Speaker 1 (00:07):
You're listening to The La Jolla Cosmetic Podcast.

Monique Ramsey (00:15):
Welcome everyone, I'm Monique Ramsey, your hostess. And today we're talking with Dr. Luke Swistun, about what happens just after explant surgery or breast implant removal surgery. So your implants are out and maybe we're on day one of recovery, not just from surgery, but really from having those implants and maybe if you weren't feeling good and that's why you wanted them to come out. So Dr. Swistun, how many people have you helped with an explant surgery? Just a ballpark.

Luke Swistun (00:44):
We haven't been keeping track, but it's by far the most common surgery that I do. I think 60%, 70%, 80%, depending on the month, of what I do is an explant usually with a combination of something else. So it's in the hundreds, it maybe reached 1,000 by now, I'm not really sure, but we should probably start counting because it's not an uncommon question, but it's certainly something I do more of than anything else.

Monique Ramsey (01:08):
And if we're a patient and we want to prepare ahead of time to help everything go smoothly, what do you suggest?

Luke Swistun (01:16):
Well, it's a surgery so the common things that are important is a support system that you have available for you after the recovery. Usually it's family members, sometimes if it's a more extensive surgery, if there's people that have a nurse in the family or a health provider in the family, that always helps. If you have kids, if you have pets, if you have animals, these are things that you consider. You probably want to have somebody there for a week or two helping you out, especially if you have a clingy child that really wants you and no one else, plan ahead for that.

(01:48):
The other big thing is there are some people that have specific problems that they may have encountered with previous surgery. A common one is nausea, there are certainly steps we can take before surgery to try to mitigate that as much as possible. So that's a discussion that we have pre-op and with me certainly in the consultation encounter.

Monique Ramsey (02:08):
Yeah, I think that is something for those of us like me, who have a little queasy stomach after surgery, it's nice that if there is something, speak up, tell them and they can help.

Luke Swistun (02:20):
Exactly. Ironically, most patients are not afraid of the surgery itself, but more the anesthesia and the immediate post-anesthesia time and we can definitely address that. If you are doing breast surgery, if you're in the appropriate age for breast cancer screening, we need to get that out of the way prior to your explanation because we don't want any surprises in the operating room, we don't want to change our management midway when you're asleep and make decisions on your behalf. And the best way to minimize those chances of that happening is to have your breast cancer screening done at the appropriate time when indicated so that we have the least likelihood of a surprise during the surgery. The one thing that a lot of patients ask about with screening is there's a lot of patients that are hesitant to get a mammogram with implants. Couple reasons.

(03:06):
Number one, they're painful. Number two, they expose you to radiation. And number three, they have been known occasionally to actually rupture an implant. Keep in mind, you can always ask for a different modality. Now not everybody can accommodate this, but you could ask for an ultrasound to screen for breast cancer, which is painless and there's no radiation exposure with ultrasounds and it won't rupture your implant. But if you identify yourself to your primary doctor as the patient who does not tolerate mammograms, then they can request an ultrasound instead, which again is perfectly appropriate. And then they might cover it if you give them a reason, you could say, "I don't tolerate mammograms because they're just too painful, I can't do it, but I need to be screened, what else is out there?" Ultrasound is the answer.

Monique Ramsey (03:52):
That's really good to know, I never knew that. Because mammograms aren't-

Luke Swistun (03:56):
Comfortable.

Monique Ramsey (03:57):
They're not comfortable, yeah. They're not a ton of fun, but they're really important so I think that's nice to know that there's an alternative. So when I just come out of surgery, I wake up, where am I going to be and who's there?

Luke Swistun (04:12):
So you're in recovery in our La Jolla Cosmetics Surgery Center, your nurse is going to be there, I'm going to be there, I'll be in and out, just checking up on you, the anesthesiologist will also be there making sure that you're recovering well. Typically, you're in recovery for about an hour or two depending on how you're doing, depending on how long it takes for us to get you comfortable. And once you're ready to go home, it's usually a family member that picks you up or somebody that's a designated caretaker of your choice. A lot of times patients just go straight home from that, we actually have quite a number of patients that come from out of town, so they typically stay in a hotel nearby just to make sure that they can be close by for the immediate recovery.

Monique Ramsey (04:54):
So for those people who do travel, how much time do you want them in San Diego?

Luke Swistun (04:59):
One week is probably great because it really gives us an opportunity to make sure we get you out of the woods for any potential complications. Now that said, the complication rate for this particular surgery is extremely low, we really do well, but we like to hold our patients hands through the recovery. All my patients have my cell number, we text back and forth directly. If I'm operating, then they can text the nurse as well or just call the center, but for the most part we just communicate and we like to talk to you the next day. So typically when, let's say you're in a hotel post-op day number one, I will call you directly and I'll make sure that your pain is under control, the drains are working, everything is doing well and if you have any concerns, you can actually come in that same day.

(05:39):
But that's almost never been necessary, most patients are just like, "Okay, this is what I expected, everything is good, pain is under control, let's just rest." And then we will see you in person the next day just to make sure everything is working well and make sure that the dressings are fitting nicely and go over a lot of the detail of what to expect for the next week and the next couple of weeks. And then a lot of patients leave after that meeting, that's usually enough, if there're any complications, most of the major ones, if any, will happen within the first couple of hours after surgery. So again, that's very rare, but if it does happen, we really will identify it on that first visit.

Monique Ramsey (06:15):
What things might that be? Even if it's rare, what are the things that people might notice?

Luke Swistun (06:21):
Sure. So the most common thing that we want to make sure is not happening is a hematoma, which would be continued bleeding after the surgery. I've seen this about twice, on one occasion it was a patient that literally sustained trauma afterwards. She basically was woozy and bumped her breast on the side of a counter and then the breast started bleeding a little bit more. And this is several hours after surgery, so that's something we had to deal with. And then there was another patient that was on blood thinners that she didn't disclose to us. So there's reasons for that, but it's my job to make sure this doesn't happen. I'm very meticulous about checking for ongoing bleeding in the operating room before we close the incision. So this is a very big rarity, but nevertheless, that is the question to ask the next day.

(07:03):
And if that was to happen then it would be pretty obvious, it usually is one breast that fills up with blood and it looks like we didn't even take the implant out yet and it's very asymmetric and very obvious. And then we might have to take you back to surgery to evacuate the blood and potentially cauterize the bleeding source and close up again. Another complication that could happen a little bit further down the line, which is usually several days to a week out, maybe even two weeks, it would be a very small local infection. Sometimes it's around the drain, sometimes it's around the skin and that would warrant maybe an antibiotic treatment to mitigate that. A lot of times, again, even if that's noticed, we can manage that remotely, but a week would give us a really good springboard to mitigate most of these problems and send you home at that point.

Monique Ramsey (07:50):
Now you talked about drains. So you have drains, can you explain the placement of those and why are they there and how long do they stay in?

Luke Swistun (07:59):
Yeah, good idea. So very common question. I do use drains for all of my explant patients so if we were explanting only or if we were doing an explant and a lift, what we do is I like to take out all of the scar tissue around that implant whenever I do this, so that's called an en bloc capsulectomy. There are various reasons why that is a good idea in my opinion, but we could get into that at another occasion. But bottom line is we take the scar tissue off of all of the surfaces that it's attached to, the capsule is attached to the muscle, to the chest wall and everything else. So shaving that off of those surfaces will create a little bit of oozing in the raw surface areas and that empty space where the implant used to be will collect that fluid if you don't do anything else.

(08:44):
So the drain is there to basically remove the fluid as it happens, as well as provide a little bit of negative pressure, a little suction to keep the breast tissue against the chest wall so that everything heals just a little bit faster. So I've noticed that patients actually heal a little bit faster in the long run if we use the drains. Most patients actually feel a lot better after we remove the implants, they feel lighter, if there's any specific ailments or pains or aches, a lot of those resolve fairly quickly and they just report soreness, like if you went to the gym and overdid it, not that bad. And usually ibuprofen and Tylenol over-the-counter medications are enough to control the pain. Now we give you something stronger in case you need it, most people don't use it.

(09:27):
And the drains are basically the only thing that they report is a little bit annoying, it's a little bit of a nuisance, it's really where they have the pain just because the stitch holds are in place. It's not a constant, ongoing pain, but that's really the only thing they feel. And once the drains are out, then that's a big milestone for them because now it's like they're feeling better, the drains are out and now they're ready to conquer the world most of the time.

Monique Ramsey (09:49):
And so is it always the same for someone, day three or day seven or is it more based on the output, I guess?

Luke Swistun (09:56):
Yes.

Monique Ramsey (09:57):
What's in the little bulb? I've seen the little bulbs and you have to count how much stuff is in there and make a log. So what are you looking for and maybe for most people, when do they get to have those drains out?

Luke Swistun (10:11):
So the output is what we look for. So for me it's about 30 ccs per side, per day, per 24 hours or less would qualify to remove the drains. And most people get there within five to seven days, sometimes they have to stay a little bit longer. But again, that's very unusual, 95% of the time they come out within a week.

Monique Ramsey (10:33):
Okay. And so once you're at home maybe that first night, what do patients experience? Anything? Since you're texting with them, you probably know, are they sleeping or are they just-

Luke Swistun (10:48):
Usually they just sleep, yeah. I mean, I want them to maybe get up and walk around just a little bit just to get the circulation going in their legs, that's by far the best method of preventing blood clots from forming after surgery. That said, again, this surgery is extremely low risk for blood clot forming, so that's almost never a concern, but it's a good idea to just walk around a little bit, 15 steps around the room, 15 steps around the house is plenty. Going to the bathroom and back, going to the kitchen and back is plenty.

(11:16):
And then just start taking the medication on a regular basis for pain. Works better if it's taken on a regular basis every six hours because it builds up in your system and eventually starts working all the time and that's when people feel most comfortable and they don't even reach for the strong stuff and just take it easy, get some sleep. It really takes about 24 hours for the anesthesia gases to clear out the system and a lot of patients basically say, "I felt much better the next day, I felt much better the next afternoon." All the nausea's gone by then and they're just feeling back to normal again.

Monique Ramsey (11:49):
Now the patient comes in the next day, you're checking them to make sure everything's looking good and progressing normally, at that point would they get to see their results or are they still bandaged up? Or maybe the better question is, when's the big reveal?

Luke Swistun (12:05):
So usually we talk on the phone the next day, but they usually come in the day after that just because I just let them relax and just stay at home for the day immediately after surgery. The day after that, we take down the dressings and some patients like to look, some patients don't, that's certainly not when we see the final result. In fact, if we do a lift then the lift is almost always intentionally overcorrected because we need to account for gravity over the next six months. I've never met any patient that has beaten gravity in the long term, everybody loses to gravity so what we need to do is make the incisions and make the suturing in a way that it's just a little overcorrected and a little bit tight on the bottom because I know that over time, once that scar relaxes and loosens and matures, then that breast will fall.

(12:55):
So when you take the dressings off on post-op day number two, the breast almost looks like it's on upside down because most of the volume is above the areola and the bottom of the breast is pretty tight. And that's exactly how I like to see it on that day because I know that over the next six weeks to six months it'll drop and then the bottom part will round out and give us a nice beautiful contour on the bottom and then the top part will settle out behind the areola and it'll be a nice breast shape overall. If they looked perfect on day one, then I will be worried because they will bottom out in six months.

Monique Ramsey (13:28):
And how many people need a lift? Does it depend on how big the implants were originally or?

Luke Swistun (13:35):
Yeah, there's a lot of factors. A lot of it is genetic, but a lot of it is how young the patient is and how big the implant was and how much breast tissue they had of their own. We look at skin quality and the age of the patient to see how much the breast will retract. So if it's a younger patient and let's say they had one or two pregnancies and they have no stretch marks, that to me indicates that they have pretty good skin quality. So let's say their implant was pretty small, maybe 300 ccs or less and they had a lot of breast tissue of their own, they started off with a pretty large B maybe, that's the patient that is pretty likely to settle back down to a normal original breast shape, which would be the best case scenario after an explanation to keep a good youthful breast shape.

(14:17):
Most patients are not like that, I would say that's about 20% of my patients. In general, 80% of the patients come in a little bit later, maybe they're a little older or maybe they had two or three implants throughout their lifetime that were exchanged, maybe they had two or three kids that they breastfed, maybe they've gained a little bit of weight. All of those factors will induce the breast skin to grow to accommodate for that extra volume. And then when the skin grows 20 years, 30 years, the skin does not shrink back to the same extent when the volume is removed so then some corrective actions have to happen in order to restore that breast shape. And usually it's basically techniques to remove the extra skin and restore the natural breast shape, just basically tighten the skin envelope around the remaining volume and that's what a lift basically does.

Monique Ramsey (15:05):
And at this point, if somebody wanted a fat transfer to the breast to give it better shape, is this something you do at this point or is this something you wait till full healing and then decide if it's appropriate?

Luke Swistun (15:20):
Again, depending on the situation, most of the time I actually like to wait because fat grafting is a little bit unpredictable. It's a great modality to basically fill out an existing cup size. So patients who get fat grafting typically have a little bit less breast tissue than they desired to begin with. We do a lift and we get a really nice shape, but the shape still looks that it's not really full, let's say we can give the patient a B cup, but it's a B cup with a little bit of a deflated upper pull, they just don't have a lot of breast tissue there. So the intent of fat grafting is to not really to give them a bigger cup size because only implants can really do that, but fat grafting will basically improve the appearance of their existing cup size. So it'll be a fuller B rather than a little bit of a deflated B, with better roundness, better cleavage area and things like that.

(16:11):
I like to wait about six months after the tissue has settled out in order to do that because number one, it's a lot more predictable, sometimes immediately after surgery you don't know how much the skin is going to shrink, how much the shape is going to change and how the symmetry is between the right side versus the left side because of swelling and because of different factors. At six months you'll know exactly how the breast is going to look for the rest of the patient's life and that's when we can be a lot more precise in targeting the fat. Maybe one needs to be a little bit bigger, but one needs a little bit more fullness centrally and so on. So we can do a lot more precisely a matching procedure between the right and the left side and really target the fat where it needs to go. If you do that anytime before that, it's more of guesswork.

(16:52):
The other thing is if we're doing a lift, then the lift itself does carry a little bit of consequences with regards to blood flow to the breast and we do not want to compromise blood flow to the breast tissue, especially the nipple. So a lot of times the lift itself is already a surgical stress and if we add fat grafting to that area, then we are running a higher risk of maybe compromising those blood vessels that we're really relying on for the blood flow to the nipple. So that would be another reason to delay the fat grafting to another opportunity six months later once everything's healed.

Monique Ramsey (17:25):
That makes a lot of sense. Minimize risk, obviously, but then also just waiting to see what you're left with and you might be really happy and have thought, "Oh, I wanted more," but you didn't or you might have more than you thought.

Luke Swistun (17:38):
Exactly. And that's actually a very good point. Most patients will inquire about the fat grafting because they think they don't have a lot of volume, but the lift is a really powerful technique. I would say 80% of the time when we talk about lift and fat grafting, the lift is enough, the patient comes back later and says, "That's really all I needed, it's just a lift because it really gave me the shape that I wanted and I'm very happy." It's unusual for the patient to actually want fat grafting after a proper lift, but it's definitely an opportunity if that patient does need volume afterwards.

Monique Ramsey (18:10):
Yeah. So when would a patient be able to lift things? Or if they have a two year old, pick up her kids or lift her arms above her head, what are your restrictions?

Luke Swistun (18:23):
So I actually encourage range of motion stuff early on. I mean, for the most part when I do the surgery I'm very careful about preserving the muscle. Most of the time I dive underneath the edge of the muscle so I don't cut the muscle so the muscle is intact but it's just sore from the capsule being removed from it. But there's nothing that precludes you from lifting your arms above your head other than how you feel. So I tell the patients, "Just listen to your body and if you can comfortably reach for a high cupboard or wash your hair, that's okay. If it feels a little bit too tight, then just wait a little bit." For lifting things, I just like to have them be a little bit less active until everything heals. So I tell them, "Don't go grocery shopping week two, week three, even though you want to because you'll feel lighter and better and you just have so much more energy."

(19:10):
And then if it's a mother of two or three, then the laundry hasn't been done in two or three weeks and then they just want to catch up with it. But I say, "Just take it easy for two to three weeks." Lifting kids depends on how big they are. If it's a baby, then I say it's the unpredictability of lifting a baby that worries me more than the weight of the baby itself. So you can lift a gallon of milk because you have control over that, but if you're lifting a baby, what if it wiggles? What if it kicks you in the breast? Or what if it tries to fall out of your hands and you have to catch them? I like my patients to be a little bit risk averse so for that reason, if you can have some help for the first two to three weeks, that would really help, after three weeks it's probably fine.

(19:51):
It really takes about two to three weeks for that breast tissue to seal back down against the chest wall and for that empty space to be obliterated. And once that happens, then we're pretty much good. So at three weeks, I tell patients, "Start doing non-impact, lower body exercises." A stationary bike would be the perfect example and start real slow, maybe do 10 minutes the first day and then take a day off and observe and if there's no swelling or anything unusual, then double that the next day and then go on and so forth and then get up to your normal non-impact routine over the next two weeks. And that takes us to week five and at week five you can do the same regimen with impact exercises such as jogging or upper body workouts such as lifting weights and stuff like that. And again, start slow and then go up from there. And around the time of six to eight weeks out, most people are pretty much fully healed and back to their normal activity.

Monique Ramsey (20:45):
Do you have certain rules about bathing as far as jacuzzis or the ocean?Because there are organisms in things, if you take a bath, you go to the jacuzzi, go in the ocean, do you have rules about that?

Luke Swistun (20:59):
In general, it's eight weeks after surgery. I think by eight weeks the scars will be matured enough that, that's not going to be a problem. Certainly they seal up way sooner than that, but if it's still a fresh scar, then my bigger concern with exposing it to water for a long time is the water logging. So it's like prune hands when you're in the bathtub for too long. If that happens to a scar early on, that can actually affect the scar in a negative way. By eight weeks out, that's not really going to happen significantly anymore, so you're fine.

Monique Ramsey (21:26):
Yeah, I think that if you're planning your vacation, you want to be thinking about that stuff.

Luke Swistun (21:33):
Yeah. But certainly showering we do right away, I mean, you can shower 48 hours after surgery. If you have drains, typically the instruction is to be very careful around the drains and try not to get too much water around that side. Certainly splashing a couple drops is not going to hurt anything, but don't sit down in the bathtub and expose it to standing water for a long time.

Monique Ramsey (21:52):
Now when you take out these implants, and I know on your Instagram you have a lot of videos showing what that explanted breast implant looks like and that en bloc technique where you're taking out the capsule with the implant as well. Where does the implant go next? Do you send it somewhere to be tested or does the patient take it home or what's that look like?

Luke Swistun (22:16):
Depends on the situation again. So sometimes patients will have a complication within 10 years, let's say there's a capsule contracture or an implant rupture and sometimes they might get a reimbursement for that. So because we're explaining for a medical reason, the patient has an indication for removal, a lot of times the implant company will want that implant back to verify that it is ruptured and stuff and they will actually reimburse the patient for some of the surgery maybe or for some of the cost because they accept responsibility for that complication. In general, the implants are either thrown away, but most of my patients actually want to keep them, which is fine. The caveat to it is if it's a silicone implant that is ruptured, then I don't recommend keeping it because that is just a mess. Imagine just spilling a jar of honey onto your desk and trying to keep that, it's just not feasible.

(23:06):
And then the other thing is sometimes if patients have textured implants, then the textured implants are designed for your tissue to grow into the texturing surface. And a lot of times when we remove them, there's just some scar tissue that's incorporated into the textured surface of the implant and that's just disgusting. So sometimes I can actually try to peel that away, but in the process you can actually rupture the implant doing that. So I actually did a case last night where the patient wanted to keep their implants, she had textured implants and then we went ahead and just cleaned them up as much as possible, washed them in soap, surgical level soap to get all the impurities out. But then afterwards I said, "Look, there's some texturing tissue in there, if you leave it there, it's probably going to start decaying so it's probably not a good idea to keep it for too long, you just look at it and then throw it away." But yeah, a lot of people want to keep their implants and that's fine.

Monique Ramsey (23:59):
Well, you guys can listen to our recent podcast we did with Janelle, you did her explant and she was able to keep them, you guys cleaned them up for her, she went home with them and she uses them as ice packs when she and her husband use them if they have a sore shoulder, there goes the implant to nicely.

Luke Swistun (24:20):
Yeah. I've heard lots of stories that we could do a whole podcast about what people do with these.

Monique Ramsey (24:27):
Now, do you send out the tissue to a lab and look for anything? Is that a normal thing or is that only if something looks suspicious?

Luke Swistun (24:36):
No, so we do, and that's a very good question. Anytime that we remove tissue, I like to send it to standard pathology. It's an opportunity for us to make sure that the patient doesn't have cancer, it's just like any other screening process and it's widely accepted that any breast tissue should be sent out for pathology just to make sure that there's no cancer hiding there. A lot of patients ask about two other things, do we test them for heavy metals and impurities and also do we test them for bacteria or mold and things like that? The answer is typically not. I actually used to do that initially when I first started it just because a lot of patients were requesting that and what ended up happening is that if it didn't look infected in the operating room, if it didn't look abnormal, then it wasn't abnormal on pathology or on those tests and we just ended up spending a lot of money and the labs came back completely normal and it certainly didn't change our management afterwards.

Monique Ramsey (25:28):
Okay. So if there's something that comes back abnormal, is it the lab that calls them or you would call them?

Luke Swistun (25:36):
99.9% of the time. In fact, in my experience, 100% of the time, everything came back as expected. This is scar tissue, it's a little bit of a foreign body reaction, which is reaction to the implant material and a little bit of granulomas, which is a fancy word for scar tissue around the implant and that's about it. If there was cancer or if there was something unusual, they would call me, they would talk to me directly and then I would call the patient immediately.

Monique Ramsey (26:02):
So we've been talking about the physical aspects of the implants, the explants, the surgery around that operating time and the post-op time. But we haven't really talked about, I guess, the mental aspects because a lot of times women are getting a breast augmentation in the first place to feel more confident with their body and so now you're taking those out. What advice do you give to the patients about the mental aspects or the confidence after they get the implants out?

Luke Swistun (26:35):
So again, it varies by patient and this is why my consultations take two hours because we really get to know each other and explore this. But most patients that come to me for an explant made up their mind already that they want an explant and they are okay with the consequences. They know they're going to be smaller, they know that if they don't want to lift, their breast shape may not be ideal, but they're okay with that. Sometimes they just feel that the implants are making them very sick and they just want them out, they just want the capsules out and they'll deal with the aesthetics later. So it's usually not a problem, most patients are pretty much okay with the outcome. Really the only thing that the implants do is they give you volume, not even shape, just volume. So if you can get a really good shape without that volume, just take the volume that you have natively and optimize that, usually that's a win-win.

Monique Ramsey (27:30):
So when the patient's either in recovery or that day one after surgery or week one, what would you say if you were to generalize explant patients? What are they feeling? What's maybe the number one thing that you hear back from them?

Luke Swistun (27:48):
After we explant? Again, it depends on the reasons that we explain. As I get a lot of breast implant illness patients, a lot of patients classify themselves as that even though they don't really have symptoms of breast implant illness because the information on the internet is not very specific a lot of times. And again this is why my consults take one to two hours is because we try to tease out what actually bothers them and what actually do we expect will improve. To generalize the answer to your question, most patients feel a lot better. I think the time when they made the decision to have them is probably a good decision. I mean, honestly I never chastised my patients for them, sometimes they chastised themselves like, "Oh, I was young and silly and I shouldn't have gotten these in the first place."

(28:31):
And I said, "No, that's not true. That was the right decision at the time and that's what you went with, however now you're in a different place and things have changed a little bit and maybe there are other factors that came into play and now this is a new perspective that we just have to explore." So I'm actually going to give you a little bit of a rundown of the big reasons why people feel better. Number one, if you have an implant complication, which is specific to having implants itself, for instance, if it's ruptured or if you have a capsular contracture, which is the scar around the implant tightening up and causing pain or if the implant is simply in the wrong place called implant malposition, those are reasons to remove the implants and those are reasons that people obviously foresee a difference afterwards.

(29:13):
If your implant is ruptured, you're asymmetric, we take it out, you're symmetric again. If you have a contracture, if it hurts, we take out the scar and it doesn't hurt anymore. So local pain and implant complications is a very common reason and that's separate from everything else. Postural problems is another realm of why people get tired of implants. I talk a lot about patients who are born with large breasts, who have very specific complaints consistently. Patients who are born with large breasts are considered symptomatic macromastia patients. So those are patients who have back pain, shoulder pain, neck pain, shoulder grooving from bra straps and sometimes tension in their neck and then tension component migraines because of this constant weight of their breasts on their front of their chest. And a lot of patients who have implants, especially for a long time, especially who have gained weight, especially who have breastfed, they put themselves in that same category.

(30:05):
So macromastia patients get breast reductions and they all feel better. Patients with large implants can get an explant and a lift and they will also 100% of the time get those same benefits. The neck pain improves, the posture improves, the shoulder pain, shoulder grooving, that improves, they feel lighter, they feel more energetic, they can sleep better at night. That's another thing that I just recently noticed that patients report to me, it was a very interesting observation that I've starting making. And my wife is a clinical psychologist with a sleep specialty so she actually compares them to sleep apnea patients. But if you have large implants, it affects how you sleep and affects your comfortable position of sleeping. So I had lots of patients who told me that, "Before I got implants, I loved to sleep on my stomach but since I had my implants, they're pretty large, I can't sleep on my stomach anymore, I sleep on my side or on my back and I hate sleeping on my back, I never get a good night rest and I don't really dream."

(30:58):
And then after we explant, a lot of patients told me, "I started dreaming again. Well, what does that mean?" Well, if you're dreaming, you're in REM stage four sleep, which means you've reached stage four after stage one, two and three, which is a restful part of sleep. They're finally sleeping normal again. Which leads me to the musculoskeletal consequences of having an implant under the muscle, which is a lot of patients, again, the most popular place to put the implant is under the muscle because it limits the amount of capsular contracture and it looks more natural, especially on thin patients. But if you put an implant underneath the pectoralis major muscle, that affects your shoulder balance, the shoulder is balanced in the front by the pectoralis complex and the back by the scapula muscles, the Rhomboids and things like that. And in the center of the shoulder is the rotator cuff that holds it in place.

(31:47):
And if you put a lot of volume underneath the pectoralis major, the pectoralis doesn't function normally anymore, it has to clear that implant before it dives back down into the humerus. So the shoulder is always pulled just a little forward and that adds up over decades, that adds up over time and that does throw the shoulder off of balance a little bit and that causes a lot of times lower back and mid back discomfort. So to get that volume away and out from underneath pectoralis major resets that problem. So a lot of patients report in significantly increased postural and musculoskeletal feel. There's one patient in specific who had back pain, she had implants for 20 years, she had back pain, she was to multiple chiropractors, physical therapy, all kinds of things. She was scheduled for back surgery in two months and we explanted and she literally canceled her surgery with her orthopedic spine thoracic surgeon because it's like my symptoms have completely gone away after my explant.

Monique Ramsey (32:45):
Wow. That's big.

Luke Swistun (32:47):
Yeah, that's big. And she had big implants, so she had a lot of volume underneath her pectoralis major muscle. But that is a real effect and it's a large body that does not belong there anatomically and then that has consequences, especially over time. The very last one is just breast implant illness phenomenon. And this is what I leave for last because it's a completely different animal, but it's definitely a real thing. The way I look at that is basically these are patients who are reacting to silicone the way anyone can get an allergic reaction to anything. In this case, basically their body, their immune system is reacting to silicone.

(33:27):
I draw the same reference to patients who are allergic to latex. If you put on a latex glove, let's say you're a nurse for a very long time, a lot of nurses and a lot of doctors, actually I use this example because this happened to me. You can be fine with latex gloves for 10 or 15 or 20 years into your career, but at some point your body will recognize latex as a foreign object and will make an antibody against it and then from then on you're allergic to latex. I think implants are exactly the same way. Patients report that, "Yeah, for 15, 20 years I had no problems with them, they were fine but at some point I started developing a problem. I'm a little bit more inflamed, a little bit more tight, a little bit more puffy and then I guess these rashes and stuff like that."

(34:08):
And that's literally the immune system at some point just recognizing the silicone as a foreign object and therefore building an antibody to that. And once the antibody is built, the immune system will remember it forever and then it will react as long as it's exposed to that. So the treatment for a nurse with latex allergy is to take off the latex gloves. The treatment for a patient with implants is get the implant out because that's what's going to reset that inflammatory cascade, all the consequences of the immune system reacting against it. If you go on Facebook, there's about 100 different symptoms that are listed for BII. If you actually look at them pretty closely, at least half of them relate to hyper-inflammatory cascade. When you're reacting to a foreign body, you're inflamed from head to toe and inflammation of different organ systems have different consequences.

(35:02):
Inflammation in the eyes is conjunctival swelling and therefore the feeling of irritation of the eyes. And as soon as you get the implants out, that's actually one of the first things that the patient's report gets better is, "My eyes don't feel dry anymore, they're not irritated." Inflammation of the hands is small joint pain and things like that. Once you get the inflammation out, the hands reset and they feel better because there's lots of moving parts in the hand that are gliding through each other, pulleys holding the tendons in place and stuff. And if any of this is inflamed and swollen, you'll feel that right away. Inflammation of the GI system is food intolerances, food allergies, things like that. And I could go on forever, I have tons of little anecdotal examples of different organ systems being inflamed and causing different problems and those problems specifically resolving after explanted.

Monique Ramsey (35:49):
And how quickly, immediately or within a week or months?

Luke Swistun (35:53):
Depends on what, typically the eyes actually get better pretty quickly and the small joint pain, the hands pretty get better pretty quickly, which is the reason I focused on those two because that's actually one of the most common complaints of patients and then also one of the most common things they report get better after their explants, within a week or two they'll volunteer that. I had an ophthalmologist who explanted with me explain to me the pathophysiology behind the eye inflammation. So she's an eye surgeon and she says, "This makes perfect sense, inflammation will cause that." Before I met her, I could not draw the association between breast implants causing eye pain or eye discomfort.

Monique Ramsey (36:30):
Who would ever think that? Yeah, I mean, it seems like a pretty far stretch, but when you understand what your body's doing.

Luke Swistun (36:34):
Exactly. And I agree, it's a far stretch, but it can't be a coincidence that so many people are reporting the same thing over and over again after we explant.

Monique Ramsey (36:45):
Yeah, that's very interesting.

Luke Swistun (36:48):
Yeah. So in general, to answer your question, that was a very long answer to your question, but most people feel much better. And then there's just different levels of how much better they feel depending on what was ailing them the most. I think the postural problems and the local pain problems resolve almost uniformly for obvious reasons. But the BII is a little bit more enigmatic I think and that's the one where it's a little bit more unpredictable, some people see a difference right away, some people take one to two years even to get better. But in general most people feel better in the long term.

Monique Ramsey (37:23):
Would you say, since we're just talking about explants in general, what percentage of people are coming to you for taking their implants out just because of a lifestyle change and what percentage are coming to you because they feel like they are feeling negative effects or feeling a little bit sick from them?

Luke Swistun (37:41):
I think about two thirds of my patients reach out to me because they have medical complaints, the breast implant illness patients. And then when we start talking, they also have the other ones, the postural problems and the local pain and the implant complications. And then it's about a third of the patients will come in saying, "Hey, these implants have been here for 30 years, I think they're just a little bit old. I'm done with implants, I don't really want them anymore, let's just get them out." Interestingly enough, the patients who come in and ask for the implants to be removed, who maybe have heard of BII or maybe have not, I ask them the question afterwards, six months later or three months later, "How do you feel?" And they're like, "Surprisingly better."

(38:21):
There's a lot of patients that volunteer, "My joints stopped hurting. I'm 60 and I thought it was just normal and I was getting older, but you know what? My joints stopped hurting more and I have more energy and I started exercising again and I'm thinking more clearly." I don't know how much of that has to do with the implants, but I do think that BII is a real thing, I think it is to some extent underdiagnosed just because maybe we haven't been looking for it as specifically before. But I mean, I see these patterns because this is by far the most common patient population that I have and the patterns are very consistent so I think that speaks for itself.

Monique Ramsey (38:58):
Now you mentioned Facebook and I know there's a lot of Facebook groups and maybe other platforms also have groups where people are talking, people who've already had their implants taken out or who are considering it. And so because of that, I know your name is thrown around in there in a positive way quite a bit because a lot of your patients do come from these social media groups and patients who have come to see you. So I'm assuming a decent percentage of your patients are coming from out of town, so do you do the consultation in-person or can you do a pre-consultation on Zoom?

Luke Swistun (39:35):
Oh yeah, we do both. As you said, Facebook is out there, there's a lot of information that is good, there's a lot of patient support networks that are great, but then there's also a lot of misinformation. And again, the reason that my consults take so long is because we try to tease out what's out there and what's real and what's not and what applies to you. We definitely do that on Zoom a lot, I think at least a third of my consultations is on Zoom and we do schedule you for about an hour and a half for that conversation. And really the only thing I can't do on Zoom is do a physical exam. And I actually have a patient today coming in after we're done with this podcast, who we connected on Zoom about two and a half weeks ago and she's in town in San Diego for another reason and I said, "Well, just maybe swing by the clinic and we can do the exam. So we'll pick up where we left off and we'll do an exam."

Monique Ramsey (40:22):
So yeah, so virtual consultations if you're from out of town, if you're in town, we want you to come in. So we really covered quite a bit of things today Dr. Swistun, thank you for your time. And for the people in the audience, we will put links for the other podcast because I know we have a podcast specifically about breast implant illness. We have also some patients that we've talked to of yours that we will put the links to their podcasts as well. And then if you're looking for information on financing, on seeing before and after photos, any of that, we'll have those links in the show notes as well. So thanks again Dr. Swistun, it was wonderful to talk to you.

Luke Swistun (41:03):
Well, thank you for the opportunity. Thanks a lot.

Speaker 1 (41:11):
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-5 San Diego Freeway, in the XIMED building, on the Scripps Memorial Hospital campus. To learn more, go to ljcsc.com or follow the team on Instagram @ljcsc. The La Jolla Cosmetic Podcast is a production of The Axis, the axis.io.