S05E93 Insights on Exercise Restrictions and Recovery After Cosmetic Breast Surgery

Ever wondered what the best approach is to recovering from cosmetic breast surgery and getting back to your fitness routine? Join hosts Dr. Sam Jejurikar @samjejurikar, Dr. Salvatore Pacella @sandiegoplasticsurgeon, Dr. Lawrence Tong @yorkvilleplasticsurgery, and Dr. Sam Rhee @bergencosmetic as they discuss advice on exercise restrictions post-surgery. The surgeons share their different protocols regarding how long to refrain from from upper body weightlifting to promote optimal healing, especially when implants are placed behind the muscle. Learn how to minimize risks such as hematomas, before gradually reintroducing upper body movements. The experts highlight the need for patience and careful progression to prevent complications and ensure long-term success.

We also tackle the tricky issues of lateral implant displacement and bottoming out in breast augmentation. Discover why even smaller implants can be prone to these problems due to pocket tension and why placing implants behind the muscle isn’t always the foolproof solution it’s thought to be. The surgeons also delve into strategies for mitigating these risks, including post-surgery exercise restrictions and precise muscle release techniques. They stress the importance of tailoring advice to individual patients, acknowledging factors such as an individual's activity level. The episode concludes with a crucial reminder: trust your surgeon and prioritize direct communication to ensure the best possible recovery and outcomes. Tune in for invaluable insights that could make all the difference in your recovery journey.

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S05E93 Insights on Exercise Restrictions and Recovery After Cosmetic Breast Surgery

TRANSCRIPT

[00:00:00] Dr. Sam Jejurikar: welcome everyone to another episode of Three Plastic Surgeons in a Fourth. I'm Sam Jejurikar in Dallas, joined as always by Dr. Sal Pacella in La Jolla, California, who is at San Diego Plastic Surgeon, Dr. Larry Tong in Toronto, Canada, who is at Yorkville Plastic Surgery, and Sam Rhee in Paramus, New Jersey, who can be found at Bergen Cosmetic.

[00:00:27] Dr. Salvatore Pacella: Ha ha ha ha!

[00:00:33] Dr. Sam Jejurikar: try to, I'll try to go on here today. We're going to talk about a topic that we all get asked about and I'm not sure if we agree on. So this will be very interesting, but we're going to talk about various exercise restrictions after different kinds of breast surgery.

Before we get into the meat of it, Rhee is going to read our disclaimer.

[00:00:51] Dr. Sam Rhee: Thank you. 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 circumstances, situation, and medical judgment after appropriate discussion with your provider. Always seek the advice of your surgeon or other qualified health provider with any questions you may have regarding medical care and never disregard professional medical advice or delay seeking advice because of something in the show.

[00:01:17] Dr. Sam Jejurikar: Alright, so the, uh, the genesis for this podcast topic is that we all have been asked by, um, our patients about exercise restrictions after breast surgery. Um, whether it's a breast augmentation, a breast lift or a combination thereof. And one of the things that I hear about from patients is that there's not a lot of consistency between surgeons.

They don't even understand our rationale behind it. So, um, Dr. Rhee, let's start with you first. What are your restrictions after a breast augmentation? Um, when it comes to doing just exercise in general, when it comes to upper body weightlifting, and does the placement of the implant in front of or behind the muscle have any impact on your recommendations to your patients?

[00:02:00] Dr. Sam Rhee: Yeah, I've gotten burnt a couple of times with breast augmentation and allowing patients to go back a little bit too early or, or maybe they took my guidelines a little bit too liberally in terms of what they did. And I've gotten more and more conservative as I've, you know, Um, I, I do, and you're right, there's no, there's no objective analysis or specific guidelines that I'm aware of in terms of breast augmentation and what sort of activities are allowed immediately or later, uh, in, uh, breast augmentation. I will say, I have heard surgeons say to patients, you should never do push ups again, you should never do certain exercises again, now that you have implants in place. And, um, I disagree with that. I think the long term, Um, outcomes for breast augmentation patients is pretty much anything you've done before you had breast augmentation.

Within reason, you should be able to do afterwards. Now, as a CrossFit coach and someone who, uh, works with a lot of CrossFit athletes, does it, does it matter? Make me wince a little bit when I see certain types of exercises being done. Uh, yeah, but I have not seen anything long term that tells me I need to restrict what, what patients do, uh, after.

Appropriate healing time. Now, during that initial healing time, I do know, and I have seen personally, that if you go too aggressively, especially as you mentioned, upper body activity, you can cause some major problems. You, you do need to allow that tissue to heal. Um, I do prefer most of my implants, um, to be behind the muscle.

Um, I don't do a ton that are only under the gland. Um, and I think that that pocket is one that Um, you know, you're cutting through the pectoralis muscle. There, there are real, uh, there's real trauma there in terms of allowing that area to heal with a foreign object in place. And so at this point, I am pretty much hardcore, you know, almost eight weeks.

Like, Can't really do much waist up. If you want to walk, you can walk. You can do very light Stairmaster, maybe Tops.

[00:04:26] Dr. Salvatore Pacella: Eight weeks, huh?

[00:04:28] Dr. Sam Rhee: Yeah, almost 6 to 8.

[00:04:29] Dr. Salvatore Pacella: do you, why do you, why eight weeks

[00:04:31] Dr. Sam Rhee: because they don't listen. So you say 8, they'll do 6.

[00:04:37] Dr. Sam Jejurikar: So really

[00:04:37] Dr. Salvatore Pacella: very, very, very scientific. I, I

[00:04:40] Dr. Sam Rhee: Yeah. So, so I go, I go beyond what I really should be. I'm overly conservative because I know that they're gonna kind of push it and go, well, he's, he said eight, so that means I'm, I'm, I heal fast, so I could do six or even four. And so, so I, I am very conservative now in terms of what I allow my patients to do.

And, you know, it's only a couple more weeks, so who cares? Like,

[00:05:02] Dr. Sam Jejurikar: so,

[00:05:02] Dr. Sam Rhee: into it.

[00:05:03] Dr. Sam Jejurikar: so I'm going to summarize your answer, because I want to go and ask everyone. For a standard breast aug sub pack, You say no upper body weightlifting for eight weeks.

[00:05:12] Dr. Sam Rhee: Yep.

[00:05:13] Dr. Sam Jejurikar: All right, Larry, what, uh, what, uh, tell me your philosophy.

[00:05:18] Dr. Lawrence Tong: Uh, so in the, in the early postoperative period, uh, I don't want them to do any form of exercise at all. And that would be for the 1st 4 weeks. Uh, 1 of my main concerns is actually, uh, hematoma. And, uh, for the, for the viewers, um, after you've had surgery, you're going to have a lot of little blood vessels.

that are healing and they're not that durable yet because they've been cut through and they've been cauterized, which means we, you know, use the, um, instrument to sort of singe the vessel. So it stops bleeding, um, or the blood vessel has clotted and they're not very durable. So if you elevate your heart rate or your blood pressure significantly, which is associated with exercise, you can get one of those.

blood vessels to pop open. And if they pop open, you're going to have bleeding inside. And once you have bleeding inside, you can have some major issues, um, all the way up to needing emergency surgery. So it's very important not to do anything that's going to elevate your heart rate or your blood pressure, um, in the first little while.

And I usually put that at about four weeks, of course. As time goes by, you're going to get, um, more and more healed and it's going to be more acceptable to, to do exercise for upper body. Um, exercises. I will start, uh, I will allow patients to start at 4 weeks after surgery, but I won't say that they can, you know, go back to, you know, bench pressing 200 pounds or something like that.

I want them to start. Um, slowly, see how they feel and gradually work their way up and probably by the time they hit about five or six weeks after the surgery, they can be back up at their original, um, you know, intensity. Um, and, you know, that's worked for me. Um, my patients generally, I, I believe they listen to me.

Maybe they've been doing it earlier than that. Um, and I've just been lucky and they haven't ran into any problems. Um, but usually I start them off at 4 weeks.

[00:07:27] Dr. Sam Jejurikar: And are you doing strictly subpectral placement of your implants or? Are you following the Canadian trend of a subfascial

[00:07:34] Dr. Lawrence Tong: No, I, I do not do subfascial implants. Um, I, I, I still believe that subpectral implants, um, give you, um, a superior, uh, result overall, uh, with everything, um, taken into account. I would say I'll do a few subglandular augmentations. I, I do, you know, very rarely do subfascial. Usually that's when a patient requests it and I've, you know, gone over the reasons and the pros and cons and if they're okay with that, then yeah, I'll do a subfascial.

Uh, but no, it's usually subpectral.

[00:08:11] Dr. Sam Jejurikar: Dr. Pacella,

[00:08:13] Dr. Salvatore Pacella: Um, so for straightforward augs, um, I usually, I usually want 'em to take it easy for the first week. And so what I, what I say by taking easy is I want you up walking around for sure can take a little stroll down the block if you like, nothing getting your heart rate up too crazy after the first week.

You can start to resume a little bit of cardio and there's a strategic reason for that. I think the risk of hematoma is really the, the, the, the concern I have in the first week. And, and if I, I personally feel if you get, if you get beyond 72 hours, I think the risk of hematoma is pretty limited in the first week after that.

So, so at the first week I allow them to do, get on the bike, get on the treadmill, do a little gentle jogging if they're up for it, keeping in mind that. You don't want to do this with your arms if you're holding on to something or you're doing a stationary bike, it's a much easier scenario. So, no, I don't recommend any lifting greater than 10 pounds, uh, until the fourth week.

So like Larry, I do four weeks. I don't think you really have to go out to six weeks or eight weeks, um, necessarily. Um, and I specifically tell them. You know, the key is listen to your body. I wouldn't, I would go very light for the first four weeks. Even if you were stopping your weight lifting for four weeks, you can't immediately go back to doing it the same way anyway, let alone surgery.

So you gotta really take it easy, go light, slowly work your way up. And, and I've found that to be reasonably successful. I, I don't think that sutures disrupt, even if I'm using mesh or some sort of other tissue support. Um, I haven't found that after four weeks. It's any, any major concern,

[00:10:08] Dr. Sam Jejurikar: and are you predominantly subpectral with your implants as well?

[00:10:11] Dr. Salvatore Pacella: you know, I'm, I'm kind of, uh, doing half and half now, so I am utilizing much more subglandular subfascial, but in those scenarios, I'm using some additional mesh support.

[00:10:24] Dr. Sam Jejurikar: I think I, yeah, I think I'm closer to Pacella and Tongue than to the Dr. Rhee, eight weeks of no exercise. Um, I do about 30 percent subfascial, about 70 percent subpectral. It's probably my, my estimate. I, um, Just like you guys, I'm worried about hematoma. I have had, uh, over the years, three patients get hematomas between weeks two and three for overzealous exercise.

Uh, one, one for a five mile run. One did a, one did a hardcore Pilates and spin class and, and, uh, and, uh, and a Pilates class. So I, I, I tell people no exercise at all for three weeks and at three weeks I'll let them do everything. One caveat though, patients that are really muscular that I've gone subpectral with, I do think if they start working out quickly, um, I think it'll take them longer for their implants to drop just because the muscle is so strong, but I don't think it really impacts their long term results.

Um, where I do change what I do specifically with upper body weightlifting is for, Secondary cases, whether it's an AugPexy and we're doing some sort of extensive capsule work, or if we're using mesh, like you had alluded to before. So before I start this, if I'm doing, if I'm doing a mesh case, let's say it's a AugPexy or someone who's implants have bottomed out.

And I, I almost always put those implants behind the muscle. Um, and I usually sew one edge of the muscle. Uh, to the mesh and those patients, I don't want to do any upper body weightlifting for about three months. Do you think I'm being overly conservative with that?

[00:11:56] Dr. Salvatore Pacella: Yes. Well,

[00:12:02] Dr. Sam Jejurikar: Okay.

[00:12:03] Dr. Sam Rhee: I mean, I've gotten burnt just like you have with the late hematoma, which is why I'm so conservative at this point. I, I, I never want to see that. Um, I don't, I don't see any major problem. Listen, I, I'm a fitness freak myself. So I understand that it can be difficult for patients not to want to exercise, but I deal with some very, um, You know, some people who do a lot of high intensity training, and if you let them go, they will just go crazy.

So I am very conservative with that. I, I feel like, um, having gotten burnt a couple times, I just don't want to deal with that. I want, I want to make sure. From a positioning standpoint as well, what, um, Sam said, like, I really want to make sure the implants have, uh, dropped into the right position. I want, I want all that to be okay before I cut, you know, I cut them loose.

Um, I think for pexies, uh, I, I sort of keep about the same, uh, protocol. Um, you know, you do have to watch the incisions a little bit more carefully, um, for scars and making sure that they heal nicely. But. I mean, you know, if, if I say eight and they cut it to six, I feel safe. If I say four and they cut it to two, I'm safe.

I'll get burnt. I know I will.

[00:13:22] Dr. Lawrence Tong: Yeah, I, I, I, you know, for, for most of my surgeries, my, my exercise protocol is, is basically the same. Four weeks and then you can start exercising again. For me, because, uh, I like to. You know, simplify things and do minimalistic sort of things. I don't want to have a protocol for every surgery that I do.

I'll just say. You know, take it easy for the first 4 weeks. You want to, uh, not do anything that's going to elevate your heart rate or your blood pressure. Walking is okay, but you know, not too fast. And then once you hit 4 weeks, you can start gradually reintroducing, uh, upper body or any kind of exercise.

And, you know, go slowly until you get back to your, your previous, uh, intensity. Do you guys think that, um, there's an issue? If you exercise too early about displacement of the implant, meaning it moving, I guess, too laterally, um, because that's what happens when, you know, for the viewers, the, when, when you have implants that are under the muscle and, and, uh, you contract the, the, uh, the chest muscle, the implants will naturally shift slightly laterally.

That's, That's generally not an issue after everything is healed, but do you guys feel that that can cause some problems with the positioning of the implant if it's done early

[00:14:44] Dr. Salvatore Pacella: mean, I, I, I disagree a little bit. I think it's an issue whether or not it's four weeks or 12 weeks or a year. I think part of the reason why I've converted a lot going towards, um, towards, uh, subfascial is to avoid that lateral displacement. And I've found that on a lot of, Primary AUGs I've done early in my career, they've come back, they've been happy, but they've bottomed, they've lateralized a little bit, and I think that's a real, real issue, just by nature of the operation, not necessarily on the immediate post operative period.

[00:15:20] Dr. Sam Rhee: Do you think that has to do with the volume of implant? Like when you're creating a pocket and you have a large volume that no, it doesn't

[00:15:27] Dr. Salvatore Pacella: No, I, I, no, because I, I,

[00:15:28] Dr. Sam Rhee: one 50 versus five 50, you don't feel like

[00:15:32] Dr. Salvatore Pacella: I, well, I mean, I mean, that that's a big difference, but say, like, say the difference between, um, a 325 and a 700, you know, I think it happens equally in a 325. Um, so yeah, maybe not in a 150 because it's relatively small, but any tension whatsoever on the pocket, I think there's potential for lateral displacement.

And that's a, that's a big disappointment in my opinion, in, in the way we've been taught to do breast augmentation. Despite the benefits of having it underneath the muscle with the reduction in risk of capsular contracture, I think the lateral displacement and the bottoming out is, is a, is an issue. Um,

[00:16:19] Dr. Sam Jejurikar: a behind the muscle is going to make them less likely to bottom out. Even after all this time, patients don't realize that the implant being behind the muscle doesn't mean that there's support along the lower margin of the implant and that they can still bottom out.

And in some ways with a lot of forcible contraction, at least theoretically, you could bottom out more because every time your muscle contracts, you could be. Pushing down with a downward vector on the implant, you know, in terms of what you're saying I think that a lot you know a lot of the cases that I do and I'm sure you guys do as well are secondary breast cases because Once you have a breast implant and you're committed to having it you're gonna need to have those implants exchange or lifts or what?

What not, just do chronically. In those cases, I think, um, I think I agree completely with Pacella. I think the smaller implants, um, can still very much laterally or inferiorly displace as much as the bigger implants. I don't necessarily agree with that with a primary aug. I don't think a 325 bonds out to the same extent as a 700 for a primary aug.

I just haven't seen that. But, um, but, but for secondary cases, I definitely would agree. Um, I will say that when it comes to these secondary cases, these Aug Pexes, I almost always go behind the muscle. I know some guys like going in front, but. I go behind the muscle. Um, and in those cases, when there are these cases where I'm doing a lot of capsule work, I let them exercise at four weeks, just like you guys, actually three weeks, but I won't let them do any sort of upper body forcible peck contractions if I can help it for three months.

Cause I do worry that a lot of these sutures that I'm putting in or the mesh that I'm putting in with forcible contraction of the pep can rip out. And I have had a patient in the past who unbeknownst to me was some sort of power lifter and, um, Two months afterwards, she completely detached the inner margin of one of her, uh, you know, of her mesh and she got this huge displacement that I had to reoperate on.

I'm sure you guys, Sam, you were mentioning you had a case where you had some issues too with your upper body working out.

[00:18:10] Dr. Sam Rhee: Yeah, absolutely. I think, um, you know, I understand when patients really care about their fitness, but as you said, you really have to let that pec muscle heal almost in its entirety before you can really start And, um, did you not know she was a powerlifter? Did she not look like a powerlifter? Wow, okay. I mean, most powerlifters I know look like Lou Ferrigno, basically.

I don't know. Okay. Okay.

[00:18:44] Dr. Sam Jejurikar: Lou Ferrigno. Not to me. Yeah.

[00:18:46] Dr. Sam Rhee: Alright, cool.

[00:18:47] Dr. Sam Jejurikar: Maybe she was new to the sport of powerlifting. She was a, an aspirational powerlifter.

[00:18:54] Dr. Sam Rhee: I always wanted to do powerlifting, I just thought that onesie was just a little bit too, uh, too aggressive a look for me, so I passed on that.

[00:19:03] Dr. Sam Jejurikar: Got it.

[00:19:04] Dr. Lawrence Tong: So, um, Sal, I was curious, so are you saying that you don't really get lateral displacement now if you, if you put these implants subglandular or subfascial? Because my impression is that that actually happens more. And I think that the. Lateral displacement, um, is, is related to the, the size of the implant.

I think that, um, when, uh, when you've had breast implants in, and when you sleep, the, the implant sort of, you know, how you, how you have patients complain that they don't drop into the armpits. I think that's because over time, if they're sleeping on their back, the, the mass of the implants will just slowly stretch that lateral pocket out and, and have it, you know, drift more and more to the side.

And I think that, um, the weight of the implant and, and time has a big deal, uh, to do with it. So the size of the implant plus time, I think can cause lateral, uh, displacement. A lot of times if a patient has a larger implant, they'll actually. advise them that they might consider wearing a bra to sleep, like a bra that pushes, uh, the implants together.

The other thing with, um, lateral displacement is that a lot of times you can prevent some degree of lateral displacement when you, when you, Put the implants in, you try not to release the muscle too much, release just enough so that you can get good positionings, especially medially. So the inner portion of the, of the muscle, maybe you just thin that out.

Maybe you don't cut all the way through, uh, so that it's totally detached. Because I think that once you detach more of the pec, you'll get more, more movement, more displacement, and that will, you know, cause, um, more animation. of the implant. So I guess, like, do you see less lateralization if, if it's over the muscle?

[00:21:09] Dr. Sam Jejurikar: You're on

[00:21:09] Dr. Sam Rhee: lost. Yeah. Mute.

[00:21:13] Dr. Salvatore Pacella: let me say, I'm almost exclusively doing subfascial with mesh. So I, with the caveat of preventing any of that from happening, I will say I think it's been incredibly successful. Um, I absolutely hear what you're saying when it comes to subfascial or subglandular without mesh and that's why I never really did or embraced that operation. And so, I, I don't, I'm never really in a situation where I'm doing a subfascial or subglandular without some sort of soft tissue support. And, and with the intention of maintaining cleavage, maintaining good medial position, preventing lateral displacement.

[00:21:55] Dr. Sam Jejurikar: These are primary orgs you're doing with MeSH

[00:21:57] Dr. Salvatore Pacella: Yes, yes.

[00:21:58] Dr. Sam Jejurikar: exclusively? Because, okay, because I'll do a fair number of subfascial without MeSH. Um,

[00:22:04] Dr. Salvatore Pacella: How do you, how do you feel they

[00:22:06] Dr. Sam Jejurikar: so, so, so first of all, I think it's worth talking about why would one do a subfascial and not a subpectral? It's not just a, you know, it's for certain anatomic issues. If they have a tuberous breast, I think it's a, it's helpful.

If they've got, um, uh, if it's a male to female case, um, which I've had a fair number of those in my practice, I think they're really useful for that. Thanks a lot. I think for women that have, you know, grade one, early grade two ptosis who are on the cusp about, you know, on the border for, for getting, uh, you know, for getting a lift, uh, or getting a mass dependency at the same time, it can be useful for that.

But I think the key is not to go too big with the implant. I think a sub fascial, uh, big implant is a disaster just waiting to happen. Um, I'm pretty restrictive in terms of what I'll have them do post operatively. I'll make them wear a bra 24 7 for Three months post op when I, when I go subthascial.

Typically, I haven't seen a big difference in terms of bottoming out compared to, to subpectral, I mean, and lateral displacement. I really haven't. Um, which means it happens with both for me. It's not like it doesn't happen. It happens with equal frequency for, for both subpectral and, and subfascial.

[00:23:18] Dr. Lawrence Tong: But I would say that, you know, lateral displacement is something that you don't see early on. Like, you don't, you see it like years after the surgery. That's, that's my impression.

[00:23:27] Dr. Sam Jejurikar: I agree. I agree. I totally agree. Yeah, a hundred percent. So I think, um, what I'm walking away from this is we do things differently, you know, and if there's a take home message that I would have for patients, it would be. Listen to your surgeon because they have a very clear cut rationale for what they're doing.

Get clear answers to, you know, to your questions ahead of time. Don't go to other patients to try to figure out what to do because there's different circumstances that may have your surgeon to have the specific guidelines they do. Um, any, any closing thoughts, anyone?

[00:24:06] Dr. Sam Rhee: Excellent topic. Excellent topic.

[00:24:09] Dr. Sam Jejurikar: Okay. Well, as always, thanks for, to our listeners for watching and until later, gents. ​