Episode 32: Breast Reduction – The Art of Lifting and Shaping the Breast!

Dr. Franco: Our team, welcome back to Plastic Surgery Untold, the greatest podcast in America as voted by us. I’m Dr. Johnny Franco also known as Austin Plastic Surgeon. We got our Celebrity crew back, and back from the B on. One Fernando Rodriguez rejoining us, I would say, by popular demand, but I don’t know that they were actually any requests, but he’s here anyway. So boom, boom, boom, there we are. So today we’re gonna be talking about a breast reduction, something that I think Fernando knows very little about, but hopefully we could still educate all of you about this a little bit. So, yeah, I should have some fun here. So let’s get caught up with what everybody’s doing since our last episode, and then we’ll get the ball rolling here. Maybe, I’ll start off with the G. Berto and Fernando. And why I’m rousing Fernando a little bit is, they actually went out for a nice like steak dinner last night across the street from my house while I was working hard. And do you think anybody got a doggy bag, any leftovers, take out? No, nothing at all. But G. Berto, please explain your reasoning behind this?

G. Berto: Well, I thought we did get you a doggie bag. I sent it home with Fernando, but I went home on my own so I don’t know where it ended up. It did, maybe in Fernando’s refrigerator?

Fernando: Yeah, that’s where it ended up at, and I was gonna bring it to you this morning. I didn’t have a key to your apartment so I couldn’t leave it there for you. So, it just brought it home instead of your home.

G. Berto: Okay. I’m glad you guys thought about me. I appreciate that.

Fernando: Well, I always think about. You were the topic of the conversation the whole night.

Travis: Oh, man. My BS-meter was just off the charts when I was listening to that.

G. Berto: It’s getting little deep in there.

Travis: It is getting deep in there.

Dr. Franco: What’s going on with you Celebrity? I don’t know that I should be the one to break this news to everybody, but word on the street is that you close on a new house.

Travis: So we have not. Incorrect.

Dr. Franco: Damn. Yeah, the rumor mill is not true.

Travis: We got a fact check that one. So we’ve not closed on the new house, but yesterday we closed on the sale of our old home. So that was exciting. Now we have it leased back for the next 20 days, and hopefully…

Dr. Franco: Nothing better than like selling a house and then having to pay to live back in it, right?

Travis: That’s exactly right, in the same one. Gotta love it.

Dr. Franco: Okay. No, that’s cool.

Travis: Yeah, so then…

Dr. Franco: Seems anti-climatic.

Travis: Hopefully in the next week or two we actually close on the new house which will be awesome. We’re excited about that. So Mary’s been having a lot of fun, at Your Trendy Therapist, give her a follow. She has been…

Dr. Franco: Well, we actually invited on this show and decided that she needed to go shopping instead.

Travis: Gotta outfit the new house, man. I mean, priorities. But, yeah, we’re trying to pick out a bunch of stuff for the new house and get everything situated.

Dr. Franco: So there’s a little bit of a chance that you guys might be living on my couch.

Travis: We may if it gets pushed back anymore.

Dr. Franco: Okay. I don’t know. Winston may have some words about somebody sleeping on his couch. Fernando, what’s going on with you? Catch us up on your life. I feel like it’s been a long time since we’ve had you on the show.

Fernando: Well, actually not a lot going on. Still sheltering at home. So my office went from my spare bedroom, so we converted that in… Other than working hard, it is just same old, same old.

Dr. Franco: Oh really?

Fernando: Nothing to write home about.

Dr. Franco: You’ve been working hard?

Fernando: Yeah, most of the time. All I can say is I think you still get paid on time, don’t you?

Dr. Franco: G. Berto, what about you? What’s going on in your life?

G. Berto: So I just got back from an education course. I think I mentioned at one of our last podcasts so I was gonna be traveling to Kansas City to go do this really cool, really interesting cadaver course where we learn how to do injectables, more advanced techniques. And then we use these cadavers to inject and then we dissect the cadavers just kinda see where placement of filler was, and make sure that everything is in the right place and make sure that, you know, we’re avoiding any blood vessels and dangerous areas just for safety of our patients, and just trying to make our skills, just hone our skills a little bit better.

Dr. Franco: Well, this is what impresses me. Here’s Austin’s greatest injector and here he is just chipping away. I mean, you know, I might be biased about you be the greatest injector or not, maybe greatest injector was a little aggressive, but I would say you’re at least top 1000 in Austin. Top 1000, I think we can all agree on.

G. Berto: I think that’s a fair assessment.

Dr. Franco: Celebrity Fernando, could you agree?

Travis: It is at least one of the best guys in the room right now.

Dr. Franco: Yeah, at least top five of people on this podcast right now. But, I’d put on from… For those of you that are listening, there is only four of us you.

Fernando: I would put him in the top 500 not in the top 1000.

Travis: There you go. Oh yeah.

Dr. Franco: Of Austin. Okay. Okay.

Fernando: Yeah, of Austin.

G. Berto: Thank you.

Travis: I love it. I love it.

Fernando: Because I think there is only for like 550 injectors in entire city, so…

Dr. Franco: Yeah, maybe 400. So, who knows, but he’s in the top 500.

Travis: I do think it is really cool that you guys got to do the injections on the cadaver and then go in and dissect and see where that filler were actually laid though. Because, I mean, all jokes aside, that is a really cool thing to be able to do to see where you’re actually hitting. And a lot of people don’t understand that when you’re injecting filler, it is completely blind. It’s based on feel, it’s based on landmarks and technique. But it’s cool to be able to go in and actually see where that landed.

Dr. Franco: And I actually think, not to give away all of our trade secrets here, but I actually think two episodes from our actually talking about some more fillers, some injectables. And so maybe you can save a few of those nuggets for that episode. Because, today we’re talking about breasts. Can we get started?

Travis: Let’s do it. Let’s do it.

Dr. Franco: You guys done reminiscing about your world travel? Okay, let’s do it. Let’s talk about breast reduction. Breast reduction is an interesting topic, because this is one of the standards of plastic surgery that’s been around for years, and years, and years. And it probably doesn’t get some of the sexy hype that BBL, these 3D sculptings stuff gets. But I’ll tell you, and Celebrity sees a lot of these patients and stuff with me, most of these patients, one, have thought about this for a long, long time. Two, they’re one of the most happy patients, because it’s been such a big process. This isn’t something they saw, you know, an Instagram post from Austin Plastic Surgeon, or one of the other great providers in town and then decide to do it. This is something that has been contmplated for a long time, because from their standpoint, it is just something that causes a lot of restraints in daily activity. Would you agree with that, Celebrity?

Travis: First thing I was gonna say was these are some of the happiest patients I see immediately post-op. They’re so excited to have this done. It’s such a life changing thing for them. Because, you know, like you alluded to, it is affected their ability to run and work out, they have some back pain related to, they feel like they’re carrying a bunch of weight around that they would like removed and taken care of. So it is, I mean, these patients are pretty fired up when we’re done.

Dr. Franco: It’s an interesting idea, because breast reduction is this big spectrum of stuff. And so, you know, there’s different ways that people get to the plastic surgeon about this. And sometimes people don’t even maybe at the initiation of this realize that that’s their cost, because, I would say, half of the people to get a breast reduction are coming because of true symptoms. You know, whether it be…and hopefully G. Berto can jump on some of this, whether it can be skin irritation, people can get rashes underneath their breasts, and, you know, can be treated medically but only to some point. If you have a chronic irritation, you gotta get rid of the irritating, you know, factor too, back pain, shoulder pain, shoulder grooving, you know, just limit from activity because of the weight and size of some of them. So it’s very interesting how that comes about.

G. Berto: Yeah, I’d say like in my practice, we see a lot of patients that come in with rashes under the breasts, and typically, it’s due to friction. You know, it’s skin rubbing on skin, and then when there is perspiration or sweat that accumulates under the breast. We live in Texas it’s hot here so, you know, you can be at work and still be sweating, you know, and just be sitting in a cubicle and still be sweating. And that area, that sweat creates friction in those creases of the skin, and it triggers a lot of irritation, inflammation. Then that is compounded by sometimes some like bacterial infections or yeast infections, and it just kind of makes the situation a whole lot more challenging to treat. So, I think, yeah, breast reduction for those types of issues would be like a godsend for some of these women.

Dr. Franco: Okay. No, I agree. And it’s interesting, because now breast reductions are created equal. So, you know, just when we talk about breast augs, you know, a 300 CC implant can look very different on one person versus another, such as calf implants on G. G. Berto, Fernando, and Travis will look very different on each of those legs. I promise you this.

G. Berto: Will look the best on me though.

Fernando: I would disagree. It will look best on me.

Dr. Franco: But so, you know, with the breast reduction, the amount that we take out or change, you know, varies from person to person, and so does the resolution of symptoms. And before we get into the actual surgery itself and the different fine points of that, I think it’s important for people to realize, you know, that it’s a spectrum of breast in terms of this, and how much tissue we take out, where we get to, and then what symptoms they get resolved. I try to be very clear with everybody in the… I’ve never had a patient, I’m knocking on wood here, who hasn’t had some improvement in their symptoms. Back pain, shoulder grooving, those type of things after a breast reduction surgery, and just feel like they’re able to move better. I even get patients sometimes the very next day at their post-op, they’ll be like, “Hey, I feel better.” And some of it, you know, maybe psychological, some of maybe the actual fact that they can stand up straight and they don’t feel something pulling them down. But I also caution patients, especially my older patients, hey, sometimes you’ve had these large breasts for 20, 30, 40, 50 years, depending on their current age, and some of that damage that’s been done, won’t undo it and sometimes those nerve damages, and Travis can jump in about this, takes a long time to really heal. And people get better and better from some of the symptoms for months, but never can promise people that 100% of those symptoms will go away. Sometimes there’s other factors going into your back and shoulder pain, sometimes that nerve damage has just been for a long time.

Travis: Sure. I mean, I would echo that 100%. I think, you know, I wish that I had more to disagree with you on so we can really go head-to-head, but I don’t. I mean, those symptoms are not gonna improve overnight. Like you alluded to before, that feeling of heaviness and being too heavy in the front, and having some of that immediate weight relief, I think is one of those things that does come immediately as far as a resolution goes. But like you said, if there is chronic nerve damage or nerve irritation, or they have some issues with their spine and degenerative, you know, disk issues, those things are gonna take time to improve. Nerves are one of the slowest things in the body to heal and regenerate. So unfortunately sometimes those things are not a quick fix.

Dr. Franco: So let’s jump into the meat and potatoes of breast reduction, i.e., that’s for G. Berto and Fernando, who had a great night last night. Breast reduction surgery, I think, one of the biggest myths that I want to clear up is a lot of times a lot of people saying, “Hey, can I get a breast reduction and a lift at the same time?” You know, and I think this is true for most plastic surgeons. I don’t wanna speak for everybody in the world, but, you know, most breast reductions include a lift. And so, you know, because part of the idea behind the breast reduction is not only removing tissue, but we want to reshape the breast, we want to get the breasts in a good position, because I do think there is some mechanics to breast reductions as well. When they’re very long and out there, it’s hard to support, it’s hard to fit in a bra. It’s hard to get into a good spot. When they’re up and high, and tight and perkyperfect as we like to say, you know, then the mechanics are overall better. So I think it’s a two-phase part for breast reduction. There’s the reduction of the actual tissue and then once you’ve got it reduced, then it turns into like our standard breast lift where now, our focus is in shaping and getting the breast as perfect as possible.

Travis: And I think you’ve had a pretty good analogy in the past as far as reshaping the envelope to put that breast back into once you’ve removed some of that excess glandular, you know, breast tissue, and then reshaping that envelope and putting that envelope back together neatly.

Dr. Franco: And it’s also a little bit challenging, because I think breast reduction is one of the procedures that, you know, in plastic surgery residency training, especially in the world of aesthetic cosmetics is probably one of the harder ones to understand, because the key is the blood supply to the nipple. And so we want to keep that nipple, you know, pink and perfect, and everything else. And the bigger the breast, if you think about it, the longer the tracks are to get that blood flow to the nipple, right? And so the more careful you have to be. But obviously, the bigger the breast, the more tissue people typically want removed. And so it becomes one of these, you know, little challenges if you will. And there’s a lot of different ways to do breast reductions. And I’m sure you, Celebrity, doing anesthesia for all the great plastic surgeons in Austin, maybe not all of them, but most of them, I’m sure, you see a ton of different methods. And what’s kind of funny is, there’s a lot of different ways to get there, but in the end, a lot of the results look pretty similar.

Travis: They absolutely do. As far as different techniques, what the incision actually looks like, the shape of the incision, what they do with the pedicle, which you alluded to before which is basically that complex of the nerves and the tissue that track directly to the nipple if I if I’m not speaking out of… I don’t wanna get too far into your territory. That’s not my area of expertise, but…

Dr. Franco: When has Celebrity ever been shy about sharing his expertise?

Travis: Yeah. I think though every guy in town and gal that I work with, they do variations of basically the same thing to get to a very similar end point. I think that’s been the easiest way I could say it.

Fernando: Dr. Franco, how difficult is it to make sure that the nipple is actually centered on the breast after it’s been reduced?

Dr. Franco: So that is a good question, and there’s a couple things. One, I don’t think getting it centered right at the time of surgery is the hard part. One is keeping that nipple alive, you know, and that really depends on the size of the breast. And so, you know, even how you do it, even how I do my breast reductions really depends on the actual size, the wish of the patient in terms of what they’re hoping to achieve, and then, you know, the one really key about breast reductions, and this true with rhinoplasties and some other things is you wanna anticipate where the breast is gonna go six months from now. And maybe that’s what you’re alluding to here, because, you know, when we were revise breast reductions, one of the complaints I get sometimes from patients is they don’t have upper pole fullness, which we’ll get to, and then two, sometimes the nipple actually rotates too high over time. And, in the end, the issue is that they have a hard time in bras and tank tops. So a lot of times when we position the nipple on a breast reduction, it’ll be just a touch low, as I did with my voice right there, and then as the breast settles a little bit, that nipple rotates up. And I think Travis has seen that with some of our mastopexies and other stuff, you know, it’s just anticipating. I know we have a lot of great rhinoplasty surgeons and they always talking about, “Oh, we’re gonna talk about how the skin’s gonna shrink over the next six months and all that’s gonna settle.” And I think that’s the true art of plastic surgery is anticipating how the tissues are gonna mold and settle down the road, because those are people who get good long-term results and not just great Instagram pictures at the time of the surgery.

Travis: Completely agree with that. I think the other really cool behind the scenes kinda deal, and I don’t wanna get too far into our behind the Bovie segment. But, one really cool thing you get to see in the surgery with these plastic surgeons is you see the true art form of plastic surgery kinda take hold.

Dr. Franco: Well, thank you.

Travis: Yeah. I got a tip my hat and when it’s necessary, or when it’s deserved, I guess.

Dr. Franco: Which is an often.

Travis: No, which is not often, but this one I definitely have to get a tip my hat on this. When they open up that the breast in open that envelope up, there’s a bunch of tissue inside. And, I guess, the goal for these plastic surgeons in, Johnny Franco, in particular, is very meticulous on how and where he removes that tissue to get that size down to what that patient’s goal is while trying to keep that nipple-areolar complex alive, and perfused with blood and oxygen. So it’s interesting to see them and we’ll take off some tissue, and then will weigh it, and then will take off some more tissue, and then will weigh it. And it’s this slow laborious process that people don’t get to see behind the scenes.

Dr. Franco: It’s not that slow, as Celebrity is pointing out there.

Travis: Okay. It’s not that slow, but it’s not just walking into the room, taking a knife, and cutting of like a big piece of skin off, and you’re done. It really is, you know, shaping a breast in his mind before he actually attacks that thing back together 100%. It’s very cool to see that happen and then get to the finished product. You’re like, “Man, that was actually pretty neat. I don’t think I could have done that after a couple YouTube videos.”

Dr. Franco: What’s the old saying? It’s not what you take away, it’s what you leave behind?

Travis: That’s exactly right.

Dr. Franco: Yeah. But G. Berto says that to his ladies all the time. I’m not really sure what that means, but who knows, you know. A little love down on the counter sometimes, you know.

G. Berto: To piggy back on what Travis was saying. You know, I’ve assisted you in a few of these procedures early on in our careers together.

Dr. Franco: And when you were assisting me, it was not a slow process.

G. Berto: It was not a slow process.

Dr. Franco: Good, good.

G. Berto: It was a properly paced process.

Dr. Franco: That was efficiently and properly performed.

G. Berto: Yes.

Dr. Franco: Thank you.

G. Berto: And it always blew my mind like you knowing exactly where to take the tissue from. Like, how do you know exactly where to take it from, superiorly, inferiorly, medially? You know, it’s really interesting to see.

Dr. Franco: And I think that one of the hard parts of the breast reduction, and to not make this super slow and last like for 16 hours is, trying to get people even. It’s when people are very off, I think people don’t realize that’s what’s really, really hard. Because, you can look at a breast and seem to, like, in your mind, you have to have an idea of how much tissue might it take to make this even or not? And I think that’s the true art and gift to plastic surgery is having a feeling of like okay, and to your point, you want them to not only be the same volume overall, but the same shape, and how do you take two completely different breasts…

G. Berto: Yeah, because nothing’s symmetrical.

Dr. Franco: Yeah. That’s kind of the trick.

Travis: Yeah, it blows my mind. I mean, we’ll set a patient up, you know, as we’re starting the case. And they may have one much larger pendulous long breast and then the other one is wide and not as big. And to you see you kinda in your plan of attack in the different guys and gals that I work with in town, it truly is. It is like watching art. Yeah, I would not be able to do it. And I think it’s one of those things were only trained hand and trained eye having done hundreds of these, would get to the point where you feel comfortable kind of making those decisions and moving forward.

Dr. Franco: Can we talk a little bit, because some of the questions I get is, “How much tissue you’re gonna remove?” And we alluded to a little bit of this. You know, some of it’s dictated on what the patient goals are? You know, we definitely have patients that want to be really, really small. There is patients who still wanna keep some fullness but wanna be smaller, perkier that we can do. And this is why I love wish pictures, because it gives me an idea of what their actual goal is. Because with the reduction, there’s not really a way to size people per se, like we do with breast augs. And so it gives me a good idea that, one, what we can do is attainable. Because as we’ve talked about here, there’s a limit to how much tissue we can take out to protect that nipple, those nerves to that nipple on those type of things. So I think that’s really important. Sometimes we have very asymmetrical breasts. There’s a limit to where we can get them, because we got to find a happy medium of making them as symmetrical as possible. So there’s typically one breast that’s the limiting factor, just like on this podcast, sometimes there’s one guest that’s the limiting factor. But, you know, we’re not gonna mention any names or point any fingers at somebody that’s got a full belly from last night. But, we’ll keep moving on. So I think that’s super important in terms of that. Also, some breast reductions can actually be covered by insurance. That’s become a much, much more commonly…

Travis: No, difficult.

Dr. Franco: …complicated, difficult, tedious path or course, I guess, should say. Some insurance plans have written it out of their plans. Certain criteria often has to be met to fit that, so in general, it has become much harder than it once was. So something to at least ask your provider about if they accept insurance, if that’s something they can do. And then just remember, just because you have insurance, doesn’t mean that it’s a service that’s covered. But it’s always worth, at least, asking the question. You know, other parts of the breast reduction stuff, because sometimes if it’s an insurance thing, there’s a certain number. They have a whole calculation of they decide how much you have to take out the get covered, and that’s a discussion for a different day about those numbers and how they come up with that. But, again, just like breast augs, one number doesn’t kinda fit of, if that makes sense.

Travis: Not at all.

G. Berto: Would you say that your practice does more of these breast reductions from an aesthetic perspective or a medical perspective, or a combination of both, or?

Dr. Franco: Our practice at this point doesn’t, we don’t directly accept any insurance at this point. So, you know, patients if they’re going to our practice and want to go through insurance, one, we’ll either happy to refer them to one of the incredible plastic surgeons here in town that does accept insurance, or patients can actually file on their own accord and we can help him with that. I would say the vast majority of ours are aesthetic patients, either patients who don’t have it in their plan, got denied, or just wanna come see Celebrity anesthesia. You know, so either one. Thank you, Celebrity. And, you know, it’s funny, because we had a patient the other day that was disappointed that Celebrity his shirt on during an anesthesia and outside. I was like, “It’s kind of sterility thing. Sorry. He’s gotta throw it on.”

Travis: It’s all there was in the hospital bylaws. I’d get in trouble for that.

Dr. Franco: But the other part is the incisions. Because, you know, one of the things that I get all the time is, “Can we do the incision that just goes around the areola and not that the anchor that goes down, and the two underneath in a breast reduction?” I would say, 99% of the time the answer is no. Because we’re taking up that much tissue, we gotta get rid of the skin envelope too, because we want you to be perky and perfect. And if we take out a lot of tissue, but don’t get rid of the skin, you’re still gonna have that pendulous breast. And that’s why it’s very rare that we do liposuction, do things like that where we’re just removing a mass effect and not removing the skin. Because, most of the time people have extremely large breasts, tend to have ptotic breasts as well, because that excess weight has pulled the breast down over time.

Travis: I totally agree.

G. Berto: Gravity is just a bear, isn’t.

Dr. Franco: You know, some other thing common questions I wanna touch base with in, and guys feel free to fire away questions at any point, is, you know, one of the big things that we get is nipple sensitivity after breast reductions.

Travis: Sure.

G. Berto: How’s that affected?

Dr. Franco: I’m glad you asked, G. Berto. I’m glad you asked. You know, with a breast reduction, 70% of patients end up back at baseline. 15% of the patients end up with some nipple hypersensitivity, and some end up with some sensation loss. The one thing with people who have very, very big large breast is sometimes that those nipple sensations are already decreased ahead of time. So, you know, if they’ve already had some nipple sensation decrease, that’s likely not gonna get better over time. And that comes from those nerves being stretched over time, and again, to what Celebrity talked about earlier is just kind of the chronic damage to those nerves that sometimes can be, take a long time to heal or may not completely come back.

G. Berto: Is there any concern about nursing or breastfeeding after having had a…

Travis: You stole my question.

Dr. Franco: Well, that’s a great question. G. Berto. That is a great question. The answer is yes from several regards. It depends again on the breast reduction type. I think most people think that the nipple, because removing it, actually comes off the breast. That’s actually very, very rare. There’s one type of breast reduction called a free nipple graft breast reduction, which we do extraordinarily rarely, and tends to be in people with just massive breasts that wanna be smaller and typically much older patients who are past the point of breastfeeding. But, in general, the nipple stays attached to the breast so those ducts interior still in a good position. A lot of times, there’s two parts to this. One, a certain percentage of people can’t breastfeed even if they’ve never had surgery. So if you never breastfed before, you don’t know if you’re in that category. Two, sometimes what typically keeps you from being able to breastfeed actually becomes the nipple sensitivity. So if people are hypersensitive, just from a physical standpoint of tolerability, they struggle with that.

G. Berto: Okay.

Dr. Franco: Great question G. Berto.

G. Berto: Thank you.

Dr. Franco: We’re waiting for Fernando to drop us a nugget, but until he does, I’ll keep rolling.

Fernando: Yeah. And what does scarring look like around the nipple itself?

Dr. Franco: That’s a great question, Fernando. The incisions do tend to vary. So, you know, one, I think some of the points to bring up around the areola and nipple, because that tends to be a huge focus on breast reductions is most of time with the whole breast being stretched and enlarged, the areola and nipple tend to be very large. And so most of the time, we’ll bring it down into a smaller size, and we have what we call cookie cutter, but they’re basically areola sizers that are different sizes, so we can make sure that areola matches the size of the new breast. Because, if the breast is smaller, perky or perfect, then we want the areola to be perky and perfect around too. And what we, happens with that is, we do try to put the incisions right around the border of the areola where people have a natural change. And so that hides pretty well. And then the incision down the front, and then some variable in the… There are versions of, I think Celebrity has seen some of these, other versions of breast reductions where you can limit the scarring to just around the areola and down the front of the breast. Some do kind of in a lazy S where it’s down and then just out laterally. Again, depends on the size of the breast, the amount of tissue taken, and then the person performing the surgery. Again, there’s no necessary one that’s better than the other per se, just depends on the situation.

Fernando: And does skin tone have any effect?

Dr. Franco: Absolutely, absolutely. You know, people with darker skin we tend to have to be a little bit more careful with scarring. But just because you’re fair skinned doesn’t mean that you can’t scar poorly. So I think it’s super important to take it very serious. You know, there’s lots of things we do to try and make it the scarring and healing as good as possible. Lots of sutures on the inside, using the dissolvable sutures so they don’t irritate the body long-term, a glue over the top which has been shown to decrease scarring. And then I do love the silicone creamer sheeting afterwards to make sure people are in a great spot to help with that. And every provider has a different kind of scar management procedure, because it has to go in rhythm with what everything else they’re doing, right? If you’re using the glue, you don’t want to do a tap till the glue comes off. I think some people like to do these steritrips, other stuff that they like to keep on for several weeks and then remove everything. So, there’s a lot of good methods, but it’s got to fit in protocols. So make sure you talk to your physician about that. But that’s a great something to remind people, Fernando, about stuff, something they should have, a conversation that you should have with their provider.

Fernando: You’re not using superglue, right? Like, you do in YouTube videos?

Dr. Franco: It’s basically like medical grade super glue. Somebody sterilized superglue, they charged a fortune for it, and then made it purple, and boom, boom, boom. They’re on their yacht being like, “Man, I love the people using crazy glue for something.” But that’s not the only thing holding them together. I promise, we do spend some time stitching you back together.

G. Berto: Do you ever run into issues with…

Dr. Franco: On the yacht? No.

G. Berto: …with issues with like keloids in the areola complex or in these breast reductions?

Dr. Franco: Keloids right around the areola are very rare, but to your point, they’re not zero. They’re not zero. And so, you know, we take it very serious, especially, people who have keloids in other areas. You know, there’s different reasons that people get keloids and that’s maybe a good topic for another day, as it’s, I feel like it’s a very complex…

G. Berto: It’s a very complex topic…

Dr. Franco: …situation with lots of different treatments. I think if you’ve had poor scarring, definitely, definitely make sure that you bring it up to your surgeon ahead of time so that you guys can have a realistic idea about what your results could look like, I think, also so you have a plan to treat them if they do you come back. There’s ways to minimize this, but there’s no… Gilbert, if you know a magic treatment, I’d love to hear it. But, there’s no way to 100% guarantee that they won’t come back or that you won’t get them.

G. Berto: Yeah. I see them a lot in like ears, in, you know, different part like back, and stuff from like acne. I just wasn’t familiar with what the probability was in some of these other surgeries if you run into that at all or have heard of anything like it.

Dr. Franco: I’ve seen it. It’s definitely tough to treat if they get it. And that’s why typically trying to look at other scars and see where they’ve had it. If they’ve had a C-section, how did that heal? Other things like that. As, you know, there’s definitely areas of the body, and fortunately breast is not as prone to keloids as arms, I mean, as earlobes, deltoids, center of the chest, and then back. Typically, the thicker the skin, the higher the chance of the scarring. Yeah.

Travis: I think another, you know, cooler point we talked about this in the past, and really getting on the same page with your provider, your plastic surgeon like, “Hey, what are our options moving forward as far as scarring goes in? And what are you thinking as far as incisions go?” And then if you want to, you could use, you know, something like RealSelf or the different websites for those providers and see before and after. Try to find somebody with your skin tone or similar breast to kind of compare. Maybe, that’s a, give you a good idea. It’s not gonna be exactly right, it’s not gonna be perfect, but at least give you an idea of what those scars look like post-op.

Dr. Franco: And an idea of what the results you’re hoping for. Because, there’s some patients, and this is I think especially in the world of YouTube, Instagram, TikTok, you know, LinkedIn, whatever you want to do, of sometimes some unrealistic expectations. Because, I have a lot of patients that want to do an augmentation at the same time of their breast reduction, and in a very small reduction that’s not unreasonable. But in our patients that were doing a 700 to 800… That doesn’t make any sense at all. Sorry guys. A 700 to 800 gram reduction, you know, to then turn around and put a 500 CC implant, doesn’t make a ton of sense, and that really, really puts us at risk for the nipple. So sometimes we gotta break these surgeries up into stages to make it super safe. Because remember, it’s all about the blood supply of that nipple and if you cut around it, the sides of it, and then we’re gonna cut underneath it, you know, it doesn’t take a lot of math there to see that we’ve really subtracted a lot of blood supply to that nipple.

G. Berto: Yeah, absolutely.

Fernando: And can you address how high blood sugar could affect the scarring on a person?

Dr. Franco: Oh, that’s a great, great question, because you’re talking about glucose, diabetics, pre-diabetic, those types of things.

Fernando: Yeah. And there’s a lot of people that don’t know that they are pre-diabetic and may be having issues with scarring, and you don’t figure that out until you run the few labs on them.

Dr. Franco: I feel like you’ve hit on like six points there. You came in strong at the end here, Fernando.

Travis: Making up for lost time.

Dr. Franco: Yeah. Because to your point, we do do labs on everybody ahead a time. And probably once a year when we’re doing these labs ahead of time, and you can refer to episode 17, if anybody would like to listen to pre-op podcast stuff. But we did do pre-op evaluations on everybody, and probably once a year, we find somebody who’s an undiagnosed diabetic. So basically what you’re saying Fernando, that their sugars are high, they didn’t know it. Because, sometimes when it’s a gradual increase, you don’t feel a sudden change. And sometimes they may be a little tired, little something, and don’t even know where that’s from. So, good point there. And if that’s the case, then we tend to just reschedule their surgery. We do have a Hemoglobin A1C cutoff. Dr. Chang actually talked a lot about that, because that gives us the big picture of glucose. So 6.9 is our cut off, trying to stay below that, because below that, people’s wound healing is actually pretty close to baseline. So we do that. And what you’re talking about Fernando, and this is super, super important is, you know, we’re deconstructing the breast. You know, it’s pretty amazing what the body will heal. We open up those flaps, we take all that tissue, we rearrange the breast, and then put it back together. But now, you know, we put everything back together with sutures and hold it in place. But, you know, the body’s gonna take over. And to your point, if the glucoses aren’t controlled, then the body won’t take over things, don’t heal, those sutures dissolves, and stuff started to fall apart, oryou’re risk for infection, poor healing, or hypertrophic scar. So I think that’s super important. On that note, just because you brought up such a great nugget, smoking, I can’t mention this enough times. Smoking is horrible. We’re crazy about it. A month before, got to be off it for breast reduction, because that’s how you lose a nipple, that’s how you get a big hole in your breast.

Travis: Yeah, completely agree. Every time I talk to patients pre-op, if they were smokers and they stop for surgery, I say, “Please, please, please, it is not even about us not wanting you to smoke for the lung and health reasons related to smoking, this is, we want this to heal properly. We want enough oxygen and blood supply to those tissues.” And when we start to damage micro vascular circulation with a high blood sugar load or with smoking, those things lead to poor wound healing, and lead to making patients prone to infections at those surgical sites too.

Dr. Franco: Because I think some of things that people forget, especially breast reduction is one of the core parts, we’re really taking off the breast and kind of making these big flaps where the blood vessels gotta go a long ways. So a lot of people who smoke, diabetic, maybe hypertensive, which is another one that leads to post-op bleeds, and that’s been shown over a certain limit, especially, facelifts, other stuff, a future topic of ours, you know, they can have an elevated, you know, blood pressure and actually has been shown statistically to increase people for risk bleed during breast reductions as well. You know, but somebody may say, “Oh, I had a knee scope and I healed.” It’s not the same. You go straight down, and there’s not these big vessels that have to come al the way through. So I think, you got to compare apples and oranges. I know we’re running a little short on time, so I just wanna hit up recovery, because I think there’s a perfect transition about healing recovery. Breast reduction, you really want to make sure people give themselves the chance to recover, at least a week and half to two weeks depending on physical labor of your job. You know, if you’re a heavy lifter such a Celebrity and I are, if you’re just living the good life like Gilbert and Fernando, you know, I mean, sometimes you gotta, you know, carry your own fork to the table. But other than that, you know, it’s a pretty easy life, then you don’t have to worry about it too much. Because, we’ve had a lot of people working from home, trying to get procedures done. I think working from home gives you a little bit more flexibility, but still got to be careful. I don’t want people, even if it’s Zoom, something else, working from home if you’re taking pain pills can make a little foggy. It’s like working on a couple margaritas. Also, you don’t wanna limit the pushing, pulling, because you want those incisions to heal. As G. Berto, Austin’s most beautiful man stated, you know, you got to make sure… That reminded me of a story that we’ll come back to. But you want those incisions to heal as good as possible.

Travis: Yeah. Anything that reduces tension on those suture lines is gonna help you. So, you know, staying, we want you moving around, and everything, and want you up, and ambulating, you know, postoperatively so that you’re reducing any risk of developing pneumonia or anything like that. But we don’t want you doing pushups, we don’t want you raising your arms and moving your arms all around. All that’s doing is stretching on that, it’s adding tension to that suture line.

G. Berto: So in terms of recovery Dr. Franco, what can someone expect as far as like pain?

Dr. Franco: You know, that’s a great question. People typically don’t have the same pain with a breast reduction that they would a breast aug or something else because we’re not messing with the muscles or bones, and that’s what tends to cause more pain and discomfort. And so they do feel some burning at the incisions, but again, with breast reduction, most of time they feel such a weight truly lifted off them that it’s almost a wash, because they’re back and other areas feel good. They’re like, “Yeah, I feel some burning, but overall I’m pretty good, you know.” And then with some of the new techniques and hopefully we’ll transition right into this but, you know, people don’t feel so nauseous, don’t feel so sick because of the ERAS and so of the other things that Celebrity and his team do to make the recovery a little bit easier. Can we talk about anesthesia a little bit to take us down the home stretch here?

Travis: And I know we’ve touched on the ERAS protocal, that Enhanced Recovery After Surgery several times and reducing our narcotic load on these patients and using some novel adjuncts as part of these anesthetic techniques to reduce pain and decrease this wind up phenomenon that’s described in the literature. And a lot of that is taken care of with preemptive analgesia, which is, you know, Dr. Franco putting local at the site, local at the skin, us loading patients with Gabapentin and other drugs preoperatively so that they don’t end up with this.

Dr. Franco: Team work makes the dream.

Travis: Teamwork does make the dream work. Hopefully, here over the next couple of months, we’re able to share a couple in new nuggets. Dr. Franco and I have been talking a little bit…

Dr. Franco: We may be getting a new Christmas present.

Travis: We may be getting a new Christmas present. And I don’t wanna, no spoiler alerts, but I’ll hint at it. We may be exploring a couple of regional anesthesia settings.

Dr. Franco: You just said you weren’t gonna spoil it.

Travis: I said I wasn’t gonna spoil it, but…

Dr. Franco: You just said that.

Travis: …I didn’t give it all away.

Dr. Franco: And then you fold it with the spoiler.

Travis: I know, okay. Sorry. I’m excited about it, and I’m excited.

Dr. Franco: Don’t worry. Don’t turn off your podcast. I’m not gonna spoil it, but I’ll let you lead right into it.

Travis: I got excited, you know, the kid on Christmas morning. So we are…

Dr. Franco: Just one present. You can just open just one present.

Travis: The one present. So, yeah, we’re hopefully gonna be able to cover a bunch of stuff in the future and show you guys on some techniques that we use with the regional anesthesia to pick off specific nerves that we can track from the spinal cord to decrease that sensation preoperatively or even intra-op so that we’re decreasing that stimulation along that nerve path before it even happens. Which is very cool stuff, and we’ve been reduced the amount of narcotics patients need and that feeling of pain completely. And some of these cases are very excited about it.

Dr. Franco: Can you maybe touch a little bit on this, because I think sometimes people get a little confusing. I am taking a selfie when I’m talking right now for the gram. But, you know, we talk about low narcotic in these local blocks, others dip. But the goal of the narcotic stuff, and narcotics aren’t bad in the right use. So we’re not saying that. If you need pain meds, you need pain meds in the right moderation like everything, it’s fine. It has a good place, that’s helpful. But what we’re trying to do is, you’re trying to decrease how sick they feel afterwards. That’s part of what some of that overall post-op recovery.

Travis: Sure. Yeah, and that’s, again, with the myriad of meds that we give to patients preoperatively and intra operatively. What we’re trying to do is reduce the untoward effects or the bad side effects of narcotics that do come with those medications, the constipation, the dizziness. That brain fog that people will describe. Opioids are also not completely benign when it comes to pain. Believe it or not, there been several studies that actually show that the amount of narcotics you’re given intraop or during surgery, and you take postoperatively, can actually increase your pain with that case. And that’s called hyperalgesia. That’s a real documented phenomenon. So we’re trying to do everything that we can to set patients up with a great post-op experience, reduce that nausea, reduce the constipation, and get them up and mobile, and feeling more like themselves, and feeling more lucid than you do when you’re taking a large amount of narcotics postoperatively.

Fernando: So you’re saying the body in motion stays in motion?

Travis: What a quote of a day.

Dr. Franco: I feel like somebody brought you a halftime coffee, because you come strong. The second half you’ve owned it was like I was watching the football games this week, and they showed that the team stats in the first half where they had scored like 7 points, in the second half, they sort of scored like, you know, 42, and whatever the last three games. Well, that’s Fernando. He was asleep the first half, but he has come on strong.

G. Berto: He is like pep talker or something.

Dr. Franco: He did, he did. It’s like…

Travis: He stayed from last night kicking and…

Dr. Franco: Can we jump into a little behind the Bovie. I know we run short on time, but we can’t miss our favorite segments. And then I know Fernando threw in a couple quotes already, but maybe G. Berto or Travis will have something to take us home with. Behind the Bovie, Travis, anything you wanna say? If not, I could throw in a nugget or two.

Travis: Well, before you said it earlier, I was actually gonna tell him about the cookie cutter. The areolar nipple sizing ring that we use to determine that the nipple areolar size which was pretty cool. We spread that nipple wide and then place that on it. And you normally trace around it with a little marker, and then you cut along that line. That is a cooler technique, and hopefully maybe one of these days in areola we can talk a little bit more about it, and show some pictures and video on Instagram.

Dr. Franco: Well, I’ve tried to convince my team and maybe we can do a poll of having an only fans account. This way we can show those portions. Because right now, when I show those portions, I get put on time out by Facebook and Instagram. And I get a Nastygram that says, “Please, take this time that we suspended your account to review our safety guidelines.”

Fernando: As it should be, Dr. Franco, should be.

Dr. Franco: So we’ll have to look into some ways to show you those. Because I think it is cool. I think the behind the Bovie nugget I would reinforce, and we’ll talk a little bit about it for the vast, vast, vast majority of breast reductions, breast lifts, augs, the nipple never leaves the body. It’s always attached. And I think because we can’t show some of those portions on social media, I think it’s sometimes gets a little confusing how when we tailor tech people, there’s no nipple, and then boom at the end, it’s back. It’s just hidden underneath, but it’s still attached too. Because that’s what preserves those blood supplies to the nipple, those ducts for breastfeeding and the nerves, so all of them run together.

Travis: Absolutely.

Dr. Franco: Can we get a quote of the day. Take us home, take us home strong.

Travis: G. Berto.

G. Berto: Yeah, yeah. So…

Dr. Franco: Why mad docs dare me right now?

G. Berto: No reason.

Dr. Franco: Okay.

Travis: Don’t let us down, man. Don’t let us down.

Dr. Franco: No reason, just dare it. Okay, look into those eyes, continue.

G. Berto: Yeah. Look into the soul. To kind of piggyback on Fernando’s little quote of body in motion stays in motion, here’s one from Albert Einstein. Says, “Life is like riding a bicycle to keep your balance, you must keep moving.”

Travis: I like that.

Dr. Franco: Okay, okay. So what would you say? You’re moving right now, like, what’s your biggest move right now?

G. Berto: My biggest move is coming with better quotes.

Dr. Franco: That is biggest move. Where is moving life right now?

Travis: Moving our house.

Dr. Franco: Yeah, that’s a little one. Okay, cool. Fernando.

Fernando: Learning more about internet technologies and how to make the systems work better.

Dr. Franco: So your credit only fans account as well. Okay. Well, on that note project now that Fernando 69 star 36. You’re welcome.

Fernando: I believe that’s 21 to 39 please.

Dr. Franco: Well, everyone, I appreciate you guys. To end up, plastic surgeon until the greatest podcast in the world as voted by us. I appreciate all of our guests. I appreciate Fernando rejoining us, coming back, and having a good time. So thank you guys. We’ll see you guys later. Bye.

G. Berto: Bye.

Travis: Bye.

Fernando: Good to see y’all. Have a good one. Bye.