One of the things that I think patients are increasingly exposed to is the issue of plastic surgeons presenting opinion as fact.
As surgeons aggressively position themselves online, and the algorithm drives surgeons away from posting clinical, factual before and after images, towards "talk to the camera" style exposition and POV experiences, we are seeing this trend increase and I think it is becoming dangerous.
I try not to aimlessly scroll on instagram because the inanity of it drives me a bit crazy, but I was doing just that recently and a plastic surgeon in LA (who I was looking up as he had performed a mediocre bit of surgery on a patient I was seeing) was talking to an Australian influencer - a cosmetic nurse who has a podcast. Now, this is already a set up for some disastrous/funny outcomes (depending on your perspective) but this surgeon was extolling the virtues of removing implants in stages. His approach (and this is something of an American approach, you don't see it so much in Australia) was to remove an implant under local anaesthetic initially (in his office), and then to go back some time later to "fix things up".
This approach is predicated on the assumption that the breast will magically "tighten" up, and he went on to say that he would do things like mastopexy or fat transfer at a later operation.
Which, honestly, is all fine. That is a valid approach, it has some potential benefits in selected cases, and whilst it isn't my usual preference (nor that of most patients I see), in a different context (like the Beverly Hills cosmetic surgery market) I can appreciate that this could be easily sold to a certain kind of patient.
None of that is the issue.
The issue is what he said next:
"Removing implants is not a simple thing" he said (yep, totally agree)...."A lot of surgeons don't really understand how to (do explant surgery)...." (ok, sure, I think there is some validity to making this sort of comment provided he can back it up with context and detail)...."if you're not doing it staged, you're not getting the best results possible".
Righto, champ.
So this is a perfect example of opinion being presented as fact.
Somewhat related, is the issue of a surgeon conflating their preference/practice/opinion with a kind of moral superiority (something I have touched on before) over their colleagues (or perhaps we should say their competition).
Much like we see in politics these days, surgeons will draw a "moral" comparison between what they do, and what other people do. What they do is "right", what others do (which is different) is therefore "wrong". If you consider this behaviour, it seems to be a way of concealing or ignoring what they don't know or cannot do.
Hence the "if you don't do it my way, it is being done the wrong way (and you will get a bad outcome)" kind of commentary.
Anyway, that is a bit of a preamble I guess to something that is worth talking about. And with a certain relish, we can make it very clear that like most things I discuss, this is just my opinion.
So, let's go back to the LA plastic surgeon in question, and his suggestion that all explant surgery needs to be staged. Just to be clear, this guy isn't alone. There are surgeons in Australia who talk about the magical breast tightening fairies too.
Like I said above, it isn't wrong per-se to stage explant procedures. Not least because there is more than one way to skin the proverbial cat.
As a rule I don't stage explant surgery for a couple of basic reasons:
1) it ends up costing a hell of a lot more.
2) the recovery time is doubled (at least).
3) the time off work is doubled.
4) and most importantly, managing an uncontrolled scar process secondarily is much harder than controlling that scar process in the first place.
There are different ideas around staging too.
On the one hand, some surgeons recommend removing the implant, but leaving behind the capsule initially, and only coming back to remove the capsule at the subsequent stage. On the other hand, surgeons might be doing the capsulectomy, whilst not doing a mastopexy or fat transfer initially.
Now, if I were to stage an explant, I would suggest to you that the premise of that idea only holds up to scrutiny if the capsule is left behind at that initial stage. So the first operation is literally making a small cut, popping out an implant, closing back up and then waiting for a while. The reason that has validity is that if the capsule is left behind, it will prevent the breast from sticking back down in an uncontrolled way. If the capsule is removed at a first stage without reshaping the breast, then the scar process (as I mentioned above) is uncontrolled and can create distortion which becomes very difficult to fix.
Whilst not common, there are a couple of reasons I would consider staging an explant:
1) a patient who is uncertain that she will be happy with the cosmetic outcome of explant, but wants to try; these are the ladies who may then consider re-augmentation at a later date.
2) a patient who is right on the edge of needing a mastopexy (or even a little over the edge) who wants to avoid that mastopexy at all costs, and who is prepared to have a go whilst acknowledging that a second procedure could be required.
In both cases, the patient would normally be the one to ASK for this approach.
However, to address the inevitable concern that some ladies will have about this sort of process, particularly those who have have been exposed to the BII/toxic implants commentary online, let me make something really clear.
If I took a staged approach, the capsule still gets removed completely. The capsule is closed off carefully at that first stage. There is no "contamination" of the breast tissue by taking this approach. And perhaps more importantly, if you are concerned about BII, then (like I said above) this very likely is not the way we would approach surgery for you. I am speaking here to a different kind of patient, whose reasons for explant are likely to very different to those ladies whose main/only reason is BII.
**
Bit of a tangent, but on the theme of our wonderful American colleagues: I looked up another LA Plastic surgeon recently (who'd have thought Australian patients would be shooting off to LA to have surgery in the first place, right?) after another patient of mine presented with pretty dramatic complications after having surgery with him. He had tried to revise her breast implants with disastrous outcomes. And this banana head was talking on a reel about the risk of complications in breast implant revision surgery, and whether the risk was higher than after a primary breast augmentation. And he says "well, for other surgeons that is true, but in my hands, no". Straight face.
Ah. Gotta love it. Ego for days. Never letting facts get in the way of opinions.
Legends.