PODCAST: Revision Breast Surgery – If It Ain’t Broke, Don’t Fix It

After 32 years in practice, plastic surgeon Dr. John Smoot explains why when it comes to breast implants, if it ain’t broke, don’t fix it.

Every breast augmentation patient knows there will be a time to remove or replace their implants. Listen to Dr. Smoot’s wise perspective on breast revision, find out how he helps patients visualize their surgery results with TouchMD during consultation, and learn how the Internal Bra technique helps create great results.


TRANSCRIPT

LJC007 Breast Revision Smoot

[00:00:00] You’re listening to the La Jolla Cosmetic Podcast with the LJC chief community officer Monique Ramsey.

Monique: [00:00:16] Welcome everyone today. We’re going to be speaking with Dr. John Smoot, one of the plastic surgeons at La Jolla Cosmetic, and we really want to talk about breast implant revision today. Welcome to our podcast.So before we have you start talking about the procedure, can you tell us a little bit about yourself?

Dr. Smoot: [00:00:36] Oh, I’d be happy to, let’s see. Let’s start back when I was born. No, I’m just kidding. I’m originally from Utah and The University of Utah medical graduate. And I trained in Chicago, Detroit, Houston, all those places for my general surgery and plastic surgery. And then I’ve been here in San Diego for 32 years. Been here practicing mostly plastic reconstructive surgery for that time for the last 15 years, just aesthetic surgery. 

Monique: [00:01:05] And would you say that breast surgery is one of your favorite things to do? 

Dr. Smoot: [00:01:10] Yes. And that’s probably the bulk of what I do, but I do all the other things too, which I’m just not a breast surgeon. But, uh, we do all the things that plastic surgeons do with tummies, and liposuction, and facelifts, and eyes, and all that stuff.

Monique: [00:01:23] Wonderful. Well, so today we’ll just be talking about revision breast surgery. So you know, many women out there and especially probably in the, I don’t know how many, maybe thousands of breast procedures you’ve done over your career. But, you know, revision breast surgery is very common. So what would you say are the most common reasons that breast implants need to be replaced?

Dr. Smoot: [00:01:48] Before I answer that. Let me just say, I always tell the patients when they come in, is that, well, I have to work with what is possible. A lot of times they come in and they say, I want to look like this. I want to be this. I want this or that. Well, that’s nice, but we have to look at what the possibilities are.

And if our expectations are not aligned, what I can technically surgically do, then was to set up for disappointment and then nobody’s happy. So that’s the first thing I want to make clear is what is their goal and making sure what they want and what we can do are the same. Now, the other question is, I guess, is, they were all assuming that patients were in seeing me for implants, they’ve already had their implants in. And fortunately, uh having done this for 32 years, I’ve got a long track record of patients who had implants. And now I’ve seen pretty the gamut of what people are coming in for. The question is as well, this is very common to say, well, don’t, I have to have my implants replaced every so often? A lot of that comes from the implant companies years ago. I think they were saying well every 10 years. And I’m not quite sure where that all got started, but it’s not like you have to do warranty work. And I tell patients if, if it ain’t broke, don’t fix it. And that’s really the truth. If there’s not a problem, there’s no reason to go in there and do something. Now if an implant is broken, obviously yes, they should be replaced. And with the new silicone implants, they’re much better implants. We don’t see the rupture rate, nearly what we saw before the pre 1992 implants. Those had a really high rupture rate. But they do break occasionally. It’s about eight or nine percent after 10 years. So occasionally they do break. And one of the ways we can tell they’re broken is by doing an ultrasound, a specific ultrasound, or doing an MRI. Both of those ways can determine if an implant is intact.

Monique: [00:03:38] Hmm. So does age have anything to do with it. Age in the person or age of the implant necessarily, or is it more that maybe, you know, the patient’s coming to you for a revision because it’s, you know, giving them problems?

Dr. Smoot: [00:03:53] You say problems, that depends on what they define as their problem. What I’m seeing a lot now is women who’ve had their implants for 15, 20, 25 years and saying, you know, I’m older, I’ve gained weight, my breasts are bigger. You know, the fantasy is over. I don’t want to use it. I just don’t want them anymore. I’m seeing a lot of that. It’s just, they’re tired of them. They don’t want to deal with them anymore. Sometimes they’ll come in because they have problems. They’re asymmetrical, they’re hard, they did determine it was broken. Now, when a saline implant breaks, that’s very easy to tell because he just goes flat. It’s pretty easy to tell that. The, the bulk of the reasons are right now, just it’s age. Age, meaning that I’m tired of them now. I don’t need them anymore. I don’t want them anymore. 

Monique: [00:04:35] So then let’s say a woman decides, okay, I don’t want them anymore. They can take them out. And then are you typically doing a lift at that point?

Dr. Smoot: [00:04:45] Can be. More common than not, we do do a lift when you take them out because the tissue has been stretched out. Things don’t set like they used to be. It’s pretty rare that you can just take an implant out and not have to do something. Now in today’s age because of the internet, everybody has heard about the en bloc resection or removing the capsules, which is a scar tissue that surrounds the implant. So most women are coming in saying, “Well, if you’re going to take my implant out, take my capsules out.” Which we can do. But we try to do that in a safe way. Just to take the capsule out, to take the capsule out, cause it wants to come out is not always the safest and best way to do it. We try to do it the best way. But if the capsule is attached to the chest wall, we definitely don’t want to be stripping that off because of bleeding, getting into the chest cavity. So we have to look at each individual situation here, but when we do remove them, we do remove the implant and capsule for the most part.

Monique: [00:05:52] And just for the audience who might be listening, who might not be familiar with what the capsule is, if you could explain what that means.

Dr. Smoot: [00:06:00] When you put anything in the body, any foreign body, which is what this is, the body is going to form an envelope of scar tissue, what you call it. We call it a capsule around the implant. And that capsule can sometimes be very soft, very thin like tissue paper, or it can start to tighten, constrict. And that’s what we call it a capsule. It encapsulates the implant, causing it to feel firm. The implants don’t get firm, but i’ts the tissue around it. And we grade them from one to four, one being perfectly soft, four being painful and very distorted.

Monique: [00:06:32] Hmm. So if it was painful and very distorted let’s, is that common if you’ve had your implants 10 or 15 years, that all of a sudden you could get a capsule? Or is it more in the early days of having that implant? 

Dr. Smoot: [00:06:45] Oh you can get a capsule at any time. Usually we see it in the first couple of years of it’s going to happen. But, you know, there have been women that have had them for 15, 20 years and all of a sudden it gets hard. What causes it? We don’t always know. Sometimes it’s one side. Sometimes it’s both sides. If we could figure this out, it would solve a lot of our headaches in this business. But it can happen anytime. Which probably leads you to the next question. Well, what do you do with that?

Monique: [00:07:10] Right. How do you fix that? 

Dr. Smoot: [00:07:12] Okay. There’s, the classical way of correcting a capsule was just to release it. The old days we used to, an archaic way, we used to squeeze it until the capsule of the scar tissue would rupture. That’s really not done anymore because it’s an uncontrolled rupture, and it can cause bleeding, and it usually comes back. Today, we like to start simply by sometimes we can just release the scar tissue surgically or remove it. But then there’s a recurrence rate. It’s about, you know, anywhere from 10 to 30%. So I have to tell patients that, yes, this may come back if we do that. The next option is to say, “Well, look, I don’t want this to come back. And I want everything we can possibly do to keep them soft and natural”. In that case, sometimes we will put a graft in there. It’s called an ADM, a dermal cellular matrix. It’s basically a collagen matrix, which is like a wet cardboard, it feels like. But it does not allow, or very much retards, that capsule from forming again and making it feel hard or firm. And it works very well. I always tell patients, there’s not many things in this business that’s better than sliced bread. But this is. This takes the risk rate from like 15, 20% down to one or 2%.

Monique: [00:08:26] Oh my goodness. And so is that used preemptively ever? Like, let’s say you’re a first time aug patient. Is that something that you would ever use?

Dr. Smoot: [00:08:36] Normally I don’t. But if they requested it, could we do it? Yes. It just added cost, a little more complexity. But you know, I would say most patients would not do it nor would most doctors do that at this point, at least for the first time around.

Monique: [00:08:49] It’s more really for the revisions, that they’ve had a capsule, it was hard, you go in, you’re going to remove that capsule and replace. Does the implant get changed?

Dr. Smoot: [00:08:59] Usually we do. You want to change the implant, create a new capsule, or create a new pocket, either remove the capsule. There’s many ways to do it. We create a new pocket, but leave the old scar tissue, or we remove the scar tissue. And when at this graft is it sits like a little, like a little horizontal football. It sits in the bottom of the breast like this. You don’t see it, you don’t feel it. It’s sutured in place. 

Monique: [00:09:25] So that’s that what we were talking about earlier where people talk about the internal bra. Is it sort of like an extra support?

Dr. Smoot: [00:09:32] Well, I don’t use that type of graft for support so much. It’s more for softness. Oh. Now, there’s another type of graft we do use, but if someone’s lost a lot of weight, they’ve got very poor skin quality and we put implants in there. We don’t want things to sag. That’s called a GalaFLEX mesh as the brand name of it. I can’t tell you the scientific name that goes behind it. But it’s basically a mesh which is put in there to help support the tissue. It’s not permanent. It lasts18 to 24 months, and it really does give a lot of support to the tissues, particularly if you don’t want them to sag. Because you can’t stop gravity. Gravity is still working 

Monique: [00:10:09] Darn it.. You haven’t figured that out yet. Dr. Smoot?

Dr. Smoot: [00:10:11] No yet.

Monique: [00:10:13] So, so the GalaFLEX that’s the more support, if you just have saggy skin and you want to prevent the recurrence of the sagging. And the first thing you talked about is that the Strattice, or is that something

Dr. Smoot: [00:10:27] That’s the brand named Strattice. They call an ADM. There is several different kinds. Some of the brands that are out there, we don’t use like flex HD, LMX yeah. That’s what it is. We don’t use that anymore. I wasn’t, I used early on, but it didn’t work as well as the Strattice. The other we use is Alloderm, which is that’s human skin. It works very well too, but it’s extremely expensive. And the Strattice is a much less expensive, but again, let me add, this is an off-label use of using it for this cause here. The FDA has not said you can use it for this purpose, but we’ve been using it for this purpose for the last 15 years.

Monique: [00:11:09] Oh, interesting. So I was reading through some of the reviews on the La Jolla Cosmetic website, and it’s really interesting because as a patient, you’re used to reading a lot of different reviews and you see a lot of first time surgery, but we actually have a lot of reviews about breast implant revision. And so one of the patients wrote,” I had encapsulation and really needed a clear picture of my options. Dr. Smoot delivered. He listened to me, heard my concerns and put me at ease. When I made my decision to have the lift, move the implants and add graphs and reduce the size. It was the right thing for me. And I appreciate his directness with me”. So is that kind of the typical patient might come in and they’ve [00:12:00] got a contracture and we’re going to do, it’s a multi. faceted approach. It’s not just lift or just remove the implant.

Dr. Smoot: [00:12:09] Well, that’s right. That’s what I have to talk to patients about clearly understanding what is your goal? What is it you’re trying to accomplish? Do you just want to lift, do you want your implants out? Do you want your implants out and done everything to keep them soft and natural? So there’s several factors that go into, but most of it it’s listening to see what it is you want to accomplish. You know, sometimes it’s no, I really, I got hard capsules and I really don’t want to get rid of my implants yet. Okay. Well then what are our options? We go through those options. Maybe it’s smaller. Maybe it’s bigger. Do they need to lift or not? But all those come with complexity of the procedure and potential risks, but they’re not many. The biggest issue I think, I think is having to lift. I mean, they don’t want to have the scars, but the scars is what gives you the shape. So it’s a, trade-off.

Monique: [00:12:56] So, how do you handle incisions or work around scars from maybe previous surgeries or is there, or does it really depend on the patient? 

Dr. Smoot: [00:13:05] Depends on the patient. But we have found over the years when I was first starting out, I used to put implants in through through the nipple, underneath the breast, but I found it as I did this, I was getting a lot more capsular contractures by using those other techniques, through the arm and armpit through the nipple. Through the years, the society and other surgeons in our group who have been able to determine that, you know, by going underneath the breast, through the fold, we don’t cut through breast tissue. So there’s less contact with bacteria that are in the ducts, less contact with nerves and things and contractures of those scars. And greatly diminish that capsular contracture rate by going underneath. So almost all of my augmentations for through the fold. Even on a redo, even if they’ve had those other incisions, I say, you know, I just don’t want to go through that again for those various risks.

Monique: [00:13:55] Definitely it’s a trade off, but I think under the fold, I mean, that seems like it heals really well and you know, is pretty easily hidden with whatever you’re wearing.

Dr. Smoot: [00:14:06] Yes. It’s a very easy scar to hide. And I always say the only way you’re going to see it is if you lift your breasts up and show everybody or you’re standing on your head. So most times it’s very well hidden.

Monique: [00:14:16] Now does it take any longer to recover from a second or even third breast surgery? 

Dr. Smoot: [00:14:22] Usually they’re easier to recover from. But again, it’s dependent on what we’re trying to do. If you’re taking implants from above the muscle and putting them under the muscle, it’s a little harder recovery. If you’ve got a lot of scar tissue and you want to do resect, a lot of that out there, it can be a little more difficult. It just depends on what you’re trying to accomplish. 

Monique: [00:14:41] And are there certain things that you recommend to help patients recover more quickly? 

Dr. Smoot: [00:14:46] Well, the most important thing they can do is to not sweat, don’t get your blood pressure up, don’t get your heart rate up. In other words, take the time to heal. I don’t want them up, moving around, lifting heavy objects, pushing, pulling things like that, for a couple of weeks. When you use graphs, you have to have drains in there. But it’s an annoyance, but it serves a very good purpose. And it’s only there for a week. That’s the only downside of having a, what we call the ADM in there.

Monique: [00:15:12] When you feel good and you feel guilty to kind of be sitting around doing nothing. And I remember a patient we had years ago who had a facelift and she felt so great the next day that, or two days later that she decided to rearrange her entire home library. She came in and her head looked like a watermelon. She was so swollen and so sad. And it was like, she didn’t, she knew she’s like, I should have listened to you. But yeah. So that’s, you know, it’s, it’s curbing that, that sense of all of us like, oh, I shouldn’t be sitting doing nothing, but you’re you are doing something you’re healing. Right?

Dr. Smoot: [00:15:49] That’s exactly right. But who listens to the doctor anyway?

Monique: [00:15:54] So. Safety is really important to everything that we do at La Jolla cosmetic. And part of, I think, safety, you know, how does that manifest, not just in an accredited operating room, or board-certified physicians. But it’s also, you know, safety is also taking the time to listen and not rushing through and building those relationships. And I’m sure over the 32 years you’ve been in San Diego, you, that you’ve probably had, have you had generations of patients? 

Dr. Smoot: [00:16:25] Well, yeah, I’ve had patients that I started out with and did their breast, and then they want their tummies, then they want their faces ,and then they come in and take their implants out. Okay. I’ve seen the whole gamut of that.

Monique: [00:16:38] Lifecycle. 

Dr. Smoot: [00:16:38] It is. But you mentioned it, you hit on something that’s important, it’s safety. And one of the things that’s important to me is it is educating the patient first off. They need to know what this is, what it isn’t, what can be done, what the risks are. So listening to what they really want to have done is important. Then being there for them. And that’s one of the things I pretty like about our, our setup here. I’ve got a nurse that worked with me. She takes calls, night, weekends. I’m always available. So they’ve never felt like they’re not attended to. Because a lot of times they don’t know what’s going on. They don’t know if that’s normal. To us, it’s oh, that’s nothing, but they don’t know that. I only tell the patients. I said, look, the only dumb question you have is the one you don’t ask me. Okay. So I want you to call. I want you to be there. So that being available for them is extremely important ,as well as the educational purposes. 

Monique: [00:17:29] Yeah. Now, do you have some tools that you use, whether you’re doing a zoom consult or you’re in an in-person consult to help them visualize? Or is it seeing other patients before and after pictures? Or what, tell us about that. 

Dr. Smoot: [00:17:42] Yeah. Well, yes, we have something called touch MD. It’s a little computer that sits on the, on the wall in our exam rooms. And on that, it’s a touch screen that I can draw on show results, how I do things and be very descriptive of how we are going to do things. I think that’s very helpful.  What I’ll do as I’ll, this is what I’m going to do. Now, let me go up on my screen and show you, diagrammatically what I just told you. Again, education is key here. So I like to use that a lot and we have before and after photos too, particularly when you use tummy tucks and things like that, people want to see what that looks like. What does a scar look like? What kind of category do they fit in? And that’s been very helpful with those tools. We also use something called Vectra, particularly for young women who want to have implants. This has really been helpful. It’s a computer simulation of what they look like. Then I can put implants in them and kind of show them how their look on them.

Monique: [00:18:38] So does it scan their body actually, or

Dr. Smoot: [00:18:41] Oh yes. It’s a 3D imaging, that actually comes up on a computer screen. And I can say, okay, let’s put a 300 CC implant in you and this is how you’re going to look. 

Monique: [00:18:49] Wow.

Dr. Smoot: [00:18:50] I also do that with lifts and it works very well. Now, some of my colleagues do a lot of liposuction and they call it 3D imaging, where they can take your whole body, turn it around. Okay. We’ll take some of this fat here. We’ll take this here. We’ll take some of that there ,and really show you what we can accomplish .Now, it’s, it’s a simulation. It’s not perfect, but it gives them a good idea of what, how it look on them.

Monique: [00:19:11] Interesting. I don’t know what made me think of it right now, but I’m going to ask the question, I guess it’s moving fat around. So if you’re moving fat around, can you use fat in the breast or, do you?

Dr. Smoot: [00:19:24] We, we do. Um, not every patient is a candidate for that. And we usually use fat for contouring issues, not for augmentation. Now, some women just want fat for augmentation, but I tell them you’re going to get a modest improvement, meaning maybe a half a cup improvement. And if that’s all they want, yeah, that works. And fat’s really good when to fill in defects. We use it a lot in reconstruction, breast surgeries. When the fat’s been removed from up here, we need to take that out, or refill  that in, recreate the mound. And it’s very helpful that way. The only problem with that is it’s not always predictable. And it may all go away, it may not. If we can get 40, 50% of it to stay, that’s really a good result.

Monique: [00:20:08] The day after surgery might not be what you see a year later. Cause part of it might have gone away. 

Dr. Smoot: [00:20:14] Right. I’d say about six months, I tell patients to look at it. By then, that’s what you’re going to get. 

Monique: [00:20:19] Hmm. Interesting. And I guess that, that also necessitates the person having fat in the first place. You know, we see a lot of patients who say, I want to BBL. I want my fat from, you know, in my butt. And then they don’t have, where are you going to take it from if they’re really thin? 

Dr. Smoot: [00:20:36] Well, that’s exactly right. The same with breasts or the buttock area. Now you mentioned the term BBL. So, listeners know what a BBL. It’s called a Brazilian butt lift, but that’s just the name. It’s basically transferring fat from other parts of the body, to the buttock area. And that’s what it is. But again, what you put in does not stay. You lose a good portion of it, so you have to put in quite a bit. But I use it, not to give girls big booties.

That’s not what I use it for. I use it for contouring purposes, particularly if they have a depression on their buttock, it’s not that nice, gentle S-curve. You want to fill out the upper part of the buttocks, so it has a nice roundness to it. That’s what I use it for. 

Monique: [00:21:14] Oh, interesting. We’ll have a different episode about that, but anyway, sorry. I had to digress. I had to just, I know I get excited about this stuff. Okay. So, where can I find information about prices? So you probably, you just do the diagnostic work, I assume in the plan. 

Dr. Smoot: [00:21:35] That’s exactly right. My job is to tell you what we can do to give you the best outcome. Once I know that, then we can fashion a plan for them.

We have consultants, coordinators, who are very good at that. And listening to what you want and make sure that what we’re doing works for you and it’s within your budget. We can always tailor something to fit your budget. And that’s important that we take that into consideration. I mean, I can say we can do this, we do that, and this and that, but you know, that may not be within their budget. But then I have to prioritize and they can do that very well too, to prioritize what needs to be done. 

Monique: [00:22:12] And I think what people don’t always realize is that there are a bunch of different financing companies out there to help you. You know, most people can’t walk into the real estate office and say here’s $500,000 for a house. We finance it through the bank and same with our car. And so, you know, there’s PatientFi, and Care Credit, and Alpheon. There’s so many different financing companies that we work with that really help it become something where, you know, you can have your cake and eat it too. Have your cake tomorrow and pay for it over the next couple of years or something. And I think that’s something that we assume most patients know about. But they really don’t realize that, you know, sometimes that can make it more affordable or get you to your goal quicker.

Dr. Smoot: [00:22:57] Absolutely. I just think that’s extremely important that they know that there are options that make it affordable. They don’t have to walk in with cash in hand. And they, some of these newer companies like PatientFi not that, I want to plug for them, but they’ve made it much easier to finance things and get things approved.

Monique: [00:23:14] Nice. And one of the things also, you know, regarding pricing that I think is pretty unique in the marketplace, is that La Jolla Cosmetic has on the website, price ranges of everything. And so it gives you an idea and there’s even a little finance calculator, like what would my monthly payment look like? Or, but, you know, you can go in and look at pricing and we have pricing on every procedure. Now probably in something like a secondary breast surgery, maybe the range might be pretty wide, because we don’t know until they see you and you make a treatment plan for them, what it’s going to cost. Especially if it brings in things like, the Strattice or, 

Dr. Smoot: [00:23:58] Well, that’s important that we see them as we get a plan that’s going to work for them. It’s not very often but there are times when I have just said, look, I’m not your doctor. Your expectations are not realistic, and I’m not gonna try to do this. So I want to be honest with them and the same with our financing. Again, that’s not really what I do per se. That’s why I’ve got the team that we have from the first call to the last post-op visit, there’s always somebody there to help them through the process. 

Monique: [00:24:23] Yeah. Now, and you mentioned the ultrasound for looking to see if the breast implant is intact or if there’s a, a leak or a rupture. So can you explain what that is? And, and we have that at this surgery center, correct?

Dr. Smoot: [00:24:38] We do. Now, it’s a very specialized ultrasound. The transducer or the head that produces the ultrasound is very specific to looking at just that. We can’t do other types of ultrasound with it. But we can put the transducer right on the breast and look and just see, we actually can see the edge of the implant. And what we’re looking for is a break in the outline of the implant. And it does work. I mean, it does help us. It’s not as definitive as an MRI, but it’s a lot less expensive and it’s something we can do in 10 minutes in the office. 

Monique: [00:25:09] Oh, wonderful. So patients could make an appointment and have that done.

Dr. Smoot: [00:25:14] Absolutely. Yeah, we do it fairly often. 

Monique: [00:25:17] Okay. So here’s a really interesting review that I found from a patient, and she said “I’m 64 years old. My implants were 30 years old and had been ruptured 12 years ago when I was hit by a car in a crosswalk. This was not an easy breast revision surgery. I feel much better, and I’m very pleased with the breast revision results.” So when I read that, I thought 30 years and they were ruptured for 12 years. I mean, can you keep ruptured implants in that long? 

Dr. Smoot: [00:25:48] You can. The problem is if you have implants from before 1992. Those were different types of silicone. It was a silicone oil and that’s the stuff that got into the tissues, got into the muscle, lymph nodes. And they said, well, does it spread throughout your body? And the silicone would do that. Those implants were a problem. And picking them out was a mess. And a lot of times we had to resect tissue. Cause once the silicone gets into the tissues, you just can’t pick it out. You have to cut the tissue away.

Monique: [00:26:17] Wow.

Dr. Smoot: [00:26:18] So we don’t see that anymore. These new, what we call the gummy bears, they are highly cohesive implants. The silicone nail comes out in one piece. It’s really nice. I can just reach in there and pull out the whole thing, and 95, 98% of it comes out in one pass. So it doesn’t get into the tissues like we used to. And that’s really been a real lifesaver for these implants. And so we don’t see near the problems we used to see with those older implants.

Monique: [00:26:45] That’s really interesting. So bringing up that rupture, obviously for her, it wasn’t an emergency because she lived with it for a long time. But for most people, is it an emergency if an implant ruptures?

Dr. Smoot: [00:26:57] No, but with saline implants, I don’t want to call it an emergency, but the longer you wait to fix it, the more the pocket shrinks, and becomes a little more difficult to match them up. So when they rupture with saline, we like to get them fixed fairly soon. Now, silicone implant, can you go on and not fix it? Yeah. Cause, you see silicone for the most part, isn’t going to travel outside the pocket of the capsule. But then again, you know, it’s a, it’s a ruptured, it’s a defective implant, it should be replaced. But it’s not like we have to do it tomorrow.

Monique: [00:27:27] So if you walk us through a little bit, what’s your consultation process. You know, what does that look like when you have a consultation for a breast revision?

Dr. Smoot: [00:27:36] Well, since COVID things have changed quite a bit. But you can do what we call a zoom consultation where we just like, we’re on the computer. We talk, you show us your problems. I can give you somewhat of an assessment. It’s not as good as an in-person. But that, gives the patient some time to think. Well, yeah, I know, I know I want to pursue this. Then we can have them come in, or we can just have an in-person consult right from the beginning now. Which has now been nice to be able to talk to patients upfront and say, yeah, this is your situation, this is what you need. I’d like to see them in person with my nurse. My nurse will talk to them, I’ll talk to them, give them the, all the information they need. Try to make sure we’ve addressed their concerns or issues in their fears, so they have good information. Because without good information, you can’t make good decisions. So again, if they choose me, that’s great, but I have, more importantly, I want to make sure they understand what’s involved. My way of approaching things is my way of things that have worked for me. I can’t say it is the only way to do things, but there’s something said for experience. I’ve done this 32 years. I’ve learned a few things along the way, which works when things don’t work and get an appreciation to do things. And that’s where experience in these types of revisions, I think is important. But yeah, then once we do the consult, you know, we, we turn them over to our coordinators who then discuss the timing, scheduling, pricing, and do those types of things. 

Monique: [00:28:57] Okay. And then at the actual consultation. So do they have a physical exam where you actually will like palpate the breasts to see the softness or firmness?

Dr. Smoot: [00:29:08] Well, yeah, that’s the problem with zoom is you can’t tell how soft something is, how things move, how dense something is, how saggy something might be. It’s harder to tell that. But you can get a good gist of what needs to be done. Now, sometimes they come in and say, “Well, you know, this is not quite what I thought.”, we can adapt it. But absolutely having them come in and have an eye contact, hands-on, to feel, to see what’s really going on, to me is paramount to be able to make the proper assessment and make the proper prognosis of what we should do.

Monique: [00:29:41] Would you say once you get into surgery, you know, is it almost 99% of the time exactly what you thought, when you had them a consult, like once they’re actually on the table?

Dr. Smoot: [00:29:51] Well, yeah, but then. You have to understand this, isn’t rocket science ,it’s surgery .And, there’s always plan A, there’s plan B, and sometimes there’s plan C. And there’s times I’ve gotten in there, patient says, oh, I had this size implant and you get in there and go, oh no, that’s not at all what they had. So you’ve gotta be prepared to adapt. And that’s, that’s the beauty of what we do. Someone told me once that if you operate long enough, you will see every complication and every situation. And that I got it, man, after 32 years, I think I’ve seen pretty much all of them.

Monique: [00:30:26] Is there any advice you could give to women who might be thinking, gosh, do I need this?

Dr. Smoot: [00:30:33] Well, do you ever need it? Probably not, but I think it’s important to realize what your options are. What are the possibilities? And the thing I dislike more than anything else is, “Well, I talked to my girlfriend or I talked to my family and they said”, well, they’re not experts in this. And they need to talk to someone who knows how to do things and how it’s to be done. Partial information is a danger. That’s what the Internet’s done. It’s once I called Dr. Google, Dr. Google said this. Well, that’s not always correct. So that’s what I like to do. I like to make sure that they have good information. 

Monique: [00:31:11] Yeah. And I think that’s, you know, you mentioned that early on. It’s really educating the patient about their options, about their situation and what they could expect going forward. But, you know, having realistic expectations is really important. And even having all these reviews, I mean, I looked up, we’ve got like 350 reviews just from people who’ve had revisionary breast surgery. So that’s pretty unique because, uh, finding reviews is one thing, but finding reviews from a Dr. Smoot patient, who’s had a breast revision surgery. Because that does help you kind of, you’re not going through it alone. You’re not going down a dark tunnel. Between Dr. Smoot, and the nurse, and the team, and then other patients who’ve actually had the surgery and what they have to say. One lady said, “My revision lift and the fat transfer to my cheeks has given me more confidence that I look my best. Since the revision included a decrease in my implant size, my clothes fit better and I’m physically more comfortable.” So there’s somebody who decided, you know, 

Dr. Smoot: [00:32:19] And that’s it. That’s one thing you mentioned, that’s important, we have to manage their expectations. By managing it, does not mean to coerce them, or talk them into anything, but make sure that what they’re wanting and what we can do is the same. And getting as close to that as we possibly can. And there’s nothing more frustrating to me then to say, oh, I did a great surgery, feeling all accomplished. Then they come back and go, well, you know, it’s not quite the size, or well, that’s not the way I wanted to look. And, that means that I didn’t do my job very well,in terms of explaining what they’re outcome would be.. 

Monique: [00:32:50] Right. Well, I doubt that happens very often.

Dr. Smoot: [00:32:53] Well, when it comes to revisions, I was going to say, I mean, not that I want to pat myself on the back here, but I’ve been doing this for about 15 years now. I was doing this before it ever really got started. And I learned from my reconstructive colleagues and my reconstructive experience, how this works. And I had a pretty big learning curve. But now I’ve done several hundred of these and I’m pretty good at it. I think I understand how to do this. I mean, back when I first started, everybody was, well, everybody, meaning other doctors were saying, oh, this doesn’t work. It’s not all that great. It’s costly to this. Now, it’s everybody’s doing it. So. You know, and I had the fortunate experience too, when my brother was practicing to have all his patients for 34 years coming with problems, and had learned how to take care of those problems.

Monique: [00:33:38] And so the last thing is really scheduling a consultation with Dr. Smoot. You know, you can go on our website and, and there’s a “Contact Us” and you can set up a consultation or you can call us at (858) 452-1981. Or you can even text us at  (858)203-2944, or lastly, you can email us @lookgreatatljcsc.com. And all of that will be in the show notes, if you happen to be looking at it. And if you subscribe to our podcast, we have a little thank you offer. So if you show us your subscription, uh, we have a $25 coupon you could use towards anything you want $50 or more. So that’s the way to come in and get your skincare, is what I think. Hit the little button and then you come get your, your Skin Medica and have your self glowing. Well, thank you, Dr. Smoot. That was so nice of you to take the time to really explain revision breast surgery, how it works, what to expect and the different options available. So we thank you for your time. Is there anything else you might, uh, that I might’ve forgotten to ask that you want to talk about? 

Dr. Smoot: [00:34:57] The only thing I just recommend we talk about is, I saw this pretty early on when I started doing this. There’s a lot of women out there who think that, oh, my breasts are just messed up. I can never have nice looking breasts and that’s not the case. And the problem is getting that information out. There is ways to do it. And I think there are a lot of women would want to have the surgery if they knew more about it. And so doing this podcast, getting this information out is becoming much more commonplace. And you know, of all the women I’ve taken that had some awful results, fixed them, and saying, God, I never thought I’d have nice looking breasts again. It’s really satisfying to me and to them as well. 

Monique: [00:35:35] Well, that’s wonderful. I love hearing happy stories like that. Well, again, thank you so much and we appreciate your time. 

Dr. Smoot: [00:35:43] It’s been a pleasure. 

Monique: [00:35:45] Thank you. And we’ll hear from you, I’m sure soon, about another topic.

Dr. Smoot: [00:35:48] Anytime. Happy to speak with you. Thank you.

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