Size Matters But It's About So Much More Than The cc's: How to Pick a Breast Implant w/ Dr. Jason Pozner

Doreen Wu (00:00):
Welcome to another episode of Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your cohost Doreen Wu. I'm excited to be here with Dr. Lawrence Bass Park Avenue plastic surgeon, educator, and technology innovator. Also joining us today as our guest expert is Dr. Jason Pozner, a plastic surgeon in Boca Raton, Florida. The title of today's episode is "size matters, but it's about so much more than the CCs: how to pick a breast implant." When you think of plastic surgery, breast implants are definitely one of those iconic things. It sounds really fun, but what should people think about and how should they pick the right implant

Dr. Lawrence Bass (00:43):
For most people, it is a lot of fun Doreen, but there are important things to know. So you understand what you're getting into implants are devices and will eventually wear out. So I tell patients if you want bigger breasts, but you never want to think about the implants. Again, this is not a good idea. If you want bigger breasts and you can accept that in the future, there's likely to be more surgery. When the implants wear out, then you can have a lot of fun with it. I think that single issue, heavily colors how to think about implant selection. The first big choice is about implant fill, which can be saline or silicone gel note that the shell of the implant is solid silicone. In any case and solid silicone is used in many, many medical devices. Currently 90% of implants placed in the United States are silicone gel fill. I'd like to introduce my colleague, Dr. Jason Pozner, who I've known for many years and taught many courses with Dr. Pozner is really an expert in complex aesthetic breast surgery and breast revisional surgery, as well as on innovations in technology across plastic surgery. So I've asked Dr. Pozner to join us today to share his expertise in the area of advanced breast aesthetic surgery. Dr. Pozner what's your approach? What type of implants are you mostly using silicone gel saline and why?

Dr. Jason Pozner (02:26):
Okay, well, first of all, thank you, Larry, for inviting me on this podcast and Doreen for having me as well. So hopefully that can be somewhat entertaining and educational. Um, I mainly use Silicon implants, I would say over 99% of our implants placed over the last five years have been Silicon gel implants once in a great while I would use a saline implant, but only because of certain FDA guidelines suggesting that for women under 22, a saline implant was the one that approved. And silicone was only approved for women who are 22 and older. Um, this is probably not the, the, uh, venue to get into why that rule came about, but, um, I still have placed plenty of Silicon implants on younger on younger women. Um, there's different brands of Silicon implants on the market. Um, I'm currently using Allergan brand and natural implants, but during the years I've used probably much every other kind of implant from different manufacturers. I like the shell wall on the Allergan implants. I like the cohesively of the gel. And I'm sure we'll be getting into that a little bit as time goes by in this podcast.

Doreen Wu (03:39):
Yeah, that sounds great. A beautiful, soft breast is always an essential goal. What do you think Dr. Bass?

Dr. Lawrence Bass (03:46):
So my approach is a little different and in my practice, probably about 90% of the implants I place are saline fill in. The reason for that is there's less surveillance required obtaining ultrasounds or MRIs to determine if the implant has remained intact is not necessary with saline implants. It's easy to know when the implant fails. Usually within the space of a day, the contour will be lost and it's obvious that the implant has deflated. Uh, it's easier to treat when it fails to just remove the shell because the saline doesn't have to be addressed explicitly the way silicone gel does. And you have more treatment options when it fails. You can leave the shell in place. You can take the shell out under local anesthesia, or you can replace the implant. So there's more flexibility and more flexibility with timing. And that's important as patients age, because you know, when you're 70 or 80, you may not want to address the implant immediately or may not be able to. And it just gives you flexibility in how you approach things.

Dr. Jason Pozner (04:57):
Uh, Larry, can I interject also, yeah, one of the other things with saline implants, and again, I use rarely use them at this point is occasionally somebody with a rupture on one side, doesn't have the time to do a revision surgery. So sometimes we'll just percutaneously puncture the good side and let them both deflate and wait a while, take out their implants. So that's another option, somewhat advantage to saline Implants, you certainly cannot puncture your silicone implants and drain them.

Dr. Lawrence Bass (05:25):
Absolutely. And you know, I had a circumstance like that in the last year where someone had a saline that was not placed by me, that failed. Uh, she was in the process of selling her business and on a lot of travel and road show to get the business on the market. We removed the failed implant under local anesthesia and removed the non failed implant. And then she circled back in about six months after her business affairs were taken care of and addressed getting re augmented. So there's a lot of flexibility with that. Another thing that I really, really love about the saline implants is the ability to tinker small assymetry. Since most women have some asymmetry, you can put the same size implant that has the approximately the same base diameter. The base diameter will vary in minor ways based on fill, but it's going to be pretty much the same base diameter, and then fill one to the lower end of the range and the other one on the smaller breast to the higher end of the range and deal with small asymmetries, bringing people a little bit closer to symmetry. If there's a big as asymmetry, you just pick a different implant, right?

Dr. Jason Pozner (06:42):
Yeah. So, you know, in the silicone world, the lower number implants, the less volume implants that go up in small increments, like 25 CC differences, which is not very much. So that allows us to tinker by perhaps choosing a 300 or a one side and a 325 on the, on the smaller side. But as they get larger in number the differences, get up to like 50 CC difference. So you can't tinker as much as you can with the saline. I'll totally give you that point. Larry.

Dr. Lawrence Bass (07:08):
Yeah. And I worry that the base diameter starts to become significantly different. A small difference in base diameter won't show externally, especially if the patient has a moderate amount of baseline breast tissue, but, uh, but potentially you're, you're inducing an asymmetry at the same time. You're taking one away. Uh, if you go to different size implants and that's a necessary evil for, for women who have big asymmetries in breast size, we just pick different size implants. And that's how we treat a unilateral hypoplasia or Hypomastia

Dr. Lawrence Bass (07:48):
Anyway. Um, there are some downsides though, because we have to tell both sides of the story. You're more likely to see the edge of an implant, especially in a very slim patient. And you can always feel the edge of both silicone and saline implants. And you're also with a saline probably more likely to see rippling. So those are some of the downsides, but I, I think at the end of the day, um, that the theoretical firmness of the saline compared to the silicone is hard for most patients to appreciate. And if there's even mild capsular contracture, which is not a rare event, then that advantage to the silicone gel goes away. Um,

Dr. Jason Pozner (08:33):
But I will bet you that if you had a saline, a patient with saline in one side and silicone and another, you can tell the difference. The, to me, the saline, the silicone size is a little bit more natural feeling and a little bit more like a natural breast. But I agree with you in many patients, especially with a lot of breast tissue, you won't be able to tell the difference, but in the thin patients, those saline, I, my experience has been a lot of rippling in the thin

Dr. Lawrence Bass (08:54):
Patients. Yeah, that's a great point. And that's the patient that I'll recommend. Silicone gel is the super slim patient, the marathoner, the patient with very little baseline breast tissue. They're really going to be better off with a silicone gel and get a more natural result, but a patient with moderate breast tissue in my hands I'm often headed towards the saline unless the patient feels strongly. They want the gel.

Doreen Wu (09:26):
Okay. I see the virtue in both approaches, but we're not done picking an implant yet. What are some other things to consider when choosing the right implant size?

Dr. Lawrence Bass (09:36):
So we started to allude to this in our recent discussion, Jason and I, the important considerations are how much baseline breast tissue there is, what the desired final size is and the heightened shape of your frame as an individual. One of the things I don't like to see is looking at thumbnails on the internet, that list out different implants. I don't think that's a very useful way to figure the right implant for you since the size and style of implant are only two factors amongst all of these that we just listed. Also, it's very hard to look at a thumbnail on, on your computer screen or your tablet and even worse on your cell phone, because you don't know how big that patient is, how tall, how heavy it's very hard to assess how much their body habitous and yours are a match in deciding what the implant looks like.

Dr. Jason Pozner (10:37):
I mean, Larry many patients come in and say, I want 3 25 CC implants, because that's what my friend has. And I like her breasts and this often leads to a whole discussion I'm sure which we're going to have in the next few minutes about, you're not the same as your friend. She has four kids and she's six feet tall and you're five feet tall.

Dr. Lawrence Bass (10:53):
Yeah. And, and so that's really important and we, we have to have these conversations every week over and over, um,

Dr. Jason Pozner (11:02):
For 20 something years each.

Dr. Lawrence Bass (11:03):
Yeah. And, and so, uh, so it's, it's a little frustrating, but the place I think the internet helps you is you can look and see how different breasts look and say, gee, that's something I think is really beautiful. Those are breasts that I aspire to. And then your surgeon has the same picture in their mind that you have in your mind. So they can then advise you what's the best way you can get to that end point.

Dr. Jason Pozner (11:34):
Yeah. I, I agree a hundred percent. I mean, I, I often have the patients bring in photos that we look at together because it gets you in their head. Are you looking for a mild improvement or you're looking for a larger size and you know, a lot of times they'll tell you why. I just want to be a B cup and they show you pictures of double DS. So I think really need to be the visual aspect really helps right. Giving the patient what they want, if it's within their

Dr. Lawrence Bass (11:59):
Limits. I think, you know, when you walk into the operating room and the picture in your mind is the same as the picture in the patient's mind, you're most likely to get the result that the patient is going to love and they can say it to you in words, but they may not be picturing or meaning the same thing. So what are the ways you help the patient, Dr. Pozner pick the right implant for shape and size?

Dr. Jason Pozner (12:24):
Sure. Well, you know, the, the first thing is we need to talk about is the shape of the patient that we're putting the implants in, you know, and that's why we do measurements. So when a patient comes in for an in person examination, we measure them and we measure their with the chest. We measure their, where their nipple placement is how tight their fold is the distance from the nipple to their fold. So various measurements that we look at that help us figure out what a potential size a patient could be. For example, if you're really narrow, there's no way you could put a really wide implant in you, which just doesn't won't fit. And we have to be able to fit it in to be able to close up and get a good long term result. And there's also the data that suggests that overly large implants tend to fail and not breaking the implant itself, but they help stretch the tissues out and fail the breasts.

Dr. Jason Pozner (13:14):
So you need to pick the proper size for the patient within reason, but there is a little variation in what you can place in those patients based upon their height and width. So that's the first thing we do is measure the patient in our office. We have a vector which is a 3d camera, and that allows us to get volumetric analysis of the patients and see their native volume. And it gives you a visual on a computer, um, what you might look like with different size implants. So we use that method. As I mentioned earlier, we get photos from the patient and then we have specific sizers that are, um, given to us by the implant companies that are basically these little foam or little sort of fluid filled, uh, devices that you put over the breast. And then we put clothes on the patient and we look at what they look like with different size sizers in place. And then the last thing is we give the patient what's called the rice test. We give them, everyone has a pre-printed information sheet where we tell them to get uncooked rice, put it in panty hose and try on clothes at home and let us know the volume of that rice. And each one of these methods is not going to give us the answer, but the culmination of multiple efforts to figure out what they want, helps us to get to where we want to be.

Dr. Lawrence Bass (14:36):
You know, it's, it's interesting because I use very much the same approach. I mean we have the, the vector so we can image people in 3d and I think that's great and you can rotate the image and patients love to look at that, but I think how they look in clothes, especially I'm in the Northeast, we're about to talk about Northeast versus Florida preferences, but how the patient looks in clothes is really what they're gunning for. And so I like them to, to try with a size or, and come, how do they look into sweater or how do they look in a blouse? And is that the look they want? And that doesn't mean that that size or is the size implant they ought to get. It gives me again the picture of what they're aiming at the same as what they're picturing.

Dr. Jason Pozner (15:24):
And it also depends what they're wearing because I find when someone comes in to try on implants and a dress, it's terrible, you can't get a shape, a look at their body. And I always tell the patients, don't look at your breasts, look at your shape, look at your butt, look at your hips, look at your waist and see how you flow. These implants have to look as part of your body. You're a sculptor, creating a Michelangelo. You're trying to create a sculpture. So with this, you need to look at the whole picture and not just focus on the breath. So we prefer if you're coming into size in my office, I like like yoga pants or low rider jeans. I find high wasted jeans or high waisted, uh, clothes, um, obliterate sort of the waist. And you can't really see the flow. And I tell 'em to go home and try on different this rice test with heels and flats and different clothes. So that's all part of our process.

Doreen Wu (16:17):
Dr. Bass. You alluded to the regional differences between the Northeast and Florida. What do you see as preferences in size and look where you are Dr. Pozner?

Dr. Jason Pozner (16:25):
Okay. It it's pretty obvious, right. You know, we have beaches and low cut clothes and golf clothes and all that stuff. So they're bigger in Florida and they're bigger in Texas and they're bigger in California, but you know, in general, many of Larry's patients, um, Dr. Bass's patients in New York are, you know, professional women attorneys who probably don't want to be too large. And you know, in Florida we have a slightly, at least for my practices, it's a slightly older population, but if I will bet you, and if we looked at all the breast implants, Dr. Bass, I have placed, I'm probably, uh, half a cup to a cup size larger than him across the board. In average. What do you think Larry?

Dr. Lawrence Bass (17:05):
Yeah, so I think that's right on most people, I mean the real question first is, is someone looking for augmentation or are they trying to restore after breastfeeding childbearing, just get back to the size that they used to be. That's obviously going to be a different calculation in most people's mind, but in New York again, because we're not a beach community 10 months out of the year, there's more focus on the look and close than bathing suit. Um, and that's just how it is on park avenue in New York city. Um, my average implant size, I mean, most of the patients want to be a big B cup or a small C cup. That's the most common in my practice in the New York area. And my most commonly used implant is a 272 CCS. Uh, and one size up or down from there, usually up is, is, uh, one or two sizes is probably represents about 80% of the implants. I use

Dr. Jason Pozner (18:12):
That's funny because you know, in my, my patients all say the same thing, I want to be a full C, maybe a small D full C. So I'm one cup size bigger than you are. And I would say my average size is probably high three is low fours.

Dr. Lawrence Bass (18:27):
Yeah. And you know, part of the reason for that, and I point this out to patients is there's horrible grade inflation in brassieres, you know, there's a technical definition of cup size, every brassiere manufacturer ignores it and has their own custom definition. So that's a great point. You know, they come in and they say, I bought a brassiere, that's a D cup and you were supposed to make me a C cup. Well, it's not really a D cup

Dr. Jason Pozner (18:53):
And a Victoria's Secret D might be a Maidenform B cup. So, you know, there's wide variation.

Dr. Lawrence Bass (19:00):
Yeah. So that's, that's something important to keep in mind. See,

Dr. Jason Pozner (19:03):
We've learned stuff over the last 25 years, just a

Dr. Lawrence Bass (19:06):
Bit. So let me, let me switch gears a little bit and talk about other variations in implant style, uh, and form stable implants. So Dr. Pozner alluded to this at the beginning of the episode, that that some of the silicone gel is firmer and gives a more defined shape to the implant. So this is what a form stable implant is. And one of the nicknames for these implants is gummy bear implants, which most people have proudly heard of. So I'm curious to hear Dr. Pozner, what role do you think these have in aesthetic breast surgery compared to reconstructive breast surgery?

Dr. Jason Pozner (19:47):
So, you know, first point is the implants that I use by Allergan. Most of the time they come in different, uh, cohesive levels. So they have really three different levels and it well depends on which level you choose the softness and how they sit up on the chest. So we we'll use different ones. So that's part of the consultation that we go into and talk about these cohesive levels. I I've done pretty much, no form stable implants or very few form stable implants in my life. I could probably count on two hands, how many I've placed. I was never a fan of them because they didn't give the look that most of the people in Florida were looking to achieve. They, most of the patients here wanted a little fuller upper pole, and then they give you a sort of a more full bottom pole and less full upper pole.

Dr. Jason Pozner (20:36):
But when push came to shove and we had all the problems with texturing implants, um, I, I didn't have to replace any of my implants that I had placed because were textured anatomic implants. So, um, most of the surgeons in this country have gone to these smooth walled implants that are around, are not using the form stable anatomic implants. I mean, when I learned to put those, it was in Sweden where they had very tall women who wanted to be B cups. So in that particular patient, it seems to play a role, but again, in Florida, where most of my bathing soup patients are looking for upper pole fullness. It doesn't really give you that doesn't achieve that with those form stable implants to, to my satisfaction

Dr. Lawrence Bass (21:19):
And, and all the form stable implants are textured in some fashion or another even micro texturing,

Dr. Jason Pozner (21:27):
Because otherwise they could potentially rotate. You know, wh when you make a pocket or the space to place the implant, the form, the anatomic implants, you make a relatively narrow tunnel so that it doesn't rotate. Whereas we make a little bit bigger space for the smoother, rounder implants and move around a little bit more, but that's just some technical technical work. So I'm not a fan of forms of anatomic implants or form stable implants.

Doreen Wu (21:55):
Before we close. I wanted to pick both of your brains on the latest trends in breast augmentation right now. And what innovations you predict are coming in the foreseeable future. Dr. Pozner, do you want to take this first?

Dr. Jason Pozner (22:08):
You know, you know, I think that we we're at a time now where there's been a lot of data, that's accumulated over a number of years about the safety of these implants. I can tell you they're safe. Um, the patients are happy with them. The generation implants we're using now is far superior to what was used 40 years ago, the patients have access to lots of educational material on the web. I think the difference is the implants are improved and the patients come in way better educated than they had in the past. Most people know what they want, they've done their homework, um, spoken to their friends. So, um, my consultations now usually are pretty smooth because the patients are relatively educated. So the implants are a little bit better, but the patients are a lot better.

Dr. Lawrence Bass (22:52):
Yeah, I think, I think that's important. Uh, information is power and there's been a lot of effort to get the information to, to assimilate the information or produce the information through clinical study and then to get the information to patients. Um, we, we never know what's coming next in implants. It's, it's hard to know what will be developed and what will be approved by FDA, but people have talked about putting chips in implants to help sense if the implant has failed. Uh, the improvements in high resolution ultrasound have made it a lot easier to monitor implants without having to go to an MRI. Those are some recent developments. Um, another one is, is something called ideal implant. Uh, this is an implant that's saline, but the saline shifts through baffles in the implant so that it gives a softer feel to the implant. It's supposed to resemble more closely, a silicone gel implant with again, the, the safety and, uh, replaceability advantages of the sailing. Uh, ha do you have any experience with that, Dr. Pozner?

Dr. Jason Pozner (24:09):
No, I don't. I've seen them at the shows, but I've never placed one.

Dr. Lawrence Bass (24:13):
And you have a sense how your population of patients has received this or they aware of it, or they interested,

Dr. Jason Pozner (24:21):
You know, there's so much, so many patients here in Florida and across the country have Silicon implants nowadays that most people coming in expect to get silicone implants. They don't want to hear about anything different. Um, they want something that's tried and true and that their friends have. So I don't go into the alternative, although I do tell them, you know, you could have a salient implant, but I probably haven't placed one in three years right

Dr. Lawrence Bass (24:45):
Now. And, you know, I, I think you brought up the issue of all the data that's available. When you have a new implant. Now it's been placed in many fewer people. It's been in people for many fewer years. There's much less information about the performance of a new implant compared to an implant that's, you know, like the current generation of silicone gel that came on the market in 2003, 2004, uh, there was 10 years of data when they came on and now there's even more data. Uh, and that data lets you benchmark how the implant's going to behave and, and really important for patients to have that predictability. And that understanding

Doreen Wu (25:32):
This episode has helped me understand a lot about the factors that go into implant, selection, and decision making. But what can you tell me to tie it all up? What are the most important things to keep in mind?

Dr. Lawrence Bass (25:45):
So, you know, I'll go back to what I said at the beginning of the episode, every implant sooner or later is going to fail. Hopefully you're going to be alive for decades, decades, many decades after you place the implant. Uh, so you have to plan for future work, but there's no set period. You run the implants till they break, or until you need to make a major aesthetic change because of aging changes. So you don't change them at a set time, uh, knowing <affirmative>, uh, no one ever has baseline symmetry, uh, but you can get approximate symmetry. We're trying to create volume symmetry, but the skin envelope is still not being changed with breast augmentation. And so I generally tell patients not to chase small issues. Perfect is the enemy of good. And because we know future surgery is coming, that's the time to chase a small issue at the same time that you do a big revision after childbearing or after aging, when you need a different size or style implant, or you need a breast lift along with the implant. So Dr. Pozner, what are the big takeaways from your point of view?

Dr. Jason Pozner (26:55):
You know, I, I think you covered it pretty extensively, uh, Larry, that, you know, there's no set time to take out these implants. They last, and you just, you evaluate them at, at a longer period of time. Like over 10 years, you see what's happening with the patients and, um, you really keep the patients coming in every year for exams and just make sure that they're doing okay. But, um, it, it's a very safe operation. Patients are very happy with the results, uh, for the most part. And I think that we've pretty covered this pretty well. And the key is really that you need to go to someone who does this on a routine basis. Um, if I was seeking breast augmentation, I wouldn't go to a hand surgeon. I would go to a surgeon that does a lot of breast augmentation, cuz they have, there's a lot of little nuances in this. You know, I'm at the point as is Dr. Bass in our careers where, when we're doing a surgery, we're looking at a one millimeter, do I go an extra millimeter dissection in this or, or this versus when the people who don't have a lot of experience with it, just pop an implant in and call it a day. There's a lot of little nuances that come from experience.

Dr. Lawrence Bass (28:01):
Well, thank you Dr. Pozner. I couldn't agree more. Uh, I think my patients have a ton of fun with breast implants. Uh, they I've gotten roses and champagne and it, it is a very safe operation that people really enjoy the benefits of. Uh, but I appreciate your joining us for this episode of park avenue, plastic surgery class, because it's really useful to hear a very experienced expert's point of view and, and advice on aesthetic breast surgery.

Doreen Wu (28:35):
I'll also add my thanks to Dr. Pozner for being with us. I certainly understand a lot more about the important considerations and decisions to be made when choosing a breast implant. If you think of other exciting trends or developments in plastic surgery that you would like us to discuss in a future episode, please reach out by email or Instagram. We'll see you next time. This is Doreen Wu thanking you for joining Dr. Bass, Dr. Pozner and me for this discussion of breast implants and how to select them. Be sure to join us next time to hear about another aspect of this fascinating field, as always, don't forget to subscribe to our podcast. So you don't miss any of the exciting content that is coming soon.

Announcer (29:16):
Thank you for joining us in this episode of the Park Avenue Plastic Surgery Class podcast with Dr. Lawrence Bass Park Avenue plastic surgeon, educator, and technology innovator. The commentary in this podcast represents opinion. This podcast does not present medical advice, but rather general information about plastic surgery that does not necessarily relate to the specific conditions of any individual patient. No doctor-patient relationship is established by listening to or participating in this podcast, consult your physician to advise you about your individual healthcare. If you enjoyed this episode, please share it with your friends and be sure to subscribe to our podcast on Apple Podcasts, Google, Spotify, Stitcher, or wherever you listen to podcasts.