Dr. Houssock (00:10):
Hi, Val.

Val (00:11):
Hi, Dr. Houssock.

Dr. Houssock (00:13):
Welcome to the Perfectly Imperfect Podcast.

Val (00:16):
Thank you for having me. I'm excited to be here.

Dr. Houssock (00:21):
So what is it you say you do here at JEV?

Val (00:26):
Everything I love, let's start there. So probably my main role that I do here is I am one of the operating room nurses, so I get to check people in. I'm also the circulating nurse, so I'm in the operating room, opening things when you guys need stuff, making sure that the patient is safe. I also can help recover if I need to.

Dr. Houssock (00:53):
So you're a jack of all trades, is that what you're saying?

Val (00:56):
I mean, I guess, yes. I'm not trying to toot my own horn.

Dr. Houssock (01:01):
Here's the thing about Val refuses to just be good at one thing. Val likes to be good at everything. So Val is not only integral in our operating room. She does a lot of our kind of preoperative things and then she also does injections. So you're going to see Val a lot on this podcast cuz she's got a ton of knowledge.

Val (01:23):
And I love the operating room. That's my home. Dr. Houssock has tried to, I wouldn't say kick me out, but she's asked me like, alright, do you want to kind of branch off to focusing on one thing? And I'm like, no, I don't. That's my home. That's what I'll be for the rest of my career for sure.

Dr. Houssock (01:43):
All right, so what are we going to talk about today?

Val (01:46):
So we're going to talk about one of my favorite surgeries, and that's a good old breast aug, breast augmentation for the full name of it. Something we do very often here and it's very fun. I love it.

Dr. Houssock (02:02):
So what we're going to do is Val's going to go through, talk through a question to answer, and that way people can learn from us. Sound good?

Val (02:11):
Let's do it. Dr. Houssock, how do you help determine the right implant size for a patient?

Dr. Houssock (02:19):
So I think there are two parts to that. So there's the part where people think about volume, which obviously is very important, but there's the whole other side that kind of gets forgotten when you see a bad augmentation. And that has to do with the patient's breast footprint. So every woman is born with a specific breast footprint. That breast footprint is measured out on the body. It's very particular to the patient's frame, and that is ultimately how you fit the best size implant. And I tell patients that I will take care of figuring out what that breast footprint is and their job is to figure out their volume. So a volume could be any number. It really comes down to then fitting that volume into their breast footprint.

Val (03:06):
Have you noticed any trends in breast implant sizes lately?

Dr. Houssock (03:10):
So I think it depends on where you are. Right? So here in Maryland and kind of part of the Mid-Atlantic, we have pretty moderate patients, meaning that they're pretty conservative. They typically opt for a more conservative implant. I will say probably over the last few years I've noticed a smaller implant size. Patients are really adamant about not looking like an implant patient. It's a very big deal to a lot of our patient population. So I would say generally speaking here we are seeing patients going more petite, but I also think that has to do with our ability to do that for them. We didn't always have those choices before. We have a lot of options. I say that, but on the same breath, last week, two weeks ago, we had literally in one day an augmentation where Val and I put in the smallest implant that exists for the company that we use and then we literally followed it by putting in the largest implant that they make. So I still think there's obviously a population for everything,

Val (04:19):
And that's the beauty of this industry is we can accommodate so many different type of footprints and looks that they're going for. So yeah. That's awesome.

Dr. Houssock (04:31):
Yeah.

Val (04:32):
Do you think a breast augmentation can improve asymmetry?

Dr. Houssock (04:36):
Oh, definitely. They're probably some of my favorite breast cases because there's a lot of fun in that, right? So if you have a patient which is most patients who come in and do not have completely symmetric breasts, it's very easy to fix that in a lot of patients just by volume. Now it doesn't work for everybody. There are still patients who require unilateral surgeries like a breast lift and whatnot. That might still be necessary. But I've certainly done plenty of patients where just that little bit of asymmetry can be fixed with implant alone. And the way we typically do that is we tell the patient to size their smallest size, meaning whatever side they use, that's the smallest whatever they want to use on that side, and then we'll just match it on the other side. And we use sizers intraoperatively, so even Val and I will sit 'em up and we can look at everything.

Val (05:28):
Dr. Houssock, what brand of implants do you prefer?

Dr. Houssock (05:32):
We use the Allergan company called Natrelle. My reason originally was because I had started working for this practice before I purchased it, and that is the company that the surgeon was using at the time, and then I got my hands on it, really loved it. But it's kind of evolved from that. I've definitely now as I become a more mature surgeon, been able to dive out and look at other particular companies and I still am tried and true with them. I find that I have so many options. So when we talk about that breast footprint, it's not just about volume, it's about projection, it's about diameters, it's about cohesive where you can decide how stiff that implant is. And I just feel like they have the best range for me. In addition to that, we have very low problems with them, meaning that they have a very low profile for rupture. Patients seem to really love how they look in the body. There's not a lot of concerns with rippling. So for right now I'm in, and it doesn't mean that I'm not always looking and monitoring what's going out in the world and we're always going to offer what's best out there for our patients. But right this second, I really love Natrelle.

Val (06:47):
I'm sure you get this question a lot during consults, patients are always looking for that gummy bear implant.

Dr. Houssock (06:53):
Yeah. So I don't even know at this point. I feel like that's so antiquated. But at some point, maybe 10, 15 years ago now, somebody came up with that word gummy bear implant, and now it kind of stuck and all it means is kind of the silicone that's inside. So the silicone inside the shell way back when these first started being made was more of a liquified silicone. So it felt really jelly-like and soft, but if the outer silicone shell ever ruptured or had a crack in it, that silicone was very liquidy. It kind of feels sticky. And so when a patient would have rupture, it was really difficult to clean that out. Not only that, it didn't really hold its shape very well. It kind of moved and maneuvered. And so patients would have rippling even though it was still silicone, it still wouldn't keep that shape well.

(07:43)
And so over time everything evolves. Just like the iPhone, I always say the implants have evolved just like that. And now that gummy bear means that the gel is much more form creating. And not only that, if it does rupture, it kind of sticks together. If you were to split a gummy bear in half, it's not going to kind of liquefy out like a gusher. It's going to be more like a gummy bear. And that is for two reasons, really great one, if you happen to have a rupture, it's really going to hold its shape well and it's not going to be extremely difficult for the surgeon to remove it. And when it's in the body, it holds a shape very nicely. So it looks like that soft round breast that everyone's looking for. So that's been around for a while and I feel like now what we really play with on that is just how stiff it is. And some patients need a lot of stiffness and a lot of shape and some patients don't need as much of it. So we can play with that a little bit for that perfect look.

Val (08:39):
And that just shows how much technology is really advanced in aesthetics with those implants back then definitely did not give that natural looking shape. And we sometimes will see these implants that are, gosh, 15 even sometimes 20 years old and just you can definitely tell that the structure of the implants have improved so much.

Dr. Houssock (09:04):
For sure. Yeah, no question. No question. It's cool for us because Val and I will take out these implants that are like 20 some years old and it's companies that don't even exist anymore and it's pretty impressive. Some of them are completely intact and they look completely fine and you no different. And some of them are crazy, crazy, but regardless, it's an inert type of product. So even when they're that old, generally speaking, patients do really well with them even when they're 20 some years out.

Val (09:35):
And now I feel like, gosh, when was the last time you put a saline implant in?

Dr. Houssock (09:40):
It was in residency. So yeah, I haven't put one in, I always tell patients that they have that option here, but that I haven't put one in since I started practice. And I think they kind of get the hint.

(09:53)
And it's not that, saline still exists for a reason, it has its place. There are plenty of women walking around with saline implants because there was a decade where we couldn't use anything else but saline. And so there are still women who have them and they're doing great. They're still being placed by a lot of surgeons. My particular choice is not saline, and it just has to do with how great and how wonderful I think silicone implants do for the patient, not only in their safety profile, but in how natural they look. And because of that, I just really opt for silicone, but if a patient demanded a saline, I would still do it. It's not my favorite.

Val (10:34):
It's good that we still have the option if we needed to use it.

Dr. Houssock (10:37):
Yeah, absolutely. And I think one of the reasons why patients come in asking for it is they think it's more natural, meaning that it's water, so they somehow see it as less concern of putting some kind of a foreign body into their body. But unfortunately, one of the statistics that I always educate on is that it doesn't matter whether it's saline or silicone. If you're worried about, for instance, breast implant illness, we see it in both populations. So you're not resistant to breast implant illness with a saline implant mostly because a saline implant is surrounded by silicone. It's a silicone shell. And then there are downsides to saline in the sense that it doesn't have that as natural feel as that new beautiful cohesive gel that silicone has. And then there's the worst case scenario. If it ruptured, it's a water balloon, so

Val (11:24):
You just absorb it.

Dr. Houssock (11:27):
Yeah, that thing ruptures and you wake up without a boob, so you have to kind of take the pros and cons with it.

Val (11:33):
Sure. Let's talk about incisions.

Dr. Houssock (11:37):
So all of my breast implant incisions are in inframammary fold, so right underneath that breast crease where they're well hidden. I do not offer any other incisions. They exist. A few of them were really popular, I mean not popular, but talked about a lot more years ago, one of them being the armpit. So the axilla going through the axilla. The other incision that was really popular was around the nipple. And the argument on that one was that it healed really well and was well hidden, which I argue it's right on the front of the breast. So I don't love that at all. And ultimately it was found that that particular incision on the nipple has a higher risk of capsular contracture because you're going through the nipple and we love nipples, but nipples are not the cleanest part of the body, and so unfortunately there's higher risk for some biofilm to get on that implant.

(12:33)
And so my incisions, if it's a straight aug, are going to be underneath the breast crease, but they are tiny. If it's a small implant in the two hundreds is a three centimeter incision, and if it's anything bigger, it's a four. We use a funnel to place it in, so it does not need to be large. That is to me, probably one of my biggest pet peeves is seeing a large incision for any size implant, it's completely unnecessary. It creates increased healing time. It can disrupt the muscle. It disrupts that beautiful infra memory fold that is so important for support. So I'm a stickler for only making the incision that you need and nothing more.

Val (13:19):
What can a patient expect their scars to look like the first couple of weeks after breast augmentation?

Dr. Houssock (13:25):
I don't really want them looking at them, quite frankly. So Val and I, we put in a bandage over the incision. We use Steri strips which cover the incision, and we tell them to keep them on until we see them at two weeks, and if they fall off, they fall off. But I don't want anybody looking at anything. But if they happen to see something and they're cleaning that area, it's going to be red. It's going to be a very obvious incision that you can see. My particular incision will have some sutures hanging out the sides. I don't like knots in that most superficial portion of the incision. So my patients will see these little whiskers coming out. The sides are these clear, they look like pieces of floss, and then at two weeks we take the bandage down for them and if it's still there, and then we trim that suture and then at that point at two weeks, they're seeing a pretty well-heeled incision at that point. It should be just a very, very fine thin line at that point.

Val (14:24):
And at that point, can they start using something on their scars?

Dr. Houssock (14:28):
Yeah, so there was a study done and I ended up having to do a grand rounds at Hopkins when I was a resident on what really works for scars. And there's all this fancy stuff out there. It is super simple. Anything that is a hundred percent silicone is your answer. No Maderma, no all these other crazy things that you like to put on your, you ultimately, once it becomes a scar, not when it's a fresh wound, you're going to want something that creates compression and some moisture and protection and all three things are achieved by 100% silicone alone. So that can come in a gel, it can come in a strip, but that's it. Nothing else. Let the body do what it needs to do. And all you're doing when it comes to silicone is creating an environment that will ultimately aid your body to do what it already knows how to do, which is heal that wound, start doing anything more than that, you'll start irritating it and it actually makes it more difficult to heal.

Val (15:26):
Yeah, we're a huge fan of Silagen. I use that on my scars after my breast augmentation and I can barely see my scars now.

Dr. Houssock (15:35):
Yeah, it's awesome.

Val (15:36):
Yeah, I used it for about a year and it did great.

Dr. Houssock (15:40):
Yeah, and that's the thing too, what you just said is so important because people think like one of my healed, but the truth is that even when we clear them for full activity, that scar is going to take a year and a half to completely mature. And some patients they are red for a while, it's a bright red scar and then they soften over time and it just depends on the patient. I never promise an invisible scar, but certainly when treated well and treated right, it can be nearly imperceptible.

Val (16:08):
How long typically does breast augmentation take?

Dr. Houssock (16:12):
It takes us about an hour. I never pride myself on being the fastest surgeon there is. You'll hear people who say that they do it in 20 minutes, that's fine. We do our hour surgeries a different way than some. I would say in the sense that when our patients choose their size, they choose a range. So some surgeons will do the sizing and make you choose your size, and that day all they do is put in that implant. There's no sizers. They clean out the pocket, they create the pocket, they slide in the implant, they close it, they're done. And that's fine. And that works for certain practices. I like a little bit of an artistic license to give the patient exactly what they want and sometimes they can't know that until I'm in there in their body putting incisors. So we do a lot of really discovering what the patient wants before we go back.

(17:02)
One of those ways, of course, is by them doing their sizing, but we also ask them for some pictures, some ideas of what they're really looking for just to see if we're kind of seeing the same thing. We show them patients that have already had the procedure done by us and it gives them an idea as to what things will look like. And then with all that information we go into or with a range of implants, usually two to three different choices, and they typically will tell us what they liked when they did their sizing, but then it allows us as a team to place the sizers and really see if we're giving them the exact look that they're looking for. For instance, if a patient picks a certain size and it goes in and Val and I see that sizer go in and we're like, what happened to the implant?

(17:44)
It's gone. It filled a lot less than we thought. We have artistic license to be able to put in a bigger size, and that certainly has happened to us. I mean, we've definitely had experiences where a patient picks a size and it's way too big for them. I can't even close the incision and we have to go down and because we've had that conversation with the patient, there's never any concern about that decision. They know that we're going to do the best thing we can for them, and because we've had that conversation, it really 100% of the time works out that they're satisfied because we've been able to do that for them.

Val (18:21):
Now during consults, if they're one of their main complaints is sagging, can they get away with doing a lift without the incisions and just using the implant?

Dr. Houssock (18:33):
So yes, the answer is yes with a question mark. Yes? It depends because let's go back to that whole breast footprint situation. So the breast footprint is measured based on where their nipple to notches and then the base width and then how low their nipple is compared to their fold, and then where's their nipple according to the chest. Some of that is natural. Some of it happens with just time or babies or pregnancy or weight gain. And so at some point there is a more aesthetically pleasing place that your nipple should be, but that's a range. So it's somewhere between 19 and 23 centimeters from the sternal notch is where your nipple should be. So that gives you a little bit of leeway, right? So let's say you're perfect location. If once I measure you would be 19 and your nipple is sitting at 21, well, it's not at 26 looking at the ground.

(19:34)
So no, you don't need to lift, and if you put a little volume in behind that nipple, it is going to naturally lift a little bit. What's not going to happen is your breast footprint isn't going to lift. That requires some surgery, but if it just needs a little bit of a little oomph, an implant alone can absolutely do that, and I think it can look very, very natural. I probably offer that more now, interestingly than I did when I first started out. I think there's two reasons. One, I think I offer that more now because women are looking for a more natural kind of soft voluptuous look more than they were before. I think they're okay with that. Look, everyone's kind of gotten out of that high and tight look, and I think I offer it more now because I've kind of gone through it all myself going through pregnancy and then breastfeeding and watching how my breasts evolved, and I certainly have drooped over time, but I still think they look very natural and beautiful. So I don't think that every patient when they walk in whose nipples have dropped a little bit, need to be committed to a big crazy breast lift.

Val (20:44):
It's great that they have the option if they wanted to though.

Dr. Houssock (20:48):
Yeah. And I think it depends on what they say. I ask patients to use their adjectives. If they keep saying perky, they're going to need a lift, right?

Val (20:55):
Right. Right. Yep.

Dr. Houssock (20:56):
It's got to jive with what they're looking for. They could not want to lift but want to have this high and tight breast, and obviously I'm not a magician, so it just depends on if we can meet their expectations.

Val (21:08):
As far as recovery, how long are you asking your patients to lay low for?

Dr. Houssock (21:14):
So if it is a straight breast augmentation, I do my implants above the muscle for almost the vast majority, and so I do find that that recovery can be quicker. So our patients are asked to really limit their major physical activity for four weeks. They can walk immediately, so I don't care how long they walk, I just don't want them having major, major physical activity running around, lifting heavy weights for four weeks, but at four weeks, they literally go back to doing whatever they want. I do think it's important. You'll see a lot out there about these flash recovery surgeries and whatnot. I think it's total bs. I think you need to give your body the time it needs, and I don't just think that I've seen it where patients at two weeks feel so great and ignore our rules and come back here with hematomas, meaning that they bled into their pocket. I've seen it time and time again, and it's why we tell patients to sit still.

Val (22:10):
What kind of complications does someone need to be aware of with breast augmentation?

Dr. Houssock (22:16):
Well, what we just talked about, I do feel very strongly if you follow our instructions, you're going to do well. And so complications can arise even when you are perfect. You're the perfect patient, but you're definitely going to minimize your complications if you follow the rules. And Val really, really goes hard at educating our patients before surgery to know what things to look out for and the things that they should avoid. But even when all that stuff happens, complications can happen. You certainly can have a bleed in that pocket, and if that happens, you have to come back to the operating room. We have to wash it out and put the implant back in. Complications can happen the entire life of the implant, so you can have a risk for rupture these days. The FDA suggests that patients get a ultrasound or MRI at five years after they get an implant placed and then every two to three years after that to make sure that it's not ruptured.

(23:09)
So that's a really good way to monitor that. Another complication that can happen is something called capsular contracture, and it's just simple. We make scar tissue around everything, and so if the body makes too much scar tissue, it can get very hard around the implant. It's not necessarily dangerous or anything like that for the patient, but it certainly can start to look funny. The implant can kind of look funny and deformed. It can feel hard. It can get sore. And if that happens, we have to take out that scar tissue and put a fresh implant in. And I would say that one in particular, it's a low risk, but it's still the most common complication, and we definitely saw an uptick of that with covid. I don't think the studies are out there yet to prove that, but certainly in the community, we saw more capsular contracture during the pandemic and it makes sense.

(23:56)
We knew before the pandemic that viruses or any kind of infections can create a biofilm around the implants that create an immune response. It can cause some of that scarring. So that's a way that it can happen. There are things like physical car accidents can cause it, but ultimately it's not something that I want our patients to worry about but be aware of because again, at any point of the life of the implant, that capsular contracture can occur, and if it does, there's an answer for it. But the sooner we know that it's happening, the better the treatments are.

Val (24:30):
As far as replacement. Do you have a suggested time that you recommend that a patient replaces their implants?

Dr. Houssock (24:39):
I don't. I get it asked all the time though. They used to say a decade. So every 10 years, I don't even know where they got that number. I think they made it up and I say, and whenever I say they, I'm talking about before I was in practice, that was what was said, and now I don't know what to say except I think that you should just continue your regular monitoring and follow up with those ultrasounds. And if the implants are feeling fine and doing fine and you're not having any issues with it, I really struggle with telling patients they have to replace them. I will say if an implant's 15 years old, something like that, and we're already going in to do something else, I will mention it to them. I'll say, Hey, at some point you're going to need something done. We're already going in for blank. Why don't we just, well, just something to think about. We could exchange the implants while we're in there, but it doesn't have to happen. They definitely don't have to.

Val (25:33):
It's like if it ain't broke, don't fix it.

Dr. Houssock (25:34):
Yeah. I would say.

Val (25:37):
As far as having kids after breast augmentation, have you heard anything about affecting breastfeeding or do you have a lot of patients that come in and will ask you, should I wait before I'm having a breast augmentation if I plan on having children?

Dr. Houssock (25:54):
Yeah, so that's actually a question I ask every patient. If they have children, are they done having children? If they haven't had children yet, are they planning on it? I think ultimately it just helps us guide them as to what the best timeframe is for them to have an augmentation. You absolutely can breastfeed with an implant. I can speak from personal experience, so can Val.

Val (26:17):
Me too.

Dr. Houssock (26:20):
Yeah. We had no problem feeding our children with implants. So I usually say to patients that the ducks don't, as far as we know, and from past experiences, the ducks are not affected by that implant. And so if a patient could produce before the implant, they'll be able to produce after. That's a hard thing for women who really young and have never tried. So I always say, if you've never tried breastfeeding, we don't know if you're one of the 30% who may not be able to breastfeed, because that's a real number out there. We don't talk about that in the breastfeeding world, but there are women who just naturally can't breastfeed productively. And so I always talk about that. I think it's really important to talk about that with every patient, that if you haven't breastfed and you're about to go undergo breast augmentation if you can't afterwards, I don't want them regretting their implants and feeling like they did this to themselves because it could very well be that they never were going to be a producer.

(27:21)
So we talk about that. The studies will show that there is silicone in the breast milk, there is silicone in the bloodstream, but the levels are so low that they are in no way at a level that would be damaging to the baby or the mom. That study has been done many, many, many times, and we're not talking about this today, but this does differ when it comes to doing a breast lift. The risk is changes. Once you start changing the topography of the breast, then breastfeeding becomes a little bit more complicated. Not necessarily 100%, but it can.

Val (27:57):
Our bodies do some amazing things.

Dr. Houssock (28:00):
It's crazy.

Val (28:01):
It's wild. Coolest thing though. How can someone schedule a consult with you?

Dr. Houssock (28:08):
So there's multiple ways. So if you want to come and hang out with us now that you've met Val and I and you love this vibe, you can email info@jevps.com and that will go right to our director of our practice, Danielle, she'll get right in there. You also can go to our website, JEV Plastic Surgery, and you can click on the link to have a consultation. You also can message us on Instagram, either Dr., Dr Care Houssock or JEV Plastic Surgery, and you can call 4 1 0 4 8 4 8 8 6 0.

Val (28:42):
Danielle's your girl.

Dr. Houssock (28:44):
Danielle's your girl.

Val (28:45):
She also talks about the financial part of it. We don't do any money. We just take care of you.

Dr. Houssock (28:49):
Yeah, please don't ask me. I mean, people are always going to want to know. So how much you augments cost, augments are a range. They're somewhere between seven and $10,000. And I know that sounds crazy, but it is a range because do you need a lift with it? Do you need an implant? Do you want silicone? Do you want saline? It all depends. So there is a range, but Danielle can give you a better number if you call.

Dr. Houssock (29:14):
Perfectly Imperfect is the authentically human podcast navigating the realities of aesthetic medicine. JEV Plastic Surgery is located in Owings Mills, Maryland. To learn more about us, go to jev plastic surgery.com or follow us on Instagram at Dr. Care Houssock, spelled D-R-C-A-R-E-H-O-U-S-S-O-C-K, or just look in the show notes for links. If you this episode, please share it and subscribe to Perfectly Imperfect on YouTube, Apple Podcasts, Spotify, or wherever you'd like to listen to podcasts.