About This Episode
On the latest episode of Carpools & Cannulas: Modern Motherhood and Plastic Surgery, Dr. Gallus and Dr. Greer discuss breast implants, breast implant illness, breast implant removal, and things to consider about breast implant surgery.
Dr. Greer: Okay. Sorry for everybody who was just live and got dumped because I don’t know what happened. If my connection went bust or what. Kat’s back on and hopefully, we will all get back. I don’t know what happened.
Dr. Gallus: I know. What a bummer. Okay.
Dr. Greer: Well, we’re back. I guess we should get to the important stuff. We were going to talk about breast implant illness tonight.
Dr. Gallus: Yeah, let’s cut to it. So, do you see a lot of women who complain of symptoms of breast implant illness?
Dr. Greer: I don’t see a ton here but we have one of the docs who’s really active in the breast implant illness sites, Dr. Lu-Jean Feng. Her clinic is in Pepper Pike, which is right near us. So, I think many of them go her way but I do see the occasional one. And I know we have some colleagues who really have spent a lot of time investigating and learning about this like Dr. McGuire in St. Louis. Do you see a lot out your way?
Dr. Gallus: I do actually. There’s a fair amount of patients and I think Dr. Feng fills a need or a niche in that. A lot of women are seeking other women for explant surgery. So, Dr. McGuire in St. Louis does a lot of them. Dr. Lawrence, Marisa Lawrence in Atlanta, and Thouder in…I think she’s in Seattle or in that upper corner of the country up west somewhere. She does a ton too and, you know, we all collaborate and talk about…we had a discussion about it at our retreat, too, presentation on explant. So, you know, for surgeons, our focus is usually on the best way to remove the implants. But for the women, it’s mostly about what symptoms are you having and whether or not that could be caused by or your breast implants could be contributing to it.
Dr. Greer: Right. And that’s the hard part because it’s just not very well characterized and certainly, the medical field is making an effort to improve, like, our diagnostic criteria for that. Right now, there really aren’t any and the symptoms are very wide-ranging and have a lot of overlap with autoimmune disorders like rheumatoid arthritis or lupus. So, what are the main complaints that you see with your patients?
Dr. Gallus: So, it’s most commonly fatigue, some memory loss, and then, I have a fair amount that have, like, a rash, an undiagnosed rash or some sort of, kind of allergic reaction that they can’t get rid of or they can’t seem to get to the bottom of. And, you know, they’ve usually seen a few other either specialist or primary care, and like you said, because there’s no diagnostic testing specifically for that, they’re just ruling out, you know, some of the other things, rheumatoid arthritis, some autoimmune disorders, and then, saying, “You know, none of this is popping positive. We don’t know why you’re, you know, feeling this way.” Yeah, so that can be tough. Some of them have gone through great lengths to, you know, do dietary and supplementation and other things to try to feel better.
Dr. Greer: It’s tough. Those kinds of symptoms are so generalized to so many different things. And with implants, you know, they’re one of the most studied devices on the market. They have been studied by the FDA to a great extent and we know that they’re not dangerous, but it’s still a foreign body and your immune system can react. We just don’t know who’s more likely to have that or how to diagnose it so that we can predict whose symptoms are gonna improve after removing implants.
Dr. Gallus: Yeah, I think that’s the crux of it. You know, the overwhelming majority of women will be fine with their breast implants, just like the overwhelming majority of my patients are okay with, you know, paper tape on their incision or Dermabond glue, but there is a small percentage and we don’t really know why, you know, who have an allergic reaction to that or, you know, it doesn’t sit well with them. So trying to suss out who that is and make sure that you’re, you know, doing the right operation for the right patient is important, and I think it is important that they look and make sure there’s nothing else. You would hate to take someone’s implants out and miss, you know, some other undiagnosed condition because of that. So, that’s really important, too.
Dr. Greer: Right. Absolutely, and I know there are a lot of online communities talking about breast implant illness. And there are a lot of surgeons who really do have a niche and many of them recommend total en bloc capsulectomy where the entire capsule’s removed. And really, I think they generally recommend to not violate the capsule at all so that it stays contained. Scientifically though, we know there’s not really a lot of data behind that.
Dr. Gallus: That’s right.
Dr. Greer: Yeah. I mean, what do you try to do normally with your patients?
Dr. Gallus: So, I try to meet in the middle, which is to do as much… So, I give the patients choices, and I talk to them about science and that there is no science that shows that doing an en bloc is better than doing a total capsulectomy or doing a partial capsulectomy. You know, there’s some controversy about what incision you use for breast surgery, for breast augmentation, and I tell people what the pros and cons are and help them decide, you know, maybe what’s best for them. So the trade-off with doing an en bloc removal is that the incision is pretty big because to take the capsule and the implant out as a whole, you need to…it doesn’t compress at all, and so, you need a big space. So if you come and say, “I want my implants out. I don’t feel great. I just want them out. Can you go through my incision that’s just around my areola that’s, you know, a couple centimeters?” Yeah, I can do that. Can I get the entire implant and the capsule all out through that incision? No, it’s not possible. So those are…that’s, like, one of the trade-offs, and then, you know, if you’re like, “Okay. Well, I’d rather have you do it through a smaller incision,” then I’d say, “Great.” I can get around the capsule and the implant, and make a small incision in the capsule, take the implant out, and then take the rest of the capsule out, wash everything, and that should be equivalent science. I mean, en bloc is usually the term, as you know, comes from cancer surgery. Right?
Dr. Greer: Right.
Dr. Gallus: The en bloc, removing everything that’s surrounding the tumor and not touching the tumor, but we don’t know…
Dr. Greer: Right. And I think the other part of this that’s not often talked about is the fact that this can be kind of damaging, especially, you know, if the implant’s behind the muscle. That posterior capsule is on the ribs and it’s really tightly inherent to the ribs, to the periosteum, to the muscles between the ribs, and getting that off can be very damaging. And most patients, if their implant is behind the muscle, I recommend leaving it in place. I mean, after all, as you mentioned, this isn’t a cancer surgery and I certainly don’t wanna injure somebody’s lungs. So, I take off what I can and I can cauterize the rest but often it’s, you know, how much damage do you wanna do when the benefit’s not really well proven.
Dr. Gallus: Right. And even in cancer operations, there’s sometimes, like, no man’s land where you can’t go further, so you have to weigh the risks and benefits of, you know, being in a major vessel or just taking the, you know, tumor right off. So, yeah, I explain to my patients, you know, that’s not always possible. I try some techniques though, to try and get that capsule off that posterior chest wall because you can hydrodissect it, you know, with different tools but I do tell them that, you know, I’m not gonna do something that’s unsafe. And there have been documented cases where people have had, you know, a dropped lung or gotten into a blood vessel because it goes way up into the chest and you’re trying to get that last bit of capsule. So, I think that risk-reward isn’t worth it, so…
Dr. Greer: Right. It’s a tough…the whole, like, field of breast implant illness is really tough because it’s this big group of women who are definitely not feeling well, and to a certain extent, have felt like they’re being blown off by some of the medical community. And then, there’s a niche of doctors, I’m sorry to say, who some of them, maybe take a little bit advantage and make these recommendations for things that are not necessarily proven with good evidence behind them and say, “Well, this is the way you have to do it.” And it’s hard because you’re, like, in this balance of you wanna take good care of people and you also don’t wanna see them taken advantage of because they’re not feeling well and they want to do anything they can to feel better.
Dr. Gallus: Yeah. Absolutely. So, I think it’s a tough spot for the majority of us. I think having that community of women with breast implant illness has raised awareness and, you know, I agree. And early on, they were ignored or, you know, sort of dismissed by many surgeons who told them, “No, that’s not…” You know, and I think it’s your implants. You elected to put them in. It’s your choice to remove them. So as long as I can educate you about the, you know, circumstances surrounding it and what the results will potentially look like then we can have that conversation. But to dismiss somebody outright, which definitely happened early on and probably still happens here and there, but, yeah, I’m not trying to sell this as a, you know, this will make you feel amazing if you get your implants out, which is kinda the thing people have but everyone to their own. And I know Dr. McGuire has a grant that she’s doing where she’s carefully studying these patients, and kinda doing all the intake stuff and testing everything and I think that’s important, too so that we can have some, you know, more hard science to back up what we’re doing and make some smart judgments.
Dr. Greer: Right. I mean, it reminds me a lot of fibromyalgia in the early days, you know. And now that we actually have diagnostic criteria, we have a good idea of what the effective treatments are instead of just kind of saying, “It’s all in your head.” So, I think science is definitely the way to go but I would like patients to know there are really sympathetic surgeons out there who are willing to listen and wanna make sure we offer safe choices that aren’t gonna do more harm than good.
Dr. Gallus: Right. And I think it does have to be kind of an education because the biggest question often is what is it gonna look like when you take the implants out, and it can be a range, and there are some many things to consider. And so, I tell patients it’s, you know, there is… One of the biggest factors is the implant to breast tissue ratio. So, how much implant you have in there and how much breast tissue you have and what…you know, if you were a double-A and you have an 80cc implant, when I take that out, that is a very different problem than a 200cc implant and a, you know, B or C cup breast now. I mean, it’s two different situations. So having a lot of, like, before and afters and talking to them about what their goals are. Some people just want them out and want to feel better, and then, kinda come back and reassess. Maybe they wanna change the shape or the volume. So, I think those are all things to consider.
Dr. Greer: Right. And there are always options down the road, you know, sometimes we do the whole list at the same time. Sometimes if there’s not a lot of breast tissue, you know, we worry about the blood supply and we wanna wait. Fat grafting is also an option that can be done at the same time or down the road. So, there are a lot of variables with breast surgery in general, and I’m a little biased but I kinda feel like women have a bit of an advantage in understanding the benefits, what things are gonna look like, and what the goal is.
Dr. Gallus: Yeah, I agree. And I think it’s great because you made a great point. Like, you can always come back and do a lift or do fat transfer so, you know, if you wanna just focus on having the implants removed, that’s totally an option and, you know, don’t panic because you haven’t burned any bridges by doing that. And so just, you know, be with you along the road to recover, and then, you can make some changes. And I’ve had some women who are like, “Okay. I’m planning to have a kid,” so it’s easier to take them out, do a lift, and then, come back around for another one. So, absolutely, those are all things to factor in.
Dr. Greer: Right. And, you know, for women who are considering getting implants, I think it’s good to know that breast implant illness is out there, that it’s something that you’re gonna hear discussed but like Kat said, you know, it’s not something I would really consider high risk. We don’t know exactly how many women have it or what the diagnostic criteria are, but when you look at the millions and millions of women in the world who have implants, it’s a pretty small fraction.
Dr. Gallus: Right. And so it’s a risk just like, you know, there’s a risk of capsular contracture or risk of having a problem or risk of rupture. And I do think, I mean, again, early on when implants were first being put in, there wasn’t a lot of discussion about what the long term…I mean, I remember having that conversation as a trainee where the nurse was like, “What do you mean they don’t last forever?” I have these (laughs)…
Dr. Greer: I still have patients come in who’ve had implants for 40 years and they’re like, “Wait, these don’t stay in till I die?” No, they don’t. And now that’s, like, straight-up first thing on the consent form, these do not last your lifetime. You will need them removed or replaced.
Dr. Gallus: Right. Yeah, so all of that. I think, again, it’s all about educating the patient. I feel like my dog is very uninterested in our conversation.
Dr. Greer: Mine is being good. He was rummaging through a bin of Legos right before we got on and it was so loud.
Dr. Gallus: Why? What’s in the Legos?
Dr. Greer: He likes to chew them. And then, after that, my husband’s waiting for me to talk about him. My husband starts rummaging, like, in the cupboards, through the bags of food and I was like, “Why are the boys just all rummaging?” It was so loud. Oh, I see we have some comments. Somebody had capsular contracture and replaced her implants and would’ve explanted them instead. Yeah, and that’s…you know, that’s another complex conversation when people have capsular contracture, which is the scar tissue around the implant getting firm. You have the option to replace. You have the option to remove. You have the option to fat graph. There are a lot of nuances and these are patients I spend a lot of time within the office discussing the options.
Dr. Gallus: Yeah, I’m currently working with somebody now that has capsular contracture and she had her primary augmentation done elsewhere. We are sort of mired in what to do, you know? And one of the things about capsular contracture is that we don’t know a lot about it, like, chalk that up to breast implant illness, but oftentimes this happens in one breast. So whatever happens…
Dr. Greer: Yeah, and then, they just don’t look the same.
Dr. Gallus: Right. And so you’re not sure. So, there were, “Replacement was my only option then.” Yeah, it’s a bummer but I think people are more educated now and know because you can…sometimes you can keep having capsular contracture, and then, what do you do, and that can be a really tough road. So, having the option to say, “Okay. You can do this. These are the odds that you’re gonna have capsular contracture again. These are the things that can contribute to it and maybe want to get off that implant train now and cut your losses,” that’s an option too. But it is hard. There are a lot of options with capsular contracture once you start having that problem. Sometimes though, it’s easy, like, smoking is a known cause of capsular contracture, so I won’t redo someone’s breast implants for cap con if they’re actively smoking because it’s kind of a waste of time.
Dr. Greer: We all know we want to minimize bacterial contamination. We all use antibacterial solution and Betadine, and some of us use Irrisept and all sorts of things to rinse out the pocket. I think most of us also do Singulair and vitamin E post-op if you’ve had a cap con but it can be very frustrating. So, Holly, I’m sorry that you went through that.
Dr. Gallus: Yes. And then, most of us… Are you using the Keller Funnel?
Dr. Greer: Yes. Yep, I use a Keller Funnel on every implant, except when it was briefly on backorder. And that, too, if you guys haven’t seen it, it’s amazing. I think I have a video back in my Instagram feed. It looks like this big pastry bag but it’s got this special, like, hydrophilic lubrication on the inside. And you put the implant in and just squeeze it right through the incision and it doesn’t touch the skin so it doesn’t get bacterial contamination from the skin flora. And also, I don’t know about you Kat, my hands are not big and I remember at residency, like, trying to get the implant in with my tiny hands and it would, like, pop out, so they also make our lives much, much easier.
Dr. Gallus: Yeah, I think I’ve explained that. That’s how I explain it. I was like, “The Keller Funnel was the best thing ever because my little fingers, like, were…you’re trying to work this implant in and it was just a struggle, and now, it’s just squeeze. It doesn’t touch the skin. It’s awesome. Wish I thought of it.
Dr. Greer: I know. That and the VAC dressing.
Dr. Gallus: Yes, I just put a wound VAC dressing on. That was my second case today.
Dr. Greer: I know. I remembered I interviewed at…where was it who invented the VAC? I can’t even think of it, but the chairman there had invented it and he had his name on the patent. It was very cool.
Dr. Gallus: Oh, really?
Dr. Greer: Mm-hmm.
Dr. Gallus: Or like the anesthesiologist who invented the Bair Hugger, the thing that keeps patients warm.
Dr. Greer: He probably owns an island somewhere, I bet.
Dr. Gallus: Right?
Dr. Greer: Wow, we have already gone on our 20 minutes. I mean, the drop didn’t help but we covered a lot today. Breast implant illness is really complicated.
Dr. Gallus: Yes, I agree. So, yeah, we’ll have to…we’ll take suggestions. Just DM us if you wanna hear a different topic, and if not, we’ll meet up in two weeks. I’m sure we’ll have something to talk about.
Dr. Greer: Absolutely. And we do alternate who hosts. So next time we’ll be on your Instagram feed but I’ll make sure to post it so you guys know where to search and find us.
Dr. Gallus: All right. Bye, everybody. Thanks for joining.
Dr. Greer: Bye. So good to see you.
Dr. Gallus: It was good to see you. Have a good week.
Dr. Greer: You, too.
About Restore SD & Dr. Katerina Gallus
As the Director of Restore SD Plastic Surgery, board certified female plastic surgeon Dr. Katerina Gallus has over 15 years of experience helping San Diego women enjoy head to toe rejuvenation with face, breast and body procedures. After a successful career as a Navy plastic surgeon, Dr. Gallus founded Restore SD Plastic Surgery with the intention of creating a welcoming space for anyone seeking cosmetic enhancement.
Restore SD Plastic Surgery offers popular facial rejuvenation procedures like facelift & neck lift, facial fat grafting, and eyelid lift; breast augmentation with implants, breast lifts or breast reduction; body contouring procedures such as tummy tuck, liposuction, mommy makeover, and Brazilian butt lift (BBL), as well as aesthetician services, BOTOX, injectable fillers, and laser treatments.