Alex: Every year thousands of women have breast surgery, whether it’s a lift or an implant, and while it’s everywhere online, breast augmentation is still a very mysterious realm. But for the surgeons at Re. plastic surgery, it’s a world that they experience every single day. So today we’ll be talking all about breast surgery, all the ins and outs, everything that we need to know.
You guys have obviously been doing it for a very long time. How many breast surgeries would you say that you’ve done in your career.
Richard: It’s probably in the thousands. I’ve been doing plastic surgery for 16 years and four years of training before that. And for the majority of my career, I’ve, I’ve done a lot of breast surgery.
So in that time, it’s probably thousands of procedures, but more specifically in the last. Five years my practice has become almost solely focused on breast surgery as has Kim’s.
Alex: And is that because it’s what’s popular at the moment?
Richard: Kind of, but, but also, when we started Re. we wanted to create a practice that was very focused.
The more you do something, the better you get at it. Plastic surgery is such a broad field, so you can be operating on someone’s toe, their hand their head. So it’s a lot of operations. So, the skill set gets diluted out a bit. So by focusing on only three main procedures, you get super skilled and proficient at doing them.
We felt that that’s the space we wanted to be in and focus on that. And, and you certainly do see it as a surgeon. You just get so comfortable doing the same procedure. Day in, day out.
Alex: And Kim, what about you? How many do you reckon you’ve done?
Kim: Probably similar to Richard, except I’ve been in practice for 11 years.
So a little bit less than him, but again, the focus being on breast and body surgery. Plastic surgery procedures are so broad so its made a big difference focusing specifically those procedures few procedures, rather than trying to be everything to everyone.
And so we aim to be experts in specific areas so that patients feel a lot more confident and comfortable coming to us because that’s really all we do.
Alex: For both of you, obviously you’ve been in it for a long time, so how has things changed? Have you seen a lot of change in terms of the surgery, but also the science and everything that goes behind it?
Richard: Technically there have been refinements rather than dramatic changes. Maybe breast reduction has changed the most from a technical point of view. 15 years ago when I was just starting doing breast reductions without getting too complicated, it was quite a different operation.
Essentially there are three components of breast reduction. You reduce the weight of the breast tissue. You reposition the nipple, and then you tighten the skin envelope. So we pretty much, apart from a sort of a small period where there was a slight variation, we’ve always done what’s referred to as the anchor scar or the inverted T scar.
20 years ago, the nipple was always kept alive from below, which meant that the bulk of the tissue was in the lower half of the breasts. And what that led to was the, the breast shape dropping out over time and lead to a lot of wound healing problems at the T junction, because that was where all the weight was.
And then probably in the early 2000s there were, there were some influential plastic surgeons, , one from France, a couple from Canada who actually turned it around and started keeping the nipple alive from the tissue above. That had two flow on effects. One, the blood supply was more reliable, but also it, it kept the bulk of the breast tissue in the cleavage area and took the weight off the lower part of the wound. This meant thelong term shape was better, with better cleavage and there were less wound breakdown problems. So that’s one operation that’s changed pretty dramatically from a technical point of view.
Alex: , Kim, what about you? You’ve been in the industry for over a decade. Well, how do you think things have changed in terms of practices as well as safety
Kim: Certainly the way we are running our practice now is quite different to what it was 10 years ago. As I mentioned earlier, previously plastic surgeons were trying to do everything for everyone. So now we really focus on breast surgery and tummy or body contouring surgery. That means our entire practice environment, all of our staff, as well as the hospitals we work at and the anesthetists and nurses we work with are all on the same page.
Additional for Richard and me, whilst we have individual patients, we have a very, very similar approach to everything that we do. We are available to cover each other and look after each other’s patients if the other one’s not available or away. Also its not just about doing an operation for someone. It’s about the whole journey, from booking your consultation, to having your consultation and discussing the operation, your preoperative care, and then finally your long term follow up and really being available as required, 24/7 afterwards. That’s all part of the patient safety and part of their journey as well. Knowing that one of us will always be there for them.
Alex: And does this mean that the end look and feel is better than it’s been in the past? And that safety, which is a big thing has really improved?
Kim: We think so. Patient safety is always one of our number one priorities. We wouldn’t embark on offering someone surgery if we didn’t think it was the right or safe thing to do for them. And I think having a focus on just a few procedures, really means that we’re particularly skilled in those, and so that if something untoward does happen, that we have all the skills and ability to be able to fix problems as well.
Alex: Have you guys found there is much more demand out there for breast surgery?
Richard: For sure. I mean, I think that’s, probably one thing that has changed a lot, the accessibility and availability of Breast plastic surgery. Whereas, maybe 10 years ago or 20 years ago, it was really thought to be something that was done in maybe LA or in Australia just in Sydney or the Gold Coast. I think women today know a lot more about the surgery, and they’re much more open about having it. We’ve seen it on our own social media platforms. The openness of, our patients to share their journeys and their stories and talk about it. I think even five years ago, women were not doing that.
And so that then opens, opens up the opportunity, and understanding of what’s involved for new patients. Recently we started our own closed Facebook group, and it’s been fascinating for us to sit and watch and see our patients interacting with new patients and with previous patients and answering questions that we actually didn’t even know the answers to.
So, for example. A common question is “I’ve got two children. I’m about to have a tummy tuck. Can anyone tell me what it’s like looking after the children”. As surgeons, we can give you general guidelines of what you can do and can’t do. But neither of us have had a tummy tuck, and then had to look after kids.
So to have someone who’s actually just been through it, explain, “well, you know, I could do this after a week, but I struggled with this and I needed help with that” Every patient’s obviously different, but it just gives them so much more insight and they realize that it’s maybe not as difficult or as scary as at what they maybe perceived it to be.
Kim: I think that when patients are coming for their first consult with us, they are so much more informed then what they have been in the past in terms of the whole procedure and the whole journey as well. Obviously we still guide them and give them advice and explain exactly what procedure is suitable for them.But they seem to have a lot more information and knowledge, well before they come to us and they seem to be more suitable. They’re self-selected almost in a way in that they know that they’re essentially choosing the right procedure with the right surgeon at the right time.
Alex: Obviously the taboo is disappearing with, platforms like Instagram and those kinds of things where women are educating themselves in those areas and coming to you.
Kim: Absolutely. There are some people who have concerns regarding those platforms, I guess about whether it’s pushing people to have unnecessary surgery, but I think it’s actually the complete opposite. Women are getting a lot more information from those platforms, seeing results that they like seeing as well as results they don’t like.
So they actually coming to us with a clear goal and a clear picture of what the issues are and what their concerns are. And also about the taboo of it I guess. With a tummy tuck, for example, a lot of these women are not having it just as a cosmetic procedure. It’s a functional procedure as well with a medical benefit.
And so they are learning that from other women who’ve been through the same journey. So kind of realizing that it’s not, a taboo topic and its ok to be discussing it in public with other women.
Richard: Just to compare and contrast. When I started in, in practice, digital photography was available, but we didn’t have great systems for, for showing patients photos.
Compared that to now. Our library of photos is, up to about 40,000 before and after photos. We’ve got a really professional setup in how we take our before and after photos. Everything’s very standardized. The lighting, focal length of the camera, the background, the position of the patients. We’ve got a dedicated staff member who takes those photos. So for starters, we can show patients really accurate photos. And when you’ve got such an extensive library, because it’s not just a matter of showing someone a breast augmentation, and that’s what a breast augmentation looks like, you need to find someone who has a similar starting shape and wants a similar finishing shape to give them a realistic understanding of what to expect. And because we’re focused on just a few procedures, you build up a massive catalog of patients. So almost invariably you can find someone who is a pretty good physical match, and then a postoperative photo that the patient is trying to achieve. This enables us to give them a much more realistic idea of what to expect. The other thing was, and this is hard to believe when I think back to this. When patients first started coming to see me for this sort of surgery, and they’d ask, do you have any patients that I could speak to who’ve been through it? We would have to go through our lists of patients and ring various people and say, would you mind if a patient rang you and asked you about your experience. It was a very laborious task. In the end they would end up maybe finding one person who they could speak to. But as Kim has alluded to, with social media platforms, our patients are direct messaging, previous patients and asking them without our involvement at all.
So it’s, all very independent of us. We’re not telling them who to speak to and who not to speak to. Also all the review sites particularly Google reviews. They are real reviews and, you just read them and you, you get a much better understanding of what it’s about. So all of those things help in reducing the taboos of plastic surgery. There’s much more of a focus on natural results, driven both by fashion but also predominantly by patients. But that really fake LA breast augmentation like the Pamela Anderson look, that is not what we do. And that is not what women of today are asking for.
Alex: Is there still a demand for that look or is that really disappeared?
Kim: I mean in our practice, that’s very rare. Our patients predominantly are requesting a very natural look. Basically, they understand, obviously their close friends and family will know, but if, if they saw someone down the beach who they didn’t know, they wouldn’t suspect that they’d had a breast augmentation.
Alex: Can you guys walk down the street and say. She’s had one. No, she hasn’t had one. Is it obvious to you?
Kim: Sometimes for sure, but if someone’s had good work done, then no, I don’t, believe it is obvious. Also, sometimes you can look at our postop photos, and unless you’re looking closely at the scars it’s hard to know whether they’ve had a breast reduction or a breast augmentation. So the aim is to have, even in a reduction, a nice outcome. It’s not just purely about making a breast smaller because you’ve got back pain and neck pain. We’re also aiming to have the breasts look aesthetically pleasing as well, and patients are demanding it too.
The other thing on that, similar to the walking down the street, going off the topic slightly, but with fillers and anti wrinkle type of treatment. Again, the taboo around that is a lot less, but people are still coming in with the image of these massive trout power lips and saying, I don’t want that kind of look.
And most of the time when we’re seeing patients the aim is to have that natural look. I shouldn’t be able to walk down the street and say, that person has had fillers or anti-wrinkle. Because if the work is done well, it should look natural.
Richard: With regards to the fillers that look over filled, I call that the area 51 look. That comes from the area people in America used to think the Government hid aliens. And so if you’re an alien and live in area 51 and everyone looks like an alien and you think that’s what everyone looks like.
Our practice isn’t like that. So we’re a non-area 51 practice. If you are sitting in the waiting room of an area 51 practice and everyone else sitting there has massive fake breast implants, and huge lips, and no expression whatsoever on their face, you would reasonably think that is what plastic surgery looks like. But it doesn’t have to be like that.
Alex: So you’re kind of like a man in black, like you really want to help these women camouflage themselves. What do you think some of the biggest misconceptions are about breast surgery? Do you think there’s still a lot of taboo around it?
Kim: I certainly think that. Yes, there is probably more so in the older generation, the younger generation and those in their thirties forties fifties now it’s a lot more open and these are women that have access to a lot of social media accounts and Instagram and Facebook, and so it’s being talked about a lot more.
One of the misconceptions definitely is that any breast implant is going to look fake and that that’s most definitely not the case. It can be achieved if that’s what the patient wants. But that’s very uncommon. Generally the patients that we see, the first thing they say is that I want to look natural. They don’t want anyone to know when they go to school drop off that they’ve had implants done.
One of the other misconceptions, particularly about breast implants is that they have to be changed at 10 years. That’s something that’s been around for quite some time. That really, really isn’t true. I do say to all my patients that have a breast augmentation that there’s a hundred percent chance at some point in their lifetime, they’re going to need to have further surgery on their breasts.
We can’t predict exactly when that’s going to be. The style of implants that we’re using at the moment, hopefully 20 plus years. But the main thing is that they have to be aware of their own body, any change, and that’s when things need to be looked at. But we’re always happy to see our patients back if they have any concerns. We have an open door policy with regards to reviewing patients.
So if anyone’s got any implants or any issues that they want looked at, then come and see us, but it’s definitely not okay it 10 years time to change your implants, like you may do with your car tyres being changed.
Alex: So it’s not like a car service,
Richard: Yeah. To that point, I had a patient exactly like that this week.
She’d had breast augmentation done by a plastic surgeon who’s now retired. 20 year old breast implants, the same exact type of breast implant that we still use today. The implants that we use are first went on the market in the 1990s. Her breast shape was great. She’s had a kid since her surgery, she was happy still with the size. Nothing had really changed, and she was just inquiring whether something needed to be done. I said, there’s, no problem. If we change the implant, that may introduce a problem. And I ordered an ultrasound just to be on the safe side, and make sure there was nothing that we were missing. But exactly as Kim has said. There was nothing that needed to be done. Other than have routine breast checks. The risk of breast cancer, independent of having breast implants is around one in eight women. So that’s a much higher risk of, anything going on with the implant. So I told her just to come back and see us if something changes, assuming the ultrasound’s normal.
Alex: Is there a way that women can maintain themselves, I guess, in order to avoid things going wrong with implants? Or is it more just how your body accepts it?
Richard: Not really. I’ve had a couple of patients now who have had breast implants and have been involved in motor vehicle accidents and the airbags have deployed and smashed straight into their breast implants with absolutely no untoward effects.
The main thing is, as Kim has said, is just to be vigilant just as you would normally, even if you didn’t have breast implants, look for any changes swellings changes in shape. And obviously lumps and then have all the routine screening that you would normally have. So. Your mammograms to start when you meant to start having mammograms and to always come and see us first if there’s a problem.
Kim: And the other thing on that about mammograms is that there is a misconception that you can’t have investigations like a mammogram when you do have breast implants. That’s not correct either. So, we encourage all of our patients to have their routine screening. It’s important that they tell the that they have implants. But generally the aim is to image the breast tissue, not the implant. So there’s special techniques that can be done to not be harmful to the implant. And also to image and to look at what needs and wants to be looked at.
Alex: That leads into why do women generally come to you guys for breast implants or breast augmentation?
Kim: Generally, women that we see that are requesting breast enhancement or breast augmentation have small breasts or have lost volume from breastfeeding. So they’re either young and have never really developed breasts. They often say they’ve never felt particularly womanly. They don’t like to wear bathers. They’re embarrassed to be putting a bikini on and going to the beach. And then the other cohort, are women that have had children. They’ve completed their family generally, and they’ve liked their appearance and their the size and the look of their breasts when they were either pregnant or breastfeeding, and then they’ve lost that volume after either pregnancy or breastfeeding.
They are generally just wanting to replace that volume back and sometimes improve on the shape that they’ve lost during their time as well. As we’ve said earlier, most are not coming in saying, I want to look like a Posh Spice or Pamela Anderson. It’s more just an enhancement of what they already have, and natural shape, and to feel a bit more womanly. Be able to fit clothing and togs and bathers, without feeling like they’re having to add in chicken fillets or wear double padded bras.
Alex: And do you find that most people’s self-confidence does improve after they’ve had breast implants?
Absolutely. A really important part of our screening process when we first have a consultation with a patient is to assess their motivations for surgery and to ensure that they’re, I guess, a sound mind and that their reasons for them wanting to go through surgery. And this goes with any of the procedures that we perform. We want to ensure they are genuine, and they have realistic expectations, and they can verbalize exactly what their concerns are and what the outcomes that they want are.
And most of the patients that we see really come in and can really explain all of that extremely well. It’s pretty rare that someone comes in and is like, my boyfriend wants me to do this and I don’t really want to. That would be a massive alarm bell. We really spend at least an hour with each patient going through a full history the indications in what they’re after, but also a full medical history as well to make sure that they’re suitable for any types of surgery.
Alex: And in the case of when you think it’s someone where it’s not necessarily them that wants the surgery, what do you do in that case?
Kim: So certainly the first thing is to not immediately operate on them, and to really try and get to the bottom of the reasons why they’re coming in, and if there’s any concerns regarding either psychological issues. If that is the case, then we would generally refer them back to their GP or refer them to be assessed by a different type of professional than ourselves. And most definitely not to be offering them surgery until we’re absolutely sure that they really are aware and know and want that it’s for them.
Richard: Yeah, I totally agree. And I think people underestimate the confidence aspect of it and also the fashion aspect of it. I think the clothing fashion has driven some of the requests as well, so the plunging necklines, and things like that in terms of then having breast shape.
We touched on the stigma before. It’s really interesting. It’s really well established for someone who has been through breast cancer and has had to have a breast removed surgically, that they do much better if they’ve had a breast augmentation in terms of their self-esteem and confidence. But women who, for whatever reason, don’t develop breast tissue during puberty. There are still, elements of society who judge them differently. And even though they’ve arrived at that point very differently, the end point is still the same. They don’t have breast tissue and they don’t feel maybe feminine or they don’t feel confident. They can’t fit out clothes. Breast augmentation patients are amongst the most grateful patients in our practice in terms of how it helps with their self-esteem and confidence.
Alex: And is there ever a case where you have to say, no to a patient.
Richard: Yeah , there is, Kim just touched on some of them, obviously for medical reasons. If they’re not safe for an anesthetic. That’s probably uncommon in the breast augmentation population. Probably the two most common scenarios that I would see where I would say no is women would come in bout after pregnancies who need to have a breast lift and they think they just need an implant. A breast lift obviously involves more scarring than a breast augmentation alone. And, they’re sometimes not prepared for that. They don’t realize that they need that to get the result that they want to have. And, maybe another surgeon has told them maybe they can get away with just a breast augmentation, but you know that that’s not going to be the right result for them for most of them.
Once you explain it, and we’ve got a pretty extensive consultation process where we can explain it and draw on patients and do simulations. We’ve got a 3D simulator and we can show them what the effects would be with or without the lift. For most patients, they accept that and they’re happy to go down that path. But occasionally they think, no, no, no, no. I don’t want those scars. And they’re trying to push you to just to do an augmentation. You have to say no.
The other scenario is when someone wants something that is more than two standard deviations away from the norm. For example big implants that really don’t fit their frame, and don’t fit their soft tissue. You know as a surgeon that longterm you are going to cause significant problems. And in those cases, I’ll say no to them as well.
Alex: Do you ever fear that those women go on to a different surgeon and request something that they know is not good for them.
Richard: I know they do. They definitely do. I mean, there are some plastic surgeons whose, practice is very different to what ours is or not as experienced as what we are.
Kim: But sometimes we see them back again after they’ve had those procedures and they’re not happy and it’s really difficult. You’re on the back foot once someone’s already had an operation that they’re unhappy and then have to try and correct that.
Alex: All right, well, thanks for coming in today, Richard and Kim, and the next episode we’ll be talking all about the journey of breast augmentation and, how to choose the right size and how to get the cleavage that you want. Thanks for coming guys.
Richard: Thanks, Alex.
Alex: Thank you so much for listening to this episode of keeping it Re.al. To keep up with our next episodes, go and subscribe on Spotify or iTunes or wherever it is that you get your podcasts. If you have further questions or want to take the next step, visit www.replasticsurgery.com.eu or follow Re. on social media.
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