“Holistic” Explant Surgery: Buzzword or Reality?

Monique Ramsey (00:03):
Welcome everyone to The La Jolla Cosmetic Podcast. Today, Luke Swistun, our plastic surgeon of the hour is here to explain how personalized care, lifelong support, and a whole health approach transform the patient experience, especially for women navigating breast implant removal and breast implant illness. So I'm happy to welcome you back, Dr. Swistun.

Dr. Swistun (00:28):
Thank you again.

Monique Ramsey (00:30):
So when you say concierge plastic surgeon, what does that mean for your patients?

Dr. Swistun (00:38):
To me it means several things. I think the most important one is just constant access to your doctor so patients can reach out to me anytime. One of the things that I pride myself on and did from the very beginning is every single patient that I've ever operated on and some that I didn't even operate on yet operate on yet have my cell number, the same number that my wife calls me on is the cell number that they get. Because honestly, communication is key. And so constant access, patients text me all the time and we discuss things, we make little corrections, we adjust course of recovery all the time, and that's how I like it. Personalized care, I suppose is the other one, just really listening to what the patient wants and their goals. There is lots of different options for the goals that the patients have and really trying to focus in on what they're looking for. Spending the time I think is key.

Monique Ramsey (01:31):
So you give them your cell phone number. I love that because I think all of us as patients, we don't want to bother the doctor. We feel bad and even though we shouldn't, we do. And so rather than just asking the quick question via text, we'll ruminate on it and worry about it and then go to Dr. Google and go down a path that we don't need to go down. And I think having that access is so important to be able to just ask the right, go to the source of what's, give me an example of some of the questions you get.

Dr. Swistun (02:11):
Well, I mean, again, this is what I do. So I don't mind talking to my patients pretty much at any time, and frankly, I'm the best person to answer their questions. And frankly, if there is an emergency, and this is kind of the key where it started, is if there was a true emergency, I really want to be the first to know about it because I can do the most about it the fastest, right? So if somebody let's say had surgery, the next day their breast starts filling up with blood and they have a hematoma. If they call the answering service and the answering service calls the nurse and the nurse calls somebody else, and then they're like, oh, I think maybe this and that. So there's a delay in care, which is completely unnecessary because eventually I'm going to find out about it and I'm going to have to be the one to take patient back to surgery. So if the patient just calls me directly and I can make that assessment and make that decision, we save time and we have better outcomes. But yes, you're right. Most people don't expect this. And some people have reservations about calling because it's the doctor. The way I explain that is like, well, if you call the answering service, the answering service will call me and then I'll call you back. So why don't you just skip a step and get me directly.

Monique Ramsey (03:12):
Cut out the middleman?

Dr. Swistun (03:13):
Yeah, yeah, exactly. And the other big part of is just the patient having my cell phone number, I believe just is a good piece of reassurance and lowers the stress, especially in the recovery period. A lot of times patients never call and everything is fine, but if you just say like, Hey, if there is anything, I did that this morning. There's a patient we operated on last night. I called her this morning, everything was fine and we went through what to expect on the phone. And the last words that I left her with was, if you have any concerns today, reach out to me directly. My phone is in my pocket. You can clarify anything you want. And they probably won't, but they have that reassurance that they can and that amounts to a lot less stress during their recovery. I don't want them to be stressed. I don't want their pressure to go up or their anxiety or their heart rate to go down because that can cause a hematoma. So all these things, these little things just add up to just a better experience overall.

Monique Ramsey (04:07):
And one of the other things that I noticed in your approach, and you talk about it often is the concept of lifelong aesthetic health and what does that mean to you and what does that sort of look like beyond the surgery itself?

Dr. Swistun (04:24):
So yes, I really believe in these power of these words really focusing on the patient's lifelong aesthetic health. And I can't take credit for these words. These are words of Dr. George Orloff from Burbank who had sort of put this together for me. But I really, really liked the concept and I sort of stuck with it since then. But if you break down the concept, the words, what they mean, first of all, lifelong. Lifelong means we are going to make medical and surgical decisions on your behalf, which give you a desired result now, but also the desired result will be long lasting. And also whatever we do now should not be burning any bridges for potential future interventions later. And it's a very generalized way of really very specific decisions for very specific surgeries. But just to give an example, let's say breast implants. Somebody wants an augmentation to give them a good desired result.

(05:24):
Now they have choices of going really big, going really small, going above the muscle, going below the muscle, things like that. So let's customize that experience to them. If they're an athlete, they may not want an implant under the muscle because that will affect their breathing and their musculoskeletal balance more, and they will feel that implant every time they try to do pushups or sit ups. So maybe for that patient, the better placement is above the muscle. If they go really big, they're going to feel that implant a lot more. So my recommendation typically is if you are actually going to put an implant in, I would recommend putting the smallest implant. You can tolerate that you'll still have a result that you'll be happy with, but go smaller rather than bigger because in my experience, the patients who explant the ones that last the longest have smaller implants because it's just less of a burden on your body and they're happier longer.

(06:14):
Whereas patients who go really big start having complications much earlier and they have started having revision surgeries just earlier, and then the entire implant experience is just a disaster because it's surgery after surgery for revisions. So that's a part of it. So we want a long lasting result. We want a happy patient in the long-term, but they also want a functional patient. And these are all questions, nuances that we tease out during this conversation that we're going to have before we commit to a surgery. And then last thing, do not burn any bridges. At some point that implant might come out at some point the patient will say, well, maybe I just want my own tissue. Maybe I just want to lift. We don't want to make any incisions on the breast that will burn bridges that will kill the blood supply to the nipple later, or something like that. Okay. So these are things that I think about and these are decisions that I make early on so that we don't have a problem 20 years later. I hate that scenario,

Monique Ramsey (07:08):
Right? Because lifelong is like implies the relationship that you're in it for the long haul with them in their aesthetic journey. But then also I like that other part of it, which is the decisions we make today, what's going to be the lifelong implication of these things and to think about it and talk about it with them. And because we as patients, we don't know that.

Dr. Swistun (07:34):
That's my job, that's my point, that's my job. Another example is fat grafting and fat transfers. A lot of patients that present for liposuction, they may be very thin and they may have a little bit of a fat problem area, let's say in their flanks. And I always ask them the questions like, okay, sure we can do liposuction, that's reasonable. However, I just need to tell you at this stage in life that if we throw that fat away, it will never be able to be used again. So if you were ever thinking of using that fat for volume anywhere else on your body, now is the time to consider that. So these are things that they may not think about upfront, but then I leave them with that information and they think about it and sometimes we make slightly different decisions based on that conversation.

Monique Ramsey (08:13):
So do you find that in this kind of concierge and lifelong aesthetic health approach that patients will stay in touch with you long after their procedures and kind of where do they pop up on Instagram or what's the normal progression, I guess, of the relationship?

Dr. Swistun (08:34):
So a lot of patients do stay in touch because they have my phone number, my cell number. So a lot of times I'll actually get a random text from a patient from 18 months ago or three years ago about just something unusual. And those are kind of funny nuances. The most interesting one I got was actually from Greece and the patient was on vacation in Greece, and I haven't seen patient in three years, but I just got a text message like, oh my God, we're in Greece, we're on vacation, and my son slipped on the rock and fell and he has a laceration on his face. And do you know any plastic surgeons in Greece that could help him out? And funny enough, I did.

Monique Ramsey (09:09):
Oh my gosh.

Dr. Swistun (09:10):
Yeah, it's totally random. If if it was any other country I would've said no, but I actually happened to know someone in Athens, so I gave him the name. So that was probably the most interesting one. But a lot of times patients will just share their success that they'll follow up 18 months later. I mean, again, in the context of breast implant removal, a lot of times patients had metabolic disturbances that self-correct some types of autoimmune inflammatory diseases that's sort of self-corrected and I'll get that follow-up 18 months later or three years later. That piece of information to me is very valuable in the long-term of patient care where a patient's presents with thyroid disorders and lots of other problems with their implants, we explant and they get better. And then 18 months later they'll text me like, Hey, I some endocrinologist for the last time because my thyroid got better. I'm off of my medication and I've been off my medications for six months now and we checked my thyroid levels and they're completely normal. Just wanted to let you know.

Monique Ramsey (10:10):
Oh, that's fabulous.

Dr. Swistun (10:10):
To me, that's huge because that's a learning experience. It's like, well, this is why I'm doing this. And when a patient comes in with a thyroid disorder, I can now use that example to say, well, I do have a group of patients where after we explanted and this was verified, but not just me, but their endocrinologist as well. So we can't guarantee that, but it may happen because it has happened before. So to me, again, that's about another part of communication and that lifelong connection.

Monique Ramsey (10:39):
And I think you considering the patient's whole health, not just the surgical area, it's not just the knee or the elbow. If you're an orthopedic surgeon, I'm just looking at the knee and I don't care about the rest of the body here. It's like you're not just thinking about the breast or the tummy, you're looking at the whole patient and how that's going to fit into maybe their lifestyle, like you say, if they're an athlete or everyday things that maybe we as patients don't realize that we want to fix it, but we dunno the ramifications of fixing it. So tell me about some of the little recovery touches that you offer that make a big difference for comfort and for healing.

Dr. Swistun (11:21):
So a lot of times compliance with medications as we prescribe 'em is huge. A lot of patients basically tell me that they don't tolerate narcotics very well or they get nauseous after every surgery because they were just treating with narcotics. And to me, the most important part of recovery is the right medication management. So we really rely on NSAIDs and Tylenol to provide the mainstay of patient's pain control. And most patients are not aware how effective those are. If you take Tylenol on a regular basis every six hours, and if you take something like Celebrex or ibuprofen on a regular basis every six hours, those medications work exponentially better than a single dose of those medications would. And in most cases, after a major surgery, once they kick in after three or four doses or five doses after, they reach a steady state in your bloodstream, they work all the time. Most patients don't have a need for anything stronger like the narcotic, like the oxycodone. And that's good because oxycodone is the one that has all the side effects. Patients who rely on the oxycodone for pain control get initial pain control, but then they get all the side effects that kind of start building up within a day or two. They're miserable, they're groggy, they're nauseous, they're vomiting, they're itchy and constipated and all those other side effects that narcotics provides. So my goal is to use that as a rescue medication early on, but to rely on the other safer medications to kick in. And after two or three days, most patients voluntarily do not take any more narcotics because they just don't need them. But explaining that to the patient and having them really understand that is key, and most of 'em are on site, are on my side. Once they experience that recovery and the recovery tend to be much easier, much more smooth because you're not adding a whole slew of side effects to your surgery to deal with.

Monique Ramsey (13:14):
I think that methodical approach is so important too, because patients will think, oh, I don't need it, and then all of a sudden they do really need it and if you stay ahead of the pain. And so I think having that where you're taking the time to explain why am I saying this? I'm one of those patients, I want to know why. If I understand why it's easy for me to do it, then I can make that connection. So I like the fact that you can help think about their comfort and their healing from a pain management point of view. Is there anything else that you kind of do that helps them in that postoperative period?

Dr. Swistun (13:55):
Yeah, I mean, so the thing you mentioned is very important as to why. If patients understand why they're doing something, they are much more likely to do it. And it takes a little bit of extra time to explain that. Instead of a doctor saying, just take this and call me in the morning, I say, I want you to take it because this is how it works. And the patient's like, oh, I see. I understand. Okay, now I'll take it. The compliance goes up dramatically, but it does take a little bit of more effort on my part to take that extra step and explain it. Other things, we talk about garments. I just want to make sure that the garments are not too tight. Sometimes pain just comes from garment being too tight. And the other things patients don't really know is that swelling is maximal 48 hours after surgery for most surgeries, especially big body contouring surgeries.

(14:42):
So a garment that is fitting perfectly on day zero and one may not be fitting perfectly, maybe too tight on day 2, 48 hours later when is maximally swollen and that tightness can chave into the skin, can leave skin marks or even compress certain areas and can cause a lot of pain. And then patients start taking more pain medications and then they get side effects and blah, blah, blah. So just being on that page, understanding and forming them. So that's another tip definitely that especially in plastic surgery where we do use a lot of garments, something to be aware of. And the third one is just don't do too much too soon. A lot of my patients are actually very comfortable after a major surgery because of our approach with medications. And a lot of our patients are very busy in their lives and it's hard for them to take some time off and maybe they have two or three kids and maybe their husband took the time off to help them in the early first couple of days, but now they're back to work and the patient's alone, and maybe it's like week one, week two, and now they want to get back into their activities or maybe start cleaning up because nothing's been done for two weeks and we had to warn them that they're still in a fresh post-surgical period.

(15:55):
And just because they're feeling awesome doesn't mean that they should be doing everything or lifting the heaviest objects or going shopping and bringing in all their groceries because these are the things that lead to sudden complications that we're not expecting like a hematoma or seroma or things like that. But again, just keeping that patient informed, those will be the big tips to a better recovery. Compliance with medications, making sure garments are not too tight early on and don't do too much too soon.

Monique Ramsey (16:23):
That's the biggest temptation. We're all such doers and we feel guilty if we're not doing something. And so having that kind of like I'm saying this for a reason, and even though you feel better doesn't mean you're healed and that your body isn't done doing its job in the area, the surgical areas. And so I think that's a huge one. So into sort of more the holistic idea of treating the whole patient and not just this one body part, tell me a little bit about any partnerships or collaborations you have with naturopathic doctors.

Dr. Swistun (17:05):
So yes, I think treating the whole patient, not just a specific area. Really, you really see that in the context of breast implant removal in my practice specifically. The biggest collaboration actually we did today, this morning earlier on, we did a podcast with my wife who's a clinical psychologist. So how is psychology related to having implants? Turns out it is anxiety, a sense of wellbeing and even sleep and how implants can affect your sleep are hugely impactful. And we had an expert in that field comment on this for the last hour, and that's a great podcast that I can't wait to until that drops, but that's an example of one collaboration with a different specialty. On my part, I also collaborate with other medical doctors such as dermatologists, such as orthopedic surgeons such as rheumatologists and immunologists about a lot of these nuances that we see for us.

(18:05):
For instance, having large implants under the muscle does affect the musculature, the posture, but also the way that the muscles sit on your entire shoulder. And there are orthopedic surgeons that have offered a solution to do a spinal fusion to treat that rather than recognize the fact that the patient had implants. Sometimes the patient doesn't even volunteer that because they don't think it's relevant, like, oh, they're just implants, it's a cosmetic surgery, it's not a real surgery. Well, guess what? It does impact your entire back, your muscles in the back get impacted by an implant under the muscle in the front. So a lot of times we've explanted and the patients had subsequently canceled their orthopedic surgeries because their symptoms went away. That's amazing. So corroborating with orthopedic surgeons is something I try to do. Dermatologists, same thing. There's lots of rashes that sometimes are unexplained and patients get treated with all kinds of medications and long-term steroid use just to try to keep rashes under control.

(19:00):
And then we explant and the rash goes away. We have very well documented cases of that. Obviously rheumatologists see a lot of autoimmune diseases like lupus, ulcerative colitis, a lot of thyroid disorders, and a lot of those tend to self-correct as well after we explant. So trying to reach out to them is a big deal. With regards to specifically naturopathic doctors, they are great because they also have a very overall lifelong holistic approach to the patient, and they really try to optimize the whole environment that the patient is in with regards to their diet and supplements and exercise and just good living. Interestingly enough, I've had a lot of having opened some of these relationships, some of the naturopathic doctors are very thankful that we have this relationship because they themselves have run into that same barrier. Basically they say, they told me, I know the patient has implants and I think the implants may be affecting them, but I don't know how to tell the patient to get their implants out because it's not really my job.

(20:08):
I don't put implants in or out. I don't know anything about implants. And then patients are attached to their implants and maybe there's a concern, what am I going to look like after I get my implants out? So I don't even have that conversation because I don't know how to, and I told the doctors like, well, I'm happy to have that conversation with them. They may have options they don't even know about. We can explant and do a lift and that result may be way better than they expect, and I can show them pictures of that so I can evaluate them and just really guide that conversation. And they were super thankful for that. It's like, oh my god, yes, if I just give that to you, I just think getting their implants out will really, really help. So it's really a two-way street, but again, it's all in the interest of optimizing that one patient's overall outcome.

Monique Ramsey (20:52):
Well, and I love that nobody feels above, we're there for the patient, not like, oh, I'm the expert here and I'm the expert there. It's like, okay, how do we get this patient today in the best situation going forward for her life or his life, not with implants maybe, but other cosmetic procedures or body contouring that you're doing for men too.

Dr. Swistun (21:19):
I suppose it takes a little bit of humility to give up some of that control. But I mean, I recognize that there are things that other people do that I'm not an expert in that can definitely help my patients and vice versa. And that collaboration is I think very key.

Monique Ramsey (21:33):
Alright, so when you were talking about detoxing after implant removal, how do you guide them through that in a safe way or how do you even talk about that topic with them?

Dr. Swistun (21:47):
Well, it comes up a lot. There's a lot of patients, how do I optimize my recovery after my implant removal? How do I detox? And I admit that this is sort of right outside of my expertise. I mean, I don't know enough about that. So for a long time I was actually a minimalist about it. I do believe that removing the implant is sort of the biggest step in your detox. I mean that implant, the silicone shell or that ruptured silicone gel inside of your body can cause an autoimmune inflammatory response and that propagates things. So just getting that implant material out of the body is probably the most important step in your detox that you can take. But that said, there's lots of other things that we can optimize. Maybe patients are some, even if they're not nutritionally deficient, they may be deficient in some specific vitamins and things like that.

(22:35):
So my approach is pretty minimal. I typically say is make sure that everything else is good, your nutrition is good, maybe supplement some protein while you're recovering, but let's just let your body catch up to this big step we just took getting the implant out and then see what happens. And if three months later, six months later there's still something left over, then we can focus in on that detox. So that was sort of my approach for a long time. And having now recently spoken with a few naturopathic doctors, I think they sort of confirmed that. I think they were able to add a little bit more of their own expertise to the picture, just maybe, well, that's true, but maybe let's put 'em on this supplement and that supplement because that will sort of optimize how their circulation or their healing or maybe the lymphatic system.

(23:27):
If somebody has ruptured a silicone ruptured implant, and I've noticed that on a few occasions, their lymphatic system on the side of the ruptured implant can get a little bit clogged, a little backed up, so they get more swelling on that side. So somebody that does lymphatic massages really key in our recovery because they can focus on that area and guide that swelling out a little bit better. There was one naturopathic doctors that also offered acupuncture for that same reason or cupping, which I didn't even think about, but she said, while cupping can expand the interstitium and therefore help with the lymphatic flow, so if you have that situation where you think there's micro silicone particles in that lymphatic system that need to be cleared, this can accelerate the process. And I did not know that, but I do now. And this is another reason that we love to collaborate with them.

Monique Ramsey (24:20):
And I think putting a little flag of caution from the patient's side, talk to Dr. Swistun about it. Don't just go off and do it with anybody who might be a expert or self-proclaimed expert in cupping or in anything. I think that's a good, when the patients know that you're on their side and you're going to be open to that discussion because some doctors don't want to talk about anything in the natural realm of medicine. Some MDs are not comfortable going over there. It's like quack medicine to some doctors. So I think the patients, even knowing that you're open to that, there's other things and other interventions and let's just make sure we go about it in the smartest way for you. And again, there's that concierge concept, not just for everybody for you and what you're experiencing right now and how to optimize that recovery process for you to get you to the goal that you have.

Dr. Swistun (25:22):
Yeah, I mean, again, I think it just comes down to a little bit of humility is that I recognize that I don't know everything. And there is lots of things that even science doesn't know that works. And maybe we'll find out in 10 years based on some landmark studies like, oh, you know what? This Chinese medicine trick that they were using that works all the works for so many years, this is how it works. This is now, we know why. That happens all the time. So again, I don't discount other specialties. I actually find them very valuable. And I've seen so many patients have very, very positive outcomes from those interventions. And you just can't dismiss that. You have to include that in your care.

Monique Ramsey (26:01):
And over time we talk about you start to see patterns and you're like, oh, wow, I never would've thought getting somebody's implants out, it's going to help with their sleep or help with anxiety, reduced anxiety. Yeah. So part of your practice is focused on women experiencing breast implant illness or BII or BIAI breast implant associated illness. What extra steps do you take to help them feel heard and validated and cared for?

Dr. Swistun (26:36):
Well, I think we just spend the time to talk about it. And my consults are typically scheduled for an hour and a half and frequently they run over that. And the reason is is that because I really want to understand where the patient's coming from and see what their concerns are. So I ask 'em a lot of questions about what are their symptoms, why are they here, what do they think is happening? And then I'll ask 'em a lot more pointed questions. Also, how is your posture? How is your musculoskeletal, so how is your breathing? How's your sleep? How is your anxiety? And then also if there is any autoimmune disorders that you think, have you seen any specialists like rheumatologist or endocrinologists for some diseases that may have crept up over time? And then once I get their full story, then I sort of offer my experience in like, well, this is a situation that I've seen on a lot of patients and this is the consistent outcome on the other side of the surgery when we explant it. The whole conversation takes a lot of time, but it's very, very validating. Spending that time is I think the biggest key.

Monique Ramsey (27:40):
Well, and I know that you do that because I see people's reviews of you, and if they go review you on Google or they review you on Yelp, I respond to all the reviews and thank them, but I'm seeing what they're saying. And so I know you validate them, and I know that you do all the things we're talking about on this episode because the proof is go over and read these for yourself and see those reviews. And I see them every day. And so that says so much about, I mean, people could go in and they could give you five stars and not write anything, but they don't, they write big paragraphs of how you impacted their life in a positive way. And I think that's such what a wonderful business to be in or what a wonderful specialty and job that you have. Not everybody gets a job like that where they get to make huge positive differences in people's lives.

Dr. Swistun (28:43):
Just to add to the final word on what you said before is just I think the way I just practice medicine is how I want to be treated or how I want my family to be treated and this is just the right way to do it. And I think this felt right for me, and I never thought this was something special or something that has a label of concierge on it, but if that's the case, then so be it, I suppose. But yeah, I think that's where it's sort of evolved into.

Monique Ramsey (29:09):
So into kind of that emotional and physical recovery. I mean, it makes sense that you come in for your post-op visits, you as the surgeon are assessing the physical recovery and what's going on and what their body's doing. But the emotional recovery too, do you help walk them through what to expect on an emotional level?

Dr. Swistun (29:34):
I think we do prepare the patient for what to expect, and I think that's, if they know what to expect, then it's a much better experience because it's not a surprise. There is pictures I have of patients during certain procedures during the recovery process. There is one that I have where I did 360 liposuction with fat grafting and I have pictures of that same patient from multiple angles on day four from recovery. And they week later, three weeks later, two months later, and then four months later, and you can see this gradual progressive change. So when a patient comes into you two days after surgery completely bruised up and swollen and thinking like, oh, this is the worst thing. Why did I even do this? I was perfectly healthy. And look at me now, I will tell them there's a goal at the end of the tunnel. Look, this is the picture of somebody that went right through this. This is where you are now four days out, this is what they look like. They actually look worse than you look better now. This is what they look like four months later. See traumatic difference. And now look at the before and after. This is where you started and this is that final result. It'll be worth it. Trust me, bear with us. We'll take you through this. We'll hold your hand through the entire process.

Monique Ramsey (30:42):
Yeah, I think having that emotional support, it's one thing to say, okay, today we're going to change your bandages, or today we're going to put new steri strips or tomorrow you can shower. But just I guess the emotional part of it and acknowledging that and helping them get through it, get through it. The only way, what did I say? The only way out is through? The only way to that pretty four week picture where you get to go shopping is through this time and you'll get through it.

Dr. Swistun (31:13):
Yeah, it'll be worth it in the end, but we'll get you there.

Monique Ramsey (31:17):
So anything else about this sort of lifelong aesthetic health or concierge concept that you want to talk about?

Dr. Swistun (31:25):
The only thing that I was thinking is when we talked about some of this is the reason that we're doing this podcast is to sort of make sure that we express to the patients where we're thinking about removing their implants, that we are a little bit more inclusive, specifically I am just to get that across. And one of my only concerns is that early on when I was talking about this whole lifelong approach is I was talking about the implants being put in, which is a part of everything. I rarely put implants in, but when I do, those are patients usually seek me out for that because they know I explant more than anything. So they think that I'll be aware of all more of the complications and what's life on the other side of that. So they want me to help them make the right decisions of what implants to put in.

(32:14):
So it's a rare situation for me, but it does happen. And the reason that I sometimes talk about breast implant placement is because I do have experience of what patients say after they've had those implants for a long time. So a lot of my experience, what can go wrong? What can happen if you put implants that are too big or if you put 'em under the muscle in an athlete, there are consequences of that. So that gives me that knowledge and understanding of how to guide a patient on the beginning of that journey. For instance, that's not something that I do frequently. I rarely put implants in, but when I do, it's usually a scenario where a patient is aware of implants potentially having caused problems in other people. They still want implants, but they are now very cautious about 'em and their approach is very different and they want to do their research and also make the right decisions, and they want me to help them through it because they know that I explant a lot and I've seen all the complications and they want to be screened for breast implant illness. If I get implants, will I get breast implant illness? Will I get inflamed? And stuff like that. There's no real good screening for that. There's no magic test for it. The only clue is that if a patient has a family history of autoimmune diseases, then they are more likely to respond or react to a for an object inside of them. But that's really the only sort of correlates.

Monique Ramsey (33:36):
Well, and I think that leads also to women who, and we're about to be following Laura Cain's sister Jennifer, and so we're having her on the podcast and following her surgery. So she has implants and has maybe, I don't know if she has a capsule or she's having pain, and she was thinking, okay, I'm going to have them out, get this capsule fixed and put new implants in. And I think you coached her through and talked to her about her options and you're going to do not another implant, an auto augmentation. Do you want to talk a little bit about the patients who already have implants and maybe they're not having any BII symptoms, but they're having capsular contracture and it's time to do a remove and replace, but maybe you don't need to replace it.

Dr. Swistun (34:30):
Yeah, so that's actually a very good example of tailoring the surgical approach, lifelong aesthetic health. How do you tailor care for each patient so it feels personal and not cookie cutter? Laura Cain's sister is the best example of that is because, because she came in basically asking for a remove and replace. She basically said, my implants are old, I think there is a contraction on one side. It's painful. But in her mind, the only solution to that was putting a new implant in. And then we examined her and then we examined how much breast tissue she has, and I said, well, another option for you would be to just get the implant out and get the capsule out and maybe rearrange the tissue that you do have into a better shape. When she said, well, I don't have a whole lot of tissue, but when we examined her, the reality is that most women gain breast volume through their lifetimes with a little bit of weight gain throughout their lifetimes with the fact that if went through menopause, there is hormonal changes that actually induce glandular hypertrophy.

(35:29):
Most women have a little bit more breast tissue than they think later in life. So I actually showed her pictures of what I would expect her result to be without implants, and she was like, oh my God, if I can have that without implants, I'll take it. And I was surprised because I thought this was more of a conversation like, this is another option for you, but we're happy to put another set of implants in if that's what you want to do. But she was like, no, well, what are you talking about? Why would I even do that if I can have that result without implants? Let's just do that.

Monique Ramsey (35:58):
Right? Not have to think in 10 or 15 years that you have to do another thing, because that's part of that lifelong approach, I think, is like if you put something foreign in, it's going to be with you for a while and you might have to change it out. It's not a forever thing, whereas your own tissue is your own tissue, so it's there forever and you're going to help reposition it into the goal of that fullness and maybe that lift and hopefully pain-free too.

Dr. Swistun (36:26):
Yeah, no, that's exactly the right thing. Whenever a patient is at that crossroads, I have implants. I know they have to come out. I'm at a crossroads. Do I put another implant back in or do I take it out? That is an excellent opportunity for me to intervene because there's no right or wrong answer here. It just depends on the goals. But if you put another implant in, you are automatically signing up for another surgery in your lifetime later on to get those implants out, because a shelf life of an implant is shorter than anybody's lifespan. I don't care what age they are. I've told that to 70 year olds.

Monique Ramsey (37:01):
Well, thank you, Dr. Swistun. This was just a super interesting episode. I'm glad we did it. We haven't talked, we've talked about a lot of things in the past, but we haven't really talked about this approach and your philosophy, and so I'm glad we were able to do that.

Announcer (37:15):
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