Introducing Plastic Surgery Decoded with Dr. Regina Nouhan

Dr. Bob Basu (00:08): Hello, I'm Dr. Bob Basu. And today on Behind the Double Doors, we're sharing a special episode I recorded on the podcast of a fellow plastic surgeon, Dr. Regina Nouhan. Her podcast is called Plastic Surgery Decoded, and she invited me to discuss the internal bra technique. The internal bra technique is widely adored by my patients because it recreates the same result as their favorite pushup bra without the need to actually wear it.

(00:32): You'll hear a walkthrough of the surgical procedure, who the best candidates are, along with a success story about a patient of mine and why GalaFLEX is a preferred material for adding that extra support back in for patients who need it. Regina also asked me the interesting question of what I'd like to see in the future for the internal bra technique. So I'd love for you to give it a listen and hear me in the opposite seat as I switch from host to guest for a conversation about the procedure I love to do.

Dr. Regina Nouhan (01:03): Welcome back to Plastic Surgery Decoded, the podcast where we demystify plastic surgery and provide a foundation for understanding it, whether you're actually considering a procedure or you're just curious. As always, I'm your host, Dr. Regina Nouhan. And in this season number four, you'll find a new approach, including interviews and covering a wide variety of subjects. But after you listen to this episode, I encourage you to go back and really explore the previous seasons, as they are full of valuable information. You get to pick and choose what to learn about next. Season one covers common aesthetic or cosmetic surgery topics and skincare, while season two explains reconstructive surgery topics. Then season three goes over general questions about plastic surgery.

(01:50): Remember that this podcast reflects my experience and opinion, as well as those of any guest interviewed. It is not intended to provide medical advice, nor is it a substitute for a formal consultation with your physician. So stay tuned for this interesting journey we'll take together in the ever expanding world of plastic surgery. Let's go.

(02:13): We've covered some interesting breast surgery topics in the past, but this time around, there's an innovative technique to talk about, one that could be a game changer for patients presenting for first-time breast rejuvenation, as well as those with previous procedures needing revision. Why the possible need for breast rejuvenation in the first place? Well, let's just take a minute to be reminded of the anatomy of the breast and how it changes. The breast is made up of skin, fat, and milk-producing gland tissue with an internal web or network of ligaments, which is usually a strong fibrous support and holds the breast up, giving it shape. Both the skin and the fibrous ligament network can give out or stretch out over time for a variety of reasons, leading to breast sag and loss of shape. Or for some people, the supporting tissues were always thin and never gave much support to begin with, even at an early age.

(03:05): It often comes down to genetics, what we're born with. And of course, gravity plays a part as well, always pulling on and weakening the breast support and the overlying skin. So I'm happy to say we have Dr. Bob Basu joining us today from Houston to discuss his internal bra technique, one in which he has excelled in achieving great, consistent results. He explains how this procedure is different from those of the past, and he describes who the best candidates would be. We also hear a touching story about a patient whose whole outlook was changed by having this surgery performed. Here we go.

(03:44): Well, it's my pleasure today to introduce Dr. Bob Basu, who is a board-certified aesthetic plastic surgeon in private practice in Houston, and he is also a board vice president at the American Society of Plastic Surgeons. So that's pretty cool, Bob. Welcome.

Dr. Bob Basu (04:03): Thank you. It's great to be with you.

Dr. Regina Nouhan (04:04): I'm glad you're here. You've also got a textbook that you published by Thieme Publishers that's called Cosmetic Breast Surgery. So congratulations on that accomplishment.

Dr. Bob Basu (04:16): Thank you. That was definitely a labor of love.

Dr. Regina Nouhan (04:18): Yeah, I can imagine. And one more thing I want to mention, you have your own podcast, and I've listened to it. It sounds great. Could you tell the listeners the podcast name and how to find it?

Dr. Bob Basu (04:29): Sure. Our podcast is called Behind the Double Doors. It's readily available on all the regular podcast services from Apple and [inaudible 00:04:39]-

Dr. Regina Nouhan (04:39): Spotify, et cetera.

Dr. Bob Basu (04:40): Spotify, the other-

Dr. Regina Nouhan (04:40): Yeah. Great. Love it.

Dr. Bob Basu (04:41): ... places that you can listen to podcasts. And we really delve into, just like the title, says Behind the Double Doors, what goes on in the operating rooms in plastic surgery, ambulatory surgery centers. And we try to dispel some of the myths that are out there about surgery and common questions and fears and also try to share some patient experiences as well, too.

Dr. Regina Nouhan (05:02): Yeah, excellent. Well, I'm all about that. That's wonderful. Well, why don't you tell us how you became interested in plastic surgery?

Dr. Bob Basu (05:07): Well, I started out thinking I was going to become a cardiac surgeon.

Dr. Regina Nouhan (05:14): A little bit different.

Dr. Bob Basu (05:14): A little bit different, and started the journey through general surgery, which is a prerequisite training before you become a specialty or specialist. And then I fell in love in plastic surgery because one of the things why I went into surgery is because I really love the precision, the functionality of the surgeries. But the thing that drew me to aesthetic plastic surgery and plastic surgery in general is that in addition to doing a functionally accurate or effective procedure, you have to make things look good. And I love the aesthetic dimension. It was an added challenge and the immediate gratification that your work shows right away.

(05:51): And so I think that's what really drew me to plastic surgery, is that whether you're doing a breast reconstruction or you're doing a cosmetic facelift, I mean, your work shows right away. And so that added challenge or dimension of the aesthetic outcome in addition to the functionality and the precision that's required to do the procedure, that's what gravitated me to plastic surgery.

Dr. Regina Nouhan (06:13): Yeah. And I think that gives some great insight to people listening of what really draws people to plastic surgery and the kind of mental outlook you have to have to be a plastic surgeon. Well, why don't you tell us about your practice in Houston? What type of patients or cases do you focus on primarily?

Dr. Bob Basu (06:31): Sure. Well, my practice is 100% aesthetic surgery of the face, breast, and body. And we see patients not just from the Houston metropolitan area, but also out of state. And now that COVID has settled down, we're starting to see our international patients. Again, Houston is the energy capital of the world, and so patients are used to traveling to Houston for work, for business.

Dr. Regina Nouhan (06:54): Yeah. It's quite the hub.

Dr. Bob Basu (06:56): A healthcare hub, exactly. So we do see patients not just from the Houston metropolitan area, but from throughout the country. And I typically focus on aesthetics of the breast. But, I mean, COVID has changed things. I think people are looking at themselves in Zoom, so my facial aesthetic practice has actually boomed, as people are being more aware of what they look like on FaceTime and Zoom and we're all overdosing on teleconferencing. And so people are more self-aware. So my practice focuses on the aesthetics of the face, breast, and body.

Dr. Regina Nouhan (07:29): Well, let's go over some helpful background information. And again, could you explain for the listeners what naturally happens to a woman's breast shape with age or after childbearing?

Dr. Bob Basu (07:40): Sure. So typically, our collagen, our elasticity, our tone to our tissue is not the same as we age. As everyone knows, you don't need to be in healthcare to understand this, but the tissue that we have when we're in our teens and our 20s is very, very different than the tissue that we have in our 50s, 60s, and 70s and moving on. So time changes things. And what accelerates change often are our life events. Pregnancies, weight loss, or other medical conditions can absolutely have an impact on tissue quality. So tissue quality is a really important factor in terms of how our bodies change, and that includes the breast. And of course, in layman's terms, gravity is gravity, right? And so time and life events can definitely take their toll on how women feel about how their breasts look.

Dr. Regina Nouhan (08:31): Yeah. And before we get into your actual procedure for combating this problem, what have been some of the shortcomings of other forms of treatment, other forms of breast rejuvenation?

Dr. Bob Basu (08:45): So a common concern for women who've had kids or weight loss or they're just born with weak tissue is they don't like where their breasts sit. And the common term is sagging, right? They're not happy with the sagging. Oftentimes, a lot of surgeons address that with volume. But volume, meaning an augmentation, does not lift the breast. We all know that. So oftentimes, surgeons will add a lift to their augmentation if there is indeed sagging. And the lift is essentially a skin-tightening procedure. However, all surgeons, including you and I, can only use the tissue that the patient has, right? That's one of the limitations. And so one of the questions I ask patients is, whenever we do an augmentation, we do an augmentation lift or we're doing a lift by itself, what is it that's actually holding our breast up when we do these procedures?

(09:35): And the answer to that question is tissue quality. And it's really important to talk about this. I find that question, that discussion about tissue quality is really under discussed in plastic surgery. And that's one of the drivers for why I decided to write that textbook on cosmetic breast surgery, is it's very important that we help educate our peers and our colleagues and have more discussions about tissue quality. So the other question is, what do we do for patients that have poor tissue quality? They have weakness in their tissue. They've either had multiple children or maybe just one child. Maybe they're a weight loss patient, and they've lost that elasticity, meaning that tone to their tissue, and they want their breasts to sit higher, and they want to have more upper pole volume and cleavage. And we're not talking about going huge in size, we're just talking about where the breast sits. And they want to restore volume.

Dr. Regina Nouhan (10:23): And just to clarify, so someone who has good tissue quality has firmer breast tissue or it maintains its shape a little bit more, and someone with poor tissue quality has looser, more stretchy or stretched out flesh tissue, if you will, that can't hold its shape or support.

Dr. Bob Basu (10:46): Right. And we see this a lot in patients who've undergone an augmentation and a lift. And they're initially happy, but then the weeks and months progress, and the breasts are kind of sagging back down again. They're fuller. Clearly, it looks better.

Dr. Regina Nouhan (11:00): With an implant [inaudible 00:11:01].

Dr. Bob Basu (11:01): With an implant, exactly. But they're settling back down again. And again, this goes back to tissue quality. Why is the breast having some recurrence of sagging, is because we've added some weight to the breast, meaning an implant, and the tissue's just not strong enough to support that implant. So in these scenarios-

Dr. Regina Nouhan (11:18): Yes, the crux of the problem.

Dr. Bob Basu (11:18): Right, exactly. And this is not only talking about sagging where the breasts are going inferiorly. We're also talking about when the breasts fall to the side for a lot of women, right, so when they're lying flat. Let's say they're at the beach, and they're lying flat, but they're noticing the breasts falling to the side. It's all about tissue support. It always comes back to tissue support. Why is it some women have an augmentation or they have an augmentational lift, and this doesn't happen? It's because they're blessed with great tissue. So this is where the internal bra technique comes into play, and again, in scenarios where there's weakness of tissue and we need to do something differently besides using the patient's tissue to give much more support. And that something else, is where I do the internal bra technique.

Dr. Regina Nouhan (12:03): Well, that's a great introduction to this technique we're talking about today. Why don't you explain what you mean by the internal bra technique to rejuvenate the breast?

Dr. Bob Basu (12:11): So for patients that have implants or want implants or they already have implants and they want a revision or they're thinking about getting implants, and they're worried about recurrent sagging, the internal bra technique... It's very simple. The internal bra technique essentially recreates the result that a woman's favorite pushup bra, supportive bra achieves for them. So if they like what they see when they have that supportive pushup bra but they don't want always have to wear that supportive pushup bra, then we need to do something else to provide that support. And the internal bra technique essentially takes the effect of the cup of that pushup bra and internalizes it in your tissue to support that implant.

Dr. Regina Nouhan (12:54): Wonderful. And how do you do that?

Dr. Bob Basu (12:57): There are a lot of different materials that are out there to provide soft tissue support. Now, my preferred material - and I've tried the different materials out there - it's called GalaFLEX surgical mesh. And I have no relationship with GalaFLEX or anything like that, but I've used a lot of it. I use the material multiple times on a weekly basis [inaudible 00:13:19].

Dr. Regina Nouhan (13:18): Yeah, you like the product. Yeah, it does a good job.

Dr. Bob Basu (13:19): I should have invested in it, but I didn't. For disclosures, no financial relationship whatsoever. But GalaFLEX. And when I tell patients GalaFLEX surgical mesh, I have to immediately tell them, now, I know you've heard about mesh and all the bad stuff with mesh with abdominal hernia surgery or OBGYN surgery, but this is not that kind of foreign body mesh. This is actually made out of a suture material called P4HB. This suture material's been around for decades, and this suture material was cleverly weaved into a mesh. And hence we call it a surgical mesh, but it's a resorbable surgical mesh.

Dr. Regina Nouhan (13:56): Kind of like a netting.

Dr. Bob Basu (13:57): Right. So what that really means is that this goes away. The suture material slowly dissolves over time, 24 months. And what replaces it is our own natural type III collagen. And the studies have shown that years out, what replaces it is anywhere from two to four times stronger than any other native tissue. So this is all about getting long-term sustained support to a breast implant.

Dr. Regina Nouhan (14:21): That's fantastic.

Dr. Bob Basu (14:23): Now, how do we place it? Well, I show patients, and I have them take their hands, and I tell them, imagine that the palms of your hands is the cup of your favorite pushup bra, and show me while you're standing in front of the mirror where you want your breasts to sit. So they recreate the pushup bra effect, and I then tell them, where your hand is sitting underneath your breast, pushing your breast up, that's where the internal bra technique material goes in internally, inside the breast. It's not outside the breast. And so that helps to support the implant and help maintain upper pole volume. It prevents the implant from dropping back down, meaning recurrent sagging.

Dr. Regina Nouhan (15:03): Yeah, that's key.

Dr. Bob Basu (15:04): It also helps to prevent the implant from falling to the side, which is a big problem for patients that have weak tissue. It's a great tool for whether you want to go very conservative with your augmentation or whether you want to go big or go home. It's a very great tool for heavy, large implants, right, because gravity's gravity. And so if you go with a large implant, that can really put stress on skin envelope. So the internal bra technique takes the pressure off weak skin and holds that implant up. And that's why it's so powerful.

Dr. Regina Nouhan (15:32): And the mesh, how do you attach it internally?

Dr. Bob Basu (15:36): Great question. So basically, I use sutures, just like sutures we use on any surgical procedure, dissolvable sutures to stick around for about three to six months. And I anchor, inset, meaning anchor it, the inferior edge of the GalaFLEX material to your chest wall where what's called the inframammary fold crease or the underside of the fold is. I anchor it to the chest wall with multiple sutures. On some patients, they're just born with their breasts sitting very low on their chest wall. In other words, they have a very tall chest wall height. And the underside of the breast, also known as the inframammary fold crease, simply sits really low, or they have fold asymmetries where one breast fold crease is much higher than the other.

Dr. Regina Nouhan (16:17): Yes, that's common. Yeah.

Dr. Bob Basu (16:19): All these can be totally addressed with the internal bra technique because I'm recreating, either reinforcing or raising the position of that inframammary fold crease, meaning that under the breast fold crease that we all have. And so the bottom edge of the GalaFLEX gets inset to the chest wall, and the upper edge of the GalaFLEX material gets anchored or inset to the inferior edge of the pec muscle or the muscle that we use when we place the implant underneath the muscle.

Dr. Regina Nouhan (16:50): That's fantastic. So you have created this internal sling, if you will, to kind of support the implant and add, as you say, an internal bra.

Dr. Bob Basu (16:59): Right. And another way to think about this for your listeners is that it's almost like a hammock effect, right? It's holding that implant up, and it gives much needed support when weak tissue's just not strong enough to do the job.

Dr. Regina Nouhan (17:13): How new is this? How long has it been around?

Dr. Bob Basu (17:16): So I've been doing internal bra technique for probably 15 years. And I'll tell you where I actually learned the technique was from breast reconstruction with tissue expander implants. And back in the day-

Dr. Regina Nouhan (17:27): Reconstruction after cancer.

Dr. Bob Basu (17:28): Right, reconstruction after cancer. So a woman who was facing breast cancer, they opted for a mastectomy and wanted reconstruction. Again, techniques have changed significantly over 20 years. But back then, we would use what's called a tissue expander implant, which is basically a saline filled implant, a salt water filled implant that you can add saline to and literally stretch out the skin envelope that was left behind after mastectomy. I would call it an under construction implant. I would place the implant partially under the muscle, but to hold that expander implant in place, we would use different materials to hold that implant in place. At that time, we used materials called... the brand names are AlloDerm or what's called an acellular dermal matrix.

(18:14): But from that experience, I applied what I learned from my reconstructive practice over to these more complex revisional cosmetic implant cases, where patients have had implants before, they're unhappy with where their breasts sit, or they've had capsule contracture, which is scar tissue around the implant, and you've got to take all that scar tissue out. Sometimes it weakens the fold, what's left behind. So all of this, the internal bra technique is really designed to give support, and it's designed to control the pocket or the housing of the implant so the implant doesn't move around and go in places where the patient doesn't want it to be.

Dr. Regina Nouhan (18:51): Yeah. That's great. Well, now you're describing use of the mesh with an implant. Do you ever use it by itself in just a breast lift if you weren't doing an implant?

Dr. Bob Basu (19:05): That's a fantastic question that I get a lot from patients. And I do have colleagues that utilize GalaFLEX surgical mesh in breast lift cases. But I'd like to be a little honest with you. I'm not that impressed with the results that I've seen. And they're okay. I mean, they're okay. Does it help a little bit? I think so, but I don't think it's a quantum leap of a difference that I'm seeing in terms of outcomes, to be honest with you.

Dr. Regina Nouhan (19:30): Yeah, to make it worth it to use it.

Dr. Bob Basu (19:31): And when we do a breast lift or a breast lift with a reduction, in those cases where we're doing a reduction, we're actually taking volume out, and we're lightening the load. Think of it that way, right? When you're doing a breast lift with a breast reduction, we're taking tissue volume out. We're lightening the load on the skin. And so when you lighten the load, there's less pressure on the skin.

Dr. Regina Nouhan (19:50): Yeah, less gravity effect. Yeah.

Dr. Bob Basu (19:52): Exactly. And with a breast lift, obviously we're not taking volume out, but I think there's things that we can do internally with a breast lift that help to keep it up a little bit better. So I typically don't use it in just a breast lift. I typically offer the internal bra technique with GalaFLEX surgical mesh in revisional cosmetic breast surgery cases. And it's quite common, and I guess I've gotten known around the country for this, where patients have had two, three prior surgeries, and they're frustrated. And so we offer this technique. Oftentimes, we have to do a breast lift with it to get them very close to the results they've been seeking.

(20:29): The other type of patient that we look at are for patients who work out a lot or lean out a lot. A lot of the people that are in the fitness industry competing, they lean down for competitions. When they lean down, they lose volume in their breasts, and that impacts their tissue quality. So the internal bra technique has become very popular for my patients who are bodybuilders or are competing in bikini competitions when they're leaning down because when they're coming in for a primary or first time breast augmentation, they want a little extra support. So the people that I offer internal bra technique are revisional implant cases or patients who are opting for an implant for the first time that just want a little bit more support, or patients who are coming in for an augmentation with a lift that want a little bit more support.

Dr. Regina Nouhan (21:15): I'm sure the listeners would like to know which type of case is more challenging, a primary case or a revision case?

Dr. Bob Basu (21:21): A revision case for sure. Primary cases-

Dr. Regina Nouhan (21:26): Scar tissue and all sorts of other things in there.

Dr. Bob Basu (21:27): Well, it depends. It's like sometimes patients don't remember what surgery they had, and sometimes...I mean, I've seen patients that have had their surgery 30 years ago. I would not expect them to remember what pocket the implant, what ty- sometimes they can't remember what kind of implant, and I don't blame them. It's been 30, 35 years. Remember that line from Forrest Gump, "Life is like a box of chocolates." So sometimes revision surgery is like opening up that box of chocolates, and you don't know what you're going to get. And the wonderful thing about the internal bra technique is that's okay because it gives me a tool. It gives me the power to control whatever scenario that's presented to me. And I think that gives me a lot of confidence going into very complex revisional breast surgery.

Dr. Regina Nouhan (22:10): That's excellent. Well, let me also ask you, in using the mesh typically for your internal bra technique, are there any contraindications? And by that, we mean any cases where you probably shouldn't use this material in someone's body?

Dr. Bob Basu (22:27): Great question. I believe there's a preservative that's utilized that has some tetracycline. So if someone did have a tetracycline antibiotic allergy, that may be a contraindication. That being said, we wash the material prior to placing it. So I'm not aware of any allergic reactions with this nationwide. So I think it's a very tolerable material, and it's a material that goes away.

Dr. Regina Nouhan (22:54): Yeah, it dissolves.

Dr. Bob Basu (22:54): But it doesn't dissolve too fast. There's some other materials that are out there that are lower cost that go away in three to four months. And that would keep me up at night because if someone's investing their time, money, and energy to do this revisional procedure, I sleep better knowing that GalaFLEX sticks around for two years.

Dr. Regina Nouhan (23:13): Yeah, there's more chance for the surrounding tissues to thicken and build up and provide that support you're talking about.

Dr. Bob Basu (23:18): Right, exactly. It just gives me more confidence. And I do have a decent amount of followup in the textbook that I wrote in the chapter. I have one of my early patients with GalaFLEX that I did many years ago. I have 18-month follow up for her. But then she came back after COVID, probably about four or five years later. No, actually five, six years later. She's happy with her breasts. And this was a severe case. She had large saline implants, had two attempted lifts and just couldn't get her breasts up. And ultimately, she wanted a much smaller result. She wanted to downsize, but she wanted that higher, tighter look. And she had undergone two other surgeries with two other very good surgeons, and they tried to revise it with a lift, but it comes down to tissue quality. And she sagged right back down.

(24:02): And in my chapter, I show a before/after picture of one side done, one side not done. And with the GalaFLEX, I've been able to raise her breast up on our chest wall by about three inches. And the wonderful thing is I have the followup, 18-month followup, that it's staying in position. And then fast forward to recently, post-COVID, she's gained some weight on our tummy. So we're going to do some liposuction. Who didn't gain weight after COVID, right? So we're going to do some liposuction on her tummy, but her breasts look fabulous.

Dr. Regina Nouhan (24:28): It's got to be a thrill.

Dr. Bob Basu (24:29): And now that's a good, what, five, six year followup, and it's sustaining. And she's super happy with her breasts, no complaints whatsoever. And I'm thankful that I had these tools to help her.

Dr. Regina Nouhan (24:40): Yeah. Well, and that touches on whether or not people should expect to need some sort of revision later in life. We often tell patients with implants they need revisions. But what about just in terms of shape and position of the breast?

Dr. Bob Basu (24:56): Absolutely. I mean, it does help to give support, but I tell patients, look, particularly in the revisional cases, this is complex stuff. And I do a lot of it on a regular basis, and I do some very complex revisional surgery. And even in my hands, I tell patients oftentimes in cases, I'm juggling volume, volume symmetry, the skin envelope, the nipple position, correcting lateral malposition, correcting inferior malposition. I mean, that's a lot of variables that we're juggling. And I tell my patients, I may need a second shot to fine tune your result. Now, odds are overwhelmingly high they're not going to need a revisional surgery. When I say overwhelmingly high, 90, 98%. But I prepare patients that I might need to revise some of your scars, or maybe I have to tweak something because this is complex revisional surgery. And oftentimes I'm managing four, five, six, seven different variables in one surgery and trying to correct them all.

(25:56): And so we understand some of the limitations of some of these complex revisional surgeries. So I do prepare them that they might need a tweaking procedure. And the good news, it's really, really rare that I need to do a tweaking procedure. Now, long term, everyone's bodies are going to continue to change. And like I said, I've been doing internal bra technique for 15 plus years now, not always with GalaFLEX. I used some other materials when GalaFLEX wasn't readily available. But our bodies will continue to change. And so one of the things that I've learned is that internal bra techniques, particularly with GalaFLEX, are really powerful of holding up the implants, but they're not as great at holding up your skin quality.

(26:44): Remember, the GalaFLEX material is kind of a little hammock for your breast implant, so it holds it in place. So the implant's happy. But if you really have weak tissue, let's say you're a massive weight loss patient, or you're just born with really bad tissue, or having multiple kids really took their toll on your breast tissue, you have a lot of stretch marks - some people have really bad tissue - you may notice over the next 5, 10, 15 years the skin kind of draping off the implant. It's called a mild waterfall effect, where the skin is kind of waterfalling off where the implant and GalaFLEX have been sitting, in which case you may need a revisional lift.

(27:19): Now how do we predict that? We can't. If I could predict that, I'd be looking at a crystal ball. I could tell the future, right? I can't. But the good news is with the followup that I have, most patients are really happy. Again, I have a good 15-year followup on different techniques. That being said, any surgery, our bodies will continue to change over the next 10, 15 years. So obviously, you may need revision surgery. And that's true for any implant surgery, right, is that if you're looking for one and done and you'll never need a surgery again, the best thing to do is to do no surgery.

Dr. Regina Nouhan (27:51): Yeah, that's a good point. Well, what can patients expect after surgery? What's the downtime like? And are there any absolute dos and don'ts you tell people?

Dr. Bob Basu (28:00): The recovery is actually very similar to revisional augmentation with a lift. So I typically tell patients you might have a little bit of soreness for a few days. I'm saying three to five days. You should be able to go back to a desk job at the office within about a week. Just no heavy lifting, strenuous activity, working out between four to six weeks, depending on what I'm doing in the surgery. Obviously, much easier recovery on a primary, meaning first time augmentation or augmentational lift. Revisional surgery, depending on what we encounter and the complexity of the surgery, but typically four to six weeks until you can get back to the gym and activity as tolerated.

Dr. Regina Nouhan (28:33): Mm-hmm. That's nice. And then are there any potential complications that are specific to this procedure? Now, all surgeries have potential complications, but patients may wonder if they're going to have inflammatory problems or reactions to the material or whether they'll be able to feel the mesh.

Dr. Bob Basu (28:52): Yeah, great question. So the good news is that it's a fairly safe procedure [inaudible 00:28:57] GalaFLEX. GalaFLEX is dissolvable. It dissolves away. So the risk profile... because you're right, every surgery has risks, and we do everything humanly possible to minimize those risks. But the risks of using the internal bra technique with GalaFLEX are no different than your augmentation with lift or revisional augmentation with lift. Now, the only additional things I tell patients are, particularly in patients that have super thin tissue... And for your listeners, you know who you are, right?

Dr. Regina Nouhan (29:26): There you go.

Dr. Bob Basu (29:27): There's some patients out there that have parchment-thin breast tissue. It is what it is. Then I prepare a patient, you may be able to feel the GalaFLEX in certain spots. Now, I try to lay the GalaFLEX out so it's smooth. But you can sometimes feel maybe where the sutures went in in the chest wall to anchor it. It might be palpable, particularly in patients with thin tissue. If you have thicker tissue, that's rarely an issue. I have not seen any cases of extrusion. Extrusion means if a foreign material like an implant or GalaFLEX bust through the skin, basically, right, work its way out. Fortunately, I have not seen any problems with that at all. But technically, in severely thin tissue, it's a risk. It's a possible risk. I just haven't seen it at all.

(30:17): The good news is risk for fluid collections or seromas are really, really rare. I mean, I am now not using drains for any of these procedures unless I am dealing with a case that has bad capsular contracture, meaning scar tissue around an old implant that I'm cleaning up, and/or they have bad scar tissue around a ruptured old implant and it's a mess in there. Then I'll put a drain in. But rarely do I put drains in now for these procedures. It's not necessary because GalaFLEX is a little matrix, and it's very forgiving, and I just don't see the fluid collections that you could potentially see with other materials such as acellular dermal matrix products or AlloDerm or Strattice. I just don't see it. So GalaFLEX is very forgiving. And from a safety profile, it's very, very similar to the risk profile of revisional augmentation with lift or augmentation, any of those procedures. It's the same risk profile.

Dr. Regina Nouhan (31:08): That's great. Well, just in general, how important do you think breast rejuvenation is to some patients psychologically? Do you have any other stories about a particular patient you'd like to share where it was very meaningful to have this type of procedure performed?

Dr. Bob Basu (31:25): Absolutely. Yeah, actually a very young patient. She was a college student. And I mean, there's so many, but this one in particular comes to mind. She had severe sagging. She was not a weight loss patient. She was not someone who's had kids. She was someone that was born with really bad weak tissue. She had her breasts sagging down to almost her belly button. I wish I were exaggerating. So you can imagine, as a young girl, the teasing that she endured, the bullying that she endured. I can't even imagine it, right? And you could see it in her demeanor, walking in. And we talked about creating a treatment plan. And I did a staged approach. I did a breast lift first because the sagging was so severe, even I didn't have the courage to do the internal bra technique [inaudible 00:32:15].

(32:15): So we did a lift first, but she wanted to restore some volume. So her breasts looked like they were completely hollowed out. They were sagging down, and the nipples were pointing down. And so we did a lift first to make the breast envelope look right. So what we did, for your listeners, what that means is we took her breasts where the nipples were pointing straight down to the floor and brought them up to point forward and give her a more nice rounded breast shape. It didn't have the volume she wanted. Now, we brought her back for a second stage, where now we wanted to add volume. But remember, earlier in this discussion, we talked about tissue quality. The fact that I did a breast lift, all I did was rearrange and tighten the tissue that she had. I didn't change her tissue at all. There's nothing I can do to change her tissue.

Dr. Regina Nouhan (32:57): Took out some extra skin.

Dr. Bob Basu (32:59): Right, exactly. It's basically skin tightening. It's a breast left. So she wanted to go a little bit fuller, but I was worried that if we added an implant to her very weak tissue, even though it's been lifted, she's going to experience recurrence of sagging. So what we did in her step two was we did an augmentation with a gummy bear silicone gel implant, and we did an internal bra technique to hold it up. And she's incredibly happy.

(33:20): Now, the confidence level that she had after she was completed, I mean, it's just a night and day difference. I mean, she walked in with confidence. Her posture's better. She's glowing because it was all about confidence. And I think that has to do with not just the internal bra technique, but so much of what we do in plastic surgery is giving people their confidence back. And I think that it's just a positive cycle of how they feel about themselves, their outlook in life. And we see this in a lot of our patients, whether [inaudible 00:33:52] young patients or moms that feel frustrated after having multiple children and they've just lost their confidence. And I think doing things to make them feel better and more confident affects their lives. And it's all about quality of life, right?

Dr. Regina Nouhan (34:05): Wow. That's a fantastic story. Thank you for sharing that with us. I'm just curious, as we're finishing up here, do you envision any future modifications or improvements of the internal bra technique or anything you would like to see but maybe we don't even have the technology for yet?

Dr. Bob Basu (34:22): I would love to see, hopefully in my professional lifetime, where we have the technology where we can inject large volumes of fat or a scaffolding where we can augment a breast without using an implant. Not that implants are bad, but they are medical devices, and no medical device lasts forever. And so it would be nice to have the technology, whether you talk about it from the field of regenerative medicine, or there's a lot of science going on that's cutting edge.

(34:53): But I don't think we're there yet. We do fat transfer for the breast, and you can do fat transfer for breast augmentation, but generally for small volume augmentations. But for someone that wants a much bolder, larger enlargement or enhancement, that requires two, three, sometimes four sessions. And that can get quite costly the number of times. And then who wants to go back to surgery three or four times?

Dr. Regina Nouhan (35:15): Yeah, a lot of healing.

Dr. Bob Basu (35:17): A lot of healing, a lot of recovery, and a lot of cost, whereas an augmentation takes us 45 minutes to an hour to do, and it's in and out surgery. Recovery's fairly quick. So I'd love to see that evolve. I don't know if we'll see that in our lifetime, but it may. But it may. Who knows, right?

Dr. Regina Nouhan (35:32): That's a great thought. Well, I tell you, Bob Basu, you've been just a great resource for the listeners today. You've really given them something to think about and explained not only the mechanical components of this procedure, but the potential psychological impact, too, which I think is wonderful. Do you have any lasting thoughts you'd like to leave the listeners with about our subject today?

Dr. Bob Basu (35:55): No. I would say that if you are considering a cosmetic procedure, I always tell all my friends, make sure whoever you go to, make sure they're board certified in plastic surgery. There's so many people that want to be plastic surgeons, and there's too many YouTube and weekend courses out there. I think people need to remember that plastic surgery is real surgery, and it's very important for your listeners to do their homework and make sure they go to a surgeon who's certified by the American Board of Plastic Surgery and who's a member of the American Society of Plastic Surgeons. I always tell patients and friends, make sure you go to a fully accredited ambulatory surgery center or hospital.

(36:36): I also go further and say ask who's doing your anesthesia. I'm proud to say that in all my cases, I have a board certified MD anesthesiologist who's got 23 years of experience under her belt. She's been with me for 14 years and counting. And I go into every case knowing I've got an anesthesiologist who's outstanding, and that gives me a lot of confidence for my patients.

(36:54): And then look at before/after pictures, clearly. I mean, you want to make sure that you see results on their website, many of them in the procedure of your interest, because that shows some degree of experience, and make sure you're seeing the results that you want to see. And ultimately, you've got to visit. You have to visit the practice and make sure you feel good about their team because what we do for our patients, look, I'd love to take all the credit, but it's a team effort. It takes the team to create the dream. And that's very true. And I think we've got a phenomenal team at our practice, but you have to make sure you connect with them and it feels right. And so don't just jump at the cheapest deal. I know it's tempting, but that can get you into trouble, right, because oftentimes, cheap cosmetic surgery can be the most expensive procedure that you endure, and you want to avoid that.

Dr. Regina Nouhan (37:46): In terms of revisions and other problems.

Dr. Bob Basu (37:48): Exactly. Exactly. So don't jump for deals, and don't jump for what looks shiny on Instagram. It's okay to go to Instagram. I mean, it's okay. It's one of the things that you want to look at, clearly. I'm not trying to discount that, but that shouldn't be the only thing. So do your homework.

Dr. Regina Nouhan (38:03): Just one part of the puzzle.

Dr. Bob Basu (38:05): That's right.

Dr. Regina Nouhan (38:05): Great. Well, thank you so much for being here and sharing your wisdom with us, and you've got a great future ahead of you, even though you're already very accomplished.

Dr. Bob Basu (38:15): Well, thank you very much, and it was great. Thank you for inviting me. It was great to be with you.

Dr. Regina Nouhan (38:26): Take care.

(38:26): Well, that's our show for today. Hope you enjoyed it and learned something too. Don't forget to subscribe, rate, and review. Please share this podcast with someone else who might be interested. And while you're at it, check out the podcast website for related topics to explore. It's www.plasticsurgerydecoded.com. And as always, thank you for listening to Plastic Surgery Decoded.