What Really Happens to Your Breasts After Implant Removal

Monique Ramsey (00:04):
Welcome everyone to The La Jolla Cosmetic Podcast. I'm your hostess, Monique Ramsey. So today we're going to talk about breast auto augmentation, and that is a technique that Dr. Swistun uses to create and restore fullness symmetry after breast implants are removed, but without the need for any new implants. So he's going to walk us through the different methods he uses and how he can help you get that best possible result after having those implants taken out and to get the best contour and the best feminine shape after the surgery. So welcome Dr. Swistun.

Dr. Swistun (00:45):
Thank you very much. Thanks for having me again.

Monique Ramsey (00:47):
I think one of the big questions that women ask, okay, I'm going to take this breast implant out. I don't want another implant put in, but will I have enough breast volume after my implants are removed or am I going to end up completely deflated?

Dr. Swistun (01:05):
Right. So yeah, that's a very common question and especially in the line of the types of surgeries that I do, I get that question a lot because the vast majority of what I do is removing implants, and majority of those patients actually have that concern because they got implants in the first place a lot of times for that reason, they did not have a lot of volume to begin with, and now here we are, the implant has to come out and now they're back to their original volume and is that going to be enough? Are they going to be happy? There's a couple factors that we discussed when we look at this question. One of them is in general, most women have a little bit more breast tissue as they get older, and there's a couple of factors that I think influence that. Number one, most patients gain a little bit of weight from head to toe, and some of that weight does settle in the breast as well.

(01:49):
So some patients are a little bit pleasantly surprised that after the implant came out, oh wow, that's actually a little bit more volume than I thought. The other, there's some hormonal changes that actually took place, especially after breastfeeding, after childbearing, certainly after menopause, a lot of women report that they have a lot of glandular hypertrophy, a lot more breast volume than they had before these things happened. So some of that time just plays in our favor that there's a little bit more volume. Typically though, what happens after implants is that volume gets splayed out over a larger surface area, which is to say when a patient has an implant in or gained a little bit more weight, then the breast footprint grows in response to that. Then with the implant, the breast footprint is lower and maybe wider, so whatever tissue they do have is spread over a larger surface area and therefore less projected centrally.

(02:39):
So what we end up doing once we remove the implant, obviously the lift is sort of the best way to gather up all that tissue into a smaller footprint, but therefore more projection. And then the part of that we talk about when we talk about auto augmentation is that we really want to optimize that opportunity and not waste any breast tissue that we possibly can. So classic lift techniques actually don't necessarily carefully consider how much breast tissue we can sort of salvage, so to speak, from different parts of the breast in order to bring it together. What an auto augmentation techniques do is they really look for anything that can be used and rearranged into an overall nice shape and preserved in order to give us as much volume as possible.

Monique Ramsey (03:26):
Let me just back up for one second. The reason we're calling it auto augmentation is not because we love our Lotus and our Lamborghini and auto, meaning from yourself, right?

Dr. Swistun (03:38):
An auto augmentation means using the surrounding breast tissue that's already available in order to augment as opposed to an implant augmentation or a fat graft, I'm sorry, or a fat graft augmentation.

Monique Ramsey (03:49):
Okay, and so let's talk about, you said there's a couple different techniques and you use all of them and you might even use all of them on one patient depending on what they need. So go into a little bit about, first of all, what's that main goal that we're trying to achieve after the surgery and then how you get there and what your different techniques are?

Dr. Swistun (04:10):
There's lots of techniques described in literature. If you look, there's a lot of variations of the same sort of principles, but bottom line is there's a lot of tissue on the bottom of the breast that typically during a lift just gets sacrificed and it's usually thin. It doesn't amount to a whole lot of volume, but hey, it's better than nothing. So instead of cutting it out, if we can just epithelialize it, which means we remove the skin from the surface of it, but then use the tissue immediately beneath it and preserve the blood supply, we can actually take that bottom of the breast, lay it down on the chest wall. I actually use that opportunity to repair the muscle too. A lot of times patients ask after we remove my implants, are you going to repair my muscle? If the implant was under the muscle, this is a good opportunity to do that, where you re-drape the pectoral muscle lower and sew it down to that, the lower breast tissue that accomplishes two things, it gives us an extra layer of tissue on top of your chest wall in order to then reconstruct the breast on top of that. So we already are starting off with a little bit more projection, a little bit more volume, and it restores the natural pectoralis major anatomy to what it was prior to the augmentation. So it's kind of two benefits in one maneuver. There's a second opportunity where immediately beneath the nipple, a lot of times basically there's a little bit of extra tissue immediately below that nipple, and what we do is we basically do the same thing. Instead of removing it or cutting it out, we remove the skin from the surface of it, but then we use the tissue beneath the nipple in order to kind of flip it underneath the nipple and the areola, and that will give us a little bit more projection of the nipple itself.

(05:48):
Sometimes there's actually enough that we can flip it underneath and hike it up higher so that we actually give a little bit more upper pole fullness as well. So that's a great technique to just achieve central projection, central fullness of the breast. In addition, that particular one is my favorite because we can actually manipulate it towards a deficient area. If a patient has very little volume centrally, we can actually take that flap and kind of move it towards the center a little bit more. If there's volume deficit laterally or on the outside, we can do the same thing. We can just kind of move it towards the outside or we can move it to the upper pole or just immediately beneath the nipple and or give a better projection. But again, it gives us a lot of flexibility and really tailor that result to the individual patient based on where their tissue is the thinnest or based on where they need or want most volume.

(06:35):
So those are the two sort of primary ones that I rely on. And the third sort of auto augmentation technique is really just the outer and the inner parts of the breast that are left over. We just kind bring 'em together and therefore up to kind of hold that almost like a bra, hold the remaining two parts together and in place, just the way I described them earlier. So a couple of different areas of opportunity where we can really save that tissue and optimize that result. Again, they take a little bit more time because we do have to take the extra step of removing the skin from the area around the areola, removing the skin from the bottom of the breast, then we are very careful to preserve blood supply. So this is usually a very meticulous surgery, very careful, very precise so that we don't damage any blood vessels in the process, so all this tissue actually survives.

(07:23):
We have to then rearrange the breast tissue. Usually there's a step during every surgery where I basically give myself all three of those opportunities pretty much for every case I use all three of these. It's just a matter of some patients have more on one area, but less in another and vice versa. But I sort of give myself all of these opportunities for every case. So I take the extra steps to remove skin from every case, and then I see what I have in front of me in order to then put the pieces back together like a puzzle, like a three dimensional puzzle and arrive at the best shape and volume that I can and then get that final result.

Monique Ramsey (08:01):
Can you determine all this ahead of time, or is it sort of also in the OR and then how do you

Dr. Swistun (08:07):
It's both. Yeah.

Monique Ramsey (08:08):
Yeah?

Dr. Swistun (08:08):
Yeah. So during the examination, a lot of times I can tell where a patient has a little bit more breast tissue over the implant versus less, and we can discuss that. So some patients are very bottom heavy, most of the volume is concentrated on the bottom half of the breast, so we know that that's going to be a very effective auto augmentation technique of using all that tissue. Some patients have a lot more volume up top and very little on the bottom, so we know the way we rearrange it, we need to account for that and maybe allow a little bit more tissue to drop to the bottom in order to have a nice and more even uniform result.

Monique Ramsey (08:40):
How much tissue isn't going to necessarily get that patient, maybe the result they're looking for. Are there any other things you can use to help them get a little more fullness?

Dr. Swistun (08:52):
I would say that this auto augmentation technique is pretty much where you should start because it optimizes the shape. It gives us the opportunity to optimize symmetry between the right and the left side, and it uses up everything that's already available, already perfused, already has blood supply, has a much higher chance of surviving and doing well in the long run. And I'll be honest, 80% of the time that's all the patients need. Even the ones that are concerned about their residual volume, when they see the result after auto augmentation, they're like, this is good enough. It's not a big breast, but it's small, but it's a breast. It looks nice. It's a nice youthful contour, and I'm happy with that. About 20% of patients do go on to do additional procedures, and that will be fat grafting. Typically, I would say these are patients who really had no breast tissue to begin with or so little that the breast still looks somewhat deformed.

(09:42):
Sometimes there is asymmetry, which is to say that the patient always had a slightly bigger one breast versus the other, so that when we do all these techniques, one of the breasts looks really good, and the other one is a little bit deficient, maybe a little bit flatter in the upper pole, a little bit tighter in the cleavage area. So those are patients that would opt for fat grafting. Typically, we would wait about six months until we do fat grafting, so it'd be a secondary additional procedure. And that just involves basically going under anesthesia again, to just get liposuction from an area that the patient already describes they have a problem with, an area a patient doesn't like, and then we use that fat in order to augment either the deficient breast or both breasts, depending on what we're planning.

Monique Ramsey (10:28):
Where are the places? I don't know, is all fat created equal or where are the places that give you a good kind of fat to transfer into the breast?

Dr. Swistun (10:38):
So classically, the places that are best that are described as the abdomen and the flanks, and to some extent the medial thighs, the inner thighs, which most patients have a little bit of fat in that area. Even the very thin patients have a little bit of fat in that area. But ultimately, it's what the patient's preference also is. We take that into consideration. Whenever I do fat grafting, I consider that as a cosmetic opportunity as well. I do not just consider the fat graft, the donor site as a donor site. I consider it as an opportunity to give a patient a nice sculpture result in that area.

Monique Ramsey (11:10):
Right, right. Because you're not trying to just grab it and harvest it like they talk about, you're wanting to give, because you don't want to have a dent somewhere.

Dr. Swistun (11:21):
Yeah, we don't want to create a problem where there isn't already a problem.

Monique Ramsey (11:24):
Now, we've been talking about auto augmentation for patients who are having an explant, so you're taking your implants out and having a lift and using some of your own tissue to create the fullness. What about patients, I'm guessing you could do the same technique for someone who just needs a breast lift and doesn't want an implant. So they've had a couple kids, their breasts have gotten bigger and saggy, or they're just not happy. Can we do the same techniques for them?

Dr. Swistun (11:50):
Absolutely.

Monique Ramsey (11:50):
Okay.

Dr. Swistun (11:51):
Yeah, and that's an excellent point because a lot of go through childbirth and childbearing and breastfeeding, and then they see a breast that they're not really happy with for whatever reason, and not a lot of discussion sometimes goes into the conversation of what are you unhappy about? The easy recommendation for a patient like that is an augmentation breast implant. I'll just fill it with volume because it looked better when they were full of milk, so now we just put an implant in there, it'll look better. That's not necessarily always the case. In fact, a lot of patients actually put an implant in and they're still unhappy with the shape, and a lot of patients that I get, basically when we explant and do a proper lift, then they're like, this is what I wanted all along. I never wanted more volume, I just wanted a better shape.

(12:36):
So my question to those patients is, if you were to take the breast tissue that you have now and put it in the bra, are you happy with that volume? You just want the better shape. The bra will give you the better shape, but the volume will be what you have. And a lot of patients say, yeah, I mean, I don't need more volume. I just need a better shape. So then the lift is the answer and the lift that preserves the volume that they already have to the extent possible is the optimal answer to that. The techniques are about the same, the steps are about the same.

Monique Ramsey (13:07):
And what about time of the result in terms of healing time and did they see a final result, and then how long will the results last?

Dr. Swistun (13:19):
I think the healing time is about the same. It's just like if you were doing a lift because it's a similar procedure overall, rearranging the breast tissue, the skin heals just on the outside of all of that, so everything on the inside heals just fine. I think the results are just as lasting. Honestly, I think the big difference is really just the extra steps taken and the meticulousness of the dissection, the meticulousness of the surgery itself to preserve all that blood supply, preserve all that extra tissue makes the biggest difference in the world for patients who really are thin and don't have a lot of tissue, and if you just borrow just a little bit from everywhere you can, it amounts to a lot, and those are the patients that, in my experience, are the most surprised, pleasantly surprised.

Monique Ramsey (14:04):
Yeah. Well, I love the fact that something that maybe it's been around and maybe it's something you're doing all the time, but we haven't talked about it before. So I love that three and a half years into this podcast, we're coming up with new topics to discuss because I do think whether it's a patient who's having the implants taken out and wants that fullness, or someone who just doesn't want implants at all but wants a lift and using what you have, we love that. We all like to use what we've got, and that's the most natural thing, and so it's wonderful to know. Now, last question is really what would you have to tell your mammographer or something if you're having a mammogram, which I just had mine on December 23rd at 8:00 PM that was my assigned spot.

Dr. Swistun (14:53):
They must be busy.

Monique Ramsey (14:54):
And there was nobody else on the road. There was nobody at the place. I'm like, well, this was easy, but is that something you would have to tell them to look for, or is everything going to look kind of the same?

Dr. Swistun (15:05):
It shouldn't look that much different. Honestly, I would just say that I had breast surgery or a breast lift to them. It's not going to make a difference other than they expect to see a little bit of scar tissue on the inside, and they would see that after any surgery, so they'll be aware of that. Scar tissue does look very different than lesions that are suspicious for cancers, which is what their job is to look for. So yeah, as long as they're just aware they had breast surgery or a breast lift, then that's fine.

Monique Ramsey (15:32):
Oh, that's good. Yeah, we got to go get those mammograms ladies. That's so important. Oh, okay. I said last question, one more last question. Do you have your patients go get a mammogram or any kind of imaging prior to surgery?

Dr. Swistun (15:47):
Well, I try to basically adhere to the guidelines that are out there for breast cancer screening, which is usually annual, sometimes biannual, depending on the risk factors. There are multiple ways of screening the breast. We always talk about mammogram because that's the most common sort of suggested technique, and it's probably the most available and the least expensive. So that's what the insurance companies will always favor for pretty much anybody. However, there's other options. I do have a pool of patients that refuse to get mammograms for one reason or another. There is the valid concern of exposure to radiation, which may or may not cause additional problems. I don't think there is any statistical evidence that shows us that this is a problem, but there's some anecdotal evidence or sometimes just kind of like a logical extrapolation of irradiating that same area over and over. Is that going to cause a problem?

(16:38):
Other ways of screening a breast is with ultrasound, which is very effective. It can sometimes be enough. A lot of radiologists can perform a very high quality 3D ultrasound nowadays that can reconstruct the breast in three dimensions and actually tell them everything that they need to know just based on that one study. And an ultrasound is a lot more comfortable, especially if a patient has a capsular contracture or some very, a lot of discomfort from their implant. They tolerate that procedure a lot better because the breast isn't getting squeezed and manipulated and they still get the same information. Another way of screening a breast is with an MRI, but usually that's a little bit of overkill. Ultimately, I leave it to the radiologist, honestly, because it's their job to make that call. I saw everything that I needed to see in this breast tissue with the study that I used, and I don't see anything suspicious. That's what I want to hear from them, and it's their job to kind of make that call.

Monique Ramsey (17:33):
Well, this is so interesting and thank you, Dr. Swistun, because I think having patients be armed with the information, that's what helps calm us down. The more we know, I think a lot of us are that way, and there's a lot of stuff on the internet, and so having an expert in breast explant or breast implant explants and the auto augmentation procedure is really important because we need more women to know about it and understand the differences of a surgeon who's going to take that extra time and really almost reconstruct, it's really almost like a reconstruction, right? And preserving as much tissue as possible. I'm sure that a hundred percent of your patients want you to do that, right?

Dr. Swistun (18:20):
Most of them, a lot of 'em actually. Yeah. So maybe not a hundred. There are some patients that do have a lot of volume, and they do actually ask for a reduction in the process. They take some tissue away because these are just way too heavy, and with an implant, they're just way, way too heavy. But yes, the majority of patients have those concerns, and when we have that discussion, it's not uncommon for me to remove the implant, which is let's say 350 ccs, 400 ccs, and then do a full lift without augmentation, and then remove as little as 19 or 20 grams or 25 grams of additional tissue, which is basically just all the extra skin, and then use everything else.

Monique Ramsey (18:58):
I love it. Well, thank you again, Dr. Swistun. And if you're interested in learning more about this, give us a call. You can head to our website at ljcsc.com and we'll put some links in the show notes about the things we talked about today, and we'll see you on the next podcast. Thanks.

Dr. Swistun (19:17):
Thank you again. Thank you for having me.

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