A ^Retired Plastic Surgeon's Notebook

This cartoon is by the late, great B. Kliban. His book, “Never Eat Anything Bigger Than Your Head” is a treasure. Get your hands on one if you can. You’ll laugh until you cry.

Portion control is very important for maintaining a healthy weight and it becomes more and more difficult as restaurants, especially fast food restaurants, keep increasing the size of the offerings.  There is a Mexican place in Seattle that  has a poster of one of its burritos next to a new born baby.  They are the same size. So sick in so many ways, huh?

I would like to introduce portion control for breast implants.  There is a condition that we plastic surgeon’s call breast greed.  Those with breast greed want to go a little larger and then a little larger and then a little larger.  This results in the eager to please plastic surgeon putting a too big implant into a too little woman.  Supersized implants have an increased chance of having implant problems.  Big implants cause thinning of the breast tissue and skin and over-stretching of the pectoralis muscle if they are submuscular.  They are more likely to result in the dreaded unaboob or extend into the underarm area.  And, in my humble opinion, they look really, really bizarre.

Fortunately I do not get many patients looking for that super top heavy look.  Implant patients self select surgeons who feature these jumbo implants on their website or social media accounts.  You won’t fine many of those attached to my name.

Thanks for reading and if you want to supersize your chest, don’t come to me!  Dr. Lisa Lynn Sowder

Follow me on Instagram @sowdermd and @breastimplantsanity.

MRI is the best test for detecting implant rupture (other than surgery) with a very high accuracy rate, much higher and mammogram, ultra sound or physical exam.  I think it is prudent for patients with gel implants, say 10 years old or older to get an MRI to make sure there is not a silent rupture.  If a patient has saline implants, there is no possibility of a silent rupture so an MRI would be worthless unless there is another reason for MRI (cancer detection for example).  I often have patients who are coming in to have their old gel implants removed regardless if they are intact or ruptured and in those cases I don’t really think an MRI is absolutely necessary.  Yes, it is nice for the surgeon to know ahead of time if there is a rupture but honestly, I approach every implant removal as if the implant is ruptured.  I try to do an en block resection and have everything ready in the event the implant is ruptured and there is silicone spillage.  We have special suction set up for ruptured implants and also some old fashioned surgical lap pads ready for clean up.  And even with a rupture, it’s usually not as messy and one might think it would be.  Even the messiest cases almost always allow the surgeon to scoop out the gel and then get all of the capsule.

“Just relax. It doesn’t hurt one bit but it is a little noisy.”

In Seattle at Swedish Medical Center, as of 2017, an out-of-pocket MRI to rule out breast implant rupture is about $1300 – $2200.  If you pay up front, you get the lower price.  The actual procedure requires the patient to lie prone (on the stomach) with the breasts hanging though these little openings in the MRI bed.  It’s important to lie really, really still for a good image.  MRI does not involve any irradiation so don’t worry about that but it can be kinda noisy with pings and dings.  When I had my knee scanned, they gave me earplugs. And after an MRI, please make sure you get the radiologist report.  It is more useful than the actual MRI itself.  Plastic surgeons are not experts at reading MRI’s although we can usually see an obvious rupture. More subtle things may not be obvious to us.  

Thanks for reading and if you are concerned about your oldish gel implants and an MRI will either ease your mind or prod you into action, you should get one!  If are ready to bid goodbye to your oldish implants regardless of their status, come on in.  I’m here to help!

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

Calcified breast implant capsules can make a breast rock hard.

Calcified breast implant capsule surrounding an 32 year old ruptured silicone gel breast implant.

32 year old ruptured silicone gel breast implant after opening the calcified capsule.

I recently removed  32 year old breast implants from a lovely lady in her mid 60’s.  She was embarrassed how the implants felt when she hugged someone.  “It’s like having two rocks in my bra.”  Here is the reason her breasts felt like rocks.

The photo on the top shows the implant surrounded by the implant capsule.  The photo on the bottom shows the implant (which was ruptured) and the capsule after the capsule was opened.  The yellow gooey stuff is the implant material.  The white structure under the implant is the inside of the capsule.  The white stuff is calcium.  Yes, calcium – the same stuff that makes your bones nice and hard.  The calcium deposits are hard and brittle and can make an encapsulated implant literally rock hard.  Nasty capsules such as this are most common in old silicone gel implants but I have also seen cases like this in saline breast implants.

These photos also illustrate another important point with removal of ruptured breast implants.  In this case, I was able to remove the ruptured implant and the capsule in one tidy piece and there was no spillage of the silicone into the breast.  I love it when I can do this.  It is not always possible but I always try.   When it is not possible and I have to remove the ruptured implant before removing the entire capsule, there is often some spillage but I do my best to minimize it and clean up any spilled silicone prior to closing the breast.

And yet another important point should be obvious from this photo.  Should the capsule be removed along with the implant?  YES!  It would be crazy to leave that nasty capsule behind.  It would shrivel up into a hard mass, be palpable and possibly visible and would look really, really funky on mammogram.   I always go after thick and nasty capsules.  If removing the capsule puts a vital structure at risk, I may leave some of it behind but I try to get as much out as possible.  Removal of the capsule is the hard part of the case but it is worth the effort and time to leave behind a nice, clean breast.

Oh, and one more point.  This were really old implants.  The implants available currently are much tougher and have thicker gel and are less likely to rupture.   The problem illustrated with this case are less likely to occur with the new generation of implants.

And check out my video where I remove a calcified capsule from a saline implant.

Thanks for reading!  Dr. Lisa Lynn Sowder

Seattle Plastic Surgeon feels like an archaeologist while removing 42 year old silicone gel implants. 

Dr. Sowder, breast implant archaeologist.

Recently I saw a lovely woman in my office who wanted removal of her breast implants and replacement with new ones.  This is a common procedure in my practice.  What made this case really memorable was the age of her implants.  They were 42 years old!  This patient was one of the breast implant pioneers and here she was, all those years later finally ready for an upgrade.

Her old implants were as hard as rocks and upon removing them, the reason why was immediately evident.  The scar tissue around the implants (this is called the capsule) were very thick and  had calcified.  The capsules had literally turned to rock.

Paradoxically, the thicker and harder the capsule, the easier it is to remove and I was able to remove the  implants and capsules in two tidy pieces with zero spillage of silicone gel.  Remarkably, when I opened the capsule to reveal the implants, the implants were not ruptured but they had oozed a lot of silicone gel into the surrounding capsule.  The capsule and calcification was the body’s response to the oozed silicone gel.   The gel implants currently on the market are much sturdier and do not have the same degree of rupture or gel ooze and these old ones did.

I inserted some brand new silicone gel implants under her chest muscle, stitched her up and she is thrilled to have a chest that doesn’t look and feel like there are two tennis balls under her skin.  As for her husband, I can’t wipe the smile off of his face.

Have I told you lately that I really dig my job?  Thanks for reading!  Dr. Lisa Lynn Sowder

Seattle Plastic Surgeon explains what causes a double bubble deformity in the implanted breast. 

The implant rides high and the breast falls over the lower edge of the implant creating the weird shape of the “double bubble”.

I saw two patients this week with the so-called double bubble.  Both of these ladies had implants that were over 10 years old and both had experienced some sagging in their natural breasts.

The double bubble occurs when time and gravity result in the natural breast drooping and falling below the bottom border of the breast implant.  Breast implants tend to stay put over time because they are held in place by the implant pocket and the resultant scar capsule that forms around them.   Or, in some cases, the scar capsule starts to thicken causing a so-called capsular contracture and the implant can be displaced up which can result in an early or really bad double bubble.

Treatment depends on how much the double bubble bothers the patient, how bad the double bubble is, the age and condition of the implants and the condition of the patient’s breasts.  Usually treatment will consist of doing a breast lift to get the breast back up into a better position relative to the implant.  If the implant has developed a tight capsular contracture, removal of the old implant and capsule and replacement with a new implant may be necessary.

Sometimes ladies in middle age develop the double bubble and don’t really want to do anything surgical.  It can be “fixed” with a good bra.  And sometimes ladies in middle age decide that their implant days have come to an end and opt to have the implants out and a breast lift.  These ladies are often relieved to be implant free and often just love their smaller and perky breasts.

So, with the double bubble and many other things related to plastic surgery, the main culprit of  is time and gravity, which keeps me in business.

Thanks for reading!  Dr. Lisa Lynn Sowder

Seattle Plastic Surgeon will present “Breast Implant Removal and Breast Lift in the Middle Aged Patient” at the annual meeting of the Northwest Society of Plastic Surgeons.

Implants? I am so over implants!

Tomorrow I am heading off to my favorite meeting to give a talk on the surgical treatment of women who have either physically or mentally “outgrown” their breast implants.  I see a lot of these ladies in my practice and I have been very happy with the results I obtain with doing a breast lift at the same time as implant removal.  This leaves, of course, a smaller breast but the shape is usually very nice and almost all of my patients are pleasantly surprised at the results.

Thanks for reading!  Dr. Lisa Lynn Sowder

Put this on your list for Valentine’s Day.  It won’t end up on your hips and you can wear it in public!

Did ya know why SmartWool socks aren’t itchy?  It’s because the type of wool that is used is very, very fine and flexible compared to normal wool which is thick, stiff and poky.   I don’t itch at all in these sock and I am a very, very itchy gal by nature.   In fact, I am sitting here right now thinking how itchy my boiled wool jacket is.   And you know how that makes me feel?  Well, it rhymes with itchy.

So check out some pink SmartWool socks for Valentines Day.  And no, no, no, I do not get a dime or even a free pair of socks for this blog.

Thanks for reading.  Dr. Lisa Lynn Sowder

Seattle Plastic Surgeon warns women of a certain age:  Breast implants that made you look voluptuous 20 years ago may  be making you look matronly today. 

I think she has crossed the line to matronly. Implant removal and a breast lift can take a lot of bulk off the chest and years off the postmenopausal figure.

 Recently I have had several ladies come in with implants that are no longer enhancing their figures.  These ladies are all  several years postmenopausal and even without overall weight gain, have added a cup size or two to their chests.  This is often how weight redistributes after menopause.  Don’t ask me why.  It just happens. 

In these cases, it is often beneficial to remove the breast implants and do a breast lift.  Many, many of these patients have enough breast tissue to leave them with a B, C or even D cup.  And to think that they started out flat chested so many years ago!  Crazy, huh?

Doing implant removal and a lift unloads the chest and makes the torso look much slimmer (much the way a breast reduction does in a lady who carries some extra weight around the middle).  These patients are often just thrilled to look slimmer and have their breast be “the real thing” after having implants for so many years. 

Also, since implants don’t last forever, removing them provides a lot of peace of mind.  Very few ladies over 60 relish having a new set of implants and then thinking about another new set at 80!

Now if I could just figure out a cure for the postmenopausal weight redistribution, I could retire and buy that little island in the Caribbean. 

Oh, never mind.  I love my job and I’m sure I would be bored to death.

Thanks for reading.  Dr. Lisa Lynn Sowder

MRI of a breast with a breast implant

Seattle Plastic Surgeon, Dr. Lisa Lynn Sowder feels very lucky to be just down the street from First Hill Imaging and their awesome expertise with breast MRI.

Today I got a question from a lady regarding mammograms, breast implants and breast cancer.  She had 20 + year old implants and they had become increasingly firm and it was difficult for her mammographer to get a good image.  She had a family history of breast cancer and she was afraid of missing an early diagnosis if she were to develop breast cancer herself.

I recommended that she have an enhanced breast MRI which is very, very sensitive in diagnosing breast cancer, even when implants make the breast firm and difficult to examine. 

Dr. Bruce Porter at First Hill Imaging in Seattle was one of the radiologists who explored this technology back in the 90’s.  I remember attending one of his lectures where he showed MRI images that were just amazing in their detail and accuracy.  And that was about 10 years ago.  It’s even more amazing now.

In most cases, implants do not interfere much with mammograms, especially if the implants are placed under the pectoralis muscle.  But if they do, it is so comforting to have First Hill Imaging and Dr. Porter and his colleagues within walking distance for my Seattle patients.

Thanks for reading!  Dr. Lisa Lynn Sowder

Breast implants are arguably the most studied medical device in the world.

Seattle Plastic Surgeon discusses the breast implant revision.

Last weekend I gave a presentation on Breast Implant Revision at the annual meeting of the Washington Society of Plastic Surgeons.  This is a topic I present frequently.

About 15 years ago, several well established and very busy plastic surgeons in Seattle retired and I started seeing a lot of their patients with old implants that needed attention.  Now that I have been in practice almost 20 years, I am starting to see my own patients whose older implants need attention.  Between their patients and my own, I do a lot of breat implant revision, removal and replacement surgery.  Hence my interest and experience.

My presentation turned out to be very timely because on June 22nd, the FDA issued their lastest report on breast implant follow-up.   Despite some sobering statistics on the incidence of reoperation after breast augmentation, the FDA still concludes that breast implants are safe and effective.

Reading this report really drives home several points about breast implants:

1. Breast implants don’t last forever.
2. Most breast implant patients will need reoperation.
3. The older the implants, the more likely the need for reoperation.
4. Long term follow-up in breast implant patients is very difficult of obtain.  This is a highly mobile and highly private patient population.

SOOOO – my conclusion about breast implants remains unchanged.  It’s a great operation for the flat chested woman (patient satisfaction rate is very, very high) but it is not a perfect operation.

Thanks for reading!  Lisa Lynn Sowder