2023 Trends & Controversies with Dr. Johnny Franco

Dr. Bob Basu (00:08): So welcome back to Behind the Double Doors. I'm Dr. Bob Basu. Today on our podcast, I'm really excited to introduce our first board certified plastic surgeon guest, Dr. Johnny Franco, nationally renowned aesthetic plastic surgeon and founder of Austin Plastic Surgery.

Dr. Johnny Franco (00:22): Well, thanks for having me. I'm super excited and honored to be your very first guest. So like you said, I'm Dr. Johnny Franco here in Austin, Texas. Our practice specializes in a lot of body contouring, and BBLs is probably the number one procedure I do. Super excited to be a part of today's conversation, and you guys got a lot of great topics.

Dr. Bob Basu (00:40): Dr. Franco, tell us, where are you from? How did you get the plastic surgery bug?

Dr. Johnny Franco (00:43): Yes, it's been a little bit of a interesting journey. I actually grew up in Las Cruces, New Mexico, in a little pecan orchard, and then have bounced around. I did my residency in St. Louis. I did a few kind of small fellowships in Taiwan, Belgium, and then did an aesthetic fellowship in Miami. Stayed there for a couple years, which probably influenced a little bit of my passion for BBLs and butt augmentation. I did my med school here in Texas. I also wanted to come back. So finally got the chance to come back to Texas, and so I've been here in Austin for about the last six, seven years. I started my own practice about five years ago. You can find us on our website at Austin Plastic Surgeon or on Instagram at @AustinPlasticSurgeon.

Dr. Bob Basu (01:21): Dr. Franco, let's talk a little bit about trends in aesthetic plastic surgery. I want to bring up the recent data from the International Society of Aesthetic Plastic Surgeons that actually CNN jumped on this. They were focusing on that for the first time, liposuction has become the number one procedure in demand. It used to be breast augmentation, and CNN felt that there were some trends about patients not wanting implants because of some concerns about breast implant illness, or maybe the information about textured implants and capsule lymphomas that patients are kind of veering away from implants. What are your thoughts about these trends? What do you think is going on here?

Dr. Johnny Franco (02:01): I think there's a couple things. This is such an interesting topic. One, I think the explosion in liposuction has a little bit to do with some of the COVID weight gain that, including myself, most of us experienced a little bit. And now that people are being active, trying to fit into old clothes, I think it's been a little bit hard. So a lot of people have turned to maybe plastic surgery to kind of jumpstart them. I think that's the growth. I honestly haven't seen in our practice a decreased demand for breast augmentation, haven't seen the concerns for breast implant illness. I think that there is an entity out there, but I don't think people realize how extraordinarily rare that is. The vast majority of breast augmentation patients are extremely happy and do extremely well.

Dr. Bob Basu (02:44): Yeah. I think with the trends, it caught a lot of people's attention. CNN obviously focused on it that liposuction has become the number one procedure in demand. I look back at the American Society of Plastic Surgeon's statistics as well. Overall demand for aesthetic surgery services is going through the roof, right?

Dr. Johnny Franco (03:01): Mm-hmm.

Dr. Bob Basu (03:01): That's nationwide. That's worldwide. But I think there's more to this change than just patients worrying about breast implant illness. And I think, as you said, Dr. Franco, that with post-COVID weight gain, I think just with that overall increase in demand for aesthetic procedures, people just want to look better in their clothing or in a bathing suit. So liposuction has just outgrown the growth rate in breast augmentation. So yes, maybe liposuction is more in demand, but I still think there's growth based on my observations, very similar to yours, that there's still growth for breast augmentation procedures.

(03:36): I'm still seeing a lot of patients coming in for primary, meaning first-time augmentation. I'm seeing a lot of patients wanting their upgrades, meaning a redo. They want to downsize, upsize. And occasionally, I do see patients that they're done with their implants. They want to downsize and do a breast lift, or maybe volumize their breast using their fat, but they're still robust and healthy demand for breast augmentation procedures. So I think it's maybe an overstatement from the ISAPS's data that it's because of breast implant illness that people are not opting for augmentation. Rather, I think it's more that there's just more robust growth in demand for lipo. You're still growing in breast augmentation. Number two is not shady.

Dr. Johnny Franco (04:12): No.

Dr. Bob Basu (04:12): Right? It's still pretty good, but there's just more growth in liposuction than there is growth in augmentation perhaps. I think we're seeing the same things in our practice and our respective markets.

Dr. Johnny Franco (04:23): Don't you think that some of the new technology has made people even more interested in liposuction with some of the skin tightening devices available? Renuvion, BodyTite. There's more and more things coming onto the market, which there was a lot of people who were not good lipo candidates that we shied away from. I know arms, other things. Now that we can include some skin tightening and we can do some high definition lipo, all sorts of different tools that we didn't used to have at our disposal I think has opened up that market too.

Dr. Bob Basu (04:49): Absolutely. Liposuction, just with everything in medicine and surgery. Technology's advancing. We're getting better results with lipo. We're seeing safer results, less blood loss. We're seeing faster recoveries. And I think this also goes into patients want curves, and liposculpting is a great tool to facilitate whether someone wants a BBL or someone just wants more of an hour waistline, whatever their wants are. But liposuction is such a great tool by itself or just an adjunct to a mommy makeover, a tummy tuck. It's just so commonplace, I think that's what that data really shows, is that people are opting for liposuction because they feel comfortable, as you said, with the outcomes we're getting and with the new technologies that are out there and the safety level. People feel comfortable with it.

Dr. Johnny Franco (05:32): Yeah.

Dr. Bob Basu (05:34): So let's switch gears and talk a little bit about buttock size and BBLs, because our guest is Dr. Johnny Franco, the BBL King. So we've got the expert. There's been a tremendous effort by board certified plastic surgeons to get the word out about the safety with the Brazilian buttock lift procedure. I think the word's getting out. I'd love to get your thoughts on the safety of BBL. So what should surgeons be doing to keep our patients safe?

Dr. Johnny Franco (06:01): Yeah, I think people forget that BBL in the world of plastic surgery is actually a relatively new procedure. Even though we've been doing it for 10, 15 years now, if you compare that to breast documentation and liposuction, that's just in its infancy. I feel like our knowledge has grown exponentially. One of the biggest change that we've incorporated into our practice is the ultrasound. We use real-time ultrasound for all of our fat transfers so we can see the muscles, we can see the different layers of fat. We can see exactly where we're injecting it, so this takes all the guesswork out. I'll tell you honestly, even from when I talk to physicians or they come shadow us, even from an aesthetic perspective our results have gotten better, because now I have so much more precision about that. So I think that's been a big change in terms of the safety of BBLs.

Dr. Bob Basu (06:45): Absolutely. Yeah. Really, if you're listening and you're in a different market, and you're talking to a surgeon about BBL, make sure they're utilizing ultrasound to keep you safe. Because remember, one of the concerns about the procedure is the fat is injected too deep into the muscle or below the muscle. Well, inside that muscle or below the muscle, there's these big blood vessels. And if fat gets in those blood vessels and, God forbid, fat travels up those blood vessels, well, that fat can clog up your heart and lungs, and that can lead to a catastrophic fat embolism. That's where those headlines come from about young women who are healthy that go down to some of these trip mall clinics and they don't make it out alive, because they're getting a fat emblem.

(07:19): So the way we keep patients safe now is we advocate for injecting fat into the safe, subcutaneous zone. So remember, in the buttock there's skin, then there's fatty layer, then there's a strength layer of collagen called fascia, and then there's our glute muscles. Well, your surgeon needs to stay away from the muscle. And now, as Dr. Franco mentioned, we use ultrasound. If you've had kids, you remember the ultrasound that probes your tummy and looks at the baby? Well, we use that same technology in the operating room to actually visualize where we're injecting every little bit of fat to keep you safe. We're doing everything humanly and technically possible to keep our patients safe. That lets Dr. Franco and I sleep at night knowing that we've done everything possible to keep our patients safe, and that's a good thing.

Dr. Johnny Franco (08:02): It was kind of disappointing that BBLs got this reputation, because when you really look at where a lot of these, and you alluded a little bit to it, where a lot of these incidents happen, it's actually a very small collection area in the United States where the vast majority of these happen. It can happen to anybody, but it was unfortunate that there was a very, very narrow area where a large collection of these happened. If it's too good to be true, you got to worry where those cost savings are coming from, because it does take time. We do invest money, effort, training. We go to courses to learn how to use these ultrasounds, to spend these times. Both you and I love to educate people. We take time out of our schedule to share that knowledge, and I think it comes from somewhere, because we care about the overall safety of everybody, whether you come to see us or somebody else.

Dr. Bob Basu (08:44): Right. Exactly. Well, let's talk a little bit more about that. Look, we know that we've seen on Instagram or the marketing of these clinics that are out there that are offering cut-rate deals for surgical procedures. Oftentimes, the pricing is lower than what you can get overseas. What do you tell a patient that's actually considering cost only? They're going for a cheap deal, and maybe these practices have slick advertising with results that look pretty impressive. How should we educate these patients when they're looking at these options?

Dr. Johnny Franco (09:16): I think I would try to tell them to just ask the right questions. Who's actually doing my surgery? Is it you? Are you the one doing all my liposuction? Who's doing my anesthesia? Do I have another anesthesia provider there? If I have a problem, who do I call? Where do I go to? Am I going to be able to reach you? Are you still going to be in town in a week if I have an issue? So I think even just answering some of these simple questions helps you get to an answer of knowing what you're getting for your money.

Dr. Bob Basu (09:41): Right. Right. And it's important for all our listeners to remember. Do your homework. As Dr. Franco said, ask the questions. The worst thing that you can do is jump for slick advertising and a cheap deal. Remember, a BBL is cosmetic surgery, but it's a real surgery. You need to have a surgeon like Dr. Franco or a board certified plastic surgeon that's well versed in the right techniques to keep you safe, is not cutting corners on safety, because this is real surgery. Things can happen. We want you to be safe and healthy, so you got to do your homework. The last thing you should be focusing on is cost. If it's not the right time for you to do the procedures, then wait. Save up. There's financing options. But don't focus on cost and slick marketing. Do your homework. I think it's super important.

(10:25): Let's talk about the fun stuff with BBL. There's trends on social media, TikTok. People are talking about BBL era is over. So I have to ask the BBL Kind, is this real? Is this true? Are people doing BBL reversals? What's up with that?

Dr. Johnny Franco (10:40): We've actually seen very few BBL reversals. I'll tell you the few places that we've seen is people who ... Number one, I think sometimes people see these massive BBLs on Instagram, TikTok, Snapchat. Most of the people that have this massive butt, it didn't happen by accident. It's like people that have these huge lips. They've worked hard for this. Most of those people have had multiple rounds of BBLs, BBL plus butt implants, lots of stuff. One round of BBL is not going to get you this massive, over-the-top butt. Let's just get that cleared up, number one.

(11:08): Two, I do think there's some people who gained a lot of weight during COVID. And remember, it's your fat. So if you gain weight, it's going to go where we've put this fat. The idea of a BBL is we change your shape and proportion so we get you to a good spot. The few people who have treated, have gone I think a little bit into some weight gain issues, things like that. I think overall, some of the concept of what people want for BBL has changed a little bit. I think when you first get it, like anything else, people just want to push the limits. How big? How much fat can I put in? I think now people look for, especially in Austin where it's a very athletic-type city stuff, people want more an athletic, but people still love the athletic look. We've combined this a lot with HD lipo, so we always tell people, "You're athletic on the front and athletic in the back." So I think a little bit of their desires has changed, but I don't think it's gone away.

Dr. Bob Basu (11:56): So you're not seeing any changes of BBL reversal, necessarily. It's not a trend that you're seeing.

Dr. Johnny Franco (12:00): We have not seen it. How about in Houston? Because everything's bigger in Houston.

Dr. Bob Basu (12:04): Right, everything is bigger in Houston. I guess, my practice sees a lot of moms. They want curves, right? I think you said it perfectly. They want to look athletic upfront, but they also want to have that balance in the back. Athletic means different things to different patients. Butt proportions, butt curves. They want to look good in form-fitting clothing, and it doesn't mean disproportionate buttocks. The demand for curves, whether it be just fat transfer to the hip dips on the sides or with BBL, the demand's still there.

(12:35): So I am not seeing that reversal necessarily, but I could see if patients gained weight, like you said perfectly, that they may want to downsize. I could see that trend, because our bodies do change with time. People need to remember that when they have a fat transfer procedure, once that fat cell has survived, it becomes a living, breathing fat cell that's dynamic. So if we gain weight, guess what? That fat cell still remembers. It came from your tummy, so it's going to want to get bigger. So if the fat gets bigger, then sometimes you might need a downsizing.

(13:04): But yeah, I do see patients coming in. They want curves, but they don't want that disproportionate look. Now, that means different things to different patients, but I don't think that trend is over by any means.

Dr. Johnny Franco (13:15): And we do so many combo fat transfers. We do as many tummy tuck, lipo fat transfer as we do just straight BBLs, because to your point, people just want that little bit of figure. How you get there may be different than just BBL, may be tummy tuck, may be all sorts of different things that we can play with. You mentioned it just a second ago, but this whole kind of body balancing concept that the breast, the butt, the tummy all go together.

Dr. Bob Basu (13:39): Right, and balancing. Exactly. So as you look into your crystal ball, where do you think this BBL trend is headed over the next year or two?

Dr. Johnny Franco (13:46): I think that it's not going away. I think the athletic is staying. I'll tell you, as the weight loss and the semaglutides have exploded, I think there's going to be a lot more combination of skin tightening combined with the BBLs, tummy tucks type things to do this. Unfortunately, when we lose weight, we don't always get to pick where we lose it. So hopefully, lose a little bit in the tummy, but sometimes we lose it in the face. Sometimes we lose in our butt. Sometimes we lose in our breasts. So I'll tell you, for me, personally, as I've lost weight, I'm much more motivated to go shopping. I'm much more motivated to do stuff for myself, because sometimes when we're not in a good spot, you go to the store, you try something on, you do something-

Dr. Bob Basu (14:23): You feel frustrated,

Dr. Johnny Franco (14:24): You're frustrated. You're like, "Well, I ain't going to move to a XXL. I'm drawing the line."

Dr. Bob Basu (14:28): Right.

Dr. Johnny Franco (14:28): So I think it's going to continue to explode.

Dr. Bob Basu (14:30): Yeah, I think it's going to continue to trend. You mentioned about weight loss. A good portion of my practice, I see a lot of post weight loss patients either through medical weight loss, lifestyle changes or bariatric surgery. And for a lot of these patients, they've lost their volume in their buttock. What's your approach to help these patients if they don't have excess fat, much left, what are some options for them?

Dr. Johnny Franco (14:50): I think that can be super challenging, because sometimes they don't have a lot of options. Sometimes they have a lot of skin laxity, which can make this hard. So sometimes we'll do circumferential lifts. We'll do some turn-down flaps. We can actually use some of their own skin and fatty tissue to get them to a good spot with that. We'll do occasional butt implants, but sometimes we have to be super cautious with that. I don't think people realize when you gain that weight and you lose that much, it not only affects the skin, but it affects some of the internal structures as well and the ability to support things. That's why we do a lot of internal bras with our breasts and other stuff. We've actually even started including some of that with some of our butt procedures to try and help support them as well.

(15:28): It can be super challenging if they don't see an expert like you who's used to managing these, making sure they're in a good spot, all the different options. Don't you think? It's challenging even making sure that how you get there safely, and even kind of a roadmap to approach, because sometimes people need more than one surgery to get them to a good spot.

Dr. Bob Basu (15:45): Absolutely. Yeah. With a circumferential body lift ... For our listeners, that's a procedure that includes a tummy tuck, a waist and lateral thigh lift, and a buttock and lower back lift. With the buttock lift, when we're tightening that skin, as Dr. Franco said, oftentimes I will do what's called composite. What that means is I'm taking the love handle tissue, we're putting it to good use, and we rotate that tissue into the buttock pocket. But if they have a little bit of ... Most people have. Even if they've had weight loss, they still have some pockets here and there. We lipo that, and I typically will inject the fat in the lower pole and in the hip dips to basically use fat transfer, using fat injections with your own tissue. It's called autologous augmentation, rotating the tissue into the buttock. That generally helps us, but it makes me think about how you're using implants on some of these patients with the internal bra to hold them. That's actually pretty innovative. Very cool.

(16:39): So let's talk about internal bra technique. So Dr. Franco, you love to use the internal bra technique. Who's a good candidate? Who should be thinking about it?

Dr. Johnny Franco (16:46): Yeah, I've loved it. And just so people know, internal bra ... I think us as plastic surgeons sometimes confuse people, because we use that term a little fast and loosely. Basically, in my mind ... And correct me, because you're the number one guy in terms of GalaFLEX and internal use. I'm hoping to learn a few pearls from you while I'm here today. But it's just basically we refer to that when we're using any type of additional structural support to help either hold the implant or soft tissue in a good spot.

Dr. Bob Basu (17:12): Yeah. Yeah. I like to tell patients that if your tissue is too weak to hold up your breast or implant, we have to use something else besides that tissue to give you that support. That something else is where the internal bra technique comes to play. There's different materials out there, like a material known as GalaFLEX. There's also another material called DuraSorb that's out there. Different tools for different surgeons, but essentially what all of this is doing is recreating the effect that your favorite pushup bra achieves on your breast. We're internalizing that so hopefully you don't need to wear that pushup bra and you get the support that you need. So it's all about support.

Dr. Johnny Franco (17:48): In our practice, there's a couple patients that we really push to do this. I tell people if you've had a lot of weight loss, typically that skin, the internal structures get really stretched out. So that would be, in my mind, someone who would benefit from this. I think patients that are going with larger implants, because gravity doesn't go away. The heavier the implant, the more it's going to weigh down on those breasts. I think patients who've already come in, and they may not have had children, but they already have very ptotic breasts. I was like, "Hey, your skin and tissue has never supported the breast to begin with. The idea that we're going to add an implant in weight, and it's going to be able to support that. I think it's probably setting us up for problems."

(18:21): Also, there's a lot of good plastic surgeons in Austin as there is in Houston. If somebody's already had a surgery and it didn't go well from a good quality board certified plastic surgeon, I tell them to do the exact same thing and hope that things are just going to go differently, doesn't make a lot of sense to me. Those are some big categories where we definitely have the conversation about it.

Dr. Bob Basu (18:39): Absolutely. No, that's great advice.

Dr. Johnny Franco (18:41): Do you have any different groups that you offer it to?

Dr. Bob Basu (18:44): No. I mean, anybody with post weight loss contouring, postpartum, meaning after having kids, or just someone born with poor tissue.

(18:51): It's amazing. When I trained, no one ever taught me to talk about tissue quality with patients. Every breast patient, I talk about tissue quality. Ultimately, no matter who your surgeon is, we can only work with the tissue that you have, whether that be the breast, the face, the tummy. With the breast, if we're adding volume, as Dr. Franco perfectly said, no matter what implant you choose, whether it be a itty-bitty small implant or a big implant, you're adding weight. What ultimately holds up the breast, whenever we do anything on the breast, it's the patient's tissue quality. We can't change that. So it's really important to have that discussion.

(19:24): And then, I love to ask my patients for a wish pic, because you and I could talk to patients for eight hours. If they show us a photo of what they want, we know, "Uh-oh, we got to do something else to get there," or, "Uh-oh, we can't get them there because of their baseline anatomy." It's important to have that discussion before the surgery so we can set up their expectations. And so through that experience, the type of patients to look at are anybody with weak tissue and if they have expectations for more upper pole volume or defined cleavage. Look, if they're looking for more of that natural teardrop shape, they like the natural kind of slope, then you don't necessarily need to do the internal bra. But if they're looking for more fullness, upper pole cleavage, or want their breast to sit higher on their chest wall than what their tissue can do, then we've got to talk about it. Otherwise, I can't get them there without the internal bra technique.

Dr. Johnny Franco (20:08): I love that you're a fan of the wish pictures, because I am too. It's just terms like natural, full, round, mean so many things to so many people.

Dr. Bob Basu (20:16): Yeah, what does that mean?

Dr. Johnny Franco (20:16): Like you said, I'd rather them be disappointed in the consultation that we can't do this than $15,000 two months later.

Dr. Bob Basu (20:23): Right.

Dr. Johnny Franco (20:23): I love that. The other portion that I always tell people is it's not even just about them following down on the front of your chest. Most people forget we go in a circle.

Dr. Bob Basu (20:33): Lateral, yeah.

Dr. Johnny Franco (20:34): That implant is always sitting on the side of the mountain. So over time, with your muscles pushing it, you're going to slowly descend out laterally. So we even do something called a prophylactic internal bra for our breast augmentations. Something to consider. It's not that we didn't know that the body needed more structural support. There just wasn't a lot of great options in the past. They were so price prohibitory.

Dr. Bob Basu (20:56): So expensive, yeah.

Dr. Johnny Franco (20:57): They had other problems in terms of needing drains, integration, other things. Hard to use through a small incision. That made it tough. Some of these new meshes that you talked about have made it accessible for patients and for us.

Dr. Bob Basu (21:09): Right. One thing that I always tell patients is when we talk about mesh ... I know as surgeons we get used to lingo, but usually someone who's not in healthcare, some of our listeners, they hear the word mesh and like, "Uh-oh, this is the bad stuff that causes problems with hernias or bladder slings. I see those commercials on TV."

Dr. Johnny Franco (21:26): At 2:00 in the morning.

Dr. Bob Basu (21:27): At 2:00 in the morning. But I want to tell our listeners that this is not that kind of mesh. What Dr. Franco and I are using are resorbable mesh. What that means is they're made out of basically suture materials that we've been using for decades. This suture material slowly dissolves either over several months or over two years' time. But as it dissolves, our own collagen type replaces it. So it's kind of like a regenerative tissue matrix. It goes away. So it's not that foreign body mesh that you hear about that potentially cause problems only at 2:00 in the morning on commercials when you probably should be in bed, but it is a resorbable mesh. It goes away. I think that puts people at ease when they know it's not a foreign body mesh.

Dr. Johnny Franco (22:09): 100%. The idea is that your body creates this structural support. They're going to build their own collagen into it. It's going to lock that implant in place. Also, you can do it without implants, for mastopexies, breast reductions, for some of these people who maybe have a little larger breast stuff and looking for some of the fullness, like you were saying.

Dr. Bob Basu (22:24): Sure.

Dr. Johnny Franco (22:25): I think so many more options. No question, these new products have put stuff out there. Because in the past, I would only use these -- because they were so expensive and hard to use -- only when people have had multiple failures. It's nice now to be proactive about it ahead of time.

Dr. Bob Basu (22:39): Right. In the past, the materials we used, what, 10, 15 years ago, were products called AlloDerm or Strattice. They were basically sterilized processed cadaveric dermis, meaning the strength layer of our skin or dermis from the pig. It would work, but they were expensive and complex. Whereas the newer materials we're using now, a much lower cost, faster healing, no need for drains. Patients are just happier with it, and it's easier to use surgically for us too.

Dr. Johnny Franco (23:07): And don't you think the idea behind these of like getting people ... Because our goal is that we want people to be happy for a long time. What's going to be super interesting over the next five, 10 years is seeing whether ... In my mind, I think these are going to really decrease even some of the not only short-term, but long-term revision rates that we see over time.

Dr. Bob Basu (23:24): Absolutely. Absolutely. Yeah, that is exciting actually, the long-term. What impact will it have on scar tissue capsular contracture rates? We don't know that. There are some theories. I know in my basic science days, I remember back in 2011 I published a paper with some colleagues about using these materials, acellular dermis matrix, and it prevented the inflammatory markers that triggered capsule contracture. Now, I'm not saying these materials prevent a capsule contracture, but that was one of the last studies that I did. It was exciting. They still reference that study this far out.

(23:57): But we don't know. I mean, some of these materials could prevent some of that, and I think it will help to decrease the revision rates on implant surgery. So long term, I'm excited to see where this goes. Right now, we use these materials off-label. They're FDA approved for soft tissue support, but we use it off-label, meaning outside of the government's labeling on the breast. And we do off-label for Botox and other things all the time. It's safe to do, but we inform patients that it's off-label from the FDA labeling and it's safe to use.

Dr. Johnny Franco (24:27): And people fly from all over the world to see you for this, because you do some super unique stuff with that. I think there is an art to how you use these special materials. It's not just like you throw it in there and done and set.

Dr. Bob Basu (24:39): Yeah. Dr. Franco, great point. This technique is taking off around the country and around the world. And I'm actually starting to see on a monthly basis someone that has had, quote-unquote, an internal bra technique, but it failed. What I'm finding is when I go back in, the material was never sutured in properly. I know there's really good surgeons out there that advocate that all you got to do is put this material in and maybe suture it somewhere once, and that's it. I think it's much more than that.

(25:09): When I use the internal bra material, I try to anchor the upper border of it to the muscle, and the lower border of it to the chest wall. So it's really good fixation. And for our listeners there, without getting too wonkish about the surgery technique, basically what I'm saying is when we use this material, we're using a lot of sutures to hold it in place so the implant doesn't move. And when I see these cases that have had internal bra technique and it's failed and they're coming to me to fix it, when I go back in, I usually find the material shriveled up. It didn't hold. So I think fixation is really, really important. Take a little extra time to make sure it's fixed in the right spot.

Dr. Johnny Franco (25:42): And I know for listeners they probably sound similar, but there's a true art, because if you make that too tight, you have something that's a little too high.

Dr. Bob Basu (25:49): Absolutely. Yes.

Dr. Johnny Franco (25:49): You don't make it tight enough, it'll ... I always tell people it's like Goldilocks. It's got to be just right. Not too tight, not too loose.

Dr. Bob Basu (25:55): Yes. Exactly. Dr. Franco, you're absolutely right. Listeners need to remember that internal bra technique procedures, although Dr. Franco makes it sound super easy because he's so talented, these are complex cases. You need to pick surgeons that have done this a lot, because he's absolutely correct. It is so easy to overcorrect, undercorrect. Sometimes I'll tell patients, "Look, I'm balancing. I'm juggling a lot of variables in your case. We're talking about symmetry. We're talking about nipple position. We're talking about where your breast sits on the right and left. We're talking about lateral malposition, inferior malposition. We're talking about your cleavage and the skin envelope. Now, I'm really good and I can juggle a lot, but sometimes we may need to come back and tweak something."

Dr. Johnny Franco (26:37): Mm-hmm.

Dr. Bob Basu (26:37): Now, with experience that revision rate goes down significantly, but sometimes we may need to come back and tweak something, because these can be very complex cases, particularly if your implant's ruptured, you've got malpositions, you've got cap contracture. Good news is we've got the tools to fix it, but sometimes we may need to come back and tweak it.

Dr. Johnny Franco (26:54): Because people don't realize that when we're in surgery, we do a lot of things anticipating where you're going to be six months from now. Do we want to tighten a little bit? Because we know certain parts are going to give. We know nipples are going to rotate a little bit. We know some skin might stretch depending on, like you mentioned earlier, how thick, how not stuff. So it's interesting and super fun.

Dr. Bob Basu (27:13): Yeah, it's super challenging, super fun, but you definitely want to go to a surgeon who's well versed in it and who actually enjoys taking on these challenges.

Dr. Johnny Franco (27:21): Mm-hmm.

Dr. Bob Basu (27:22): As you can hear from Dr. Franco and myself, this is a labor of love. We love it. We love the complex cases, but some surgeons don't. We understand that, and it's okay.

Speaker 3 (27:35): Basu Aesthetics and Plastic Surgery is located in Northwest Houston in the Towne Lake area of Cypress. If you'd like to be a guest or ask a question for Dr. Basu to answer on the podcast, go to BasuPlasticSurgery.com/podcast. On Instagram, follow Dr. Basu and the team @BasuPlasticSurgery. That's B-A-S-U Plastic Surgery. Behind the Double Doors is a production of The Axis, the axis.io.