S05E89 Mastering the Craft of Breast Augmentation Through Long-Term Study Insights

Discover the keys to a successful breast augmentation as plastic surgeon hosts Dr. Salvatore Pacella @sandiegoplasticsurgeon, Dr. Lawrence Tong @yorkvilleplasticsurgery, and Dr. Sam Rhee @bergencosmetic unpack the findings from Dr. Paolo Montemurro's 12-year study, a treasure trove of data and experience featured in PRS Global Open. Step into the surgical room with us and understand the factors that influence complication rates, with a keen eye on the meticulous techniques to improve patient outcomes. Capsular contracture, often a chief concern, is dissected for its occurrence rates and preventative measures, emphasizing the role of submuscular placement. With the insights drawn from comparing our own practices to Dr. Montemurro's, we chart a course for safer, more effective procedures that prioritize patient well-being.

Navigating the nuanced waters of patient characteristics and their impact on breast augmentation, we sift through the complexities of textured implants and the implications of BMI and initial cup size on postoperative complications. Dr. Montemurro's research throws a spotlight on the delicate balance of implant volume and risk, a conversation we bring to life with our collective wisdom. Surgeons at any career stage will find value in our chapter highlighting peer learning and knowledge exchange. Embrace the continuous journey of growth and education as we share the gratitude for insights that propel the surgical community forward. Join us and elevate your understanding of the art behind the science of breast enhancement.

Dr. Sam Jejurikar @samjejurikar @3plasticsurgerypodcast #podcast #plasticsurgery #cosmeticsurgery #plasticsurgeon #beauty #boardcertified #aesthetic 3plasticsurgeonsandamicrophone ⁠#bergencosmetic ⁠#bestplasticsurgeon #beforeafter #aesthetics #realpatientrealresult #boardcertifiedplasticsurgeon #njplasticsurgeon #njplasticsurgery #nyplasticsurgeon #nyplasticsurgery

#BreastAugmentation #BreastImplants #MedicalResearch #CapsularContracture #PatientCare #SurgicalComplications #SurgeryTips #MedicalAdvice

00:00 Introduction and Overview of the Study

05:08 Implant Placement and Surgical Techniques

13:05 Shaped Implants: Pros and Cons

23:14 Patient Education and Expectations

S05E89 Mastering the Craft of Breast Augmentation Through Long-Term Study Insights

[00:00:00] Dr. Sam Rhee: Welcome to another episode of Three Plastic Surgeons in a Fourth. And as always, I have my esteemed colleagues, Dr. Sal Pacella, Salvatore Pacella from La Jolla, California. His Instagram handle is at San Diego plastic surgeon, Dr. Lawrence Tong from Toronto, Ontario, Canada. And his Instagram handle is at Yorkville plastic surgery.

And of course, still missing, but due to return very soon is Dr. Salvatore. Sam Jejurikar from Dallas, Texas, and his Instagram handle is at samjejurikar. Um, our topic today is about a single surgeon, basically a surgeon who has done over 1, 200, uh, surgeries. Breast augmentations, and over 12 years, and he recently published his experience in PRS Global Open, and I thought it would be a very interesting, uh, discussion to talk about what he found were his, uh, Problems, issues, uh, characteristics about his breast augmentation, and then compare them a little bit to ours and see if what we do, uh, jibes with what Dr.

Paolo Montemurro from, I think it's Sweden, that's such a Swedish name there, um, uh, does, and, uh, and, uh, see if, uh, you know, if we agree or disagree with, with what Dr. Montemurro has done, uh, in his, uh, extensive experience. Uh, but before we proceed, uh, Dr. Tong, if you could give us the disclaimer.

[00:01:44] Dr. Lawrence Tong: My pleasure. This show is not a substitute for professional medical advice, diagnosis, or treatment. This show is for informational purposes only. Treatments and results may vary based upon the circumstances, situation, and medical judgment after appropriate discussion. Always seek the advice of your surgeon or other qualified health provider with any questions you may have regarding medical care.

Never disregard professional medical advice or delay seeking advice because of something in this show.

[00:02:11] Dr. Sam Rhee: So the study. evaluated 1, 200 of his patients, and his average, or sorry, mean age of these patients was 31 years old. And he followed them for at least six months after surgery, and he is going to report, and he reported all of the different statistics and characteristics of these patients and the implants and, and how, what his outcomes were like.

And, um, let's just start with the complication rate. His total complication rate was listed at 7.1%, and the most common complication he reported in his series over, uh, from 2009 to 2021 was capsular contracture, which he reported occurred 2.64% of the time. Uh, what do you think about that complication rate as well as.

Capsular contracture. Complication rate.

[00:03:15] Dr. Salvatore Pacella: Well, he's only following the patients for six months, right?

[00:03:18] Dr. Sam Rhee: Uh, mean was 18. Minimum, 6. Average, 18 months.

[00:03:23] Dr. Salvatore Pacella: Oh, okay. 18 months. Okay. Um, so, I mean, it's, it sounds relatively low from the standpoint of capsular contracture, right? I think, um, you know, I think if you, if you look at the literature, I've heard the rate, um, anywhere from 10 to 33 percent I've heard. Um, and so I, you know, I commend him that, that. That rate is very low.

It's cur I'm curious to know what, um, what he rinses the implant with, um, you know, what his hematoma rate is, what, you know, the size of the implants, the texture of the implants, submuscular, subglandular. These are all kind of factors that have been shown in the literature to affect the risk of capsular contraction.

[00:04:09] Dr. Lawrence Tong: I think that, um, No, his rates are very good. Capsular contracture, I would say, aside from maybe cosmetic issues, is probably, you know, the most common type of, um, complication. Um, I would say, and I'll ask you guys, if you see capsular contracture in a patient, uh, would you say it's usually within that first 18 months of, um, of surgery?

Because in, in my, you know, in my experience, yes, I would say it's within the first year, uh, you would generally see it. But I, I would say that. You know, capsular contracture rate in my hands is generally fairly low. I do probably 99 percent of my breast augmentations, um, under the muscle. And I think that by far is the most important, um, factor.

But, um, Sam or Sal, um, what is your common sort of, or most common mode or, um, way that you perform the surgery?

[00:05:13] Dr. Sam Rhee: me, I do it almost, uh, a majority of them through an inframammary incision. So that's under the breast, not around the areola. And I would say almost all of them are under the muscle or what we call dual plane, uh, which is what this guy reported. He reported 96 percent of his implants were placed dual plane and maybe 3.

7 percent were sublangular. So I don't know if that jives with you. Sal, in terms of what you do,

[00:05:43] Dr. Salvatore Pacella: Yeah, I would say that probably a good 90 95 percent I do, just like you two guys, dual plane underneath the muscle. I think that's a very low rate of any complications. Um, I, in general, I think my complications are, or my, uh, capsular contracture rate is relatively low. And I think, you know, I've never seen this really reported in the literature, but I have a distinct feeling that Professionally, that one of the risks of capsular contracture is the size of the implant.

I have found that when patients come to see me and secondarily, and they've, they have capsular contracture, it's usually a very large implant stuffed into a very small And that, to me, can contribute to issues. So, in general, I would say that my implant usage is very small to modest size. Very kind of yoga mom type of appearance.

Not, I don't see massive, massive breasts. Um, in the sub glandular implants, I do. Um, it's usually in someone who is very exceptionally fit, who is worried about a pectoralis animation deformity. And invariably in those types of patients, I'll use some sort of additional tissue support with it, um, like a mesh.

[00:07:03] Dr. Sam Rhee: he does mention that he found using a funnel reduce the risk of capsular contracture. And that I think, I mean, I like both of you, my risk of my occurrence of capsule contracture is pretty rare, but I am also, and I'm sure you guys are also pretty fanatic about no touch, about the antibiotic and the betadine use.

Um, all of those things are crazy important to me when I do a breast implant, uh, placement. And I think that those are things that have been proven, uh, in the literature to, to help. Um, the large size implants, that's very interesting. Um, what would you consider large? Like, um, Over what volume? His mean implant volume here was 316.

And

[00:07:56] Dr. Salvatore Pacella: Yeah, I, I would say not necessarily large in the sense of, you know, a thousand CC implants. I rarely ever see that, but I would say a mismatch, like a D sized cup going into somebody that's a tiny. You know, five foot, 105 pounds, you know, that's, you know, so it's not on a numerical standpoint, it's a proportion issue, you know.

[00:08:19] Dr. Sam Rhee: do you think that's because of the dissection is exceptionally hard, there's more bleeding, or is it just, you know, mechanically, there's more

[00:08:28] Dr. Salvatore Pacella: I think it's my, I think it's mechanically very tight and I think it's a contraction issue. I think a lot of times when I've seen this, the pocket has been under dissected. And with the intention of, well, I'm going to stuff a big of an implant is into this tiny pocket that I can find without causing any lateral distent or contraction.

rising up high. And so it's a, it's a, you know, hand in glove type of situation, you know,

[00:08:54] Dr. Lawrence Tong: our viewers or listeners out there, um, just want to, um, clarify a few terms. So capsule contracture is something that occurs when an abnormal amount of scar tissue forms around the implant. So whenever you put a a foreign material in the body, whether it be a breast implant, a chin implant, any kind of prosthetic joint or anything, the body is going to react by putting some scar tissue around it.

And that's normal. However, In some cases, you can have excessive amount of scar tissue, uh, forming around the implant, and in a, in a breast implant, that excessive amount is called, uh, is termed a capsular contractor, and what can happen is that it makes the breast feel hard, it can make the shape of the breast, um, look abnormal, and, uh, it can cause pain and discomfort in, uh, in more severe cases.

So we are, as surgeons, we want to try to avoid that type of, uh, complication. And so we have talked about different ways that we do the surgery in order to minimize that risk. So the theory of why capsular contracture occurs, um, in breast implants is, uh, the biofilm theory, which in essence is a theory that, uh, Um, says that, uh, bacteria, small amounts of bacteria can get onto the implant, um, for whatever reason and that, uh, bacteria, um, stimulates the, the scar, uh, formation.

So what we are trying to do when we're doing these surgeries is trying to minimize that effect from happening. So placing it under the muscle, which is something that we, um, all generally do seems to have a protective effect. And why is that? Uh, It's theorized that when the implant is, um, over the muscle, um, that means that the, um, implant is directly in contact with the breast tissue.

And when it's in contact with the breast tissue, then, um, bacteria can actually go through the, the nipple, which is, um, an opening. Go backwards and maybe seed the implant. That's, that's one of the theories. So if you have the implant under the muscle, uh, that doesn't tend to happen because the implant generally is not in direct contact, uh, with the breast tissue.

Cleaning it with, uh, solutions. So antibiotic washes, betadine, which is, is a form of iodine that we use also is theorized to, uh, to kill, um, the bacteria and, uh, decrease, uh, the rate. So, I agree with what both of you said that, um, you know, doing those things. Oh, and the, um, the funnel. Uh, so that is a way where we can insert the implant in which it's a place through it.

Um, a disposable device. Um, that's sort of like a, what is that called? An icing funnel that you see that they use for, uh, Topping cakes. You can actually squeeze an implant through that so it doesn't touch the skin, and that's what's termed as the no touch technique. You don't have

[00:12:01] Dr. Sam Rhee: or gloves.

[00:12:03] Dr. Lawrence Tong: or gloves, that's right.

So your hands aren't even touching it. So that is theorized also to reduce the rate. So I think all those things are, are very positive and we should encourage it.

[00:12:14] Dr. Salvatore Pacella: the, the funnel I think is one of the most simplistic, most brilliant, um, inventions in plastic surgery in the last hundred years. I mean, it's so, so incredibly simple and it has saved so much time. It has like such, you know, great outcomes. And, you know, I just remember years ago in residency, just trying to jam your.

You know, this thing through a small little tiny hole. It's like, yeah. Um, you okay? Yeah,

[00:12:48] Dr. Sam Rhee: and like, using his fingers to try to shove it into a pocket, and I literally felt like, the implant was like, was already fractured or ruptured halfway just from jamming it in there. And, and the fact that we no longer have to do that is, is, is a blessing for sure.

[00:13:08] Dr. Salvatore Pacella: it's fantastic.

[00:13:10] Dr. Sam Rhee: Um, the one thing I want to point out in his case, which really blows me away is that 80, over 80 percent of his implants were anatomic and only like 18 were 18 percent were round, which, I mean, who uses anatomic implants anymore, honestly, like. Do you?

[00:13:29] Dr. Lawrence Tong: No, I don't, but you know, for the time period in which his data was collected and

[00:13:35] Dr. Salvatore Pacella: They were very popular.

[00:13:37] Dr. Lawrence Tong: Yeah, I don't think that's so unusual. I was never really on board with, um, shaped implants, uh, mostly because I didn't think that it, it gave the benefits that were purported, meaning the shape was actually all that different and it, and in my opinion, it gave other problems such as, uh, rotation and, um, now, as we know, um, a rare form of, uh, cancer that's associated with these, uh, textured implants.

So I never really got onto that bandwagon, but, um, you know, his. This surgeon's data, I think, is consistent with, with the time period and where he was practicing.

[00:14:23] Dr. Sam Rhee: What about smoking? He had over, almost 10 percent of his patients, uh, were tobacco smokers, and I have never operated knowingly on a tobacco smoker for a primary breast augmentation, ever. Like, they might have lied to me, I don't know, but I have been pretty adamant that no patient should ever be on nicotine if I'm gonna do a breast augmentation on

[00:14:48] Dr. Lawrence Tong: So you mean, you mean when, when you're doing the surgery?

[00:14:53] Dr. Salvatore Pacella: he's in Europe, right? Um, Sweden. Yeah. I mean, it's, uh, probably a significantly larger proportion of smokers in Europe than in the United States, I would imagine. Um, You know, and if none of these are mastopexy patients, right, so, you know, yeah, so, I mean, in theory, you're not making these big, large flaps where there's, you know, skin to be necrosed.

Um, so, you know, I, I don't, I, that statistic doesn't necessarily surprise me. And I, and

[00:15:29] Dr. Sam Rhee: do you operate

[00:15:30] Dr. Salvatore Pacella: my, my understanding is there, no, no, I mean, I would try to avoid it at all costs, I think, you know. Um, but. Yeah, I mean, I would not willingly, yeah.

[00:15:43] Dr. Lawrence Tong: So, um, getting back, yeah, I, I tried to have patients stop smoking. I mean, for certain operations, that's a definite no go, like a tummy tuck or a facelift. For breast augmentation, I will tell them, With all, you know, as with all patients, you're making an investment. You want this to go the best it can go. So you should stop smoking. I would assume that a proportion of my patients who say they've stopped smoking probably haven't stopped smoking, but I think it's generally a little bit more acceptable for a primary breast augmentation than for some of those, um, other surgeons, but I wanted to get back to, um, an interesting point about the type of implant.

Do you guys still use, uh, shaped implants?

[00:16:33] Dr. Sam Rhee: No. Um, do they even sell anatomic smooth implants out there? Is that even a thing?

[00:16:40] Dr. Lawrence Tong: No, there's no such, there's no such thing. Um, and for viewers, the, the, um, the texturization. So implants come in smooth or textured. Texture is means that the implant has a rough surface on it. And what that does is, um, in the context of a teardrop shaped implant, it prevents the implant from rotating because once it's inside, if you have a smooth surface, that Teardrop could be upside down and that could cause some, some problems.

So all implants are, uh, textured. Um, so Sam, you don't use, uh, shaped implants. How about Sal, do you?

[00:17:17] Dr. Salvatore Pacella: uh, there was a period of time where I used it for probably a year or two, and then I was very unhappy with the appearance. I think, I think they're a little bit too stiff, I think you see a ridge up top where you're not supposed to, I think they distort themselves, and I, I actually believe that when it does develop a capsular contracture with the With a shape device, it actually looks a lot worse than it does with a round device, just because the distortion of the pocket is so odd shaped.

[00:17:48] Dr. Sam Rhee: Yeah. I, I've never loved them and I feel like, uh, I've taken some out recently and They're a bear to take out, I think, just because they're so adherent. And, uh, you gotta, I have had to be really, really slow and careful, uh, especially if there's any sort of capsular contracture around them, which I've encountered a couple of times.

Like, it's, it's just, uh, just to peel that, uh, Textured implant off is, is very tedious for me.

[00:18:17] Dr. Salvatore Pacella: Yeah, I sort of have the impression of texture devices that my daughter does when she orders something and doesn't like it. She says to the waiter, she's 11, didn't love this.

[00:18:32] Dr. Sam Rhee: Wow.

[00:18:33] Dr. Salvatore Pacella: I don't, I don't love them. I

[00:18:37] Dr. Sam Rhee: Let's talk about some of the other risk factors that are involved. He had a higher complication rate with patients who had a BMI of 25 or higher. Is that, do you feel like that is? In line with what you see?

[00:18:57] Dr. Lawrence Tong: I haven't tracked it, but I would say that in general, as, as a person has a higher BMI, their, their complication rate probably goes up. I don't, I mean, 25 is still a reasonable weight to do breast augmentation. Um, I guess it depends on what kind of complications you're talking about. If it's sort of minor complications, yeah. I can see that, um, if he, if, if the paper said 35 or higher, I could definitely see that, that to be true. Um, but, uh, no, I haven't, I, I haven't looked at my series, uh, but I would say that's possible.

[00:19:45] Dr. Sam Rhee: How about in Canada? Cause I would say that this guy was in Sweden. So I would imagine that, I mean, just on stereotypes alone, that we as Americans are just, you know, higher BMI population, uh, than the Sweden, uh, Swedish, uh, People, but, uh, in Canada, do you find the BMI to be comparable to Americans? Higher, lower, same?

What do you think?

[00:20:11] Dr. Lawrence Tong: So from, from what I see coming from, um, you know, Southeast Michigan, where I used to practice, um, coming to Toronto, the BMI is definitely lower. Um, in Toronto. Um, and, you know, I would, I would say that, you know, complications related to breast augmentation, I, I don't think it's really changed that much. But I think for, uh, things like, uh, body surgeries, uh, you probably have a higher I've seen a lower risk of complications from that.

Maybe not from, from, uh, from breast surgery. So, but definitely BMI is lower in Toronto than in Southeast Michigan.

[00:20:55] Dr. Sam Rhee: Uh, he also noted an increase in, uh, complications with patients who had initial B or C cup sizes versus patients who had an A cup size prior to surgery. Do you find that to be the case?

[00:21:12] Dr. Salvatore Pacella: mean, if anything, I would say the opposite is true in my practice. I mean, I think going from an A to a D cup, you know, thin skin, not a lot of extra breast tissue. You're going to see some rippling, some issues, potentially some bottoming out from structure. Um, small changes from a B to a C, C to a D. I think patients tolerate that really easily.

[00:21:39] Dr. Sam Rhee: How about you, uh, Larry?

[00:21:42] Dr. Lawrence Tong: Um, I would agree. I think that there, there's sort of like a, a spectrum, right? So if a patient. If they're too, um, you know, large, then they're more likely to have problems. So getting a patient sort of in that, um, ideal range is probably going to reduce, um, your complication rate. But, I mean, again, I haven't looked at my numbers.

So specifically, um, I, but what you said about the, you know, A versus B or C, I, I don't think I see that.

[00:22:22] Dr. Sam Rhee: How about implant volume range? She noted an increase in complications. If the implant was larger than 370 cc's versus under 370, how do you feel about that?

[00:22:37] Dr. Salvatore Pacella: Yeah, I mean, I, I, that kind of goes along with what I was saying a few minutes ago. I think, um, you know, the bigger the implant, the more weight, the more potential for bottoming out. I think, uh, putting a large implant into a small space, going up dramatically in size, I think is associated with some issues.

Um, so yeah, I mean, I, I would agree with that.

[00:23:02] Dr. Sam Rhee: Uh, what do you think patients can do best in terms of trying to avoid any complications for a primary breast dog? Like, what do you tell them, hey listen, this is what you need to do to minimize risk, to make sure everything goes smoothly.

[00:23:20] Dr. Lawrence Tong: So I would say, um, as a surgeon, you, you, you have to make sure that the patient is a candidate for, so, you know, general health, as mentioned before, you know, weight in the right, right range, make sure that they are not, um, you know, smokers or they're going to quit smoking. And then there, you know, the important things are for patients to follow in your, your, uh, instructions.

So you can get, uh, complications, um, from patients not, you know, following preoperative instructions. And you can have patients having complications from having, um, not following their, their postoperative instructions either. Like, trying to exercise too soon or, or not taking it easy after they've, uh, they've had surgery.

Um, but. You know, in terms of the size, choosing an implant that's going to, you know, work with their, um, with their frame, just like Dr. Pacella said, don't try to, um, force an implant into a patient that won't fit into them because you're going to be, um, asking for trouble and it's, you know, it's our role as surgeons to, to try to guide them through that process to choose the implant that's going to minimize the risk of complications.

[00:24:42] Dr. Sam Rhee: How about you Sal?

[00:24:44] Dr. Salvatore Pacella: I mean, same sort of thing. I think, you know, the last thing I would say in addition to everything Larry pointed out was, um, you know, just understanding expectations about size and, and such. Um, you know, I, I try to use a lot of photographs and pictures and sort of model, uh, on things that patients bring in to show me.

And I think that helps quite a bit to, to get realistic expectations.

[00:25:11] Dr. Sam Rhee: I think we should all take a trip to Stockholm, Sweden. I've never been there. I think it would be awesome to go visit this guy's practice and, uh, see what he does. I thought I would love to, um, sort of, I always love watching other surgeons. I always feel like I learned something from them. So I thought it was interesting that he decided to go ahead and present at this point.

I don't know what stage of his career he's in. Um. or, uh, why he decided after only 12, like 12 years. Like that's, I mean, I think all of us have practiced for longer than that at this point. So, um, you know, I, uh, I would, uh, I would like to pick his brain a little bit more. I appreciate him for publishing this.

Thank you guys. I really appreciate it. Uh, look forward to our next episode and as always, thanks again.