S05E86 Size Matters - Navigating Choices in Breast Implants
Embark on an insightful exploration of breast augmentation with hosts Dr. Sam Jejurikar @samjejurikar, Dr. Salvatore Pacella @sandiegoplasticsurgeon, Dr. Lawrence Tong @yorkvilleplasticsurgery, and Dr. Sam Rhee @bergencosmetic
as we navigate the nuanced landscape of sizing patients for breast implants, marrying aesthetic desires with anatomical must-haves.
This episode peels back the layers on how we, as plastic surgeons, harmonize a patient's vision with practical considerations, ensuring the chosen implants complement their individual body frame and personal aspirations. Together, we delve into the interplay between motivation, self-esteem, and the surgeon's role in guiding choices that resonate with each unique patient.
Sizing isn't just about numbers—it's an art form, and this episode pulls back the curtain on the personalized techniques and cutting-edge technologies we wield to sculpt confidence. We discuss the hands-on approach with sizers, which affords patients the opportunity to 'try before they buy,' often leaning towards a marginally larger implant to nail the anticipated look. We also examine the digital revolution in consultations, where 3D imaging, powered by AI, is transforming the way we visualize potential outcomes and the continued impact of virtual consultations post-pandemic on the evolving practice of plastic surgery.
As we conclude, the spotlight shines on the potent combination of patient autonomy and the surgeon's expertise in cosmetic surgery. Nurturing a relationship anchored in trust and informed choice is paramount, especially when considering larger-than-life implant sizes. We unpack the collaborative process, empowering patients to steer their journey while leaning on our professional acumen for what's achievable. Tune in to discover how we align dreams with reality, ensuring patients are not just satisfied but truly elated with their surgical decisions.
@3plasticsurgerypodcast #podcast #plasticsurgery #cosmeticsurgery #plasticsurgeon #beauty #boardcertified #aesthetic 3plasticsurgeonsandamicrophone #bergencosmetic #bestplasticsurgeon #beforeafter #aesthetics #realpatientrealresult #boardcertifiedplasticsurgeon #njplasticsurgeon #njplasticsurgery #nyplasticsurgeon #nyplasticsurgery
00:00:06 Sizing Patients for Breast Implants
00:14:11 Implant Sizing Techniques and Technology
00:18:53 Choosing Breast Implants With Breast Lifts
00:33:09 Empowering Patients in Plastic Surgery
S05E86 Size Matters - Navigating Choices in Breast Implants
TRANSCRIPT
[00:00:00] Dr. Sam Jejurikar: Welcome everyone to another episode of 3 Plastic Surgeons and a 4th, not and a mic, and a microphone, even though there's only 3 Plastic Surgeons today. Um, as always, I am Sam Jejurikar in Dallas, Texas, and I'm joined by Dr. Lawrence Tong in Toronto, Ontario, who is at Yorkville Plastic Surgery. And Dr. Sam Rhee from Bergen County, New Jersey, who is at Bergen Cosmetic.
Um, and today we're going to talk about an interesting topic that was actually prompted by a conversation we had a few podcasts ago, and that is How we size patients for breast implants. Um, at, at the previous podcast, Dr. Rhee had made a quip about patients with large implants. I think you said 650
[00:00:51] Dr. Sam Rhee: and then
[00:00:52] Dr. Sam Jejurikar: and
[00:00:52] Dr. Sam Rhee: it
[00:00:53] Dr. Sam Jejurikar: implied somehow that they might have low self esteem or might have, uh,
[00:00:58] Dr. Sam Rhee: will do
[00:00:59] Dr. Sam Jejurikar: he'll get to, he'll get to actually.
I'm not going to present his version of the thing, but of what actually happened, but, but suggest that maybe they had motivating factors that weren't, weren't the best. And, you know, we, uh, we didn't really get into how we actually help our patients pick implants. So that's going to be the focus of what we talk about today.
Um, before we get into the meat of the, uh, of the issue, uh, Dr. Tong, you want to lead us with the disclaimer?
[00:01:22] Dr. Sam Rhee: is not
[00:01:23] Dr. Lawrence Tong: Absolutely. This show is not a substitute for professional medical advice, diagnosis, or treatment. This show is for informational purposes only. Treatment and results may vary based upon the circumstances, situation, and medical judgment of the appropriate discussion. Always check, always seek the advice of your surgeon or other qualified health professional with any questions you may have regarding medical care.
Never disregard professional medical advice or delay seeking advice because of something in this show. So
[00:01:50] Dr. Sam Rhee: So, um, this
[00:01:54] Dr. Sam Jejurikar: I guess just to lead off, um, you know, a lot of times when I will see patients coming in for a breast augmentation consult, they'll have pictures from social media where they will show pictures of other patients and they'll say, I really like this result. I want a 450 cc
[00:02:08] Dr. Sam Rhee: I want a
[00:02:09] Dr. Sam Jejurikar: moderate profile plus implant.
What they don't know is the height of that other patient, the weight of that other patient, and how that patient might actually compare to them. And so, we have to take a step back in terms of how plastic surgeons think about, um, you know, sizing patients for implants versus how patients might do it. So, Dr.
Tong, imagine you're seeing a new patient in your office who wants to talk about a breast augmentation. She's there in your office. She's a blank slate. She wants to know what you think. How do you approach how you're going to help this patient select the right size of breast implant?
[00:02:43] Dr. Sam Rhee: So, the way I sort
[00:02:45] Dr. Lawrence Tong: the way I sort of think about this at a, um, like a zoomed out view is that, um, primarily you want to get a result that the patient wants. So you need to know what kind of look the patient wants and obviously the consultation is is for them to tell you that, and they might show you pictures from, you know, whatever source.
But then, I think the job of the plastic surgeon is to guide that patient along so that they can choose an implant that meets their needs as much as possible. And the caveat to that is, there are going to be certain factors that the plastic surgeon will Um, uh, be assessing to try to get the sort of, uh, best result for them.
Um, things, uh, like their anatomy. Uh, things like, um, you know, if they have, um, specifically, if they have already fairly large breasts or small breasts, or what is, what are their measurements, if they have asymmetries and things like that. So, I think it's my job to sort of try to guide them as they choose their implant.
I never, the kind of,
[00:03:56] Dr. Sam Rhee: at somebody
[00:03:57] Dr. Lawrence Tong: Surgeon, and I'm sure you guys aren't either to just look at somebody and say, okay, you have to have this sort of implant. Uh, my God, my job is sort of to guide them to try to choose the best implant that works for them and also fulfills, um, uh, their sort of, um, wants or at least as close as possible.
[00:04:19] Dr. Sam Rhee: So, uh, let me provide my version of the story that, uh, that Sam is talking about in terms of how we got to talking about sizing of implants.
Um, Larry, you're absolutely right. Uh, it is our job to guide patients. Uh, there are a lot of factors that you mentioned that all play a role. But the reason why we brought this up and we discussed it before, it was a couple episodes ago. ago we were talking about difficult patients and I had a patient who came in and I said, she says, I want to, I want 650 cc implants because my sister has 650 cc implants and that's exactly what I want.
And I said, well, I think it behooves us to find out a little bit, like, what is the motivation of this patient? Are you, you know, what's your relationship? Like, what, why are you mentioning your sister when you're talking about your body? And the quip, That, and obviously it was a joke, that Sam said, was, Well, what I would say is, you know we go up to 800, why not go bigger? Because everything's bigger in Texas, so that's what, uh, So that would be the response that, um, someone liked. Dallas Plastic Surgeon, Dr. Jejurikar would say, and he's obviously kidding, but I would say, uh, when you size a patient, there are many motivating factors, as you mentioned, uh, in, that patients bring to the table, and one of them is, I want to look like someone, whether it's in social media, someone they know, Someone who has, uh, already had breast augmentation, and that's pretty common as well.
And so, what Larry said is we have to help navigate it. You might have a look, but that implant might not give you that look. So what is it that we have to do? What factors? How do we guide you, uh, to get to that look that you want? Even if you don't look like me. That person did before they had their plastic surgery done.
So how do you do that? Dr. Jejurikar in Texas.
[00:06:18] Dr. Sam Jejurikar: As it turns out, everything is It is not bigger in Texas. Um, you know, so I think what you guys have been saying, um, is that we need to have a dimensional analysis to the patient when we're thinking about how we're going to get an implant that's going to fit our patient. We're thinking about anatomic measurements.
Specifically, what's the width of their chest wall? What's the width of the breast on the chest wall? And what's the degree of breast ptosis, which for the, which for the listeners out there is the degree of drooping is that they have, and all of those factor into our decision making process. Fact of the matter is, if you pick an implant that's too wide for a patient's chest wall, it's not going to look good.
And it's probably going to lead to some postoperative complications. Within that, you know, within those measurements of implants that will, quote unquote, fit in the chest wall though, plastic surgeons are able to vary what's called the implant profile. The implant profile is basically an adjective that describes the relative width of the implant, um, and how much it sticks out for that width.
So the more the adjective sounds like the word high or extra high, the more the implant sticks out relative to a given width. And the more it sounds like low or moderate, the less it sticks out. And in general, and there's a lot of exceptions to this, but in general, more natural looks are, uh, are more affiliated with a profile that is going to sound more like the word low or moderate.
Conversely, a faker look or one that sticks out and gives you a slope on the upper aspect of the breast is one that, um, is going to give you a faker look. And that's more of a high, a higher profile look. So my approach is dimensional analysis, two measurements. Figure out, like you guys were talking about, what's the look the patient is going for, and then figure out what is actually possible.
So, gentlemen, let's say we do this dimensional analysis. And you have a patient with a really wide chest wall. Um, let's say they have a base width of their, of their, uh, of their, you know, their breasts of 14 centimeters or 15 centimeters. And they say, no, I want a really small implant. I want an implant that's only going to be about, you know, 150 cc's.
I barely want you, barely want you to even be able to see it. How do you handle that situation?
[00:08:33] Dr. Sam Rhee: want to get, like,
[00:08:35] Dr. Lawrence Tong: So,
[00:08:36] Dr. Sam Rhee: How do
[00:08:36] Dr. Lawrence Tong: you know, in some cases,
[00:08:38] Dr. Sam Rhee: know, in some cases,
[00:08:39] Dr. Lawrence Tong: this may or may not be one of those cases, but in some cases, what a patient wants, they can't necessarily get. So,
[00:08:46] Dr. Sam Rhee: that.
[00:08:47] Dr. Lawrence Tong: um, if a patient says,
[00:08:50] Dr. Sam Rhee: is a
[00:08:51] Dr. Lawrence Tong: this, this is a classic, I want to, um,
[00:08:55] Dr. Sam Rhee: large
[00:08:55] Dr. Lawrence Tong: you know, I want this large size implant, but, um, I don't want it to feel
[00:09:02] Dr. Sam Rhee: or,
[00:09:02] Dr. Lawrence Tong: that heavy. You know, or, you know, they'll say things sometimes that contradict each other and then sometimes I'll have to tell them well, you can have one or you can have the other, you can have a compromise between the two and you can't always get it.
But in the, in the example that you mentioned, so
[00:09:21] Dr. Sam Rhee: an implant
[00:09:22] Dr. Lawrence Tong: the listeners, in general, we like to choose an implant that is going to fit.
[00:09:27] Dr. Sam Rhee: is 50cm,
[00:09:28] Dr. Lawrence Tong: So, if the example is 15 centimeters, you sort of want to, ideally, try to choose an implant that's about 15 centimeters wide. Um,
[00:09:38] Dr. Sam Rhee: as the
[00:09:39] Dr. Lawrence Tong: and for the listeners, in general, as the width of the implant increases, the size of the implant also increases.
So, the volume of the increase, uh, implant increases. And so, if you're choosing a 15 centimeter implant, Implant, you're usually going, you're usually, uh, obligatorily having a larger implant. So the way that I would deal with this, um, if she doesn't want a larger implant, first I would say, well, you're going to have to go a certain size.
But then the other thing I would do is, as Dr. Jejurikar had mentioned, is probably go with a lower profile. So that means that the implant doesn't stick out that much and it won't have as much volume. Um, and so that can. Achieve, you know, a smaller, uh, cup size. Um,
[00:10:25] Dr. Sam Rhee: Um,
[00:10:26] Dr. Lawrence Tong: goal when I size patients Uh, is to try to get, um, an implant with, uh, that fits their chest, and then based on, um, on that, we'll start trying some implants, and when I say trying some implants, the typical thing I'll do is have a patient, uh, put on a bra that, uh, that we have, sort of a tighter fitting sort of sports bra, and we'll have all the implants there in the office, and they can be put on.
Um, you know, try any of these implants on, and I'll start by, you know, picking a size that's sort of in the mid range of what I think, or very close to what I think they'll want, and have them look in the mirror after they have them on, and then they can give me some feedback. If they want to go bigger or smaller, then we'll just keep going bigger or smaller until they get to the point where they, they have sort of have it narrowed down to a size that they want.
Usually it just takes a few minutes. Um, you know, tries and patients generally get a pretty good idea of what they want.
[00:11:27] Dr. Sam Rhee: a
[00:11:28] Dr. Sam Jejurikar: Do you find that that's accurate? That using a sizing bra and using implants correlates pretty well with how they're going to look postoperatively?
[00:11:34] Dr. Sam Rhee: is
[00:11:35] Dr. Lawrence Tong: the other thing that I have is the, uh, the imaging, um, which is, um,
[00:11:40] Dr. Sam Rhee: It's a
[00:11:41] Dr. Lawrence Tong: it's a system where, uh, for the viewers, they, uh, they get, go in front of a, um, a camera system,
[00:11:49] Dr. Sam Rhee: picture of
[00:11:50] Dr. Lawrence Tong: takes a picture of the chest and then computer software generates a three dimensional model from that. And then from that software, you can actually try on implants.
And, um, they can see what it generally will look like. Um,
[00:12:04] Dr. Sam Rhee: like.
[00:12:05] Dr. Lawrence Tong: the one that I use, uh, is Vectra. Um, there are other, uh, competing systems. I find that actually Vectra is less accurate than, um, trying the, the, uh, the implants on with a bra. So,
[00:12:21] Dr. Sam Rhee: Docs.
[00:12:22] Dr. Lawrence Tong: I'll, I'll use, uh, the trying on the implants as my primary. method. And then sometimes if patients want to see what that looks like to the Vectra, um, I'll do that.
But I find that visually, or for whatever reason, the image on Vectra looks smaller than what they'll get. And I learned this a while ago when I first started using this system where I would have patients only choose their implants using the Vectra imaging. And what I found was that they consistently chose an implant that was way too large.
[00:12:57] Dr. Sam Jejurikar: Interesting.
[00:12:57] Dr. Lawrence Tong: Yeah, so I don't, I don't have any experience with the other systems, but that's what I found to be the issue. And I found that with the, you know, dimensional analysis and trying on implants. With a bra, that's generally the most accurate way to get a happy patient. Yes, the bra method is not entirely accurate.
I usually tell patients that they can expect a slightly smaller size when the operation is finally done. So, I would say maybe anywhere from about 10 to 15 percent smaller than what they're seeing in the office with the bra method.
[00:13:36] Dr. Sam Jejurikar: You okay, Dr. Rhee? You're, you're channeling season one Breaking Bad Walter White over there.
[00:13:40] Dr. Sam Rhee: Yeah.
[00:13:41] Dr. Sam Jejurikar: What?
[00:13:41] Dr. Sam Rhee: Uh, just a little con, just a little, uh, congestion there. I'm, I'm, uh, I'm feeling okay, but I would say this, uh, so I, you're right. I think the two measure, the two ways most surgeons will help, uh, patients is either with some sort of imaging software or with some sort of sizing, uh, ic, uh, physical sizer type, uh, method with dimensional analysis.
And I, uh. I think both, both ways can be really helpful for patients. I think it is very dependent on the surgeon, just like we always say in my hands, blah, as a surgeon, like same thing with how we help patients get to implants. I don't think there's one right way. I think whatever way that that surgeon chooses, that is the way that works for them.
Just like we have different instruments, techniques that we all use that, that vary in some way. I think for me, I, uh, am a Sizer guy, uh, for a couple reasons. Um, one is I like that patients can sort of feel what that weight is, uh, when they put it in them. Like you can't, when you see a picture, it looks awesome, but Lady, you gotta live with that, and you gotta walk around with that, and you gotta exercise with it, you gotta move with it.
And you may or may not necessarily understand that, but when you use a sizer and you put that in, there is a palpable sense of that. Um, uh, I think the other thing is, is uh, that for me, sizers tend to go a little small. Like, so Larry, you're, you're, you think you have the OR, if you use the same size, you would go 10 to 15%.
It ends up being 10 to 15 percent smaller. I think, I think the same. I actually have to go up a little bit with the implant to, to reach the desired sizer that they want. So, um, For whatever reason, I have experimented with imaging. I think imaging is great, and I know, Sam, you use it, so I'd like to hear your take on that.
Um, it, it really is what, uh, what you make of it as a surgeon helping your, your, your patient. I think it's not likely that I will see a patient who's 15 centimeters wide who wants 150 cc implant. It's usually someone who's like, really tiny and petite, who wants. A really large implant. And that's where we're sitting there saying, listen, this may or may not be even technically feasible, and even if it is, you may not like that look.
And so it, it really is, as, uh, as Larry said, you know, working with. different volumes, different sizes to help a patient because I have had some very, very small petite patients who wanted very large implants at first. And I said, listen, my job is to help you achieve what can be technically or realistically achievable.
And, and this is, is, this is not the case in this instance, but most patients fall somewhere in the middle where they, they can physically accommodate the implant. It's really about aesthetically achieving that, that, that That, that result that they want.
[00:17:20] Dr. Sam Jejurikar: I also found that if they liked the way that the sizer looked. If I was going behind the muscle with my implant, I'd have to go up cc's to accomplish that look. I think there's something about the implant sitting in front of the breast that makes it look more projected in a sizing bra that probably contributes to the look that the patient wants.
So when you're going behind the pec muscle or even just behind the breast gland, you need to accommodate for that. I've used Chrysalix, which is sort of the other competing, major competing, uh, 3D imaging to Vectra that Larry was talking about. I've never used Vectra. Um, I've used CrystalX a lot over the last eight years and it's changed a lot over the last eight years.
I didn't think it was very good when it first came out in all truthfulness. Around the pandemic they, they really started changing the software. And started incorporating more AI and machine learning to it. And that the models they were creating were, were better. And they just keep getting better as the sort of AI machine learning component is, is, uh, changing.
And they've actually just updated it in the last couple of months so that it's gotten even more accurate. I do find that it is pretty accurate and that the looks that I accomplished from a sizing standpoint, match up pretty closely. And, and I also like it because if I'm doing an initial consultation virtually with a patient, which is a lot of the patients that I see, it kind of became a big thing during the pandemic and it's sort of stuck with us.
I can do that with Crystallix and actually do a really good job of sizing people and then I'll see the patient the day before their surgery, just to confirm it with measurements. Um, but I do agree with you that having that palpable sense of what the weight of the implant does. This is important for many patients and I think particularly if they're going with an implant that's really large, it's important for them to get a sense as to how heavy that might actually be.
[00:19:06] Dr. Sam Rhee: actually be. Uh, I
[00:19:08] Dr. Sam Jejurikar: I want to
[00:19:08] Dr. Sam Rhee: ask you
[00:19:09] Dr. Sam Jejurikar: ask you guys about another very common scenario that we see, and that is how does your choice of breast implants
[00:19:16] Dr. Sam Rhee: uh, vary if you
[00:19:17] Dr. Sam Jejurikar: vary if you see a patient that has a lot of breast ptosis and you think they need a simultaneous breast lift?
[00:19:24] Dr. Sam Rhee: Uh, do you
[00:19:25] Dr. Sam Jejurikar: Meaning, do you still use the same metrics to pick the implant or might you be more conservative in your choice of implant if you're going to do additional procedures on a patient to tighten their breast gland at the same time?
[00:19:38] Dr. Sam Rhee: going to do is, when, um,
[00:19:41] Dr. Lawrence Tong: uh, for the viewers, When, um, a patient has, um, droopy breasts, you can't necessarily just put an implant in because, um, the implant will sit at a certain point in the chest, and if the breast is fairly droopy, it's going to sit way below that implant, and it's going to give you a very strange look. So in those cases, uh, we will discuss having a breast lift.
Now, breast lift is a procedure that involves, um
[00:20:10] Dr. Sam Rhee: that
[00:20:11] Dr. Lawrence Tong: Reshaping the soft tissue, moving the nipple and the areola upwards, and it involves removing, um, some skin when we do that surgery. So in those situations, you have to be wary of that because, uh, when you put an implant in, you're going to make the skin envelope tighter because you're expanding the volume.
[00:20:33] Dr. Sam Rhee: At
[00:20:34] Dr. Lawrence Tong: At the same time, if you're doing a lift, you're going to be removing skin. So you have to be very careful that you're not getting into a situation where You are putting in an implant that's so large and then you're trying to do, um, a breast lift at the same time that, um, makes it so that all the incisions are very, very tight.
And that's detrimental because, um, in the worst case scenario, you can have the wound open up. That's unlikely, but in a more common scenario, the scars are going to work worse. Whenever there's a lot of tension on the scars, when the scars are tight, uh, the body is going to So, in a sense, that the wound is, needs to be stronger.
And it's going to respond to that by putting down more scar tissue. You know, that's what you don't want. You don't want to have a bad looking scar when you do these surgeries. So to answer Sam's question, um, I won't
[00:21:27] Dr. Sam Rhee: um, I won't, um,
[00:21:28] Dr. Lawrence Tong: be as liberal in terms of the overall implant size. When somebody is going for a breast lift at the same time, um, that might just be limiting the actual volume or maybe in some cases,
[00:21:42] Dr. Sam Rhee: in some
[00:21:43] Dr. Lawrence Tong: um, sticking to a, you know, a moderate profile as to, um, as opposed to a high profile implant.
I find that, you know, I've been surprised when, um,
[00:21:54] Dr. Sam Rhee: when, um, sometimes
[00:21:55] Dr. Lawrence Tong: sometimes I've thought that, you know,
[00:21:58] Dr. Sam Rhee: where they
[00:21:59] Dr. Lawrence Tong: in a patient where they might have chosen an implant that I thought was going to be certain size after the lift. It actually looks a lot bigger once the lift is done, for whatever reason. So I think that, um,
[00:22:11] Dr. Sam Rhee: So, I think that,
[00:22:12] Dr. Lawrence Tong: my general approach is choosing an implant that's probably a little bit smaller than what I would usually use if I was doing a primary breast augmentation with no lift.
[00:22:23] Dr. Sam Rhee: I mean, I think there are a couple moving targets here when you're working with a patient, uh, who has a certain amount of ptosis or droopiness. So the first is determining how much droopiness there really is. Yeah. And how much is the patient willing to accept? Because as you know, when you do a lift or a mastopexy, you're putting scars on the breast.
And that's a, that's a hard stop for a lot of patients. And I understand that. Uh, if that's the case, you as a surgeon have to help the patient understand how much droopiness or as Larry says, artosis, they're going to end up if you just put a straight implant in, and there are different ways we sort of manipulate it, like techniques and stuff to try to help with that.
But, uh, you know, that's, that's something that you have to sort of work with the patient and understand. And I have in many, many patients gotten, you know, they're willing to accept a certain amount of droopiness. They even think it's a little natural appearing. Put in a reasonable implant and, and they were really happy with that.
In other cases, I just know, listen, this droopiness is way too much. There's no way you're going to be happy. I think, uh, from what I can tell talking to you that You would accept that without, without these incisions. And in that case, um, I've gotten, you know, I think mastopexy og or what we're talking about with putting implants in with a breast lift is very surgeon, like, it's experience dependent.
I've gotten way more comfortable over the past five or six years doing it than I ever was. I mean, this was something back in the day when we trained that, you know, was like a, Third rail, be careful, you know, sort of situation. And I think with experience, I've gotten comfortable with fairly large implants with a lift.
Now the issue really is, you can achieve a pretty good result, like even a great result that way. But you gotta remember, Droopiness is progressive and it will continue. And so I talk to patients, you choose a really large implant, we can do a great lift, but that doesn't mean that that weight isn't going to keep pulling that breast down.
And so there are ways to mitigate it. I know, um, Sam, you might talk about that or, or what you might use or different techniques. I know, Larry, you might talk about that too, but, but it's really a complex interplay of, Like, what do you feel comfortable as a surgeon putting in? What is the patient willing to, uh, have in terms of scars?
And, Will the final result turn out the way that that particular patient wants? And I think experience counts for a lot. There's a lot of intuitive thinking when I talk to a patient about it, like, you know, as Larry said, can I make sure the scars stay nice and tight? Can I make sure I get the nice lift?
And a lot of patients, when you put an implant, if they're droopy to begin with, just getting the lift alone makes them feel like they're bigger. To a certain degree, because it's always been that volumes and so down on their chest, sitting on their, you know, halfway down to their belly. Once you just put that volume up, they'll, they feel like they've gotten an og almost.
So you have to sort of play that into consideration. So as you said, Larry, it might be a smaller implant, but they might think it was actually a bigger implant just because of the reshaping that you did with it.
[00:25:42] Dr. Sam Jejurikar: I think those are great points that you both made. Um, you know, I, I am very much sort of of the Larry school of thought where in general, if they're doing a lift, if they need a lift and they want a simultaneous implant, I do tend to heavily try to steer my patients towards smaller volumes. And more moderate profile implants.
Um, I, again, I, this is why I like 3d imaging, um, because I can, I can sort of, I feel pretty good that the images I'm showing them with that are pretty accurate of what, you know, and, and if it's clear that when they see that, but that's not going to be enough volume for what they want in that scenario, I either will try to convince them to be happier with a smaller volume, or I'll try to actually talk them into staging it where they would do the lift in stage one.
Maybe do some fat grafting at the same time to give them a little more upper pole fullness. Um, but ultimately come back six months later, do a relatively straightforward breast augmentation to give them the size that they actually want. Because, um,
[00:26:43] Dr. Sam Rhee: know, it's not, it's
[00:26:44] Dr. Sam Jejurikar: although it's not a hard and fast, I won't put in a big implant.
My complication rates pretty high when I put in a big high profile implant at the same time as doing a lift. It can be recurring droopiness, it can be poor scars, it could be widened areolas. It could be all of the above, um, but, but it's, you know, it's not, it's not insignificant. So, um, you know, patients will tell you at the time of a consultation that they're going to be okay if they need a revision, but they're really not that okay with it if they need it when the time actually comes.
actually comes. But, but I do think, you know, I think that the trend that we all have here and that we're all saying is if you're needing a breast lift, there may be a situation, if it's a mild degree of, uh, you know, ptosis where an implant alone might make you happy. And that's important to communicate that with your patient.
But if you need a breast lift, nobody wants a breast lift, but if you need one, you need one and you're going to have to get it. And then the timing of the implant will very much depend on, you know, how much volume you actually want.
[00:27:45] Dr. Sam Rhee: What, what size do you guys consider big? Cause I rarely, honestly put in anything more than about a 550 in my practice. Like 600 plus is pretty unusual.
[00:27:58] Dr. Lawrence Tong: In, in a general sense, yeah, I would say, I would say 500 is, is my sort of, you know, Definition for a big implant. Of course it depends on the patient's height and chest width and their overall body habitus, but in general 500 is the cutoff point for me because I think that Despite the body habitus,
[00:28:22] Dr. Sam Rhee: The
[00:28:23] Dr. Lawrence Tong: the weight is the same, no matter who you put it on.
And that's the cutoff where you start seeing the complications. The malposition, the stretching of the skin, the unpredictable way that implants settle. So I think around 500 is when I start telling patients, okay, you can, you can get this implant, but there are higher risks that could potentially happen.
It's not necessarily going to happen for sure, but the rate starts jumping up at that point.
[00:28:52] Dr. Sam Jejurikar: Are you, are you referring to big with a primary A or with an aex.
[00:28:58] Dr. Lawrence Tong: I'm referring to primary OG, so I would very rarely put in a 500cc implant in an OG mastectomy. Of course, again, depends on the patient's body habitus and height, but I can't think of the last time I did that.
[00:29:14] Dr. Sam Jejurikar: Yeah. I, um, you know, I, I think, not to make too nuanced of an answer to your question, Sam, but, um, I mean I've had, I had two sisters recently who were both like six foot one that I operated on and, um. And for them, I think I used 450, 400 cc implants and that was a very conservative, moderate profile implant that didn't look like that big of an augmentation.
But in your typical, you know, 5 1, 5 2, 5 3 patient, I would consider that to be reasonably large. I think I consider, you know, with that, with that disclaimer, I think I would consider anything bigger than about four 50 to be a big implant. That doesn't mean I don't put in big implants for primary SI do it.
I mean, I do it with some frequency, uh, but, but, but I, but it, it, it tends to be more of a high profile implant in a patient to try to fit that dimensional parameters that we were talking about before.
[00:30:12] Dr. Sam Rhee: Got it,
[00:30:21] Dr. Lawrence Tong: a patient comes in with, uh, something from Instagram or whatever, they show you a photo on their phone, this is what I want to look like, and then you measure them out, and you say, okay, you can, you know, it'll work for you, and then you, you have them try the implant, what you think will, uh, achieve that, and then put it on, and they go, Bob, this is way too big. Do you guys get that reaction? Because I get that
[00:30:43] Dr. Sam Jejurikar: Yeah, sometimes.
[00:30:44] Dr. Lawrence Tong: often, I think,
[00:30:46] Dr. Sam Jejurikar: Yeah.
[00:30:46] Dr. Lawrence Tong: I, and I think that's just a reflection that what you see on the internet might look good to you, but when it's on yourself, it might not be that appealing.
[00:30:57] Dr. Sam Jejurikar: It's, it's like an old wives tale where, um, where patients always used to come in and all their friends would always, always would tell them, well, you know, go, you know, when you see the implant you like, just go a little bit bigger. So you don't have. Regret over that. That's just not the way it is anymore.
More commonly, there's concern that they're going to end up too big. Um, and so I think, I think what you're describing is very common, Larry. Um, and then conversely, it seems to be just as common that patients think it's not big enough when you Pick the implant that, that, that, uh, you know, that you think is going to work for them.
So,
[00:31:30] Dr. Sam Rhee: Uh, I don't see as many of those as I see of patients who are indecisive and they are vacillating over one size versus another and they can't make up their mind and they talk to their friends and then they come back.
And so those are the patients that I often counsel, listen, don't listen to anyone else. Go with your gut. Whatever your real intuition is telling you, that's what you should stick with. And more times than not, if you, if they really go with what they feel true to, to themselves as opposed to listening to others, they are more than happy.
And sometimes it takes a little bit of resisting peer pressure when everyone's telling you, go, like you said, go a little bigger, make you know you're gonna regret it, blah, blah, blah. And, and they say, you know what? I think this is really what I want. More often than not, that's, that's, they're, they're really happy with what they, when they stick to their guns and they choose what they choose.
[00:32:24] Dr. Sam Jejurikar: yeah, I agree. Well, as we wrap this episode up, gentlemen, what are, what are sort of the key points you think our listeners need to take away from, from what we've talked about today?
[00:32:35] Dr. Lawrence Tong: So I think that, um, it's important for your surgeon to take into account your anatomy and for your surgeon to take into account. what you want to achieve and have your surgeon sort of guide you through the process of choosing the one that hopefully will achieve both of those, you know, both of those things optimally, but also understanding that sometimes you have to make some degree of compromise on one or the other.
[00:33:03] Dr. Sam Rhee: I think there are a lot of patients who have told me of surgeons who tell them, this is what you must have, or, you know, sort of take the decision making process out of their hands. That is not what we're talking about here. If you listen to Larry and Sam, we're, we're helping you try to achieve what you want, but you have to know what you want and you have to, you have to.
Know that that's what our goal is. We're, we're not trying to make you look a certain way. You tell us what you want and we'll tell you if that's technically possible or what it would take to achieve that. And we have a lot of different ways of doing that, as you mentioned. So. You know, the best thing to do is pick a surgeon that you trust, stick with that trust, but also believe in what you believe in terms of what you want.
And, and nine times out of 10, we'll help you get there.
[00:33:53] Dr. Sam Jejurikar: Yeah. Well said. And, um, I don't think I have much to add to that, but to our listeners, if Dr. Rhee does happen to be your surgeon, just remember that if your implant is 650 or greater, or I guess 500 or greater, he may be wondering what your motivation is. And with that, thanks everyone for listening, and we'll wrap up this episode yet again.
