Demystifying Breast Augmentation (Ep. 5)

Dr. Hall: Welcome to The Trillium Show, where we help you make the changes you want to see in your body, in your mind, and in your life. I’m your host, Dr. Jason Hall.

Dr. Hall: All right, and welcome to the show. Today we’re going to be discussing breast augmentation. And just for point of orientation, it’s the fourth quarter of 2021, we’re recording this. And just want to start with a couple of facts about breast augmentation that you may or may not have known.

So, the last year that we have data for numbers of breast augmentations is the year 2020, and almost 200,000 women in 2020 underwent a breast augmentation. Now, 2020 was—we had some issues in 2020, but that is trending down fairly significantly from previous years, where other procedures did not during the year of COVID, which I kind of thought was surprising. Usually, the statistic that I remember seeing is, you know, about 300,000 women a year have breast augmentation. So 2020, we saw a fairly sharp decline over the years past. Most of the women—and this is another surprising statistic is most women who have breast augmentation are between the ages of 40 and 55, and there are more women between 40 and 55 that have a breast augmentation then there are of women between 20 and 40. That’s another statistic that I found a little bit surprising from 2020.

I didn’t go back and double-check my stats from previous years, but I’m assuming that those trends are fairly consistent year-over-year, and I’m sure if they’re not, somebody will happily point that out to me. That just kind of gives you an idea of who has breast augmentation. So, then the question is, why? There are a number of reasons why women—of course, everybody says, “Well, to have larger breasts.” Well, yes, of course they do but, you know, the overwhelming majority of women don’t want to look like an adult entertainer, and, you know, just as a personal point, thankfully, that look is going out of style and a much more natural look is kind of coming into vogue. Most women have breasts that are slightly asymmetric, and an augmentation can help to correct some of that. Although it won’t help to eliminate it, it will help to correct some of that.

But really, the big reasons that women are interested in breast augmentation is that they just want to feel more feminine, they want to fill out a bathing suit, they feel like they’ve never had breasts they’re happy with, or after having children they’ve lost the size and the fullness of their breasts that they had in the past. And so all of these things, we can very effectively treat with a breast augmentation. So, before we really get into the procedure and kind of how the procedure works, we first kind of have to define a glossary of terms to make sure that we’re really all speaking the same language when we’re talking about breast augmentation.

First thing we’re going to discuss is implant type. And now, there are two real implant types that we need to talk about: First is the saline breast implant, the second is the silicone breast implant. Now, saline breast implants are essentially water balloons. Now, an interesting fact about saline breast implants is that the outer shell—so the part of the saline breast implant that actually touches your body—is silicone. And I see patients in my office who are interested in having saline breast implants because they’re afraid of the silicone, and they’re shocked when I tell them that the part of the implant that touches them is silicone in a saline breast implant.

So, they’re silicone outer shell that is filled with sterile salt solution in the operating room. Now, saline implants are less expensive than silicone implants. They’re very effective, but they do have their issues. They tend to be fairly stiff, they’re heavy, and the saline just what I feel is probably effect of the saline kind of sloshing back and forth on the inside of the shell causes a lot of stretching of the tissue of your breast tissue over time. It also has a higher incidence of being able to see the implant ripples or ridges through the skin especially in thinner-skinned patients. In my opinion, it is really kind of a second-tier choice if you’re looking at breast augmentation for the vast majority of women. Now, some women, obviously, saline implant is the exact right choice, but we really need to talk about those reasons why before we choose a saline implant.

In my practice, the most common type of implant we use is a silicone implant. These are now all cohesive silicone gel implants, so the gel within the implant itself is a solid. So, you can cut these implants in half with a knife. And I’ve done that’ if you want to go check out my YouTube channel, I’ve got a video of cutting one of these implants in half, and it doesn’t go anywhere. The older silicone implants that got temporarily recalled from the market back in the 1990s were filled with a liquid type of silicone, and those are gone and the gummy bear is the, kind of, standard silicone implant that’s on the market these days.

These look and feel much more natural than a saline implant, they’re easier on the breast tissue because they’re effectively solid, so there’s not a lot of sloshing back and forth on the inside, and there is less incidence of rippling that’s seen through the skin, even in thinner-skinned patients. And so in my opinion, the silicone implant is the way to go.

So, that’s implant type. Implant shape, there’s really two shapes, there’s round implants and then there are the shaped or anatomic implants. Now, the round implants are by far the most common implant that’s used in the United States. They’re less expensive than the shaped implants, they require less surgical planning in terms of placement, and you really don’t have to worry about rotation of a round implant because it’s the same all the way around. If it spins like a top, you can’t really tell.

Where the shaped implants are good for a natural result, they give a much less obvious upper pole look than the round implants will, but placing these implants is a little bit more technically challenging because they’re not round, they have a width and a height that are different, and so making the space for that implant needs to be much more precise. And because we want to prevent rotation of that implant—because if that implant shifts or moves, it causes a significant breast deformity which can require, and usually does require, a second operation to correct. The shaped implants, because we depend on them staying where we put them, are all textured, and we’ll talk about what that means in a minute. And so shaped implants definitely have a role, but are not for every patient.

After shape, the next term we need to define is the profile of your implant. And now, there are profiles which go from low to ultra high, the most common being what we refer to as the moderate-plus profile, or the high profile. And profile really describes how tall an implant sits. So, if you set it down on a table, how high it sticks up from the tabletop is your profile? The moderate-plus and high profile again are the most common, but depending on your individual anatomy and your goals, a moderate profile implant, an ultra high profile implant may be needed to get you where you need to be.

The higher the profile implant, the more upper pole fullness—or what we kind of refer to as the high cleavage—look you’re going to get. And so this is an important thing to keep in mind when we’re talking about surgical planning, kind of underscores the need to know what you want to look like in the end to help determine implant choice. And a word of caution here is that higher profile implants typically tend to be harder on the tissue. They stretch the breast tissue and the skin more, and don’t tend to age as well; they age a little bit prematurely when compared to lower profile implants, simply because the higher profile implants are much harder on the tissue than the lower profile implants are.

So, we’ve talked about type, we’ve talked about shape, we’ve talked about profile. Now, let’s get into texture. Implant texturing made the news a few years ago, when Allergan’s textured breast implants were voluntarily recalled because of concerns over ALCL, which is anaplastic large cell lymphoma. It is a very rare and very unusual form of lymphoma that is strongly associated with the texturing on the outer surface of breast implants. So, there are two types of texturing on implants, one are the smooth-textured, and the other is the rough-textured, which we just refer to as textured implants.

So, smooth implants are, by far, the most common implant used in the States. These have a smooth outer shell and are certainly the implants if you’ve been to a doctor’s office or you just Google breast implant, that’s the picture that you see is very likely to be a smooth breast implant. Now, the textured breast implants are, same gel, can be round, can be shaped—or that anatomic shape—but have a sandpaper-like texturing on the outside. And it’s important to understand why we have textured implants. Textured implants were created to decrease capsular contracture—which we’ll talk about in a minute—in patients who have over-the-muscle breast implants.

And again, we’ll talk about capsular contracture here in a minute. What that texturing does is when we use that texturing it allows your actual breast tissue to stick to the outer surface of that shell and gives you a more stable result for a longer period of time than a smooth implant would. Now, there are certainly problems with breast texturing.

The Allergan textured breast implants, forcibly, voluntarily recalled from the market, back in 2019, out of concern for ALCL—which is anaplastic large cell lymphoma—which is fairly strongly associated with the texturing on breast implants, specifically these very aggressive what we call macro-textured implants. And you can think of that as just a really rough sandpaper feel, as opposed to micro-textured implants, which are still in the market, which you can think of as a really fine gauge or less rough sandpaper.

ALCL is a topic of another show altogether. Just to discuss it here briefly, the overall incidence of ALCL in women with breast implants is about one in 30,000, which is not very high. Contrast that to your risk of getting breast cancer if you are a woman who has breasts, which is one in eight. So, you know, significantly increased risk of breast cancer as opposed to ALCL, which is not breast cancer.

ALCL is fairly easy to diagnose. It typically happens between five and ten years after implantation and shows up with one breast all of a sudden over the course of a couple days, getting a lot larger than another is a typical presentation. An ultrasound will show fluid around an implant. That fluid is then sampled with a needle, sent to the lab, and there is a cell marker which we look for called CD30, which tells us that ALCL is present. The treatment for ALCL is implant removal and removal of the capsule, which is typically where the LCL is, where it lives, effectively. And it is exceedingly rare for chemotherapy to be needed in these. Only for cases of significantly delayed diagnoses, or where the ALCL has spread outside of that implant capsule which is, again, very rare. Again, we’ll devote an entire episode to ALCS down the road, but there’s just a little primer on ALCL here in the context of talking about textured implants.

So, now you got texture out of the way, position: The over versus under-the-muscle. Under-the-muscle, by far the most common placement in the States. It allow—the muscle, kind of, cushions or shields the top portion that implant, allowing for a more natural result, a more gentle slope to the upper pole of the breast. And so that is far and away the most common placement for a breast implant here in the States. Over-the-muscle implants is a good option for some patients, patients who are into fitness and use their pectoral muscle quite a bit typically prefer an over-the-muscle placement because it minimizes the risk of an animation deformity, where your pectoral muscle pulls on the implant capsule and, kind of, can deform your breast if you’re working out.

Women with lots of breast tissue also do well with an over-the-muscle placement because the implant exerts more pressure on their existing breast tissue because the muscle is not there to, kind of, hide it or cushion it. So, it’s more that implant is more visible over the muscle in women with more breast tissue to start with. So, we’ve talked about texturing, we’ve talked about position, and both of those are factors in preventing capsular contracture.

So, capsular contracture, what that is a scar tissue formation around an implant that starts to deform the implant. Anytime a foreign body is implanted in your body, your natural defense mechanisms are to form a scar capsule around it to protect your body from whatever this foreign thing is. The same thing happens with every breast implant, has a scar capsule around it. Most of them are very thin and never become a problem. In some patients, and in patients with smooth under-the-muscle implants, this is about 6% of all of those patients end up developing a pathologic capsule or a capsule that becomes a problem.

And what happens—we feel that this is likely the result of some mild underlying bacterial contamination—is that your body continues to produce scar around the implant, which gets thicker and thicker and can cause implant position problems, so they tend to be high and tight, and can progress to deforming that implant, squeezing that implant and being very uncomfortable. And some of these capsular contractures that get too pronounced require surgery to treat. So, the under versus over-the-muscle discussion kind of factors in here because in women who have smooth under-the-muscle implants, your capsular contracture rate is about 6%. In women who have smooth over-the-muscle implants—remember, we talked about over-the-muscle implants are definitely a thing in some women—so smooth over-the-muscle implants, that capsular contracture rate doubles, and is now about 12%.

And here is where the texturing comes in. For women who have textured over-the-muscle implants, your capsular contracture rate drops back down to about 6%. So, a textured over-the-muscle implant has the same capsular contracture rate as a smooth under-the-muscle implant. Now, you have to take that risk of ALCL, which we talked about, but if you’re one of the women who really would do better with a implant sitting on top of your muscle than below, that’s a risk benefit discussion that we have to have during a consultation. So, that’s kind of a brief discussion of position.

And then lastly, is incisions. Most common incision we’ll start with is the inframammary or breast crease incision. It arguably has the best visualization of what we’re doing, so it gives a surgeon the best view of what’s going on during surgery. Because it is away from the nipple areola complex and the breast ducts, there is a decreased incidence of bacterial contamination—because bacteria live down in those ducts—which can theoretically decrease the capsular contracture rate. So, for those reasons, it is the most common and certainly the most—in a primary breast augmentation when that’s all we’re doing—is the most common incision that I use.

The periareolar or nipple, kind of, around the nipple scar is a very well hidden incision. It is placed at the boundary of the pigmented portion of your areola in the breast skin, so when it heals, is very difficult to see. You do need to have an areola there’s a certain diameter to be able to make an incision long enough to get an implant in. However, you know, we talked about the bacteria that live in the milk ducts, there is a theoretically increased risk of capsular contracture with a periareolar incision.

Third is the transaxillary incision or the armpit incision. This is something that I think very few surgeons use frequently. It has a fairly limited use. It is for women whose breast anatomy is almost perfect, it’s very difficult to manipulate the breast crease through that incision because it’s so far away.

Most surgeons who use a transaxillary approach use very specialized equipment, an endoscope and specialized long instrumentation to do that procedure. It does give very nice results in the right patient. Because of the specialized equipment and the narrow range of patients who are really good candidates for transaxillary breast augmentation, it is not a very commonly used approach.

And lastly is the TUBA procedure—T-U-B-A, or transumbilical breast augmentation. Fortunately, I don’t see anybody advertising this anymore. This is a terrible idea, in my opinion and really, it offers no control, very little precision, and fortunately is largely gone. Interestingly, in the manufacturer’s inserts for silicone breast implants, the manufacturers themselves recommend either the inframammary or periareolar approach to prevent fracturing of the gel during insertion, largely because both of those incisions offer the best visualization, the shortest path to where the implants need to go, and the least amount of manipulation of the gel. Even the manufacturers agree that the inframammary or periareolar incision is the best.

So, now we’re coming to the point in the podcast where I have an admission to make. Is that, as surgeons, as plastic surgeons, we’ve done breast augmentation patients a disservice. We have put out there online, and in magazines, and in magazine articles, and YouTube videos, and probably other podcasts, that you as the patient have lots and lots of research and learning to do and that you have lots and lots of decisions to make. All of the things that we just talked about are your responsibility to come in armed to my office and tell me exactly what you want. You pick out your incision, you pick out your implant size, the profile, the shape, the texture, and you tell me how you want your operation done.

And I think that could not be further from the truth or really more of an abdication of our responsibility as surgeons, as educators, to assume that you can get online and correctly make all those decisions with some Google research. The way that I like to approach breast augmentation is like this: Your primary responsibility is to determine what look you want when we’re finished with surgery. And that involves research that involves looking at pictures and narrowing those choices down to one, maybe two, photos of things that you like of women who look kind of like you before surgery, who you would like to look similar to after surgery. If you can do that and come into your consultation with a photo or two of women who you like their results, and after examining you together, we can kind of go through all these options and can plot a course, develop a surgical plan, to get you from where you’re starting to where you would like to be. That is, assuming that goal is reasonable.

The implant size, implant profile, implant position, incision placement, all of that will all naturally happen if we can determine where you’re starting and where you’d like to be. Now, you can find tons of breast pictures on the internet, on Instagram, Facebook, Snapchat, Google breast augmentation and you’ll be on the internet for days. You do want to be aware of these because a lot of your social media influencers and pictures that I see people bringing in have all been photoshopped, they’ve all been airbrushed, they’ve all been touched up, the waists are thinner, the breasts are larger than they are in real life. And so you have to be really careful with that and really tailor your search toward plastic surgery sites to find unaltered before and after photos that you like, of real people. Now, I’ll tell you, ignore a lot of what you see on most websites of, you know, height, weight, implant, size, position, all of that because, you know, what looks right on one person may not look right on you.

But finding pictures on other plastic surgeons’ sites is good because, ethically, we’re bound by our society’s bylaws to not alter any of our pictures other than cropping them to make them fit. We can’t alter the colors, we can’t Photoshop. You know, we can cover a tattoo with a little blur-out or a little sticker if it identifies a patient, but we can’t alter our pictures. And so those are the most accurate thing you want to find when you’re doing your pre-consultation research. The other thing that I talk to about patients is when they come in, say, “Well, you know, I really would like to be a C cup,” or, “I really would like to be a D cup,” is that you know as women that bra sizes vary from shop to shop from store to store.

And so, kind of, get the idea of shopping for a cup size and put that on the backburner and focus on the result. Because we may give you exactly the result that you’re looking for based on your pictures, and the cup size may not be what you think it is. And if you’re kind of married to being a C cup and you come out a D cup, you automatically think you’re going to be too large even though you look very similar to the photograph that you liked on the front end. So, you know, just be aware and just put cup si—you’re going to end up at whatever cup size you’re going to end up on the other end of surgery; the important thing is that we get the look right.

So, the other thing that I really discourage women from looking at is the implant size and implant profile. These really are things that we determine during the consultation after examining you, after looking at your pictures of where you want to end up. And we can—and will—pick an implant that gets you there based on where you’re starting. You know, different women, even same height, same weight, are going to have different chest dimensions, different chest wall dimensions, different breast tissue, different skin and connective tissue, and all of these things are things that we’re thinking about as surgeons when we’re planning an operation and taking that into account with how your breast is going to interact with that implant. And so it’s important to trust in that process and let that play out, and not come in married to the idea of having a 352cc high-profile implant as being the one that’s going to give you the result that you want because there was a picture that you liked online with that implant. That rarely turns out to be the case.

And then lastly, and I think another thing that goes very much unsaid in the breast augmentation consultations or the run up to surgery, is that if you’re young and you are choosing to have a breast augmentation, there is a about a one hundred percent chance that you will need another surgery later in your life. Your breasts will continue to age, your weight will fluctuate, you may or may not get pregnant and breastfeed, the tissue of your breasts, regardless of what happens, is going to change over time, it’s going to lose its elasticity. You will likely want and/or need another operation at some time down the road. Most of these are done for change in size or to correct the results of natural breast aging, except that going into it, that if you do have a breast augmentation, you will need another surgery later.

So, now that we’ve got all that out of the way, let’s, kind of, talk about the consultation itself. Typical breast augmentation consult takes about an hour. You talk to the patient care coordinator, you talk to our nurses, we’ll discuss your goals. For most women who are looking for primary breast augmentation, we will use our 3D cameras to take pictures and then actually simulate your surgery digitally so that we can decide on the look that’s right for you. It also helps us to narrow down the size and the profile of the implants that we’re going to use, based on your specific measurements.

The simulation is also a good time to point out what most women see and think they’re alone in and we can point out tiny asymmetries which are present in the vast majority of women. Mild asymmetries, when we do a breast augmentation, will look a little bit more noticeable. Putting an implant in is like putting a magnifying glass on little asymmetries that exist. For more significant asymmetries, these may need to be corrected, either by using a different implant size, by altering the position of the nipple areola complex with a little donut breast lift or removing a little bit of skin at the bottom of the breast, and these really are kind of dependent on you and your specific anatomy and what asymmetries you’re trying to correct. Your surgeon—or I—will go over what needs to be done to correct those during your consultation.

And then lastly, is the question of do you need a lift or do you not? This conversation typically happens with women who have either had multiple pregnancies, or significant change in size with breastfeeding, or women who have had significant fluctuations in weight and weight loss, resulting in stretching and sagging of the breast tissue. An easy pre-consultation do-it-yourself at home test to determine whether you may or may not need a breast lift in conjunction with a breast augmentation is to look at yourself in the mirror, find where your breast crease is, and then look at where the position of your nipple is relative to your breast crease. If your nipple itself is below the level of your breast crease, there is a very high likelihood that you will need a breast lift with an augmentation, regardless of what implant we use.

There’s also the pencil test, which I know has been popularized on the internet: If you can hold a pencil underneath your breast crease, then that’s also another good sign that a lift may be needed in surgery. Word of caution here is that there are patients who have heard from probably well-intended surgeons that we can avoid a lift by just using a larger breast implant. If you’ve got a nipple that is below your breast crease, or you can hold a pencil in your breast crease, a larger implant is not the option. That will not fix the problem, it will—now you’ll just have a big saggy breast instead of a small saggy breast. If you hear that you just need a larger implant, that’s a good time to go get a second opinion and ask somebody else what they think and whether they think that will help. In my practice, there isn’t a time when I recommend using a larger implant than we otherwise would have, just to avoid the scars of a breast lift. If that’s the case, then we need to have a really serious discussion as to whether surgery is really the right option or whether we need to wait until we’re more accepting of the scars that come along with that.

Now, we kind of get to the choosing a size. Now, the Vectra helps a lot. It’s important to note that even once our Vectra analysis is done, that’s not really the final judge of what size we’re going to be. What that does is gives us a good starting point. Choosing an implant size is very much like trying on shoes: We measure, we select an implant based on your measurements and your desired outcome that think is going to work, and then once we’re actually in the operating room, we have a ton of sterile what we call sizers. It’s essentially an implant that we keep and test out to see if the size works.

We’ll start with the implant that we chose during the examination and then see how it looks. Sometimes we have to move up or down depending on how your breast interacts with that implant, to choose the size that gets the result that we want. So, there is a little bit of fluidity; the consult is not the final determiner of implant size. What it should be is the final determiner of the look that we’re going for.

So, one word on choosing a look. A lot of times we talk about cleavage and what an implant will do to cleavage, and cleavage is really not a function of breast size as much as it is a function of how close together your breasts are. This is determined by the width of your sternum or your breastbone. It’s also determined by the width of your breast. And so, if you kind of push your breasts together with your upper arms, kind of, almost give yourself a little hug and look down, that’s about what we can accomplish with a breast implant without doing anything else.

Now, there are things that we can do. If you have a wide breastbone and narrow breasts, there are things that we can do to give you better cleavage. One of those things is using an over-the-muscle implant. That allows us to push those implants a little bit closer together in the middle because we can go past where your muscle interacts with your breastbone that we can’t do if that implant is under the muscle, for obvious reasons. The other neat trick that we can do to fake better cleavage is once we have our implant in, do something called fat grafting, which is doing liposuction, taking that fat, purifying it, and then injecting it into the inner aspects of your breast underneath your skin to make your breasts appear like they’re wider and you have better cleavage.

So, this is another one of those customizable things about breast augmentation that we can do in patients who need it. The final trick about cleavage is that no matter what size your breasts are, there are bras that can help you with that, and that’s something to keep in mind, no matter where you’re starting is that the right bra can give you cleavage with most sized breasts. Okay, so we’ve done our consultation, we’ve kind of gone through the glossary. Now, let’s talk a little bit about the surgery.

So, for a routine breast augmentation, this surgery takes less than an hour. It is outpatient surgery, and in my practice, these are performed in our accredited on-site surgery center using a general anesthetic, so you are asleep for the whole process. Some board-certified plastic surgeons will do these in their office, either awake or under kind of a twilight sleep and that really is an individual preference. You know, in my mind, a general anesthetic is very safe, is probably done under the most sterile, controlled conditions that we can have, and is my preferred method of performing the surgery.

You go home, you have a short incision, which is covered with some tape after surgery. You go home in a compressive surgical bra. And shortly after surgery, within 48, 72 hours, you can switch that into any snug but not tight sports bra for fashion, just because a lot of the sports bras just look better and you’re used to wearing those as opposed to a surgical bra. I do not want you in an underwire bra for six weeks. I had somebody laugh at me the other day because I told them that and they said, “Who wears underwire bras anymore?” And so that may not even be a thing anymore, but I say it just because I’ve been saying it for years.

So, in terms of pain control after breast augmentation, this operation, at least in my hands, is not a terribly painful operation. Most patients, if they take narcotics, take them for the first 24 hours and then can transition off to switching back and forth between Tylenol and Motrin. So, a lot of—they have a couple—I send people home with a couple narcotics, they take them for a night or two after surgery just to make sure that they get a couple of good night’s sleep and don’t wake up sore, but during the day, Tylenol and Motrin cut it for most people. Assuming that you’re not in a job where you’re lifting things at work, you can typically bank on being back to work after a long weekend. If you work at a computer or you are in college or graduate school and sitting at a desk, or sitting at your laptop, or going to class, then, you know, a long weekend, maybe an extra day or two after that, is typically enough time to recover from a breast augmentation.

Now, after that long weekend, that’s when the real recovery starts because you feel like doing things. You’re happy with the way you look, and you want to be out being active, and I don’t want you to. So, I tell my primary breast augmentation patients, no gym for two weeks, and then after that you’re limited to activities where there is no lifting more than ten pounds, and no bouncing—so no running—for another month after that. And the reason we do that is not to be mean and punish you, but is, you know, I want that early scar capsule to form around that implant, to stabilize the implant position on your chest without beating it up trying to work out. And that typically is the hardest part of recovery is not being active for six weeks.

Just to address the bra size and shopping questions, wait for about three months before going bra shopping. Your breasts are going to change a lot in three months. The first day or two, they’re going to be high and tight and huge and swollen. Your breasts are going to drop, the implants are going to settle into position, the swelling which is present at the top part of your breasts is going to go down a lot. And that process takes at least three months until you start to settle into a more long-term stable breast shape and size.

And so avoid the urge to go out and shop for all new bras and swimsuits right after surgery. Wait about three months until going shopping after breast augmentation. So, we’ve been through a lot. I think the biggest take home out of this podcast, in addition to just going over terms and the augmentation process itself, is find pictures from plastic surgeons’ websites of women that you like. Come prepared with an outcome that you’re looking for, and then now that you kind of know the lingo and you know about different sizes, and shapes, and profiles, and texturing, and non-texturing, and implant position that you and your surgeon can work together with those things and help you get from where you are to where you want to be, you and your surgeon—or I—have a good understanding of where each other is coming from. So, thanks for listening, and we will see you in the next show.

Dr. Hall: Thanks for listening to The Trillium Show. You can keep up with the latest on the podcast at jhallmd.com. Be sure to follow us on Spotify, Apple Podcasts, or wherever you listen to podcasts. If you want to connect with us on social media, you can find us at @jhallmd on Instagram and Twitter and @DrHallPlasticSurgery on Facebook. Remember, be the change you wish to see in the world.