Revision Breast Augmentation with the Internal Bra Technique

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 I'd like to welcome Dr. John Smoot. And he is going to be talking about the internal bra, which is something we've done for a long time now, but it's now more well known and talked about on social media and in the press. And so, it's something for augmentation patients. And so, tell us, Dr. Smoot, what is the internal bra exactly?

John Smoot (00:43):
The internal bra is just a name for doing things that can't be seen on the outside. Now, it's a way to support tissue without being seen that'll help lift and support tissues. That's essentially what it is.

Monique Ramsey (00:58):
And so, what kinds of cases would you recommend an internal bra for?

John Smoot (01:04):
Well, it depends on what each patient has to deal with. Basically, it's there, like we said, for support, to elevate and reinforce tissues, native tissues that have lost their integrity after years of weight gain, weight loss, children, nursing, age, such that a 50-year-old breast is not like a 20-year-old breast, just like an abdomen from a woman who's had no children versus one who's had children. The tissues get stretched and aged in a way that they don't look as good as they used to be. And so, you need to do something to reinforce it.

Monique Ramsey (01:36):
Would it ever be something that a primary breast augmentation would need?

John Smoot (01:43):
Rarely. It depends what they're coming in for. Now, a woman who's had nice breasts before and then has had a couple of kids, and now lost some weight, and now things have stretched and bagged. Yes, then we might want to put something to support the tissues as well as put an implant in. But it's mostly for that, it's to support the tissues back up to where they were. And so, it doesn't mean that everyone who has an implant primarily needs to have one, it's usually a secondary type procedure to do.

Monique Ramsey (02:14):
Could it be used in a surgery where you're not using implants, like a breast reduction, or a lift, or fat transfer breast aug? Or does there need to be an implant involved?

John Smoot (02:26):
It usually involves an implant, but it doesn't necessarily mean that we have to have implants. Yes, you can use it on breast reductions. I've used it on occasion for that. That's usually not what we use it for, for just supporting just the tissue alone. It's more for when you have an implant, you want to re-support that bottom pole.

Monique Ramsey (02:44):
I would think that if the tissue, like you say, you've had either kids and breastfeeding or you're an older patient, it's, I guess, if you put a heavy implant in there, it makes sense that you need something to help, almost like a sling maybe, to help, so that tissue doesn't have to take the whole weight to the implant by itself.

John Smoot (03:05):
That's right. And it's been around for a while. Over the years, I've used several different types of meshes. Now understand, patients get mixed up between meshes and we call ADMs. That's the collagen matrices that we put in, like the AlloDerm. It's cadaver skin and pig skin, something like that, which is a totally different use for what you're trying to achieve here. I'll explain that in a minute.

Monique Ramsey (03:33):
Okay. Does it matter if you have saline or silicone implants when you're using one of these? Is it a device? Would you call it a device?

John Smoot (03:42):
Yes. It doesn't matter. The type of device is not really significant. The size becomes significant. The quality of the tissues, the width of the breast, how big can you put in, those things are more important than the actual style of implant. Now, if you get someone who's very thin and doesn't have much breast tissue, then, yeah, silicone becomes a much better choice, because it is more natural feeling, it's less palpable. You see less rippling with the silicone implant versus a saline implant.

Monique Ramsey (04:13):
Now, if you're having this mesh... I guess we're talking about mesh, right?

John Smoot (04:18):
Correct.

Monique Ramsey (04:19):
Now, I'm already confused about the ADM and the mesh.

John Smoot (04:22):
No, just we'll talk about mesh. And we'll-

Monique Ramsey (04:24):
Okay. So, with that mesh, now, is it something that you could see?

John Smoot (04:29):
No. You're really never going to see this. Now, what it is, when we say mesh, it's literally like a mesh screen. If I was to take it out and show you, it looks something similar to that. Now, what it's made of is it's a bioabsorbable material. It's called poly-4-hydroxybutyrate, or what we call P4HB, or in the common era, it's GalaFLEX. That's what we call it. And it is a bioabsorbable material. It bakes down through a hydrolysis procedure, so it gets bioabsorbed over time. But what it does do, over time, is it creates a scaffolding of thicker tissue, so it has more strength to it, even though it dissolves. Now, we've used the permanent meshes in the past and had a lot of problems with those. So, this is really good, because it will not last. Now, you mentioned, is it palpable? If someone is very thin, they don't have much coverage when you put it in there, yes, you might be able to feel this for a while. But it typically does dissolve over time.

Monique Ramsey (05:24):
Okay. And could the patient feel it on the inside?

John Smoot (05:30):
No, you'd feel it on the outside.

Monique Ramsey (05:31):
Okay.

John Smoot (05:31):
Like when they feel underneath the breast, they can fill the edges of the graft, sometimes, the mesh graft. But again, that has to do with how much tissue we have to work with. Someone who's very thin and got a lot of sagging, yeah, you might be able to feel that. Yeah.

Monique Ramsey (05:46):
But then, like you say, over time, it's going to dissolve and your own body's-

John Smoot (05:50):
Right.

Monique Ramsey (05:51):
... creating a structure. And how long does that take?

John Smoot (05:54):
It takes about 18 to 24 months.

Monique Ramsey (05:57):
Oh, interesting. So, it takes a while. Now, does the patient need to think differently about recovery in any way with either exercise or lifting, or is everything the same as you would tell a breast augmentation patient?

John Smoot (06:11):
It's pretty much the same. But most of the time we're using this and we're doing lifts and re-supporting and retaking out excess skin and sometimes some tissue to keep the breast shape. So, that's usually why we're putting it in there. And the recovery is pretty much the same, whether I use it or not. The question more is in terms of how much do I need to do? Is it just an implant? Is it an implant, a lift, and reinforcing the tissues? The only downside about the meshes is that it costs a little more. But it does prevent some long term problems. When girls come in and say, "I want to do one more procedure and it's the last one. I want you to do everything possible to keep me looking nice," well then yeah, we consider some of these meshes and some of the time some of the ADMs we talked about.

Monique Ramsey (07:00):
Okay, so let's go back to that. The mesh versus the ADM. So the mesh is actually, like you say, a scaffold that will dissolve over time that your body integrates with. What's the ADM?

John Smoot (07:12):
Well, the ADMs is for a different purpose. That's not necessarily for support. We use ADMs for capsules. In other words, when girls say, "My implants got hard," there's this tissue and to keep it, but to lessen that we use the ADMs. That's, we want to keep it soft and feeling natural. But the mesh is not used to prevent or to treat capsules. Now, some people said that to some degree, but there's no proof out there right now that it does do that. It might, but we'll know in time, as we do more studies.

Monique Ramsey (07:44):
So the ADM, does it wrap around the implant or what does it look like? And I guess, when it's in you, where is it?

John Smoot (07:52):
There's two kinds. There's cadaver skin, human skin that's treated and it becomes just made of collagen. There's also, we called pigskin, which is called Strattice. Now, both work equally well. And people freak out when they say, "Oh, you're putting pigskin in me?" Well, yeah, we've been using this in heart valves and other things for many, many years. So, it's been proven to be safe. But when you look at it, if I took out a package, it'd look like white, wet, cardboard. It's what it looks like. But it's just collagen. And you almost never can feel it. You can't put it in there now. Depending on what we're trying to accomplish, we can wrap the entire implant in this stuff. We prefer not to. Usually, it sits in the bottom part of the breast, like a half moon support bra, like a couplet that sits in there. We just sew it into the tissues. It gets integrated into the breast tissues. And for the most part, it stays there for a long time. I've had a few times it's been chewed up by the body and removed, but not very often.

Monique Ramsey (08:50):
Interesting.

John Smoot (08:52):
It really works though. I mean, we've done some podcasts on this before.

Monique Ramsey (08:56):
Yeah. We did one on revision breast surgeries, and the different types you might need, and what they all mean. And so, that's very interesting. For the person who might have gotten either really bad capsules or keeps getting capsules, then this is where you might lead them to choose-

John Smoot (09:14):
Right. We wouldn't be using a mesh, we'd be using the ADMs. That's correct. This is for someone who's just, no matter what you do, they just keep bottoming out. They have no support. You've got to get something to support and create that new fold and make sure that fold doesn't descend.

Monique Ramsey (09:31):
Now, how many times do you think you've done this internal bra procedure?

John Smoot (09:37):
I've probably done 50 to 100 of them would be my guess. I mean, I've done a lot more ADMs, because that's the nature of my practice is doing this revisionary surgery. But again, I've used it. I don't use it all the time, but there are times when it is necessary to use.

Monique Ramsey (09:54):
Now, what do patients usually say after they're through recovery, they see their results?

John Smoot (09:59):
Well, usually it does work now. It doesn't always work perfectly. Nothing's a hundred percent. But it does tend to keep that shape up. The most times where I use this is where the implant has descended and dropped down below their fold. And so, the implant is lower than their breast. We call a double bubble. And now, you've got to reinforce that tissue because it's weak. And if you just try to sew it down, a lot of times it doesn't work. You have to reinforce that fold. And that's what that is used for is to reinforce and get that nice round shape again.

Monique Ramsey (10:32):
Now, do patients who might have had a few surgeries, like a second or a third breast surgery, does it take them longer to recover? Or is it however their body recovers, it doesn't really matter whether it's the first-

John Smoot (10:45):
It's a little different. It's never as hard as the first time. But again, that's variable. Because if I have to sew the pockets down and put some of the grafting material or the mesh in there, I have to sew it along the rib, and that's what hurts. That's what gives the strength. Now, it's a little uncomfortable for a few weeks, but it's not the same pain you have when we have to put the implant in, and release the muscle, and put it under the muscle.

Monique Ramsey (11:08):
Yeah. Just you saying that, I was thinking of my next question, which is, I remember... I've been in this business now 30 years. So, there's been trends in breast augmentation. Over the muscle, everybody's doing subglandular, meaning it's on top of the muscle, the breast implant's sitting on top. Then, everybody was moving to submuscular where the implant goes behind the muscle. I have two questions. One is, what do you tend to do more of now and why? And then the second question is, when you're using this internal bra, does it matter whether you're going over or under the muscle?

John Smoot (11:42):
Okay.

Monique Ramsey (11:44):
Sorry. That was a lot.

John Smoot (11:46):
Just your first thing. The trend is, well again, this is my experience over 35 years of doing this, I almost never go above the muscle. Initially, it looks good, yes. But the long term consequences are usually not good. It's a higher rate of hardening or capsule contracture. It can sometimes thin out and you get that half dome look, or there's no support in the tissues because it's a weight, a rock in a sock type look. So, I tend to put them under the muscle. That tends to maintain the shape, hold its position better, and give it a more natural look. The only drawback, the muscles that when you flex, yeah, they can move a little bit. But I ask women, "How often do you go around flexing your pecs?" So, it's usually not a big deal.

John Smoot (12:29):
Now, when we use either one of those items, either the mesh or the ADM, and we're talking about mesh today, I tend to put it as like a half cup, like a couplet. I should have brought a piece here and showed you what it looked like. I didn't think about it. But you just sew it into the muscle and you sew it into the fold, so it creates a little sling in there. So that's why I like to do it. Can you use it above the muscle? Yeah, but you don't have anything to anchor it to. It's a little more difficult to anchor.

Monique Ramsey (12:57):
Okay. Well, that makes sense. And we'll put in the show notes, we'll get some pictures of it, and then we can put some links in the show notes for everybody who's listening to go look at what we're talking about in each of these cases. For patients who are thinking about cost, revision breast surgery ranges between, let's say, $11,500 to $16,500. We have all our pricing on our website. We have ranges for a reason, because everybody's a little different type of implant, et cetera. Does it add a lot of cost to include the GalaFLEX?

John Smoot (13:31):
It does. I mean, it's not inexpensive, but it's not overly expensive either. Sometimes, I use these products as a prophylactic measure, an insurance measure. Like they say, "Look, I'm going to do this one more time, and I want you to do everything you can to keep this looking good." Okay, well then we need to consider this.

Monique Ramsey (13:48):
Yeah, it's worth it.

John Smoot (13:48):
There are times when I just say, "No, you need to have this material." And everyone's a little different. But I think that when I talk to patients, money's not on my forefront, in my mind. I don't talk the money. I don't talk the cost and prices. I talk about what I can do to make it work. I am sensitive to budgetary items. I don't like to just run the cost up because I can. But I only suggest things if I think it's going to be some help. But sometimes it's, okay, half dozen one way, six ways the other, to a certain degree. And like I say, it's up to the patient. There are times you say, "No, you need this."

Monique Ramsey (14:24):
Yeah. Well, and it's probably cheaper than having another surgery down the road.

John Smoot (14:30):
Exactly. That's exactly what I tell them.

Monique Ramsey (14:31):
Whatever that ends up being. And this is where, I think, the issue for financing really comes up, because a lot of people don't realize that you can finance your surgery. It can help a lot. And maybe you don't finance all of it. Maybe you have a certain amount saved up, and then you finance the rest, because maybe it was more than you thought. And that's, makes it a way that it... We're very easy to talk to about money, because it's a concern for everybody. We can't pretend like it doesn't exist. So, I think knowing that there are tools and that our team will help you figure out what's the best way to make this work for your budget so that you can say, yes, if you need it. Then, it makes that a little bit easier.

John Smoot (15:14):
Right. Sometimes, it's a little more cost upfront, but if you have to come back for second or third surgery, because you got a little too conservative, and then you're not doing anybody any good. Okay. So, I'm very honest about that. And I'm not terribly aggressive when I do, but I like to be very clear. I really want my patients to be educated when I talk about these products and why I'm using them, what are the alternatives. And sometimes it's, "Well, I can't afford this." Okay, well then we'll taper something to your budget. But again, my focus isn't to say, okay, how can I maximize the profits of these procedures? That's not what's on my mind.

Monique Ramsey (15:50):
Well you want the results, right? You want the best result possible.

John Smoot (15:54):
I mean, it's just the old saying of, if mom ain't happy, nobody's happy. If my patients aren't happy, nobody's happy.

Monique Ramsey (16:00):
Right. Right. Like I said, we have another podcast talking about breast augmentation revision with Dr. Smoot. It's a great episode, so go back. It was one of the first ones we did, so go back a little bit. We're now up to like 57 episodes, which is so cool. We'll link that in the show notes. And then, we'll also have some links to pictures on our website with breast augmentation revisions, so you can take a look at that. Now, Dr. Smoot, I would assume, now that we're in this post-COVID world, that people come in for in-person consultations. But if they want to, can they still do a virtual consultation with you?

John Smoot (16:39):
Well, absolutely. There's no problem, we can do it virtual. It is limited though. Because particularly when you're talking about firmness and positions, it's hard to tell in a Zoom consult. But I can get some idea to say, "Yes, you're going to need this. You're going to need that." And we'll talk more in detail when I actually see them in person. But it's a good start for someone who just wants to get some information.

Monique Ramsey (17:01):
And/or if they're out of town. That's the other thing, we do have patients travel a lot of times to see our doctors for surgery. And so, it's a good way to get that first step. If you're listening today and you have questions and needed information about scheduling, financing, reviews, or photos, check our show notes for links. We'll have all of those there. We'll also get some pictures of the GalaFLEX and the Strattice, which is the ADM, so that you can have an idea of what we're talking about there, a good visual. Dr. Smoot, anything else that you wanted to mention about this procedure?

John Smoot (17:37):
There's few things in our business that have really been remarkably in terms of changing the outcomes, and one of them was those ADMs. That was a real game changer for women who had implants and then had multiple problems with capsules or deformities, and, "Will I ever have nice looking breasts again?" And it's been a game changer to correct those problems, where beforehand it was just like, "Well, I can try it again or take your implants out." Now, the GalaFLEX is a little different, and the mesh is a little different, what it's doing, but it's more for reshaping and supportive issues. Again, it very much helps. It's one of the tools we have to have some outcomes that are good. Again, I'm not trying to toot my own horn on this, but in terms of these revisions, I've got... Instead of doing the straight easy cases, I get all the hard ones.

Monique Ramsey (18:27):
Isn't that fun when you're so good at what you do, that you get all the hard stuff?

John Smoot (18:32):
Yeah. But again, it has taken me 25 years, since I started using this stuff, to learn how to use it. Now, when I first started using these things, it was poo-pooed and oh, it doesn't work. And now, it's like everybody uses it. And I was out there teaching and talking about this, and there's a lot of skeptics. But now, it's pretty much part and parcel of all of our practices now.

Monique Ramsey (18:57):
Wonderful to talk with you again this morning. Thanks for taking time out of your day.

John Smoot (19:01):
Thank you, Monique.

Monique Ramsey (19:02):
I hope this was helpful for all of you. If you liked it, please give us a little review wherever you listen to your podcast and tell your friends, share it out. And we'll see you again next time Dr. Smoot.

John Smoot (19:15):
Well, just let everyone know that I am more than happy to see you, if they have questions, at least to come in and talk. We don't have to make any commitments. But women are listening to this and thought they can never have their breast fixed, there are options out there. I'm not because I am the only one who knows how to do this. I'm not. But I've got some experience in it.

Monique Ramsey (19:32):
That's wonderful. All right. Well, thank you very much. Okay.

John Smoot (19:36):
Thank you.

Speaker 1 (19:43):
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