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
Looking for the perfect gift this holiday season? That perfect gift may just be a plastic surgical procedure. Here are a few tips if you are considering this most thoughtful and personal of presents.
Only consider this if your loved one has confided in you that he/she is considering “doing something” or that he/she just wishes that he/she could just “get rid of this ______(fill in the blank)”. Remember, it’s about him/her, not about you.
Make sure the lucky recipient is a good candidate for surgery. Good candidates for surgery are in good heath (physically and mentally) and are in a socially stable place in their life. If in doubt, shoot me an email and I can probably make an educated guess. Do not, I repeat, do not give the gift of liposuction as a substitute for weight loss. Need convincing that doing so is a bad idea? Check out my blogs on obesity.
Make sure that you can afford the surgery! You wouldn’t want to have to back out because of sticker shock. I have a lot of ball park prices posted on my web site. Or feel free to shoot me an email and I can give you a financial idea of how much this could set you back.
Make sure that lucky guy/gal will be able to take enough time off of work and/or household duties to recover. It’s misery to try to get back to work too soon. You want your gift to be a positive experience. I have recovery times listed for most procedures on my web site. Or shoot me an email.
Make sure you have nice package to present. You can’t wrap up a tummy tuck or eyelid lift, but you can wrap up something they might love to wear or use after all the discomfort and bruising is gone. Maybe something sassy fromHanky Pankyfor that mommy makeover patient or a pair of beautiful Firefly earrings for that eyelid lift patient. Or for that dude of yours, how about a nice pair of Ethica boxer briefs You can include one of my practice brochures and a procedure brochure. Oh, I can just hear the shrieks of joy now!
And just think, your gift of plastic surgery will last years, even decades. You and your loved one will be enjoying the benefits much longer than a new car or television or laptop. Do the math. It could end up being a great value as well as a great gift!
HAPPY SHOPPING AND 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.
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 allI 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
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.
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
Alison giving the elbow to one of our hard working nurses.
Yesterday we had a wonderful massage therapist come into the office to give our staff 30 minute massages in celebration of Nurses Week. Oh yeah, I sneaked in and had one too and it was great. While having my back, neck and shoulders, arms and hands kneaded, pulled, rubbed and elbowed, I had a very nice chat with Alison the therapist. She is a weight lifter and I had a lot of questions about the mechanics of power lifting, what she thought of body builders, strength training for the over 60 crowd (me, for example), dwarf throwing contests and a bunch of other stuff. I was so impressed with her knowledge and explanations of how strength isn’t just from muscle bulk but also from neurons in the neuromuscular junction acting in a coordinated fashion, from muscle memory for some actions, from bone strength and angle and from mechanical advantage. This lady’s b.s. meter was set at zero, just where I like it.
It was particularly nice to have this encounter because a few days earlier there was an article in the Seattle Times about craniosacral therapy which had my b.s. meter red-lining. Nicole Tsong, who is a yoga instructor, has a nice weekly column about exercise, nutrition and other self care and I usually enjoy reading it. But this past Sunday, yikes did she go off the rails. Nicole’s treatment, basically a massage, sounded pretty standard and pleasant but then the therapist started talking nonsense.
Cut and pasted from the article: Craniosacral therapists observe your cerebrospinal fluid, which moves in roughly eight-, 20- and 100-second cycles, Christman said. My flow was good from my tailbone up until she got to my left shoulder, she said, where the flow contracted. She could work on my connective tissue to help the fluid move, or manipulate the fluid to move back into my shoulder, she said.
Yes, this is a head rub and it feels great but she’s not manipulating your skull and she is not observing your cerebrospinal fluid. Just sayin’.
Christman had asked me before the session about head injuries, and I told her about a concussion I had in college. After working on my spine and pelvis, she moved to my head and started gentle pressure around my skull to manipulate the tissue and bones. I was already relaxed, and when she started to work on my head, I succumbed and closed my eyes, nearly nodding off.
Since this is my blog, I’m just gonna get this off my chest. Cerebrospinal fluid (CSF from now on) sort of circulates and sloshes around in the ventricles of the brain, between the brain and the skull and in the center of the spinal cord but ………………… 8, 20 and 100 second cycles? Why not 34 seconds or 82? Hmmm. It has been awhile since I took neruoanatomy but that sounds like b.s. to me. Oh, and the therapist observes the CSF? I don’t think so. CSF can be observed when doing a diagnostic spinal tap or doing a spinal anesthetic or during brain or spine surgery or in cases of a skull fracture when CSF can be observed dripping out of ears and nostrils. Methinks Ms. Christman was not really observing CSF in a therapy session. But why would she say she was? Oh, and then CSF in the shoulder? Nope. Not there. There is synovial fluid in the shoulder joint but not CSF. If you have CSF in your shoulder you should report of the emergency room … stat.
Now lets deconstruct that head rub that Nicole got. God, I love a good head rub, don’t you? But I know that a head rub does not manipulate the skull. The skull does have joints (called sutures) but they fuse in early childhood. The only way to move a skull around is with power tools and preferably in the OR with a neurosurgeon.
Nicole almost dropped off to sleep and maybe would have been the best way to avoid listening to this balderdash which is fancy word for b.s.
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
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
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
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”.
@lisalynnsowder
