As controversy surrounding breast implants continues, many women have questions about their choices for implant removal or replacement.
Dr. Luke Swistun is known throughout Southern California and beyond for this unique specialty and uses his expertise to answer your biggest questions about explant surgery, including:
- Will I look awful after my implants are removed?
- What’s the purpose of en bloc capsulectomy?
- How is capsular contracture prevented and treated?
- What is breast implant illness?
- Can you have a breast lift or fat transfer with breast implant removal?
Speaker 3 (00:07):
You are listening to The La Jolla Cosmetic Podcast.
Monique Ramsey (00:15):
Well welcome everyone to this episode of The La Jolla Cosmetic Podcast where dreams become real. I’m your host Monique Ramsey, and I’m really excited today to be joined by Dr. Luke Swistun, who’s here to talk to us about a very specialized kind of breast surgery called the en bloc capsulectomy. And en bloc is spelled E-N-B-L-O-C, so you might’ve seen that around the web, it’s possible. It’s actually, I think a French word and we’ll get into that with Dr. Swistun. So welcome Dr. Swistun.
Dr. Swistun (00:52):
Thank you very much. Great to be here.
Monique Ramsey (00:53):
So starting with the basics about this en bloc capsulectomy, why is it called en bloc and what is it? What does it mean?
Dr. Swistun (01:06):
So en bloc literally means altogether or all at the same time. And what it refers to for breast surgery is removing the implant and the scar tissue around it, which is commonly known as the capsule as one piece when we are removing the implants. And this is a very well-known procedure that’s originated in surgery a long time ago, even before this was applied to breast surgery specifically, it was more applied to treatment of cancer specific cancers, which sometimes encroached upon other structures. And in order to get a surgical cure for that specific cancer, we needed to do an en bloc resection. So basically the cancer itself and all the involved structures around it and then deal with the consequences later. So as you can imagine, it’s kind of a morbid procedure and it’s considered one of the most aggressive procedures for that specific indication.
Monique Ramsey (01:56):
Taking it all at one time.
Dr. Swistun (01:58):
Yes. And then in the case of cancer, you want to make sure that the margins around the cancer you’re resecting are appropriate so that there is no chance of leaving the cancer behind. And so en bloc typically meant, let’s say somebody had pancreatic cancer somewhere in one portion of the pancreas, they would take up half of that pancreas and anything that’s around there, maybe some of the small intestines, some of the colon, maybe some of the liver, things like that. So obviously again, big morbid procedure we’re digressing a lot, but essentially that’s the concept of en bloc. And when we’re discussing breast surgery, the phenomenon of breast implant illness is an issue that I believe we’re going to discuss in a couple of minutes, and it was applied to that specifically because the belief with breast implant illness is that in order to cure or at least have a chance at curing breast implant illness, we need to remove the implant. But in addition to that, we also need to remove all the scar tissue that’s associated with that implant, which is typically surrounding the implant and maybe even encroaching in some of the structures surrounding structures. So an en bloc essentially means that we remove the entire capsule, the entire scar tissue with the implant still inside.
Monique Ramsey (03:08):
Okay. So how was capsular contracture treated in the past and is this different or is this replacing old methods, would you say or not really?
Dr. Swistun (03:21):
I think this is a method that existed. It wasn’t really necessarily applied a lot in the past just because like I said, it is kind of an aggressive procedure and the belief in the past was that this is just not necessary to do that in order to treat something very specific like capsular contracture. And again, capsular contracture is different from breast implant illness, which again we’ll get into in a second. But capsular contracture essentially means that the scar tissue around the implant has tightened, has contracture and potentially became painful and maybe even has deformed the breast. And in order to relieve that, there’s lots of different ways to do it. For low grade capsular contracture that are fairly subtle, you can actually just start with medications. There’s medications such as montelukast, some people believe vitamin E or indomethacin or combination of all of those can be given to the patient and that’ll actually soften the capsule and you don’t have to do surgery if it’s much more advanced.
Then surgeons in the past used to perform something called the closed capsulectomy, which is essentially just squeezing the capsule as hard as you can in order to rupture it on one side or another. And that would essentially relieve the pressure. It’s not done anymore because it’s a little bit of a dangerous procedure because it’s not very well controlled. You can get bleeding in that area and that can lead to more capsular contracture. And then most of the time after that procedure was done, the recurrence rate for recurrent capsular contracture was actually very high. So the procedure has been largely abandoned. So today typically for a significant capsular contracture, we will do something called an open capsulectomy, which means that we would go back into the surgical field and just cut the capsule in certain places just to relieve that pressure, relieve that tension, leaving the capsule behind.
Monique Ramsey (05:01):
So for the audience to picture what a capsule looks like and when it’s contracted, how would you liken it so we could picture it?
Dr. Swistun (05:10):
So a capsule essentially is scar tissue that your body will build around any implanted device. So if you have a pacemaker or a knee replacement or a breast implant, your body will automatically respond by building a very thin layer of scar around that device which will be shaped essentially just like the device if you think about it. And that scar is supposed to be very thin. Basically you can liken it to a Saran wrap. It’s super thin, it’s transparent, and essentially you don’t even feel it under the tissue, under the skin if you have that. And that’s an appropriate normal capsule. When it contractures, it’s usually because of some sort of a problem. Sometimes you can contracture early because you have some low grade infection or some bleeding in that area that causes more inflammation, more scarring, and that can lead to that capsule being tighter and thicker.
And when it tightens scars by nature contract, that’s what they do. If you have a cut on your arm, the intent is that you heal it as soon as possible so that you can go on with life. It’s an evolutionary protective mechanism and the scars basically have myo fibers in them, which basically has got a little muscular fibers that actually contract and shrink the scar. When that happens around a solid object like a pacemaker, nobody really knows because the pacemaker is made of metal, so it’s able to withstand a contracture of a capsule. But when it happens around the soft object like an implant, the scar tissue is actually stronger than the implant itself and it’s going to squeeze that implant and distort it. And that can be very painful and it can actually obviously affect the cosmetic result of the patient as well.
Monique Ramsey (06:40):
So this is when women say, oh, maybe my implants got hard. It’s not the implants that got hard, it’s what your body built around that implant.
Dr. Swistun (06:49):
That’s exactly right.
Monique Ramsey (06:51):
Okay. So glad we got that. Just so everybody can kind of picture it, I think unless you’ve seen it, it’s hard to know what that means. Now for some women say they don’t have a contraction on their implants, their implants are soft, but they just want to get them out. Would this be something that they come to you and ask for an en bloc procedure?
Dr. Swistun (07:12):
Potentially and everybody’s different and everybody has their reasons for asking for that. And I think most of the time that I get asked to remove the implants with the capsules on block is from a patient population, a very specific small patient population who believes that the implants are making them sick. And the belief in that population, which I agree with is that some of the toxins or some of basically the chemicals of the implant can affect the body and cause other additional symptoms. These are symptoms that are basically unrelated to normal known surgery complications and complications of having breast implants. So things like joint pain, fatigue, tiredness, malaise, cognitive impairments, some people call that brain fog, things like that. They’re very unspecific and for a very long time they were not really linked to having breast implants. But the belief is that if we remove the implant itself, that’s part of the game, but because some of those toxins were affecting the body immediately around it, the belief is that we want to remove the entire capsule or the entire scar tissue surrounding that implant as well in order to maximize the opportunity for removal as many toxins as possible in that surgery.
Monique Ramsey (08:24):
So this doesn’t happen to the entire population who get implants because I would say probably the vast majority don’t have any problems. It’s affecting some people?
Dr. Swistun (08:34):
That’s correct. The specific phenomenon of breast implant illness is not experienced by everyone. In fact, I think 80 to 90% of women have breast implants and they do with them just fine. They don’t have any systemic side effects. They have the known issues that implants can cause, including the fact that you have to have surgery in the future to remove it because they’re not a forever product. But those are unknown things that in most patients come in knowing the breast implant illness phenomenon is a little bit different in that it’s very insidious and it presents quietly and it mimics a lot of other diseases. And most people that have those symptoms don’t necessarily attribute them to having breast implants. And a lot of times they’re actually right. We have to make sure as surgeons and as doctors to evaluate that patient for more common different reasons.
For instance, a lot of times the symptoms that patients complain about are very similar to that of hyperthyroidism. So if somebody has a thyroid imbalance, they will complain of similar things, fatigue and difficulty concentrating, losing hair, rashes, joint pain, things like that. And a simple thyroid test will prove that, hey, this is just a thyroid imbalance, let’s treat that and then you’ll be fine. And that’s a lot of times the case, so we have to do our due diligence before we commit to a surgery for those reasons. So that’s one thing that I always look for in patients, make sure that they had a primary provider and possibly some visits with some specialists to rule out those common entities.
Monique Ramsey (09:53):
And what kind of specialist would they go see.
Dr. Swistun (09:56):
So they usually start with their primary doctor, but a lot of times they will also get referred to a rheumatologist or an endocrinologist, sometimes a neurologist. Those are the more common ones, but pretty much any specialist that will deal with their presenting symptoms. The list of symptoms is huge and sometimes they’re very obscure and I think it’s important that all of those get addressed by at least a primary doctor, if not a specialist before we commit to surgery to address these issues. There’s a lot of patients who are out in the population who may have some of these symptoms and not necessarily attribute them to implants. And a lot of them, they’re right, they may have other things going on, but more and more I’m discovering that patients are coming to me and said, I had these symptoms for years and years. I just thought I was getting old and sick and I blame it on my age and my doctor said I’m fine.
And then I found out about these breast implant illness support groups and I started to read about it and educating myself. And I think I fall into that category and that’s when they come to me and we have a discussion about it and we make sure that again, they’re screened appropriately. And the caveat to undergoing this surgery is again, it’s a very serious surgery and we don’t really know if removing the implants and the capsules will help the patient’s symptoms. Typically, the patient will have had full workup and all their tests come back negative and they still feel crummy and they said, you know what? I just want this card off the table. I just don’t want that in the back of my mind. I’m ready to get them out. I basically support that decision because again, they have to come out sometime. They’re not a forever product, so it might as well be up to the patient to decide when that is and if there’s all these other things going on. I tell them that we don’t know if your systemic symptoms will go away, but really the only way to know is to remove the implants and see.
Monique Ramsey (11:36):
And so you mentioned support groups, so is that how some of the patients are finding you specifically?
Dr. Swistun (11:43):
That’s correct. There’s actually some closed off groups on Facebook that I can’t even join, and these are groups that are patients only and these are patients who basically share their experiences and share their symptoms, share who they went to see, who did their surgery, how it went, and then how their symptoms improved. The one thing that I want to stress is I see a lot of improvement in these patients. These are again, patients who had full workups, they don’t,
Monique Ramsey (12:07):
No other reasons for feeling maybe the way that they feel.
Dr. Swistun (12:10):
Exactly. Their doctors basically turned them away and said, look, all your labs are normal, all your tests are normal. I don’t know what it is. I can’t do anything else for you. And then they come to me and we remove the implants knowing that this may not help, but I’m surprised how often it does help.
Monique Ramsey (12:23):
How many have you done of these procedures?
Dr. Swistun (12:25):
Several hundred now, I’ve actually aren’t counting specifically, but I need to start counting because I get that question a lot from
Monique Ramsey (12:32):
You probably get the question all the time. Yeah. And would you say, could you count on one hand, two hands, the women It didn’t help?
Dr. Swistun (12:39):
Yes, that’s actually exactly how I presented. Literally on one hand, I think there’s about four that basically we went through the entire process and they said, we removed the implants and my symptoms are still there, my labs are still negative. There’s nothing else that we can prove that is going on medically with me, but I still have these symptoms. And then even that group, we don’t really know. I mean there’s some theories out there that you just have to take a lot of time. There are some patients who had implants for a very, very long time, like 15, 20, 30 years, believe it or not. And in those populations, the trend is that you need to wait a little longer for the body to actually reset itself and clear some of these toxins before the patients feel better. So my chances are that if we follow up with these patients later, then they may have it improved. And then again, these are very subtle elusive factors. There may be other things going on. There may be psychological disorders or some underlying family issues that the patients are dealing with as well, which are also affecting how they feel overall. And those are all things we discussed.
Monique Ramsey (13:37):
So seeing these women and doing all these surgeries and knowing what as a surgeon now, do you still put implants in as well as take them out?
Dr. Swistun (13:47):
They have to come out sometime. So I immediately upon making the decision of putting implants in, you are deciding that sometime in the future you are going to have another surgery related to having implants because they will have to come out or
Monique Ramsey (14:00):
Exchanged for a new pair or
Dr. Swistun (14:02):
Exchanged or maybe you’ll need a lift or there’s going to be some issue with them that you’re going to undergo another surgery in your lifetime. And that’s basically the standard. And then there’s the known complications that we all talk about. There could be bleeding, there could be infection. The capsular contracture that we talked about, that’s the dreaded complication. There can be malposition, there could be pain or depending on how big they are, they could be encroaching on other structures and pushing on nerves and causing some subtle chronic pains and aches and things like that. They could cause what I call acquired macromastia, which is a term that I’ve never heard anybody else use. Maybe it’s out there, I’m not sure. I don’t know if I can actually say I coined it, but there are patients who have implants put in that then put themselves in a subcategory of patients with large breasts, patients with large breasts, patients who are born with large breasts have a very specific constellation of symptoms that they’ll suffer from.
It’s usually back pain, shoulder pain, shoulder grooving from the bra straps, sometimes rashes underneath the breasts, posture problems, which translates to neck pain and maybe even lower back pain eventually. And sometimes even tension headaches because they’re compensating for all that weight of their chest, they’re sort of forcing their neck backwards and they’re using their occipital muscles which are always under tension, and that can actually promote tension headaches and doing a breast reduction in patients like those cures. A lot of these symptoms, it’s a very well known phenomenon, and breast reduction is a very well accepted surgery. It’s something that’s actually usually covered by insurance. For that reason, the insurance companies figured out that if we pay for this surgery, the patient will be better, we’ll do better, and we will have to pay less for that patient’s care throughout the rest of their lifetime. All these things go away. The shoulder pain, the back pain, I’ve had several patients who had chronic migraines treated by neurologists with no success, and after a breast reduction, those aches and pains went away, the headaches went away. And most of my patients will tell me that this is the best decision that they have ever, ever made and that they should have done this 10 years ago.
Monique Ramsey (15:59):
Very happy patients in that group.
Dr. Swistun (16:02):
These are the macromastia patients who are born with large breasts, but you can make the argument that if you actually put large implants in and then you have them for 10 or 20 years and maybe you breastfeed two or three children, they’re going to be large and they’re going to fall a little bit and you’ll essentially be just like a large breasted patient, a macromastia patient. So this is what I call acquired macromastia because you essentially contributed to it by putting an implant in. But those symptoms, I always ask patients about those symptoms as well. Aside from the systemic things that they’re complaining about, the joint pain, the breast implant illness symptoms, I specifically ask them separately, do you also have shoulder pain, back pain, shoulder grooving, rashes on their breast? And if they have those symptoms, then I tell them, look, we should remove the implants and maybe even do a lift. I don’t know if the breast implant illness symptoms will go away, but I for sure know that your macromastia symptoms will improve. And that sort of helps them make the decision. Sometimes it’s like, well, I was thinking about removing them, I don’t know if this is going to help. But yeah, I definitely have shoulder pain and back pain and stuff and that would help a lot. And again, going through the exercise of identifying what definitely will happen and what may happen helps them make the decision to have surgery.
Monique Ramsey (17:12):
Right. So if it was a woman who was thinking about implants or let’s say they’re thinking about wanting maybe a larger chest, they want their breasts a little bit bigger, is there a way to accomplish that without an actual implant?
Dr. Swistun (17:26):
There is. A lot of times the problem isn’t necessarily the volume of the breast, but it’s the shape of the breast and a lot of women have a lot of volume, but maybe over time and after going through childbirth and breastfeeding, the volume has shifted. Whenever a woman breastfeeds or increases volume in any way, the skin grows in response to the increased volume and notice I don’t say stretches, it actually grows. So then after breastfeeding, when the breastfeeding volume goes away, the skin is still there and then the breast sort of resettles itself, the entire shape changes because now there’s a lot more skin than there used to be relative to the volume underneath. So the breast sags and it becomes sort of droopy for lack of a better word. And a lot of times if you just do a proper lift procedure that will restore the breast to a very nice shape.
And a lot of women don’t really necessarily want volume on top of that because it’s really the shape that makes a big difference. If they do want a little bit of volume, then another option without an implant will be fat grafting. We can perform liposuction. A lot of times women use that as an opportunity in order to correct an a problem area of somewhere else that’s going on, such as most commonly it’s either their abdomen or their flanks. And that way we can use that opportunity to give them a much nicer figure, maybe pull in the waist a little bit and just give ’em a nice tighter waist and a nicer hourglass figure. And then the fat that we extract during the liposuction procedure, we can then re-inject into the breasts in order to add or improve the shape. And this is a very important distinction I wanted to make.
The fat grafting is not really reliable as far as increasing the breast volume. It’s really not going to get you from a B cup to a C cup, but it will improve the shape in the places that matter that we sort of identify as problem areas. So if we can target it a little bit better towards maybe the inner part near the sternums improve the appearance of the cleavage, or maybe if one breast is larger than the other, which is almost always the case, nobody is born symmetric. Sometimes this asymmetry is actually a little bit more pronounced into some patients than others. If we identify that as an issue, then we can definitely fat graft one breast a lot more than the other in order to try to get a better symmetry.
Monique Ramsey (19:34):
And fat, since it’s coming from you yourself moving from one place to the other, it’s safe, correct?
Dr. Swistun (19:40):
That’s correct. There are some known things that we can talk about, things to know about fat grafting in general, about half of the fat that we inject will actually survive in the long run, and half is kind of an arbitrary generalization. It really depends on where the fat is placed, how close to a blood supply and things like that. But in general, I just say half. So if we want to increase the breast size and certain areas by 100 ccs, let’s say, I would want to put in twice as much because I know that in the long run, half of that fat that I injected will not revascularize, we’re not regain, blood supply will not survive and it’ll just get reabsorbed by the body and go away. But the other half that does revascularize will survive and you keep that for the rest of your life and you’re right, that is your own fat and you don’t have to worry about it. We basically moved it from a place where you don’t want it into the area that you do want it.
Monique Ramsey (20:31):
Isn’t that every woman’s dream and they call it autologous fat and autologous means it’s from yourself.
Dr. Swistun (20:38):
Correct. That’s exactly right.
Monique Ramsey (20:39):
Okay. So now we talked about breast implant illness and sometimes you might hear it referred to as BII for breast implant illness. So there’s some other little acronym out there called A LCL. What is that and are these two things related?
Dr. Swistun (20:56):
So A LCL is basically a very specific form of a rare lymphoma anaplastic large cell lymphoma. And the context with which this is used typically it’s called it’s the acronym is actually a little bit longer, it’s BIA dash ALCL, so throwing out some more letters at you, but BIA means breast implant associated anaplastic large cell lymphoma. And the reason that this is actually a phenomenon is because we noticed over the last decade or decade and a half that there are some women that had had textured implants put in that then developed a very specific type of lymphoma, which is this anaplastic large cell lymphoma, specifically in the capsules or in the scar tissue immediately around their implants. And this was an association that we started tracking. It’s exquisitely rare. There’s only 700 or so just under 700 last I checked cases documented in the world, not just in the United States but in the world. So 700 is really not that many, but the ones that we did find, we noticed that they are definitely associated with breast implants and specifically textured breast implants and specifically from one brand. And the thought is that the texturing process somehow induces some pro-inflammatory process in the body and can actually cause this lymphoma.
Monique Ramsey (22:10):
And so breast implants are either smooth, slick on the outside or textured. And so what was the thought behind having it be textured in the first place?
Dr. Swistun (22:23):
Excellent question. The textured implants are also known as the gummy bear implants, and that’s sort of the common name for them. The reason that the companies decided to try using textured surfaces on the implants is in order to reduce the incidents of capsular contracture. And that actually worked if you put in smooth implants, the capsular contracture rates are a little bit higher if you put it above the muscle, whereas if you put textured implants in the capsular contracture rates are a little bit lower.
Monique Ramsey (22:50):
So they were trying to solve that problem. Exactly. And for a few very rare group of women maybe created a different problem.
Dr. Swistun (22:58):
Exactly right. So obviously again, it’s a very rare entity. I’ve personally never had a patient with anaplastic large cell lymphoma, but it is a allowed entity. Obviously if you can basically claim accurately that a breast implant can cause cancer, that is going to make headlines and that’s going to be a very prominent topic. So that’s not necessarily breast implant illness related, but it does contribute to the overall sort of one more problem that breast implants can cause and sort of is absorbed into this whole spectrum of breast implant illness and breast implant related diseases. So it definitely doesn’t improve the reputation of.
Monique Ramsey (23:39):
And so these textured implants, are these something that are still on the market that you can get or get or how does that,
Dr. Swistun (23:46):
The ones that are most associated with have been recalled. They’re off the market at this point, so they’re no longer used. And the FDA has basically made the recommendation that if you do have those implants, you don’t necessarily have to remove them because of, again, the rarity of the lymphoma. The lymphoma is so rare that the risk of surgery to remove ’em, even though it’s low, it’s still higher than how rare this disease is. So basically if you have those implants, but everything is normal, it feels normal and it looks normal and there’s no swelling over any kind, then the thought process is that it’s safe to actually leave them in. But the recommendation is to really look for any signs of what might be a presenting sign of a lymphoma, and that would be swelling on one side typically, or a fluid collection that presents itself years and years after the implantation.
I think the average is about eight years after the implantation. So a classic and a plastic large cell lymphoma patient who has textured implants will present with swelling on one side. That started eight years after the implants were placed and it’s kind of growing bigger and there’s not really a good explanation. There’s nothing else, there’s no pain, there’s not really anything. So when a patient like that presents, our obligation is to do an ultrasound and to prove that there’s actually fluid around the implant. And if there is, then we need to do an ultrasound guided fluid aspiration and then send that fluid out for specific markers, CD 30, lympho synography marker. And what that will do is that’ll prove or disprove whether or not the patient has a lymphoma. A lot of times even that swelling 99 out of a hundred times, that swelling is still not a lymphoma that is basically just a fluid collection. It’s seroma.
Monique Ramsey (25:25):
Your body’s just having its way
Dr. Swistun (25:27):
Correct. And that’s actually another phenomenon that’s attributed to textured implants. And they can form something called a double capsule where they have a capsule immediately around themselves and another capsule around the tissue. And that’s just how the inflammation, that inflammatory process is induced by those. But when you have a double capsule, then you can get a seroma in between those two capsules, and that’s what that is. And it’s basically just regular fluid that you just pull out. And then the treatment for that is just remove the capsule, exchange, the implants. If you do have a diagnosis of anaplastic large cell lymphoma, then obviously we have to get oncology involved because that is technically a cancer that we’re now treating. And then we have to do a PET scan to make sure that it hasn’t spread anywhere else. But ultimately, most of the time the treatment for that is an unblock capsulectomy, which is kind of where we begun this discussion in the first place.
Monique Ramsey (26:12):
Right. Okay. So if you’re getting your implants out, let’s say you’ve decided for whatever reason that you want your implants out, no new implants put in, just take ’em out. Will the person end up looking bad or deformed or does it matter how long they’ve been in as to what you might look like after if they were in for 25 years? Is that patient if they take their implants out different than somebody who’s had ’em in for two years?
Dr. Swistun (26:41):
So that is a very patient dependent question. That’s a very common reason that people are just removing their implants. They basically say, I just want them out. And that’s a perfectly valid reason. I mean, the patient made the decision to put ’em in for whatever reason. It was a good decision at the time. These are the effects, sort of the result that they wanted at the time. And now maybe in a different place in life where it’s like, Hey, look, I just don’t want these anymore. I had a patient who had them for 20 years and then got into CrossFit and she said, look, I do this every day and the bar that I’m lifting is hitting my breasts because they’re too large and I just absolutely not using that volume anymore for any reason. I just really want to be able to exercise the way I want to please take them out.
That’s a good enough reason. And then there’s other reasons that we have already touched on that can also sway a patient one way or another. Now the appearance is completely patient dependent. It really depends on many, many factors, mostly how much breast volume you have and also how good skin quality you have, the younger the patient, and if there’s no stretch marks on the skin, that to me on the physical exam indicates that the skin will sort of shrink back to some extent and give them a favorable appearance. The larger the implant, the more skin stretch there happens. So usually if with patients with very large implants will not necessarily go back to the previous shape that the implant is removed. If you had breastfed with the implants in, that is additional volume of the implant on top of that additional volume of breastfeeding of the breast and government or breastfeeding, that gets the skin to be a lot more incongruent with the remaining volume of the breast as well. So those patients typically need a lift or some sort of a procedure in order to improve the shape of the breast. And then also it’s ultimately a patient’s decision as to what they’re comfortable with looking like. There’s some patients that want to retain a little bit more volume, then there’s some patients that want a natural look. There’s some patients that want to really perked up look. And those are all points of discussion that I explore with the patients, what their goals are before we kind of commit to a surgical plan.
Monique Ramsey (28:41):
So that would be disgusting consultation and depends on what they started with and what their goal is.
Dr. Swistun (28:46):
That’s exactly right. There’s some young patients that come in who had a really nicely shaped breast before, and they just got a very, very conservative augmentation, maybe like 200 cc implants just to give a little bit more upper pole fullness. And they had the implant for three or four years and they decided they don’t want it anymore. And then we go ahead and remove the implant. And that patient comes back to exactly where they started pretty much, I mean, there’s not really a lot of change. And the other extreme patient would be someone who got their implants 25 years ago, which were very, very large, like say 600 ccs. And in the interim, they also breastfed three children for a year at a time. That breast is going to be very, very different. It’s going to have a lot more skin, it’s going to be a lot lower, and maybe the patient’s older, they’re in their late forties, early fifties, and that breast will typically need a formal procedure lift. And depending on how much volume there is in the breast and how much volume the patient wants to wind up with, maybe might need some fat grafting for symmetry or for improvement of shape overall.
Monique Ramsey (29:43):
So they could have that breast lift at the same time that you take the implants out?
Dr. Swistun (29:47):
It depends on the patient. Most of the time, yes, it really depends on whether or not they had previous surgery, previous breast lifts, because anytime you have a breast lift or anytime you have scars on the breast, that’ll potentially compromised blood flow to the remaining tissue, specifically the nipple. That’s always what we worry about. And then it also depends on whether or not the original implant was placed under the muscle or over the muscle. And that again has to do with blood supply. If the implant was placed under the muscle, then there’s an artery that goes from the muscle to the nipple, and that is a really good backup plan to make sure that the nipple survives. So we can do a lift in that context and be safe. Whereas if the implant was placed over the muscle under the breast tissue, the net artery was cut, the implant now lives where the artery used to be.
So now the nipple is only getting blood supply from the skin. And the superficial arteries, again, we’re getting very technical here, but bottom line is it puts me in a little bit more of a risky situation, and at that point it may not be a good idea to do the lift at the same time that’s a patient, especially if they don’t have a lot of tissue of their own, they have a very thin skin or very little breast tissue that becomes more dangerous. So then I would recommend maybe removing the implant and getting the capsule out and then letting it heal for about six months, reestablish healthy blood supply, and then go back and potentially do a lift at that point.
Monique Ramsey (31:07):
So what’s the recovery like on an block capsulectomy?
Dr. Swistun (31:13):
Most patients will tell me that it’s actually a lot easier than putting implants in, especially if they went in under the muscle. If you put implants in under the muscle, then there’s a period of time immediately after surgery where the muscle, the pectoral muscle gets stretched and tightens and spas because essentially we just lifted the pectoral muscle off of the chest wall and put a lot of volume underneath it so the muscle will spasm and complain, and it needs time to just adjust and stretch and grow around that implant for that tightness to go away. With an unblocked capsulectomy, we’re sort of doing the opposite. We’re removing the volume, we’re removing scar tissue. Now I as a surgeon have to be very, very careful. It’s my job to make sure that I preserve as many of the structures that the capsule is adherent to as possible.
So I take my time to make sure that I preserve the pectoral muscle underneath because the capsule, basically, it’s associated with everything that is immediately around it. So it’s attached to the pectoral muscle, it’s attached to the chest wall and pectorals minor, which is off to the side. And my job is to basically remove the capsule itself, but disturb as little of the remaining tissues around it as possible. Sometimes if the capsule is very thin, it’s not necessarily possible to take the capsule out in one piece. And I tell the patients that as well upfront. I may say that, Hey, look, we’re probably going to be able to get 90% of it out, but then there’s going to be maybe some that’ll stay on the chest wall, and I’ll go back and remove that little portion separately once the implant is out of the way, because that’s safer.
Very rarely I’ll tell patients that I cannot remove the entire capsule. I think I can think of maybe just three occasions where that happened, and I can usually identify that in advance. And that would be a patient who had multiple lift procedures in the past, they had multiple scars on their breast. The blood flow to the nipple is already compromised, and maybe they also have very, very thin breast tissue. And so the blood supply to the nipple may be immediately under the capsule. And if I identify that situation, and if I see it in the operation where the capsule is literally lying on the artery that is supplying the nipple, I will elect to leave that portion of the capsule in the body. I will take out 95% of the rest of it, but that little 5% that’s covering the artery, I will leave behind because I do not want to disturb that artery. I don’t want to kill the blood supply to the nipple because then we’ll lose the nipple. But again, that’s something that I can usually tell the patient prior to surgery based on the physical exam.
Monique Ramsey (33:36):
Oh, interesting. So if somebody’s thinking about getting their implants removed, what do they do? First,
Dr. Swistun (33:43):
I think we should ask the patient to explore the reasons why, what’s motivating them. And again, they could just be saying that I’m just done with implants, or they could say, I’m having pain in one area, or some patients have very normal result and they say, I actually like my implants. I like the way they look, and I like the way they feel, but I have these other symptoms and I heard about breast implant illness. Should I remove my implants? And that’s when I say, well, let’s make sure that there’s not an other disease process causing all those symptoms before we jump into surgery. But I think a discussion with their primary doctor about their symptoms, the reasons that they want to pursue removal of implants and a discussion with a plastic surgeon would be the thing to do.
Monique Ramsey (34:23):
And so then they could have a consultation with you and get the low down for them.
Dr. Swistun (34:29):
So I’m very comfortable having that entire discussion, not just about breast implants or the cosmetic result per se, even though I’m a plastic surgeon. I do explore all of those other medical reasons and even psychological reasons why patients would want to remove their implants.
Monique Ramsey (34:43):
But getting your questions answered and having all the facts, I mean, that’s really important to explore all that. So I was just reading through your reviews and a patient of yours left a consultation a few days ago, and here’s what she said. It was lovely to have a doctor ask me so many questions. Not only was he genuinely interested in what I was looking to have done, but he was able to elaborate in great t detail everything he would do to help me achieve the most desired results. He was able to be honest with me about the results that I would receive for my body type. I appreciated that. That’s really, I think for many women it can be intimidating to sit down and have this discussion with a doctor and you might feel like, oh, he’s going to judge me or think I’m crazy. I mean, we build up more in our minds probably as a patient than what really would happen in reality. But is that what we might expect a consultation where you’re doing all the questioning or is the patient doing, or is it kind of just a sharing of the information?
Dr. Swistun (35:44):
I think it’s just a two-way communication bottom line. And I think what you touched on is very important. As a medical community, a lot of times we do a lot of disservice to the patients just not listening to them as a whole. There’s a lot of doctors who are sort of under pressure to just cover their bases. And if this is a complaint, we’ll just order these tests and these tests come back normal, then there’s nothing else I can do for you because the tests show that you’re normal. So it must be normal. I think one of the very first lessons we learned as doctors in medical school is listen to your patient. And I remember this specifically on day one of medical school. There’s an old senior doctor that comes into the office and he’s retired about 10 years, and it’s really his only purpose is to greet the class, the incoming class of medical students.
And then the one lesson that he always shared would just listen to your patients. If you just let them tell you what is hurting them, you will figure it out. They will tell you what’s wrong. And then after that, you get four years of everything else. You get four years of how to read a lab, how to read a CAT scan, how to do this test or that test, how to do physical exams and all these other things. But that first lesson sort of gets lost, especially in this day and age where we really rely on CAT scans and imaging studies and lab tests and things like that. And we are rushed by time and pressured to make a decision. And a lot of times we don’t have the time to sit down and actually listen to what the patient has to tell you. And I find that that’s a disservice that we’re doing to our patients. And I find that that’s one thing that I’m trying to correct.
Monique Ramsey (37:12):
Yeah, well, and I think cosmetic surgery, plastic surgery, it’s not something that you’re in HMO system and the doctors have 12 minutes to have, I mean, it’s funny, but it’s not funny. They really are under major pressure, I think, to get in, get out and move to the next patient. And something in, we at La Jolla cosmetic really have always believed in really good communication with our patients and taking the time. And you probably know because done work in so many different fields, literally in the military and then with patients, and I’m sure through all your internships and all the things that you do to learn how to be a doctor. Is that sort of the case?
Dr. Swistun (38:01):
Yeah, absolutely. So I totally agree with you is that we have the luxury of time to actually spend the time to listen to our patients. And there are lots of specialties who are rushed by that. And these are doctors who have huge loans to pay, and they have to have a quarter of patients to see before they get paid, which is just the reality of it. So I feel very fortunate to be in a position that I am. I was in other positions in the past where it was just not as conducive to communicating for one reason or another. But yeah, I think the bottom line is I think the patient has to be comfortable with their surgeon. I comfortable with the communication process, comfortable with a two-way exchange and make sure that they feel that they’re heard and their issues are being addressed.
Monique Ramsey (38:40):
And I think one of the ways that obviously having a consultation, having really good open communication, that’s part of that decision-making process. Absolutely. Do I bond with my doctor? Do I feel comfortable in the facility? Does it look right? Is it accredited? Is my doctor board certified in plastic surgery? They kind of get the checklist, but part of that checklist is almost, it’s hard to measure. It’s like, what is the feeling? Do I feel like I trust these people and do I feel like I’m being listened to and are they really here for me? Because maybe sometimes, and depending on the type of surgery, you might turn somebody away and say, no, no, you don’t need that surgery, whatever it is,
Dr. Swistun (39:23):
Or redirect them. And I think that just comes from listening as well, listen to what their goals are and then explain why the better procedure may be this rather than that, because that will meet the goals that you’re describing rather than doing the procedure that you suggested, which may not necessarily accomplish the goals.
Monique Ramsey (39:41):
Yeah, because we as patients, since we have the internet, we can look everything up and almost get too much information. So it really helps to be able to download it all to a specialist like you who can help us say, okay, well actually you’re bringing up this point that’s really not that important, but over here, this is what I want you to be thinking about. Another way is to see before and after pictures, I think being able for patients to say, okay, here’s a woman who had her implants and then now she doesn’t. And here maybe she had a lift or maybe she had some fat grafting or maybe she just took ’em out. And what does that look like? And of course, you don’t know for yourself if you would heal the exact same way as that patient, but don’t you think that that helps patients be able to sort of picture what the result is going to be?
Dr. Swistun (40:28):
Tremendously. And I try to select patients before and after photos that are similar to the patient that is presenting and we’re building that library. It is growing for sure, but there are several consultations that I can think of where the patient was unusually thin and she did not have a lot of breast tissue, and she was considering just removing the implants, and she was debating whether or not to do a lift. And I sort of told her that this is the result to expect, and I tried to verbally describe it, but then I did have, I think two photos of before and afters of patients who were presented in a very similar fashion with basically the same body build, maybe the same size implants and the scar located in the same location, which is another thing that’s actually important. And I said, this is sort of what she looked like before, which is very similar to you. This is what we took out. This is what she looks like after a lift.
Monique Ramsey (41:16):
You mentioned scars. So no matter where the patient may be, had their implants put in the first place. So some doctor might have put it in through the armpit. Somebody might’ve used an incision around the arreola. Some doctor might’ve used
Dr. Swistun (41:30):
Monique Ramsey (41:31):
The fold under the breast, or even there was some doctors way back who were doing through the belly button.
Dr. Swistun (41:36):
Yeah, that’s a kind of accepted method.
Monique Ramsey (41:38):
Yeah. So you might’ve had your implants put in a certain way, but you as Dr. Swistun, what’s the method that you’re going to want to remove them?
Dr. Swistun (41:46):
So if we’re doing an unblock capsulectomy where I need the comfort of having a big enough incision that I can see the entire capsule and the implant as I negotiate around all those structures. So I typically remove them through an extended inframammary fold incision. So in the fold, but it’s typically a little bit longer. It’s about 10 to 12 centimeters long, whereas a typical incision for implantation is about four centimeters. If we’re doing a lift, then it’s a little bit easier. I basically just use the lift incisions, which are usually a little bit more extensive, so that makes it a little bit easier to get the entire capsule and the implant out. The problem is when a patient had the alar incision, and they don’t necessarily want to lift and they don’t have a lot of tissue because the areola incision tends to pucker a little bit.
Again, like we spoke before, any scar will contracture. So once you remove the volume from beneath the areola, the scar around the areola will actually try to contracture also. And this is a scar that extends through all of the tissues that are in the, also the areola itself, then the fat underneath and the breast tissue, and maybe even the muscle. And all that tissue that I just named, all of those become one single scar entity and the scar contracture. So when you remove the volume, that kind of pops it out. Then it just kind of goes in and then it creates, at the very least a fold underneath the nipple itself and sometimes a fold across the entire breast. And that may also be something that sways the patient towards doing a lift, because a lift will sort of remove all of that redundant skin, remove the problem area, and kind of reshape the breast that way, assuming they have enough tissue.
Monique Ramsey (43:20):
And so I would say another tool for patients to use our reviews, and we’ve really made a commitment. I mean, we’ve got thousands and thousands and thousands of reviews, and they’re hard to find for, you might find reviews on Botox or on eyelid lifts or breast augmentations, but finding a review for a breast implant removal in general can be sort of hard, but we’ve really made it a priority. You can rate ’em on our website, and I think that’s a patient telling you his or her experience on whatever surgery they had. And we also have patients who will talk to you, we’ll put you in touch with a buddy, you can talk to people in our office who’ve been patients, but we’ve had things done to ourselves. We have great access. But if you want to talk to another patient and just see what their experience has been, we can usually make that happen. And most patients are very happy to share. So really, our commitment has always been to open, transparent, patient communication so that you’re entering in not in a dark tunnel, what’s going to happen. You can expect it, and you know that we’re going to be with you throughout all of it. So you said you’ve done a couple hundred of these implant removal surgeries. Are there any red flags or warnings you would tell patients to look for when, if they’re thinking about having a breast implant removal, how do they choose a doctor?
Dr. Swistun (44:42):
All of the plastic surgeons that are board certified in the United States are capable of performing the surgery. We have all been trained to do an unblocked capsulectomy in one form or another, but it is a little bit more of a difficult procedure. It is a little bit more time consuming, and not every surgeon is committed to that. So I think the very initial criteria would be make sure your surgeon is board certified and make sure that he’s doing it in accredited surgery center. And then you just have a discussion with them. And there are some surgeons that are a little bit more recommended than others for this particular procedure, and I happen to be one of them. But we are sort of recognized by the patient community as the ones that are really committed to doing the procedure correctly and really standing behind the patient when they tell you that they think their implants are making them sick.
I think the most important thing is that this is an issue that needs to be talked about and researched appropriately, and it’s an elusive problem that is difficult to prove, again, because of how many other diseases mimic the symptoms that these patients are presenting with. So the design studies that statistically prove this to be the case is extremely difficult. It needs a lot of patients and a lot of controls, and it may not even be able to be designed appropriately ever, but at least we are paying attention to it, at least we’re taking it seriously, which is a big change.
Monique Ramsey (45:57):
That is a big change. So we talked about before and after photos, and if you go to our website, lj csc.com, we’ve got a gallery and I think that’s the best place to look. You can meet Dr. Swistun on his profile page. You can read reviews from his patients, and then you’ll see before and after pictures. And then I think the other thing is really openness about pricing. And so we publish on our website prices. I think it doesn’t do anybody a service to say, oh, call and we’ll tell you in the super secret interview, it’s all there. And it’s a range. It depends on what you’re going to do, the extent of the surgery, how long it might take, but we do have those fee ranges on the website, which I think it really helps people. And then we also do financing. So there’s patient Fi, there’s CareCredit, there’s alion, and our patient coordinators.
And we actually have a episode that we just recorded about this where we’re talking about how do you investigate your options for paying, because I think that’s something that not everybody realizes is that there’s financing. So we’ll have in the show notes, ways to contact us, how to call us, how to text us, how to email us. You can look at all the links there. We’ll have them in there. And I want to read one more review. I just thought it was so sweet. So here was a recent breast implant removal review, and she said, Dr. Swistun, nurse, Jasmine, Rihanna, Dr. Haas, who’s our anesthesiologist, and the entire team were incredible. Their attention detail and excellent communication kept me and my husband calm and informed throughout my entire process. Their high level of professionalism, yet compassion and empathy were like, no other offices I’ve been to. Their energy was gracious down to earth and never made me feel small or too much. It felt like seeing old friends instead of the often snobby cosmetics offices. I have been to such a great crew, so congratulations team then, Dr. Swistun. That’s really so touching and so heartwarming.
Dr. Swistun (48:07):
I think that’s what it’s about. I mean, you have to, as a patient, you have to feel comfortable with your surgeon because ultimately this is teamwork and the success of the surgery depends on that communication, that relationship.
Monique Ramsey (48:19):
Thank you, Dr. Swistun. It was wonderful having you today. And I think that you’ve brought this sort of mystery procedure or topic, not mystery, but not everybody knows about it, and it’s hard to find information. And when you find information, how do you trust it? And I think that’s really the key because there’s a lot of stuff on the web, but that doesn’t mean it’s right. And so really, patients be able to talk to you and you sharing with us today about breast implant illness and about what an on block cap select, what that entails and what that kind of looks like, what it means. That’s really wonderful that we’ve had that expertise from you today. So thank you very much. And for everybody in our audience, don’t forget to follow, subscribe, whatever little button they put on your, whether it’s Spotify, iTunes, wherever you are, we’d love for you to keep following us and listen to more episodes. And we even have a little incentive if you subscribe or follow you, come into our office, show us that you’re subscribing, and we’ll give you $25 off of 50 or more. So that might get you a really nice eye cream or something fun up in the med spa. And we look forward to seeing you all soon, and we look forward to talking with you again, Dr. Swistun on our next episode.
Dr. Swistun (49:36):
Thank you again. It was my pleasure. Thanks, Mike.
Monique Ramsey (49:38):
Speaker 3 (49:45):
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 Xed Building on the Scripps Memorial Hospital campus. To learn more, go to lj csc.com or follow the team on Instagram at @LJCSC. The La Jolla Cosmetic podcast is a production of The Axis.