Are My Breast Implants Too Old? The Answer is Maybe

Announcer (00:02):
You are listening to Alabama the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis.

Kirstin (00:11):
Hey, Dr. Koehler.

Dr. Koehler (00:13):
Hey, Kirstin.

Kirstin (00:15):
What do you want to talk about today?

Dr. Koehler (00:18):
I always leave that up to you.

Kirstin (00:21):
You never want to pick.

Dr. Koehler (00:23):
All right. I don't know. What's your favorite movie?

Kirstin (00:27):
Oh, I thought this was a plastic surgery podcast.

Dr. Koehler (00:31):
Well, go ahead, give me a topic.

Kirstin (00:33):
Okay, on our last episode, we talked about breast implants, so do you want to talk some more about that?

Dr. Koehler (00:39):
Sure.

Kirstin (00:40):
Okay. You told us that breast implants don't last forever and that they're not meant to.

Dr. Koehler (00:45):
No, they are not meant to.

Kirstin (00:47):
Well, then today I want to talk about what happens when the day comes that those breast implants need removed or we need new ones.

Dr. Koehler (00:55):
Sure.

Kirstin (00:56):
Okay. So how long should we expect implants to last usually?

Dr. Koehler (01:01):
Well, it just varies. There's not a number. I mean, there's no surgeon out there that can say, oh, this will last you five years, 10 years, 15 years. Certainly I know myself, and I'm sure any doctor that does this. We've had patients that have required revision surgery in short periods of time, maybe six months to a year for various reasons. And there's people that go 15 plus years doing great without any issues. So there are some pitfalls that come along with implants. Some of them can be avoided to a certain extent, but some of them are just unfortunately your bad luck. And when that happens, then we need to discuss doing a replacement. So I guess the two most common unplanned reasons for replacing implants would be if the implant leaks and if it's saline, you're going to know because it'll go flat pretty quick with silicone, you may not know, but it may show up very rarely.

(02:02):
It may be detected on a mammogram, but really you typically need a MRI or a screening ultrasound to determine it's ruptured. But if imaging shows it's ruptured, then it should be replaced. It's not like it needs to be replaced that week. I mean, certainly you can get on the schedule and get it done. It's not urgent, but it does need to be replaced. So the first reason would be a rupture. And the second reason would be capsule contracture. And capsule contracture is one of the nuisance problems that we have with implants. So any implant of any kind, whether it's a pacemaker or a breast implant, the body will form scar tissue around that. And it's a thin layer of scar tissue. And in breast surgery, we call it the capsule, and it's supposed to be there. That's what we expect to happen. But what we don't want to happen is for that thin layer of scar tissue to become thicker and start to tighten up around the implant.

(03:02):
And there's a number of reasons why that could potentially occur, but one of them is considered bacteria that's within your body that at the time of placement, your own body's bacteria can get on the surface of the implant and create a biofilm. And again, it's not an infection, but it can be a contributing factor to over time creating thicker scar tissue that tightens up around your implant. So when you get that, and it's usually not bilateral, it'll be one side and not the other, although I've seen it bilaterally plenty of times too. But what'll happen is the patient will come in and they'll be like, well, my right breast is soft. It feels good, but my left one, it's sitting up high and it's hard. And that's typically a capsule contracture. And so those are the two main reasons that we would need to do some kind of replacement or revision surgery. But sometimes people just want to change their size. Sometimes the implant has maybe changed position over time, and it needs to be put back in place.

Kirstin (04:06):
Be put in its place.

Dr. Koehler (04:08):
Yes.

Kirstin (04:09):
Does anybody ever come in and just want their implants out for any particular reasons?

Dr. Koehler (04:14):
Yes, we do see that. Actually, I won't say commonly, but there's definitely been a trend over the last maybe five years or so of women having concerns that their health may be affected by implants, and so they would like them out. And so we see a lot of people to do that, to take them out. The only thing that we can really tell these people is we're happy to take their implants out and do the necessary treatments that they're requesting. But right now, there's not really good data. There's not a blood test, a skin test or some kind of test that we can say, oh yes, your body doesn't react well to silicone. We can do if you have a nickel allergy. I mean, it's pretty obvious when you have earrings that have nickel in them and your ears turn all red, but you can do an allergy test and see that you're allergic to nickel. There's not really any good testing. And so can these implants affect a person's health? Maybe, we just don't know enough at this point in time, but we do have people that want 'em out for that reason. Sometimes people are like, yeah, I got these when I was younger and I loved them at the time, but I'm just done. I want 'em out. We will take 'em out and maybe we'll do a lift. There's a lot of different scenarios there, but yeah, we see people that want 'em out for various reasons.

Kirstin (05:29):
So what are signs to look for that a patient may need a breast implant revision?

Dr. Koehler (05:35):
Well, I mean, we talked about a couple. If the implant was ruptured, if they had that tightening, then we would do an exam and talk about options. Each scenario has its own set of challenges or issues that you might need to address, but again, the implant may position could change over time. So not uncommonly implants that are under the muscle when if you are working out a lot or just the movement of daily activity, your pectoral muscle flexes and doing that, it tends to push the implant up and out. And over a period of time, it can stretch out that pocket and your implants can start to sit a little bit more laterally. So sometimes we'll have people that come in, they're like, yeah, when I'm standing up, they look good, but when I lay down, my implants are under my armpit or they way over the side, the implant's still under the muscle.

(06:25):
It's just that the pocket, the muscle has kind of pushed that implant laterally over time. And so in those cases, we do a revision surgery to try to move the implant back to the midline and close up that space that's been created laterally. Or maybe they went with an implant that was too big for their body to handle, and so now it started up sitting high on their chest, but now it's dropped down and now it's sitting too low. And in those cases, we'll have to move the implant back up and maybe we need to put something in there to support it and hold it in place.

Kirstin (06:59):
Can under the muscle implants ever be moved to over the muscle or vice versa?

Dr. Koehler (07:04):
It's much more common to move above the muscle implants to under the muscle, not typically the other way around, although sometimes that may be an option in certain circumstances. But usually what we see is people who had maybe older implants, especially the old silicone that were put above the muscle, that was pretty common back in the day, and then they got capsule contracture. And so we do know that when if you have capsule contracture, especially if it's above the muscle, and even though you take out all the scar tissue and put a new implant in, if you put that new implant back above the muscle, there's probably like a 25% chance that it's going to form another thick capsule. So a lot of times what we do is it's called changing the plane. So we just take the implant that was above the muscle and we put it under the muscle.

(07:50):
We know that the rate of capsule contracture is lower when you have implants under the muscle, which is why nowadays most people have their implants or why most surgeons put the implants under the muscle. The implant is not in as much contact with breast tissue. And as I mentioned earlier, the bacteria that's in the duct of the breast is implicated in causing capsule contracture. So when you put it under the muscle, most of the implants under the muscle, but actually part of it is not typically. And so it's still in contact with some breast tissue, just not nearly as much as if you're above the muscle.

Kirstin (08:26):
So we talked just a second ago about bigger implants and possibly needing to help support that. So that procedure, at least online or in communities online is called the internal bra technique. We explain to us what that is.

Dr. Koehler (08:43):
Yeah, so we call Victoria's Secrets and we get them to send us the appropriate cups, no.

Kirstin (08:50):
Yes. Okay.

Dr. Koehler (08:52):
Yeah, no, the internal bra is, I mean, it actually is a pretty accurate thing. Hold on on a second. I just happen to have one of these here so I can show you.

Kirstin (09:02):
Oh, yay. I love show and tell.

Dr. Koehler (09:04):
Yeah. So this is actually an example of one of the materials that we use. This particular one is called GalaFLEX, but what you can do, let's see if I can get this in the camera. Here's like an implant, and then the mesh would be under the bottom of the implant. And then anyhow, the mesh is the top part. The top part here is sewn to the muscle, and then the bottom part here is sewn to the chest wall. And so it truly acts like a cup supporting the implant. It's not something that we would routinely do with a straightforward breast augmentation, although you could, it just adds a lot to the cost when we know it's not needed for a routine breast dog. But in patients who their tissues can't support it then, and you're doing a revision, well, then that's something we might consider.

(09:51):
Years ago before we had these materials, we would just do something called a capsulorrhaphy where we would do internal suturing to try to lift that implant up. And the problem is is that especially if that capsule, the scar tissue is kind of thin, it doesn't hold the suture well. And so it works good right at first, but then it kind tears and breaks away. And so long term, it doesn't hold the implants in place as well. It's not as predictable. I've done many capor and had it work perfectly fine, but the mesh definitely makes it more predictable.

Kirstin (10:26):
Well, the incisions be in the same place when you go back in for a revision versus your primary?

Dr. Koehler (10:31):
Well, if we're talking about putting mesh in, if you had your incision through the areola or underneath the breast, the inframammary approach, then yes, possibly you can use those incisions. But if you had it through the belly button or the armpit, then the answer is no. You cannot do that surgery through those incisions. So it's certainly, I think, for me, easiest and most predictable and safest to place it through an inframammary incision. When you're putting that kind of mesh in.

Kirstin (11:00):
Does it matter if you go bigger or smaller than your primary augmentation during a revision?

Dr. Koehler (11:06):
It depends. So if the problem really was because your tissues couldn't support it, and even with the mesh, I mean, do we really want to push the limits and try to, do we want to do another one? I mean, we might have to go smaller. So it just depends. Again, each case is so different, and that's where you need to have that discussion with your doctor. And I would listen to your doctor if they said, look, it's not safe to go bigger. Well listen to that. I mean, sometimes people just want to hear what they want to hear, unfortunately. But if you get an opinion, and certainly I always encourage people to get other opinions, but don't just go around until you find the opinion you want to hear. If you see two doctors and they tell you the same thing, then maybe you need to listen to that. But that's why getting other opinions can be important.

Kirstin (11:56):
Yeah. So on that note, should you go to the same surgeon who did your initial augmentation for a secondary surgery?

Dr. Koehler (12:03):
If you still have confidence in that surgeon and just realize every surgeon that does this has revisions. If they say they don't have any revisions, they're either lying or they have not done enough surgery. So I mean, it's unfortunate. I mean, surgery is not perfect and we are not perfect people. But the thing is the revisions are for straightforward. Breast augmentation are typically not high, but they are absolutely real. But yeah, I mean, I certainly would want my patients to come back and see me for the revision surgery if they had confidence in me. If they didn't, well then they need to see a surgeon they feel confident in. But the one good thing about you want a surgeon that feels confident in handling their own problems, so I mean, just because you had a complication doesn't necessarily mean that your surgeon is bad. I mean, everybody expects to be problem free and all that kind of stuff, but I promise you, even the best surgeon, if you could tell me, oh, I've heard this doctor's the best. They have complications, all of us do. So anyhow, I just think I would at least go back to your original doctor and talk to them. And then if you want other opinions, yeah, I get other opinions, but at least I would start with your other, the doctor that did it.

Kirstin (13:15):
Does a revision always involve swapping out the old for a new, or are there other options like fat transfer or something else?

Dr. Koehler (13:24):
Well, I am not a huge fan of fat transfer to the breasts. I'll share a couple stories where I'll at least tell you why I don't like it. Years ago, many years ago, it was really considered malpractice to put fat in the breast, but nowadays it's accepted and it's used in reconstruction for breast reconstruction. It can be an adjunct to what other things are being done, like an implant placement. So it has a place, but I would just say this, if fat grafting to breasts was really a good idea, why are more people not just getting fat grafting to the breasts? You would think that that would be a thing, but try and find it. There's people that do it, but the reason it's not a thing is because if you want a certain size, you can't predictably get that with fat grafting, or it may take multiple surgeries to get to where you want to be.

(14:16):
And fat grafting can have problems with cyst formation and microcalcifications and other issues. So it's not without its own set of problems. And so to me, if somebody says, well, I want my implants out and I want fat grafting, I mean, first of all, you got to have the fat. So if you're thin, it may not even have the fat to do that. But even if you do have the fat, recognize that it could require multiple surgeries and you still may not get what you want. So it's not ideal. It's a tool and we use it, but it's not a replacement for implant surgery.

Kirstin (14:46):
Is recovery about the same as a primary breast aug, or is it easier or harder?

Dr. Koehler (14:51):
Well, it depends. If you just have a ruptured implant, and if you don't need to have the capsule taken out and you're just swapping an implant out, well then the recovery's really easy. The next day you'll be like, well, did I have surgery? I don't even feel like I had anything done. But if you have to have a capsulectomy, which means removing all of that scar tissue around the implant, well, there's a lot of raw surfaces there. It's tender. You might have a drain tube, and that's not necessarily comfortable, but if you have those things, it's just part of the process. So I won't say that that's more painful than the original surgery, but it's certainly not like, oh, next day I feel great. There is a recovery associated with that. So it just depends what the revision is. And if you have to have that mesh put in, having that suture to your chest wall can be a little uncomfortable. It's not terrible, but there's some discomfort associated with that.

Kirstin (15:37):
Do you have the same roles for as far as six weeks back to the gym and that kind of thing?

Dr. Koehler (15:44):
Yeah, I'd say more or less. That's a general rule for most things, but that can be modified. I mean everything, if it was really difficult, I may want some more time before they start putting stress on a repair. So as a general rule, I think, yeah, that's probably safe, but there's always exceptions.

Kirstin (16:03):
How long does somebody need help at home after a revision?

Dr. Koehler (16:08):
Well, I mean, if somebody like yourself, they may need it for months. It's hard to say. I mean, I'm kidding.

Kirstin (16:16):
I'm a strong independent woman, Dr. Koehler.

Dr. Koehler (16:18):
Yeah, I know. No, I mean, really the first 24 hours you need somebody there. You've had anesthesia. You cannot be left alone even though you might feel great and you're like, oh, I'm fine. Listen, you've had anesthesia. Somebody needs to be around. So first 24 hours after that, you might be perfectly fine on your own. You might not need somebody. But again, we don't want you doing anything crazy. I don't want you doing heavy lifting. If you have young children, you need help. You can't be picking up kids. So every situation is different as far as what your personal needs might be. But as far as just typical discomfort, I mean, you'd probably be fine on your own the next day to take your medicine and do what you need to do. I mean, you can still walk and you can still go to the fridge and get food and all that kind of stuff. We just don't want you doing heavy lifting and driving a car until you're off pain medicine. So it depends what your needs are.

Kirstin (17:08):
So if somebody comes from out of town and flies to see you, which actually we have a current patient that's coming back for her second surgery from California, but are they safe to fly home right after?

Dr. Koehler (17:19):
Well, I don't know what you mean by right after. I wouldn't do surgery and get 'em on the plane that afternoon. But I think I generally like people to stick around for a week so I can at least look at their incisions and when we take their dressings off, we can advise them, make sure everything is a okay. And then if everything's good at the one week, then sure. I don't know. It depends a little bit on the surgery. Sometimes if it's a bigger surgery, if they can stay longer, I certainly would encourage it. I mean, that's the problem that we have with people that fly out of the country and get surgery. They fly out of the country, then they come back in the country and then they have an issue, and then nobody wants to touch 'em because they didn't do the surgery.

(17:58):
So just think about that. I mean, I always find it flattering when patients say, oh, I'm coming from California to have you do my surgery, and that's awesome. I mean, I'm glad that you're coming and we want to help you, but we just realize if there's issues, you may need to come back and see us, or we may want you to stay a little bit longer if it's a more complicated surgery. But yeah, I mean most of the time people do. 99% of the time it's smooth sailing. Go home. You could go home in a week.

Kirstin (18:23):
So we've talked about financing on previous podcasts. Just want to remind everybody that we take financing and those options are on our website, and you can apply straight from the website for those financing options. But also, one of the questions that I have for you, is there somebody here in the office that can help patients get approved for financing?

Dr. Koehler (18:43):
I'm talking to her.

Kirstin (18:45):
Me?

Dr. Koehler (18:47):
Can't you? Can you not help?

Kirstin (18:48):
I can. I can help do that for sure.

Dr. Koehler (18:51):
Yeah, we've got lots of people in the office that can help.

Kirstin (18:53):
But yes, we have two surgery coordinators, Jessica and Denva that love to help people get some money for surgery.

Dr. Koehler (19:00):
Okay. And they're great. They're both really good.

Kirstin (19:02):
They are wonderful. Okay. Do you have anything else to add about revisions?

Dr. Koehler (19:06):
I will add something about revisions actually. So I mean, I would just say this to patients. If it's a simple revision, maybe it's no big deal, but we occasionally see people who've had two or three prior breast surgeries and maybe their situation is not really ideal. Those can be extremely challenging cases. Certainly mean sometimes those cases are really rewarding because you can really help somebody out. But they also are stressful for the patient and the doctor because I want to do it in one surgery and get them fixed and get them happy. But sometimes people don't like it when I say, okay, this is going to be two surgeries, or this could be more than two surgeries to get you where you want to be. Again, sometimes when people recommend, we're going to do baby steps and we're going to do part one here, and then this'll be part two, it's for a reason.

(20:02):
It's for your safety. And I sometimes feel that patients think that, oh, we're telling 'em that because we want to do two surgeries. I definitely don't want to do, if I can do it in one, I want to do it in one. But if I'm telling you two, that's a reason. I mean, you've got a difficult, difficult case. And anyhow, people who've had multiple or had a bunch of revisions and they have difficult revision surgeries that are required, I mean, they need to go in with a open eyes and just really understand that we don't have a magic wand and we may never be able to get them to their ideal, but hopefully we can get them close. And those are definitely people I strongly encourage. Definitely get more than one opinion before you choose your doctor, because we want you to make sure that you feel good about what we're telling you. There may be somebody out there that's willing to do it in one procedure when we say two, but I just know I've been doing this for a long enough time. If I say two, there's a reason I'm saying two because I've seen I've tried to do it one, and maybe it's just not the best way to do it. There are sometimes safer, better ways to do it.

Kirstin (21:13):
Agreed.

Dr. Koehler (21:14):
Anyhow, that's my soapbox.

Kirstin (21:15):
In my professional opinion. Agreed.

Dr. Koehler (21:20):
Okay. Thank you.

Kirstin (21:20):
Okay.

Dr. Koehler (21:21):
I'm glad you agree with me.

Kirstin (21:24):
Okay. On our next episode, we're going to be doing our first ever call in Q and A with Dr. Koehler. If you have a burning question for me or Dr. Koehler, don't forget to go to our podcast website at Alabama the Beautiful podcast.com, and look for the button that says record a voicemail along the side. We can't wait to hear your questions. I can't wait. I'm so excited.

Dr. Koehler (21:48):
Oh my God. <laugh>

Kirstin (21:51):
Okay. Thanks Dr. Koehler.

Dr. Koehler (21:53):
You're welcome. Bye.

Kirstin (21:55):
Go back to making Alabama beautiful.

Dr. Koehler (21:57):
I'm on it.

Announcer (21:58):
Got a question for Dr. Koehler? Leave us a voicemail at Alabama the Beautiful podcast.com. Dr. James Koehler is a cosmetic surgeon practicing in Fairhope, Alabama. To learn more about Dr. Koehler and Eastern Shore Cosmetic Surgery, go to eastern shore cosmetic surgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, Apple Podcast, Spotify, or wherever you like to listen to podcasts. Follow us on Instagram at Eastern Shore Cosmetic Surgery. Alabama the beautiful is a production of The Axis, T-H-E-A-X-I-S.io.