Beauty and the Beasts
Beauty and the Beasts is a plastic surgery and cosmetic surgery podcast hosted by Dr. Sam Jejurikar and Dr. Sal Pacella. Each episode explores trending cosmetic surgery topics, real patient questions, and the latest advances in aesthetic medicine. You will hear expert discussions on facelifts, breast augmentation, tummy tucks, injectables, and modern cosmetic surgery techniques, all explained clearly and honestly.
If you want trusted plastic surgery education, insights into cosmetic surgery trends, and real conversations from two board certified experts, this is your go-to podcast.
Beauty and the Beasts
The Preservé Method: A New Era in Breast Augmentation
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Dr. Sam Jejurikar and Dr. Sal Pacella dig into Preservé, the new breast augmentation technique built around the Motiva ergonomic implant, and ask the question dividing plastic surgery right now: is it a real breakthrough or just great marketing?
Dr. Jejurikar makes the case for why Preservé may be changing breast augmentation in a way the field has not seen before. Rather than cutting the tissue behind the breast, the technique uses fluid infiltration and a balloon dissector to gently separate the natural plane between the breast gland and the muscle, preserving the circumareolar ligament that locks the implant in place. The payoff is a smaller incision, no tissue cutting, and an implant that sits remarkably stable. He shares what he is seeing across more than 100 Motiva cases and why he has become a believer, while staying candid about what the data does and does not yet prove.
Dr. Pacella brings the skeptic's eye, drawing on the technique he has watched performed in Costa Rica and pressing on pocket tightness, capsular contracture, and whether the balloon dissector is truly necessary or whether this is simply a small implant through a small incision. Together they land on the points patients need to hear, including the local anesthesia marketing, the micro-texturing and capsular contracture debate, and the key caveat that Preservé is a retroglandular procedure without the long term track record we have for subfascial and subpectoral placement.
In this episode:
The embryology behind breast preservation surgery
How the Preservé balloon dissection actually works
Local versus general anesthesia for augmentation
Micro-texturing and the capsular contracture data
Why the implant may matter as much as the technique
Does Preservé just mean using a smaller implant?
Whether you are researching your own options or you work in the field, this is the honest, two sided breakdown the Beauty and the Beasts audience comes for.
What is it about the Motiva implant that makes it set up for the preserve technique?
SPEAKER_01Because the Motiva ergonomics implant is a more deformable implant, so it's stretchier. You can make a smaller incision to place it into that space. If you are going to use a different, uh, a different brand of implant, you'll have to make a bigger incision to do that.
SPEAKER_00Welcome everybody for our next episode of the Beauty and the Beast podcast. I'm, of course, Dr. Sal Pachella from San Diego, California. And I'm here, of course, with my very good friend and exceptional surgeon, Dr. Sam Jajirikar from Dallas, Texas. How are you doing this morning, Sam?
SPEAKER_01So good. So happy to be here.
SPEAKER_00All right. Are you ready to talk about a fantastic topic that is just hot out there in the world right now? Oh, I can't wait to hear what this is. This topic is about breast preservation augmentation, specifically a new technique called Preserve. And Preserve is a packaged device that from a company, a new company out there called Motiva. And it's all about preserving the natural architecture of the breast. So let's talk a little bit about preserve. So can you tell me a little bit about what it is?
SPEAKER_01Yeah. So it's a hot button topic right now among plastic surgeons. And I think you've got um two camps. Um, one that says this is just another form of breast augmentation, and another camp that says that this is changing breast augmentation in a way that we haven't seen before. And I'll admit I'm kind of in that second camp. So is it real or is it hype? Oh, it's real. So um so let's talk about what it is, first of all, and how it's different. Um, you know, in plastic surgery, preservation is a hot button topic, whether it's rhinoplasty, now breast surgery. And um, the concept, you know, uh anatomically is us thinking about the breast differently than we have ever before. In previous episodes and when we learned how to be a plastic surgeon, when we talked about how to size a woman for a breast implant, we would do typical measurements where we would measure the width of the breast and use that base width to determine how an implant would actually sit. Well, there's anatomic studies that are old studies, 20, 25, 30 years ago, where they actually talk about the embryology of the breast. Basically, not to get too technical, but within our body, we have three different, you know, tissue types that we all, that different things come from. And the breast tissue and skin come from what's called the ectoderm. Muscle and fascia all come from the mesoderm. And embryologically, there is a split behind the back of the breast between that ectoderm and the mesoderm, and something called the circummammary ligament, which until Motiva or Establishment Labs, which is actually the name of the company, started presenting all these topics, we never really think about the circummamorary ligament. But in cross-sectional studies, you see this very thick fibrous band around there. So the constraints of which you can use breast preservation surgery are implants that are much smaller than a given base width. So for a woman that comes in and says, look, I just want to look with my implant the way I might look like in a push-up bra, so very small implants. Preserve is a technique where you use infiltration first to put fluid in that retroglandular plane, so between the ectoderm and the mesoderm, and it auto-dissects that whole plane. You then make a very small incision, you use a balloon to then go into that plane and blow the tissue apart. You're not cutting the tissue. There's no cutting of tissue that happens. And so the tissue, instead of it being cut and disrupted, just gets pushed out to the side. You then use a funnel to put in a small implant through a small incision, and the tissue just sort of forms like a bird's nest around it. And what's really cool when you're done with these cases is we always sort of learn that going behind the muscle, or we thought was provided more support for an implant. But when you do this and you try to move that implant laterally, inferiorly, any direction, it's really locked in place because you preserve the circummandary ligament. So is this a technique that's done under local anesthesia or general anesthesia? Yes. So both. It can be done under both. I mean, the marketing, so that that's where I think some of the hype comes in, right? Like you can do a traditional breast augmentation under local anesthesia, and they're marketing it under local anesthesia. And you can do it under local. And I I've never done it under straight local. I've done it with some sedation for people, and um, but I've done it under general under plenty as well. You have the option of doing under local, but to me, that's not the bigger selling point.
SPEAKER_00So can any implant be placed in through a preservation technique or a so-called preserve, or does it have to be a Motiva implant? That is the question.
SPEAKER_01So I think the short answer and so depending on, I've talked to representatives of both companies, relatively high people in both companies. Uh, when I say both companies, I mean Allergan, which is the number one market share in the US. Um, because preserve is getting so much buzz, um, you know, I've heard it speculated for whether or not it would be beneficial for them to come up with their own version of doing it. And I've heard from people in establishment labs that say you would need a different implant to do that. My belief is that you could use the same principles with any implant.
SPEAKER_00Um, the bold- Well, what is it about the Motiva implant that makes it set up for the preserve technique?
SPEAKER_01Because the Motiva ergonomics implant is a more deformable implant, so it's stretchier, you can make a smaller incision to place it into that space. If you are going to use a different, uh, a different brand of implant, you'll have to make a bigger incision to do that. Um, and so um, and you know, in other countries, um, they have another implant uh establishment lab does that ergonomics too, which is even more deformable, and they're using incisions as small as two to two and a half centimeters. With with Preserve, it's about a three centimeter incision, and with other brands, it'd probably be a four, four and a half centimeter incision.
SPEAKER_00Well, the the company claims, obviously, and they have some fantastic data behind their claims, um, that the implant is just as important as the technique. Okay, so there's a this mic, this idea of micro-texturing that we talked about. So there's something about the sweet spot of six microns, which is the the undulation or the textured surface of the implant um that prevents against capsular contracture. And for our viewers out there or listeners, um, one of the things that, as plastic surgeons, why we avoided subglandular implants in the past is because of the higher risk of capsular contracture. But motiva sort of takes that out of the game, doesn't it?
SPEAKER_01If you look at their studies, right? This is an apples and oranges comparison, and it's such a controversial topic because you will heal here many plastic surgeons, you know, banging the drum saying Motiva is the best, safest implant that's out there. And you have other patients, other doctors that say we don't have enough long-term data. So let's look at it. The Motiva published data at this point, I believe they now have preliminary FDA data through about five years, shows that the rate of capsular contracture, which is pathologic scar tissue formation around the implant where the implants get hard, is about 1% through about five years in either subpectral or behind the muscle breast augmentation or subfascial, where you separate the lining of the muscle from um, you know, and you raise it in continuity with the breast gland and you put in the implant. When you look at other brands, whether it's mentor, whether it's Alargan, whether it's Cientra or whoever owns Centra at this point, their data is through 10 years. Allergan's data, which is what, which is what I'm most familiar with, subpectral through about 10 years is 6% to 8%. So on the one hand, you have a 1% through 5 year comparison versus a 6 to 8% through 10 year comparison. What the Motiva folks will tell you is look, our nanotexturing was not discovered through happenstance. It was basic science data that was that was actually utilized to help us create a surface that would create less um, you know, less um capsule formation. In our longer-term follow-up in Europe, Central, South America, we're seeing the same trends kind of you know hold up, you know, hold true. So I believe that those that data will hold true, and I believe that it's better, but I don't have long-term data to prove that.
SPEAKER_00Well, let me throw this out here. So um Motiva is an implant that's only been in the US market for about a year and a half or so, right? Um, and preserve has been a technique that has only been available for approximately about a year in the United States, right? If not, not even if you must. And and across the world, preserve is a new technique as well, right? So it's going to be very interesting to see in five, 10 years with the acknowledgement of the novelty of preserve and not dissecting the pocket out traditionally the way we do it, with that particular ergonomics implant, whether or not there's any effect on capsule or contracture. So any predictions there?
SPEAKER_01Yeah, I'm I mean, I'm already doing a lot of preserve in my practice, and I'm a believer in the technique, and the early results are great. I do believe because of the surface of the implant that the long-term results will also be good. But there's two important caveats. I think one, the data that we have from Motiva implants, and you didn't hammer me enough about this, so I'll hammer myself, is through subfascial or subpactoral breast augmentation. It's the viewers need to know that if they're getting preserved, it is not a subfascial breast augmentation. There's no way to use a balloon dissector to do that. It is a retroglandular, meaning it's just behind the breast gland itself. We don't have data for that. So we don't have any long-term data whatsoever. So we're trusting that this capsule is going to protect us for that. The second thing is going back to your previous question, how much does the balloon expander matter? And how much does preserving and obeying the anatomy matter? I do think that the way that I do subfascial breast augmentation, even if I'm not using preserve, has changed because of the preserve technique. I'll now use that same hydro dissection in the beginning where I'll actually instill fluid to make the plane really easy to elevate. I'll use a lot more blunt dissection once I get into the subfascial plane, and I'll use smaller based implants even without the balloon. And that, you know, what I was describing about the implant being relatively fixed in place, it's still the same with that as well. The balloon dissector is a comfortable way to do it. It's a really elegant, quick, and efficient way to do it. Is it important? I don't know. That's my honest answer.
SPEAKER_00So one of the things I I truly believe in when I'm doing a breast augmentation is that the the risks, and I've never seen this published anywhere, but I think the risks of capsular contracture very frequently occur with under dissection of the pocket. Okay. If the pocket is too tight and I'm throwing an implant in there and it's it's I can see rippling and wrinkling in the pocket, you know, to me that's that's not a that that's not a case where I feel comfortable long term, the patient's not going to develop a capsular contracture. So I I want that implant to fit hand in glove or a little bit looser than hand in glove. But preserve is a little bit of the opposite, isn't it? It's it's putting that implant in, it's slightly tight. And I I've seen the preserve technique down in Costa Rica at the Motor.
SPEAKER_01It's very tight. It's not slightly tight.
SPEAKER_00Very tight. Very tight. And when you when you sit the patient up under local anesthesia, you know, that implant's riding up fairly high. So you your thoughts on that. You when you close up that patient and you see how tight that implant is, yeah, what are your what's going through your mind?
SPEAKER_01I a lot to unpack there. Because I think one, you know, your thought that that's more correlated to capsular contracture isn't a classically described etiology behind that. I mean, most people generally attribute it capsular contracture to either uh low-grade bacterial colonization of the implants or um, you know, trauma, whether it's a little bit of bleeding in the pocket that creates scarring. So I haven't ever really made that correlation per se. Two, I would say that um the preserve patients on the table look really tight. But when I see them a day or two later, they don't look that tight. Um they actually look pretty pretty good already at that point. Three, between preserve and traditional um breast augmentation, I've done over 100 patients with motivative implants, and I've yet to see a capsular contracture case. So it doesn't mean it's not gonna happen. Uh it doesn't mean it's not possible. But I think I'm drinking the Kool-Aid.
SPEAKER_00And what other things are you doing to prevent capsular contracture during those preserve cases or post-operative care afterwards?
SPEAKER_01Um so um, in terms of um what I'm doing during a preserve case, you're actually doing less than you do during a traditional breast augmentation. So when we do a traditional breast augmentation, we typically irrigate the pocket with antibiotic solution to try to decrease bacterial colonization. That's not a standard part of the preserve case. That's not a step that you build into it. I do soak my implants in a mixture of uh betadine or providine iodine, which the company does not, they don't discourage you from doing it, but they also don't encourage you to do it. Um, but that reduces that. And then you're putting the implant in through a funnel. So there's a no-touch technique where the implant will actually go into a little plastic sheath, it'll go into the body without ever touching the skin. Um, and we think that that decreases bacterial colonization. And that's really all I'm doing. I'm not putting them on any anti-inflammatories postoperatively accolade or singular or anything like that afterwards.
SPEAKER_00No? Do you have you routinely done that in the past for your patients?
SPEAKER_01I've never routinely done that in the past for breast augmentation. I've only done it for cases where that were recalcitrant, um, you know, capsular contractor cases?
unknownOkay.
SPEAKER_00Well, I want to ask you a very controversial question, our probably our last question of the session here. Um isn't preserve just using a small implant? Like, do I need the balloon? Can I just make a small incision and do a small augmentation and you know dissect with my finger, dissect bluntly, and just use a small implant from any company?
SPEAKER_01There's some technical things that the balloon make easier. Um, so the hardest part of a preserve case when you're doing it is the insertion of the implant. So you put in this balloon, but between where the balloon blows up and the tunnel that you have to get the implant into that pocket for it is actually quite tight. So the balloon allows you to actually, as you're pulling out, to expand a little bit more to make that tunnel a little bit easier. So it does make the insertion easier, but even with an ergonomics implant, which you would agree is the most deformable implant we have in the US right now, it's the hardest part of getting the case in is actually, I mean, it's not that hard, but it's but it's it can be a little tricky sometimes. So if you're willing to make a bigger incision and maybe use some cautery dissection to open that up a little bit, then I don't know if you're preserving the circummamorary ligament quite as much. But yeah, you can do it. You could do it. And I know there are other companies that are talking about trying to come up with their own version of it.
SPEAKER_00Yeah, and I think I think one of the biggest wins that Motiva has as a company is the marketing associated with Preserve. Even just the the name, it sounds very very fancy, very very French. Preserve. It's a great, I mean, it's a it's a it's either way you cut it, it's a it's a great new technique, a great new idea, a great new revolution, I think, for breast augmentation.
SPEAKER_01And I think it's great to have a new company on the market that is not owned by a larger company where breast implants are just a small portion of their pie. This is all Establishment Lab does, and it's pushing implant technology forward, and I think the whole market will benefit from it.
SPEAKER_00Well, Sameer, I want to thank you for joining us today again for this uh great discussion about preserve, and uh hopefully we can incorporate that into our practices.
SPEAKER_01Cheers.