East vs. West: Comparing Breast Surgery Size Trends with Plastic Surgeon Dr. Anna Steve

Speaker 1 (00:07):
You're listening to The La Jolla Cosmetic Podcast.

Monique Ramsey (00:14):
Welcome everyone to The La Jolla Cosmetic Podcast. I'm your hostess, Monique Ramsey. And today on the cosmetic podcast we've got with us a very special guest, Dr. Anna Steve. She's a plastic surgeon based in New York City, and she's becoming known in New York for elegant breast surgery. And her approach to plastic surgery is described as both people oriented and purpose driven. So that feels very much aligned with our mission here and our philosophy at La Jolla Cosmetic. And we have, again, with us, our own breast surgery expert, Dr. Hector Salazar, here to discuss or maybe debate breast surgery trends from the East Coast to the West Coast. Dr. Salazar trained at the very same place where the breast implant was invented, and he's devoted to breast implant safety. He's a member of the public education committee at A S P S, which is the American Society of Plastic Surgeons, and he's on the patient safety committee for A S A P S, which is the Aesthetic Society. So welcome to you both Dr. Anna and Dr. Salazar.

Dr. Anna (01:21):
Thanks so much for having me. It's a pleasure to be joining you, uh, from the East Coast.

Dr. Salazar (01:26):
Thanks so much, Monique, and uh, it's great to have Anna as a guest and uh, hopefully we can have a very, very nice conversation.

Dr. Anna (01:33):
Yeah,

Monique Ramsey (01:34):
Yeah, when we're talking East Coast, West Coast, and so I don't know what the East Coasters say, but it's like West Coast, Best Coast it What, what are the, what are the east coasters? Do they have a, you know, some slander against us over here? ?

Dr. Anna (01:49):
No, there's no rebuttal for that. And, and I'm actually from closer to the West Coast originally, so to some degree I still agree West Coast, Best Coast,

Monique Ramsey (01:57):

Dr. Anna (01:58):
But for the purpose of our discussion today, I'm gonna talk about the East Coast trends and I'm looking forward to hearing very much about what you're seeing in the West.

Monique Ramsey (02:07):
So tell us a little bit more about yourself, Dr. Anna.

Dr. Anna (02:10):
Yeah, so I have a New York City based practice. Most of the patients I am seeing are coming to me for breast surgery, so the full spectrum of breast surgery, everything from breast augmentation to breast reconstruction revisions. And I certainly noticed since starting practice in New York that the trends here are a little bit different, often dictated by fashion and that sort of thing. So I'm really interested in hearing how things are on the west coast.

Monique Ramsey (02:36):
And Dr. Salazar, welcome back to the podcast.

Dr. Salazar (02:39):
Thanks so much. You know how much I enjoy having these talks with you, Monique. And, and now with Anna here, the only thing we're gonna see is such an enriching, uh, conversation and hopefully our audience, our patients can enjoy a couple of different points of view of the same topic. Or actually maybe our points of view are well aligned, so we'll, we'll find out. We'll see what's going on.

Dr. Anna (03:01):
Yeah,

Monique Ramsey (03:01):
Yeah. Have the specific reasons for women seeking a breast augmentation changed or, you know, whatever their motivating factors are? Are they kind of the same as 10 years ago or five years ago?

Dr. Salazar (03:16):
I would think that women actually, as you're correctly saying, they look for breast augmentation for very different reasons. I would say that it's a much more individualized perspective and that's why I think it's important for us to meet with them, to dedicate a good amount of time, to have a nice conversation, to listen to what their goals are because every single woman will have a different motivation. It's important to mention that, I wouldn't say that the gamma of different reasons has changed too much, but I would say that recently everything behaves like a pendulum. So sometimes it goes to one side and then as you start to see it coming back, coming back and then it reaches the completely opposite side. And I think we're seeing that a little bit, or at least in, in my experience and also some of my colleagues. But in reality, I would say that patients are looking for different types of augmentations. They have different philosophies now than five, 10 years ago, 15, 20 years ago. And as Anna was mentioning, like fashion or art or other trends are in evolution are constantly evolving. I say, like, breast augmentation is not an exception. It's also, it's evolving and, and things are changing. And I, I think that we're gonna go into the great depth of this topic.

Dr. Anna (04:30):
While I haven't been in practice for 10 years, I certainly see patients who got breast implants 10 years or even more than 10 years ago. And the trend that I'm seeing in those patients is definitely that they're interested in downsizing implants that they got because they find that the large implants that they got 15 or 20 years ago aren't the right fit for their body anymore. They're having trouble fitting clothes, fitting fashion, more sort of in align with what you'd see in women who come to you for a breast reduction. So I'm finding that's a seemingly common trend in women who had authentication years ago.

Monique Ramsey (05:05):
So when it comes to breast implants, there are differences in style profiles, you know, more moderate profile or more maybe teardrop or high profile for different body types and different breast shapes. But then there's also obviously the size difference. So let's start with Dr. Anna for that first time breast augmentation patient on the East coast. What is sort of the main thing that they're looking for in terms of size and maybe shape?

Dr. Anna (05:36):
So for the most part, they're looking for a natural, elegant, small volume breast augmentation. Do a lot of breast augmentation that's in like the 200 cc range. But I do think it's important to recognize that while that's the trend, breast augmentation to some degree is really influenced by your patient's anatomy. So the conversation that I have with them includes sort of a multi-step process for how we go about choosing the size. I start by having them use some adjectives to describe the type of a look that they're going for. And that's where those words come from, like the natural elegance, small volume, sort of like keep them guessing kind of a shape. And then next step for me is to take measurements to make sure that we choose an implant that's a good fit for their chest dimension and then within the fit for their chest dimension.

(06:27):
Usually the way that we modify the size the most is to vary the profile. So the profile really affects the fullness or the, the type of look that you get, particularly in the upper pole. So I'm using a lot of the moderate profile implants to achieve that sort of more natural look. And I'm sure Hector, you can comment on this as well with respect to like your starting volume, but your starting volume has a big impact on the overall size of an implant that you choose to achieve. Any aesthetic? Well, so I also incorporate the final step of size selection to have patients show me inspo photos and their inspo photos really help frame our discussion and really calibrate our visual scale because adjectives can be subjective, but a visual scale I find is a lot more objective. So we can get an idea of where they're starting out and where they wanna be. And sometimes that creates a conversation with respect to like expectation management. If they choose someone as their inspo that has like a totally different body type than them, then you know, we have at least a starting point to sort of start unpacking some of those differences. But I do find that it really helps frame the conversation because often patients come in with the idea of wanting a specific volume and actually a specific volume looks very different on two different women.

Dr. Salazar (07:52):
Yeah, I, I fully agree with your approach and that I like to start my consultation by telling patients that by the end of that consultation, the goal is for both of us to close our eyes and have exactly the same mental image. Cuz when they get to the office, I close my eyes and I only see black, right? And, and they have that very precise idea of where they want to go. So as you're saying, the first thing I think that conversation start to ask them sometimes even silly questions as, uh, we're standing in front of a mountain that has two tunnels. One tunnel says over here, you walk through this tunnel, you get a natural result, you walk through this tunnel, you get an augmented look. No right or wrong answer, what route would you take? And start looking at photographs that they bring.

(08:35):
And we are so blessed right now with the moment that we're practicing in the sense of all the different instruments that we have, right? Because other than our conversations, that's a very powerful instrument. There's also that physical exam part of the visit that's, I fully agree with you. One thing is that we should not violate the natural footprint of the breast that the patient has. And as Anna is saying, based on that, we would sometimes modify the profile of the implant Monique, as you were asking, but to provide the volume that they want, not based on, as Anna correctly is pointing out based on a pure CC number, but the look that they wanna achieve. And then after that we have like, we have sizers, right? That they can try and then we have simulators like vector. Now we have those, uh, virtual reality glasses that also now becoming a trend as well. So you have all these different instruments and then by the end of the visit then you know exactly, exactly what is the implant that the patient's gonna like. Not only the the one that's gonna fit her, but the one that's gonna take her to the image that she wants to achieve, that she wants to obtain.

Dr. Anna (09:48):
Mm-hmm. , what you say about the breast footprint is so important. I really think that there's like a specific dimension, very narrow range of dimensions that you can use to fit a woman's chest well. And I think if you don't pay attention to the breast width specifically, you can end up with an implant that changes the overall aesthetic of the breast in a, in an un pleasing way. I think the other thing that's important to recognize about the, the breast footprint, that's kind of where your breast lives on your chest. Some women are low breasted, some women are like medium breasted and some women are high breasted, so to speak in celebrity terms. Like Kate Hudson has a very low breast footprint, so an implant on her will look very different than the same implant on Halle Berry who has a very like high breast footprint. And so talking to patients a little bit about that and like where their fold sits can also influence how any given implant looks on them. With respect to the virtual imaging, are you using that regularly in your practice sector?

Dr. Salazar (10:50):
Uh, vector, I would say we, we offer that to patients and we simulate different sizes of course within a certain range that will fit them well and we provide them with a t-shirt. They take pictures of, well we're trying some sizers, then we go in and we look at the different vector simulations and then by the end I can we narrow it down? You were mentioning Anna about celebrities and I would say to me when I was training, I, I used to hear more celebrity names being called than, so that means 15 years ago than what I hear now. At least on the west coast. I don't hear those many names. And again, like throughout the years, I mean you get like different icons, right? You get like starting from Rita Hayworth to Marilyn Monroe, to Bo Derek, to Pamela Anderson. And I feel that around there, at Pamela Anderson, calling names for breast augmentation started fading a little bit more and noticing that patients tend to individualize it a little more.

(11:55):
I must confess that when I heard, uh, the invitation from Monique, uh, to have this conversation, I said, you know what, since I have not been hearing a lot of names, let me look for a list of names of breast that are in trend breast augmentation or breast implants that are in trend. And funny enough, the first list that came up on my Google search were like a lot were from 2012 to 2010, 2014. So that kind of proved a little bit of my point. So I had to go down maybe 20 results down the list and then the celebrities that came out as having like trendy breast and that list was from 2020. And I'm gonna open here, the discussion, uh, with you was, you know, like Kendall Jenner, Demi Lovato, Gigi Hadid, so all patients that actually the cup sizes that they were actually even listing there are in the range of about like a B or a B plus cup and those being the trendy breasts now. But it was not a list that came up. All the lists that were up from previous times, there were, I mean all the names were like Ds, double D's or Triple D's. I, I don't know if that you, you find the same thing over there on the East Coast.

Dr. Anna (13:14):
So actually I can't say I've ever like googled like trendy breasts, but I do ask all my patients to send me photos. Mm-hmm and the patients that send me photos, they often send me the exact same photos and I don't think they talk to each other. So there's like a specific photo that they show me of Kendall Jenner. There's a specific photo that they show me of Kylie Jenner actually for women who want like a fuller look. Totally. Kate Hudson is quite common and I, where I thought you were going with that was that maybe celebs have become less common because I also see a lot of photos of Instagram influencers. Correct. So not so much celebrities but like Instagram influencers. Some people also do like make it a little bit more intimate. They're like, this is my friend, this is super awkward, but I really like what she's had done. But I find the nice thing about celebrities, and I think probably part of the reason why a lot of people provide celebrities is because their photos are so readily accessible online and similarly Instagram influencers. And so, you know, I think they tend to just look for someone who's wearing a low cut top. But certainly the trend that I'm seeing is, is exactly what that list you had sort of alluded to is the size that they are looking for is really quite small.

Dr. Salazar (14:33):
And I would say that maybe to your point and to underlying your point, I think probably now since pretty much anybody and everybody are famous, I mean we're all, we're all now everybody, anybody can be famous quote unquote. That's why I would say it has opened up a little more for body image and breasts specifically than only people that you would see on a movie or people that you would see on a um, TV show. Mm-hmm . And I would say that that's like where those, the influence of those true celebrities have like lost a little bit territory in terms of breast popularity.

Monique Ramsey (15:12):
Let me jump in and ask you guys a question because of the internet, you know, way back when I started we had what we called the boob book. And the boob book was sort of like a little notebook of a bunch of sort of magazine pictures and things because we didn't have the internet, right? So, so now everything is the internet, but does that also mean that people are not just looking for what the celebrities are doing or what the influencers are doing, but are they bringing you pictures from your own gallery of your before and afters and say, this kind of looks like me or this I like this one or real self or other online tools or forums?

Dr. Anna (15:52):
100%. In fact, I've started to try and post more things on my Instagram that actually like stay and live on my Instagram because people were coming in and they're like, you know, you posted this thing last Thursday in your stories and I wanna look like her. And I'm like, Hmm, which one was that? So I'm, I do think that's a really nice aspect of being able to use social media to interact with your patients is, people already have a little bit of my idea of what you do specifically and it makes that information readily accessible to them. And so yeah, I guess in, in some ways I am having my patients use my other patients as their own inspo now. Yeah,

Dr. Salazar (16:31):
Yeah, absolutely. Monique, we have a rich, uh, gallery of photographs and they come and say like, oh, I sometimes just enough for them to say I like her, I don't like her, I like her, I'm looking for this, I don't like that I'm look and, and that's invaluable, I would say, as part of the armamentarium of where we're gonna go. Can I, I throw a question to Anna in terms of, uh, trends, like at least over here. I, I see, I mean I, I would say that in terms of technique, technique for, for breast augmentation, if, if you ask me, I would say that our patients now are much more educated than before, right? But at the time they come in, probably the only thing we could actually, here, here's the blade here, the implants, I mean they're very knowledgeable and uh, but when they come in it's pretty much a uniform thing when we start a conversation in terms of silicone versus saline, at least over here in the west coast, everybody I would say the gray majority would go, I think silicone.

(17:25):
But let, let, let's have the conversation then the other thing would be under the muscle or on top of the muscle. Submuscular or subglandular, I would say uniformly the knowledge that they come in is like I heard submuscular is better, so probably I would like to go underneath the muscle, but let's see what you have to say doc. And then where to place the incision around the areola or underneath. I would say that uniformly everybody, cuz I want to hear what they know or I wanna hear what they, what they have researched and they all say underneath the breast IMF incision. So in a way to, to recap would say silicone submuscular below the muscle meaning and then IMF incision or underneath the breast incision. That's pretty much I would say the trend of their request. What, what would you say, uh, Anna over there

Dr. Anna (18:11):
That is very, very aligned with the east coast. That's something we can agree on for sure. Similarly, patients come in very, very well educated and they say very similar things. The only thing I would add is some people are so well educated that sometimes they're like, have you heard of the stool plane technique? So sometimes they even like get into it with respect to under the muscle, like how far you're gonna release the, the pec. And so by and large that's, that's where we put the implants. In rare cases, I do talk to them about the benefits of a subular approach if they're bodybuilders who do primarily chest or if they've had animation deformity and we're swapping out the implants or some of those intricacies. But for the most part that's very aligned. Interestingly, I was at the ASPS meeting in Boston and there happened to be a, a west coast cosmetic surgeon who put out these actors of a patient and was seeing, you know, these really small volume elegant implants and he used the same word choice that I often hear from patients and often often use

Dr. Salazar (19:16):
. And

Dr. Anna (19:17):
Then the patient had about 400 cc implants. And so I was shocked because I was thinking in my mind like that's actually not really the aesthetic that I had in mind. And it got me thinking about the importance of really like calibrating that word choice. But I, on that note I was wondering like what range are you using in most patients?

Dr. Salazar (19:39):
So I would say that probably it ranges anywhere from 2 50, 2 75 to 3 50, 3 75. I would say that for our patients that are listening to this podcast, for them to kind of get a little bit oriented, we start like in the, in the range of one 30 s, one 40 s 130, 140, then we can reach up to 900. So if that's why, even though it sounds like it might sound that I'm giving a a big range, but in reality it's a narrow range. And if you think about like the midpoint being, I don't know, just arbitrarily to say from one to a thousand, we're talking about below 500. I would say that that's a little bit of the sweet spot on the, on the medium minus side of things. And in terms of cup sizes request, the great majority would be saying I'm an A or a B make me a B plus a C, I'm a B, let's try to achieve something like a good C.

(20:39):
There are exceptions. And again, there's, I'm not saying that there's nothing right or wrong about these, it's we're just talking about trends, but it, it's rare that I get like a request like make me a double D. I mean I feel that overall and I wanna hear the numbers that are your sweet spot. But, but I would say overall we are getting more of a request for natural and, and of course also we hear the patient that can make me natural and let, let me try those 600 CCs. But, but that's out of a that that I would say it's a little bit out of the norm. But are, are those numbers around where, what, what you're thinking or what you're seeing?

Dr. Anna (21:13):
I would say my most common range is between 1 95 and 2 95.

Dr. Salazar (21:19):
Okay.

Dr. Anna (21:20):
And I'm using a lot of moderate profile implants in women who want like a more natural shape and a less augmented look. And in the younger patients who do wanna look a bit fuller, I'm using generally a full profile implant. I rarely use extra full profile implants. And most of the women that I find that I see who want the fuller projection are fairly narrow framed. So that's why I think to some degree the implant is still, you know, under the 300 cc mark because if, if their chest width is only 11 centimeters

Dr. Salazar (21:57):
Mm-hmm

Dr. Anna (21:58):
, you gotta get up fairly high in profile before you're getting into those higher range implants.

Dr. Salazar (22:05):
And the other thing in, in reality for me to, if you ask me how often for instance do I use extra projecting implants and for our patients, extra projecting means when you talk about projection is how much the implant is elevated based on the base of the implant is in your chest wall, how much it gets you towards the front, how much it projects and that that's the what we talk about projection. And the more an implant projects, the more you're getting away from a natural look. We have certain ways of making it look more or less natural but, but in reality, to use an extra projecting implant I would say it's an exception. Or is it something that you don't even use over there?

Dr. Anna (22:46):
In rare circumstances I will, but fairly uncommon. I tell most patients too, like the more projection you have, the extra full projection actually are the most round looking in shape and because they're the most round looking, they do have an increased tendency to flip because they, they almost look like a beach ball. They sometimes behave like a beach ball. So if you over dissect the pocket now this is getting into technical terms, they can be at higher risk of flipping than the other ones. So I reserve them for like fairly unique circumstances.

Monique Ramsey (23:20):
Let me ask you both, you know we were talking about trends and for a while, and I don't know if it's still a trend, but it was like, oh I want a really nice side boob, you know, they're all talking about the side boob cuz and then you see, you know, from the MET gala and all these different things where certain dresses are cut in a way to really show the side of their breast or if you know, if they're looking for cleavage, are people coming to ask you for certain things like that about what it would look like in clothing or that they want a certain look?

Dr. Salazar (23:51):
I would say that if you compare a trend in the past with the side boob, I would say the side boob is less of a trend. And even I feel I get the feeling, I sense that even patients that they want a little bit of side boob, it's hard for them to say that they want side boob . It's funny, I I feel that that has been a little bit of a change in terms of, "no, i I wanna make it look natural. No, no side boob", and cuz I, I I I bring it up sometimes just again too as part of the different aspects of breast augmentation, it's important for me to understand if they want it or not. And some patients I would say are the great majority would talk about not a lot of side boob. Everybody talks about cleavage then it's something that, it's important for us to educate our patients that the ultimate cleavage will be provided by the bra. But honestly I'm, I don't sense that I get requests for exaggerated cleavage. So I would say more of a natural look.

Dr. Anna (24:46):
I would say some differences. A lot of my patients wanna have breast augmentation cause they don't wanna wear a bra at all, so most of them aren't interested in wearing a push up bra. They either wanna go braless, wear pasties only or maybe just a little bralet agree with the side boob. Most people don't want that. You know, they say I want my implants to fit my frame. I don't want them way out to the sides. I've seen people have 'em in their armpits, I don't want 'em in my armpits. I actually think probably the sort of like strive to achieve side boob, resulted in people using maybe implants that are either too widely placed or too wide for the chest. And when you try and place an implant that's too wide for someone's chest, it ends up in the armpit cuz the ribcage is round at the side.

(25:24):
So you know, if you put it in an implant that's too wide, it tends to move its way into the armpit. The other thing I would say, with respect to cleavage, most of my patients don't want their implants too close together either because they think that looks too augmented. The thing that I use to sort of like customize shape, if they do wanna custom shape, I say look the implants around, if you wanna like change the volume, any specific area, create some custom cleavage. If you wanna be sure that we're hiding the borders of the implant because you don't want that visible look and you want a really nice takeoff, we can use fat for that. So for those cases I do a bit of a hybrid case, use a little bit of purified fat to sort of like customize their shape in, in the particular way that they want it to look.

Dr. Salazar (26:04):
And Anna, in terms of the cosmesis of the breast or that ideal shape of the breast, remember that 60%, 40%, 60% in the lower pole, 40% of the upper pole. Meaning if you divide the breast by half, half, quote unquote being the nipple and areola where your patients request most of the volume, most of the volume below the areola or like 50/50, 50 above 50 below or no, no, give me much more on top. Give me 60% on top, 40% below. What's the ideal breast shape that your patients would actually try to look more European or more quote unquote what Europeans call more American?

Dr. Anna (26:42):
I love that question. So I find this is so individual and that's another thing that the photos help with. Cause some patients actually will bring in, when you ask them for inspo photos, they'll bring in photos of women who have seven different sizes of breast, but they all have the 60-40 combo. So like I'm, I'm like, oh okay, so it's the shape that you like and the distribution. So I think that's very varied,

Dr. Salazar (27:07):
Right? Cause and and again, again a little technical here in dorky here, but pseudo right pseudo they, they enjoy that a little bit of that lower pole volume

Dr. Anna (27:16):
And even some of them will show me photos of patients who have bottomed out implants where they've come through the fold a bit and they actually prefer that look. So I haven't intentionally started like, you know, lowering the imf but there's certainly some patients that like that pseudo.

Monique Ramsey (27:32):
So pseudo meaning semi

Dr. Salazar (27:35):
Lax? Semi droopy.

Monique Ramsey (27:37):
Semi droopy. Okay. Now when we talk about trends east west, is there any difference in terms of maybe what percentage of your patients prefer saline or silicone?

Dr. Anna (27:50):
So I would say most of my patients prefer a silicone implant once they feel what that's like. And most of the patients that have questions about the option to use saline implants either want to avoid the silicone altogether. And then we have a conversation about how the, the shell of the saline implant is actually silicone as well. Some people actually do think that if they have a saline implant, their scar can be smaller. And then I have a conversation with them about, you know, the, the size of the scar is actually designed so that you can have good access to do like create the pocket that you need so I can fit the silicone implant through the same size of scar that I can fit the saline implant. And then the last thing that they wonder, and to some degree this is true in women who worry about silent rupture, they say, you know, I would just rather know if my implant is ruptured right away.

(28:46):
And to some degree, you know, if a saline implant ruptures, you know, because it starts deflating so it's not an emergency, it's maybe an aesthetic urgency. But um, I do offer the patients the option of having saline implants if they really want it. Just advise them, you know, some of the differences and the, the risk of course of the visible rippling and the less natural feel. I also make sure that they know that for an equivalent volume the saline ones are heavier. And so we just go through all of those, all of those scenarios and at the end of the day most people still choose silicone.

Dr. Salazar (29:20):
I fully agree on that. And I would say that 99% of my patients, literally they've request silicone gel implants. We go over the differences cause I think it's important that patient education is important. Let them feel as Anna is saying and they immediately kind of start getting it. They said okay, so definitely this is different. It's a different, I mean it's a different product. Both implants will get you to where you wanna go but in a little bit of a different style. But it's a matter of patient preference and making a, an educated decision based on our discussion.

Dr. Anna (29:54):
I say it's reasonable to take that one step further and if patients do have concerns about silicone after all of the discussion about safety, that there's lots of good options for breast enhancement that don't involve implants. And so, you know, if if it's a silicone then the saline still has a silicone shell, then maybe a fat grafting option or just a breast lift or a breast lift with fat grafting is a better option for you.

Dr. Salazar (30:17):
Agree.

Monique Ramsey (30:18):
And that actually segues perfectly, Dr and I right into my next question. So I've seen in the tabloids and popular media like People magazine and US Weekly, they're starting to say, well if we're starting, are we starting to see the end of the big booty? You know, with a BBL surgery where fat is being grafted to make the butt bigger. And a lot of times if you have a bigger booty, you might have bigger breasts to sort of offset it or make it more proportionate. So if we're kind of, are we seeing the end of the big booty and then as a result are patients asking for maybe smaller breast implant sizes than in previous years?

Dr. Anna (30:56):
What you really mean is are we seeing the end of the big booby ? Which is actually what I thought you were gonna say. I think definitely that a lot of women talk about in their consultation that they want their breast size to really match their frame. I don't do bbl but at our office some of my colleagues do and it's, it's definitely a trend that they're seeing. They do the fit BBL or the athletic bbl, they don't necessarily use the high, high volumes that were so common initially.

Dr. Salazar (31:33):
Yeah, no, that I feel that we're living in a world that wants to turn or wants to go back to the basics more organic and definitely those terms of proportionate terms of natural, I would say it's the same thing that I hear. I do do fat grafting or BBLs to the buttock. So it's something that I hear both ways to the front and to the back. So more of a, more of a natural, something that maybe people can't tell that I had it done more than a place for you to place your glass of champagne. It's something for them to just correct a little paucity of volume or just augment a little bit.

Monique Ramsey (32:15):
So getting back to that hybrid idea, that hybrid breast augmentation, you know we were talking about natural and so how to accomplish maybe a small breast augmentation.

Dr. Anna (32:27):
Yeah, so I think in thin skin, women with very little breast tissue, it's a nice option. Even when you put implants below the muscle. In some women it's a nice option to be able to add a little bit of that extra volume of your own tissue. Cause you take it from somewhere that's a stubborn area. So we use liposuction and then that tends to behave the way it behaved in the location where it came from. So if you take it from a stubborn area, it's more likely to be retained. I do find it's a nice option for some women and in other women I say, you know what, like you've got enough of your own breast volume already. I don't think it's gonna make much of a difference in you. So I think it's very individual in addition to the implant important things for patients to know just with respect to safety, the fat transfer can affect your imaging.

(33:20):
So generally if you're getting mammograms to evaluate for breast cancer, regular screening, if there's any areas on your mammogram that are identified as abnormal because of areas of fat that haven't survived, sometimes you need extra imaging. So with that in mind, some people choose to forgo the fat grafting and they prefer to just have the implant and not worry about extra imaging down the road. The other thing I was gonna mention, just when you were talking about a little bit, patients identifying what they don't want, I do think sort of like anti inspo photos can be helpful too. And if patients can provide images of what they don't like and what it is that they don't like about it, that can also really help you explore what their ideal rest aesthetic really is. So I find both equally helpful.

Dr. Salazar (34:12):
I would say that, uh, agree with you in terms of the potential or the use of fat grafting. And I would say in that the great minority of uh, patients, uh, would come in asking for a pure, like if you talk about like pure fat grafting, use your own fat only augmentation. I would say that that's some someone it's, it's really, really rare. The other thing is that it's important for patients to understand that fat will provide you volume but fat wouldn't provide you structure. So it it's also sometimes they, they have a a breast with a different shape that actually would help having a breast implant there to provide some structure and pure fat is not gonna do that, that job for them. But if a part of the questions and the trends would be, do you see a lot of people asking for a pure fat breast augmentation? Mm-hmm. , I would say it's very minimal. I, I don't see like a new wave of like, again very organic only fat only augmentation and I don't have that. I don't get

Dr. Anna (35:14):
That. I do, I first sure do. Yeah.

Dr. Salazar (35:17):
Without a good difference.

Dr. Anna (35:18):
I have a lot of people come in and say I don't want an implant, I just want that. Okay. And I would say often that's like a discussion that we start out with, but then once we explore what it is that they wanna achieve mm-hmm , most people sort of have a little bit of a disconnect about what that can achieve. I think that's a great tool for some purposes for like improving the aesthetic or customizing cleavage. It's awesome for breast reconstruction revision when you're like trying to really fill in contour deformities or that sort of thing. It's really great. Also if they have some mild asymmetries and you don't wanna use two different size of implants, but almost no one I think is a good candidate for like a fat grafting only breast enhancement. And those people who wanna achieve a significant difference with a fat grafting only, I think it's really important to advise them that you are going to need more than one surgery to achieve the type of look you want.

(36:17):
Because really, you know, you can only take so much fat. When we take fat via liposuction, we remove it from its blood supply. So then you have to transfer it into the blood supply of the breast and ask it to like seek its new blood supply via diffusion. That's a very sciencey word. But if you try and over inject, the fat doesn't survive. So then you can go back later and once you have more volume, then you can again add more volume later and you can kind of build on that. But to achieve a significant difference in what most people are looking for, it's almost never a great option to be like a one and done back grafting only transfer. I've done it in like very, very small women and they were quite happy. But it's pretty rare that that's the be all, end all. I don't think it's a replacement for breast implants for sure.

Dr. Salazar (37:04):
So I would say that that is not a difference between the east and west coast because I would say we have the exact same experience. We talk about our patients in the same way. I would exactly educate them the same way that that you do. And I agree with what you can achieve with pure fat. I fully agree on that. But yeah, we, we found a difference. You get a lot of requests for pure fat only breast augs and we, I I would say we, we don't.

Dr. Anna (37:30):
I do. Yeah.

Monique Ramsey (37:32):
Now what are the very smallest implants that you can get? What size?

Dr. Anna (37:37):
? That's a great question. So in the moderate volume implants that I use, the smallest is a one 40 in like the lower projecting, which is not something that I use commonly you can get down to like a 100 cc implant and then you can also, you can, you can custom order implants. So really like any size is an option. But in the, in the standard implants and the type of implant I use, those are the sort of smallest ranges. To give you a bit of an idea, it's kind of a fun fact. The 140 cc implant that is the moderate volume, like smallest diameter fits on the top of a coffee cup. So it's about the same diameter as your average coffee cup

Monique Ramsey (38:14):
.

Dr. Salazar (38:14):
Oh. Whenever we get close to those in the operating room, you get the classic, when we are about to place it, it's like, "oh how cute".

Monique Ramsey (38:22):
, that's funny.

Dr. Salazar (38:26):
I wanted to also share with our patients in our audience and with Anna to see if she has different numbers. But going back and looking at the procedures performed in 2021, seeing how breast augmentation is still a very, very important procedure. I would say it's a procedure that patients are constantly seeking. It's the second most common procedure performed. And we, we, if you look at the numbers back from 2021, you're talking about 365,000, a little bit short of 365,000 breast augmentation cases. And in addition to that you have to add 150,000 cases of remove an old implant and replace with a new one. And so it's still a trend breast augmentation, it's a trend that's present. It's a trend that it's considered safe till today. And there are some patients that are also looking for implant removal. But that is the great minority I would say. I mean the numbers were called for 2021 of 71,000. So it's a little bit around like 12, 13% if you compare them to the implants being placed. So breast augmentation, it is a trend.

Monique Ramsey (39:35):
And let's talk about predictions for 2023 and beyond. Talk about the future and maybe have both of you give us your aesthetic breast surgery predictions and then we can come back in a year. We can see if you're right and we can award, you know, whoever wins like gets the fish tacos from San Diego or gets the, I don't know, what's New York famous for cheesecake or pizza? Hot dog Pizza. Pizza. Okay. See how much I know as a San Diego girl. So, so let's talk predictions and we'll start with you Dr. Anna.

Dr. Anna (40:07):
My prediction is we're gonna see more and more of the re-styling. So I think re- styling big implants for a smaller implant is gonna become increasingly more common.

Dr. Salazar (40:19):
I would agree. I and I feel that if you asked me 2023, I would still say that it's more of a, I'm gonna keep on hearing, listening more of give me a natural result, give me something that fits my body, something that doesn't get out of the boundaries of my chest. Give me something that's proportionate.

Monique Ramsey (40:39):
So one last question. If you're comfortable sharing, I know there's many brands of implants and what brand do you tend to use the most?

Dr. Anna (40:51):
The implants that we have on consignment are the Allergan implants. So I mostly use the Allergan smooth round breast implants in my practice.

Dr. Salazar (41:01):
I would agree with you. I mean it's a, it's a very, uh, reputable company and we use, uh, natural implants the most, uh, patients actually sometimes come in with other, for instance, um, Mentor implants or Sientra implants, and we're we're never closed to, to using a different type of implant they specifically request for that. The other thing, and, and I I would like to hear from Anna, me personally, we, we are not using textured implants uh, anymore. Meaning for patients to picture that the surface of the implant can be smooth or can have some texture and a texture. The way it works, it decreases uh, some of the contracture problems with implants and also allows the, the implant to be fixed and stay in the place where you leave it. But I would say that we probably stopped using textured implants about three years ago. In our practice we have four surgeons that are implanting then I would say one surgeon uses textured implants. Then I would say the other three, we don't use them. Is it something that you use?

Dr. Anna (42:02):
I've never put in a textured implant. Actually I use all smooth tissue expanders as well. So all of the tissue expanders I use have a tab that you use to suture the anatomic tissue expander in place.

Dr. Salazar (42:16):
So I would say that that's another trend, right? Like smooth implants over textured mm-hmm and it's the same there then here. Okay.

Dr. Anna (42:23):
Yeah. And I, I don't know that you mentioned but the, the textured implants are associated with a rare type of lymphoma and so the type that they were most highly associated with was removed from the market and recalled other textured implants to some degree have a lower risk. But that's the main reason that I use the smooth round is because to date there hasn't been a case in smooth round implants. But I do think from a safety perspective, that's the main, the main reason and the main influence in my practice to use the smooth.

Dr. Salazar (42:51):
Fully agree.

Monique Ramsey (42:52):
That's good to know. Cuz you know, these things do change over a period of years, like mm-hmm. , like you were talking Dr. Salazar a little earlier, you mentioned, you know, is the implant over the breast muscle or behind it and you know, over time these things changes. Everybody learns more and more. So anything else that, is there anything else we missed covering or any other fun facts that besides fighting over fish tacos and pizza that ,

Dr. Anna (43:20):
I gotta know, where's the best fish taco in San Diego?

Monique Ramsey (43:24):
Oh, well I have my opinion.

Dr. Salazar (43:27):
Um,

Monique Ramsey (43:28):
Go ahead. Are you ready for this? Well, actually Dr. Salazar, you might have had them.

Dr. Salazar (43:32):
Yeah. Where, where,

Monique Ramsey (43:33):
So it's a man who does catering and he's Casanova Fish tacos. Well, his mom was Spanish and his dad was Italian. And so he's got a little bit of both. But we've had him at some of the lolla cosmetic parties and oh, they're just far and away the best. But other than that, I'm pretty much happy wherever you, wherever you take me. Where do you like to go?

Dr. Salazar (43:54):
Well, hey, now we have a commitment because in speaking about New York and the West Coast, Anthony Bourdain once came to, well, came many times here to San Diego, but Anthony Bourdain came from New York and on his last visit he was asked which one was his, um, best place to eat while he was in San Diego. And his answer was, go to Baja . So fish tacos, the best fish tacos are in Ensenada, Baja, California. And it's only 45 minutes away from where we're recording this podcast. So

Monique Ramsey (44:25):
I think we need a road trip. My stomach's rumbling now. Okay, so for pizza though, Dr. Anna, tell us about, you're so tiny, you probably don't even eat pizza, but if you did , where, where's your favorite place?

Dr. Anna (44:37):
Oh, fun fact, when I was here for my fellowship training, my husband and I ate at over 100 pizza places in, our time here.

Monique Ramsey (44:48):
Oh my goodness.

Dr. Anna (44:50):
We had lot of pizza. We made a rule for a while that you could only have a slice and not order to a whole pie, but that didn't last very long. So we're making, and we've tried all the spots. The best place by far is a slice shop in Brooklyn. It's a long way away. It's called Di Fara, but there's lots, there's lots and lots of, so I could give you a recommendation for any like specific area of New York you're staying in .

Monique Ramsey (45:17):
Well, thank you both today . This was really fun. And I really do think we should do a follow up next year. Absolutely. Yeah. And see what other things we could talk about. But for our audience today, if you're listening, we wanna ask you for a special favor. If you love our podcast, we hope you do, if you learned something from it and if it's helped you make a decision, you know, please tell your friends and write a review or share the show out to your friends. You can write a review on Apple Podcasts or good pods or wherever you're listening. So we love to know that we're doing a good job. Or if you have certain topics you want us to talk about, please do that. And then of course we'll have links in the show notes. So maybe from Dr. Anna, we'll have to even get a link for that pizza place. But we will have the links in the show notes talking about some of the things we discussed in terms of types of implants, those profiles and projections. And if you'd like information about Dr. Anna, Steve in New York City will have links to her bio and her Instagram. Same with Dr. Salazar here in San Diego. And well thank you again for listening and thanks all for joining us.

Dr. Anna (46:23):
It was a pleasure. Thanks for having me.

Dr. Salazar (46:25):
Thank you so much, Monique. Thank you. Thank you, Anna, for being here.

Speaker 1 (46:35):
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 five San Diego Freeway in the XiMED Building on the Scripps Memorial Hospital campus. To learn more, go to lj csc.com or follow the team on Instagram @ljcsc. The La Jolla Cosmetic Podcast is a production of The Axis, the axis.io.