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 Implants


En Bloc Resection of Breast Implants and Capsules

April 2nd, 2019 — 9:20am

I get a lot of requests from breast implant illness patients to do an en bloc resection of their implants and the surrounding implant capsule.  The term en bloc refers to a procedure that removes the structure in question in one piece or all together.  This term is used most commonly in cancer surgery where a tumor is removed in its entirety without actually cutting into the tumor itself.  Except in cases of BIA-ALCL, implant capsules are not cancer.

The photo below shows an en bloc resection of two ruptured breast implants and the surrounding capsule.  In cases like this, doing an en bloc makes a lot of sense in that it prevents any spillage of silicone and makes for a much cleaner explant.  Fortunately it is cases like this where an en bloc is usually doable.  The thick, nasty and calcified capsule often just peels away from the adjacent breast tissue, muscle and chest wall without causing any collateral damage.  Doing a clean and slick case like this is what surgeons live for and believe me, I wish every explant would go just like this!

But……….it is not always possible to do an en bloc resection.   Sometimes the capsule is very, very thin and fragile (sort of like a wet Kleenex) and it is not possible remove it unbroken.  Sometimes the capsule is very adherent to adjacent structures such as breast tissue, ribs and chest muscle.  It is just not worth the damage to those normal structures to get an en bloc resection.  Sometimes, with implants under the muscle, the patient is at risk for a collapsed lung when trying to peel a very adherent capsule from the rib cage. In cases like this, the capsule can be removed with curettage.  And sometimes, with really large implants or those put in though the axilla (arm pit), the upper part of the capsule cannot be visualized with the implant in the way.  And if I cannot see it, I will not cut it.  In those cases, I remove the implant and then am able to safely remove the capsule.  I am very careful about minimizing or, in most cases, eliminating spillage of any leaking gel.bessss

 

I am aware that the breast implant illness community is obsessed with en bloc capsulectomy.  I’m not sure why because for clean, intact implants, there is no compelling reason to do an en bloc, except maybe to show off and promote oneself, and yes, I am guilty of that!   Many patients are lead to believe that there is some sort of evil humor or miasma that exists in the space between the intact and clean implant and capsule.  The space (which is actually what we call a potential space because it contains nothing) contains nothing!

It is really easy to pontificate for a potentially dangerous procedure when one has zero responsibility for any downside.  Who is responsible for harm to the patient – the surgeon holding the sharp instruments or the social media pundit?

And I am also aware that there are surgeons out there who guarantee an en bloc, every implant, every time.  I honesty don’t know how they can.  I also provide a guarantee… I’ll do my best.

Thanks for reading!  Dr. Lisa Lynn Sowder

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

Breast Implant Illness, Breast Implant Removal, Breast Implants, Patient Safety, Plastic Surgery

What does this plastic surgeon really think about breast implants?

March 27th, 2019 — 3:59pm

On Monday I testified in front of the FDA General and Plastic and Surgery Devices Advisory Committee on breast implant safety.  I think I surprised a lot of people in the room when I stated that I wasn’t crazy about breast implants.  Let me clarify a bit.

For the flat chest woman who could be mistaken for a boy with gynecomastia or a pubescent girl, and who does not have enough available fat for fat transfer, breast implants can be beneficial. Ditto for women who have a significant breast asymmetry or tuberous breast deformity that cannot be significantly improved without implants.  And some women with a pear shape (big hips and thighs and a narrow chest and small breasts), implants can add balance and be very beneficial.  Also, for women who have experienced deflation after pregnancy and nursing or after major weight loss, breast implants can restore volume to an extent that fat transfer usually cannot.  For mastectomy patients who are not good candidates for autologous reconstruction, implant based reconstruction can restore a sense of wholeness.  For these patients, breast implants are very beneficial.  And really, some patients find implants to be life changing in a good way.  Don’t judge a woman’s desire for implants until you’ve gone bra shopping with her breasts. That’s the upside of breast implants and really, all aesthetic breast surgery.

This might not end well.

Now I would like to wander into territory that a male plastic surgeon could not go lest the sisterhood ask for his head.  I would like to discuss the concept of bimbofication.  There are many, many women with perfectly fine breasts (defined by me as a nice shape and a size proportionate with the rest of their body) who opt to go larger, sometimes much larger in order to produce a hyper-sexual look and persona.  And I think this is a bad idea. Bimbos have a very short shelf life and getting what one wants via this sort of manipulation of certain types of men is not a good game plan at any age and is not going to work after a certain age.  It just won’t.

I also think that breast implants have skewed the vision of the ideal.  It is not normal for lean women to have huge breasts.  Yes, it occasionally occurs in nature (and a lot of them come in for breast reduction!) but it is not the norm.  I do think that the tide is turning some.  I think a more natural look is becoming more fashionable and I, for one, am glad to see it.  And for those who think I make millions stuffing breast implants into unsuspecting victims: if implants disappeared tomorrow my bottom line would likely go up because of my interest and expertise and experience in non-implant based aesthetic breast surgery.

Are breast implants safe?  I think smooth shell implants are.  (Textured implants, on the other hand, are worrisome.)  Breast implants have been around since the 1960’s and have undergone many design changes and a lot of scrutiny.  Many of the studies looking at implant safety are sorely lacking in follow-up (that’s also another blog) and it should come as no surprise that inserting a large foreign body has a lot of implant related down sides – rupture, deflation, malposition, capsular contracture, etc.  And they are not life time devices and have to be removed and/or replaced eventually.  I recently did a permanent removal of a ladies fifth set!  Do I think breast implants cause systemic illness?  I think there may be a teeny,  tiny subset of women who are sensitive to the materials in implants.  But I think breast implants are safe for the vast majority of women who choose to have them.

Now would I let my mother have implants?  No, she passed away 2 years ago (at 97!).  She had a full and lovely set probably because she did not breast feed her three children (it wasn’t in fashion in the 1950’s).  How about my sister?  I don’t have one but one of my sisters-in-law had postmastectomy reconstruction with an expander followed by an implant and balancing breast reduction and she looks better than she did before breast cancer.  She is thrilled with her result.  And how about my daughter? She is heading off to college this fall and will be making many, many decisions about her life without my input.  Actually, she has been making most of her decisions for a while now.  This is just one of many decisions.  Fortunately this young lady has a healthy body image and zero bimbo tendencies.  Lucky me.

So there you have it.  Implants are beneficial for many, many women and for some they are not.  I’m just glad to live and work in a society that allows adults to make their own choices!  You should be too.

Thanks for reading and I would be honored if you followed me on Instagram @breastimplantsanity and @sowdermd.  Dr. Lisa Lynn Sowder

Breast Contouring, Breast Implants

Breast implant revision vocabulary

November 1st, 2018 — 12:05pm

Over the years, I have done a bajillion implant revision cases.  This comes with the territory of being in practice many years (27 years and counting as of this blog post!) and also with showing and voicing an interest in revisional surgery.  Implant revision is a fact of life.   Breast implants are not life time devices and in general what goes in must eventually come out.  Here a primer on the vocabulary of breast implant revision.  Your surgeon may throw around these terms.  Make sure you understand what he/she is saying and ask for clarification if you need to.  Here goes:

Capsule:  The scar tissue that forms around the implant.  This happens with ALL implants.  It’s a normal response to a “foreign body”.  Yes, breast implants (like all non-biologic implants) are a foreign body. 

Capsular contracture:  The presence of a tight and often thick and sometimes calcified capsule.  This results in a “hard implant”.   This is abnormal scarring.

Implant pocket:  The space where the implant resides.  In cases of submuscular implants, the pocket is between the pectoralis major and the rib cage.  In cases of subglandular implants, the pocket is between the breast gland and the pectoralis major.  Sometimes a change in the implant pocket is advised for implant revision.  

Implant malposition:  Implants that are too high, too low, too medial or too lateral.  This is most often corrected by modifying the implant pocket.

Bottoming out:  A condition that occurs when the implant settles too low and/or is too loose.

Inframammary fold (IMF):  The crease under the breast that is densely attached to the chest wall.   The IMF tends to go back to where it was before implants after implant removal. 

Double bubble: A condition that occurs when the implant falls below the inframammary fold.  This is often accompanied by a crease along the lower breast at the level of the native inframammary fold or the edge of the pectoralis muscle.   

Waterfall deformity: A condition that occurs when the implant stays put but the breast sags as it ages and falls over the implant. 

Synmastia a.k.a. unaboob:  Implants that are too close together.  This looks really weird and is very, very hard to fix. 

The gap:  The space over the sternum that separates the breast.  Sometimes the patients anatomy will result in a wider gap than she desires.  Trying to close the gap can result in really lateral nipples or the dreaded unaboob.  See above.   

Capsulotomy:  Cutting open the layer of scar tissue either to loosen it up or to change the position of the implant.  This can sometimes be done with a local anesthetic.

Capsulectomy:  Cutting out the capsule.  This always requires a general anesthetic.  This can be very difficult.  

Capsulorrhaphy:  Putting stitches into the capsule to either tighten it up and/or to raise the implant.  This usually requires a general anesthetic. 

En bloc capsulectomy:  Removing the implant capsule with the implant without opening the capsule.  This is the preferred method for removing a ruptured silicone gel implant.  This is not always technically possible. 

Acellular dermal matrix (ADM) and surgical mesh:  A sheet of collagen or other substance that controls position of the implant and may prevent recurrent capsular contracture.   Alloderm and Strattice are two of the ADMs I have used.  I have also used Seri surgical mesh.  Think of these as an internal bra, a very, very expensive internal bra.

Perfect symmetry:  Not possible but we try.  

Touch-up:  This term best used when referring to make-up application.  I try to avoid this term when it comes to breast implants.  It implies that it’s easy and it’s never easy. 

Revision:  This term best used when referring to repeat surgery on a breast with an implant.   

So there you have it.  Now you can translate what your surgeon has told you needs to be done.  And again, if you don’t understand make him/her go over it again until you do understand.  Tell them Dr. Sowder told you to do so.  Thanks for reading and I would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.

Dr. Lisa Lynn Sowder

 

Breast Contouring, Breast Implant Removal, Breast Implants

Another side of breast implant illness : one woman’s misdiagnosis and journey back to health.

October 23rd, 2018 — 8:57am

Recently I received this email from a former breast implant illness patient.  I am sharing it with her permission but she has asked me to protect her identity.  I will call her Celeste because I love that name.  I have made no changes except for correcting a few typos.

Celeste:  I read your blog post on breast implant illness and it literally brought tears to my eyes. Tears of joy!!!!  Back up three or four years ago when my life was in shambles – emotionally abusive husband, stressed out to the max at work, sex hormones had crashed, possible thyroid issue…..but yet my family physician said I was fine according to my lab tests. I wasn’t able to see what my ex husband and stress were doing to my body at the time and so I was bound and determined to find an answer. Then I found it – the BII group on Facebook. I had found my answer so I thought. Went through the surgery and wow none of my symptoms got better! It wasn’t until my divorce was final and I was able to relax and started taking a low dose thyroid medicine and got my estrogen back to a normal level that I started to feel normal again. Long story short, I miss my implants like crazy and want them back. I’m soooooo happy to see a plastic surgeon standing behind her beliefs! I totally think it wasn’t my implants at all and more stress and hormone related. I guess I’m going to be the first trial case to see what happens. lol. Thanks for the blog. I really enjoyed it.

Me:  I am very glad you are feeling better after getting your life in order and getting good medical care. Sorry about your implants, though. Have you shared your experience with the Facebook group? I am just curious.

Celeste:  Hahahah.  To spare myself the verbal attacking that would come with it, I have not. All of my friends have implants – a good mixture of saline and silicone, and none of them have issues. I even have one older friend who has had her saline implants for 20+ years to the point one ruptured and still no issues. I don’t want to fight with 18,000+ desperate women who are looking for an answer to their issues when in reality it is probably what you said, the general human condition and life itself. My mom has a lot of allergies and it is possible that my body reacted to my silicone implants (second set), but it took several years for me to feel bad. So, doubtful in my opinion. I had my saline implants for six years with no issues. The issues of general fatigue were once again a result of stress and being on birth control most likely. When I got my silicone implants I went off birth control and my stress was at an all time high. Perfect storm imo. But we shall see what happens. I’m torn on what to get again. I loved how my silicone looked and felt, but still have a slight fear that maybe just maybe it was my body reacting to the silicone (doubtful)……

I’m sure that group has attacked you. It’s like the blind leading the blind and defintely a herd mentality. I can’t bash them too much because three years ago I was one of them – desperate for an answer……and I’m a research scientist, so no dummy either ….. I was just that desperate to feel better.

Me:  Is there any advice you would give women who like their implants but think they have breast implant illness?

Celeste:  Oh geez this is a hard one. There is so much misinformation out there that if it seems pretty far fetched, it probably is.

I lived with my symptoms for years and even had my best friend, who is also my family physician, tell me that I was super stressed and THAT was my problem. The funny thing I have learned about stress in our society is that it starts out small and slow and that becomes the new normal. Then a little more stress gets added on, then that is the new normal. The cycle continues to repeat itself until something or someone stops it. In my case I got my second set of implants (silicone), stopped birth control causing my hormones to crash because I was basically dependent on it, major stress in my marriage, and I was studying for my board exams. And I was the silly one sitting in my doctor’s office telling her that I wasn’t stressed, but yet I couldn’t sleep, felt tired and heavy all the time, my weight was increasing quickly, etc. I went on like this for six years! I’m a little stubborn, ha! Removing my implants helped momentarily because all I could do was sit around and relax. That should’ve been my huge red flag. But nope, I missed it, lol. It wasn’t until just recently that all the pieces started coming together. My hormones are finally at normal levels, my stress is down, my divorce was final two weeks ago. I am finally relaxing and it feels good! I’m still going to the gym and doing strenuous weight lifting and from time to time when I don’t get enough sleep because I’m enjoying life too much and burning the candle at both ends, guess what????? My symptoms start to come back!

For me I’m skeptical that the millions of women that have implants are walking around like zombies (basically what I felt like). I was barely functioning – getting out of bed was difficult, but I didn’t want to lose my job so every morning was a struggle and a pep talk to do it one more day. And what about all the celebrities that have butt implants, chin implants, cheek implants, pec implants (men) – all silicone. I suppose one could argue that those are different than breast implants in chemical consistency, but why aren’t they feeling awful????  I’m more of a believer of an inflammatory response to implants that are too big for the body and overtime the body starts to reject them. My last set were DD and way too big imo. I’m naturally an A, so that is a big difference. And what about all the women in the bikini industry – models and competitors??? They are fine. I’m not saying breast implants are 100% safe, but causing issues almost a decade later is something that I’m not too sure on. My implants came out looking brand new with a thin capsule and no other issues. It is interesting though, the doc that took mine out says he’s seen some stuff that he just can’t explain and the lab can’t identify what it is……so maybe there is truth to it????

With all that being said, I think my biggest piece of advise is know that the mind is very powerful and when you are desperate for an answer, almost anything can be made to fit the given scenario. I wasn’t able to take a step back and evaluate my life and see that the problems I was having were self inflicted. Stress, abuse, lack of sleep, etc. had nothing to do with my implants. After years of living like this, my body was burned out and literally quitting on me. What it needed was lots of TLC! I’m still happy I got my implants removed. That set was too big, but I wish I would’ve swapped them out for a smaller set like my first set of implants. At this point I do miss my implants enough that I’m willing to risk that I’m completely wrong about all this and get implants again……..

So there you have it.  Another side of the breast implant illness conundrum.

Thanks for reading and I would be honored if you followed me on Instagram @breastimplantsanity and @sowdermd.  Dr. Lisa Lynn Sowder

Breast Contouring, Breast Implant Illness, Breast Implant Removal, Breast Implants

Maximizing Follow-Up in Cosmetic Surgery Clinical Trials – Money Helps

July 26th, 2018 — 9:05am

In a previous blog post bemoaning the difficulty of good follow-up in clinical research I sort of place most of the blame on patients who blow off the follow-up  once they have their desired implants.  This was my experience with the implant study I participated in many years ago.  I had an 80% follow-up at 5 years (which was really, really high)  mostly because I pestered patients relentlessly to come back for their follow-up exams.  I have taken a bit of flack (especially from the breast implant illness activists) for my blame-the-patient stance but now there is a recent study out that supports my politically incorrect opinion.  Check this out.  It seems if you pay the patient big bucks to show up they do!  This study has an astounding 94.9% and 96.7% follow-up compliance at 5 years.  The study has another 5 years to go and my guess is that given the size of the monetary award, those numbers will also be very high.

“Maybe I will show up for my follow-up.”

Novel Approach for Maximizing Follow-Up in Cosmetic Surgery Clinical Trials: The Ideal Implant Core Trial Experience

Mueller, Melissa A. M.D.; Nichter, Larry S. M.D.; Hamas, Robert S. M.D.

Plastic and Reconstructive Surgery: October 2017 – Volume 140 – Issue 4 – p 706–713
Cosmetic: Original Articles
Background: High follow-up rates are critical for robust research with minimal bias, and are particularly important for breast implant Core Studies seeking U.S. Food and Drug Administration approval. The Core Study for IDEAL IMPLANT, the most recently U.S. Food and Drug Administration–approved breast implant, used a novel incentive payment model to achieve higher follow-up rates than in previous breast implant trials.

Methods: At enrollment, $3500 was deposited into an independent, irrevocable trust for each of the 502 subjects and invested in a diversified portfolio. If a follow-up visit is missed, the subject is exited from the study and compensated for completed visits, but the remainder of her share of the funds stay in the trust. At the conclusion of the 10-year study, the trust will be divided among those subjects who completed all required follow-up visits. For primary and revision augmentation cohorts, the U.S. Food and Drug Administration published follow-up rates from Core Studies were compared for all currently available breast implants.

Results: Five-year follow-up rates for the IDEAL IMPLANT Core Study are higher for both primary augmentation and revision augmentation cohorts (94.9 percent and 96.7 percent, respectively) when compared to all other trials that have used U.S. Food and Drug Administration standardized follow-up reporting (MemoryShape, Allergan 410, and Sientra Core Studies).

Conclusions: This trial demonstrates the utility of a novel incentive strategy to maximize follow-up in cosmetic surgery patients. This strategy may benefit future cosmetic surgery trials and perhaps any prospective research trial by providing more complete data.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Hey, thanks for reading and I really thank Drs. Mueller, Nichter and Hamas for this awesome article.  And my hat is really off to Dr. Robert Hamas who not only thought up the idea of the Ideal implant but actually brought it to market.  And Ideal only sells its implants to surgeons certified by the American Board of Plastic Surgery.  That means if your surgeon is using an Ideal implant, he/she is actually a real honest to goodness plastic surgeon, not just poseur.

And I would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity. Dr. Lisa Lynn Sowder

Breast Implant Illness, Breast Implants, New Technology, Now That's Cool

14-Point Plan for Breast Implant Placement

June 26th, 2018 — 1:53pm

Surgical techniques are constantly evolving and breast implant technique is no exception.  In the past couple of years recommendations to minimize implant and implant pocket contamination have been developed.  This is in response to overwhelming evidence that bacterial contamination is the main cause of capsular contracture and may also be the cause of breast implant associated anaplastic large cell lymphoma (BIA-ALCL).   Both of these conditions have been linked to the presence of biofilm around the breast implants.  Biofilm is the product of certain bacteria, Staph epidermidis in the case of capsular contracture and Ralstonia piketti in the case of BIA-ALCL.  It is our hope that with the adoption of the Surgical 14-Point Plan for Breast Implant Placement the annoying and difficult problem of capsular contracture and very serious and potentially fatal problem of BIA-ALCL will drop in frequency.  If you are planning on breast implant surgery, you should ask your surgeon if he/she uses the 14 point plan.  They should!

Surgical 14-Point Plan for Breast Implant Placement, from Aesthetic Surgery Journal, 2018, Vol38(6) page 625

Thanks for reading and I would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.  Dr. Lisa Lynn Sowder

Breast Implants, New Technology

Liposuction-Augmentation Mammaplasty – A Bad Idea IMHO

May 3rd, 2018 — 9:33am

Liposuction-augmentation mammaplasty has been on my radar since I stumbled across an Instagram video a few months ago of a surgeon sucking the fat out of a perfectly full breast and then inserting an implant to make up for the lost volume.  I started humming Ozzy Osborn’s Crazy Train!  The rational for this procedure is to provide a bit of a lift without the lift scars. This procedure is described in detail in this April’s edition of the Aesthetic Surgery Journal.  The authors reported on 125 patients and compared them with 188 patients who had just a regular old breast augmentation.  The amount of lift achieved was very, very modest.  The authors were very meticulous in their details – age and weight of patients, how much fat was removed and how large an implant was inserted.  Their minimum follow up was 12 months. These authors put a ton of work into this study and I admire them for that.

BUT…………………………………………..Just because something can be done does not mean it should be done.  And I think this procedure is misguided.   Breast tissue is made to last a lifetime and it does.  Implants last maybe 20 years or so if a patient is lucky.  Here is a list of implant related problems:  too high, too low, too lateral, too medial, too loose, too tight, leak or rupture.  Here is a list of breast tissue related problems: benign cysts and breast cancer.  Why, oh, why would a lady trade in her natural breasts for implants (unless she has breast cancer)?  Apparently there are some patients out there, mostly young, who want a really fake look and you bet that this procedure can deliver a fake look that a breast lift cannot.  But isn’t it our duty to let these young patients know that when they are 60, they will likely be on their 3rd or even 4th set of implants with no end in sight because their natural breast volume was sucked away?????  And those high round globes will look pretty odd on their post menopausal body.

And there’s more:  Removing fat from the breast via liposuction leaves a breast more glandular and fibrous and thus harder for breast cancer detection on mammogram.  And add an implant and the mammogram is even harder to interpret!  A lifted breast poses no issues for mammograms once the internal scars have settled.  And speaking of scars, breast lift scars almost always fade to a point of being a non-issue.

There is one instance where I think liposuction-augmentation mammaplasty is a reasonable idea and that is in cases of breast asymmetry.  It is really, really hard to get a great result when one breast is mostly implant and the other either has no implant or a very small implant.  In these cases, i think it is reasonable to reduce the larger side either with liposuction or an actual breast reduction so implants of similar volume can be used.

I do not know if this technique will gain traction but I hope it does not.  My enthusiasm from breast implants has waned over my 26+ of practice.  I’ve just seen so many implant related problems.  If I can get a breast looking good without an implant, that is what I will recommend.  If implants are the only way to get a nice result, I will certainly go there but I can assure you that I am not going to sucking or cutting away perfectly good breast tissue and replacing it with an implant!

Thanks for reading and be careful out there.  Dr. Lisa Lynn Sowder

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

Breast Contouring, Breast Implants, This Makes Me Cranky.

Capsular Contracture 102: Treatment

April 19th, 2018 — 3:59pm

My last blog discussed the difficult and frustrating problem of capsular contracture of breast implants.  As with just about every problem known to mankind, prevention is the best approach. But despite doing everything correctly pre-operatively, intra-operatively and post-operatively, a small number of patients will experience capsular contracture.

First a little history:  Way back when the Earth was cooling and breast implants were the newest and coolest thing, surgeons would treat capsular contracture by “popping” the breast, the so-called manual or closed capsulotomy.  Here is how it worked.  The surgeon would take his great big strong paws and basically mash the poor breast until there was a pop and the breast went soft as the scar capsule ruptured and released its pressure on the implant.   As you can imagine, there was a lot of moaning and screaming in the exam room during this process.  It wasn’t long before surgeons realized that: 1. the capsular contracture always came back, 2. this can rupture a breast implant, 3. this can cause acute bleeding and 4. women don’t like being manhandled this way.  I was just starting my training in plastic surgery just as manual capsulotomy was falling out of favor.  I’m happy to say that I have never done this crude procedure and it is likely that I would not have succeeded had I tried.  I have teeny tiny and not-so-strong hands.  I would have likely ruptured one of my tendons before rupturing a capsule or implant.

Okay, that was then and this is now.  For early capsular contracture, it’s worth trying medication.  A dozen or so years ago it was observed that implant patients on a certain kind of asthma medication has a very low rate of capsular contracture.  These medications are leukotriene receptor antagonists and they work for asthma by reducing inflammation.  And inflammation is thought to be the final common pathway to capsular contracture.  The two medications used are zafirlukast and mohnelukast.   Accolate and Singular are the brand names respectively.  I have had several patients resolve an early capsular contracture with these medications. I have also had a few patients who did not respond to these medications

These implants were 41 years old and had a grade 4 capsular contracture. I removed them and the capsule and inserted new implants. She is shown 18 months after surgery.

Once a capsule is well established, surgical intervention is the only way to resolve it.  Complete capsulectomy removes the scar tissue and then the question  is how to prevent a recurrent capsule.  And does it make sense to just pop in another implant right away?  This is just such a difficult question because none of us has a crystal ball to tell the future.  Sometimes capsulectomy and a new implant works great but sometimes another capsular contracture starts forming despite doing everything right.  Sometimes we create a new pocket and make a pocket under the muscle if the over the muscle implant had a capsular contracture and vice versa.  Adding Accolate or Singular makes some sense.  Sometimes adding a piece of acellular dermal matrix like Strattice (which should be spelled  $$$$trattice) will decrease the chance of another capsule.  And whenever there are several different approaches to a difficult problem, you can be sure that none of them works every time.

The only surgery I know of that will for sure prevent another capsular contracture is implant removal and total capsulectomy without implant replacement.  This definitive treatment is readily accepted by many of my older patients who are sick and tired of their nasty, rock hard and uncomfortable implants.  They look forward to being implant free.  For younger patients, however, this can be a very, very difficult thing to accept, especially if they were really, really flat to begin with.  I have at least one patient that comes to mind who had several capsular contracture related surgeries by me and finally we just threw in the towel and removed her implants along with her capsules.  Her breasts returned pretty much to their preoperative size and shape but let me tell you, her wallet was never the same.  A problem with capsular contracture can be very, very expensive and result in a lot of down time – off work, off exercise, off fun.  This particular patient went on to have some fat transfer several years later and did well.  She and I are both glad to have her implant saga behind us.

Just writing this post makes me feel like I never want to do another breast augmentation!  And then I think of the patient I saw in clinic this morning.  She was very, very flat chested and was too lean to consider fat transfer.  I inserted 250 cc low profile cohesive gel implants last week and this morning I could not wipe the smile off her face.  I think as long as there is Victoria’s Secret, there will be a demand for breast augmentation.  I am just grateful that implant technology keeps improving as does our surgical technique.  Hopefully sometime in the near future capsular contracture will be of historical interest only.

Thanks for reading and I would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.   Dr. Lisa Lynn Sowder

Breast Contouring, Breast Implant Removal, Breast Implants, Plastic Surgery, Uncategorized

Capsular Contracture – the final frontier in breast implant surgery?

April 3rd, 2018 — 10:52am

Capsular Contracture 101

Anyone who knows my practice well knows that I am not a big fan of breast implants.  I much prefer fat transfer and/or breast lift to get a breast looking nicer.  But sometimes only a breast implant will get the patient the size and shape of breasts they desire.  Implants have many issues including malposition (too high, too low, too whatever), size problems (too big or too small), leaking or rupture problems.  Those issues can usually be address with revision surgery.  There is one issue that has tortured plastic surgeons and their patients from day one of breast implants decades ago.  That problem is capsular contracture.

All implants develop a capsule.  Actually it is the body that develops the capsule.  This is normal reaction to a foreign body and, yes, breast implants are a foreign body, a large foreign body.    A capsule only becomes a problem when it become thick and/or tight.  As the capsule thickens or tightens, it puts pressure on the breast implant and turns any shape or profile of implant into a sphere because a sphere is the shape that supports the largest volume in the smallest surface area, or something like that.  Geometry was a while ago for me!  Thus most badly encapsulated implant all look sort of the same – like a ball.  And they all feel hard, sometime really hard and often they are very uncomfortable.  Capsules can even become calcified in which case the implanted breasts are literally rock hard.

Capsular contracture: Looks bad, feels bad.

So what causes capsular contracture?  Good question and I hope the smart researcher who breaks the code wins the Nobel Prize in medicine some day.  A lot of progress has been made, especially in the past 10 years or so and it sure seems like inflammation is the common pathway to capsular contracture.  The most common causes of inflammation around the implant and resultant capsular contracture are 1. bleeding in the implant pocket, 2. subclinical infection and biofilm in the implant pocket, 3. leakage or rupture of silicone gel implants.  Let’s look at these a little closer.

Bleeding in the implant pocket has been known to result in capsular contracture for decades.  Plastic surgeons take a lot of care to really “dry up” the implant pocket prior to inserting an implant.  This is usually done with an electrocautery device call a Bovie.  This little gizmo allows the surgeon to zap little oozing vessels and help prevent any significant blood from accumulating around the implant.  Also, in the rare incidence of post operative bleeding around an implant, surgeons are very quick to take a patient back to the OR to “wash out” the pocket, find and treat the bleeding and reinsert the breast implant.  Sometimes a very minor bleeds can avoid a trip back to the or but in cases like these, the surgeon is on high alert for capsular contracture.

Subclinical infection and biofilm have been on our radar screen for 10 years or so.  Biofilm (which deserves it’s own blog post) is a slimy substance that is produced by certain types of bacteria.  It serves as a protective hiding place for bacteria and is resistant to antibiotics.  The most common example of biofilm is dental plaque.  Yuck.  Anyway, once the biofilm issue became well known, much more attention was paid to reducing the exposure of implants to bacteria.  We are now compulsive about washing out the implant pocket with antibiotic solution, using a no touch technique with a Keller funnel when inserting the implant, changing gloves prior to touching an implant and such.  Remember the billionaire Howard Hughes and his OCD about germs?  Well, we really go totally Howard Hughes with implant surgery!  Also, the location of incision has been shown to have an effect on the rate of capsular contracture.  Incisions around the nipple, through the arm pit or belly button have the highest rates of capsular contracture.   Incisions under the breast (the inframammary fold) have the lowest rate.  This is very likely due to a lower level of bacteria in the area of the inframammary fold as opposed to the other areas.  I use the inframammary fold incision almost exclusively for this reason and also because it allows me to see the pocket really well.

Leakage or rupture of gel implants results the in silicone gel coming into contact with the capsule and this often seems to cause inflammation and hardening or tightening of the implant capsule.  When I am going after a particularly nasty capsule, I expect to see an leaking or ruptured implant and I am usually not disappointed.  The advances made in implant construction – thicker implant shells and more cohesive gel – will hopefully decrease this cause of capsular contracture.

So that is Capsular Contracture 101.  Next up will be a blog about what can be done for capsular contracture.  Stay tuned and thanks for reading.  And I would be honored if you followed me Instagram @sowdermd and @breastimplantsanity.  Dr. Lisa Lynn Sowder

 

Breast Contouring, Breast Implant Illness, Breast Implant Removal, Breast Implants

Breast lift: Fear not the scars!

January 23rd, 2018 — 9:57am

I see many, many women for implant removal after years of being unhappy with their breast implants.  Many of these ladies consulted a plastic surgeon for sagging of the breasts and instead of ending up with a breast lift, ended up with breast implants.  Often the explanation for this is that the patient did not want the “scars of a breast lift”.

So here’s the deal on breast lift scars.  Yes, they are more extensive than the scars from an augmentation but,………………………..in the vast majority of patients, the scars fade to near no-big-deal status in about a year.  Check out the example shown.  The top photo is before a lift, the middle photo about 6 months post op and the bottom photo is one year post op.  See the scar?  Well you hardly can see the scars in the bottom photo.  This is not an exceptional case.  This is usually how it goes.  Now there are some rare individuals who scar badly because of their particular biology but they are the exception.

So………….if you are saggy, you should get a lift.  If you are really small you should get an augmentation with either an implant or fat transfer.  As with everything, the correct diagnosis should lead to the correct treatment.

Thanks for reading and follow me on Instagram @sowdermd and @breastimplantsanity.  Dr. Lisa Lynn Sowder

Breast Contouring, Breast Implant Removal, Breast Implants, Breast Lift, Scar

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