Perennial Problems and Innovative Solutions: Update on Aesthetic Breast Surgery w/ Dr. Jason Pozner

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Welcome to another episode of
Park Avenue Plastic Surgery Class,

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the podcast where we explore controversies
and breaking issues in plastic

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surgery. I'm your cohost Doreen Wu.

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I'm excited to be here with Dr. Lawrence
Bass Park Avenue plastic surgeon,

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educator, and technology innovator,
and our guest expert plastic surgeon,

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Dr. Jason Pozner from Boca Raton, Florida.

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The title of today's episode is Perennial
Problems And Innovative Solutions:

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An Update On Aesthetic
Breast Surgery. Dr. Bass,

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tell me, what are some of the big
issues in aesthetic breast surgery?

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Well, there,

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there are a number of significant issues
and common sticking points that plastic

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surgeons continue to endeavor to improve.

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One of the most common issues
with breast implants is capsular.

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What is that? And how does it happen?

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Capsular contracture is a
tightening of the capsule that forms

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around the implants. So the
body reacts to the implant,

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lays down collagen that looks to us
as surgeons in the operating room,

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like a white glistening membrane.

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And we want that membrane to be
soft and thin that preserves the

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shape of the pocket for the implant
that we fashion during the surgery,

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occasionally that thickens or over many,

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many years even calcifies,

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and that can distort the
shape of the breast and the

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softness of the breast. So we get
firmness and we lose symmetry.

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The implant looks like it's
riding up or the shape at the

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edge of the breast. Contour is no longer
the nice curvy shape that we like.

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There are a number of thoughts
about how this occurs,

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and if we go back many years, uh,

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one of the contributing
factors was gel bleeds,

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silicone gel leaching out of the
implant, even with an intact shell.

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And that was a promoter
of capsular contracture.

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Now modern implants
are low bleed implants,

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and that's probably helped tremendously
to stem the tide of that issue.

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And people also thought that blood in
the pocket at the time of surgery was a

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promoter of capsular
contracture. And it probably is.

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But more recently,

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data has come to light that is
pretty persuasive that bacteria

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not free floating,

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but in the form of a biofilm
or colony are probably

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the major contributor
to capsular contracture.

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Well, that does not sound
like a pleasant experience,

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what can be done to prevent it.

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Okay. You know, so let's go
back a little bit to capsules.

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So everyone says, well, why do I
have a capsule? Do I need a capsule?

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And the issue is whenever you
place a foreign body in a person,

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be it a pacemaker or a hip
joint or a breast implant,

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the body's reaction is to
form a thin film around it.

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And that's called a capsule.
But as Dr. Bass said,

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as it thickens up or becomes misshapen,

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it can cause tightening around the
implant and basically squeezes it like a

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balloon to the point that
the breast is misshapen.

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So I think in terms of what to do for
this, I think the first thing is we,

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we talked about a little
earlier is prevention and I,

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the ways and steps we do to
place a breast implant in

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2022 is different than what
I was taught in the mid

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1990s. So just to kind of go
from, start to finish with this,

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it is some perioperative antibiotics,

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as we always gave a clean
in incision and dissection

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with minimal blood in the
pocket. Because as Dr. Bass said,

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bacteria are probably
the cause of contracture.

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And guess what bacteria like
to eat and grow on it's blood.

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That's how you grow bacteria in a lab.
You put them on blood agar plates.

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So meticulous dissection,

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no ripping millimeter by millimeter
dissection with basically

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minimal handling of the
tissues and atraumatic surgery.

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A typical breast augmentation for
me, there's three drops of blood.

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I mean,

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there's almost nothing you would think
that you could brush your teeth and get

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more blood out than we would
placing your breast implant.

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Well, because you're probably doing
it mostly with electrocautery, right?

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Yeah, of course, with electrocautery.
And incision makes a difference.

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If you want to talk about incisions
there's data that suggests that an

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inframammory incision that's an incision
at the fold of the breast has less

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problems with contracture
than an areola incision.

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The areola incision cuts
through a lot of breast tissue.

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The breast ductular tissue is open
to the air, has bacteria in it.

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We find cysts in it all the time.

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And when you place it through
an inframammory approach,

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you avoid cutting through
the ductular tissue.

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And I believe it's a cleaner approach.

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And I think most surgeons in the country
are using an inframammory approach

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these days because of this data. Um,

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the other thing is no touch technique. We,

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we don't put our hands all over
these implants before they're placed.

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I use a Keller funnel to place the
implant we wash with triple antibiotic

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betaine solution, our close friend,

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Larry and I friend Bill Adams did
most of the seminal research on this.

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Now, now let me stop you
there for a second and ask,

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what do you think is going
to happen now that FDA has,

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has taken bacitracin off the market?

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Because that was one of the
antibiotics that was used in, in the.

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Solution. Right. But
actually it wasn't. So, um,

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so what happened was the original,

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the original triple antibiotic
solution was betadine gent

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and ancef. That was the original
triple antibiotic solution.

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The FDA thought that betaine was having,

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causing some shell problems with the
implant and put a recommendation in that

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you should not use betaine in
your washes with breast implants.

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So his formula was changed to gentamycin,

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ancef and bacitracin,

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but the original triple antibiotic
solution does not contain bacitracin.

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It's ancef, gentamycin, and, um.

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Betaine.

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And betaine so that's what, that's what
I currently use. So hasn't affected me.

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All right. And you're not going
back to, you're not going to,

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to hypochlorous acid
or something like that.

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I

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actually like hypochlorous acid in
my capsule contracture cases. So, um,

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when I'm, we're going to
get into that. Right. So.

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Yeah. And so these are
just different ways that,

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that we try to create a
pocket and in the implant that

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is as clean and protected against

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biofilm and therefore capsular
contracture as possible.

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And there's good data that shows this has
a major impact on capsular contracture

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rate.

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Major. And, and this is on the prevention
side of things. So if you ask me,

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what's changed in the
last 20 something years,

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since Larry and I both were
in our training programs,

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all of these steps have played a role.

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I can't tell you there's one step that
played a role. It is the no touch.

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It is the aseptic placement
of the implants with,

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with washing with triple
antibiotic solutions and

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meticulous tissue handling
and no blood in the pocket.

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Each one of these has added up to a
significant reduction in risk of perhaps

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contracture and most experienced breast
surgeons probably have an under 1%,

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um, rate at this point in their practices.

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So that, that covers prevention,

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which was the question that
Doreen asked. But regardless,

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there still is an incidence
of capsular contracture.

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It's not common for it to be major,

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but it's not our rarest potential
problem with breast implants.

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So if the contracture is mild,

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usually it's treated with massage
or with ultrasound treatments in

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some people's hands. Some
people actually give, uh,

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medicines that are used
for asthma, like accolade,

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to Luca, right? Luca inhibitors inhibit,

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you know, a, a proliferation
of the capsule.

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I never had a res good response
to any of those medications.

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I've never once in 20 something years
seen one work. Yeah, maybe you have.

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I have.

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I, I have not. I have not. And I
don't use them, but it, it is a.

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You gotta be careful. You have
to follow liver functions,

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they mess up your liver a bit.
You gotta be careful with that.

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But I do like for early
capsular contracture, the
Aspen ultrasound technology,

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it's a big ultrasound probe,
uh, specifically made for this,

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that goes on either side of the breast
and for mild capsular contracture,

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or early positional problems where
you have a high riding implant,

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it does a miraculous job. And
perhaps it's breaking up the biofilm,

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if there's a mild biofilm and allowing
the body to come in and take it away.

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Not sure, but it does work in mild cases.
If you have significant contracture,

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it won't do a thing.

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Yeah. And so that's the lesson.
Mild can be treated non-surgically,

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but if you have moderate or severe
capsular contracture with a big

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distortion of shape or a
big change in firmness,

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you're probably headed back to the
operating room and treatment in

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the operating room typically
is something like capsulotomy

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cutting the edge of the capsule
to expand out the pocket.

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If there's a thickened or not
healthy portion of the capsule,

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capsulectomy, which is usually
done in a partial form.

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So partial removal of the capsule,

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and sometimes in someone who's had
recurrent capsular contracture,

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you will change planes.

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The implant is subglandular
under the breast tissue.

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You'll go submuscular under
the pectoralis muscle.

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Or if it's submuscular again,

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you'll flip it to subular.

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But where has treatment of capsular
contracture gone from there?

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Dr. Pozner,

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because I know this is something in
particular that people seek you out

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from around the country to help them
with when they get in trouble with their

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implants.

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Yeah. Um, you know, I,

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I see a lot of these patients per week
and I enjoy taking care of these patients

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because we can make miraculous changes
to their breast shape and feel.

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So with the understanding in my mind
that capsular contracture is most likely

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caused by bacteria in a biofilm
situation. My thinking is always,

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you need to get that biofilm out.

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So I wish we had a magic
antibiotic that would clear it up,

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but unfortunately it
doesn't. So I like to,

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to get rid of all the capsule
in significant capsule cases.

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So that's called a complete capsulectomy.

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There's some data where people talk about
on block and not on block and how you

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take it out. I don't think that
makes a damn bit of difference.

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And there's some recent data that says
that there's no difference in types of

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capsulectomies that's performed,

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but I like to take out the capsule then
I like to try to sterilize the pocket.

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So I will use hypochlorous acid there
after the capsule's out to sterilize the

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pocket as best as possible.

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I then wash just to have a belt and
suspenders approach with the triple

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antibiotic betanine
solution. So I don't have a,

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I don't have a horse at either one
of these races. I use both. Um,

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and then as Dr. Bass said,
I like a sight change.

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If they're over the muscle
to under the muscle,

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I way prefer an under the muscle implant
to an over the muscle implant for

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prevention of contracture.

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And the data and the data on
that is pretty clear as well.

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Isn't it, it's pretty clear,
pretty clear pretty clear.

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I mean all of these steps have been, well,

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everything I'm talking about has been
studied and I don't think any one of these

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is a controversial topic, new implants.

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You don't put the same implant in
cause there's biofilm on the implant.

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So you gotta change the implant. You
can't clean it, you can't sterilize it.

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You put a new one in,

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I use a drain in these cases because
these capsulectomy cases drain like crazy.

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I don't like drains and tummy talks.

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I don't like them in my primary
surgeries and lifts and things,

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but I do use them in
capsular contracture cases.

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I also place an ADM, um,

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which we learned from the cancer patients
and ADM is a Stratus is what I like to

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use, which is pig skin, porcine dermis,

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or skin that has no cells left in it.

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You can also use human tissue or if you
want to use a synthetic there's some

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evidence that GalaFLEX mesh also
has some antibacteria properties.

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And I usually will place the implant
under the muscle with the mesh underneath

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it so that the implant is completely
separated from the breast tissue where the

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bacteria is, because the bacteria's
in the ducts of the tissue.

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So that's sort of my process.

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And the last step is we send
the capsules fresh out to

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Texas for PCR analysis. Everyone knows
what PCR is now because of COVID,

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but we send it to the lab. And
in our studies of our patients,

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we found that about 50% of the
specimens come back with a bacteria and

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a lot of weird stuff in there. It's
not one bacteria it's usually multiple,

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which is what you would expect from
a biofilm and believe it or not,

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the number one bacteria
that we found was E coli.

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So we're thinking that a
lot of the etiology of these
capsular contracture comes

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00:14:08,421 --> 00:14:11,980
from urinary tract infections,
which many women are very prone to.

227
00:14:12,480 --> 00:14:15,060
So I think it gets in the
urinary tract and get,

228
00:14:15,061 --> 00:14:19,820
see it seeds the breast implant. Um,
but we did find lots of weird bacteria,

229
00:14:19,821 --> 00:14:23,900
including dinitrobacter reductant,
which is a soil bacteria.

230
00:14:24,150 --> 00:14:27,540
Don't ask me how that got
into the breast. Interesting.

231
00:14:29,240 --> 00:14:33,180
So, so that's sort of my roadmap to
treatment of capsular contracture again,

232
00:14:33,840 --> 00:14:38,420
capsulectomy new implants,
ADM wash, wash, new site,

233
00:14:38,560 --> 00:14:41,540
new site, and drain and send
that out to see what's in there.

234
00:14:42,080 --> 00:14:46,260
Because if it does come back positive
for bacteria in my PCR analysis,

235
00:14:46,570 --> 00:14:50,300
I'll give them a month's worth of specific
antibiotics based upon the bacteria

236
00:14:50,301 --> 00:14:51,134
that we found.

237
00:14:51,300 --> 00:14:55,800
And there are certain antibiotics that
penetrate biofilms better than others.

238
00:14:56,640 --> 00:14:58,000
So once you know what bacteria,

239
00:14:58,440 --> 00:15:01,320
then you pick an antibiotic
that's gonna penetrate and,

240
00:15:01,680 --> 00:15:03,880
and a good long course of it, as you said.

241
00:15:05,000 --> 00:15:09,440
And the company we use MicroGen
out of the labs in Texas,

242
00:15:09,840 --> 00:15:11,480
they're based of Orlando, um,

243
00:15:11,800 --> 00:15:15,560
they provide you with analysis of bacteria
and the antibiotics that they suggest

244
00:15:15,920 --> 00:15:18,760
based on those bacteria. And if it
comes back negative, I say, look,

245
00:15:19,640 --> 00:15:21,880
there's no current bacteria in there, um,

246
00:15:22,240 --> 00:15:25,760
that we've found or it's below a
certain threshold to be detectable.

247
00:15:25,880 --> 00:15:27,880
You're good with just your perioperative,

248
00:15:28,000 --> 00:15:31,520
antibiotics and massage and
perhaps some ultrasound. So I mean,

249
00:15:31,600 --> 00:15:32,480
there's a roadmap, it's,

250
00:15:32,600 --> 00:15:36,840
this is information that we have now
in 2022 that I'm able to use to help

251
00:15:37,880 --> 00:15:38,200
prevent recurrence.

252
00:15:38,200 --> 00:15:43,000
And I think our recurrence rates are
very low back in the day when I was

253
00:15:43,440 --> 00:15:47,320
just taking out the capsule and putting
the new implant in and doing the wash.

254
00:15:47,321 --> 00:15:52,160
I would say that my recurrence rate
was 50% with the steps that I'm

255
00:15:52,380 --> 00:15:56,360
taking now, including an ADM
and yada yada, as I explained,

256
00:15:56,361 --> 00:15:59,800
I'm down to under 5%. So I think
that's a significant change.

257
00:15:59,801 --> 00:16:02,600
So the steps we're taking
seems to be important.

258
00:16:03,650 --> 00:16:06,110
So shifting gears from
capsular contracture,

259
00:16:06,420 --> 00:16:08,830
what is your next topic
of discussion Dr. Bass?

260
00:16:09,420 --> 00:16:13,190
Well, the next topic is breast lifting.
This is also known as mastopexy.

261
00:16:14,660 --> 00:16:18,950
This has been an area with
a lot of tinkering and
aesthetic breast surgery with

262
00:16:19,270 --> 00:16:21,230
techniques to improve the,

263
00:16:21,460 --> 00:16:26,350
both the degree and durability
of improvement and in the effort

264
00:16:26,370 --> 00:16:28,350
to reduce the length of scars.

265
00:16:29,530 --> 00:16:34,510
So if we look at the classic mastopexy,
basically it's a skin brassiere,

266
00:16:34,690 --> 00:16:39,030
the skin is being used to hold the
breast up in its lifted position.

267
00:16:39,530 --> 00:16:44,150
And the problem with that
is skin stretches out when
it's placed under tension.

268
00:16:45,290 --> 00:16:49,750
Simple example of that is if you
put the abdominal skin on tension,

269
00:16:50,460 --> 00:16:55,430
like when a lady is pregnant, that skin
will stretch out over a few months,

270
00:16:55,600 --> 00:16:58,030
quite a bit larger than
it was to start with.

271
00:16:58,570 --> 00:17:03,150
So that was intrinsically a limitation
or problem in the way breast lifting

272
00:17:03,610 --> 00:17:06,070
was done in past decades, uh,

273
00:17:06,150 --> 00:17:11,110
attempts more recently to build a
pillar of breast tissue to support the

274
00:17:11,111 --> 00:17:15,670
breast or even to place the
bra tissue in a sling of

275
00:17:15,880 --> 00:17:20,710
chest muscle has been
used to try to enhance the

276
00:17:20,930 --> 00:17:23,630
degree and the durability
of the correction.

277
00:17:24,620 --> 00:17:26,120
So what else is happening,

278
00:17:26,460 --> 00:17:31,080
Dr. Pozner with mastopexy to
try to enhance the results

279
00:17:31,570 --> 00:17:34,360
along this particular direction?

280
00:17:34,940 --> 00:17:39,240
So we it's funny because we
were discussing this last
night on, on a, on a call.

281
00:17:39,420 --> 00:17:42,480
So I learned a lot from a friend of ours,

282
00:17:42,481 --> 00:17:44,560
Bruce Van Natta in Indianapolis.

283
00:17:45,140 --> 00:17:49,720
And he was one of the early
pioneers in using mesh specifically

284
00:17:49,721 --> 00:17:54,280
GalaFLEX mesh in mastopexy
so that the breast tissue,

285
00:17:54,460 --> 00:17:56,800
the breast skin is not
supporting the implant.

286
00:17:57,520 --> 00:18:02,400
The mesh is creating a scaffold and a
little bit of scar that holds up the

287
00:18:02,600 --> 00:18:05,760
breast tissue. I do far more, um,

288
00:18:06,680 --> 00:18:09,080
implants with lifts than
I do just lifts alone.

289
00:18:09,400 --> 00:18:14,200
So mastopexy with implant and in pretty
much a hundred percent of those cases I

290
00:18:14,480 --> 00:18:19,280
add mesh just so that the implant
is held up by the mesh and not

291
00:18:19,520 --> 00:18:22,240
held up by your skin. For example,

292
00:18:23,120 --> 00:18:28,120
none of us in 2022 would think to do a
facelift without tightening the internal

293
00:18:28,560 --> 00:18:32,720
layers. Right. So why would you
expect this skin on the face?

294
00:18:33,040 --> 00:18:35,920
Not to hold up, but the skin
on the breast to hold up,

295
00:18:36,360 --> 00:18:40,360
it just doesn't you put a weighted
implant in over time, it's gonna stretch.

296
00:18:40,920 --> 00:18:42,360
So I'm a big fan of support.

297
00:18:43,320 --> 00:18:46,560
Yeah. The breast is a lot heavier
of course, than tissues on the face.

298
00:18:46,920 --> 00:18:51,480
So there's a lot more
stress there and it even

299
00:18:52,560 --> 00:18:56,040
greater priority to the need
to have some kind of support.

300
00:18:56,670 --> 00:19:00,480
So what else is, is happening with, uh,

301
00:19:00,481 --> 00:19:05,480
more limited incision lifts, uh
circumareolar lifts? What do you think in,

302
00:19:05,500 --> 00:19:09,640
in 2022 are the indications
for these more limited

303
00:19:10,040 --> 00:19:11,360
incision procedures?

304
00:19:12,020 --> 00:19:14,760
You know, you know, there's
I always tell the patients,

305
00:19:15,040 --> 00:19:16,080
there's not one patient who's coming,

306
00:19:16,440 --> 00:19:20,600
came into my practice since the day I
started who asks for scars on their body.

307
00:19:21,560 --> 00:19:22,880
Okay. So nobody wants scars.

308
00:19:23,280 --> 00:19:27,080
Everybody wants a procedure that has no
scars that gives you maximal results,

309
00:19:27,920 --> 00:19:32,320
but unfortunately breasts come in
many shapes and sizes from mild

310
00:19:32,960 --> 00:19:36,440
droopiness to significant
droopiness. So for mild droopiness,

311
00:19:36,640 --> 00:19:39,000
I find an incision around the areola can

312
00:19:40,800 --> 00:19:44,200
help the patient if it's a
mild degree of areola, um,

313
00:19:45,120 --> 00:19:47,800
droopiness for a little
bit more droopiness,

314
00:19:48,040 --> 00:19:52,280
I like what's called a lollipop incision
or a circum vertical where you're

315
00:19:52,400 --> 00:19:56,160
taking off skin in both around
the areola and a vertical fashion.

316
00:19:57,000 --> 00:19:59,320
And then for bigger droopiness,
I use a wise pattern,

317
00:19:59,840 --> 00:20:02,000
which is a inverted T incision,

318
00:20:02,280 --> 00:20:06,880
which is the lollipop lollipop plus an
incision along the, inframammary fold.

319
00:20:07,600 --> 00:20:10,480
So basically it depends on how droopy
you are and what you're looking to

320
00:20:10,760 --> 00:20:11,380
achieve.

321
00:20:11,380 --> 00:20:13,680
So it's really, you know, there's a,

322
00:20:14,160 --> 00:20:17,700
a stage of aging issue and uh,

323
00:20:18,090 --> 00:20:22,660
necessarily technique needs to be
adjusted. There's no one size fits all,

324
00:20:22,670 --> 00:20:24,340
which is not a big surprise.

325
00:20:25,280 --> 00:20:29,740
So I guess your stage of aging figures
pretty heavily in the procedure selection

326
00:20:30,320 --> 00:20:34,620
is breast lifting, always standalone or
are there some combination procedures?

327
00:20:35,360 --> 00:20:40,220
So let's back up a little bit and just
talk about what we're trying to do in

328
00:20:40,221 --> 00:20:41,580
conjunction with the lift.

329
00:20:42,320 --> 00:20:47,100
If you want to be smaller in size
and have the breast tailored and

330
00:20:47,290 --> 00:20:49,880
shape and repositioned
back up on the chest,

331
00:20:49,900 --> 00:20:52,000
that's basically a breast reduction.

332
00:20:53,280 --> 00:20:58,240
A reduction always has those sort
of lifting and shaping components

333
00:20:58,420 --> 00:20:59,680
as part of the procedure.

334
00:21:01,280 --> 00:21:06,100
If you're staying the same
size lifting alone is done. Uh,

335
00:21:06,400 --> 00:21:11,300
and sometimes there's a lot of ptosis

336
00:21:11,360 --> 00:21:16,140
or drooping of the breast along
with a lot of volume loss and

337
00:21:16,141 --> 00:21:20,780
you're trying to restore the volume loss
or some people always wanted to be a

338
00:21:20,781 --> 00:21:25,460
little bigger than they naturally are.
So in conjunction with the lifting,

339
00:21:26,290 --> 00:21:29,320
they get a breast augmentation, uh,

340
00:21:29,390 --> 00:21:32,640
this and that volume loss is very common.

341
00:21:32,780 --> 00:21:37,680
Volume loss occurs with aging. It
occurs obviously with major weight loss,

342
00:21:38,300 --> 00:21:42,130
but also after breastfeeding.
So breast lifting

343
00:21:43,710 --> 00:21:48,130
as an augmentation mastopexy
when we want a sizing increase,

344
00:21:49,060 --> 00:21:53,970
especially if we want fullness in the
upper half of the breast is very commonly

345
00:21:53,971 --> 00:21:57,450
done. And Dr. Pozner's
already said this, uh,

346
00:21:57,950 --> 00:22:02,530
now augmentation mastopexy is often
regarded as one of the most difficult

347
00:22:02,740 --> 00:22:05,250
procedures in aesthetic plastic surgery.

348
00:22:06,320 --> 00:22:11,080
I didn't realize that Dr. Pozner, why is
augmentation master Pepsi so difficult?

349
00:22:11,080 --> 00:22:12,520
Well, it's,

350
00:22:12,840 --> 00:22:16,560
it's two operations with
different vectors of force one.

351
00:22:16,880 --> 00:22:19,720
You're trying to lift something high
and tight. And on the other side,

352
00:22:20,040 --> 00:22:21,680
you're trying to put an
implant in to make them bigger,

353
00:22:22,120 --> 00:22:24,160
which basically puts
tension on your repair.

354
00:22:24,840 --> 00:22:26,920
So your forces are in opposite directions.

355
00:22:26,980 --> 00:22:30,800
And that's why I mentioned that I don't
do that case without mesh anymore.

356
00:22:31,180 --> 00:22:33,880
It has changed my practice completely.

357
00:22:33,881 --> 00:22:38,080
And I have hundreds and hundreds of
cases cuz I've been putting mesh in and

358
00:22:38,081 --> 00:22:40,120
various types of mesh for a long time now.

359
00:22:41,030 --> 00:22:43,730
And we have women in their
eighties who come in,

360
00:22:43,731 --> 00:22:46,050
who look like they have
breasts from their twenties,

361
00:22:46,120 --> 00:22:50,290
sitting high on their chest, not
needing to wear a bra and super happy.

362
00:22:50,800 --> 00:22:54,850
Whereas prior to using support mesh
in these augmentation mastopexies,

363
00:22:55,950 --> 00:23:00,330
the patients would often
come in six months later with
bigger, droopier breasts,

364
00:23:00,460 --> 00:23:01,490
which nobody wants.

365
00:23:02,150 --> 00:23:03,210
And I'm just curious,

366
00:23:03,400 --> 00:23:07,530
have you run into because you have ladies
who you said have had this for some

367
00:23:07,640 --> 00:23:08,360
time,

368
00:23:08,360 --> 00:23:12,850
have you run into lead issues with the
mesh or it seems to be well tolerated.

369
00:23:13,140 --> 00:23:17,930
Especially the GalaFLEX it's super
well tolerated and the newest version

370
00:23:17,990 --> 00:23:21,370
of the GalaFLEX mesh, which I've been
using since August is called GalaLITE.

371
00:23:22,190 --> 00:23:26,490
So it's a one step lighter and it's
stretchier and it seems to the small

372
00:23:26,491 --> 00:23:30,330
problems I had with the previous
generation were an occasional high riding

373
00:23:30,360 --> 00:23:34,170
implant that didn't fall perhaps
a little bit excess scar tissue,

374
00:23:34,550 --> 00:23:39,480
but with the new mesh, it is just
phenomenal. And zero infections in,

375
00:23:40,040 --> 00:23:44,280
um, a couple of hundred cases with me
between Dr. Van Natta's office and ours,

376
00:23:44,281 --> 00:23:47,120
we have over a thousand
cases with zero infections.

377
00:23:47,510 --> 00:23:48,520
It's very impressive.

378
00:23:49,260 --> 00:23:53,000
Are implants used with reductions the
same way they are with breast lifts.

379
00:23:53,060 --> 00:23:56,880
It seems counterintuitive. If you're
trying to go to a smaller size,

380
00:23:57,100 --> 00:23:59,400
why would you increase the
size by adding an implant?

381
00:24:00,260 --> 00:24:04,720
It is counterintuitive, but it
is something that is important.

382
00:24:04,960 --> 00:24:09,400
Particularly if the patient
desires that upper pole fullness

383
00:24:09,550 --> 00:24:13,280
basically volume in the
upper half of the breast,

384
00:24:14,180 --> 00:24:16,920
making that part of the
breast full is a challenge.

385
00:24:17,780 --> 00:24:19,920
So if that's a priority for patients,

386
00:24:19,990 --> 00:24:24,880
they often have to agree to
have a small implant added

387
00:24:25,830 --> 00:24:28,520
just to help round out
the shape in that area.

388
00:24:28,950 --> 00:24:33,320
When they're in light clothing or
undressed, if you wear a pushup bra,

389
00:24:33,340 --> 00:24:37,320
you can get upper pole full, but
in the absence of a pushup bra,

390
00:24:37,590 --> 00:24:42,080
it's almost impossible to
get that in any adult woman

391
00:24:42,270 --> 00:24:43,960
without an implant in place.

392
00:24:44,740 --> 00:24:45,320
You know, I,

393
00:24:45,320 --> 00:24:49,560
I agree a hundred percent and what we
call these cases is a plus minus case.

394
00:24:50,380 --> 00:24:52,640
We take out the droopiness of the,

395
00:24:52,710 --> 00:24:54,920
usually the bottom hanging
heavy breast tissue,

396
00:24:55,340 --> 00:24:59,320
and we replace that volume with an implant
that gives you upper pole fullness.

397
00:24:59,321 --> 00:25:04,080
So I call it plus minus. The other option
is if someone's looking for a lift,

398
00:25:04,220 --> 00:25:09,160
but wants a small degree of upper pull
fullness we'll put some fat grafting in.

399
00:25:09,180 --> 00:25:13,600
And that works very well for
patients looking for a lesser amount,

400
00:25:13,700 --> 00:25:14,800
but some fullness.

401
00:25:15,260 --> 00:25:18,320
So it's plus minus, but,
but with natural tissue.

402
00:25:18,320 --> 00:25:19,153
That's plus right.

403
00:25:19,190 --> 00:25:22,760
Plus minus with an implant, in some
ways that's the best both worlds.

404
00:25:23,380 --> 00:25:26,600
You get your desired size
and you get better shape,

405
00:25:26,620 --> 00:25:30,680
but it's also the worst of both worlds
because you have the incisions and,

406
00:25:30,681 --> 00:25:35,440
and therefore the scars and you also
have delayed implications of adding an

407
00:25:35,441 --> 00:25:39,720
implant of some future
malfunction of the device,

408
00:25:40,070 --> 00:25:42,960
somewhere in, in the remaining
decades of your life.

409
00:25:42,960 --> 00:25:44,640
Dr. Pozner,

410
00:25:44,641 --> 00:25:49,120
you mentioned that sometimes fat grafting
can be used to modify breast shape or

411
00:25:49,121 --> 00:25:51,240
even for augmentation
in place of implants.

412
00:25:51,770 --> 00:25:52,220
Right?

413
00:25:52,220 --> 00:25:56,560
So we learned this from our colleagues
doing breast reconstruction where they

414
00:25:56,561 --> 00:26:01,520
found that that putting fat into breast
cancer patients often fix some of

415
00:26:01,521 --> 00:26:05,920
the radiation problems and some of the
dents and on other malformations that

416
00:26:05,921 --> 00:26:07,600
happen in cancer patients.

417
00:26:07,620 --> 00:26:12,280
So we started using it on the aesthetic
side and we found that we could

418
00:26:12,310 --> 00:26:16,760
achieve some reparable fullness and I
put it in for rippling all the time,

419
00:26:16,820 --> 00:26:20,680
if someone's extremely thin breasted
and you have a visible implant.

420
00:26:21,380 --> 00:26:26,200
So it's just another tool in our toolbox
that allows us to achieve more natural

421
00:26:26,201 --> 00:26:28,200
looking better results in patients.

422
00:26:28,220 --> 00:26:32,040
But we do a lot of fat grafting to the
breast and other areas of the body. Now.

423
00:26:32,560 --> 00:26:33,880
I agree with you completely.

424
00:26:34,000 --> 00:26:38,360
I think fat grafting is an
extremely powerful tool for really

425
00:26:38,690 --> 00:26:41,440
perfecting roundness of,

426
00:26:41,441 --> 00:26:46,120
of the edge of the breast
contour and all manner of minor

427
00:26:46,630 --> 00:26:49,080
sins or minor defects in perfection

428
00:26:50,670 --> 00:26:52,600
without doing any kind of big surgery.

429
00:26:52,780 --> 00:26:57,120
And if you go in and try to recontour
the pocket for some little shape,

430
00:26:58,240 --> 00:27:03,200
uh, you know, you're risking everything.
Sometimes all the cookies crumble and

431
00:27:06,580 --> 00:27:09,080
fat grafting is easy to do.

432
00:27:09,081 --> 00:27:13,560
Low recovery patients after
they've done around a fat

433
00:27:13,600 --> 00:27:14,420
grafting are,

434
00:27:14,420 --> 00:27:18,840
are so pleasantly surprised at how
minimal it is for them to do that.

435
00:27:18,870 --> 00:27:23,760
And it can really advance
the aesthetic quality of the

436
00:27:23,761 --> 00:27:24,594
result.

437
00:27:24,820 --> 00:27:27,080
And I always tell the patients,
you get a little free liposuction.

438
00:27:27,660 --> 00:27:29,080
So they're usually happy about that.

439
00:27:29,410 --> 00:27:31,880
Right? I mean, what, you
know, what's not to love.

440
00:27:31,880 --> 00:27:34,080
What more could you ask for? Wow.

441
00:27:34,240 --> 00:27:37,800
I didn't realize how many complex issues
are under evolution in breast surgery

442
00:27:38,540 --> 00:27:39,960
as we wind down this episode.

443
00:27:40,100 --> 00:27:43,600
Are there any additional key takeaways
you think patients should keep in mind?

444
00:27:43,601 --> 00:27:44,434
Dr Pozner.

445
00:27:44,940 --> 00:27:49,480
I think the only thing we missed that
we didn't talk about and I'll mention in

446
00:27:49,481 --> 00:27:51,960
just a couple sentences is, um,

447
00:27:52,360 --> 00:27:56,320
problems with positioning of
the implants on the chest.

448
00:27:57,280 --> 00:27:58,113
Sometimes you'll,

449
00:27:58,160 --> 00:28:02,520
you'll find circumstances
where the patient will come
in with a two lateralized

450
00:28:03,160 --> 00:28:07,160
implants, two media implants,
two inferiorly placed implants.

451
00:28:07,440 --> 00:28:11,880
So we use pocket control techniques
and mesh to help support the pockets,

452
00:28:12,080 --> 00:28:14,120
to put the implants in a better position.

453
00:28:14,600 --> 00:28:18,560
So we do a lot of fold repairs and other
things now that because sometimes the

454
00:28:19,000 --> 00:28:22,120
tissues just couldn't hold up and
we use the mesh for support in those

455
00:28:22,640 --> 00:28:27,400
instances. But again, if you're seeing,
if you have a complex breast issue, um,

456
00:28:27,800 --> 00:28:30,840
you know, look to someone who
does this on a routine basis,

457
00:28:31,760 --> 00:28:34,480
you know I'm not an
expert in hand surgery.

458
00:28:34,560 --> 00:28:38,080
I wouldn't go to me for hand surgery.
I haven't done one in many years,

459
00:28:38,440 --> 00:28:41,320
but you know, we all sort of super
specialize as we get a little older,

460
00:28:42,320 --> 00:28:43,070
do your homework.

461
00:28:43,070 --> 00:28:45,640
Yeah. And I mean, I think
that's really important.

462
00:28:45,940 --> 00:28:50,400
The experience and specialization breeds,

463
00:28:50,460 --> 00:28:53,840
predictability and control
in the results and pocket

464
00:28:55,550 --> 00:29:00,520
control and the use of mesh to help,
particularly for the inframammory fold.

465
00:29:00,620 --> 00:29:02,960
You know, once that
fold has been destroyed,

466
00:29:03,420 --> 00:29:08,400
the ability to make a stable fold and
have control over the height of the

467
00:29:08,430 --> 00:29:11,200
fold, which is key to the breasts,

468
00:29:11,720 --> 00:29:15,720
positioning and height has
been a classic problem area.

469
00:29:16,140 --> 00:29:20,640
That's probably been very well
addressed with these mesh techniques.

470
00:29:22,210 --> 00:29:22,560
Well,

471
00:29:22,560 --> 00:29:27,420
I'd like to thank Dr. Pozner for
joining us today and providing so much

472
00:29:27,450 --> 00:29:30,620
clarity on these very complex issues.

473
00:29:31,470 --> 00:29:34,020
Thank you very much, Dr.
Larry, thank you so much.

474
00:29:34,120 --> 00:29:37,940
Doreen I really enjoyed being on this
show cause it was, you know, a lot of fun.

475
00:29:38,150 --> 00:29:38,980
Thank you so much.

476
00:29:38,980 --> 00:29:43,040
And it's always nice to see
Dr. Bass smiling face. Um,

477
00:29:43,340 --> 00:29:46,240
because I haven't seen you
in a while in person, right?

478
00:29:46,380 --> 00:29:50,520
Yes. The pandemic has certainly
interfered with so many medical meetings.

479
00:29:50,521 --> 00:29:53,040
They're they're taking
place, but they're virtual.

480
00:29:53,980 --> 00:29:58,960
So the ability to see friends and
colleagues in person is something

481
00:29:59,010 --> 00:30:01,400
we've missed in the last couple of years.

482
00:30:01,980 --> 00:30:05,640
But I'll see it as at a laser meeting
first. That'll probably be our next venue.

483
00:30:06,270 --> 00:30:07,200
Well, thank you again,

484
00:30:07,201 --> 00:30:10,120
Dr. Pozner for sharing your
insight and expertise with us,

485
00:30:10,270 --> 00:30:13,720
I've definitely learned a lot and thank
you to our listeners for joining us

486
00:30:13,721 --> 00:30:14,001
today,

487
00:30:14,001 --> 00:30:17,440
to hear this update and learn about
the evolving issues in aesthetic breast

488
00:30:17,441 --> 00:30:18,274
surgery.

489
00:30:18,300 --> 00:30:21,800
If you think of other exciting
developments in plastic
surgery that you would

490
00:30:21,801 --> 00:30:24,040
like to see us discuss
in upcoming episodes,

491
00:30:24,140 --> 00:30:28,080
please feel free to reach out via email
or Instagram. We'll see you next time.

492
00:30:29,350 --> 00:30:32,080
This is Doreen Wu, thanking
you for joining Dr. Bass,

493
00:30:32,180 --> 00:30:34,600
Dr. Pozner and me for this
discussion of breast surgery.

494
00:30:35,220 --> 00:30:38,480
Be sure to tune in next time. And don't
forget to subscribe to our podcast,

495
00:30:38,740 --> 00:30:42,160
to stay up to date with all of the
exciting content that is coming your way.

496
00:30:43,250 --> 00:30:47,280
Thank you for joining us in this episode
of the Park Avenue Plastic Surgery

497
00:30:47,410 --> 00:30:51,920
Class podcast with Dr. Lawrence
Bass Park Avenue plastic surgeon,

498
00:30:52,720 --> 00:30:54,560
educator, and technology innovator.

499
00:30:54,900 --> 00:30:57,360
The commentary in this
podcast represents opinion.

500
00:30:57,510 --> 00:30:59,960
This podcast does not
present medical advice,

501
00:31:00,260 --> 00:31:04,440
but rather general information about
plastic surgery that does not necessarily

502
00:31:04,500 --> 00:31:07,600
relate to the specific conditions
of any individual patient.

503
00:31:07,980 --> 00:31:12,680
No doctor-patient relationship
is established by listening
to or participating

504
00:31:12,820 --> 00:31:13,653
in this podcast,

505
00:31:13,870 --> 00:31:17,760
consult your physician to advise you
about your individual healthcare.

506
00:31:18,060 --> 00:31:19,480
If you enjoyed this episode,

507
00:31:19,780 --> 00:31:24,000
please share it with your friends and
be sure to subscribe to our podcast on

508
00:31:24,001 --> 00:31:27,880
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509
00:31:28,180 --> 00:31:30,480
or wherever you listen to podcasts.