A ^Retired Plastic Surgeon's Notebook

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

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.

Can’t tell which side is anatomic and which side is round? Neither can I!

I think the anatomic implants vs. round implants smack down may finally be over.  As those who read my blog know, I am not a huge fan of anatomic implants although I have tried really, really hard to learn to love them over many, many years.  Anatomic implants are presented as the best thing since microwave nachos and those of us who keep going back to round implants are sometimes dismissed as Luddites.  Anatomic implants are pushed by industry paid “experts” who make the rounds at meetings and extol the wonder of these more-expensive-and-more-complicated-than-round implants.  And patients ask for these anatomic implants being lead to believe that they will look more natural.  

A few years ago, evidence started trickling in that anatomic implants actually did not have  advantages over round implants in standard breast augmentation in anatomically normal women. There were studies where before and after photos were shown to expert plastic surgeons and they could not tell which patients had which implants.  I was present at one of these sessions where a panel of experts did no better than a coin toss.  But the study that nobody thought could be done – put an anatomic in one side and a round in the other side on the same patient – has been done!  No patient would sign up for having two differently shaped implants used for her augmentation and no institutional review board would approve such a study.  But some very clever surgeons did this study in 75 volunteers.   Their average age was 39 and their average BMI was 20 (this, by the way, is quite thin).  The surgeons took the patients to the OR and put a round implant in one side and a comparably sized anatomic implant in the other side and then took standardized photographs.  They then removed the anatomic implant and replaced it with a round implant to match the other side.  The standardized photographs were shown to a panel of experts.  Even the panel of experts could not tell the round vs. the anatomic when presented with these side by side breast implants!

I really take my hat off to the Drs. Hidalgo and Weinstein for doing this study.  It is this sort of research that helps us make decisions based on reality rather than the latest hype from an industry hired gun.  

Intraoperative Comparison of Anatomical versus Round Implants in Breast Augmentation:  A Randomized Controlled Trial.  Hidalgo, David A. M.D.: Weinstein, Andrew L. M.S., Plastic & Reconstructive Surgery:  March 2017, Pages 587-596.

Thanks for reading!  Dr. Lisa Lynn Sowder

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.

Seattle Plastic Surgeon Discusses Mommy Makeover on Mother’s Day

Ah, the joys of motherhood! I can wax eloquently about fat little feet, apple cheeks, wet baby kisses and so on but one of the joys I did not expect was a boost in my Plastic Surgery practice, especially my “mommy makeover” patients. Since becoming a mother myself, I speak “mommy” really well. I know first hand the glorious details of feeding, bathing, changing, and schlepping the baby. I can recite the stages of the toddler, the preschooler, the gradeschooler, the tween, the teenager and currently I am becoming an expert on the joys of being the mother of young adults.  

Being familiar with all that being a mother requires makes me much better at counseling patients about the process and timing of a “mommy makeover”.

“Mommy makeovers” usually combine breast surgery (augmentation and/or lift or reduction) with body surgery (usually abdominoplasty and/or liposuction). Most women are healthy enough to have a combination of procedures during one operative session. It is, however, the first couple of post operative weeks that are the most challenging for the patient.

Mommy is used to taking care of everyone but herself. After surgery the Mommy needs to take of only herself. She needs to be “Queen for a Week or Two” and resist the urge to cook, clean, change, wipe, mop, vacuum, load, unload, fold, etc. And if her youngest weighs over 20 pounds, she may not pick him/her up for at least two weeks if breast surgery was done and for at least six weeks if an abdominoplasty was done. The little one can crawl into Mommy’s lap for a cuddle but NO HEAVY LIFTING for Mommy. This also applies to the dog.

It’s very important to for patients to discuss these issues with their families. I’ve had a few ladies who have underestimated their recovery time, have done too much too soon and have turned what should be a relatively comfortable and relaxing recovery into a very sore and frustrating one.

So, calling all mothers interested in a “mommy makeover”: Plan ahead and get your husband and your children and your friends on board. Make a sign for your bedroom door. “DO NOT DISTURB – MOMMY RECOVERING”.

Shaped vs. Round Breast Implants

Shaped or Round Breast Implant? Toss a coin!

Shaped breast implants are all the rage these days.  A lot of this is driven by the manufacturers who love to promote these implants and a lot is driven by patients who sometimes insist on the latest and greatest be it a cell phone, blender or breast implants.  And I use shaped implants from time to time but in many cases, a shaped implant is of no advantage over a round implant.

About a year ago, I attended the annual meeting of The American Society for Aesthetic Plastic Surgery (ASAPS).  One of the best presentations involved a panel of five well seasoned (a.k.a. over 50) plastic surgeons.  They were shown multiple before and after photos of breast implant patients and asked to comment on the cases, in particular whether the patient had shaped or round implants.  The panel of experts was right less than 50% of the time!  In other words, they could have had a panel of five year olds toss a coin and come up with better results!

Years ago I was quite enamored with shaped implants and actually came to rather despise them!  I had issues with malposition and particularly rotation which can lead to some funky shaped breasts and which requires re-operation.  I have gotten a whole lot better with these implants with improved implant design and modifying my technique, but honestly, in 90% of cases a round implant will work just fine as long as it’s NOT TOO BIG (that’s another blog).

So in most cases a patient can save themselves some money and me some aggravation by going with round implants.  Yet another win win.  I just love win win, don’t you?

Thanks for reading!  Dr. Lisa Lynn Sowder

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 wishes everyone a Very Merry Christmas.

The Christmas season is always super busy in my practice.  It seems crazy to have surgery around the holidays but it is the choice of many, many patients.  They already have time off of work or school for recovery.

In my 23 years of practice, I have only taken time off around Christmas twice; once to take care of my newborn daughter and once to have surgery myself.

So Merry Christmas to everyone.  I’ll be working every day except for Christmas, New Years Eve and New Years!  It’s a good thing that I love my work!

Thanks for reading and stay tuned for some upcoming New Year’s Resolutions.

Dr. Lisa Lynn Sowder

The ideal breast has a little more fullness below the nipple and above the nipple.

The Ideal Breast

I just read an interesting review of an article published in the Journal of Plastic and Reconstructive Surgery about the ideal breast.   Here’s the link.

If you don’t want to read the review, I will summarize.  A bajillion individuals which included men and women of various ages and nationalities were asked to rate a series of breasts on their attractiveness.  The findings were interesting in that size was not as much of a factor as was the shape and proportion of the breast.  And – surprise!- the majority of judges preferred a breast that looked natural which translates into a breast that does not have a bulging upper pole.

I am just glowing after reading this article.   I have made it my life’s work to make breasts look like they could have occurred in nature on a really, really, really good day!

Thanks for reading!  Dr. Lisa Lynn Sowder

Check out these el cheapo breast enhancers.

Those of you familiar with my web site and this blog know that I really like to emphasize that fat transfer to the breasts is much different than a breast implant procedure.   Fat transfer results in a much more subtle and natural appearing enhancement compared to breast implants.   Here is a great way to determine, in the privacy of your own home,  if you will be happy with fat transfer.

There are a bajillion kinds of breast enhancers (we used to call them falsies when I was in high school) on the market.  I keep the June Tailor Beautiful You enhancers in two sizes in my office to help patients visualize that fat transfer can do.  These enhancers are available at Joanne Fabrics and they are very reasonably priced.  The larger size is pretty representative of the size increase a woman with a little breast laxity and  nice juicy donor sites (hips, tummy, thighs) can expect.  The smaller size is a pretty good idea of what a smaller, slimmer woman with tight breasts can expect.

So if you are thinking about fat transfer to the breasts, buy a pair of enhancers and wear them around for a few days.  And if you come in for a consultation, make sure to bring your enhancers with you.  That will give me a good idea of what sort of volume increase you will be happy with and help me determine if you are a good candidate for fat transfer to the breast.

Thanks for reading!  Dr. Lisa Lynn Sowder