Breast Implant Complications: Ruptures, Bad Capsules, & Emergencies Worth Panicking Over

Bri (00:00):
Rupture. Do you just hear one day you're just driving and you just hear "Boom". My titty burst.

 

Dr. G (00:09):
My juicy titty burst.

 

Bri (00:10):
My juicy titty is gone.

 

Dr. G (00:14):
You're listening to another episode of All the B's with me, Dr. G, and my scrub tech, Bri. Okay. Our last episode, we were talking about breast augmentation or breast implants or something about breasts as we usually do. And we mentioned Bri's post-op hematoma, which I had nothing to do with. I didn't do that surgery. But she went through a lot of work to find a photo of it because I do remember she was like, "I think there's something wrong." And the surgeon was like, "You're probably fine." And then she's like, "No, I think there's something wrong." So she found a photo which we shared in the last podcast. And in case you missed it, we'll show it again here. Complications are rare, but they do happen. So things like hematomas and infection and just implant malposition, here's Bri's hematoma.

 

Bri (01:09):
Thank you.

 

Dr. G (01:09):
I've unfortunately seen worse when I've done legal reviews where -

 

Bri (01:15):
It got bigger.

 

Dr. G (01:16):
Yeah. I mean, so the issue isn't that there is a hematoma, right? The issue is that you don't sit on that. So in the cases I've seen where I've functioned as a expert witness, this gets worse and worse, and then the skin starts to die over it, which is a very, very unfortunate complication. In this case, which is Bri, the surgeon did the right thing, took her back to the OR, washed everything out and re-closed, which is the right answer. So complications can happen, but we're going to break down complications specific to breast augmentation that you need to know about, what to panic about, and then what the data shows on the newer implants out there, and then what to do about it. And it does not involve going on Reddit and polling the audience, generally speaking. So let's talk about current events. Tom Holland, Zendaya.

 

Bri (02:15):
Do we think they're actually married?

 

Dr. G (02:17):
I feel like they're probably married.

 

Bri (02:19):
Probably.

 

Dr. G (02:20):
It seems like a move they would make.

 

Bri (02:22):
Yeah. I agree.

 

Dr. G (02:23):
I feel like they would move in the opposite direction of Taylor Swift of having the biggest blowout situation.

 

Bri (02:29):
Right. Just nobody's going to know.

 

Dr. G (02:33):
They're cute together.

 

Bri (02:35):
They are super cute. They're such a great couple. I don't know why. I don't know. It's such an odd couple and they're so perfect for each other. I know.

 

Dr. G (02:44):
And she's totally slaying the Odysseus, the Odyssey movie situation.

 

Bri (02:51):
I didn't even know there was a movie coming out.

 

Dr. G (02:53):
Oh my God. Yeah. We just do not share the same TikTok algorithm.

 

Bri (02:57):
Is it out?

 

Dr. G (02:58):
I think so. They're on the promo tour, Red Carpet Premier Tour.

 

Bri (03:03):
Oh, they did it together.

 

Dr. G (03:04):
She's in it and Anne Hathaway is in it. And Lupita Young is in it and Elliot Page is in it. All these people are in it. It's this huge blockbuster. There's a lot of controversy about the casting in general. And I'm like, everyone just. But it's nice. They don't care. Any discussion about anything gives you the opportunity to get more press. But there's a lot of discussion about the casting because Lupita's like Helena Troy and people are like, "Is she the most beautiful woman in the world?" I'm like, "Oh my God."

 

Bri (03:39):
She's going to come out next year as it.

 

Dr. G (03:41):
Yeah, I guess so. Anyway, I have not seen it. I don't usually like long, weird movies like this, but it's the kind of movie that costs a gazillion dollars to make. Christopher Nolan. You didn't know?

 

Bri (03:55):
I don't know who that. No, I don't know what's going on with my Instagram feed.

 

Dr. G (04:00):
Okay. Well -

 

Bri (04:01):
It's currently just all.

 

Dr. G (04:03):
They're all slaying on their red carpet premieres as they go from place to place. And Zendaya is just doing one beautiful outfit after another. She just looks so good I can only imagine. It's what was her makeup look? What was her outfit? I haven't even seen those. To be honest, you were busy this weekend, so it's fine.

 

Bri (04:22):
I was.

 

Dr. G (04:24):
She just looks so good. The press tour is.

 

Bri (04:27):
Insane.

 

Dr. G (04:28):
Insane. So good for them. I'm sure they're having time in their life.

 

Bri (04:32):
Zendaya and Tom Holland give me Timothy Shale and Kendall,

 

Dr. G (04:35):
Chalamet.

 

Bri (04:36):
Whatever his name is.

 

Dr. G (04:37):
And Kendall Jenner?

 

Bri (04:38):
No, and Kylie Jenner vibes.

 

Dr. G (04:41):
Whatever. Yes.

 

Bri (04:41):
Which is very interesting.

 

Dr. G (04:42):
Timotee?

 

Bri (04:43):
Also you know who looks so good this weekend, Jacob Alordi and Kendall Jenner at the soccer game. And it was so funny because I was at my little sister's bachelorette party this weekend and everyone's younger than me. And I talked about it and the girl that was like 26 was like, "Who's Jacob Alordi?" And I was like, "There's no way you don't know who he is."

 

Dr. G (05:05):
She didn't?

 

Bri (05:06):
Give me PTSD right now.

 

Dr. G (05:08):
Oh my God. How did these girls not know who that is?

 

Bri (05:11):
I have no idea. They're like the most perfect aesthetically pleasing couple ever. If they had babies.

 

Dr. G (05:18):
Yeah. I just don't think it'll last because I'm not sure anybody can put up with a Jenner for that long. Yeah.

 

Bri (05:26):
But he's not an athlete, so maybe it might work.

 

Dr. G (05:29):
Yeah. Although he did survive Olivia Jade.

 

Bri (05:34):
Yeah. They knew who she was. We got into a whole discussion because one of the girls that was there was friends with the guy who also got in trouble for the same thing with Olivia Jade. They all went to the same school together or whatever.

 

Dr. G (05:47):
USC?

 

Bri (05:48):
Yeah. And she gave us all the tea because whe knew all about it.

 

Dr. G (05:52):
Oh.

 

Bri (05:52):
Yeah. It was so good.

 

Dr. G (05:53):
Interesting.

 

(05:54):
I don't know if I can say it, but it was really good.

 

Bri (05:56):
Did that guy stay at the school because she dropped out? He left too?

 

(05:59):
He had to leave too. It was a whole thing.

 

Dr. G (06:02):
How mad would you be? Because I feel like their parents did a lot without them.

 

Bri (06:06):
Yeah.

 

Dr. G (06:07):
Okay. Prince Harry attends Time event in New York City after King Charles Reunion. I'm not sure I give a shit about Prince Harry, but that's fine.

 

Bri (06:17):
Yeah. I'm on the same -

 

Dr. G (06:19):
Him and Meghan Markle just need to go away. No one cares.

 

Bri (06:23):
Is he not there with Meghan? So I don't really follow them too much. I did watch all of Meghan Markle's show just because it was really good.

 

Dr. G (06:32):
Oh, suits?

 

Bri (06:34):
No, the one she did. The one that was so unrelatable.

 

Dr. G (06:39):
Oh my gosh.

 

Bri (06:40):
You can't not watch it.

 

Dr. G (06:41):
The stupid home cooking show.

 

Bri (06:44):
I'm going to make my kid's breakfast and I'm going to put this four tiered flour on it and I'm going to make tea for their. I don't even know. Pop some Ego waffles in and let's get to school, man.

 

Dr. G (06:57):
The Meghan Markle show With Love, Meghan got nominated for an Emmy.

 

Bri (07:02):
It did not.

 

Dr. G (07:03):
It did.

 

Bri (07:04):
It did not.

 

Dr. G (07:04):
It did.

 

Bri (07:05):
I don't even believe that for a second.

 

Dr. G (07:06):
It did.

 

Bri (07:07):
An Emmy, this is reality TV.

 

Dr. G (07:12):
On the documentary thing. It was so bad and it got nominated. It just came out like a week ago.

 

Bri (07:17):
Who nominated this?

 

Dr. G (07:19):
I don't know. The people she paid didn't nominate it.

 

Bri (07:21):
That's literally so Insane.

 

Dr. G (07:24):
The Duchess of Flops.

 

Bri (07:26):
Wow. That's so crazy.

 

Dr. G (07:28):
But it got nominated.

 

Bri (07:30):
Maybe because her acting is so good.

 

Dr. G (07:33):
Maybe they had to pad the.

 

Bri (07:35):
That's insane.

 

Dr. G (07:36):
Yeah. It's crazy.

 

Bri (07:37):
They needed a filler show and that's what they chose? Choose Love Island or something.

 

Dr. G (07:42):
I don't know, man. It definitely got nominated. Heard it here first.

 

Bri (07:46):
That's crazy. That's some wild work.

 

Dr. G (07:48):
Okay. Let's talk about celebrity gossip that has something to do with plastic surgery. Kelly Killoren Bensimon endured a really difficult time during ruptured breast implant emergency. I'm dead. And breast cancer scare.

 

Bri (08:10):
Oh, okay. So I'm not going to, breast cancer scare always scary, but an emergency ruptured breast implant emergency.

 

Dr. G (08:18):
We have questions.

 

Bri (08:19):
I have some questions. Why was this so emergent?

 

Dr. G (08:26):
So I think that is actually, it is a segue to what we're going to talk about, but if you have implants, right? If you have saline implants and one ruptures, you know it's ruptured because it deflates. And this is a common question because people will have a deflated saline implant.

 

Bri (08:40):
I thought she had silicone.

 

Dr. G (08:41):
I know, but that's not an emergency. You're okay. If you have a ruptured silicone implant, you probably are just going to be walking around not knowing about it. But in her case, it can rupture and then create some inflammation. And then it probably threw off her mammogram, which is the cancer scare part. In which case, then you need to take it out. But as per usual, people are being overly dramatic.

 

Bri (09:07):
Right. And most of the time when your silicone implant is ruptured, when we go to take it out, it is all within this capsule. It's not sitting there leaking into your heart. I don't know. It is ruptured, but it's within a capsule.

 

Dr. G (09:25):
Yes. It stays contained unless it's been ruptured for a long time and then it starts leaking out of the capsule and then you get inflammation.

 

Bri (09:33):
I did have a girlfriend though, question, and she had a ruptured implant because she started a GoFundMe for it. She said it was into her back, her armpit. How would that happen? How would the silicone spread all the way back there?

 

Dr. G (09:48):
Okay. So that's a good question. And here's what happens. So the capsule is holding the implant together and the rupture and the capsule tears or breaks or just wears out a little bit and the silicone leaks out. And what your body will do because it's a foreign body reaction is like inflammation around it. But the other thing your body is trying to do is get rid of it. So sometimes the little silicone particles will get carried away by the lymphatic system. So that silicone will get picked up by the lymphatic system. They're just trying to do their job. And what that does is pull it into your lymph nodes and then the silicone just gets stuck there. And it's not common with an implant, but to this day, some people will go overseas or to a hotel room or something and get silicone directly injected into their breasts, which is such a terrible idea.

 

(10:43):
And you can imagine you get that silicone injected everywhere. Your body's going to have a foreign body reaction and it's both going to create little granulomas, little inflammatory capsules around it wherever it is, but it's diffuse through your whole breast. And then part of that silicone is also going to get picked up by your lymphatic system and carried to new places and end up in your lymph nodes. And there's no getting rid of it. It's now just there.

 

(11:12):
So you're not going to clean it all up once it spreads everywhere. Which is why if you know you have a ruptured implant, you can't sit on it forever. You have time. It takes a long time for that process to happen, probably years, but you can't be like, "Oh, I have a rupture. I'll deal with it four years from now," because you're just giving the silicone time to get carried out to other parts of your body.

 

Bri (11:38):
I love the way you explain that because you're like, "They're just doing their job." It was very like Bill Nye, the science guy. Well, on the magic school bus, that's what I envisioned. Silicone is going through the.

 

Dr. G (11:49):
It's what the lymphatic system's supposed to do. And so we use that when we're looking for like, what's the first lymph node? Is a cancer cell going to end up? We'll inject blue dye into the breast and then look for it in the axillary lymph nodes because it only takes like five minutes and boop, it's here and it's picked up by those lymph nodes. Silicone moves more slowly, but it's just doing, again, their job. Just doing their job.

 

Bri (12:16):
Just doing their job. Okay. Totally off topic, but this is what it, who came into the OR the other day and told us that women actually inject saline into their breasts to go out? Yeah. Total segue, but I just thought of it.

 

Dr. G (12:30):
So we were doing a Preserve case and the first step is to inject saline into the breast. So it provides numbing and a little bit of stretch and then we can safely inflate the balloon. And it's funny because you put about 150 CCs in and you're like, "Huh, looks good."

 

Bri (12:50):
Looks good.

 

Dr. G (12:51):
And so someone was like, "Yeah, I think they do that." Was it our resident, Allie? Dr. Tren?

 

Bri (12:57):
I was trying to think of who. No, it was a man.

 

Dr. G (12:59):
Oh, Ricardo?

 

Bri (13:00):
I think so.

 

Dr. G (13:01):
Oh, so Dr. Rosales?

 

Bri (13:03):
Yeah. Yeah.

 

Dr. G (13:04):
I mean, I could see that.

 

Bri (13:05):
So crazy.

 

Dr. G (13:06):
Being a stupid but temporary idea.

 

Bri (13:09):
You need a little extra cleavage, but then we segued into you go home with a man and then you see him the next time. And he's like, "Where'd your tits go?"

 

Dr. G (13:17):
Yeah. It's so temporary. It's crazy.

 

Bri (13:19):
And then it also segued into all of a sudden he starts helping you inject saline. He's like, "I want them bigger"

 

Dr. G (13:25):
No. I mean, if you out inject saline, I did see a case once where I can't remember what the circumstances were. She had implants removed or fat grafting. I think it was fat grafting. And the person tried to break it up by injecting a bunch of saline in there. And then it all got walled off. And so literally she just had permanent saline floating around in her breasts, which made no sense because it should get absorbed.

 

Bri (13:55):
Interesting.

 

Dr. G (13:56):
Yeah. And it just was very squishy. And I was like, "I mean, I feel like there's nothing I can do but operate." And she was so done with surgery. She's like, "I'm just going to let it ride." And I was like, "Wow." I mean, I feel like some people would want that if you could figure out how to get the saline to stay, but it doesn't make any sense.

 

Bri (14:15):
It's not like it's a foreign body.

 

Dr. G (14:16):
No.

 

Bri (14:17):
Your body's not going to attack it.

 

Dr. G (14:19):
I think somehow whatever was injected in there, again, don't let people inject stuff into your breast if you don't know what it is. It's crazy. Maybe it wasn't really saline. It's hard to know. I did see someone who had silicone injected all throughout her breasts and it was a hot mess. I don't understand that. And impossible to get out. You cannot remove it. You need a mastectomy. Okay. Anyway, so if you have the standard breast implant though, and it's ruptured, picks up on MRI or ultrasound or mammogram, then just schedule a consultation with a plastic surgeon. You have time to figure it out, but not all the time in the world, and then get it removed. Anyway.

 

Bri (15:01):
I'm pretty sure my left one's ruptured.

 

Dr. G (15:05):
Okay. And then Mandy Moore shares loose skin after welcoming three kids.

 

Bri (15:13):
Well, of course you're going to have loose skin after having three kids. Yeah.

 

Dr. G (15:17):
Welcome to my world.

 

Bri (15:18):
After having two.

 

Dr. G (15:19):
Let's see it.

 

Bri (15:20):
Geez.

 

Dr. G (15:21):
You do not have loose skin. Just FYI.

 

Bri (15:23):
I do.

 

Dr. G (15:24):
Okay.

 

Bri (15:25):
Yeah. Why does she look so young still? I feel like that's what I. You can't be for real right now. That's her loose skin she's sharing. Okay. That seems so unrelatable. I am so sorry because she has barely anything. She looks amazing.

 

Dr. G (15:48):
Yeah.

 

Bri (15:48):
I guess to everyone to each's own, what your version of loose skin is. But I've also seen a mom with triplets.

 

Dr. G (15:58):
Yeah. She's trying to be relatable.

 

Bri (16:02):
Little tiny pinch is what people without children have.

 

Dr. G (16:06):
Yeah, that's true. You lose 20 pounds on a GLP, you're going to have that loose skin.

 

Bri (16:11):
She looks so good.

 

Dr. G (16:13):
But whatever.

 

Bri (16:15):
She really has not aged.

 

Dr. G (16:17):
No.

 

Bri (16:17):
Since a walk to remember.

 

Dr. G (16:18):
I wonder if she's doing the halo tribred.

 

Bri (16:21):
She has to be here. I'm about to be doing that. Uh, she looks totally - Her mouth looks bigger than her head.

 

Dr. G (16:32):
She does look different. Yeah. She looks.

 

Bri (16:36):
I don't know what's happening.

 

Dr. G (16:36):
Is that her now? I don't know what's going on there. She used to have such a nice round face. I mean, some of it could just be -

 

Bri (16:44):
Chin filler.

 

Dr. G (16:45):
Lot of. Yeah. She's also kind of skeletal. Oh God.

 

Bri (16:50):
Wait, why is her mouth so big?

 

Dr. G (16:53):
Yeah. I don't know. It's stretched out or something.

 

Bri (16:56):
I'm very confused.

 

Dr. G (16:57):
She looks nuts, actually.

 

Bri (16:59):
She looks like a clown on the right one.

 

Dr. G (17:01):
She's all mouth.

 

Bri (17:03):
Her smile is ginormous. What?

 

Dr. G (17:05):
Maybe it's Botox. Maybe she Botoxed her DAOs. I did that to myself once and I was like, "Holy shit." My smile is crazy.

 

Bri (17:15):
Oh.

 

Dr. G (17:16):
Because then you're like unopposed. And then cheek filler. I feel like she had buccal fat pad removal at some point maybe because she did have a nice round face. Somebody talked her into that.

 

Bri (17:28):
The middle one just looks so good. I'm just confused on what's happening on the right.

 

Dr. G (17:32):
I know. Oh, well. Poor Mandy Moore. I love that you're re-watching Entourage.

 

Bri (17:38):
I've never seen that.

 

Dr. G (17:39):
I actually watched the whole season while I was in Afghanistan randomly.

 

Bri (17:43):
Oh, so it's so old.

 

Dr. G (17:45):
It's old. Adrian Vernier.

 

Bri (17:49):
Not new show.

 

Dr. G (17:49):
There's a lot of good people. No, it's not a new show.

 

Bri (17:52):
Okay.

 

Dr. G (17:53):
Okay. All right. What's the plastic surgery issue 2026? Full disclosure, Bri and I did no prep for this.

 

Bri (18:00):
We did not. We didn't even look. Yeah.

 

Dr. G (18:03):
Had no time. Oh, okay. All the things we're supposed to break down. Wow, that's a lot. But yeah, I mean, at this point -

 

Bri (18:14):
The new face of Hollywood.

 

Dr. G (18:16):
Is the same face of Hollywood. Slop face.

 

Bri (18:20):
Slop face? Wait, what?

 

Dr. G (18:23):
It's because everyone starts to look the same. Although I will say -

 

Bri (18:26):
That's what slop face is?

 

Dr. G (18:29):
Yeah. Everyone starts to look the same. Some of it is some insane contouring.

 

Bri (18:36):
And making beauty boring.

 

Dr. G (18:37):
What show did I watch? Oh, I've been watching, It's Also Old The Sex Lives of College Girls. And it's kind of entertaining because these girls are all. I mean, they're cute, but they're all different and not traditional. They don't look like the slop face. And it sometimes adds a little dimension to the show to not have everybody look the same.

 

Bri (18:59):
Like what's her face in the one we just watched off campus?

 

Dr. G (19:03):
Oh, yes. Yeah. I feel like there's going to be a backlash and everybody that looks the same is. We're going to start to push them out.

 

Bri (19:14):
Everyone has the same nose, the same Botox, the same hair, the same press-on freckles, the same.

 

Dr. G (19:20):
The same -

 

Bri (19:21):
Eyebrows.

 

Dr. G (19:22):
Copper. Stop.

 

Bri (19:24):
We're moving out of lash extensions back to natural. Right.

 

Dr. G (19:30):
But the chiseled face, the extra contouring, all of that stuff is. Yeah. Oh my God. Those photos.

 

Bri (19:39):
Interesting.

 

Dr. G (19:40):
Okay. Well, yeah. I mean, the fox eyelift.

 

Bri (19:45):
Yeah.

 

Dr. G (19:46):
The really slim, pointy nose.

 

Bri (19:49):
Yeah.

 

Dr. G (19:50):
But I feel like we do this every 10 to 20 years where the new aesthetic is created and then everybody wants to look like that. I mean, even back in the days when I was younger, it was like the Christie Brinkley, who I'm going to guess you don't know who that is. But anyway, it was like blonde, smaller eyes. It was a different aesthetic for sure. And if you were not blonde and looked like Christie Brinkley, then you were on the outs. It was like a Charlie's Angels look.

 

Bri (20:24):
Oh.

 

Dr. G (20:25):
Yeah. Anyway. All right. So let's move on to breast complications. First, one of my friends asked this question in one of our little group chats because she was seeing Instagram posts where people were talking about juicy tits.

 

Bri (20:42):
Juicy tits.

 

Dr. G (20:44):
And she's like, "What is happening?"

 

Bri (20:47):
What a way to describe that. Yeah.

 

Dr. G (20:49):
She's like, "Am I just old?" And I'm like, "No."

 

Bri (20:52):
Those aren't juicy. That's your lips. Yeah.

 

Dr. G (20:54):
It's weird.

 

Bri (20:55):
Like with Lip gloss.

 

Dr. G (20:57):
So then you have to kind of pole the different generations, like what do you call breasts? And I think boobs are fine. Breasts are fine. I don't personally love tits, but I feel like Gen Z is okay with it.

 

Bri (21:10):
It really depends on the context of who you're talking to.

 

Dr. G (21:13):
I know. Yeah.

 

Bri (21:14):
If you're doing a little sexting, you might call them tits. But If you're talking to your boss, you might call them boobs.

 

Dr. G (21:22):
Yeah. But the juicy part, I was like, that's going to be a no for me. That's weird. We're not -

 

Bri (21:28):
But it is funny you said that because one girl over the weekend at the batch party was like, "I just lathered my tits and self-tanner." And she said, "They look so juicy." Which is actually kind of funny.

 

Dr. G (21:42):
Well, she used tits.

 

Bri (21:43):
Yeah. Okay.

 

Dr. G (21:44):
All right.

 

Bri (21:45):
Juicy Tits, it is.

 

Dr. G (21:46):
I guess it is.

 

Bri (21:47):
Like baby oil. I envision them glistening with Baby Oil and tanner and highlighter.

 

Dr. G (21:55):
One of the most repulsive things I've ever seen actually that I had to endure as a surgical resident, because sometimes the old guys are so gross. Anyway, we did a breast augmentation. We set the patient up to make sure they look symmetrical. And the anesthesiologist, AKA the boob police was like, "Yeah, it looks good." And my old man attending was like, "Oh, it looks good." And he took a lap, which is just basically a wash rag, dipped it in water, and then squirted the water over the breast.

 

Bri (22:29):
Stop it.

 

Dr. G (22:30):
How about now? And I was like,

 

Bri (22:34):
That's crazy.

 

Dr. G (22:38):
I wanted to be like,

 

Bri (22:39):
What a man.

 

Dr. G (22:40):
I'm still here. Patient's asleep. Like what the fuck?

 

Bri (22:41):
That's crazy. How about now?

 

Dr. G (22:47):
Dirty old man, man. I hate. Anyway. All right.

 

Bri (22:51):
That's some wild work.

 

Dr. G (22:53):
All right. So we'll have to start doing that. No, you're lube them up because I also -

 

Bri (22:59):
Wet T-shirt contest.

 

Dr. G (23:01):
I also see sometimes on Instagram, people will show their before and afters. And it's less of a trend now because I feel like BBLs are kind of going to the back burner, at least in my algorithm. And the post-ops are always glistening and lubed up. And I'm like, "What are they doing?" No one looks like that on the OR table, but they're adding lube.

 

Bri (23:21):
Yeah. I see that because I follow it in Mexico because I follow all those little places. And they literally, they lube them up. It's crazy. It looks so good though. But they're just sitting there lubing your body up. It looks not even -

 

Dr. G (23:36):
While you're asleep.

 

Bri (23:37):
Yeah. Crazy. Where's the prep?

 

Dr. G (23:39):
I know. Yes. Okay. All right. So when patients ask about breast augmentation risks, what actually makes my top 10? Okay. So I always say the risks of any breast augmentation are rupture one day, possibly. Capcon is number two, is up there. So capsular contracture, anytime you put an implant in, you're going to form a smooth capsule around it. Should be thin and filmy. You should not know it's there. But in certain situations, that capsule can get thicker and harder and start to kind of push on the implant and distort things that we call capsular contracture. And it can be caused a bunch of different things, which we can go into in a minute. So I would say rupture and capcon are the two things we worry about. Immediately post-op, you can have bleeding. You can have an infection. Both of those are extremely rare. You can get a fluid collection.

 

(24:37):
You could have the incision breakdown. That's really it. Other complications you can have, because I'm trying to come up with 10. You can have decreased nipple sensitivity afterwards.

 

Bri (24:49):
Or increased.

 

Dr. G (24:51):
Or increased. I used to always be so aggressive in warning everybody about numb nipples because I feel like, I don't know, the more traditional old school breast augmentations, that was pretty common. And you would see people at the beach and stuff and their nipple just popping out because you don't really feel it.

 

Bri (25:07):
Maybe that's why my nipples always come out.

 

Dr. G (25:09):
I know. Sometimes that happens to me.

 

Bri (25:11):
They're just really high.

 

Dr. G (25:13):
So I used to warn people about that. And then I wasn't saying, or hypersensitive. And then patients like two weeks out would be like, I can't touch this. And I'm like, oh, okay. Well, good news is you're not going to have a numb nipple after this. Bad news is that it's going to be hypersensitive for a while and it's going to take some time for it to settle back down. But you can desensitize it. It doesn't make sense, but touching it more will desensitize the nipple, so get you through that. So that is also a possibility. You can potentially have decreased breast milk afterwards or that's more common if the incision was made through the areola, but it's not like you can't try breastfeeding. So then there's things like malposition, asymmetry. Those are also potential complications. I guess those are more common. I don't know. It can happen. Yeah. So it's certainly not a -

 

Bri (26:13):
Sisters, not twins.

 

Dr. G (26:14):
Yeah. They're sisters, not twins. So if your breasts are in different places, we're going to try to center the implant with that breast. And so if your breasts are a little bit different, that's where the implant is going to be. So I don't really consider that a complication. I just think of that as pretty normal. But you don't want the implant too high. You don't want the implant too low. Too high is usually pretty easily correctable. Too low is a little bit more difficult to correct that we call bottoming out where the implant has slid out from under the breast and your inframammary crease, that thing that is your under boob has been released or is relaxed or something and is not holding up your implant. So that is kind of a difficult thing to correct. And then you can have a waterfall deformity. These are things that usually tend to happen over time.

 

(27:07):
And that's just aging of your aging of the implant. But especially on my dual plane patients or patients that have submuscular implants, this is not 100% all the time because I see variations on this, but your implant tends to stay up and under the muscle and your aging breast or your breast will slowly kind of fall off. We call that a waterfall deformity. So the breast is kind of hanging off the implant. It's usually more noticeable from the side. There's a lot of potential things. I say the most common reasons for someone having a second breast surgery is ruptured capcon, size change, lifestyle change. That would be my top four. Malposition would be number five. So yeah. So a double bubble is when that IMF gets disrupted or just ignored. Yeah. So that's the implant sneaking out down below the breast tissue. So I do also a fair amount of implant removal.

 

(28:04):
And what I think is interesting, I just did one on Thursday when you were gone.

 

Bri (28:08):
Obviously it wasn't great without me.

 

Dr. G (28:10):
Okay. So this patient had a breast augmentation that I don't do and most people don't do, but there was someone in town who's not a plastic surgeon that does, I don't know if he still does them, is called a tuba. So trans-umbilical breast augmentation. Terrible idea. Anyway, her results were not good. So he went transumbilical -

 

Bri (28:33):
This is so difficult.

 

Dr. G (28:34):
Shoved a saline implant in there through the belly button. And her implant, even though it was submuscular, that's why I was saying these things don't all hold true because he went from below to up. I know.

 

Bri (28:46):
How do you get it all? Do you have to stick a tube in there?

 

Dr. G (28:49):
It's a blind technique.

 

Bri (28:50):
The whole implant just goes through this tube?

 

Dr. G (28:54):
Yeah. Saline.

 

Bri (28:55):
Make it make sense. Okay. So that's fair.

 

Dr. G (28:59):
Anyway, so her saline implants were submuscular, but also really low and lateral because I don't think you can dissect whatever. So they were low and lateral, but she didn't have an incision. She didn't have an inframammary crease incision because they've gone through her belly button. So I have to make an incision somewhere to pull it out. So most people would just go, "Oh, your crease is down here. I'll make an incision. But I know that your inframammary crease actually does have some memory. And when I take that implant out, it's going to spring back up. And we're going to go back to wherever you started wildly." So I was like, "Well, I don't know where that's going to be. So where do I make my incision?" But this lovely young woman had photos, had her before photos. Nice. And she has a tattoo that was right here.

 

(29:50):
So what I did is I looked at her before photos and it was a very elaborate tattoo. So I could take, okay, the height of this leaf or whatever, what. Is where her IMF was and then marked that out and marked it out on the other side. That's smart. And it was not where her IMF was currently. And I was like, "Okay, I'm going to go with my gut." Made the incision there and boop, ended up perfect.

 

Bri (30:14):
Perfect. That's awesome.

 

Dr. G (30:16):
I know. And then we took out a little bit of skin, so it all sat there and it's back to where she was.

 

Bri (30:21):
I love that. I'm not a single before photo of my boobs. Right.

 

Dr. G (30:25):
I know.

 

Bri (30:27):
Nobody wants to see that.

 

Dr. G (30:28):
She had them from the website or I don't know. But anyway, it worked out perfect.

 

Bri (30:31):
That's amazing.

 

Dr. G (30:32):
But I did learn that if they already have the IMF incision, I got to use that. And I've seen people where I go through that incision, take the implant out, and now their IMF incision is here and their breast is up here. And so that is kind of a trick to put the incision a little bit lower because you know that lower pole's going to stretch out. But then I think, oh my God, if you take them out, that incision's now going to be on your chest. So I just hedge my bets and sheet up a little bit. And then it's a little tucked under, but at least if you decide to take them out, you don't have an incision on your chest. I mean, most of us are not doing the periareolar incision now because slightly increased risk for capsular contracture.

 

(31:12):
You're cutting through the duct. So if you want to breastfeed later, that's not a great idea. So anyway, if your implant is pushing down below the IMF, yes. If you're going to keep implants, you probably need some internal support, like mesh to hold the new one in place. If you're taking them out, then you're probably going to be fine to correct that. But a lot of people don't want to take them out. So that's double bubble.

 

Bri (31:40):
Double bubble. Okay. And then CapCon, what would be the first indication that somebody would be like, "Oh, I'm getting CapCon."

 

Dr. G (31:48):
So this comes up a lot. Sometimes people freak out about it and they're fine because you just feel something different. But it's a slow, like your implant moves around less and less. You want it to move around a little bit in the pocket, but it starts to get stiffer. And then you always have the other one to compare to. So even though there's a lot of things that cause CapCon, like smoking cigarettes or smoking nicotine is one of them. Even those patients often will just get unilateral CapCon. So I don't know why. But yeah, so the implant doesn't move around as much. And then it starts to just get firmer and firmer. And then you got to figure out, okay, well, why is this happening? Are you smoking cigarettes? Probably not. Do you have a rupture? Because that's the easiest one to fix, right? Because then we have a reason we can take it out, put a new implant in and you're good to go.

 

(32:41):
I see a lot of ruptures where there is no CapCon. So again, that's why Capcon's so tricky. We don't know really what causes it. Sometimes it's just the way your tissue is reacting. We do think it's probably related to biofilm. So a low grade infection, breast augmentation infection is really low, but the thought is that there's some just subclinical inflammation going on that's creating that. That's why we do all those crazy things in the OR when we put implants in so that we don't get that.

 

Bri (33:14):
So many steps.

 

Dr. G (33:14):
Walk us through the steps of prepping the implant on the back table.

 

Bri (33:18):
Oh, Jesus. Well -

 

Dr. G (33:19):
That's your job.

 

Bri (33:20):
Implant, we poke a little hole because she saw that there was a study that when you remove the film, all the little particles fly in. So we do a little tiny hole. We soak it in Betadine. We change our gloves. We soak our instruments in Betadine. We wash out the pocket with Betadine saline phase one. We do the Keller Funnel, which is a non-touch technique. So we don't actually touch the implant. What else we do?

 

Dr. G (33:49):
At the very beginning, you put the nipple shield, which are just -

 

Bri (33:52):
We put tegaderms on the nipples.

 

Dr. G (33:54):
Yeah. And then we chant.

 

Bri (33:56):
So we don't have a dirty nipple. Yeah. And then we chant and then we do a little blessing and then we put the implant in.

 

Dr. G (34:05):
And I mean, I do think Cap Con's a lot lower rate overall than it used to be because of the Keller funnel, because of this technique. For a lot of times we did a triple antibiotic wash, remember those days? And then the studies have come out and shown that that isn't as effective as the dilute Betadine and/or the phase one, which are both better.

 

Bri (34:26):
The pool water.

 

Dr. G (34:28):
And because of antibiotic resistance and people's allergies, half the time you weren't using all the triple antibiotics. But yeah, they proved that it wasn't as effective as we thought it was. So most of us have moved away from that. And for a while, Betadine was considered like off label or bad to use to wash out of pocket, but then the FDA relented and we all do it. Yeah.

 

Bri (34:54):
Everyone I've seen does it.

 

Dr. G (34:56):
Yeah.

 

Bri (34:56):
And then if it's your second time getting CapCon, you'll usually put them on doxy and singulair.

 

Dr. G (35:01):
Yes. Right. So Singulair is an asthma medication, but it's a very effective anti-inflammatory. And instead of standard couple days of Keflex, they put people on doxycycline, which is both an antibiotic and also has anti-inflammatory properties. They stay on that for two weeks to a month and the singular is three months. And there are some limited studies that showed those are effective. Vitamin E is sometimes prescribed. I don't because there haven't been any great studies to show that as effective. You can wrap the implant in mesh or put in a little mesh or use acellular dermal matrix. Those are all other tricks of the trade. There's a study going on right now where you remove the whole capsule, put a new implant in, and you kind of put it in a little ravioli, a mesh and stick the implant in.

 

Bri (35:51):
Ravioli sounds good right now.

 

Dr. G (35:53):
I know. That study is ongoing. We tried to be a center for that. And then I think they're just, I don't know. I feel like I got approved and then nothing happened. So that's fine.

 

Bri (36:05):
Kind of a slow go. Okay. So double bubble, bubble, bubble, whatever you called it, bubble, hubba, bubble. Capcon infection. Early warning signs of infection that patients should know about.

 

Dr. G (36:16):
Red, warm, painful, fever. All of those things are bad.

 

Bri (36:24):
Yeah.

 

Dr. G (36:25):
That's pretty much standard for infection anywhere.

 

Bri (36:27):
Yeah. And what would you do to treat an infection?

 

Dr. G (36:30):
Oh God. Antibiotics are your first start. If it's really mild, then you can sometimes get away with antibiotics. But unfortunately, if you think you have a. If I saw somebody who had maybe a breast dog elsewhere and they look like they'd have an infection, I'd probably wash out and it'd be a tough call. Wash it out. I know for breast reconstruction, we'll often try to salvage it, but you're just at high risk for CapCon, unfortunately, which is a bummer. Which thankfully is so rare. But some of these people be going down to Mexico or going to non-core people. Those are usually the people we see who get infections and it's a hot mess. The downside of taking the implant out and then letting everything rest is that depending on where they are post-op, the tissues can heal really weird and it can be kind of a nightmare to fix.

 

(37:23):
So I would definitely try to deal with it on a case by case. There's no straight answer for that. But it's going to suck.

 

Bri (37:31):
Sucks to suck. But it happens. It's manageable. Rupture. Do you just hear one day you're just driving and you just hear , "boom" my titty burst.

 

Dr. G (37:45):
My juicy titty burst.

 

Bri (37:46):
My juicy titty is gone.

 

Dr. G (37:48):
No. I mean -

 

Bri (37:48):
Saline, yes. Silicone, no.

 

Dr. G (37:50):
Yeah. Saline, you'll know. Silicone, you're not going to know. I have had patients that have come in - No one's going to know. After trauma or a fall or something, and then they get it checked and they're like, "Oh, it's ruptured."

 

Bri (38:01):
We've also taken out a lot of implants under local that we're like, "Oh yeah." Well, I don't know if they're under local or general, but they have no idea it's ruptured. And then we go in and it's completely ruptured.

 

Dr. G (38:15):
Which used to be so stressful because it's such a hot mess, but now we have the max vac.

 

Bri (38:19):
We have this great new device, which is amazing. And it just sucks all of the silicone out and keeps everything really clean because when it's ruptured, it is so messy. Everything is getting messy and it's everywhere and it's slippery.

 

Dr. G (38:32):
Silicone gets on the instruments. We're trying to clean the instruments.

 

Bri (38:36):
Yeah. And there are a lot of things that we do. We put clindon saline to try and get the silicone up. There's a lot of things that we try to do, but regardless, no matter how many, it's just everywhere.

 

Dr. G (38:46):
Yeah. It's super sticky. Yeah. And impossible to remove it.

 

Bri (38:49):
Yeah. But this thing just takes it and it sucks it right up.

 

Dr. G (38:52):
It's so good.

 

Bri (38:53):
Yeah. Very excited about it.

 

Dr. G (38:56):
At first, I was like, how much for this device? And then I used it and I was like, oh my God.

 

Bri (39:00):
So worth it.

 

Dr. G (39:01):
Worth every penny.

 

Bri (39:01):
So worth it.

 

Dr. G (39:02):
Okay. So I think the one thing I'd like people to know about complications before they do surgery is we always harp on this, take the time to recover. Because if you're going to have a bleed or a big, huge problem in the immediate post-op, the ones I've seen are generally related to some -

 

Bri (39:21):
You're doing too much.

 

Dr. G (39:23):
Yeah. You slammed that car door, you picked up that load of laundry and then something bled.

 

Bri (39:28):
Tripped over the rug.

 

Dr. G (39:30):
You had a Preserve breast aug and then you went to a HIT class.

 

Bri (39:33):
Yeah. Don't do that. Please just don't do Pilates the next day, guys.

 

Dr. G (39:38):
Yeah. Take it easy. Other than that, there's not too much you can do except make sure you're using a board certified plastic surgeon. You're not going to some Yahoo who's.

 

Bri (39:48):
Yeah, because your post-op care is just as important as.

 

Dr. G (39:51):
And you want to know that the people doing it know what they're doing, that they have a certified OR.

 

Bri (39:58):
Yeah.

 

Dr. G (40:00):
Yeah.

 

Bri (40:00):
Being certified, that means having everything and all the medications need. If something were to go wrong, God forbid, hasn't happened in OR, but you have a crash cart. You know what I mean?

 

Dr. G (40:11):
Right.

 

Bri (40:12):
You have something for every situation, which apparently not everyone does.

 

Dr. G (40:16):
Not everyone does. So just ask. I mean, I always mention it in my consultation

 

Bri (40:21):
We do drills, we do trainings.

 

Dr. G (40:22):
Yes. All of that comes as a requirement for having a fully certified OR. We have a quad A certified OR. We use a board certified anesthesiologist.

 

Bri (40:31):
Not a CRNA. No harp to CRNAs. Y'all are still great, but you essentially still need to work under another doctor.

 

Dr. G (40:41):
The shit hits a fan. Yeah.

 

Bri (40:43):
It's great to have two doctors in the office.

 

Dr. G (40:46):
Yeah.

 

Bri (40:46):
Yeah. What are some symptoms where. What to call the office right now?

 

Dr. G (40:52):
My breast is.

 

Bri (40:55):
I feel like talk to your doctor first before you decide like, "Oh, I'm just going to go to the emergency room."

 

Dr. G (41:01):
Oh God. I mean, if you want to waste your time, hours.

 

Bri (41:09):
But so call your doctor.

 

Dr. G (41:12):
I was going to say, don't go on real self and post photos. What do I do?

 

Bri (41:16):
Yeah. The whole reason she gives you her number for that night is to like, if you have questions.

 

Dr. G (41:23):
Right. You can go to the ER, but I don't recommend it unless you've talked to your physician.

 

Bri (41:29):
Right.

 

Dr. G (41:30):
Because the ER is going to be like, "Oh, you just had surgery. We don't know what to do."

 

Bri (41:34):
Reach back out to your doctor. I can give you an IV and maybe some antibiotics.

 

Dr. G (41:39):
Draw a bunch of labs.

 

Bri (41:41):
Antibiotics. Yeah, you're just going to get stuck with a big bill. So I think that's why important. I think some people freak out. I don't know if it's happened here so much. I feel like we've definitely had one or two people that have been like, "I'm going to the ER." But I feel like that was not fully related to surgery. There were some other things going on.

 

Dr. G (42:01):
Yeah. There's been a couple. But if you do have a rapidly swelling breast, that's to call your surgeon.

 

Bri (42:10):
Yeah, absolutely.

 

Dr. G (42:12):
And if they don't answer, go to the ER. So the breast augmentation emergency is a rapidly expanding hematoma. And I have taken care of those for somebody who I was covering for. It sucks. I mean, it happens. Of course, the patient was a scrub tech and she had a rapidly expanding breast. And you have the other one to compare it to. It doesn't necessarily look purple until later in the game. And I've had that happen with a patient I took implants out. Do you remember it was around the Christmastime last year? She came back in and I was like, and we tried to drain it. And then I just took her back and washed it out. Because unfortunately, if you have all that blood around there, if there's an implant, you have to get it out of there because that's just a giant Petri dish waiting to be a CapCon.

 

(43:00):
So you should clear the giant hematoma. If it's a little bleeding around the incision, fine. But taking an implant out, she didn't have an implant. So I was like, we could let it absorb. But also then it takes, again, forever for your body to break that down and heal. And sometimes it's just faster to wash everything out, re-close and then tea.

 

Bri (43:23):
Yeah.

 

Dr. G (43:24):
She did way better.

 

Bri (43:25):
Makes it so much better.

 

Dr. G (43:26):
So that would be the come back, call, do not pass go.

 

Bri (43:32):
Do not pass go.

 

Dr. G (43:34):
That, although likely rare is a red, warm, I feel like I'm sick, infected, breast.

 

Bri (43:43):
And how does that conversation go with patients versus their first surgery consult? The, oh, we have to go in and have surgery again.

 

Dr. G (43:51):
Oh. Well, first I usually forgot to mention that I'm not going to charge them for it. So we just need to go back. And I want to say it's free, but I appreciate the fact that it's not free because it's costing them time and recovery. So nothing's really free. So I do want to. It's a massive inconvenience if I have to take somebody back to the OR. And I understand that, but I'm not going to charge you.

 

Bri (44:16):
Most patients. Yeah. And I feel like if it does happen, they're pretty understandable. They're just happy to get it fixed.

 

Dr. G (44:23):
Yeah. They just want to get it fixed.

 

Bri (44:24):
Yeah.

 

Dr. G (44:25):
I think we've taken one or two. Again, a lot of it is covering for other surgeons, but sometimes there is an infection. You just got to - We did that one infection where it was really out of pocket. I still don't know why she had an infection. Remember she looked awful. She looked sick. It wasn't our patient.

 

Bri (44:45):
Oh, that was the one we gave IV vanco or something too. I don't even know what it was. And she looked so much better after it. Was that it?

 

Dr. G (44:53):
Yeah. There was one a year ago. Anyway, yeah. She looked gray when she came in.

 

Bri (45:00):
She looked unwell.

 

Dr. G (45:01):
So this particular person that I cover for, his patients sometimes have concerns and then they come in and they look totally fine. They're just very nervous. And so whenever I get a call like, "He's out of town, this patient has a concern." I'm like, "Yeah, yeah, yeah." And then they come in and I look at everything's great. They look great. They're just super, super nervous and they're fine. So that's kind of what's in my head. And this lady comes in and I was like, "Oh, you look unwell."

 

Bri (45:35):
Yeah. Very unwell.

 

Dr. G (45:36):
And was being very stoic about it. I was like, "I'm going to have to call him and let him know that we're going to have to take you back and wash everything out." And then she did a million times better because she did have an infection in there. It was just kind of funky because it's very unusual to have happen. But it happens. And if you do, you got to recognize it. And if you're not feeling good, that's a big sign.

 

Bri (45:57):
I also feel like this particular person never really prescribed antibiotics for surgery.

 

Dr. G (46:02):
That's true.

 

Bri (46:03):
Which I think. I don't know. What are your thoughts on that?

 

Dr. G (46:07):
This one's hard. Okay. So theoretically for a clean case, you should just need IV antibiotics before you go to sleep. Yeah. And you should not need to take oral antibiotics afterward. So when we do an implant removal under local, we give them oral antibiotics and they're good to go. I think the longer you're in the OR, the more hours you're open. If you're putting in a foreign body, like an implant, I don't think a few days, five days of antibiotics is going to kill anybody. I just feel better doing that.

 

(46:42):
I feel like I even do it for my breast reductions, even though I feel like there have been some studies to show that you don't need it. But again, I have a lot of open tissue planes and stuff. And you're cutting through breast tissue. I just feel like it's. Yeah. Yeah. But you're right. A lot of times he does not prescribe post-op.

 

Bri (47:01):
I've seen it a lot more now on the post-op instructions, but I wasn't sure. Everyone's different about antibiotics.

 

Dr. G (47:08):
Yeah. I mean, antibiotics are fine. I think there's honestly no downside.

 

Bri (47:13):
Right. All right. Myth versus reality. If your implants feel hard, it's always CapCon.

 

Dr. G (47:22):
I don't know what that means. I mean, if they're harder than they used to be, it probably is capcon.

 

Bri (47:28):
Okay. Because what thing would make them hard? A hematoma? But that would be immediately after surgery. Yeah. Okay. Well, we're going to do like a, we don't know. A double bubble means your surgery failed.

 

Dr. G (47:41):
No, it just means your tissues failed potentially. Depends on when it happens.

 

Bri (47:46):
Something has failed.

 

Dr. G (47:47):
Something over time is not going well. It depends. If it's an immediate double bubble, then the surgery was a fail. If it's over years, then it's -

 

Bri (47:55):
You're five years out.

 

Dr. G (47:57):
Tissue failure.

 

Bri (47:58):
Preserve by Motiva means zero risk of complications.

 

Dr. G (48:03):
For now, because we haven't been doing them long enough, 100% fail. That's not true.

 

Bri (48:08):
There's no way. Everything can have a risk.

 

Dr. G (48:11):
There is no surgery that cannot have a complication.

 

Bri (48:14):
Yeah. If something feels off years later, it's too late to fix.

 

Dr. G (48:19):
No. If something feels off years later, it's totally fixable. You just need a good analysis to see what that is.

 

Bri (48:27):
Yeah. Everything's fixable, I think. Complications only happen with cheap surgeons.

 

Dr. G (48:33):
No, that's not true.

 

Bri (48:35):
Happens to everyone.

 

Dr. G (48:36):
More likely to happen with your cheap. I don't know what's happening surgeon, but it can happen with anybody.

 

Bri (48:42):
Literally anybody. Some of the greatest surgeons have complications.

 

Dr. G (48:46):
100%. All right. Well, if you have questions about breast augmentation or. So I will leave it with this. I tell people, especially if you're in your 20s and you're getting a breast augmentation, you need to plan for another surgery.This is not, "I've got a $5,000 breast aug and I'm good to go for the rest of my life." At some point in your life, you're going to need to do another surgery. So you just need to mentally and financially prepare for that, whatever it is. Is it going to be taking them out? Is it going to be doing a lift? Is it going to be changing the size? It's going to be addressing a long-term complication like rupture or CapCon. But the longer you have them in, the longer. They're not lifetime devices.

 

Bri (49:33):
Right. But they do stay in, I feel like, longer nowadays than they did before.

 

Dr. G (49:36):
100%. Yeah. So if you're putting them in now, like my 70-year-old ladies, generally speaking, you're going to go to great with those. You're good to go. Assuming you don't already have a complication. And I do have a lot of patients in their 50s that are like, "I did this in my 20s and 30s. I got away with 20 or 30 years. I don't want to have to do this again. So I'm just going to take them out." That's fair. Or you can just put new ones in and hope they last longer. I don't know. It's a gamble, but if you're putting them in at 20, you're going to need another operation.

 

Bri (50:11):
Right.

 

Dr. G (50:13):
So just back of your mind.

 

Bri (50:15):
Keep that in mind.

 

Dr. G (50:17):
All right. That's all.

 

Bri (50:18):
Okay.

 

Dr. G (50:19):
I'm going to scrub in

 

Bri (50:20):
And scrub out.

 

Dr. G (50:23):
If you're listening today and have questions, need info about scheduling, financing, reviews, or photos, check out the show notes for links. Restore SD Plastic Surgery is located in La Jolla, California. To learn more about us, go to restoresdplasticsurgery.com or follow us on Instagram @RestoreSDPlasticsurgery. If you enjoyed this episode, please share it and subscribe to All the B's on YouTube, Apple Podcasts, Spotify, or wherever you like to listen to podcasts.