All things breast surgery (and is breast implant illness a thing?) - Nora Nugent

0:00This show is sponsored by Primadine, a clean, natural and science-based spermidine supplement that's been a long-time staple in my own longevity stack. Because studies suggest that through autophagy, spermidine increases healthspan and upregulates a range of health markers, from memory and cognitive function to heart health, hormone balance, fertility and even hair growth. Plus, you can be assured that all ingredients undergo rigorous third-party testing. Buy Primadine now at OxfordHealthSpam.com and use the discount code DrSophie, that's D-R-Sophie for 20 % off. This show is sponsored by Microbes, an award-winning liquid probiotic that's now a staple for me, because Microbes, with a Z on the end, is different.

0:47For one thing, they source directly from the soil on their Wiltshire farm, meaning more diversity, with at least 15 strains of good bacteria in every single shot. It's brewed so it can survive in the stomach and a remarkable 92 % of customers say it makes a difference. Plus they offer micro-friendly cleaning, gardening and even microbes for dogs. Buy now at microbes.co.uk and use the discount code SOPHIE20 for 20 % off. Hi, I'm Sophie and this is Age Well with Dr. Sophie Schotter, a space devoted to all things health, wellness and longevity. because for me, aging well is about looking and feeling like the best possible version of ourselves inside as well as out.

1:31So together with my producer Fee, I'll be deep diving into the latest research, sifting fact from fiction. I'll also be talking to all kinds of trusted experts tapping into their knowledge, along with bringing you conversations from a range of interesting women and men finding out how they age well. So this is my show. Welcome along. And as always, thank you so much for listening.

2:00Nora, firstly, it's a pleasure to have you with us. Besides your incredible work as a surgeon, you're also the president of BARPS, the British Association of Aesthetic Plastic Surgeons, which is dedicated to safety and education in cosmetic surgery. And I don't know how you're managing this, but you're also the current president of the European Society of Aesthetic Plastic Surgery. so we could not be speaking to a more qualified and credible spokesperson so thank you so much for your time. You offer all kinds of surgery but today we're going to talk about breast surgery. We want to talk about everything here including uplifts, reductions, implant removal but to start with maybe breast augmentation so making the breasts bigger.

2:44In terms of market forces, trends whatever you want to call it I think the 90s were especially challenging for a lot of women because of all those lads magazines that pushed a very specific agenda of female sexuality. It was all fake tans big hair and huge breasts. Fine if somebody wants to emulate that but not fine if the rest of us feel less than because of it. But I've been reading a lot more about a modern day trend for smaller cup sizes and more subtle surgery or women who don't necessarily want bigger breasts but more defined shape. Can you talk us through the kinds of choices that your patients will need to make beyond size?

3:23So silicone or saline, smooth versus textured, teardrop versus round and where you're placing the implant above or below the muscle. And if you can also maybe go into a little more detail on that silicone versus saline piece, what are the pros and cons of each? I know a lot of people feel that saline implants are safer because if they rupture it's only salt water that your body can absorb but they also have a reputation for maybe feeling more unnatural and having more of a tendency to wrinkle. So broadly speaking what might the best options be if somebody wants their breasts to look and feel as natural as possible while still having implants?

4:00Firstly thank you for inviting me to join you. I'm looking forward to our conversation a lot. To start at the beginning about the trends for sure we are seeing a move towards more natural breasts in terms of shape and size. And nowadays, it's very much about enhancement rather than distorting a breast. So it's making the best version of your breast rather than making it as large as possible or as perky as possible if that results in an unnatural shape. I think it's one of these things that happens with many cosmetic areas. We've seen it in facelifts. We've seen it in buttock lifts. We're seeing it in the non-surgical side in fillers that when something comes out, it starts off slow, then suddenly it's everywhere and it's pushed to the extremes.

4:44And then it pulls back as we realise what groups of patients it's good for and what actually looks good and what lasts. And I think breast augmentation is a prime example of this, but we're seeing it in other areas of aesthetics as well. So right now, it is very much more about enhancing and having a fuller aesthetic rather than an unnatural or an over-the-top or disproportionate aesthetic. and from a technical point of view this is much better too. It technically doesn't stress the breast tissue as much and it lasts longer because you haven't overstressed the breast tissue or put in something that's too heavy to last.

5:20So definitely we've moved towards a more natural aesthetic. I ask my patients to think about breasts in terms of size and shape and shape is as important as size and implants might be used for size but in some patients it's shape. Particularly weight loss patients or post-pregnancy, where after breastfeeding and the pregnancy changes, when all those hormonal changes settle down, when milk production stops, often breasts are left emptier. And sometimes the implant is simply about restoring a pre-pregnancy shape or about giving more structure or shape to the breast rather than necessarily lots and lots more volume.

5:57So, definitely enhancement rather than distortion and a more natural look. In terms of silicone versus saline, to deal with that aspect first, my strong preference is silicone. And the reasons are several. It is more durable. It feels more natural. It lasts longer. And while it's in place, it definitely fits the breast better than saline implants. Saline are salt water filled implants. So it is true when they rupture, it is just salt water, but they still have a silicone shell.

6:31So rather than silicone itself. And ultimately, the level of silicone absorbed by the body is quite low. Breastfeeding is still safe with implants and silicone implants in place, and the levels have been measured. So actually, ultimately, a better and a longer lasting result is seen with silicone implants over saline. And that's the reason they're by far my preference. If a patient wants a saline implant, I can do it and I'll discuss it with them. But for a better result technically and a longer lasting result silicone by a long shot. And they allow more versatility with women who have very thin skin or very little breast tissue as well.

7:11Under or over the muscle? Actually, if you asked me this question 10 years ago, I would have said under the muscle. But more and more now I'm placing implants over the muscle because they harmonise with breast tissue better. It really depends on the quality and thickness of breast tissue in the upper breast and the skin of the upper breast as to whether I go under or over the muscle. If you have very, very thin breast tissue and skin in the upper breast, then it is better to go under the muscle by and large because you have more padding over the implant. But otherwise, actually, it's less traumatic to your body anatomy and it's easier for second time round surgery to stay over the muscle.

7:50And it can be a very, very good option in many, many patients. So right now, I would say I do both, but actually more over the muscle, whereas 10 years ago, it would have been vice versa. I think the next part of your question was round and anatomical. And I guess from that aspect, it really depends on your start breast shape, because some breast shapes will get a better outcome with an anatomical or teardrop implant. Some will get a better outcome with a round implant. So the first criteria for this is the original breast shape. if the breast shape allows for both then it depends what kind of a result or shape you want at the end of the day because sometimes I can work with either whereas other times I definitely favour one over the other.

8:33Tuberous breasts where you've got a very specific shape deformity breasts with a mild drop or wide short height breasts do very well with anatomical or teardrop shaped implants so that really boils down to breast shape rather than me having a preference that one is better than the other. Such a great and thorough answer. Thank you, Nora. Going back to size, in terms of size, how do you feel about women who want to go substantially or even, if I can say it this way, cartoonishly bigger than their natural frame? Do you acquiesce to these sorts of wishlist goals or do you send them packing? I mean, I wonder if some women, younger women, I guess, are so used to seeing what's on socials or in magazines that they just can't see what they already have.

9:16I mean, more generally, what sorts of conversations do you have in clinic on size? I start off by finding out what my patient's goals are. So this is before I've examined them. I ask what they're looking for, what the end goal of the surgery is. And sometimes they have wish pictures that they show me. People view these things in a good or a bad way. I find it helpful to see what patients like or what they want as an end result. But I will be very, very honest after I examine them about whether it bears any relation to what their body and breasts are like and whether I can achieve that particular result for them.

9:51By and large, after the conversation, I examine my patient next and see what their breast tissue actually can fit and actually can hold and support over the long term. And then I try and put the two together. Most of my patients want proportional results, just fuller than what they already have. but if we're going into the realm of disproportionately large breasts or unwise decisions then I'm very honest in clinic that this will have a long-lasting impact on their breasts and it may not be quite so easy to correct second time round and remember if I place an implant there is a second time round but you want that second time round to be as far in the future as possible and as least complicated as possible.

10:29It's not about imposing my taste on someone, it's about picking something that's sensible for their tissues and the long term and not just forcing something in, it can overstress the breast tissue and cause healing problems as well as tissue quality problems. The pressure of the implant can damage breast tissue over the long time. Thank you, Nora. That makes a lot of sense. What are your thoughts on some of the newer products and techniques on the market? For example, your thoughts on mesh and the so-called next gen of lightweight implants. I'm also really interested to hear your views about fat grafts or fat transfers and the hype around MIA Femtech, which is this injectable and biocompatible implant.

11:11And I've also been reading about a few new tech startups focused on 3D printed implants that grow new breast tissue. Is breast surgery now becoming this rapidly evolving space, partly fueled clearly by tech innovation? What's your viewpoint on all of these new technologies? I guess to answer the The last bit first, breast surgery has gone from being relatively static over many years with refinements of techniques rather than a huge amount of new devices to, in the last few years, having some real innovative devices come on the market. And overall, my viewpoint is positive on these new technologies.

11:48It's the way to advance and to progress and to ultimately get better results for our patients. I work my way through the individual items that you've listed now. But I guess the first viewpoint for me is that it's progress and positive. But I would also say don't jump on the bandwagon too early for long-term devices. Long-term data is important when it comes to implants and meshes. You've got to scratch the surface and look beneath and make sure that the data is stacking up. So I'm going to come back in order about the things you asked me about. And starting off with mesh, I use mesh in select cases, either where there's very poor tissue support, for example, after extreme weight loss, where the breast tissues have been very stretched and the base of the breast is very lax.

12:32And I think there would be difficulty in supporting an implant in the long term. Then I use a mesh as like a sling on the bottom of the breast, like a hammock that supports the breast. I also use it when the implant is slightly larger than I would usually wish for a patient. And I don't mean cartoonishly large. I tend to steer away from that. But when it's towards the larger end of what I'd recommend and I'm worried about support and when I'm replacing implants for the same reason if I'm worried about support or if patients have medical conditions for example some collagen disorders where intrinsically their support is going to be less than the average breast patient.

13:08So meshes are very useful as a support. They are an additional foreign body in the breast and they are an additional cost added into the surgery. So I don't routinely use mesh, but I will use it in select cases. And I tend to use long absorbable mesh that is supposed to integrate with your tissue. And what that means is that over time, your body grows into the mesh, essentially replacing the mesh. So if you went back to re-operate in two years or five years, you shouldn't be able to see the mesh, but it should have imparted some support to particularly the lower breast. It's also useful to give another layer of tissue coverage over very thin breasts to pad out the implant a little bit more.

13:48It is only a very thin there, but it can be useful for that as well. Fat is probably more useful for that, and fat is really useful for padding out over an implant or in its own right to enlarge breasts. But it's not quite like for like with an implant. It is a little bit less predictable. We predict how much fat will take or survive. But on average, you absorb 20 to 30 % of what I transfer. And if someone's a smoker or has, say, for example, diabetes or other health conditions, they may absorb less and therefore need more rounds of surgery. And by and large, it's a more subtle result than implants.

14:26But it's a very, very good choice for some women, especially those who want to avoid implants and only want a modest increase or a little bit more fullness in their breasts. Finally, Mia Femtech, the injectable and biocompatible implant. Honestly, injectables is a little bit of a misnomer. It's an introducer, but it's that the implants passed through, but it is actually still a silicone implant. It just tends to be a smaller implant that fits inside an introducer. So it can be put in through quite a small incision. The implant itself is a diamond shaped implant. So it sits slightly more proud than an implant with a flat back.

15:04The flat backed implant, which is how most implants are shaped, sits directly against your chest wall and there's no gap as such between the implant and your tissue. With the diamond in the beginning, it pushes out more. So for the equivalent size implant, it gets a little bit more projection. They tend to be small implants, so a little bit more projection does count. I think it's a very exciting new development, but quite honestly, there's also been significant hype and marketing around it. And some of the claims with Mia can still be achieved with conventional implants that can also be placed through very small incisions these days as well.

15:40So it's something I'm going to watch for a little bit longer before bringing in and it is something that will suit some women but not all women and it needs to be for small to medium implants rather than large implants. If someone wants a larger implant it's not really suitable. Thank you so much for going through all of this with us. I mean obviously many women express that breast surgery has been life-changing. But despite the obvious advantages, it's still surgery and all surgery carries risk. So what are the main risks and what can we do to try and mitigate these, especially things like capsulocontracture, implant ruptures, and when the implant may have started in the right place, it ends up in the wrong place.

16:23So for example, do implants need to be monitored? What are the chances of them breaking? So you're absolutely correct. It is real surgery that comes with some risk, just like all surgery does. And it's absolutely transformative for many, many women. And I see it every day in my clinic, the positive aspects. But at the same time, it has to be taken seriously. And actually, I would say at least half my consultation is going over the recovery and the risk side of it, rather than the positive side of it. I really want to make sure women understand what we're planning to do before I do it. For implants, I will break it into three components for the risks.

17:00There are the risks that come with any surgery, a general anaesthetic, infection or bleeding, healing problems or scar problems, clots in the leg that can travel to the lungs. And those can happen with any surgery, not specifically breast surgery. The next group, I would put more implant or breast complications. And those are things like the implant moving out of place or the implant rupturing, problems with the implant sitting too high or dropping too low problems with the breast tissue sagging over the implant and the final group i would say are i wouldn't call them complications i would say end of device lifespan issues because remember these are long-term but not lifelong devices so they will come to there will come a time when these implants need to be changed and some of those problems are the same as the early problems like implants moving out of place the capsular contracture or hardening around the implant are rupturing.

17:55But if it's happened 20 odd years later, it's not really a complication of the first surgery. That's the end of the implant lifespan. Or if it's happened, you know, if your breast has dropped over the implant after having the implants in 10 years ago and having a couple of pregnancies and breastfeeding in between, that's again, not really a complication of the implant surgery. That's life having carried on over the years, and that will happen with or without surgery. So I think of it in terms of complications related to a problem with the implant that shouldn't have happened that early, complications related to the surgery, and then revisions due to the implant coming to the end of its lifespan or breast changes over time with ageing, hormonal changes, weight changes, and so on.

18:39But the bottom line is implants should be monitored. At the end of my surgery sign-off, usually around the one year mark, I have that conversation with my breast implant patients. And I say to them, you are welcome to come back for routine checks. And I recommend that you do that. But you should also come back if you notice a change in shape or you feel something different in your breasts or you notice a lump or any other change in your breasts. And some things are not a problem. Many women have lumpy breasts and notice changes around the time of their period. But something that's not usual for you should be checked out.

19:15And if implants are still said to have a lifespan of 10 to 15 years, then if you have not had them checked coming up to that time, then definitely you should see your surgeon and have them checked. And the check is a clinical exam and sometimes an ultrasound scan, occasionally an MRI, but more commonly ultrasound. And ultrasound is not needed every year, but periodically. Can you talk us through breast uplifts and breast reductions. What do we need to know here? For example, can you have an uplift without having an augmentation at the same time or do the two always go hand in hand? They can go hand in hand or separate.

19:53As part of a reduction, almost all the time there is an uplift as well because the way we reduce the breast is also taking shape into account. So it generally is lifting and reshaping the breast as well as reducing the size. An uplift doesn't always come with a reduction, but a reduction almost always comes with an uplift. And an uplift can come with or without an augmentation at the same time. If size is an issue as well and a woman wants to go larger, then an augmentation can be done at the same time as the uplift. And that augmentation can be fat for a more subtle enhancement of volume, or it can be an implant.

20:30It's more commonly an implant, but an implant is sometimes added for shape. You can have an uplift with or without an implant, and with both you'll get an improvement in shape but sometimes a little bit more structure is needed if the breast tissue is very loose or lax even with the uplift and an implant can give that and it can be helpful for women who actually are not really looking for a size change they're just looking for a better shape so sometimes an implant's helpful in that situation for structure and shape purposes more commonly it's to give an increase in size as well so they can all go together or separately.

21:04There's also a reduction that can go with an augmentation as well. You can do what's called an augmentation reduction, where you add an implant, but also reduce the breast tissue. And it's not done to increase size. You're actually overall reducing size. It's done for shape purposes. Gosh, so helpful. Thank you. And what can we expect on the day of any breast surgery in terms of the moment someone wakes up in the morning through to what happens when they're wheeled into the operating room? Well, actually, what happens on the day starts before that with a pre-assessment. This is usually, not always, but usually general anaesthetic surgery.

21:41So there will have been a pre-assessment or pre-anaesthetic checks before the surgery takes place. And in our clinic, our specialist nurses will also have gone through some of the recovery aspects, bra fitting, scar care, all of that ahead of the day of surgery as well. So on the day of surgery, when you wake up, you will have already received instructions about when to stop eating, how long you can drink for. Usually eating has a longer time frame in which it needs to be stopped and clear fluids such as water can be had much closer to the surgery time. You will be given a time to come into the clinic or hospital where you're having your surgery.

22:18And before the surgery takes place, three sets of people will see you. I will see you and do my markings and measurements, some of which are better done standing up ahead of going to sleep. I check for any last minute questions and I will have done the main consent form ahead of time, but there's usually a confirmatory one just to sign on the day. So that's done with me. Our nurses will check blood pressure, do the last minute urine test, get you changed into a hospital gown and stockings. And And so I run through the final pre-surgery identity checks and allergy checks and so on. And then finally, the anaesthetist will come and see you as well.

22:57And they'll already have received the pre-assessment information, but they'll go over any anaesthetic questions or last minute checks that they need to do. Next step is actually going to sleep. And then the next step is waking up, usually in the recovery room. And quite often it's common to be a little bit disorientated and drowsy for a short time after the anaesthetic. Teva anesthesia, which is what we use, it's intravenous rather than gas-based, has less of that associated with it, but it can happen after any anesthetic. We have antiemetics or anti-nausea medication, painkillers at the ready if needed.

23:32Some people need more than others. Some people don't need much at all. And then finally, when you've recovered from the anesthetic enough and the things that indicate you have recovered are being comfortable, been up and about having been to the bathroom having eaten and drunk something then it's home and this is often day case surgery but an assumption is day case surgery it's home to a calm restful environment hopefully for the first evening. In terms of recovery from surgery and I know this is so variable between individuals as well what very practical tips and advice do you tend to offer, including advice on scar tissue management and pain.

24:13What can people expect day-to-day, week-to-week in terms of recovery and what good or new habits need to be factored in? So I give the rough timeline that I give most breast patients. There are obviously some individual variations, but by and large, I say six weeks to get back to your normal day-to-day activities and to stop wearing the surgical bra, six months for shape and swelling to mostly be settled out and about a year to 18 months for scars to settle out. So those are the broad time frames for breast surgery that I give patients. There are nuances from patient to patient and surgery to surgery, but broadly speaking, that covers most timelines.

24:52I have tapes on the incisions acting as a dressing and the bra acting as a support bandage after surgery. There are specific surgery bras that we use and they carry on almost untouched for the first two weeks. they can be removed for showering purposes. And there's a specific routine about drying the tapes after showering, but that's the regime until the scars are healed well enough to remove the tapes, usually about two weeks, but between two and four weeks. Once tapes are off, I want patients to get in with scar care. So moisturising, massaging, silicone scar gels. And the other two adjuncts that are really important during recovery are things like lymphatic massage and good nutrition.

25:34Nutrition is the foundation for healing. So while I'm not specifically advocating complicated diets or complicated supplementation, if your diet isn't good, this should be looked at ahead of surgery and you should consider supplementation to aid wound healing. And we have specific surgery supplements that are designed around wound healing after surgery to take before and after surgery for patients who want to go down that route. What good or new habits need to be factored in? Well, generally speaking, good nutrition and a healthy attitude to life and exercise and weight need to be factored in and kept.