BIA-ALCL and Other Implant Associated Cancers

All right, everybody share this. We're going to talk about breast implant-associated anaplastic large cell lymphoma, other breast implant-associated cancers. We'll even touch on a little breast cancer, and, uh, it's going to be a fascinating discussion tonight. Share this around with all your friends. Get everybody involved. It's gonna double check all the live streaming is happening.

Hmm.

All right, there we go.

All right.

All right, everybody, share this around. Good to see you, Marie, Rhonda, Lisa. LS Hunter, thank you for joining. Jennifer Visa 559. Miss Siam. Siam. Hi Carolyn. I really can't see how my people on the others, so let me just see. We're gonna have a special guest come on later. She's gonna wait, and then after our talk, we're gonna have her jump on. The big tease there. So for Instagram, TikTok, YouTube, Facebook, LinkedIn, X, Rumble, Substack, everybody has to chime in and make sure the audio is fine. If you can't hear me properly, you got to tell me now and we'll adjust things. We have a number of cameras and phones and all the usual things happening, so So I'm just gonna check across, and everybody give me a thumbs up if I sound good. You can hear me all right. Any background noises, you gotta let me know. Thank you. All right, awesome. Thanks for joining, Lisa, Heather. All right, perfect. All right, share this around. We want to get as many, um, involved in on this live stream so they can learn as possible. And then, uh, we'll have a special guest, and we'll do that in, um, my private community, drrubscircle.com. It's free to join. No complicated issues. Just sign up. You get a little link in your email and boom, you can join. Can do live chat, not video chat. Oh my goodness. Everybody asks me what kind of doctor I am all of the time. I'm a plastic surgeon. Yeah, I'll have to read my bio at some point. Thanks for joining, Sally. All right, we don't have that many on yet. We're going to wait a few minutes and then we'll get started. Remember to share this, uh, to your friends. If you have a community, share it. All right, and we don't like obnoxious people, so don't post any stupid things. That will get you blocked. Yeah, don't come into my chat saying ridiculous things. No place for that. Okay, we'll wait a few more minutes, then we're gonna get going. We have the usual format. We have a talk. We're fortunate enough to have a special guest this week. So we'll take— I'll do the talk. We'll do a couple questions from each platform. Then we'll go into my private community, drrobbscircle.com, where it's obviously free to join. You can ask me anything you'd like.

Hey, Sally.

And we have all sorts of patients in town this week. I got people coming in from Idaho, people in from Minnesota. Oh my gosh, I have people in from all over the place right now. It's been a busy week. We already did eight cases this week, one simultaneous fat transfer, the rest were implant removals, lips. A busy week. Even had a few patients with implants above the muscle.

So.

Hi, Danielle. Good to see you. How many people did we have in here? We just have one.

Okay.

And then have some folks putting comments up. Sounds good. Okay, perfect. You can hear me on YouTube.

Great.

Awesome. All right, we're gonna get started with our talk tonight. It's obviously a concerning topic, and the topic at large we're going to discuss is BIALCL and other implant-associated cancers. So what if a breast implant looks larger years after surgery, or the breast looks larger years after surgery? The first explanation that comes to mind is a rupture. Now that's certainly a reasonable first thought. It's not the only thought though. A delayed fluid collection around an implant Can be many things. It can be a retreating seroma, so just a fluid collection. It can be related to a capsular contracture. It can also be from a rupture. It can also, in uncommon cases, be the way a rare lymphoma of the immune system first shows itself. Tonight, we are going to talk about breast implant-associated anaplastic large cell lymphoma, or for short, BIA-ALCL. And about other rare cancers that have been reported in the capsule around breast implants, and then we'll have a special discussion around breast cancer itself. And so the goal of this is to educate; it's never to create any any fear. The goal is just to give you a clear map of what this is and what it is not, and who appears to be at higher risk with the symptoms. Or, and which ones deserve more evaluation and what the evidence does not tell us to do. So if you have implants and no new symptoms, this talk is not a reason to rush into or get concerned about surgery. If you have a new late swelling, a mass, or unexplained change, this talk is a reason to see your provider and ask the right questions. Hopefully that's what you can glean from this. Thank you.

All right.

So I'm Dr. Robert Whitfield, and thank you all for joining me tonight for BIALCL and other important implant-associated cancers and breast cancer itself. This program is educational only. It is not personal medical advice. It cannot diagnose you. It cannot tell you What implant you have or if you have a fluid collection or what treatment you may need. Those are obviously things you have to take, both the questions or symptoms, any imaging you may or may not have, and see a clinician and do an in-person examination. I'm a board-certified plastic surgeon and I take care of women with implant-related concerns. And that includes, but it's not limited to, Explant surgery. We do simultaneous fat transfers and explants, as I mentioned previously. And I talk, uh, at length about chronic and acute inflammation, scar capsules, biofilm, and surgical preparation and recovery virtually every week. That background just informs how I teach. It does not replace or complete a workup for you by an individual provider and yourself together. My goal is simple. I want patients to leave obviously understanding a bit more about this and not be fearful. And once again, please share this with others. So if you have a friend, a loved one, or someone who could learn from this discussion or is concerned about these issues, they may find this, you know, beneficial. So what Bialcl is and and what it is not. So BIA alcl is an uncommon T cell non Hodgkin lymphoma. So in plain language, it is a cancer of the immune cells, not a cancer of the breast gland itself. So once again, this is not a breast cancer. It's not part of the breast gland. It's an important distinction. We don't ever want to confuse that. This is generated predominantly in the scar tissue of and around the implant. The cells that define this disease are typically CD30 positive and ALK negative cells. Those are just specific pathology markers. They are how a laboratory distinguishes the lymphoma from other diseases. They are not something you can feel or see at home. Clinicians can't examine you and figure that out. So where does it arise? We find those cells in the fluid around the implant and in the fibrous capsule, and that's the scar layer that your body forms around the implant. So per Open Evidence, which is an AI platform that we can utilize as physicians to access literature, both that and drawing on the NCCN guidelines and pathology sources, it describes it as a disease of the implant capsule rather than the breast itself. As I mentioned previously, the FDA also says the same thing. In most cases, it's found in the scar tissue and the fluid near the implant, not in the breast tissue itself. That distinction matters. People hear breast implant and cancer in the same sentence and assume that it is a breast cancer, which it is not. It is a lymphoma associated with the capsule and the fluid around some Implants. The World Health Organization formally recognized BIA-ALCL in 2016. When the disease is confined to the effusion, which is the fluid, or the capsule, it typically follows a very slow, indolent course, meaning it often behaves in a slow, like I said, more localized way, and the prognosis is generally excellent. A subset will have capsular invasion or a mass that behaves more aggressively, and deaths have been reported. So this is uncommon.

Okay.

But it is very serious. Those two facts can sit together, of course. The FDA puts it this way: An individual's risk is considered low, but this cancer is serious and can lead to death, especially if it is not treated promptly. In most patients, it is treated successfully with surgery to remove the implant and surrounding scar tissue. Some patients also may need other therapies like chemotherapy or radiation therapy. So, and I just, uh, I'll stop here for a second and say I have come across one of these in my first 1,000 cases, and it's very, very different versus other cases. And I recently was asked to see somebody in consultation and operate on them who was concerned for having this. But fortunately it did not have this. So nearly all of the reported cases occur in people with a current or prior history of a textured implant. The risk is highest with the macro-textured devices— they're rougher— particularly the ones with the BioCell surface. So those were voluntarily recalled in 2019 worldwide, and it has been reported with both silicone and saline implants. It has been reported after cosmetic augmentation and after breast cancer reconstruction. Fill and reason for surgery do not make someone immune, obviously. And the plastic surgery societies have stated that there are not confirmed BIA-ALCL cases involving just a smooth implant. Now, the FDA's medical device reports include a small number of smooth implant cases, but most of those reports had incomplete histories, or they didn't know if they had prior textured devices, or the texture was unknown. So incomplete records are not the same as proof that smooth implants carry the same risk. The honest summary is this: the signal is overwhelmingly associated with textured surfaces, and the highest signal has been with more aggressively textured devices. The plastic surgery societies currently estimate lifetime risk among women with textured implants in a wide range from about 1 in 2,200 to 1 in 8,600 based on confirmed cases and textured implant sales data. Physician resources also cite incident estimates ranging from about 1 in 3,800 to 1 in 30,000. Those ranges are wide because the denominator is so hard to determine. We do not have the perfect worldwide sales data, and reporting is is incomplete. A 2026 Journal of the National Cancer Institute analysis of the U.S. SEER data reported age-adjusted incidence of 17.2 per 100 million person-years in 2021 with a confidence interval from 7.6 to 33.8 and 26.9 per 100 million person-years in 2022 with a confidence interval of 14.8 to 45.5. Those numbers are higher than earlier FDA estimates. Textured implant use peaked around 2016, so some research projects will probably peak around this year, 2026. So please hear what those numbers are. They are population incidence rates. They are not a percentage of people with implants. They are not a prediction for any one given person. As recognition improves, reported incidence can rise, of course, even if the underlying biology is not changing or dramatically increasing. The FDA's April 2022 tabulation counted 1,130 unique ALCL cases in medical device reports. Median age at diagnosis was 53. Median time from the last implant to diagnosis was 8 years. About 71% of those reports listed a textured surface. Those reports are important. They still cannot give us the true incidence because the system can underreport Or duplicate or miss the total number of people living obviously with implants. The most common presentation, and this is what happened recently, was a delayed fluid collection developing, and that's around the implant itself. And so that gets examined usually by ultrasound, and that usually takes about 8 to 10 years to develop. And then the patient will notice it. And once again, ultrasound's typically done. The reported range is about 1 to 28 years for that to develop. What does that feel like? So the breasts will swell and look asymmetric to the patient. It will look full. It may be painful or not painful. It's usually not, once again, an acute change. It's usually slow. It develops slowly over time. So less commonly, people present with a mass in the breast, or the mass is in the capsule, new or a worsening capsular contracture, or lymph nodes in the armpit area or the region around the breast, a rash or an ulceration of the overlying skin, or rarely more distant disease found on scans. This is where clinical judgment matters. So late fluid around an implant is often attributed to rupture or to capture contracture. Sometimes that is correct, but it always has to be evaluated because sometimes it's not. Open evidence synthesis and the pathology literature it cites is very plain about this: maintain suspicion in any implant patient with a new set of late onset symptoms. Plastic surgery societies list common symptoms as breast enlargement, Pain, asymmetry, a lump in the breast or armpit, overlying skin rash, hardening of the breast, or large fluid collection, typically more than 1 year after receiving an implant. So if those symptoms appear, the next step is not social media. The next step is head to the clinician, get evaluated. So it's very important not to delay this. If this is, you know, a visual change, then you definitely want to go and get an ultrasound. That would be the easiest way to look for fluid around the device. And so in the fluid, if it's there, remember those markers, we'll talk about those again now. So ultrasound of the breast and the axilla is the first-line imaging to look for fluid or a mass. MRI or PET/CT is used in selected cases or cases that are inconclusive. If fluid is present, ultrasound-guided aspiration— so drawing some of the fluid— is essential because you want to send that fluid off for what we talked about earlier, which is CD30, and you want to do flow cytometry. So looking for the CD30 will help you make that diagnosis. Now, NCCN guidelines are summarized in open evidence and ask for an adequate volume of fluid. So more than 50 cc's. So 1 ounce is 30 cc's, so almost 2 ounces of fluid. And more than 10 mL just for flow cytometry because repeated small taps can dilute the tumor cells. So aspiration is not sufficient for diagnosis, but it does help you identify the cell types. The Plastic Surgery Society has gone on to direct us Testing for CD30 is required to confirm or rule out BIA-ALCL. Leukemias that are not tested for CD30 can miss the diagnosis and then get treated as an ordinary sarcoma, which should not be appropriate. If there is a solid mass, that mass needs obviously a biopsy and not a fluid sampling, but that would be dealt with differently. The tumor cells, when present, are large and typically called anaplastic cells. They are uniformly CD30 positive and ALK negative. Diagnosis also requires correlation with implant history. The pathology should be reviewed at a center that sees obviously these types of cases. Once the diagnosis is confirmed, staging has got to be performed. That will include history, physical examination, other laboratory studies, and typically a PET/CT scan. A bone marrow biopsy may be indicated, but not in every case. So it would need plastic surgery, surgical oncology, the medical oncology folks, and that would be the best multidisciplinary approach. So I want patients to hear this clearly: a delayed sarcoma is not automatically a lymphoma. Lymphoma is not automatically excluded because someone was told it is just fluid. The test has to be done correctly to look for CD30, and has to be ALK.

Negative.

Excuse me. So once again, the— it's different swelling, it's late onset, and it's go get an ultrasound. Ultrasound shows fluid. The fluid has to be aspirated. Almost 2 ounces have to be sent. 50 for, uh, exam for CD30 and 10 for flow cytometry. So for the disease confined to the capsule and implant Complete surgical resection is the cornerstone. So like doing a total intact capsulectomy or en bloc capsulectomy is the treatment. In most of those patients, that surgery is the complete treatment. The oncologic goal is complete removal of the implant, the entire capsule, and any associated masses. Suspicious lymph nodes are also going to need to be biopsied if you found those on an exam or a scan. The contralateral implant is often removed as well because contralateral involvement has been reported in about 4.6% of the cases. So once again, that is not a reason for everybody to panic and go out and get a bilateral treatment of this. It is a reason to obviously understand and have a plan. If excision is complete and there is no residual disease, surveillance follows. Clinical exams every 3 to 6 months for 2 years, and imaging considered no more Often than every six months during that time frame, if excision is incomplete, so like a partial capsulectomy, if disease remains or if nodes are involved, the team discusses obviously next steps, which may need radiation therapy or systemic chemotherapy or both. For more extensive disease, stage two to four, systemic therapy is used. NCCN guidelines. Have options that include a MAB-based regimen or CHOP-type regimen. Those decisions belong to obviously the team, the oncology team. They do not obviously belong here. So local relapse can sometimes be managed with re-excision alone. Again, that has got to be a case-by-case multidisciplinary decision. And confirmed cases should be reported to the Profile Registry and to the FDA MedWatch, and that's how we learn about the incidents. And I'm certainly not going to tell you that every case has been cured. I testified at FDA hearings in front of a patient who had residual ALCL on their rib cage from an incomplete resection. That was one of the impetus for me to try to do my best to better understand the Bialco breast implant illness population and provide clarity through research around that. While I was president, we did do that. So I mean, more has to be learned about this. Obviously, I can tell you obviously what the public sources say when this disease is found early. And this has been my experience. If it's completely removed, the patients do very well. If there's delay or incomplete surgery, or in those instances, as the person who testified before me in the FDA hearings, it becomes dangerous and it can cost the patient not just the quality of life, but it will ultimately then cost them their life. So, like moving forward, you know, this is one of the most important, you know, aspects of the talk. So we don't recommend routine removal of textured implants or of implants in general. It's it's so that people can make their best informed decision, and people who have no symptoms only because of concern over BIALCL, you don't have to run out and get your implants removed. So the same is true for the rare capsular cancer. Capsule cancers we will discuss next. If you do not have symptoms, then removal is definitely the patient's decision. So we can't ignore symptoms, but we just need to understand them and understand how to work them up and what are the indications for the workups. So if you have textured implants, especially The recalled BioCell device. You should know your implant type, have your records, and stay in consistent follow-up for that reason. You should know the symptoms that deserve, uh, reaching out, making a call. You definitely— you have to know that. If you understand it, then you're going to be calmer about the entire situation. So obviously your individual's decision to do something still belongs with you in conjunction, you know, with your provider and discussions with your family. Some people choose explant for other reasons, whether it's contracture or rupture or pain, or like I deal with commonly, broader problems with inflammation. Those are obviously different than BIA-ALCL. So Let's talk a little bit about some of these even more unusual things like breast implant association, breast implant associated squamous cell carcinoma. So, in September of 2022, the FDA issued a safety communication about squamous cell carcinoma and various lymphomas in the capsule around breast implants. Those other lymphomas are not the same disease as BIA. ALCL. In a March 2023 update, the FDA reported that a literature review through January '23 identified 19 published cases of squamous cell carcinoma in the capsule around the breast implant. There have been reports of death from this disease and its progression. The FDA still believes these occurrences are very rare. The cause, the incidence, and the risk factors remain completely unknown at this point. When timing, um, Was available. The diagnosis occurred about seven to forty-two years after the initial implant placement. The tumor was in the capsule, often behind the implant, not in the breast tissue. Plastic Surgery Societies describe BIA SCC, which is squamous cell carcinoma, as a very rare but potentially even more aggressive epithelial tumor because that's the nature of a squamous cell carcinoma. Unlike many early BIA ALCL cases, this tumor can invade. Tissues more aggressively. It doesn't stay confined to the capsule. That is why we separate the diseases. BIA-ALCL is a lymphoma of immune cells in fluid and capsule. BIA-SCC is a squamous cell cancer of epithelial cells in the cancer capsule. They can mimic each other clinically. A late mass, a late fluid collection still needs to have a tissue diagnosis, but you cannot tell these apart. From a photograph or a caption, providers can now report BIA, ALCL, squamous cell carcinoma, other lymphomas, and other capsular cancers to the profile and MedWatch. So rare events become obviously understandable only when they are reported and we know the numbers. You will hear all this like different. Pathogenesis, and, and we just want to frame it properly. A proposed pathway for BIA-ALCL is chronic inflammation in a more genetically susceptible person, possibly including biofilm. Now, there are some mutations in JAK1 and STAT3 that seem to drive the T-cell population in this. So that is a hypothesis with some biologic plausibility, but it is not the complete verdict. Last week we talked about microbial findings around implants on my livestream. Detection of bacterial genetic material does not by itself prove living organisms or material biofilm or active infection. It also does not prove that biofilm caused lymphoma in any one person. So chronic inflammation may be part of the story. Genetic susceptibility may be part of the story. Textured surface biology may be part of the story as well. We should keep obviously studying all of these. We should not tell patients that. The, um, the diet, you know, any of these laboratory examinations that we do, um, or, um, any of the diagnoses we make, um, may lead to exactly which mechanism is explaining like each individual case, because I imagine they're all going to have, um, quite a bit of variability, especially in such a rare problem. The constructive position, I think, is this: the association with textured implants is strong enough to change device use, and obviously do that with informed consent. The mechanistic details are obviously still not completely understood, so obviously patients need to be aware and follow up. And so One, you have to know that BIA-ALCL is rare. It's a lymphoma. It's in the capsule and the fluid. It's not a breast cancer of the breast tissue or the breast gland itself. Two, no late symptoms: swelling, asymmetry, a mass, a painful capsule contracture, rash, large fluid collection, more than a year. Uh, or so after implant surgery or many years later. So you gotta acknowledge those and get seen and examined. If those symptoms appear, obviously we want you to see your providers, ask for ultrasound. Um, if fluid is present, now it's gotta get tested for CD30, and it needs about 2 ounces of fluid 'cause they need to do about 50 cc's for one testing aspect and about 10 cc's for another. And do not let it go untested. It does not solve the question. Number four, if you have no symptoms, the current guidelines do not recommend removing implants solely for cancer concerns. So you have to stay informed, do what's best, what aligns with you, and make your own obviously your own decisions. Number five, other rare capsule cancers like we talked about tonight, including the squamous cell carcinoma. We didn't talk much about B-cell lymphomas, but those are also very rare, are even less common and they still deserve evaluation as well. So the reason I gave this as an update is I had a patient come to me recently with a late onset sarcoma, no answers as to why. And then ultimately on examinations and workups, she had a rupture. So your history, your exam, your imaging, your pathology are all very, very important to, you know, clarify this picture for the patient. And so I'm going to take a couple questions off each platform, then we're going to go to drrobscircle.com. It's free to sign up. I'll put it in the comments now. And while I'm doing this, formulate some questions. It's free to sign up. So, oh my, TikTok is so hard for me to make a comment. I struggle. Okay, so I'm gonna put one more thing up, and we're gonna take a couple questions. Then we're gonna have a discussion with a special guest. The only way you can see the special guest is you have to go to the circle, because if you're on Instagram and TikTok, I'm gonna. shut those feeds down. And the same with, uh, Facebook and YouTube and X, and this will just be in Dr. Rob's circle. So let's take a couple questions. And Jamie says she wishes her primary doctor knew more about this. She just, um, says her doctor keeps checking her for lupus. Yeah, this was way different than than that. Jenny, you said that you're in Chicago near Northwestern, and they haven't heard of BIAALCL. That's very concerning to me. And I don't take insurance. I haven't since 2019. So everything we do for cancer patients or cosmetic patients is fee-for-service.

All right.

So I'm looking for some questions here. And I don't see any. Now, can y'all get— oh, here, somebody wrote a— oh, here we go. Somebody wrote a long one. I had an explant 4 years ago, was told one implant was busted. I have no idea if she took out the encapsulation. I wasn't asked about that at the time. Should I find out? My highly sensitive CRP stays at about 10. Um, yeah, I think anybody who has had the surgery and had an implant removal should see if they had a capsulectomy. And if you had a textured implant, that's even obviously more reason to make sure you understand your operative report and what was done. And, um, we're going to talk to a special guest here in a moment who is obviously one of the— she's near and dear to my heart in my practice. She's one of the main reasons I always do things the same way so I don't miss any of these implant-associated cancers, whether they're a lymphoma T cell or B cell or squamous cell. And I certainly obviously do my best to never miss a breast cancer. And so I'm going to shut down these feeds. I would like everybody to roll into the circle. If you're a member of the circle, you're going to be able to see all this on replay. If you're not, You will not be able to hear it, um, because I'm going to be doing that with headphones unless I change the speaker settings. I guess I could do that. Let me do that. I'm gonna just change a speaker setting. Oh, it's set up anyway. Let's do a sound check. I'm going to add Why won't it unmute? Says you're muted. Can you hear me, Tiffany?

I can.

Okay, I'm just going to turn Tiffany up. So my special guest is Tiffany Blackman, one of my patients. So Tiffany, we are still live across all of the platforms, and I probably have to get someone smarter than me to be able to herd everybody onto the main platform. But be that as it may, thank you for joining me. So everybody can't see Tiffany from Instagram and TikTok, but I believe you can hear her now.

Can you hear me, everyone?

Um, I think you have to speak a little bit louder.

Okay, can everyone hear me? I am live with Dr. Rob. Can everyone hear me?

Yeah.

Can you hear me?

I'm gonna put this mic right next there, next to it there, so it sounds a little quiet.

Okay, so I'm gonna speak up even louder.

Yeah, that's better actually.

Jamie can hear me, good.

Okay, now I turned it up.

Good, okay, here we are. I'm gonna do mine as well.

Now it's loud. All right, now it's a party.

You can totally hear me now.

Yes, ma'am. So, um, I think it's probably best to hear from Now, for everybody listening, Tiffany is not a patient who had a breast implant-associated cancer. So I have had one in a thousand of those, but that patient is a very private person, and I was kind enough to get Tiffany to come on, and I want her story to be heard because it is very important, and it's one of the main reasons I do the explant surgeries the same way all the time, fundamentally. So if I were to operate on you and we did not know pre-op that you had an underlying breast implant-associated lymphoma or squamous cell carcinoma, um, you actually wouldn't really have to have a concern about how we do the case because we always do the case with the intent of taking out everything Um, that way we know when we send it off to pathology and have it examined, we don't miss anything. And when I was operating on this young lady, I found something, and then I sent it off. And I will let Miss Blackman tell her story.

So I was very ill for many, many years. Can everyone hear me? I hope they can. Um, very ill for many years. Found Dr. Whitfield online incidentally and was going to another surgeon. I'm in Fort Worth, Texas, and she did not remove the capsule. I didn't know, not know one thing about this. So obviously, as many of us do not know. And then I went to pre-op with her and she said I was taking steroids and couldn't see her. Found Dr. Whitfield. We had explant. I had all the symptoms of BII, obviously couldn't nail it down, but then went into surgery. He removed my implants. He did the en bloc, everything just fine. And then about 4 weeks later, the pathology came back with cancer cells. And I was shocked. I had no idea, but when he found these, went to pathology, I went to an oncologist in Dallas, and the radiologist said, this plastic surgeon, whoever he is, saved your life. So here I am now, a healthy woman feeling fabulous after November 9th, 2023, seeing this fabulous man, Dr. Whitfield. He found this in my capsule, if I'm not mistaken, Dr. Whitfield, you can clarify this. In my right side, he had some issues. It was on the right side of my body. It was not as comfortable. And I don't know the science behind it, but he found it and removed it. And now my protocol with my oncologist in Dallas is MRI, not MRI, no. PET scan. MRI and then mammogram. So 6 months apart. This we are. He got it and removed it. And I don't know where I— things would look very differently in my life now if he hadn't found that. So here I am.

So I think it's important to highlight that was found deep, very deep up against the scar cap. And so that was the main issue for you.

Yes.

You had a deep-lying breast cancer that would have been missed on traditional scans or imaging because of its position relative to the, the implant and the scar tissue. So I always talk about, Tiffany, that implants don't hide breast cancer in general because usually they're on Thinner patients, that helps in a way make it so the patient can examine the breast a little bit more easily and find things more easily. But in your case, it was the opposite. It was actually going to be very, very hard whether you had just your own breast tissue or an implant because of where it was. It was not—

Right.

And I have a picture of it. I'm just sitting here looking at it to my right. On my screen, which we won't share online. It's a little too graphic.

But you know what's interesting? A lot of people ask me constantly, were you doing regular mammograms? Were you doing self-checks? And yes, the answer is I had a mammogram in August before I saw you for surgery November 9th, 2023. And there was no signs of Anything? Nothing. I had a regular normal mammogram. And why is that?

Yeah, because of its position. Yeah, it is so close to the implant, and when they're trying to move it around, it's probably obscured because it was so close. So that's one, you know, glaring disadvantage, uh, in that case, because your I remember doing this, the right side. And I remember when I was doing it, I came across this little projection. And I was like, well, this isn't normal. And I went around it. And it was all intact and everything. And we took it out. It's, it's a lovely little photograph we have of it too. So I think it's important always when to do a capsulotomy, We're always trying to do them intact. I gave this huge talk, I know it was a couple weeks ago, about totally intact and en bloc and margins and all these things because all this confusion around that, that kind of language, and, and there shouldn't be. Had I not done Tiffany's operation the way I traditionally do any cancer operation, she would have been left with a deep-lying cancer up against her chest wall that who knows when it would have been found and how much more advanced it would have been when it was found. Because we found it, it was found so early, there was nothing else to do. And it's just surveillance.

That's it. Dr. Rob, what is the percentage of people that you see, your clients, that are, uh, that end up like me?

So we've only actually— that's interesting. So I've only had one person have breast implant-associated lymphoma, and it was a B cell, not a T cell. And that's in over 2,000 cases. And I've had only, uh, 6 breast cancer cases out of all of the cases. You're one of the 6 people who had breast cancer. And so those are super low numbers, and I do as many as anybody in the country. So you would expect me to find more. But if you ran our pathology results, you would see that we do not find breast cancer. Now, that's all deep stuff. That's all up against the implant. So it's, it's just your case. That was a deep one that we found. We've found some in like bag capture contractures. Things like that, more common.

So what do you say about the surgeons that are not doing the M block like you are because they're not finding what you found with me? And I'm a low percentage, obviously.

But right. Well, I mean, if you do it, what is it the saying? How you do anything is how you do everything. I just try to do everything. Really consistently for as I'm approaching the cancer case, and I'm you know me. I've I've done a lot of cancer reconstruction and things. So like doing your case was had some like experience that I wasn't used to or didn't understand or was you know concerned about you know doing for you just like any of the other ones. I had this patient the other day. Who was potentially an anaplastic large cell lymphoma case. She had had a seroma. It didn't quite fit, but you never know in those cases. So I, you know, and I don't ever get nervous in the operating room, but I think obviously you want to make sure that you take care of everybody and do the best you can to always help them. You know, Tiffany survived breast cancer. My sister passed away from breast cancer. Many of our clients have family members and loved ones who pass away from breast cancer. So one case, your case, is all the reason I need to ever do or support my decision-making in the operating room because I always want to have clarity for the patients and their families and loved ones. So there's no questions at a week, a month, a year, 2 years. I get these DMs all the time, Tiffany, that, you know, I don't know if they took out my capsule. I don't know if they took it out at all. Like, they just— patients have no idea.

Mm-hmm.

And now things are getting done that are, I find, really unethical. Like, people are getting taken— implants are getting taken out under local in the office. Even if they're ruptured gel, and that is just bad practice for patients and for everybody listening. Like you should be seen and taken care of by somebody who understands really, really well what's going on. And if this talk did anything to enlighten you, there's a lot that's going to be learned over the next five to ten years about the tissue. Around the implant mast cell activation syndrome, T-cell activation, B-cell activation, plasma cell activation, all the things that are going on that are contributing to the reaction that the body's having. And some people don't have it, as you know, Tiffany, hardly at all. And then other people react and have really significant symptoms like you did. And then, you know, much, much, if not all of what you're experiencing has resolved at this point.

Yes, absolutely. Absolutely. Can I ask you a question?

Yeah.

When you received my pathology report, yeah. Were you shocked? Were you, what are we going to do? I mean, I just, because that was in 2023, so almost 3 years ago. What was your feelings when when you received that? I know what my feelings was fear.

I knew it was abnormal, but I knew I had taken it out.

Okay.

So like I obviously when I'm doing things and feeling you know you know it's like when Elon Musk says robots are going to replace me.

Yeah. Okay.

That's that's fair. But so. Surgery is a very tactile sport, if you will.

Yes.

Your hands tell you what's going on. The reason that cancer is completely intact is because I found it with my left hand while I was operating with my right hand.

Right.

And I, I didn't injure— I didn't go through it. I went around it because I found it.

And you could feel it.

That's how I found it.

I could feel it was different. And, you know, how many cases have I done? 10,000+ easy.

Right.

So, you know, am I always going to be perfect? No. But I'm always going to try to do as good of an operation, clean of an operation, certainly make sure that we get all the tissues out because, like, I had this discussion about this the other day and You know, there's this confusion about what an en bloc capsulectomy is versus a total capsulectomy and what a margin is. A margin can be as thin as a millimeter, you know, as thin as a millimeter.

Yes.

But somehow that's become this discussion point, and if you're always doing a capsulectomy, and I try to do it intact all the time, and I try to keep Obviously, all the tissues as they come away, we want to keep the breast tissue obviously with the breast tissue and the muscular tissue with the muscle. So if you're sacrificing a millimeter of tissue, I mean, I think that's fine. You're not, you know, injuring and creating more problems. I think you're actually going to get rid of tissues that are inflamed, potentially infected with bacteria, other bacterial contamination. And then in your case, you had malignant cells. So I don't, you know, it's not even a discussion point anymore. I think the right thing always is to just remove the scar tissue. And that way there's no confusion. Now it is easier in some and harder in others. And that kind of bothers people. So I get that. I mean, that's fair. I've done, you know, thousands of these now, and none of them are really that complex. Sometimes they're a little bit harder than others, but, you know, this is for you a, you know, potentially life-saving type procedure that you had because we found this. And it was isolated. And then, you know, on your follow-up studies, everything's been fine. There hasn't been any issues. So to your point, when I found— well, I always know when I send something to the pathologist, when it takes more time, what they're going to do. And I, I never know how much time they're going to take, but I tell my office girls, like, okay, The pathology people are going to call here. I don't know when, but they're going to call about Tiffany.

Oh no.

And that's going to be, you know, they're either not going to like what they found, or they're going to want to talk to me, or they want to send it out for a second opinion or something else. Any of the lymphoma cases, they always want to send them out for another opinion. So for yours, it was more about like Talking to you and then getting you with your people there, which you already had good relationships. So it's, it's the same thing. Like, I'm a good operator and you have one in your area for breast surgery, and then that was better for you because you had someone you could trust.

Right. So when you're— when you— when in my situation and any other woman in situation. Do you see this futuristically moving on to a different type of breast cancer or this type of breast? Do you see it popping up again? And I'm talking in layman's terms because I don't know how to medically talk about this, but is there a scare of this coming back? Because I'm good right now as of my last mammogram, and I'll have my MRI again in December.

Yeah, I think the short answer is, as you control your inflammation and things that can affect you, I think the, the chance is obviously always there. But I think you're doing all the things to help, I think, that are important to modulate that.

Yeah.

So I think, like many of our diseases, inflammation plays Huge role. And when you have less inflammation, like you've worked really hard to lower yours. And Tiffany is a, you know, a stellar, you know, speaker about our program, but she's done tons of work on her own and done lots of other things besides my program to lower her inflammation. And that's going to hold her and put her in a better position over time. So of course you can develop something like anybody who had that diagnosis. But I think you're doing all the things that I would want you to do to keep that in the background.

Right. You know, doing the SHARP Method, just staying on top of everything for sure. You know, when I saw you initially, and anyone listening now, When I saw him, I wanted to be in there the next week taking, but we had to prepare. And I understand now why, following Dr. Whitfield, why we have to prepare and be prepared for surgery. And then it's not over when it, you know, I mean, it's not over when it's over. You just keep taking care of yourself, just like you said. And I do to the best of my ability to take care of myself and to keep this from coming back.

Yeah, I think, you know, when, when patients ask or when they come in contact with us, they initially don't really understand the program, right? So, correct. For everybody listening, I was taught— I'm old now. So I finished medical school in '96 and surgical training in '02 and plastic surgery training in '04 and microsurgery training in '05. So for the math wizards, that's 13 years after I got out of college, 9 years after I got out of medical school. So in the time I trained, a lot of things changed. We went from doing open surgery to doing keyhole surgery, or what you know as a laparoscopic procedure. All that happened while I was in training. I learned how to do a modified radical mastectomy with a cold knife. So just a knife. And then by the time I got done, we were doing just lumpectomies for the most part. And all sorts of other advances. Stenting came along basically and changed cardiac surgery while I was in So I've seen all these things change. I've seen the Genome Project get completed, and now we can just spit— have a patient spit in a tube and send it in a few weeks, have their genetics back, just like we did for you. Or we can have you do a challenge with supplements including glutathione and then get your tox report back, which I can look at right here and know like what other things are affecting you and your gut health. And, you know, you look at food sensitivities, all these other things like you already know because you're already trying to lead this more, you know, natural holistic lifestyle. I know those terms get, you know, bantered about all the time now, but it's, it's very important that you understand that what you put in your body and on your body and the things that you drink and the things that You eat, like I said, and the air you breathe are critical to how you experience life, basically.

Well, Dr. Whitfield saved my life. That's all I can say. And I've had multiple doctors, not just him, tell me this. But thank you for all you do. And I wish all of my friends would listen to me.

Well, that's all right. I think everybody, you know, Maybe we'll see if anybody has a couple questions, and then we'll get Tiffany off here. She's been so kind to hang out. Does anybody have a question for Tiffany? I'm gonna take a question from TikTok and Instagram and YouTube, and then I'm gonna shut it down. I I really appreciate Tiffany's time tonight. What are we doing here? Nobody's. Doing anything. They're just like vexed. This is so weird today. Like, I thought, uh, there would be so many questions I wouldn't be able to handle them. Okay. All right. Have you heard of ground glass in the lung? So that's not exactly the topic for tonight, but yes, we have. Um, so we're talking about breast implant-associated cancers, and we're also talking about Tiffany, who had an explant in a, a way that provided her relief from something that could have caused her a lot of problems down the road. She's got a daughter, a family. She wants to be around for them always. All right. I don't think I have any questions for you, miss. Thank you so much for hopping on. It's great to see you.

You too. We need to spread the word more for sure. Yeah. We'll figure out how to do it.

All right. Thank you.

Thank you so much. Have a wonderful evening. Bye.