Breast Augmentation: The Most Interesting Interview of All Time

Speaker 1:
You're listening to the La Jolla Cosmetic podcast with the LJC Chief Community Officer, Monique Ramsey.

Monique Ramsey:
Welcome, everyone. I am your host, Monique Ramsey, for the La Jolla Cosmetic podcast, where dreams become real. Today I have the pleasure to speak with Dr. Lori Saltz, board-certified plastic surgeon, and the person who I go back the furthest with. We're looking at a 30-year relationship now.

Monique Ramsey:
Dr. Saltz, today we're going to talk about breast augmentation surgery, and specifically for women who are thinking about getting breast implants for the first time. Welcome. Let me have you tell us a little bit about yourself.

Dr. Lori Saltz:
Well, as you've already mentioned, I've been at the center at La Jolla Cosmetic Surgery Center for over 30 years. I've always been interested more in breast and body work. Over the years, I've sort of divested myself of facial work and things like that.

Dr. Lori Saltz:
My practice is primarily breast and body. I've done, literally, thousands of breast augmentations on first-time patients and probably almost as much on other patients coming back when they need new implants, or they've had children, and they need a lift.

Dr. Lori Saltz:
I have a lot of experience. I've learned a tremendous amount over the last three decades. Plus, our technology and our knowledge about breast implants has increased considerably to our benefit so that we have a better procedure to offer first-time patients. I'm really excited about that. I love doing it.

Monique Ramsey:
What's the first question that most women have when they start thinking about breast augmentation surgery?

Dr. Lori Saltz:
Most of the women, by the time I've seen them, have already been online, and done a ton of reading, and talked to a bunch of friends, or their hairdresser, or their doctor, or somebody. They already have a lot of thoughts in mind. Some of them actually know everything they think they want.

Dr. Lori Saltz:
I think that the first thing women think about... There's one of two things. The first and the most frequent is, "I don't like the size of my breasts. They're too small. They're out of proportion." One might be bigger than the other, so it's size.

Dr. Lori Saltz:
Then a secondary thing that we get for special kinds of breasts that we know, as soon as they say, "I don't like the shape of my breast. I'm not really concerned about the size as much as the shape." Then we know what kind of breast they have, and that's a different discussion. Those are the two, sizes being the biggest one, and how am I going to decide what size? Or they have a size in mind. Unfortunately, cup sizes are not standardized anymore.

Monique Ramsey:
Oh.

Dr. Lori Saltz:
It's not like batteries where AA is a AA, no matter which company you buy your batteries from. Cup sizes don't work that way. If you go to Victoria's Secret, she upsizes, what we call vanity sizes, all of her bra. Just about everybody gets to be a DD.

Monique Ramsey:
Oh.

Dr. Lori Saltz:
At all possible. Women come in, and they're wearing bras they think they want to wear. They'll go, "I'm wearing a D-cup bra," or, "I'm wearing a C-cup bra." They'll come in, and it's totally empty. Their breast is this little puddle in the bottom of the cup. You're going, "No, sweetheart. You're really an A. We can make you a C if you really want to be a C."

Monique Ramsey:
Right.

Dr. Lori Saltz:
And fill this bra or one that's bigger. Cup size is really hard for us to work with.

Monique Ramsey:
Then how do you determine the right size? What tools do you have to help the patient kind of try on a size?

Dr. Lori Saltz:
Well, the first thing, and I think it's an important thing, is we do a lot of measurements when the patients come into the office. The most important measurement we take is how wide is their breast. We call it the base width. From side to side, how wide is your breast? Because if the implant is wider than that, you may see rippling. You will definitely feel the implant along the sides and the bottom because those are the parts that aren't covered by the muscle.

Dr. Lori Saltz:
We do the measurements. We look at the numbers of the measurements of the implants. We have the charts there in the room. We say, "This is the size range that would look good in your particular breasts." Sometimes that's going to change with age, and pregnancy, and all this stuff, but basically, that's what we want to go by.

Dr. Lori Saltz:
Usually, in Southern California, that's smaller than most of my patients want to go. Then we have sizers that were engineered. We happen to use Allergan sizers, but we also have Mentor sizers. They were engineered to look approximately like that volume implant will inside your body.

Monique Ramsey:
Oh.

Dr. Lori Saltz:
Using the regular sizers that we use in the operating room, or some people use, I no longer use them, is not very accurate. It just doesn't look right. These were made to look pretty much like you will. They're not perfect. Nothing's perfect. You don't know what you want in your mind. You won't know if you're happy with it until you had it for a few months. You're going to go up and down. You like it. You don't. It's fine. It's not. We put the sizers in the bra. You put a shirt on. People get to look in the mirror, and they get to own the result for a minute.

Monique Ramsey:
You actually are wearing it.

Dr. Lori Saltz:
Right. I stay in there for the sizing. I do not leave it up to Ruth. Even though she's been with me for 18 years and she knows, I want to see that look on their face.

Monique Ramsey:
Ah, because then you'll know what they really like.

Dr. Lori Saltz:
I start lower than I think they want, and I go up until we see that little light go on. They just resonate with what they see in the mirror. It shows in their face, even with a mask on, in their eyes, and know, okay, we're in the ballpark. Then we start getting into the more intricate things: profiles. Those are hard for people to understand.

Dr. Lori Saltz:
If patient picks out a larger volume, we can adjust by using different profiles. We can get one that fits closest to or close enough to inside their base width. People don't understand. We talk about high profile. High profile doesn't mean that it comes up higher on their chest. In fact, it comes lower on their chest.

Monique Ramsey:
Oh.

Dr. Lori Saltz:
Because what it means is if you're looking at the implant sitting on the counter, which, of course, is not how it is when it's in your body, it has a smaller base diameter. The circle is smaller, but it projects more. It means it's going to go in and out on your breast and up less and stick out more than a wider profile implant. The higher or fuller the profile, the narrower the base and the more projection they get. If they want bigger breasts, you need a smaller footprint that... Especially if they pick a larger size, you need to get the smallest footprint you can to fit behind their breast.

Monique Ramsey:
Oh.

Dr. Lori Saltz:
Sometimes their breasts are so closely spaced, and we can't put them further than the edge of the breast bone, you need that smaller base. That's where profiles can come into play if somebody's breasts are further apart. Then sometimes we can use a wider profile because then it reaches towards the center more, and it also reaches up higher. Then it also reaches to the side more if your breasts are already far apart. There is no perfect implant. I know there's an implant called the ideal implant, which I think is fabulous marketing, but it is not the ideal implant. It's just a saline implant.

Monique Ramsey:
Oh, interesting.

Dr. Lori Saltz:
It has baffles in it like those old waterbeds that I'm old enough to remember, and you probably aren't. I use saline implants when my patients say, "I'm afraid of silicone." Then we'll use saline. I have no problem with that. Given the choice, I will always use silicone because I feel it looks and feels more natural. It just stands up. It just has better performance than a saline implant, which tends to stretch the skin more. I really hate putting it in a young girl because it's going to stretch out her tissues.

Monique Ramsey:
Oh.

Dr. Lori Saltz:
It's just not going to be good for them. I went through the '90s. You and I went through the '90s when we could only use saline implants.

Monique Ramsey:
Right, right.

Dr. Lori Saltz:
Now, since silicone came back in 2006, we're seeing all these women we were putting the saline in. Now I'm seeing patients that have to have them exchanged, or they've deflated, or life has happened, and they need their breasts lifted, or whatever. Their tissues are just stretched out because of that water hammer effect of the saline.

Monique Ramsey:
Is it because they're heavy or what-

Dr. Lori Saltz:
They actually, technically are a tiny bit heavier than silicone, but that's not what makes a difference. I think it's because saline is not a cohesive filler. When you're moving or jogging, it's like a water hammer.

Monique Ramsey:
Oh, I see.

Dr. Lori Saltz:
Silicone is a cohesive, and it stays as one piece and kind of moves differently. It doesn't go up and come down the same.

Monique Ramsey:
Slosh back down.

Dr. Lori Saltz:
Yes. It doesn't move the same as a silicone. It doesn't stay together. I think that may be one part. I don't want to be putting those in young women, especially, but if they say, "I'm afraid of silicone," then we get to the issue of, this is supposed to be making you feel better and prettier, not worry that you have bombs in your breasts.

Dr. Lori Saltz:
If you're not going to feel comfortable or feel safe with silicone implants, then it totally defeats the purpose. I'm not going to try to talk anybody into them and say, "They're just as safe. There's all these studies." No, they don't care about that. This isn't about that. It's about how they feel.

Monique Ramsey:
Right.

Dr. Lori Saltz:
The whole idea of breast augmentation, this is an operation you do not need except to make yourself feel better. It's all about how you feel. It's how you feel as a woman. It's how you feel just about yourself, your confidence. It's a whole bunch of complex stuff, but it should not be making you feel unsafe.

Monique Ramsey:
There's saline. There's silicone. Now I'm seeing more and more women ask about fat transfers into the breast. Tell me a little bit about that.

Dr. Lori Saltz:
Fat transfer to the breast is a good adjunct to breast augmentation in some cases. It will only add about half a cup of volume to your breast. It doesn't give you a lot of projection. It will give you more around the edges.

Monique Ramsey:
Oh.

Dr. Lori Saltz:
People that have really narrow breasts can often be helped with fat, putting it up and around, or people that have what we call constricted or tubular breasts, that are short on the bottom. Their breast didn't develop on the bottom half. We can put fat in and balance their volume that way. To actually do breast augmentation, most of our patients that ask for fat grafting don't have much fat.

Monique Ramsey:
Where do you take it from?

Dr. Lori Saltz:
Then they're getting fat from every part of their body. Then you've got to pay for that. It's only going to give them maybe half a cup. If you don't have much tissue, the fat... When you put it in there, those fat cells have to get blood supply, or they won't survive. They have to go in in little threads or little amounts and in-between the cells that you have in your breasts.

Dr. Lori Saltz:
There used to be a product or a device called BRAVA that was basically a huge suction cup for your breast. You wore these things, hours, and hours, and hours most of the day and only took them off for a few hours a day. They expanded the tissues. They used them for people's breasts to get larger.

Dr. Lori Saltz:
When we first started doing fat grafting, the guy that did these BRAVA machines, he was onboard with that very quickly. He found that the fat survived better because that suction that the breast had been under pulled the cells kind of apart. When you put the fat in, it had more room to go around all the cells and in all these little nooks and crannies because they had been pulled apart, and fill those out, and get the blood supply that they needed to survive. You can't just put a lake of fat in there because it's going to die.

Dr. Lori Saltz:
The bottom line is you need some breast tissue there. You can only put so much in to the amount of tissue that's there. If you don't have very much breast tissue to begin with, you're not going to be able to put a whole lot of fat in there at one time. You can opt to do them serially, do several sessions of fat grafting, which is expensive. It's a lot more recovery. By and large, I think at this point, I like it best for situations of improving the shape and the proportions of the breast, not augmenting the breast itself.

Monique Ramsey:
Interesting. You mentioned Allergan implants or Mentor. Does it depend on the patient, which type of implant you might choose, or is it more within that product line that you would say, "Oh, Allergan has five implants. This is one that might be best for you"?

Dr. Lori Saltz:
Well, during my 30 years, I've been able to spend time using all the companies' implants, Mentor, Sientra, and Allergan, which used to be McGhan. It's been a lot of things. Right now, it's Allergan. It's been around as long as the other two, but they don't all perform the same. I like some better than others.

Dr. Lori Saltz:
We used to use a lot of Mentors. As you know, that was the company that we used predominantly in the beginning, in the 2000s. When the 10-year study data came out on their silicone implants, and that was just a couple years ago, it turned out that they had a 25% 10-year rupture rate. 25% of their silicone implants ruptured in the first 10 years.

Monique Ramsey:
Oh wow.

Dr. Lori Saltz:
Whereas the other two companies were around 8 or 9%. It was a significant difference. Because we'd been using Mentor for a number of years, we have seen a lot of them back. Now when I do see somebody back that's had Mentor implants for a long time, I want to do an ultrasound on them, now that we have the ultrasound in the office, to see if that implant is still intact. Not that it's a problem to the patient if it's not intact, but it certainly changes how surgery is going to go because we're going to have to be taking out all that silicone, and scrubbing, and doing a lot more steps that we need to do to get all that silicone out of the pocket. It's nice to know if they're ruptured ahead of time.

Dr. Lori Saltz:
Either Allergan or Sientra are... They're comparable in the way they perform, but Mentor does not perform as well as those two. For myself, I've excluded Mentor from my game plan. Sometimes patients come in, and I'm amazed at the amount of research people do online. I had people come in and say, "I looked at all the data." They looked at the 10-year study data.

Monique Ramsey:
Wow.

Dr. Lori Saltz:
They look. I mean, one woman who worked for the company that processed or crunched all the data from all three companies-

Monique Ramsey:
Oh wow.

Dr. Lori Saltz:
Studied protocols. I've had other patients say, "I've read about all of them, and I want this implant. I want Sientra," or, "I want Allergan." They know the numbers.

Monique Ramsey:
They know. Interesting.

Dr. Lori Saltz:
I feel some people think they're not commodities. They do perform a little bit differently. They have different fill volumes. There's a lot of very subtle aspects that probably most patients wouldn't notice in the least. I like paying attention to that and looking at them.

Monique Ramsey:
If you're a patient who doesn't want to read all the studies-

Dr. Lori Saltz:
Right.

Monique Ramsey:
That's why we come to you because you've already done it.

Dr. Lori Saltz:
Right.

Monique Ramsey:
Right. We don't have to feel like we have to go off into the internet, black holes, to read the study.

Dr. Lori Saltz:
No, that's what you're supposed to be depending on your surgeon for, is... No, it's my job to know how these perform and to pay attention to how they look and how patients experience them. It's subtleties of the differences. I make it a point to do that.

Monique Ramsey:
Now, I remember back in the day, people were talking about capsular contracture, basically, if the implant gets hard. Everybody was trying to figure out it's smooth outside, or textured, or under the muscle and over the muscle. Where does all that stand right now? What are the rates that people might have a capsular contracture?

Dr. Lori Saltz:
When I first went into practice, the capsular contracture... It was 30 to 50% depending on the study that you looked at. It was a lot. It drove us nuts. A lot of people had ideas about, it could be this. It could be that. That's where the oldest wives tale of breast augmentation, as far as I'm concerned, came up. You need to massage the breast. You need to keep the breast pocket really big.

Dr. Lori Saltz:
No, you don't. There has never, ever been a study that proved that or even studied it. What happens? What I explain to patients is that when I do a procedure now... I learned part of this because Sientra sent me to Sweden to work with a man over there that had 20 years of the most minute data of every aspect of breast augmentation. He had it down cold.

Dr. Lori Saltz:
I came back and started adding all the things that he had taught me. It makes a difference. One of the things I learned is that you want to put the implant exactly where it belongs. That's why I don't use sizers anymore. I do the sizing ahead of time. I say, "This is the implant. This is the size. This is the profile. This is what we're going to use."

Dr. Lori Saltz:
Then on the day of surgery, I mark exactly where that implant belongs on their chest. If I have to lower the fold, I do that. It has to be sort of in the middle of their breast. I mark it exactly. I go in there and make an incision under the breast.

Dr. Lori Saltz:
We used to make them all around the areola, or people say the nipple. Has much higher capsular contracture rate. Another story. I make a house for that implant that is snug. It fits nicely. Then your body is going to start forming a capsule scar tissue around that space.

Monique Ramsey:
Which is normal, right?

Dr. Lori Saltz:
It's forming it around the space, okay? Now the space happens to be around the implant, but the capsule is forming against the tissues. If it's a textured implant, they are in close contact, but it's responding to the presence of the implant by creating a capsule of scar tissue around the implant, the space that it's in.

Dr. Lori Saltz:
That's a normal form body response. If you got a BB or a splinter under your skin, or you have a pacemaker put in, your body does the same thing. It makes a little scar tissue capsule. It walls it off from the rest of the body and holds it tight just where it is, separates it.

Dr. Lori Saltz:
It takes four to six months or longer for that capsule to be what we call mature and have the most strength it's going to have. Sometimes when it's developing, it gets contractile fibers in it, somehow develop. Then that capsule... Because it's got circular fibers around this round implant or even around a shaped implant, it can contract. It squeezes on the implant, sort of like you're squeezing on a balloon.

Dr. Lori Saltz:
The breast starts feeling really hard. It looks really round because the smallest surface area for volume is round. It usually pulls up in the breast, and it looks higher. It can begin to hurt. That was happening, really, a lot in the beginning of my practice. Since then, we've learned a lot of things.

Dr. Lori Saltz:
The first thing we learned, as I remember it, is that smooth implants over the muscle have a higher capsular contracture rate. When textured came around the end of the '80s, early '90s... Well, actually, we had the Memes, the polyurethane-covered implants before that. The reason we got textured silicone implants is that the polyurethane implants, covered implants, had the least number of capsular contractures and the softest breasts. They felt and looked the most natural.

Dr. Lori Saltz:
Everybody thought, "Well, it must be the foam and the texture disorganizes the capsule as it forms. Let's texture the outside of the silicone implants, just imprint it or add it." There's different ways of making the surface texture. They found that over the muscle, the capsular contracture rate with textured implants was lower than it was with smooth implants. Then we started putting most implants under the muscle. The capsular contracture rate for smooth and textured was about the same.

Monique Ramsey:
You went under the muscle for most people. Why?

Dr. Lori Saltz:
Well, in young or thin people, it just gives you better coverage in a part of your breast that you see in a lot of clothing.

Monique Ramsey:
Oh.

Dr. Lori Saltz:
It just softens the look of the breast. If you're really thin or if I have a young girl who's not had kids and has small breasts, I don't want to go over the muscle on her because I don't know what's going to happen to her breast when she has kids. That was the first thing we learned. We also learned things bit by bit. Then a theory came out about 10 years ago, that there's these little... Biofilms are everywhere.

Monique Ramsey:
Is it something that your body makes or?

Dr. Lori Saltz:
No. It's a colony. It's a neighborhood of bacteria, usually more than one. They live in a neighborhood. It's a gated community. The bacteria actually secrete a fence around the colony or the neighborhood so that they're flying under the radar. Your immune system doesn't recognize it.

Monique Ramsey:
Oh.

Dr. Lori Saltz:
They don't cause these overt infections, but they can cause problems. There is a theory that a biofilm forms inside this pocket around the implant and that that can cause capsular contracture. Over the years, there have been all these theories. A number of years ago, I think it was Sientra that came up with the 14 steps that you can use in handling the implant during surgery that really cuts down on the capsular contracture rate, which we use, even things like putting an occlusive dressing over the nipple at the beginning of procedure, because the ducts in your breast have bacteria because they're there to see a newborn's gut. That's why it's there. Well, that doesn't mean we want it around our implants.

Monique Ramsey:
True.

Dr. Lori Saltz:
They found that when you're manipulating the breast during a breast augmentation, you can express bacteria out of the ducts through the nipple. Likewise, if you're cutting right below the nipple and going down directly through the breast, you're cutting through ducts, and you're releasing bacteria. Biofilm theory, here you are.

Dr. Lori Saltz:
Now we put these occlusive dressings over the nipple in the beginning of the procedure. I don't use periareolar incisions very often. That cut down the capsular contracture rate just a little bit. We found Betadine. There was awhile of Betadine spout from the implant. No, it's not spout from the implant.

Dr. Lori Saltz:
Oh guess what? It actually cuts down the bacteria load in the pocket. Now we're using Betadine again. Well, now you have to soak the implants for five minutes, at least, in Betadine before you use it, which is why, another reason, I make patients decide what implant we're using, because I show them the box.

Dr. Lori Saltz:
Here are your implants. We go through the number, the profile, the shape, everything. These are your implants. We take them directly into the operating room, and they get opened as soon as the instruments are open. Before surgery even starts, they barely open the package that they're in, and pour Betadine in there, and cover the implant. It's 15 minutes before we are using those implants. Then we have the Keller Funnels. They look like pie funnels that-

Monique Ramsey:
They are like icing, if you were icing a cake with the decorative tip.

Dr. Lori Saltz:
Well, we have really fancy, expensive ones that we use for the implants. It's called a no-touch technique. We change our gloves. We put pocket mints in. There's just 14 steps we go through. One of them is using inframammary incisions. There are breasts under, infra, meaning under, mammary, the breast, in the fold, because then go just a little, tiny distance, and you're right where you need to be.

Dr. Lori Saltz:
You're right on the muscle. You cut through a little bit of the muscle. Boom, you're under there. You're not into the breast at all. We're not releasing ducts. We're not doing anything like that. Just boom, you're right there. That's one of the 14 steps. Doing all these steps has reduced our capsular contracture rate to around 2 to 5%.

Monique Ramsey:
Wow. That's amazing. Each little thing, if it's 2% here and 1% there, and all of a sudden-

Dr. Lori Saltz:
All of a sudden, because there was a time that I just wanted to give up because it seemed like half the cases I was doing were revisions for capsular contractures. At that time-

Monique Ramsey:
Right.

Dr. Lori Saltz:
We didn't have a good answer for capsular contractures because if you got one, you had a greater chance of getting another. Then if you got another, you got even more. Each time you were taking out that capsule, and doing a capsulectomy, and everything, you were taking a little bit of breast tissue. You lost a little bit of volume. You just got people that had had so many capsule removals, their tissues were really bad.

Dr. Lori Saltz:
We didn't have a good answer for them. Then we got the ADMs. We use acellular dermal matrices. Well, 12, 15 years ago, Dr. Smoot and I started using them. We found that people who had had capsular contractures, that it really reduced the rate of capsular contractures. Whereas before, every time you would get one, the chance of you getting another went up. Then all of a sudden, boom, it was down to just a few percent.

Monique Ramsey:
He and I recorded a episode about secondary augmentation or revisions. We talked about that. Back to the patient who this is a first-time thing, we talked about the incisions. How long are they under anesthesia?

Dr. Lori Saltz:
For me, having done thousands of them, I can do a normal, uncomplicated breast augmentation, first time, in about half an hour, but you got to put the patient to sleep. You got to put on the dressings. You got to wake them up. All told, they're asleep maybe an hour.

Monique Ramsey:
Not long.

Dr. Lori Saltz:
No, no, no, not at all. Then they're in recovery. The nice thing, a lot of women having augmentations for the first time are younger, and they've never been put to sleep before. They're really worried about-

Monique Ramsey:
What's that going to be like?

Dr. Lori Saltz:
What's that going to be like? If they're mothers, if they're young mothers, especially if they're single moms, what if I don't wake up?

Monique Ramsey:
Oh.

Dr. Lori Saltz:
That's very rare. I tell the patients, "We have board-certified anesthesiologists that have been with us for as long as I've been there. They're all hand-picked, excellent. They've all done cardiac anesthesia. They all know what they're doing. They know how to handle emergency. Our staff is ACLS certified. They know how to handle an emergency. We're right next to the hospital. It's going to be fine. We're going to keep you safe."

Dr. Lori Saltz:
For the first-time patients, they're thinking, "Oh, is it going to hurt, or am I really going to be asleep?" They imagine it's like they go to bed at night. No, you're unconscious. To you, it will seem like you blinked your eyes. You will not know you're going to sleep. You will not know you're waking up. It will be, literally, you open your eyes, and you're in recovery. All that time, we're going to be monitoring everything going in and out of your body and keeping you safe.

Monique Ramsey:
That's really a key differentiator. I mean, the operating room is accredited, so it's set up just like a hospital. We have dedicated circulating nurses. You have anesthesiologists, board certified, many of them multi board certified. For anybody who hasn't met Dr. Saltz before, there's two Dr. Saltz's at our center. Dr. Saltz's husband, Steven Saltz, is one of our anesthesiologists. He's got four board certifications.

Dr. Lori Saltz:
Yes, including critical care.

Monique Ramsey:
He is the one to trust. Each of the doctors, whether you have Dr. Haas or Dr. Young, whoever in our group, that's been the same group for the whole time I've been at the center and the whole time you've been at the center, which is really nice. It's not some stranger coming into the OR. They pre-vet the patients. I mean, they look at the charts ahead of time, making sure that they don't see anything that could be alarming in any way.

Dr. Lori Saltz:
In fact, it happened to be, my husband picked up on a patient recently. It was just a breast aug, I thought, who was having trouble with her blood pressures and didn't think the cuff was working. He and Danielle were moving the cuff all around. He was taking it several times. He was not happy about it because the pressure in the upper limb was so much different than in the lower limb.

Dr. Lori Saltz:
They did all these shenanigans again in the recovery room. He ended up saying, "I think maybe your doctor will think I'm crazy, but you need to go to the doctor soon. You need to have your heart looked at because I think you have something called a coarctation," which is a constricture of the aorta after the aortic valve. It's after the blood vessels that go off to your upper limbs and before the ones that go to your lower limbs. The blood pressures are different in your upper and lower limbs. It can be a severe problem. It can lead to death. She's 30. She went in. By God, she had coarc. She was on the schedule.

Monique Ramsey:
Oh my goodness.

Dr. Lori Saltz:
For her heart surgery.

Monique Ramsey:
Wow.

Dr. Lori Saltz:
I mean, that's the kind of quality our anesthesiologists-

Monique Ramsey:
Right.

Dr. Lori Saltz:
Have in picking up problems. This is a problem he picked up during surgery.

Monique Ramsey:
Wow, wow.

Dr. Lori Saltz:
Managed it, and told her, and actually, she got taken care of.

Monique Ramsey:
That's amazing.

Dr. Lori Saltz:
They're good.

Monique Ramsey:
Yes, they're really good. Some of the other questions people might have is if you're a first-time breast aug patient. Maybe you haven't had children yet. You say, if I decide to have kids, what will happen to the breast? Can I breastfeed? What happens to the implants? What do they need to know?

Dr. Lori Saltz:
Well, speaking from personal and professional experience, if you've never breastfed, you don't know how much or if you can breastfeed in the first place. You heard me mention constricted breasts before. Those breasts don't produce much milk. I can't tell you how many patients have come in so frustrated they couldn't breastfeed. We look at their breasts and go, "Well, you never could."

Monique Ramsey:
Not your fault.

Dr. Lori Saltz:
Yes, it's not your fault. They go, "Why didn't nobody ever tell me this?" We say, "Because they don't really know." You don't know how much or if you can breastfeed. We do know that there's five times more problems breastfeeding if you go in around the areola or the nipple, as some people call it, than if you go underneath. You don't know, but if we go underneath, we're pretty much not disturbing your breast ducts at all. Most breast ducts that are producing milk are in the upper part of the breast in the first place.

Monique Ramsey:
Oh.

Dr. Lori Saltz:
It probably isn't going to affect their ability to breastfeed at all. How their breasts are going to change is really, really variable. I mean, some people's breasts change a lot. As soon as they get pregnant, they're two-cup sizes bigger. Other people, their breasts change maybe half a cup. They don't change much at all.

Dr. Lori Saltz:
Then it depends on if you breastfeed, and how long you breastfeed, and how big your breasts got, how engorged they got, how stretched out they got. All these things go into it. You don't know. You do not know what is going to happen.

Dr. Lori Saltz:
Now generally speaking, people who have really small, small breasts to begin with aren't going to get very big during pregnancy. Ruth, my nurse, always asks them, "Well, are you on birth control pills? What happens to your breasts around your period?"

Dr. Lori Saltz:
If you're on birth controls or around your period, your breasts get a cup size bigger, then you're probably going to have a bigger change during pregnancy. That means your breasts are hormonally responsive. If your breasts stay pretty much the same, then probably, probably not going to change tremendously during pregnancy and breastfeeding. That's not set in stone, but it's sort of a guideline.

Monique Ramsey:
A good guideline.

Dr. Lori Saltz:
You don't know. The thing is the implants aren't forever. No, they're not just 10 years. The new warranties are 20 years.

Monique Ramsey:
Oh. It used to be the 10-year. That was a, oh God, I got to come in for my 10-year exchange.

Dr. Lori Saltz:
You know what? I've been on the boards for Mentor and Sientra, both. We've asked that question. Where did this come from? They said, "We have no clue except that the warranties used to be 10 years." The warranty doesn't mean you go get a new car.

Monique Ramsey:
Right. When the warranty is up, doesn't mean it's not useful.

Dr. Lori Saltz:
Right. That means you're going to be paying for the service. Pretty much, that's what the warranty was. It was 10 years. People thought, "Warranty's up. I got to get my implants changed." No, no, no, no. Now the warranties are 20 years, okay?

Monique Ramsey:
Interesting.

Dr. Lori Saltz:
Now we should start hearing, "Oh, in 20 years, I have to get a new implant." No, if they're not broken, do not fix them.

Monique Ramsey:
Right, because you have to outweigh the risk of surgery, any kind of surgery. If everything's fine, then why cause a trauma? They talk about implant settling. At the beginning, I would say they're probably more swollen, right, and maybe more tight, or how would you describe that initial period?

Dr. Lori Saltz:
That's a really good question because I learned to do things a little bit differently. When we put them under the muscle, your muscle wants to lie flat against your chest. That's where it's been your whole life. It's a strong muscle. You use it all the time. It's going to be smashing your implant flat against your chest.

Dr. Lori Saltz:
It's going to look flat. It's going to look wide, and high, and sometimes for reasons I don't completely understand, square. That muscle's tight. That muscle is going to cramp. That's where a lot of the pain comes from after surgery.

Dr. Lori Saltz:
What I have my patients doing is putting their arms up straight over their head, stretching that muscle. Every marathon runner knows that the next day, you stretch, and stretch, and stretch. Five times an hour, they're putting their arms up over their head. I have them taking muscle relaxants because we want that muscle... The muscle is holding that implant up there.

Dr. Lori Saltz:
You want that muscle to relax. As it does, over the first few weeks, the implants can start to, quote, "settle," and come down into a teardrop shape. The volume gets less on top and more on the bottom. You get that teardrop shape that everybody wants. It takes a couple of months. Even at two weeks, they feel a lot better. Ruth, my nurse, tells them, "Just don't look at them the first week. You won't like them." Look at them the second week.

Monique Ramsey:
Hang out. Hang in there.

Dr. Lori Saltz:
Just wait. Of course, everybody looks. We look. It doesn't happen overnight. It happens over a period of weeks that they, quote, "settle." Usually, by four to six months, they have, quote, "settled" as much as they're going to settle.

Monique Ramsey:
When can you go back to normal activities and work, or when can you go back to going to the gym or for a run?

Dr. Lori Saltz:
Now I said I make that pocket just the precise size for your implant. You don't have a capsule right away. Your muscle is... When it pushes on that implant, when you contract it, it's going to push the implant down and out, perpendicular to the fibers of the muscle. I don't want my patients exercising for this at all for the first six weeks. Then I don't let them do chest exercises, isolated or activities like surfing, for six months, not because I'm mean.

Dr. Lori Saltz:
I want that capsule to form around the precise space that I made for that particular implant. Once it's stable and, quote, we said, "mature," you won't be able to move your implant out of place. Then you can do whatever you want. The body is what it is. The healing process, the maturation of the scar tissue... It is what it is.

Dr. Lori Saltz:
I tell patients, "After two weeks, you can go back to exercising except for your chest." They can do biceps and triceps. Ruth is a workout freak, as you know, so she goes through all the exercises and things they can do with them. I tell them, "It's up to you. If you want to do things at two weeks, go ahead and do them, but if the implant gets displaced, we have a problem. Neither one of us is going to like it. You choose what you want to do with your investment. It's your choice."

Monique Ramsey:
Now if they're at a desk job or something sort of sedentary, then I would assume they could go back to work when they feel ready, maybe in four to five days?

Dr. Lori Saltz:
A lot of people do go back in four and five days. Now with the pandemic still going on and a lot of people working from home, they're back at work in two days because they don't have to get up, and drive someplace, and go through all. They just get out of bed, and they work. A lot of them are accountants, or they're not interacting face-to-face with people. They can work for as long as they want, and go take a nap, and then come back. They're back to work in a couple of days.

Monique Ramsey:
If you are in a job where you're lifting something, what do you say in terms of, you can't lift anything heavier than what? For how long?

Dr. Lori Saltz:
Obviously, half a gallon of milk. Let's be real. A lot of these women have young children, need to be picked up. If they're toddlers, so they're on their feet. I tell them, "You need to bend down like you're supposed to," and nobody does, "and put them on your hip, and stand up using your thighs, your legs, to come up. Don't bend over and use your arms to pick up the baby."

Dr. Lori Saltz:
When they're in a crib, that's a different story. Now then, they don't weigh very much. Within a week or so, they're going to be picking the baby whether you tell them that they can or not. Let's be honest. I tell them getting them in and out of the crib, nowadays... My days, you could let the crib, the sides down, but now you can't. You have to get up and over.

Dr. Lori Saltz:
Somebody, either a older sibling, or your husband, or you need to get a little step stool that you can get up. The kid that's 10, 12 pounds, you're going to be picking them up in four or five days. You just are. There's no, let's not joke with each other.

Monique Ramsey:
The risk of, if you pick up something too heavy is that they could get a little hematoma, right, which is a little bleeder or.

Dr. Lori Saltz:
Right. That's true. You can do nothing and get a hematoma.

Monique Ramsey:
Well.

Dr. Lori Saltz:
Yes, doing more. There are different ways of picking things up. If you pick things up straight up with your biceps, you're not using your chest muscles at all. There's other ways of picking up when you reach out and pick things up that you can feel your chest muscles engage. Those are the ones that are a problem.

Dr. Lori Saltz:
I tell my hairdressers because they are working with their hands all day. I said, "You've got to put your clients down lower. You have to think about keeping your elbows closer to your body when you're doing your blowouts, and your cutting, and stuff like that. You just have to think about how you're doing things and adjust a little bit for a while. You can do them. It's just how you do them."

Monique Ramsey:
Right, interesting.

Dr. Lori Saltz:
I feel if I tell patients what they're thinking about and why, they figure it out.

Monique Ramsey:
One of the things that I think patients don't really always know where to start is, how do we choose a good surgeon? If they're not in San Diego, let's say, what should they look for? What would you recommend people look for?

Dr. Lori Saltz:
Well, obviously, board certification by the American Board of Plastic Surgery. This is something that so many patients get tricked by. How long they've been in practice can be some guide to it. Obviously, I can tell you that the longer you've been in practice and the more you pay attention, the more you learn over the years. The other thing is, how many other things do they do? What do they do primarily? Because most of us, we like doing some things more than other things. You remember, I cannot stand breaking bones.

Monique Ramsey:
She did not want to do noses.

Dr. Lori Saltz:
I did not want to do noses. When Dr. Olsen was in there, tap, tap, tap, breaking the nose bones, No, I never did noses. I really don't like face work. It just makes me nervous. I don't feel comfortable. It's just not my thing.

Dr. Lori Saltz:
Other people don't like doing breasts. Other people don't like doing body work. They want to do hand work, or we all have something we do more than others. I think I'm better limiting what I do to what I really like and what I can really focus on because I spend a lot of time reading and going to focus meetings, board meetings with the implant companies that pertain to what I like to do best. I think that is a benefit.

Dr. Lori Saltz:
Another thing is to go to their gallery, and look, and see what kind of results are they getting because I like a real, natural look. Other people, they like really huge breasts, and that's what they go for. I get a little uncomfortable when people ask me for something I'm not really comfortable doing. I'll tell them, "It's not really what I like doing. I'll try to do my best for you." I think you really have to look at their results and see what they like.

Monique Ramsey:
You can look for something. I think with breasts, you look for somebody's who's maybe shaped like you are, right, because breasts come in so many different shapes.

Dr. Lori Saltz:
Well, that's why when I did my gallery, I took the same set of patients, and I divided them up separately. I put them in there based on height because a lot of people say, "Well, I'm tall, and I need bigger breasts." Then I based them on volume. They're just sorted differently, one by height, one by volume.

Dr. Lori Saltz:
Actually, what I wish I could do is by chest circumference because I think your breasts need to be in balance with how big your chest is. You might have a big backend and a narrow chest. If you put big boobs on it, you're going to look like that Veronica in the old comic books.

Monique Ramsey:
Right.

Dr. Lori Saltz:
Just, it has to be balanced. Patients go through the galleries because I put on my own gallery the ones I did. I put how tall they were, how many kids they had, how much they weighed, all that stuff. People do go through it and pick out, this girl looks the closest to me.

Monique Ramsey:
Don't you think that's way more accurate than trying to bring in something from a magazine or showing somebody's Instagram of some celebrity and going, "I like those boobs." That's not how it works.

Dr. Lori Saltz:
Actually, I really don't like seeing photos out of magazines and stuff because usually, the people, the celebrities, or the models, or whoever... They're in a bathing suit. They're in clothing. They're in some sexy dress. Those clothing has all kinds of ways of magic, smoke, and mirrors, to make your breasts look better.

Monique Ramsey:
Not to mention the filters and photo shop.

Dr. Lori Saltz:
Right.

Monique Ramsey:
You don't know what you're looking at.

Dr. Lori Saltz:
You don't know what you're looking at. I tell patients this. Well, should I bring in photos? I said, "If you do, I want you to bring in naked photos, good photos. What you need to do is go through my galleries, go through other people's galleries, go through galleries, and look at real before-and-after photos, and come in, and tell me, 'This is what I want to look like.'" Then they're naked. I can see the shape. Sometimes patients are looking at shape more than they are spacing or things that we may not have control over.

Monique Ramsey:
Right, because of the anatomy.

Dr. Lori Saltz:
Right. If they bring in somebody whose breasts are way far apart and they want cleavage, you have to sit there and say, "I can't make you look exactly like that because your anatomy is not like that." Photos for me are only good if they're naked photos.

Monique Ramsey:
Well, thank you so much. We'll put in the show notes, links to Dr. Saltz's profile, links to the gallery. We'll put in links to learning more about breast augmentation, so you can see that. You can see all of her reviews. She's got over 1,300 reviews from her patients on her website. Thank you, all. Thank you, Dr. Saltz. We will catch you next time.

Dr. Lori Saltz:
Thank you. Bye-bye, Monique.

Monique Ramsey:
Bye.

Speaker 1:
Take a screenshot of this podcast episode with your phone and show it at your consultation or appointment, or mention the promo code PODCAST to receive $25 off any service or product of $50 or more at La Jolla Cosmetic. La Jolla Cosmetic is located just off the I-5 San Diego Freeway in the XIMED building on the Scripps Memorial Hospital campus. To learn more, go to ljcsc.com, or follow the team on Instagram @ljcsc. The La Jolla Cosmetic podcast is a production of the Axis, T-H-E-A-X-I-S, dot I-O.