Blog — Notes of a Plastic Surgeon

Welcome to my blog. I am a plastic surgeon in Seattle and have been in private practice since 1991. I've seen more than a few interesting faces and cases through my years spent in the exam room, the operating room and the emergency room. And I have an opinion on just about everything relating to plastic surgery (and a lot of unrelated stuff). If you like my blog, let me know. Thanks for reading! Lisa

Category: Breast Implant Illness


Breast Implant Illness Fear Mongering

May 23rd, 2017 — 10:01am

I came across a post on the Breast Implant Illness Instagram site recently that really made me really cranky.  And it made me want to holler, “STOP THE FEAR MONGERING!”

Let me walk you through this image.  Obviously it is a lady and in the upper left corner you can see her breasts which have been removed and placed on a serving tray.  Um, very edgy.  And you can see the chest width slash across her chest where her breasts used to be.

The Breast Implant Illness community is on a mission to ban all breast implants, saline and gel, for enhancement and for reconstruction.  Their modus operandi is to scare the bejesus out of anyone who has breast implants, has had breast implants or is thinking about getting breast implants.  I find their IG posts mostly rather boring especially when it is the same set of moldy and/or ruptured implants that have been posted half a dozen times already.  But this post really crosses the line.  This post implies that breast implant removal requires a double mastectomy and an incision across the width of the chest.  I have been doing breast implant removal for over 26 years and I have never, make that NEVER had to do a mastectomy or use an incision of this length.  And most of my patients look better after parting ways with their implants.  I see ladies in my office frequently with old, hard, nasty implants who have suffered with pain and tightness and embarrassment for years but have been fearful to seek implant removal because they equate implant removal with mastectomy. Disinformation like this IG post feeds that fear and is a disservice to women.

Posting this sort of rubbish must provide a certain type of person with a feeling of satisfaction and self worth.  As for me, I prefer to satisfy myself by providing careful, competent and reality based care for women seeking breast implant removal.  If you want to see what breast implant removal really entails, I have a ton of information on this web site and also my IG:  @breastimplantsanity.

Thanks for reading.  Dr. Lisa Lynn Sowder

Breast Implant Illness, Breast Implant Removal, Breast Implants, This Makes Me Cranky.

Louis Pasteur and why you shouldn’t worry too much about mold or fungus in saline breast implants.

April 25th, 2017 — 9:49am

Louis Pasteur in his lab.

I have had a lot of questions lately about mold and fungus in saline implants. I have even read online that some people think intact sterile saline breast implants can somehow get filled with germs.  When I read stuff like that my thoughts go to the great French Scientist Louis Pasteur and your thoughts should too.   Pasteur contributed many, many great inventions and discoveries.  If you drink milk or wine, you can thank Pasteur for the safety of those two nourishing beverages.  If you and your children benefit from vaccinations, you can thank him for that too.  If you have pondered the deeper meaning of stereoisomers in your organic chemistry class, thank Louis.

But enough about that stuff and lets talk saline breast implants. One of Pasteur’s greatest contributions was the debunking of the myth of spontaneous generation.  You see, way back then before microscopes, microbes could not be seen.  When something would ferment or rot or putrefy or suppurate (I’m making myself a little sick), it was believed that the agent of this process just materialized from, well, nothing. The noxious effluvia that generated the aforementioned conditions was referred to as miasma.

In a series of really elegant experiments using some custom made glass vessels, Pasteur showed that a liquid rendered sterile by heating would remain sterile unless it came into contact with something that had not been sterilized.  The infectious agent had to exist in the environment.  It just did not spontaneously generate.  He figured all of this out before even seeing those nasty little germs under a microscope.  Very smart guy.

So what does this have to do with mold, fungus or bacteria in saline breast implants?  Every reasonable implant surgeon on the planet uses a closed system to fill an implant. The saline that goes into the implant comes from a bag of sterile saline for intravenous use into a sterile length of IV tubing and into the sterile implant.  The saline is never exposed to the air which can harbor spores and other creepy things we cannot see with the naked eye.  No contamination means the saline in the implants stays sterile.

What about the implant pocket?  We know that bacteria are present in cases of capsular contracture.  The current working theory of capsular contracture is that it is an inflammatory response caused by biofilm caused by certain types of bacteria.  One type of biofilm causing bacteria, Staph epidermis, is ubiquitous.  A conscientious surgeon does everything he/she can to help minimize the exposure to the implant to the environment, including the patient’s skin, prior to insertion.  Another type of bacteria could be one cause of the very creepy BIA-ALCL and again a conscientious surgeon will use techniques to minimize contamination.   So yes, we know the breast is not a perfectly sterile environment.  The more we learn about the microbiome that is us the more we realize that healthy people co-exists with a lot of “germs”.  If the presence of a microorganism meant illness, we would all be at death’s doorstep.  In fact, our mitochondria (tiny organelles in our cells that generate energy) are likely the descendants of bacteria that some single celled organism co-opted.  God, I love cell biology.  Don’t you?

What about saline implants that leak from a tear or from the fill valve?   Could microorganisms creep in there?  Yes they could but they will need something to eat.  Normal saline, which is used to fill saline implants has no energy source. Those microorganism are going to go pretty hungry.  I am aware that here are some really weird life forms that seem to exist in the most hostile and unnourishing environments – bubbling mud pots in Yellowstone, deep ocean sulfuric steam vents, etc – but me thinks that those critters aren’t going to show up in a beast implant.

I have taken out a bajillion old saline implants and, I swear on a stack of plastic surgeon journals, have never seen one that was contaminated with fungus.  I have seen a few with little floaters that I cannot explain.  When I’ve sent the saline in such implants, the cultures have come back no growth.  What does that mean?  I don’t know.  There I said it:  I don’t know.  Could a little speck of something floating around in an intact saline implant destroy a person’s health?.  I don’t know but it seems unlikely to me unless that little speck was Polonium-210.

I have had a quite a few breast implant illness patients who were absolutely bummed that their implants were not contaminated because they had become convinced that they were.  Yes, I have seen photos of really nasty and moldy implants out there in cyberspace and yes it is obvious that some implants are contaminated and that there are unreasonable surgeons who don’t used a closed system but I think those cases are rare. Nobody posts photos of old, pristine saline implants (except me on my Instagram @breastimplantsanity).  Pristine saline implants are boring.  And I promise, cross my heart, if I take out a nasty implant filled with fungus balls, I will let you know.

Soooo, if you think your implants are moldy, you could be but probably are not right.   But as anyone who knows my practice, I will take implants out for any reason.

Thanks for reading and you should read up on Louis Pasteur.  The contributions he made to science are nothing short of amazing.  Dr. Lisa Lynn Sowder

I would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.

Breast Contouring, Breast Implant Illness, Breast Implant Removal, Breast Implants, Stuff I love

Breast Implant Illness – a seasoned plastic surgeon’s humble opinion. Updated October, 2017.

February 28th, 2017 — 2:24pm
worried_1375864c

“This stuff online just scares me to death.”

Warning:  This is a long one.  A really, really long one.

I recently counted up all of my operations for 2016 and I removed more breast implants than I put in.  Last year I removed implants from 44 women. Twenty-seven of those women had removal for the usual reasons:  “I don’t like them anymore, they make me look fat, they are too hard, I finally divorced that s.o.b., I’m becoming a nun, etc.”  But 17 women had breast implant removal because they believed their implants were ruining their health.  I have gotten to know these patients (and many more from prior years) and their families, have heard their concerns, looked at their medical histories, examined them and removed their implants.

I have given this topic of breast implant illness a lot of investigation and thought.  This blog represents my opinion based of what I have read, what I have heard from patients and my colleagues, what I have seen in the exam room and OR in over 25+ years of practice.  I recently presented a paper on breast implant illness for the Northwest Society of Plastic Surgeons.

A very brief history:  Back in the early 1990’s, just when I was entering private practice, silicone gel breast implants came under intense fire for being linked with health problems, notably autoimmune diseases like lupus and rheumatoid arthritis.  This concern led to silicone gel implants being taken off the market in the United States for cosmetic purposes.  It also lead to large amounts of money finding its way into the pockets of trial attorneys, the bankruptcy of silicone supplier Dow Corning, and at least one case of a woman removing her own implants with a razor blade in a fit of anxiety.  This moratorium on gel implants lasted well over a decade.  For over ten years, the only gel implants I used were used in one of the several studies of gel implants in which I was an investigator.  Finally, in late 2006, after exhaustive analysis of many implant studies, gel implants were again approved by the F.D.A. for cosmetic use.  Interestingly gel implants remained available for post-mastectomy reconstructive use during the moratorium.  I always thought it was odd that the it was okay for patients with a history of breast cancer to have the same silicone gel implants that were deemed too risky for a healthy woman.  And I thought it was odd that the FDA was not recommending the removal of implants that were deemed unsafe for use.    So did breast cancer survivor and congresswoman Marilyn Lloyd who asked in 1992, “How scientific is the FDA’s decision that no woman should have implants put in, and no woman should have them removed?”  Good question.

Fast forward to the past few years and I start seeing women with implants who are convinced their implants are ruining their health.  About 1/3 of them have saline implants which were never taken off the market.  These breast implant illness ladies tend to be a little younger than my average breast implant removal patients.  They tend to embrace alternative medicine and distrust the medical establishment.  And they are all connected to the online breast implant illness community.  And another thing I find so odd – some ladies with all of these symptoms often look so healthy and they ask questions like “When can I go back to teaching Pilates?”,  “Can I hike the Appalachian trail two months after surgery?”, “Is it okay if I go snowboarding after a couple of weeks?”.

Many of the symptoms of breast implant illness are a vague and/or very common complaints.  Most of these symptoms have significant overlap with the most common complaints related to common health issues including menopause, hypothyroidism, depression, anxiety, general aging and the human condition.  And some patients blame conditions with very clear etiology on their implants.  A few examples include plantar fasciitis (an overuse injury of the foot seen in runners and dancers), chronic Epstein-Barr virus (cause by a ….. virus!), Lyme disease (a tick-borne bacterial infection) and dental cavities (caused by the acid produced by sugar loving bacteria).    And then there are the fringe disorders such as leaky bowel, chronic candidiasis, multiple chemical sensitivity, etc.  To quote the very smart Dr. Marcia Angell, former editor of The New England Journal of Medicine: “These much discussed but elusive disorders remain entirely speculative …. they are variously said to consist of just about every symptom imaginable in biologically improbable and shifting combinations.  Since they have yet to be objectively and consistently defined, it is impossible to study whether they have anything to do with breast implants.”  For some really good reading and a wonderful primer on the scientific method and statistical analysis by Dr. Angell, you should really check out her book:  Science on Trial:  The Clash of Medical Evidence and the Law in Breast Implant Cases by Dr. Marcia Angell This book is a decade old but its lessons are very timely.

If a patient goes to enough alternative health providers, they will eventually find one willing to take their money to tell them that they have one, two or more of these disorders and that it’s their implants that are at fault.  They may even offer $50,000 worth of testing and treatment (as reported by one of my plastic surgery colleagues). I have one patent who saw seven naturopaths before she found one who told her what she wanted to hear. Did she ever go at an actual rheumatologist for her autoimmune symptoms?  Of course not.  She could not trust a rheumatologist.  I have patients who pay hundreds of dollars for hyperbaric oxygen treatment that does not involved a pressurized capsule.  Ladies, if you are sitting in a room without an airlock you, are not getting hyperbaric oxygen!   Several months ago I saw a middle aged lady who after reading one of the breast implant illness websites was worried that her implants were causing her sleep disturbance, brain fog, low energy and general feeling of malaise.  Then she told me that those symptoms had recently resolved.  Upon further questioning, she told me her primary care doctor had diagnosed depression and had put her on an SSRI.  After a week or so on medication, she was feeling so much better.  And her implants not only looked fine, they looked great!  This lady did not have breast implant illness.  She had depression.  She needed medication and a boost in her seratonin, not an operation.  Oh, and then a few weeks ago my nurse took a call from a lady who was in a panic about needing her 10+ year old implants removed the next day before they killed her.  I was scrubbed in the OR and could not talk to her.  My nurse explained that she would need to come in for a consultation and that it may be a few weeks before I had the OR time to do her surgery.  She berated me, my nurse, the universe and then hung up before we could get contact information on her.  I have no idea what has happened to her but whoever in the BII community scared her silly about her breast implants did not do her a favor.

I regularly visit some of these breast implant illness websites and Facebook groups and Instagram and to be very honest, I find so much of the content just outrageous.  Several of my patients noted the onset of their breast implant illness after stumbling into one of the breast implant illness communities.  Is this the nocebo effect (the placebo effect’s evil twin a.k.a. the power of negative thinking)?  Maybe.  One thing I find very interesting is the number of women who have their implants removed and still feel ill months and years later.   Do they think that maybe their problems were perhaps not related to their implants?  No, they are told that even after removal of the implants and scar tissue, the fact that they ever had implants condemns them to a life of ill health as if implants somehow have thrown a biological switch from healthy to sick.  Some of these posts are just heartbreaking to read. And most of the advice being given by non-physicians has no basis in reality based medicine.  And then there is the dismissal of surgeons like me who spent their youth training in medicine and surgery (I completed my residency training at the tender age of 35), took the Hippocratic Oath and devote most of their waking hours doing their best to provide competent and conscientious care to patients.  I take it a little personally when someone is more receptive to the advice or opinion of someone on Facebook who posts photos of themselves having a coffee enema that to the advice of a fully trained and experienced plastic surgeon.  And then there are those who feel that banning breast implants and denying their access to women who either want to enhance or rebuild their breasts is somehow empowering.  Give me a break.  I get cranky just thinking about it.

Do I think breast implants can cause problems?  Oh yeah.  For a small number of unlucky patients, breast implants can be a mess.  Although implant construction has improved over the years, implants can still get hard, they can become too loose, too tight, too low, too high, too medial, too lateral, too anything.  They can develop thick scar capsules that can cause distortion and cause pain in the breast, chest wall, upper extremities, neck and back.  Implants can leak which will deflate a saline implant.  A leak or rupture of a gel implant can result in silicone granulomas of the breast and even the chest and abdominal wall.  And then there is the more recent worry of ALCL which is looking like it occurs exclusively with textured implants but the jury is still out on that one.  I sometimes see patients who have had 3, 4 or more operations related to implant problems.  And yes, I am the original surgeon on a couple of them.  And yes, if a woman has breast implants she will likely need an implant related procedure sometime in the future.  And one more thing – IMO the bigger the implants, the bigger the problems.  That’s why you don’t see any large casaba melons in my photo gallery!  And you will also see a lot of non implant breast surgery in my photo gallery.  If I can make a breast look nice without an implant, I will encourage the no-implant route.

Do my implant removal patients feel better after removal?   Most, but not all of them, do feel better.  One interesting finding in almost all of my breast implant illness patients is a tight implant capsule.  Sometimes it is very thin and fragile and sometimes it is thick and even calcified but they are always really, really tight.  That tight scar tissue can cause discomfort that can include the entire upper extremity, chest, back and even the neck.  Removal of the scar tissue capsule (a procedure called a capsulectomy) will often result in a lot of relief.  Sometimes in surgery, I think I can hear the pectoralis major muscle breath a sigh of relief as I remove the tight scar tissue.   Also, capsule formation is an inflammatory process and we all know that inflammation is the new bogeyman.  And then there is the placebo effect.  I have a deep belief and deep respect for the mind–body connection.  Some patients fret every day about their implant’s effect on their health.  After removal, they often report just feeling better all over.  Is it that they don’t have the constant worry anymore or something else?  I really don’t know.  I can never guarantee what effect breast implant removal will have on a patient’s health.  I think many of my breast implant illness patients are worried sick and if the object of their worry – breast implants- can be removed, I am happy to do that.   I will also go after every bit of the scar tissue around the implants if it is safe to do so.  And, if the breast tissue is healthy enough, I will do a breast lift at the same time if it will improve the appearance of the breast.  And there’s more!  I will consider doing fat transfer a few months later if the patient wants a little volume back and has some good donor fat.  And I have to say, I just love sending patients on their way to an implant-free rest of their lives with no worries about the need for further implant related surgery. I call this “graduation” from breast implants.

If you are looking for a careful and conscientious surgeon who will remove your implants and capsules and offer non-implant options to enhance your breast appearance, I’m your gal.  Come see me!  If you are looking for a surgeon who believes that breast implant surgery destroys women’s health, I am not your gal.  And really, would I use breast implants if my implant patients came crawling back to my office sick?

So, if you want your implants out for any reason, come on in.  I will  listen to your concerns and answer your questions to the best of my ability.  I’m not Marcus Welby but for a surgeon, I am really pretty nice (at least that what I have heard).

Wow, this was a long one.  Thanks for reading!   Dr. Lisa Lynn Sowder

If you want to follow me on Instagram, I would be honored.  Look for me at @breastimplantsanity. and @sowdermd.

 

 

Breast Implant Illness, Breast Implant Removal, Breast Implants, General Health, This Makes Me Cranky.

Placebo and Nocebo Effect : The Power of Positive and Negative Thinking

February 6th, 2017 — 12:18pm

The Placebo Effect and its evil twin, the Nocebo Effect.

I’ve been doing some interesting reading lately on the mind/body connection in preparation for a presentation I am giving at the annual meeting of the Northwest Society of Plastic Surgeons this month.  I have been reading up on the “Nocebo Effect” which is the evil twin of the much studied and celebrated “Placebo Effect.”  Any one who has kissed a child’s owie is well acquainted with the placebo effect.

The nocebo effect is a more recently studied phenomenon.  One nocebo effect study involved giving a fake lactose solution to a group of participants which included lactose tolerant and lactose intolerant individuals.  44% of the lactose intolerant and 26% of the lactose tolerant reported gastrointestinal distress after ingesting the sham lactose.  The study participants were told that the solution was know to cause gastrointestinal symptoms.   The nocebo effect can be disruptive when it comes to new drug trials.  In some cases almost 10% of the participants in the placebo arms of clinical trials have to drop the study because of adverse effects.  I have come to view the nocebo effect as the Power of Negative Thinking.  We humans are very susceptible to suggestion.

I had a patient recently who came in for removal of her surgical drains after a breast reduction.  She was just a nervous wreck and was clearly bracing herself for the most painful thing ever.  I asked her about her anxiety and she told me she had seen a YouTube video of a young man who had had a gynecomastia procedure getting his drains removed.  He apparently was howling like an injured wolf.  He must have either had a very low pain threshold or maybe he was a drama student?   Anyway, while chatting with my patient, I slipped out her first drain in about 3 seconds.   Then I slipped out the other one.  She was pleasantly surprised at how quick and easy it was.  Yes, it stung a little but no need for howling.  The howling wolf video she saw was the nocebo effect at work.  The nocebo effect is one reason I implore my patient to avoid surgery horror stories before and after their procedures.  For every horror story out there are likely 10,000 undocumented stories of uneventful surgery and recovery.  But uneventful isn’t nearly as interesting as a howling wolf.

Thanks for reading and beware the nocebo effect.   Dr. Lisa Lynn Sowder.

 

 

Breast Implant Illness, General Health, Now That's a Little Weird, Postoperative Care

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