for the IV so even if you're nervous about that, there's a tiny little, a tiny little bit of numbing medicine we put on there and so you don't even feel the IV going in and you get some medication that will help you relax, and then the surgery starts.

The surgery starts with me confirming my markings, making sure that everything is completely sterile and numbing the entire area. I do three specific nerve blocks, I do the incision, I do the medial chest nerves and I do the lateral chest nerves. So all the nerves that are going to the breast for sensation, I do nerve blocks on. And that way when you wake up, you just have a little bit of pressure from the, from the implant itself. You're not feeling very much pain. I also put a lot of numbing medicine inside the breast pocket, which you could see at some of my live surgery videos. I’m really careful, because, like, who wants to wake up with pain? A lot of people are worried about that. I want to take that away from people. Most of my patients, they wake up with a little bit of pressure.

So I do the surgery. Again, most of my time is spent dissecting the perfect pocket...sizing. I sit you up, check out sizers, compare to your photos, make sure we go up or down and correct any asymmetries at the time. We do our five layer, we get the permanent implant there with all the six different things we do to prevent capsular contracture. We do our five layer closure, we cover with steri strips, we gently wake you up, clean you up. That's a big thing. I hate it when patients wake up and they have Betadine or prep all over them. I get you cleaned up.

And then we get you to recovery and we're keeping you warm the entire time. I use normothermic pads on, on the bottom of the operating room table. And we use Bair Huggers in the recovery areas to keep you warm the entire time. Because what happens when you get anesthesia, your body can't thermo regulate. So we, we control your body temperature very precisely during the operation. And a lot of places don't do that. I even got fancy IV warmers. So the IV fluid is exactly your body temperature, okay? That's a big thing to help prevent wound infections too, by the way, but also, it makes you feel really comfortable so you don't wake up shivering after the operation.

Then you wake up, you recover in recovery for about an hour or so. Make sure that you're comfortable. And then we get you home. And you can go home right away or you can stay at an aftercare facility or have a nurse take you to your hotel room. And I don't like prescribing Norcos or opioids for my patients. I do, but I recommend most of my patients take ibuprofen or Arnica after their, after their procedure. Most of them do not need to have opioids because of all the pain blocks that we do in the nerve blocks, okay?

All right, so we are getting down here...recovery time, we talked about it. Three days solid downtime, seven days relative recovery time, six weeks return to full activity. And if you do have children, you don't want to lift them up for that first six weeks.

51:00 VISITING PATIENTS

If you come to visit me out from various locations, different country, different state, I like to have you here for at least five days so that we can get your first layer of stitches out. I, if I can, a second post-op visit is great. And I always tell people, if you come out to see me, plan for an unexpected problem, that you might have to come out one more time, for us to take care of a particular complication. Because if you, if you plan only for one visit, and something happens where you need to come back out again, then, and you didn't plan for that, then you're kind of, you're kind of bummed, if that happens. Majority of my patients, they go home, we follow up on Skype, and we don't have any issues with that.

Okay, you guys so we got through all these 30 questions. And if you guys have more questions, check out my website BreastsByBarrett.com. I've got a lot of myths. I got a lot of before and afters up there. For more, for more information about that...also if you are on my YouTube, feel free to leave your comments, questions, feedback right here on my YouTube page. And don't forget to subscribe if you want to see more videos like this. And obviously if you're on the podcast, you can shoot us an email: info@barrettplasticsurgery.

If you have any questions about breast augmentation, breast augmentation consultation or setting one up, you can email us or you can also give us a call 310-598-2648. You guys, thank you for listening to this. I know it was a lot of information. You can play it back on slow so you can get all the details and all the information that you need for your breast augmentation surgery. And good luck.

Thank you for tuning into our podcast. If you liked today's podcast, don't forget to share rate, review and subscribe. Join us every Monday at 10 am for upcoming episodes. Also, find out if plastic surgery is right for you by using our virtual consultation. See you soon.

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