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 Truth About Downsizing
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One of the most common consults in breast surgery today isn't augmentation, it's downsizing. Dr. Sam Jejurikar (Dallas Plastic Surgery Institute) and Dr. Sal Pacella (San Diego / La Jolla) sit down for another candid, no-filter conversation, this time on why so many women who got bigger implants in their 20s and 30s come back 10, 20, even 30 years later wanting something smaller and more natural.
They cover:
- Why cup sizes (C, D, double D) mean something different from every implant manufacturer, and why that confuses the consult from day one
- The anatomy problem: what happens when a patient chooses an implant wider than her own breast base, and why that choice catches up with her later
- "Internal bra" mesh support: what it actually does, what it doesn't, and where Sam and Sal disagree on how well it holds up over time
- When downsizing requires a full breast lift versus a smaller scar option, and why patients often want to skip the lift they actually need
- The ethical question both surgeons wrestle with after two-plus decades in practice: how much responsibility does a surgeon carry for an implant choice made years ago
Whether you're considering your first augmentation or thinking about going smaller after years with implants, this episode lays out the physics, the anatomy, and the honest tradeoffs nobody tells you about upfront.
Hosted by:
Dr. Sam Jejurikar, MD, Dallas Plastic Surgery Institute
https://dallasplasticsurgery.pro/
Dr. Sal Pacella, MD, MBA, San Diego, CA
https://drpacella.com/
Beauty and the Beasts: two plastic surgeons, no filter.
The dilemma we face as plastic surgeons is a lot of times we know what we believe is right for the patient, but that's not what the patient wants. How much responsibility do we bear for patients that come back and see us, you know, now that we're both coming up on our second, you know, our third beginning our third decades in practice? We're seeing patients that we put some of these implants into now coming back and wanting to downsize. How do you how do you grapple with what you wish you would have told the patient then and now what you know? Well, welcome everyone to another episode of the Beauty in the Beast podcast. I'm Sam DeJuricar from Dallas. And as always, I am joined by the illustrious Dr. Salvatore Pachella, plastic surgeon extraordinaire of San Diego and La Jolla. Glad to be in your company. Always a pleasure, my friend. Yeah. So today we're going to talk about something interesting. We're going to talk about one of the most common scenarios we're seeing in breast surgery. And that is not a patient coming in for a breast augmentation, but someone who's coming in and saying, I want to get my implants downsized. Is that something you're seeing a lot of?
SPEAKER_00Absolutely. It um, you know, as my patients get augmentations in their 20s and 30s, one of the things I have a discussion with them about is, you know, these are not lifetime devices, right? I'm sure you you talk to them about that, right? And as you get older, you may gain weight, you may lose weight, you may breastfeed, you may not. And your breast will change as you get older. And so, and trends change, right? In the 80s and 90s, it was all about big breasts with bay watch, having a lot of projection, an augmented look. And those those trends are changing dramatically. And so it is a very, very common uh operation that's being requested, particularly for patients that are in 40s, 50s, MAC.
SPEAKER_01What's one of your uh favorite stereotypes about the state of Texas? Bigger is better. Everything is bigger in Texas. And uh that definitely was true in Dallas when I started in practice. Big highways, big tires, big breasts, big implants. And we're seeing exactly women in their 30s, 40s, 50s, even late 20s at this point who have implants that are just simply too disproportionate for their frame. I think, you know, society is changing in many ways. People are looking for more of a natural aesthetic. And what we're seeing with these larger implants is that people can't wear athleisure. They can't wear, you know, the clothes that they want to without looking fat or physics. The you put a heavy weight in a small woman in a relatively small space, over time, there's some real anatomic changes that will actually that will actually happen.
SPEAKER_00Yeah, and that, you know, like you said, uh the skin thins out, the distance from the nipple to the fold of the breast, the undersurface of the breast expands. And it's a little bit of an optical illusion because the breast looks flatter up top, but it's you have this massive bottoming out deformity. So, you know, bigger is not always better, despite what Texas may show you.
SPEAKER_01Yeah, and and so let's let's start, let's take it back. So, because I do think plastic surgeons bear a responsibility for sure when we see a patient for a primary breast augmentation consult. Let's say you see a young woman in her mid-20s who's coming in for breast augmentation, and she says, Look, I I just I want to be big. I want to be really big, and I'll just deal with it later and get them smaller if I don't if I don't like it. How are you gonna handle that?
SPEAKER_00Well, so I think we got to have a big discussion about visualization, what this actually looks like. So to me, the translation of the word big, I think is a key concept. So that patient can tell me, well, I want to be a D or I want to be a C, right? And every bra manufacturer has a different definition of C and D, right? So one of the things I like to look, I like to do with patients is we look at pictures. And to me, a picture is worth a thousand words. And what their definition of D is might not be my definition of D. So that being said, let's say that that visualization is really large. To me, there are anatomic constraints that are obvious, right? So if the base width of a patient's breast is only 11 centimeters, and then we're choosing an implant that is 600, 700 centimeters, by definition, that implant is gonna have a base width of 12 or 13 sometimes, right? And so I really try to explain to the patient, well, imagine yourself on a treadmill and you're running, okay, and you're see, and every time you move your arm, that side of your breast is gonna hit your arm. So that anatomic constraint is a huge problem.
SPEAKER_01Very true. So um, first thing is when you talk about C cup, D cup, double D cup, you are so right. I don't think people realize how big of a disparity there are between different manufacturers. In one study, they showed there was a from one extreme to the other, when they do a volumetric analysis, there's a 350cc difference in a D cup from one manufacturer to another. So nobody knows what a D cup or is that.
SPEAKER_00Yeah, it's it's like it's like saying, you know, I'm gonna get a suit tailored and give me a large extra large. You know, it's not it's not measured that way. That's right.
SPEAKER_01That's right. The other thing is, you know, you talk about base width. And that is a typical measurement that we use. And what that basically is, is you know, you you take one circle, which is an implant, and you're putting it in another circle, which is the breast. And if you pick a circle that's too big relative to the circle you're putting it into, it just doesn't fit. The problem with doing that is the long-term consequences of doing that. So you put an implant, whether it's you know, let's say behind the muscle for the purpose of this conversation, but could even be in front of the muscle, there is no support laterally. So it may start off one or two centimeters, you know, past the breast. But over time, when a woman is laying on her back, when she's sleeping at night, gravity is gonna pull that further out to the side, and the implants are gonna start falling, falling further apart. When you stand up, there's nothing holding it on the bottom. So it's gonna start falling further down and it will sag.
SPEAKER_00And as you mentioned, that there was a technologic strategy that implants manufacturers use for many years to prevent that from happening, right? Texturing. Now, texturing is much out of favor because of the risks, potential lymphoma, et cetera. So that's less of a less of a weapon we have now to prevent that lateral drift.
SPEAKER_01Yes, for sure. The one thing I'll say is macro texturing for sure is gone. Right. Yep, that's what I mean. Yeah. Nanotexturing, um, which creates less capsule, is very much in vogue these days. But there is a strategy that we can use to prevent that lateral drift, and that's this notion of an internal bra. Do you, if you see a patient who is picking an implant that's say one and a half to two centimeters or two and a half centimeters wider than their base diameter, will you use additional soft tissue support and give that patient what they want?
SPEAKER_00Right. So let's go back to the original discussion about the visualization of moving that arm. Okay. So if a patient comes to me and says, Well, I like this appearance of a breast by this photograph, but I want to be bigger. Okay, there are potential options we could do without widening the breast width, and that's projection, right? So in those scenarios, I will try to push a patient towards using a high of a higher projection implant or an ultra-high projection implant. That allows for better projection towards the front, but less projection on the side. But let's say we've gone beyond that point and we're now at I'm not letting you off that easy. We're and we're in and maybe that may get 20, 30% of patients, right? So now we're at the point where we're we're we've chosen a 600cc ultra high profile implant and it's massive. So absolutely, I think you need soft tissue support. Otherwise, you're you're playing with fire there in another couple of years. That implant's gonna bottom out, it's gonna drop, and patients are gonna be sorely unhappy.
SPEAKER_01So you will do it.
SPEAKER_00Absolutely. Yeah. Okay. I will usually always put in in a in a larger implant. I will usually always put in some sort of soft tissue support.
SPEAKER_01Yeah, I will too. But the one thing I'll try to tell my patients is we use this marketing terminology, internal bra, and that's just BS. Like it is not a bra. It is not going to be a long-term support that's actually going to push it together or higher. It's additional soft tissue support. But ultimately, it's the laws of physics. You've got a heavy weight, you've got your intrinsic support, which is very little, and then this piece of mesh, whether it's acellular dermal matrix, which is what you like to use, which is an artificial skin substitute, or a bioesorbable mesh, which is synthetic, which is what I like to use. Either way, eventually they don't maintain, they don't have the same level of tensile strength later on. And so you're slowing down the progression, but there'll still be problems. And ultimately, I'll tell people you're an adult with free will. I'm gonna make sure you understand the risks that are involved with all of this, but you need to understand that there will be long-term problems that go along with it.
SPEAKER_00Right. Well, I I gotta say, I don't I don't know if I agree with that statement about it not being an internal bra. And I wanna I want to go back to my experience in breast cancer reconstruction. And I would arguably say that there are problems in cosmetic revisional breast surgery that are the worst problems in that discipline that don't even come close to the issues we have in breast reconstruction. And so in breast reconstruction, after cancer, we have issues like radiation, we have thinness of tissue, and those patients, you know, we're really relying on a piece of cadaver skin or some sort of other mesh to hold things in place because there is zero support right there. So I think it really has to do with the type of mesh you you pick and the way that it's sewn in. I think the tendency sometimes is, for example, there is a company out there that makes a very small type of mesh that looks like a canoe and you put it in the into the breast pocket and it's got some suture tabs. And every time I've used the device, it looks like it's just gonna fall apart over time. Okay. But if I take a big piece of cadaver skin and really drape the implant around this and secure it with undermining and and soft tissue support with maybe even some permanent sutures, I have found that that holds, and sometimes it holds it even too good.
SPEAKER_01Yeah, I mean, I I hear what you're saying. I don't I don't agree with you. Um you use the you talked about radiation, which I think is a confounding variable where that actually creates more, you know, fibrosis and that actually creates more support in a bad way over time. I think in this particular scenario that we're talking about, where we're trying to utilize mesh to hold an implant in place where we know there is no support of any kind, and it's a heavy weight typically that is disproportionate for a patient. Um, yeah, it's gonna provide additional soft tissue support, but there will be some gravitational changes that happen over time. I think mesh is great, but it's one piece of the puzzle. It's a piece of the armamentarium, but it's not foolproof. And I think I'm I'm being so dogmatic about this because so many patients come in saying, I'll just put in big implants and use an internal bra. I use internal bras on probably 60 to 70 percent of all primary breast augmentations, even smaller implants. And so I just I want people to understand that it's that it that it works really well if you are obeying the anatomy of a patient. But if you're going beyond that, it's much less reliable. And what mesh are you using? Mostly. I use three different meshes typically. I'll and it kind of depends on the indication. For this particular scenario that we're talking about, um, where we're talking about implants that are too big for a patient, I'll want to use something that sticks around longer. Uh, I'll typically use um P4HB mesh or Galiflex is, you know, or phasics are sort of the names by which it goes by. For people who I'm I don't need it to stick around so long in smaller implants, I'll use ones that go away faster, like Durazorb or Phasix. I don't typically use acellular dermal matrices other than in capsular contracture cases. So getting back now to patients who are downsizing who come to see you. Patient has large implants, they have regret uh ever, you know, having these implants that don't match their body. How do you frame the conversation about whether or not they're gonna need a breast lift?
SPEAKER_00So it really has to do with the extent of the soft tissue that has loosened up over time and the position of the nipple. I think those are two key concepts that patients have to really get a handle on and understand before we make the decision to downsize. And invariably, in unless there's a downsize of five to 10% or something like that, you know, most of the time they're gonna need soft tissue support with a mesh or a biologic, and they're going to need a full deal mastopexy with an incision that goes around the nipple, uh, straight down and then across. It looks like an anchor mostly. And I think there's just no way to temper the extra tissue other than cutting it out.
SPEAKER_01But can I just use an internal bra? Will that take care of it? Well, but I get that question frequently.
SPEAKER_00It it can take care of it. So I think you have to think about the difference between the breast implant and the breast that you have, the breast mound that's there. Okay. So the mesh is really there to support the implant. It's not there to support the soft tissue of the breast, the the breast paranchyma, the breast organ itself, right? So that has to be dealt with in two separate ways. So yeah, it just doesn't look right if you're not doing that.
SPEAKER_01Yeah, you're 100% right.
SPEAKER_00And um which kind of begs the question too, right? Like philosophically, you know, patients have an idea in their mind of what they want, you know. And you know, we live in a world of social media and Google and Yahoo and ChatGPT and Claude, right? And you know, you have patients who come in and well, I I don't want to lift, you know, I research this on ChatGPT and it says I can do a breast lift, but ChatGPT doesn't have their medical degree as of yet, right? Or your plastic surgery board surface. Thousands of medical degrees according to patients. So it's it's like you know, you you sort of have to defend your thought process with them.
SPEAKER_01Yeah, I mean, and I and it comes down to the fact that you have a heavy weight in your soft tissue for many years, it creates changes to the elastic properties of that skin. Um, both the breast tissue itself and the skin just don't have that same stretch. It's like a balloon or a rubber band that you've stretched out multiple times. It doesn't have the same bounce back to it. And the same is true with breast tissue as well. Nobody wants a lift, but if you need a lift, you need a lift. And that's just that's just the way it is.
SPEAKER_00Yeah. And I think the the thing I oftentimes tell patients is you know, okay, so you don't want to lift, you don't like the scars, but even in the tiniest of bikinis, you're not gonna see those incisions necessarily. Maybe a little bit on the side, but you know, in in everything you want to wear, no one will know the difference between you having a lift or not unless you know your bra is removed.
SPEAKER_01Yeah. And the other thing I'll say is when you described a lift, you describe an anchor pattern lift. You didn't describe smaller incisions. And I agree with that for the majority of these cases as well. But a lot of times patients will say, Well, can I just have an incision around the areola? Can I have a smaller incision to do that? And what's the problem with doing that?
SPEAKER_00So, great question. You know, a lot of people come in and they say, Well, can't you just do a this circular incision around? Okay. And throughout the history of plastic surgery, there have been techniques to optimize that operation. It's called a circumareolar mastopexy. Some surgeons use um Gore-Tex. Gore-Tex uh suture, which is a foreign body that stays around permanently. In my career, I've taken out more than my fair share of those Gore-Tex sutures. Okay. They tend to have pus around them, they tend to erode through the skin, they have to be removed. And what happens after that is if you have a circle diameter that's four centimeters, when once that suture is removed, it's going to spread out five, six centimeters. So it really causes a tremendous amount of widening of the nipple areolar complex, the nipple. So not a great operation in my hands. Yeah.
SPEAKER_01I think the other problem with that operation is if you try to do too much, the breast gets an abnormal flat appearance. Yeah. And the vector ends up pushing the implant out to the side a little bit as well. Well, um, you know, I think ultimately the the dilemma we face as plastic surgeons is a lot of times we know what we believe is right for the patient, but that's not what the patient wants. And I'm still trying to struggle with how much responsibility do we bear for patients that come back and see us, you know, now that we're both coming up on our second, you know, our third beginning our third decades in practice, we're seeing patients that we put some of these implants into now coming back and wanting to downsize. How do you how do you grapple with what you wish you would have told the patient then and now what you know?
SPEAKER_00I told you so. No, I never said. Okay. No, so I I think you know, we I go back to that discussion of, you know, it's this is what you we have decided. I I tend to share that responsibility. I use the word we. We decided years ago that we were gonna do this. Okay, and it worked for a number of years, but trends changed. Your body has changed, what you want out of your appearance has changed. But, you know, not to worry, there are treatments for this, but we just have to be flexible about what treatments we're gonna use, right? Yeah. And I think overall it is a common law in my practice, I would say, law or trend, I would say, that a secondary breast augmentation is always more complex than a primary breast augmentation. You get, you have small breasts, an A cup, you throw in a set of implants, everybody's happy. But when that implant gets bottoms out or your breast changes or your body changes, it's a much bigger deal the second time around.
SPEAKER_01Yeah. I think if I had one bit of advice for women getting their first breast augmentation, and that is that is, you know, less smaller implants do tend to cause fewer problems over time, and the revision surgeries are a lot easier. And for women who are finally tired of their bigger implants, the advice I'd give them is we can make things better. You're gonna have to have some scars to make that happen. And it's a much bigger operation. Any closing thoughts? Bigger's not always better. That's right. Well, thanks again for watching this episode, and uh, we can't wait to see you on the next one.