A ^Retired Plastic Surgeon's Notebook

Looking pretty awesome after all these years.

This is a question posted by a patient on RealSelf.  She’s a lady in her 50’s with 11 year old anatomic Allergan Style 410 implants.  She has typical menopausal symptoms and does not think her implants are causing her night sweats, mild brain fog or hot flashes.  She’s heard about BIA-ALCL and wants to know if she should have her implants removed.  The photos she submitted show an absolutely beautiful long term result and the rest of her looks pretty awesome too.  She’s obviously either biologically privileged or she’s a gym rat or maybe both.  She’s very lean.  She doesn’t have enough fat for a meaningful fat transfer. Her breast volume is mostly implant. She loves her implants but she is scared.  What should she do?

So let’s be rational about the advice we give her based on what we know about BIA-ALCL.  First of all, she cares about her appearance.  Will she look good after explant?  IMHO, no.  She will be very, very small breasted.  If she’s okay with that, fine.  But I don’t think she will be okay with it.

What are the odds that she will get BIA-ALCL?  The latest numbers coming out of Dr. Mark Clemen’s work at MD Anderson estimate the chance of her developing BIA-ALCL is about 1 in 3000.  What about the chances of her DYING from BIA-ALCL?   Well, with increased awareness, early diagnosis and proper treatment, those chances are approaching ZERO.  I cannot rationally recommend she part ways with her awesome and great looking implants for those odds.

Now let’s look at breast cancer.  What are the odds?  Well, about 1 in 8 or 9 women will be diagnosed with breast cancer. The cure rate for breast cancer is much lower that the 90% plus cure rate for early diagnosed and properly treated BIA-ALCL.  Do we recommend bilateral prophylactic mastectomy for your average patient with average breast cancer odds?  Of course we don’t.  Women should be freaking out about the fact that they have breasts instead of the fact that they have textured breast implants!  And this post is in no way dismissing the suffering and, yes, death of patients with delayed diagnosis and/or treatment of BIA-ALCL.  These numbers mean nothing to someone who has died or lost a loved one BIA-ALCL.  We now know so much more about the etiology, diagnosis, prevention and treatment of this really weird malignancy.

So this is what I would advise this lady if she were my best friend or sister:  Her implants are getting up there in years.  I would get them removed and replaced with smooth, round cohesive gel implants.   With her anatomy she will look fine with round implants.  It’s been demonstrated very well that anatomic implants offer almost zero benefit over round implants in patients with normal anatomy.  If her surgeon finds seroma fluid or capsule nodules, he/she should do a capsulectomy and send the fluid and capsules for examination.  If the capsule is smooth and thin and unremarkable, he/she can just adjust the implant pocket if necessary to accommodate the new implant and leave the existing capsule in place.

And then she needs yearly exams and regular mammograms based on her breast cancer risk.

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

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.

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.

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

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

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

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

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

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

If you have not read my initial post on Breast Implant Illness, I recommend you do so now.  In fact, I implore you to read it.  Here’s the link.  https://www.sowdermd.com/blog/breast-implant-illness/.

I belong to a few physician only message boards and breast implant illness has been a hot topic in the past few months.  It is interesting to see what other plastic surgeons think and especially what physicians in other specialties think about this controversial topic.  These boards encourage free discussion without anyone being shut down, banished, blocked, or slammed on social media.  This makes me grateful to be part of a group of professionals that value serious and candid discussion of complicated issues.  Here I present a few thoughts I have curated from the past several months.

Dry eye and breast implants:  Many, many ophthalmologists weighed in on this one.  The consensus is that dry eye is very common in middle aged women.  Women are 10 times more likely to develop dry eye. One doc said 80% of his female patients over 50 had dry eye.  Conditions that contribute to dry eye include previous eyelid surgery (blepharoplasty), too much screen time, and some medications including SSRI antidepressants.  Implants?  No support for that theory from any of the ophthalmologists.  My ophthalmologist, who recently did my cataract surgery, looked at me like I was nuts when I asked him about implants and dry eye.  The eye docs also reminded us that silicone products are used extensively in ophthalmology:  punctal plugs for dry eye, silicone stents for nasolacrimal duct reconstruction, silicone buckles used to treat retinal detachment, silicone oil used as a replacement for vitreous humor in the posterior chamber (eyeball), silicone intraocular lenses used after cataract extraction and finally silicone contact lenses.  WOW.  That’s a boat load of silicone.

When docs congregate is it wisdom of the crowd or groupthink?

Mold and biotoxins:  General consensus from internal medicine and infectious disease is that patients ill with systemic fungal infections should be in the intensive care unit.  None of the plastic surgeons, with one  exception, had seen a case of mold growing in a saline implant.  I added up the years of practice and it came to about 250 years.  That is a lot of experience.  One plastic surgeon who has written a book on BII seems to see mold and biotoxins wherever she looks.  She puts her implant removal patients on extensive anti-fungal therapy post-operatively.  She has extensive experience with mold and biotoxins but has not been published in any recognized peer reviewed medical journals.  Her reason for not doing so has something to do with being targeted by Big Pharma.  Hmmm.

Autoimmune issues:  There were several rheumatologists weighing in on silicone triggered illness.  Their opinions varied from no evidence whatsoever to there are some individuals who are genetically susceptible to autoimmune diseases (this is well known) and exposure to silicone may trigger the onset of disease in these individuals.  It was noted that women are affected by autoimmune disease about 4 times more commonly than men.   One infectious disease doctor thinks breast implants caused slceroderma (which is very, very serious connective tissue disorder and is usually fatal) in 6 of his patients.  He recommended checking how wide an implant patient can open her mouth to diagnose early perioral and TMJ fibrosis and scleroderma.  The rheumatologists thought that this doc was really out there.  The plastic surgeon who has written a book on BII, who is not a rheumatologist, stated that rheumatoid arthritis is caused by an intracellular mycoplasma infection and she can cure rheumatoid arthritis and scleroderma with non-conventional therapy.  None of the rheumatologists believed her.  They all wondered why she had not published her results in a peer reviewed medical journal.  Same answer.  Big Pharma.

Breast Implant Associated Anaplastic Large Cell Lymphoma:  It is rare.  It is treatable if caught early.  It is really creepy.  It is associated with textured breast implants and/or tissue expanders. The plastic surgeon who wrote the BII book stated that BIA-ALCL was the most common cause of death in her implant patients prior to 2005.    It was pointed out by several other doctors that BIA-ALCL was recognized as a disease around 2012.

Other stuff:   Many of the internal medicine docs, ER docs, pain specialists, psychiatrists and OB-gyns weighed in on so called functional and somatic disorders including fibromyalgia, chronic fatigue syndrome, pelvic congestion, brain fog, anxiety, poor memory. depression, and malaise as primarily affecting women and pointed out that the vast majority of these women with these disorders do not have breast implants.  This chatter of functional and somatic disorders made me think of the Freudian disorder of “hysteria” of yesteryear which was supposedly caused by the uterus wandering around looking for a baby.  This sort of stuff gets my hackles up a bit, being a woman and all.  One doctor wondered if there were any male to female transgender individuals with breast implant illness.   Now that is a great question.

Future research:  Everyone pretty much agreed that a large, multi-center, long term (10+ years) may help answer many questions about breast implants.  Several plastic surgeons, myself included, pointed out that the dismal long term follow-up in previous studies was in part due to patient non-compliance with follow-up.  I know this will make a lot of people angry but it is really true.  Back when gel implants were only available through studies like the one I participated in, once patients had their coveted gel implant, they were gone, gone, gone.  My follow-up for the McGahn study was about 80% which is really high because my staff and I pestered the participants mercilessly to come in for their appointments.  Once doc suggested maybe a prison study using inmates with really long sentences.  Maybe this could be Orange in the New Black meets Extreme Makeover?

Breast implants in general:  Whoa, were there some strong opinions about this.  Many, many non-plastic surgeons think any woman who gets implants is by definition is a mentally impaired bimbo.  One doc divulged that his wife was going to get implants to treat her postpartum atrophy and boy did he get an earful!  Many of the male doctors assumed that she was preparing to leave him once he had paid for her surgery!  Such cynicism.  But there was one family practitioner who has had the same set of implants for over 30 years (!) who said they absolutely changed her life.  She went from a wallflower to a confident young woman.  She even credits her implants for giving her the confidence to apply to medical school!

Plastic surgery and plastic surgeons in general:  Some of the docs think that any sort of appearance altering surgery (except for obvious reconstructive procedures) was morally and intellectually bankrupt.  This was an opinion shared by many anesthesiologists!  Weird, huh?  I wonder if my anesthesia group thinks they are slumming to work in my OR?  I guess I should ask.   Many of the male docs stated they didn’t need plastic surgery because their female partners found them totally smokin’ hot just the way they are.  Hmmmm.  Some of the docs think we plastic surgeons are a bunch of money grubbing fools.  Oh well.  I chalk that one up to jealousy.  ; )

So there you have my carefully collected and curated review of some wild times on the doctor only message boards.  You too can join a doctors only message board but first you have to finish medical school.

Thanks for reading and check out my Instagrams @sowdermd and @breastimplantsanity.    Dr. Lisa Lynn Sowder

K (Ryan Gosling) and the very evil Luv (Sylvia Hoeks) stroll among the newly finished small breasted replicants.

My husband and I went to Blade Runner 2049 this past weekend at Seattle’s wonderful Majestic Bay Theater.  I am a big fan of the original Blade Runner thus the bar was very, very high for 2049.  IMHO, Blade Runner 2049 was too frenetic, too convoluted and the only characters I really cared much about was Rick Deckard (the still handsome and wiley Harrison Ford) and his big ass shaggy mongrel doggie.  I shed a tear when the doggie is shown peering out of a shattered building, wagging his tail just a bit, wondering where his human went.  I’m tearing up now just remembering that scene.

One thing I found interesting throughout the movie was the relatively smallish breasts of all of the female characters.  Hardly any cleavage at all – a real change for Hollywood.  K’s (played by a deliciously disheveled Ryan Gosling) made-to-order AI concubine Joi (Anade Armas) and her human side kick, Mariette (Mackenzie Davis) with whom she mind and body melds, were both small chested.  The LAPD’s Madame played by the ever wonderful Robin Wright was lean and mean and small chested.  The still-under-construction and just “born” female replicants would all measure into an A or B cup bra.    Even the gigantic virtual reality pleasure girl with the pastel hair was small breasted.  The only bouncing breasts seen in the movie was in the cocktail lounge hologram dancing girls of the distant past.  They contrasted nicely with Deckard and K beating the bejesus out of each other.

So maybe this return to a natural sized breast will be the next not-so-big thing for the ever scrutinized female figure?

Thanks for reading and if you haven’t seen the original Bland Runner, you are missing out on a great movie.  Follow me on Instagram @sowdermd and @breastimplantsanity.  Dr. Lisa Lynn Sowder