Well with Arielle Lorre - 202: All Things Breasts with Plastic Surgeon Dr. Robert Cohen

Episode Date: October 12, 2022

In this episode, I'm talking to board-certified plastic surgeon Dr. Robert Cohen, who performed my procedure, about all things breasts. We discuss the benefits of plastic surgery and how it can improve your happiness and quality of life; breast augmentation procedures; the differences between implants and fat transfers; how to best determine size; breast implant illness and risks and so much more.   For more info, visit Dr. Cohen's website at www.drrobertcohen.com.   Go to Nuuly.com and enter the code BLONDE20 when you sign up to get $20 off your first month.   Right now, Sakara is offering our listeners 20% off their first order when they go to Sakara.com/BLONDEFILES20 or enter code BLONDEFILES20 at checkout.   Visit athleticgreens.com/blondefiles for a FREE 1 year supply of immune-supporting Vitamin D and 5 FREE travel packs with your first purchase.   If you’re looking for a sign to buy yourself the diamond (or gold hoops, bracelet, or necklace), then this is it. Make your own day and go to mejuri.com.   Right now, LMNT is offering my listeners a free sample pack with any order. Get yours at DrinkLMNT.com/BLONDEFILES.   Produced by Dear Media.    See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

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The following podcast is a dear media production. Hey, welcome to the Blondefer podcast. I'm your host Ariel Lori, and I'm here to talk all things wellness. From how to achieve optimal health and well-being to the best beauty tips and everything in between, no topic is off limits, and I'm bringing it to you real and unfiltered. I know there is so much information out there, so I'm here to help you navigate it all. Thanks for listening. Let's get into it. Hi, everybody. Welcome to the show. I am very excited about today's episode. because it is one that people have been asking for ever since I shared about my breast augmentation over on

Instagram. And I also talked about it in my podcast as well a couple weeks ago. I kind of went over the basics of what I did. But I wanted to have the real expert on. So today I'm talking to my doctor, Dr. Robert Cohen. And I told him in this episode, and we talked about it after, I really think that this is like the best comprehensive episode on breast augmentation. We cover different types of lifts, different types of implants. We talk about fat transfer versus implants, which I know a lot of people are interested in. We talk about breast implant illness, which I know is a big concern for people. So whether you are thinking about having a breast augmentation or you have one scheduled

or you are just interested, I think that this episode will really be helpful. and resonate and you'll have all of the information that you need to go into your doctor and ask questions or make a consultation with Dr. Cohen, which I'm sure you'll want to after you listen to the episode. He has a passion for education and that really comes through in this episode. So it's very comprehensive, like I said, but also really easy to digest. So a little bit about Dr. Cohen. He went to Tulane University School of Medicine in New Orleans. He chose that school for its intense hands-on surgery training. In med school, he earned top honors in surgery and published numerous research papers. One of these appeared in Plastic and Reconstructive Surgery,

the Journal of the American Society of Plastic Surgeons. Then he was accepted into the exclusive Ivy League Plastic and Reconstructive Surgery Program at Dartmouth, where he honed his skills under the instruction of some of the world's leading plastic surgeons and educators. In 2005, Cohen returned home to Scottsdale, Arizona, where he established what is now a thriving private practice. He earned board certification from the American Board of Plastic Surgery in 2006 and continues to be an active member of the American Society of Plastic Surgeons and the American Society for aesthetic plastic surgery. Through his continuous research, publishing, and presenting, Dr. Cohen has pushed the frontiers of his specialty and emerged as a thought leader in aesthetic

surgery. He is regularly invited to present and teach courses to his fellow plastic surgeons on topics such as optimal techniques in breast augmentation and complex breast revision surgery. We talk about all of this in the episode and he also practices in Beverly Hills now in addition to Arizona, which is where I saw him. So with that, I will let Dr. Cohen do the rest of the talking. Please enjoy the episode. Welcome, Dr. Cohen. Thank you so much for having me. I really do appreciate it very much. I am really excited to talk to you. And I know my audience is very excited as well to just talk all things,

breast, and maybe we'll get into some body as well. But yeah, ever since I shared on Instagram that I had this procedure done, there have been just endless questions. A lot of people who are really curious, a lot of people who are having a procedure coming up themselves. And so we got tons of questions. But to start, why don't you just introduce yourself to the audience? tell them a little bit about who you are and what you do. Okay, sounds good. So my name is Dr. Robert Cohen.

I'm a board certified plastic surgeon. I specialize in aesthetic surgery of the breast and body. I've been in practice since 2005, so quite a number of years and I've been, you know, operating in some forms since probably the late 90s during my med school and residency years. My practice is very heavily focused on breast and body and a lot of complex surgeries. So from kind of early in my practice, I got very interested in dealing with some of the hardest problems and the most difficult challenges in aesthetic surgery, the breast and body tend to be revision surgery. But I also got into basically anything to do with breast and body. I really got very into deep techniques, like trying to learn as many different ways of approaching

problems as possible. And so as a result of that, you know, I sort of got recognized for what I was doing and I ended up doing a lot of talks around the world to present to other surgeons as far as different techniques, written quite a few book chapters and tons of articles on these topics. So for me, it's always been a real passion and just kind of getting as educated as possible. Staying on the cutting edge of all these different techniques has always been a big, kind of a big deal for me. And that's something I've always focused on. How did you land on breast and body?

I'm just curious. Well, you know, so in terms of getting just into plastic surgery in general, I actually am one of the rare people who knew what they wanted to do in high school. So basically, if somebody had asked me what I wanted to be when I, you know, grew up or however you want to put it, I would have said plastic surgeon. And surprisingly, I didn't realize how much work it would take to get from high school to where I am right now. And probably if I had, it would have been a little scary.

But so that's what kind of got me interested. I was very good with my hands in terms of art and sculpting and things, but I also liked science a lot. And then when I did my residency, we did quite a bit of breast surgery during my residency. So it was something that I had a very wide array of techniques I had learned there. And then during my fellowship, even more so. So for me, that was sort of where a lot of my skills were oriented already. And then when I got into practice, I decided that, you know, in my opinion, I think when you're more focused on something and you have a deeper level of knowledge on that, you're better than if you just do a lot of everything.

So I wanted to get a little bit more focused. So I still do quite a wide array of surgeries, but I decided to focus more neck down, leaving the neck up for other surgeons. And so I got more and more focused on that. And for whatever reason, I just find it's very, it's very satisfying surgery. You get instant gratification. you can see the changes physically that you're creating during surgery. And it's a surgery that makes patients really happy, you know, whether it's a breast reduction or somebody's having like back and neck and shoulder issues

and you make their breasts lighter and feel better, or somebody's had pregnancies where they've lost a lot of their volume and maybe you have drooping of the breast or the abdomen and they're maybe self-conscious about being, you know, intimate with their partner or whatever it might be, you fix these problems and it really boosts people's quality of life and self-confidence and stuff. So for me, I really love doing that kind of story. surgery. That was one of the reasons why I chose you. I have other friends who have gone to you as well,

and they had great results. So that was kind of like the best testimony, I guess, testimonial. But I also like that you, like you said, focus on the neck down. I mean, there are great surgeons who do a little bit of everything, but I was like, I want somebody who does like breasts day in, day out and, you know, and I just felt really comfortable with that. And I can definitely attest to be just change in quality of life. I mean, I didn't have like really significant drooping. We'll get into my whole procedure. And I never really cared that much until the last couple years because I had like loss of volume, some sagging. And a lot of my friends who have done breast augmentation said, like, you have no idea how just confident you'll feel.

feel. Not that I felt like I even needed the confidence. But I was like, yeah, yeah. And then when I did it, I mean, one of the best things I ever did. I'm glad to hear that. I like it really does. Like I just feel so good in my body. So let's kind of dive into what we did, which I've talked about a little bit on Instagram. But I initially for years said that I would do fat transfer in a lift. And then when I came to see you, we ended up doing a lift and an implant. So we'll get into like the difference between the two and the difference in outcomes. But we also did a circumariolar mastopexe, right? And back to what you were saying about like really honing these skills.

And I feel like that's a procedure that some surgeons don't like. So let's get into like that type of lift in particular and kind of what we did. Sure. Sounds good. And just to go to your prior point just really fast, you know, when you said, like, you just felt confident already, but it just gave you another level of confidence. And it's like one of the best things you've ever done. Studies have shown that with plastic surgery, like, let's say you go buy a new car and the excitement of the first couple months. And then after a while, it just becomes your car and then sort of like the excitement wears off. We found that with plastic surgery, when it's done, you know, properly for the right reasons, that the happiness doesn't wear off. It's like every time you try on a new outfit or yourself in the mirror in a different angle, that kind of happiness returns. So it's one of those things that you don't tend to get a lot of buyers remorse with plastic surgery. If it's done properly, patients are usually just happy year after year. So I'm really glad that's been your experience so far. Something that I am really trying to focus on right now is celebrating the small moments every day that deserve to be recognized,

not just the big moments. This is especially helpful to do if you're going through anything hard, just looking around and appreciating things and being grateful and doing nice things for yourself. That is what I have been doing for myself as I have been navigating a very challenging time, as you guys know. And one of the things that has been making me feel really good is buying jewelry for myself. So I think most people think about buying jewelry for occasions only. But this is where Missouri comes in. So Missouri does find jewelry differently by celebrating every day. not just those big moments.

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dainty. It's perfect for stacking. And then it also just looks really pretty on its own. And then I got the bold huggy hoops. So you guys know I have a lot of piercings in my ears. And I love these hoops because they're this beautiful gold and they're still small, but they're a little bit thicker. So they really stand out while still being perfect for just every day wear. So definitely. go check out everything on Missouri's website. They're all so beautiful. And if you're looking for a sign to buy yourself the diamond or the gold hoops or the bracelet or the necklace, whatever you're looking for, then this is it. Definitely treat yourself. You can make your own day and go to Missouri.com. That's M-E-J-U-R-I.com. How do I ask my boss for a race? I'm so jealous of my co-workers' promotion. I just don't know what to do. is there a good way to brag about my accomplishments? Careers are complicated, and there are so many hush, hush topics we're told we can't talk about.

That's why you have the Career Contessa podcast. I'm your host, Lauren McGovern. And each week I'm joined by experts to help you overcome your workplace woes with actionable advice that you can use today. Subscribe to the Career Contessa podcast and make progress in your career every Tuesday. So talking about your surgery specifically in circumary or mass, So basically, when you came to see me, you know, we had a discussion. And the first thing I always do is really, I want to understand what is the patient's goals, what bothers them, what is, what are they seeking to change so I can try to match the surgeries closely as possible with their personal goals and also make sure that their goals are realistic for their anatomy. So you came to me saying, you know, you felt your breasts are a little bit smaller than you liked. And then when we did the exam, we found out that, you know, you had one breast was a little bit bigger than the other and had some mild drooping. And you don't have a lot of body fat. So for somebody coming in interested in fat grafting, but not having a lot of fat to graft,

then you have to make a decision. Do you want to compromise significantly on the size? Or do you want to get the volume that you want, but maybe compromise on having implants instead? So in your situation, when we're talking about maybe about a cup size increase, I didn't feel like you had the fat to do that. And so I felt I was going to be able to get the shape and the look that you wanted with implants as long as you were open to that option. So that was kind of our first big decision that we made.

And then in terms of creating better symmetry, because really shape and symmetry should be the priorities with breast surgery oversize. Size is secondary to shape and symmetry. That's really what creates the beauty. And so with the symmetry, we wanted to make sure that we evened out the size because your breasts had little different volumes, plus the drooping. So if you don't correct grouping at the same time as implants, then you can have a fuller breast that's still droopy. That's not a good tradeoff. So for you, I felt like you were kind of between techniques. And that's the case with a lot of patients.

And that's why it's so important to have a really wide array of techniques available is because there's no one size fits all. And sometimes, you know, you might need different techniques in each breast to get them to look even. So for you, I felt you're kind of in between the techniques of a tightening around the a areola, which is called a circumarial massapsy, which is just like a circle scar where you remove a donut of skin and tighten things up that way. And a lollipop or also known as a vertical mastapxy, which you think of a child's drawing of a lollipop, that's sort of the scar pattern. and so a circle around the aerial line going down the breast. And that allows the breast to be really dramatically tightened and to shift the nipple wherever it needs to go.

So sometimes it's very clear cut. You need one technique or another. In your situation, I felt we were sort of in a gray area between the two where I could probably get a tighter, better shape of the lollipop scar, but you'd have to accept that vertical scar, and you were kind of averse to having those scars, which is understandable. And in your situation, I felt like we could probably get away

with the tightening around the ariola and still get a very nice result. If I didn't think I could have gotten a result that was acceptable, I wouldn't have offered you that option. And then furthermore, we discussed, you know, we can do the tightening around the aerola first. And if you ultimately feel like you weren't as tight or as perky as you wanted to be, we can always convert you to a lollipop scar. But I can't do the reverse. Obviously, once there's a scar, you can't take it away. So that's kind of how we came to the decision to do a breast augmentation, slightly different size implants, and then tightening around the aerola to start.

And you also had a little bit of fullness in the area around where the breast meets the armp. And these are like the little refining procedures that aren't absolutely critical, but I do think they make a nice difference. So I try to make sure that the patients understand all of their options, and then they can pick and choose what they want to do. So as I explained, do you know, if we do a little contour here, we'll get a nicer curve on the side of the breast, everything's going to flow better, very low risk, minuscule scar. And it sounded good to you, and that's what we ended up doing as well. So that's kind of your surgery. Did you want me to talk about like the circmarial technique a little bit, or what would you like to discuss as far as that?

Yes, let's talk about that. And then I have a couple follow-up questions about the fat. Okay. So with the tightening around the a aerial, as you mentioned, some surgeons don't like to do it or it can get a bad reputation. And the reason that the tightening around the aerial gets a bad reputation is because a lot of surgeons don't understand the technique well and they misuse it. So somebody might come in and they need a lollipop or an anchor.

An anchor scar is a circle, a line, and then a scar that runs under the breast and the breast crease. that's the biggest like three-dimensional way to tighten up a breast. Lollipop is just a circle with a line down and then the circumario is just the circle. So some patients will come in and they'll say, well, I don't want the vertical. I don't want the under the breast, but I just want the circle around the ariola. But if they have a lot of loose skin and a very groupy breast and you try to apply that technique, it distorts the breast.

It creates a lot of, you know, weird shape and it doesn't look good at all. So part of this process is determining who's an appropriate candidate for that technique or not. And if you misuse that technique, you're going to get terrible results. When you use the technique properly, it's actually very good at reducing aerial size. You can use it to shift the nipple in a different position on the breast without disconnecting it. You can use it to help snug up the breast skin around an implant. It's very good. It has a compressive effect.

So if you have a pointy breast, which is also known as a two breast breast in certain cases, you can use it to compress a pointy breast into a round shape. So there's a lot of great uses for this technique. But when you misuse it, you're going to have problems. you can get, like if you try to take a really big circle and shrink it down, it'll stretch out again. You can get oversized aerolas or stretched out scars. Or again, if you have a droopy breast and you try to do this, the compression creates more grouping at the bottom, which looks really terrible.

So it's all about good patient selection, understanding how each of these techniques work and applying them appropriately to the proper patients. And if that patient wants a technique, but they're not a good candidate for the technique, don't do that technique and explain to them why it won't work. Don't just do it to try to please the patient knowing that you're going to get a bad result. So that's my philosophy is being very blunt with my patients, telling them, really explaining their anatomy to them, explaining how the techniques work so that I'm not just telling them what to do. They're joining me on this process and they understand why I'm doing everything I do so that it makes sense to them.

Because that's really the key is you understanding why you're doing what you're doing in order to get the results you're going to get. So you have good expectations of what your outcome is going to be. Yes. And you did that very clearly. And like you said, I was averse to the lollipop star, but I think ultimately we agreed that once you got in there, if you really felt that the best procedure for the best possible outcome was going to be that lollipop. I think I said, go ahead and do it. And then I vaguely remember after surgery you saying that like this ended up being a good option. Absolutely. And that's always, so I always tell patients, the more options you leave me during surgery, the better result I can get you.

because you don't always know, especially when you're using implants, you don't know exactly what things are going to look like until the implants are in place and the patients in the seated position in the OR. When I say that, sometimes people are like, I have to sit up. When you're doing surgery with me, you're basically lying down fully asleep connected to the bed and the bed's electric so I can basically sit you all the way up and then lie you all the way back down. Because when you're doing breast surgery, it is absolutely critical to see what the patient looks like in the upright position because sometimes things are great lying down and you sit up and all of a sudden the skin or something will group off the implant.

So it's critical to be able to see patients in both upright and lying down positions to make sure their results are excellent. So let's talk about size and how to determine the best size. Obviously, part of it is whatever the patient wants. And I'm sure everybody comes into you with an idea of how big they want to go. And for me, I remember being really concerned about staying small. Right. And we actually, the picture that I brought in for reference was the picture that you pulled up as well.

for my body size and all of that. So we were kind of on the same page from the beginning, but we did end up using two different sizes because of asymmetry that I had and one breast having more tissue than the other. But how do you best determine the size of the implant? And let's also talk about implant techniques over and under and all of that. Sure. I'm going to talk for hours on this stuff. I know that I have a really health conscious audience,

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So you have nothing to lose. Again, drink element. dot com slash blonde files. Fall is here and I could not be more excited because first of all, it's my favorite season. Second of all, fall fashion is the absolute best. And there are so many fun things to do from concerts to parties to date nights, weekends away, pumpkin patches, you get the idea. And part of the fun of making all these plans is having an amazing outfit.

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$20 off your first month of Newly when you sign up with the code blonde 20. Just go to newly.com. that's newly with two U's N-U-U-L-Y.com and enter the code blonde 20 and sign up to get $20 off your first month. That's newly.com, newly with two U's with the code blonde 20. Newly subscription, clothing rental, change your clothes. So as far as determining size, there's lots of ways to figure this out, and each surgeon is going to have their own style that they use. For me personally, you know, having been doing this for, you know, going close to 20 years now, I've kind of developed my system that's worked really well for me over the

years, and that's what I do. So first, I kind of talk to patients about, like, what's their general idea? And cup size is a very inaccurate way of measuring things, so I never stick with cup size, but I use that as a starting point because that's kind of what patients understand. So, you know, just to give me an idea, I'll say, you know, what cup size are you right now and what cup size you want to be, and if patients say, like, a B or a C or a D, I get a pretty early sense of like they want to be more small, more medium or more, you know, larger. Okay. Then we do measurements because the implants really need to fit the patient's chest and base width.

If you go too big, too wide or too narrow, it doesn't blend with the body and it doesn't look right. So that's also going to give me information about what size range is appropriate for that patient's body. Then what we did was in bra sizing in the office. So if you remember, we had those like specially shaped kind of, they're not real implants there, but there's silicone inserts that have various numbers of C. So you can see what you look like with 250, 300, 350, whatever number of CCs in the bra. And then you can look real time in the mirror and kind of turn sideways and sort of get a sense of,

you know, does this feel big to me, small to me, or about right? And then lastly, I use photos. So my website obviously has hundreds and hundreds of before and after photos that I've done. So usually I'll just tell patients, try to find somebody on there that kind of demonstrates the overall vibe, proportion, look that you're going for. not that I can match one patient exactly to another, and I make that very clear, but if I know visually what you're like what you really like, then that helps kind of drive me in that direction.

I try to get just close to that kind of look as possible. Because if a patient could say something verbally, but you may not have that, you may not have that image that they have in their mind. So if you're both looking at an image together and agree like, okay, this is pretty much close to what I like, now I have a visual of what you like and I can try to get you in that range. And then, you know, on top of that,

this size is really going to be, it's not like you can just pick any size you want. There are some surgeons out there who a patient comes in and they stuff whatever in the bra and they say, okay, that's what you pick and that's what you get. And the problem with that is that then the patient has surgery and if they're not happy, the surgeon says, oh, well, that's what you picked. And that's not really fair because patients don't really understand necessarily the dynamics of how a certain number of CCs will affect their tissues, what profile is going to look best, you know, etc. So it's really on the surgeon to make sure you guide the patient properly, with an implant that's going to fit them well,

that's not going to be unlikely to cause tissue damage from being too heavy or big. If it's a little bit fuller implant, I would normally recommend some kind of reinforcement material to help take some of the pressure off the tissues or if somebody has weaker tissues where you're already worried about that problem. So there's a lot of nuances to this stuff

in terms of implant selection. And then with regards to profile and things, because people always have questions about that. So basically the concept of profile is, if you have a lower profile implant, it's gonna be flatter and wider. And the higher the profile you get, the narrower and the more projected it is.

So in general, I tend to use mostly moderate profiles, which are kind of like the middle of the road, like not too projected, not too flat, because that's what looks best on most patients. And then some patients, if they already have a lot of projection, they may need like a low plus, which is a flatter implant, just to push things out a little bit without over projecting them.

And patients who are very, maybe flat chested and very tight skinned, who need some force to create roundness in the breast, might do better with like a moderate plus or a higher profile. I do find the surgeons who are just constantly putting in high-profile implants. It's just, I don't think it's a great style. to go for patients. It tends to create a more unnatural look. People get that very, like kind of that round fake look, which maybe it may have been more popular back in like the 90s and the early 2000s.

And some surgeons still like that look and some patients still like that look. But thankfully, I was never into that. I always wanted natural. Natural I think is by far the one of the most important things in any kind of plastic surgery. Natural appearance, I think is key. And so for me, I always sort of went with a more natural look and I tended to attract patients that were seeking that natural look. So if somebody wanted a really big round breast, they probably weren't coming to me because they saw my photo gallery and realized that that's not the kind of a surgery that I'm doing. Thankfully, that's sort of the trend now.

Everything is going a little bit more towards natural year after year. And I think it's a really good thing. So back to what we were talking about before with fat, I think that sometimes when people think of getting a breast augmentation, they think, well, fat is more natural. It will look more natural. It's more natural because you're just moving tissue from one part of your body to the other. We talked a little bit about the limitations. of it, but can we talk about like when it's best to use fat versus an implant? And you mentioned

that like I didn't have enough fat to do a fat graph for the size that I wanted. But if somebody doesn't have enough fat, can they gain weight and then use that fat and then go back to their normal weight or will they lose it? I mean, how does it, how does it act when you move it to the breast versus where you take it from? Got it. All right. So let's go through all that stuff. So I guess we can start with the last question first. So when you're taking fat from one area of the body and putting it somewhere else, those fat cells will act the same way in the new location that they acted in the old location. So generally what we want to do is you want to harvest diet-resistant fat cells,

meaning wherever on your body is the last area for fat to go when you lose weight, those are the most diet-resistant fat cells. Those are the best ones. So usually for women, it tends to be like maybe love handles, abdomen, thighs. men usually is more chest, abdomen, love handles. Like, you know, male and female tend to have a little bit of different distribution on the body, but for the most part, pretty similar areas. Then the fat comes out of those areas.

You process and purify the fats. You're getting rid of the oils and you're getting rid of the fibrous tissue and trying to get just down to pure fat cells. And there's different systems to clean and wash the fat. And then that fat is re-injected into the breast or wherever you're going to inject the fat. Now, what I always tell patients is with fat grafting, we don't know how much fat we're going to get out in the first place. then once that fat comes out and it's processed and purified, you're going to have a little bit less.

We don't know exactly how much that's good enough to put back in. Fat that we're re-injecting into the patient's body, not all of it will stay permanently. And it can vary patient to patient. So on average, we're expecting, you know, about maybe 60% of what is injected to stay permanently. But in some cases, it seems like a lot better. In some cases, it's a lot less. So there's not the same predictability of volume that you get with fat as you would with an implant. So that's probably the biggest disadvantage.

of fat compared to implants is you don't you can't just guarantee a certain volume like you could with an implant where you take a 300 cc implant out of a box that patient's getting 300 cc's of volume guaranteed with fat you know you can inject it and you don't know exactly how much you're going to have so for me when it comes to making choices about fat grafting first thing is you have to be fairly okay with how the breast is going to look before the let's say somebody is very groupy and we want to lift the breast and do the fat grafting the lift is going to do the lion's share of the work and reshaping the breast and the fat's going to be like the icing on the cake to give more volume and fluff things out. So but you kind of have to make sure that things are looking good

even before the fat goes in. So generally the patients that I tend to do fat grafting on the most are patients who are getting like a lift where they have like maybe a loss of volume in the upper breast where you want to fluff that out. Patients who are having a breast reduction with the same issue where they may have a little scoop out in the upper breast. Patients who are having breast revision like let's say they have implants but they've had a lot of tissue damage from prior scarring and prior surgeries and you can embed more fat into the tissue to thicken it so it creates a smoother look. Those are the best cases for fat grafting in general. If you're talking about somebody who's just, let's say, flat chest of a tight skin where they want to go from like a B cup to a C cup, it just doesn't

work as well because you can inject the fat and the skin is kind of tight and it can compress the fat. You might not see that change as much. And you have to harvest a lot of different body areas to get the fat to add in as opposed to just putting an implant in. So if somebody is just coming in for a primary breast augmentation, meaning just adding some volume. I find that implants are a much more straightforward, predictable, and easier way to go with that. And they have these devices that they've used to try to stretch the tissue out to allow for fat grafting. There's something called a bra. There's like these giant suction cup things that people wear on their breasts for hours a day, for weeks in advance of surgery. And like nobody would comply with it because it was uncomfortable

and awkward and whatever. So for me, like with just like flat chested, just wants volume, I'm usually going to go with implants on that kind of case. As far as you were asking about, yes, about weight gain. So in the old days, and still I hear surgeons saying, oh, put on 20 pounds and then we'll fat graft you, that means no sense to me because fat cells, you have a certain number of fat cells in your body and that's what you have. And they're going to shrink and grow depending on your weight gain and weight loss. So if you gain weight, the fat cells will get bigger and it looks fuller, right?

So if you're gaining weight for surgery and then you're harvesting those fat cells and re-injecting them, and then after surgery you lose the weight, those fat cells are going to shrink down, he didn't really gain anything in that process. So for me, I always recommend that patients do fat grafting at their sort of long-term stable weight. So whatever they think their natural weight is going to be, that's where we should be for the fat grafting. And the nice thing there is like, let's say patients, sometimes I'll patients say, well, I kind of want to lose some weight before surgery because I don't like how this pocket or that pocket of fat looks. But I'll tell them, well, in reality, it's not that you need to lose weight. You don't like these contours. We're going

improve those contours by taking the fat out of those areas and plug it back into an area where the fat's going to be doing it a favor, like let's say in the breast, for example, where they want more volume. So you don't have to lose the weight because we're just going to make you look better with the liposuction and fat grafting. But at the same token, I don't want patients gaining weight either if they're just going to end up losing it later. And I really want patients to go into surgery pretty healthy. So you don't want to go into surgery eating a bunch of donuts and pizza and stuff trying to put on a bunch of weight. I want patients on a clean, healthy diet, lots of protein, good vegetables, trying to minimize all the process, you know, carbohydrates and all the other things that are

not good for you. So being healthy is part of this whole process. So that's kind of how I look at fat-crafted. When I find something that I love that makes me feel really good, I get passionate about it. And that is what happened to me with my athletic greens. I started taking it a couple years ago in the morning, every morning. And it's become a daily non-negotiable. for me. So basically what I do is when I wake up on an empty stomach, I mix one scoop of AG1 from Athletic Greens with about eight ounces of water. Sometimes I put some ice cubes in there and shake it up. And it just gives me this little buzz of energy. I feel really good. It has helped me in so many ways because basically one scoop of AG1 from Athletic Greens has 75 high quality vitamins, minerals,

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Also, the Sakara Shop is stocked with functional plant-rich products and wellness essentials to help you create a body you feel strong and vibrant in, like their best-selling metabolism, super powder, their plant protein bars, which I love. I brought them with me to France. They have really great teas and functional snacks. So right now, Sakara is offering my listeners 20% off your first order. If you go to Sakara.com slash Blond Files 20 or enter the code Blond Files 20 at checkout. Again, that's sacara.com, S-A-R-A-R-A-com slash Blond Files 20 to get 20% off your first order. Sikara.com slash Blondfiles 20. I think that probably why it's appealing to some people is because of the risks associated

with breast implants, whether they're real or exaggerated. Maybe we can discuss that. I know the two main ones are capsular contracture and then the other one, of course, is breast implant illness. So let's start with capsular contracture and just talk about that and how it happens, who's at risk, if anybody is more at risk than anyone else or if it's just kind of random. Sure. I'm going to take it one step back first, just conceptually. So what you're basically referring to is sort of the idea of like a foreign body versus all natural tissue. And so anytime you add a foreign body, meaning an implant, yeah, this is a device that's not part of your biology that's in your body now. Your body is going to form a layer of scar tissue called the capsule capsule around that implant. And in most cases, people do do great. But there is maintenance. There are things that can go awry with implants. Capsar contractures, one, malposition if the implant shifts out of position is another.

Rest implant illness, which we'll talk about in a little bit, is another thing. So all these things can happen. And with fat grafting, if you give up some of the predictability of volume that we're talking about, you're gaining a lot lower maintenance. So once that fat is in, and after about six months, we assume whatever volume I have is pretty stable and it'll just shrink and grow with weight gain or weight loss, that's just your body now. So you don't have to worry about a lot of the maintenance with implants.

So for me personally, if I see a patient who comes in who I think is a pretty good candidate for fat grafting, I will generally almost, I don't push people too hard. I try to explain stuff and then let them make decisions with me, but I'll kind of guide them towards fat grafting over implants when I think that's a good option because I do think it's lower maintenance and anything that reduces a number of surgeries you need during your lifetime is a good thing. There are patients where implants definitely work the best in terms of getting the aesthetic that they want, or again, if they're flat chested, they don't have a lot of volume, but they want to be a cup size bigger. there may not be another good option. In those cases, implants work really well. So let's talk about capsule contracture then. And we can talk about capsules as well because there's a lot of controversy about this stuff.

So again, when you put an implant, it doesn't matter what kind of implant. There's a breast implant or a pacemaker or whatever. If you put a foreign body in a human body in a sterile way, your body is going to form a layer of scar tissue to kind of wall that foreign body off from your body. And so that's called the capsule. The capsule is just a layer of scar tissue. And it's your tissue.

There's nothing like inherently bad or wrong about. about it. In most cases, that capsule is very, very thin. It's almost tissue paper, like see-through thin. And then in some cases, for various reasons, the capsule can get thicker and tighter. And if that happens with an implant in place and the capsule starts to shrink and tighten up, it causes distortion of the implant where the implant can start to shift out of position or it can feel really hard. And that's usually the first sign is the breast kind of getting a little bit out of position and hardening up. Capsular contracture, that's the process where the capsule gets it normally tight. Usually happens maybe a year plus out from surgery, but it can happen earlier

and it can certainly happen later. The most common theory as far as what's causing it is bacterial biofilms. So, you know, nothing is 100% sterile. When you put an implant in the body, there are milk ducks. There are other things that you can get some bacteria in the tissues that can get on the implant. The way to avoid bacterial biofilm is to use a lot of antibiotic washes during surgery. So, and very, very careful tissue handling. So when we're putting implants in, we don't want to touch the implant with gloves that aren't anything but just fresh on your hands. We use usually a device called the Keller Funnel, which is like a lubricated funnel device. You put the implant in and squeeze it in.

So you're not touching the implant to the skin as it's going into the pocket. Or washing the pocket out with multiple types of antibiotics. It has to be a very clean dissection where it's minimal blood because blood can be a medium for bacteria. Where you make your incision matters. So if you go through a areola or through an armpit incision, data shows higher risk of contamination from milk duct bacteria or from armpit gland bacteria. So usually going under the breast and the breast crease is the cleanest way to put implants in. So there's a lot of different ways you can minimize contamination. And when you do that, your capsule contracture rate should be very low.

My personal rates are probably under 1%. You'll get them every once in a while just from bad luck or whatever. But if you're doing it properly, the rate should be extremely low compared to like maybe back in the 1980s where maybe 30 plus percent caps or contracture rate was considered normal or acceptable. I don't know exact numbers, but it was pretty high. And you just sort of assume that was part of just doing business. You know, you do breast augmentation. You're going to get a lot of caps of contractures. As we had more and more science, more refinement on this, we started to realize, hey, there's lots of things we can do to reduce these risks. And now, if you're a good surgeon, you should

have like maybe a 1% or lower rate. Now, if you get a capser contracture, the solution generally is treated as a biofilm issue. So you take out the implant, you take out all the scar tissue, you wash the pocket out, put a fresh implant back in. And there's other, like, reinforcing materials that may have some benefits also in preventing the recurrence a little bit. One is called an accellular dermal matrix, which is basically the skin derived from pigs and all the cells are processed out and your cells grow into it. And what it does is it kind of blocks the formation of scar tissue where you place that material.

And there's some resorbable meshes now that there's some early evidence to show they may help with capsule contracture as well. So there's less of things you can do to prevent that. And if you don't have an implant, you're not going to get a contracture. So that's the big things about fat grafting is, you know, if you have that as an option, capsule contracture isn't even really on your radar anymore. And then the other big one is, of course, breast implant illness. That was maybe the most common question that I got.

I don't know if it's because people are talking about it more or I'm not sure. Maybe you can speak to that. Absolutely. So this is a huge topic. And it's a very, there's a lot of controversy. It's a very nuanced conversation. and you have people all over the map on this topic. So you have some surgeons who say,

I don't think it even exists. You have some surgeons that say, everybody's getting implants is getting sick and nobody should have implants. And I think the truth is in between there. I do think this has been kind of exaggerated beyond its incidence in the population. So people are like, you know,

if you went online, you think everybody is having implants getting sick. But on the flip side, I definitely think it exists. I have had patients who I've taken implants out, who felt not well, and they feel better after the implants are out. What's the theory? There's a lot of studies going on in the plastic surgery societies right now to sort out what's going on here.

And the most common, again, theory on this stuff is biofilm. So you have a foreign body, you get a bacterial biofilm. You have a patient who's got maybe more sensitive immune system and that bacterial biofilm where in one person it may not cause any symptoms or it might cause just a contracture, and this other person it may make them feel unwell, like tired or fatigued or brain fog or just not quite right. And so for those patients, when you get the implants out and you wash the pockets out, and I'll talk about the capsule in a second, that situation, they feel better. And then you can reconstruct them using fat grafting and lift techniques or whatever else you need to to make them

look as good as possible. I would say there's a good number of patients who come in with some of those symptoms, which unfortunately, the symptoms of like fatigue and all that stuff, that's associated with a bunch of other problems too, autoimmune illness and everything else. So a lot of those patients, you take their implants out and they don't feel any better. And in those situations, you know, it wasn't the implants causing the issue in the first place. But I would say even with those patients, there's generally like a peace of mind for them knowing that at least they've ruled this particular possibility out and they can focus on other things to make themselves feel better.

So anybody who comes into me and I get a ton of patients coming into me with requests for breast explant where they want their implants out, I always have this long conversation. I make sure they understand the pros and cons of everything. And then if they want their implants out, that's their right. I'll take their implants out, and I keep my fingers crossed that they feel better. And when they do, it's like, it's a win. And if they don't feel any better, okay, well, we know it's not the implants. With regards to the capsule, because we were talking about capsule contracture,

and we're talking about breast implant illness, there's a lot of confusion about the capsules with breast implant illness. And a lot of people think that the capsules have to come out. And that's not true. So the capsule itself is your scar tissue. It's vascularized tissue, meaning that your blood supply reaches that tissue can bring white blood cells, antibiotics, all this stuff you need to fight infection can come in there. So once you get the foreign body, meaning the implant out, the capsule is just part of your

body's tissue. So a recent study was done by a number of prominent plastic surgeons doing a, like a study of patients who had breast implant illness symptoms, taking their implants out. And some cases had complete capsuleectomy, some case, meaning all the capsules removed, some cases it was, you know, unblock or was removed without disrupting the capsule, which is not always physically possible. So I guess that's a whole different topic we can discuss in a sec if you want. And then partial capsule like me were some of the capsules removed, but not all of it. And they did not find a statistically significant difference in how patients got better based on those different things. So what we're finding is the key is the implant removal, not the capsule

that's making people feel better with breast implant illness. So for me, when patients ask about the capsule, if they want their capsules out, I will take their capsules out. But if the capsule is very thin and normal, especially when you're under the muscle, there are, you know, there are downsides for removing that capsule. You know, it can create a whole raw surface area inside the pocket. which increases the risk of bleeding, the risk of fluid formation, which is called a seroma. It can increase the soreness after surgery and the recovery. And if you're fat grafting, it's nice when you have the skin here and you have a capsule here.

When you embed that fat into that tissue, the capsule in the skin helped the sandwich the fat grafting in place. So there are advantages in certain cases to leaving the capsules in. So I have this kind of conversation with patients. Now, if the capsule is really thick or calcified or abnormal looking, absolutely I take that out. And again, if the patient wants their capsule out, I'll take it out. But there are some cases where it's better to leave it in and having that discussion, understanding the science behind it, why we make decisions rather than just kind of a blanket statement like all capsules need to come out or whatever.

That is part of that, again, nuanced conversation that each patient needs to have and then we make decisions together. And then just the whole unblock thing. So when they talk about unblocked Capsulectomy, that means removing the capsule and the implant as one unit without breaking through the capsule. If you talk to any good surgeon, you will know that that is not something you can guarantee. If you are under the muscle and you have very thin capsule and you're trying to take the capsule off the rib cage, it can be literally like one cell layer thick, like a wet piece of tissue paper.

And so there's no way you can promise somebody you can take that off as one unit without kind of being dishonest. Now, if you have a very thick capsule and it's over the muscle, sure, that's pretty easy to remove as one unit. So not only do I not think it's possible in certain cases physically, there's not really a specific advantage to it and it requires, you know, significantly larger incisions and stuff. So what most surgeons that I know that are high-quality breast surgeons will promise a complete capsulectomy if patients want that where we take all the capsule out, get the pocket just as clean.

We're not promising you taking it out as one unit because that's not always something that is theoretically doable. I had, it's interesting that you said that some people have them taken out and still don't feel better. I think that's something that not a lot of people talk about. And when I shared about my procedure, it was kind of frustrating because I got so many messages from people saying, be careful of breast implant illness. And I was like, they're in. Like, there's nothing I can do at this point. And then I also got a lot of messages from people saying that they had theirs out because they thought that they had breast implant illness. And it turned out to not make a difference and they wish that they had them in. So what I'm gathering from all of this information is that it's just so nuanced. and it's really dependent on like the person and their overall health and circumstances in their life. And it's not necessarily a deterrent.

The other question that I have, I have a lot of follow up questions here. I'm just thinking of what some of the listener questions were. Is there a difference between like somebody who has fat transfer or maybe a lift in fat transfer versus an implant in being able to detect something like breast cancer? Yeah. So a lot of studies have been done with regards to that. And what we found is that having implants doesn't delay diagnosis or hide the diagnosis of breast cancer. So thankfully, that's not impacted.

There are a couple of very rare types of cancers that are associated with implants. There's something called ALCL or anaplastic large cell lymphoma. It's only been associated with textured implants as far as we know. And it's, again, extremely rare and extremely curable. So probably about a 99% close to 99% cure. rate just by taking the implant and the scar tissue out. And the odds of getting it, it'll vary depending on which type of texture it is and which brand. So some brands are like in the one in 50,000 or one in 100,000 odds. The one brand biocell, which was made by Allergan, which had like the quote

unquote recall that people maybe read about. That was maybe closer to one in three thousand-ish odds, you know, and the numbers change. So it might be a little bit off. But still very, very rare. And there's another thing that is just now coming out a little bit more called squamous cell carcinoma, breast implant associated. I think there's been like now around 16 or so cases, but again, we're talking about millions and millions of patients with implants. So all these things can be kind of sensationalized in the news or on social media or whatever. But if you really look at the statistics, you know, the odds of like I always tell patients like if they're nervous about anesthesia, for example, the most dangerous thing you're doing the day of surgery is driving your car to

my office. You know, if you look at statistics, what's going to kill you? Driving your car around town is by far the most dangerous thing. So it's not like every time you go to the grocery store, you're like, do I have to get this groceries because do I want to take the risk of getting in my car? You just get in your car and you drive. You don't really think about it. So it's kind of the same thing. You're taking calculated risks. I mean, surgery has risk.

I have an implant technically has a risk. But the risks are incredibly low when they're done when things are managed properly. So with true breast cancer, which is unrelated to implants, we're talking about a regular old breast cancer. That's like one in eight odds for a woman during her lifetime. And then we're talking about these other things, which could be one in hundreds of thousands of odds or one in millions. of odds. So, you know, again, you have to balance all this stuff out and understand what the risk is. And if there's certain things you're going to do that are very, very low risk and are going to give you a lot of improvement of quality of life, that patient may decide it's a fair tradeoff.

And maybe another patient would say, I don't want even a one in a million chance of this. And then that patient shouldn't have implants. And they will either get what they can, you know, do what they can do with fat grafting or maybe not have surgery at all. So again, I think what you said earlier, like when you said, this is a nuanced conversation about breast implant illness, for example, everything in plastic surgery is nuanced. This is not a cookie cutter kind of field. Every surgery that's done, the exact surgery, everything should be customized to each patient. So it's not like a right and wrong answer on this stuff.

It's all about communication, discussion, figuring what's right for an individual. And then sometimes no surgery is what's best for that person. So these are all part of the, this is why you need to be, you know, with an experienced surgeon who understands that every patient has totally different goals and maybe different anatomy and different pros and cons are going to sound better or worse to them. This is really probably the most important part of plastic surgery in some ways is this initial discussion figuring out what's right for a given patient and making sure that patient has the information, the data, and the understanding to make good decisions for themselves with you.

So it's a team approach, really. You mentioned earlier that anything that reduces the amount of surgeries that somebody needs in a lifetime is a good option when you were talking about fat grafting. how often do breast implants need to be replaced? So that's a really good question because there's this sort of like, you know, if you ask people just based on like their kind of online understanding, like people are like, oh, I heard implants need to be switched out every 10 years. That's kind of what I hear all the time.

And in reality, that's not true. So implants will have ruptures. So eventually, you know, you have an implant long enough, the shell of the implant will break and the implant will rupture. Now, the good news is with these days with the very modern implants, the new generation gel implants. If you have a rupture, the gel just really sticks to itself. You know, people call it the gummy bear or whatever.

There's no gummy bear implant. But the concept is that the gel is not like a liquidy gel. It's more solid gel. It's what it holds together. And different implants will have different rupture rates. So some brands have significantly higher rupture rates than other brands. So I just part of my process as far as what I'm choosing for patients, I'm always trying to pick the best quality product to use.

So for me, I want the implant that is the lowest rupture rate. the best warranty, the highest quality gel, all that kind of stuff. And that's part of the process. So sure, is it possible that you might need the implant switched out within 10 years? If you have a rupture, that's possible. What I find is the weak link in patients is not the implant. It's usually the patient's tissue. So if you're going to have a reoperation, usually what's triggering that is not that

the implant broke. It's usually that something happened biologically with the tissue or mechanically with the tissues that needs to be adjusted. For example, somebody has droopy breast. you put an implant, you do a lift, and then over the years the skin maybe wasn't that strong because of pregnancies, and now it sort of re-drooped a little bit, and you may need to tighten them up, or the implant dropped too low and you need to tighten the pocket up, or they get a caps or contracture, and you have to fix that. So those are the more common reasons that trigger a

re-operation rather than implants breaking. But, you know, obviously they're not a lifetime device, so at some point in the future with implants, you will have to swap it out, either take it out completely or swap it out for a new pair. Okay. I think the last thing we should touch on is recovery. Obviously, this varies vastly person to person, I'm sure, depending on lifestyle factors, and then, of course, depending on what the procedure is. But can you give us kind of a general timeline for the kind of different options? I mean, it's going to vary, obviously, depending on what surgery we're talking about. So, you know, it's going to be different if you're just putting implants

in versus somebody who needs a lift and multiple layers of body liposuction and fat grafting and all that kind of stuff. But in general, I usually tell most breast surgeries, most people are okay to go back to work, desk work within about a week or so. Maybe a little sooner if they're up for it, maybe a little bit longer if they're a little slower to recover. As far as like exercise, I usually want things to stay fairly quiet for about a month or so to let everything sort of heal properly, reduce a chance of fluid collections and other issues. So I usually have patients just do a lot of just walking in that first month and not walking

for exercise so much, just, you know, walking to stay active because it's really important not to be bedridden after surgery. You want to be up and walking around, honestly, the night of surgery the day after. that's really important. Then by six weeks, I'm usually allowing patients to do, you know, kind of easing back in more and more. Scar tissue kind of reaches as maximum strength around three months. So at that point, there's really not a lot of worries. Between the six week to three month mark, you know, patients are really advancing a lot in terms of their exercise, but maybe not doing stuff like snowboarding or something where they could really hit the breast hard while they're

healing. And in the one exercise, if you have implants and you go under the muscle, which is called dual plane, you know, the peck muscle gets lifted up and the implant fits under like that. So if you really strengthen these muscles a lot, it does have a tendency to want to push the implants down and out to the side a little bit. A lot of the revision cases I get in where patients are, they have their implants out on the sides, one of the first questions I'll ask are, you know, you're doing a lot of push-ups or chest exercise, and a lot of times they are, I have them stop doing that. So for people under the muscle implants, I usually recommend trying to avoid bench press and push up as much as possible to keep these muscles a little bit less, you know, toned or not quite as strong. And then,

but they can do, you know, planks and back and pretty much shoulders, everything, you know, around it, just not pushups, flies, or bench press to try to keep these muscles a little bit softer. So they kind of go over the implant without pushing them down to the sides as much. Yeah, and people asked about my recovery. Obviously, I had a few things going on. So it was probably, I would say, a couple weeks before I felt like good energetically and all of that. I mean, I also had COVID. We waited.

We had to reschedule my surgery because I had COVID. So we waited six weeks or whatever it was. But I still kind of had like lingering stuff. Like it just, I think this is why it's so different person to person because I have friends who had their surgery on a Wednesday and we're at brunch on Sunday. You know, so it's like totally. So many people ask me about recovery and how realistic it is to like go back to work

and when can you drive and all of these different things. And I think it's just so different person to person. And people have to understand that. You know, everybody can't compare yourself to somebody else. Everybody's body heals at a different rate. So I have some patients, like you said, who day after surgery are just on Tylenol, and they're like asking about exercise already.

I'm going to go it down. I have some patients who, you know, are on pain pills for, you know, a number of days after surgery, and they just feel really tight and stiff, and it takes a little longer. Everybody's pain tolerance is different. Everybody's recovery is a little different. So I try to give, like, averages, you know,

as far as, like, probably back at work within a week, maybe a little sooner or whatever. But really, each patient just needs to recover at their own rate. The key is, as long as you're kind of making general progress day by day, even if it's slow, that's okay. If things are going the wrong direction or something's getting worse, that's where I need to get back involved, you know, or really see what's going on. But thankfully, that's very unusual. Patients usually just make good progress after surgery, and the rate of progress will just vary person to person, depending on them and their anatomy and their biology and depending

on what the exact surgery was and a bunch of other factors. Well, this has been fascinating. I feel like this is the most comprehensive. like concise episode on breast surgery. If anybody is interested in it, I think that this is like the perfect thing for them to listen to because we covered so much. And I know that we didn't get to specific listener questions, but I think we covered most of them in our conversation. So thank you so much for coming on. Can you tell everybody where they can find you, how they can make an appointment or consult with you, all of that? Sure thing. So, you know, I have, my primary office is in Beverly Hills at 465 Roxbury, Sweet 750. My website is www.

Dr. Robert Cohen.com, so D-R-R-R-B-E-R-T-C-O-H-E-N.com. My Instagram is at Robert Cohen, M.D. And so if you go to the website, that's kind of got more details as far as how the procedures work and a huge photo gallery, et cetera. Instagram will have a lot of, like, interesting cases and, like, little videos and stuff. So I think the two of those are kind of helpful together for different reasons. I don't think patients should ever pick a surgeon just based on Instagram.

I think to me that seems a little crazy. I think it's a good way to get to know them better and start the process. And then I think the website usually is where you can go a little deeper, really see a lot of photos and get a sense of who they are. So if somebody is interested in doing a consultation with me, they can put an inquiry in through the website. It's usually probably the easiest way. Or they can DM me on Instagram,

but that's not quite as efficient as. But yeah, you know, like we just went through like an hour of talking about breasts. I could literally, I mean, we could do 10 more sessions like this. And each of these topics could be expanded. You know, I do talks like that when I just spoke at the Toronto Canadian Society Plastic Surgeons meeting last week, you know, I did an hour long presentation just on strategies for managing patients who want their implants out and how to how to do all that. And that was just an hour on that topic alone. There's so many details.

I hope nobody finds it's boring. I find it just fascinating, just like the depth you can go into this information. And that's what I love about this specialty is like there's, there's so many unique aspects to each surgery. It just makes it really fun and being able to talk to patients and get to know what they're, you know, what's bothering them and how to help them and seeing the, you know, when you see a patient come back in after surgery and they have that like kind of glow or they just, you can tell they're really just feeling good about themselves. That for me is like, that makes my day every time. That's when patients are crying because they're so happy. And that's like, I've had some patients where they literally said they would not show their partner their breasts without the lights off for years. And then after the surgery, all of a sudden, they're just like a different, you know, a different person.

And it's, in a way, it's a little sad that maybe humans and focus on the appearance and I wish it wasn't the case. But it's just the reality that there's, you know, how we feel about ourselves is partially related to how we see ourselves in the mirror. So when what we see in the mirror matches up to kind of how we think about ourselves in our head, that brings like a level of kind of comfort, satisfaction. self-confidence that really improves the quality of people's lives. So that's what makes this such a rewarding specialty for me. That's a really great way to put it. And I feel like that just kind of shows that you understand the psychology behind it a little bit from the patient's perspective because I've always said that like the things that I've

done surgically were just kind of so that my outsides matched how good I felt on the inside. Again, not that that should be the focus, but it is kind of a reality. and when you can kind of align those things, like it really just, it just kind of enhances your quality of life in that way. So you're amazing. I'm so happy. I'm going to see you tomorrow. So we can talk then. And thank you. Again, we'll put all of your information in show notes as well so people can quickly access your website and see all of your amazing work. And thank you again for coming on. Thank you so much for having me. You're like just a wonderful person. You're an awesome patient. And I really appreciate the chance to, you know, talk to your audience and kind of help with a little education.

Because I think this is really important information for people to know. And surgery is not right for everybody and which type of surgery, you know, it might vary what's best for each person. So, again, this is a individualized, very customized, very nuanced kind of thing. And that's how it should be. It should be very individualized for each patient. Well, thank you. Thank you. I hope you enjoyed that episode.

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