Breast Implant Illness and Explant Surgery with Dr. Feng and Dr. Robert Whitfield

Doctor Feng is internationally renowned as a microvascular, plastic and reconstructive surgeon and the founder of the Fang Clinic. While she specializes in cosmetic surgery of the face, breast and body, Dr. Fang is recognized for being one of the first to use autogenous tissue for breast reconstruction, which gained national attention in the 80s. Dr. Fang has pioneered research on the integrity of breast implants as devices for the decades and has testified about her findings before the fda. She is also one of the few surgeons to perform all natural breast enhancement using the patient's own regenerative stem cells and fat tissue. And most recently, she introduced a painless and drainless abdominoplasty or tummy tuck procedure, which has dramatically reduced recovery time. Thank you for joining me today, Dr. Fang. I have Dr. Fang from Miami on vacation and she is literally kind of an icon in terms of breast implant ill transplant surgery, really providing nutritional support and helping explain and broaden the discussion around breast implant illness. So I want to give Dr. Fang a very warm welcome and thank you for coming on the show.

Thank you, Rob, for inviting me and this is such a pleasure. I would take any time out to join your podcast.

You're one of the few people I can say this to because. And we'll start off, we'll throw in some controversy out. I know you did microsurgery and you know I did microsurgery, so I'm quite happy to see microsurgery listed as part of your credentialing and part of your history. I find that kind of thrown around too much in the groups that advise patients, but a long standing history in microsurgery. I have a healthy respect for, I have a, you know, a mentor who passed away. Bill ZAMBONI and then Dr. Jack Coleman was my mentor in microsurgery. So I think both you and I know how rich and important that history is in surgery. And that really is part of the reason I got involved in obviously cancer reconstruction and then ultimately taking care of patients with implant problems. And I'm sure you had a lot of this experience as well throughout your career and taking care of problems and trying to fix them and maybe arriving at what you arrived at was many, many of these things are complicated and not, not well understood. So a long way of saying, like, how did you become involved in breast implant illness and explant surgery? Because that's the question I get all the time.

Yes. So Bill Shaw. Do you know Bill Shaw? He was the.

Oh yes, of course.

Plastic surgery. Yes. So he was my mentor and in 1990, he called me up, and this is after I have already trained with him at nyu. He said, you got to go to this FDA meeting because you may find patients there, consumer groups that might need your help. I went to the FDA meeting in 1990 in Fredericks, Maryland, and I was shocked because I met some of the Command Trust network. Responders and also Dr. Pierre Blay. I think one of them said that silicone is not containable. You'd be surprised if it goes to the liver and distant organs. Then I met Dr. Pierre Blay, who said, you have to take out. If you're going to take out these implants, you have to, you have to take out the entire capsule. Now, when I trained with Bill Shaw in New York, we did a lot of that. We did a lot of salvage breast reconstruction where patients don't tolerate the implants. We took out the implants and capsule and put free flap in them. And at that time, we were using the gluteus maximus, superior gluteus maximus free flap, and the TRAM free flap. So that's the first exposure. The first exposure is really on local problems. The earliest exposure was 1990, where there was reports of systemic problems. And then I realized that this is nothing new because the first paper on systemic problems from silicone was in the 70s, even 60s. Miyoshi, Japanese researcher Miyoshi, he wrote about that. Those were case reports. So I was never a fan of implants in my training. And I've always thought that autogenous tissue reconstruction is far, far superior than implant reconstruction for breast cancer patients.

Right, that's. And so it's easy for me to talk to you about this. I mean, that predated a little bit of how I trained. Dr. I interviewed with Dr. Shah when he had already went to UCLA and was, was the chair there. But when I trained with Dr. Coleman at Indiana, we all were taking care of problems from basically the 70s and 80s and 90s, right, with ruptures, etc. And I'm sure you're less of a fan of the implants that had a Dacron patch on it. I found those to be the most awful things known to man because they were supremely difficult to deal with. But I try to generalize if, if we can a little bit and say that when each of us was faced with an implant, a breast implant reconstructive problem, infection, radiation, injury, extrusion, capture, contracture, whatever the, you know, litany of problems that we were faced with, we knew if we took all that material out, and we did take out the capsule because as I was taught by mentor, my mentors, and I'm sure you were as well, like, you want to look for recurrence, you want to look for infection. So you get all that material out and you have as natural a start as possible to put the flap tissue in and revascularize it. So for everybody listening, Dr. Fang and I both did the similar types of operations where we took skin, fat and muscle, or skin and fat from other areas of the body connected to its blood source, an artery and a vein, and we hooked that up underneath or in the armpit based on the blood vessels that we were using to revascularize. So perform a tissue transplant if, if that's easier to understand. And I knew, just like you knew when I did, that if there was a problem caused by the device, that would go away. And it did. It always went away. So I, you know, like you had to have and help many, many colleagues with implant based problems. So neurosurgeons, orthopedic surgeons, vascular surgeons, I, I feel like you and I are uniquely suited to discuss this because I spent my whole career taking care of those problems.

Yes, absolutely.

They're not.

Yeah, we're not, yeah, we're not married to the implants and we see the implant problems. So I think it's much easier for people to accept breast implant illness if they're doing cranial facial surgery or microsurgery.

Yeah, I think, unfortunately, those subsets are so small within the general plastic surgery groups that it's. Although it's growing and you've put forth literature, we've tried to put forth literature to help support and explain and give testimony, listen to testimony, and really participate in support science. And the best way to be, you know, somehow providing explanations, like I'm sure you've hypothesized, just like we have, that there's too much immune system activation and that leads to more symptoms. And now you. We were on a call a month ago, I guess it was now for the Breast Implant Health Summit. And we discussed Dr. Cena's paper, which I, I still feel like it's the best paper going in terms of explanation regarding cause and effect between bacterial contamination, biofilm interaction between the breast tissue, and then formation of Oxylipin 10 home, which creates more and more symptoms. I know you have a lot of thoughts about genetics as, as Louis in our clinic and look at that carefully. So maybe, maybe it would be good for the audience to understand, like how you used to think about it and the progression now. With more available evidence. Because I, I was really impressed by the amount of evidence put forth on that call. Like you wore that we were on. It was really, it was just good. It'll help the patients better understand the problem as well.

Right. You know, because the reason that I got interested in genetics is because I realized that patients present problems, symptoms quite variably among the different people. Because I think the only way to explain it would be genetics. Because we do have patients that have a rupture that only have local symptoms. I really try to differentiate between local versus systemic. If you have numbness and tingling in the upper extremity, it could be local. If you have pain is local. If you have pain in neck, shoulder, upper back, that's local. If you have difficulty taking a deep breath, that's local. But if you have numbness and tingling in the feet, fatigue, brain fog, those probably would be systemic. So I am particularly interested in those patients. If you can match up the type of implant, whether they're ruptured or not, and the difference in the symptoms and the difference in the genetics. I use GX Science, which is actually based in your hometown, Austin. You know, I know you know that.

I think that's funny because, you know, you told me that we were conversing about it and I don't use them. I use a different company. And you know, I'm really fortunate to be in Austin. Things worked out and we arrived here and, and it's really like a hotbed of like wellness and, and healthy kind of lifestyle. It's just a really great atmosphere for that. So there's so many people interested in your health and well being and advancing, you know, health span and lifespan and longevity. Like it's an easy discussion to have around here. Whereas you're in the Midwest where I trained and lived for a long period of time. Might be a little challenging.

Right. I know you also. Yes. So the reason I like, I like the GX sciences because you can calculate, they taught me how to calculate methylation deficiency in a quantitative manner. So I was thinking about seeing if that makes a difference. Otherwise, if you look at detox, their detox panel, you can only say, well, how many are homozygous, how many are heterozygous? Sure. Methylation, you can actually put a quantitative number on that. I don't know how you feel about that. I don't know if that measurement is able to separate, differentiate the two groups, those with symptoms and those without systemic symptoms.

Well, I think or I feel that since, you know, the genome project Which, I mean, when I was in college, genetics was the craziest course I ever took because it was so far out there and the professor was so smart. I felt like a complete, you know, I was lost. And then things kept advancing and advancing and you know, as well as I do, the Internet came on board basically after we were done with training. And now functional genomics is like you're describing, I think, the key to understanding more and more problems that we were taught to be able to assess symptomology, do a physical exam and assign a diagnosis and create a plan. I don't, I don't think like that anymore. Probably, you know, basically what you're describing is listening to people, understanding how they detox genetically and then try to correlate that so it makes more sense to you, which it does to me that way. Like I try to tell everybody, I don't sit here and try to assign a set of symptoms to the problem. I try to understand, just like you're talking about how is someone methylating, how are they able to, you know, maybe through a glutathione pathway or antioxidant pathway, how are they able to function day to day? Now that's the principal part of my book Sharp, where I talk about genomics because I feel that plays and has played a critical role in how I've thought about this problem. And the advancement of the genome project has certainly let both of us have a bigger window and be more open to understanding the problem. I think that, and you can comment on this too, I think that's a huge mission in medical education now is not really aggressively addressing even the simplest understanding of single nucleotide polymorphisms and mutations and things where instead of a symptom based disease model, you go back and think about like, all right, you can't pick your parents and you can't outrun a bad diet. That's what I always say. So those are the things principally, you know, can we address those? And you have your fit foods that you've created that are plant based. You know, we are all the. When you come to my clinic, you better not be drinking out of a plastic water bottle. We don't eat gluten here. We don't have dairy except for grass fed butter and ghee. I don't care what animal or protein or plant based source you get your protein from. That I don't, I'm not in that fight. I don't care. I just want everybody to be as healthy as possible, taking enough good dietary protein, concentrating on Sleep. So these factors we're talking about with genetics, you give yourself a chance at least, right?

Yeah. So, you know, so basically based on genetics and then epigenetic factors, so your epigenetic factors is going to be your diet and what do you do, you know, the pollution that your pollutants that you're exposed to based on, you know, what kind of water you drink. All of this really play into health. And I have no disagreement with you that it's, it's so important to control the epigenetics. And I don't have a, you know, a particular diet. I think different diets for different people. What we produce is, what we try to produce in our thinkfit foods is, is we take out, we take out everything that's harmful and produce, say, a salad that it's complex, it tastes good, that has all the helpful antioxidants. We produce the dressing that goes with it, but we take out all the seed oils, unhealthy oils, and then we use water that's has a powerful reverse osmosis. So we don't have glyphosate. That's the kind of thing that, you know, and this is what we see. I mean, I'm sure you meet patients who are super super, has super, super healthy diets, who do very well in surgery, who have minimal symptoms. And that's how, that's how this food idea was born, is really to help people heal. And you do see that food is medicine.

Well, you know, where I trained, and I don't remember NYU's program specifically or or UCLA's program that was set up by Dr. Shot, but our program was ran by Jack Coleman, and we took care of every barren patient in Indiana that was severely burned that plastic surgeons did. We had no hospitalists, as you remember, you trained at a time when that was not a thing. Like ER doctors and hospitalists were all things that came on after I finished training. We didn't have any of those things when I trained. So you took care of the burn patients in the icu. And so this for everybody listening, you know, short of a liver transplant, there's nobody sicker in the entire hospital than a burn patient. Typically, like a severely burned patient, is compromised because their skin is compromised. So your natural barrier is compromised, your fluid balance is, is compromised. Your, your metabolic rate, if you want to think of it that way, your hyperdynamics, you're just really ramped up and you can pass away very easily. You know, it was, it was learning about taking care of those patients that really reinforced all the things that I think about with nutrition. And you know, if you didn't give them enough protein, we'll just start there. They, they couldn't survive. And you didn't feed them through parenteral nutrition, which is through an iv. You actually fed them through their gut because as you know, if the gut doesn't work, nothing's going to work. And we have a lot of patients who have a lot of gut trouble.

Yes. I actually worked six months at the North Carolina Memorial Hospital burn unit during my plastic surgery training. So I'm familiar with all those problems that you see.

Yes.

Yeah. And you know, we even, you know, dealt with people with 90% burn from a house fire who survived. It's a young kid that did that. But you know, adults with 30% burn with inhalation injury, they are really tough in terms of survival. And there's a lot of all these feeding tubes going, you know, so it's, it's amazing. I mean that is devastating, devastating injury. But I do agree, I think the gut problem is probably the hardest. The longest, it takes the longest to fix after explant.

Many of we've had years of abusing the gut, so that's why it takes so long.

Yes.

Sorry to interrupt. That's. That I find it too. I mean that's. I'll let you continue on that because I hope you just take a minute to explain like what you've seen and then, you know, steps you all try to take. Because that is by far the poor. Probably from a patient perspective, it's harder for them to understand how long that takes relative to recovery.

Yes. So the gut problem is so variable. I mean there are patients with nausea out of nowhere and there are patients with true food sensitivities and they have a very limited selection of food. And patients with mast cell activation disorder where they have to avoid all histamine releasing foods. So much variability. Then there's patients that you almost have to kill the biofilm that's in their gut and reintroduce a healthy microbiome. These are some of the problems that the functional GI person doctor can help them. We do have some referrals out there to help them, but I think that this problem is probably beyond the scope of a plastic surgeon. Now some patients will do well with our food, basically high antioxidant food, everything that's cooked in water, soup. But some patients, you know, cannot take raw food. They, they have to have cooked vegetables. So I don't know how you feel about that, but I think It's a tough problem.

It is a very difficult problem. So within our program, recognizing just what you highlighted prior to the pandemic, we referred a lot of people out. There were a lot more functional options in and around my area. And then post pandemic, we've had to just bring that in house. So we have our own functional practitioners as part of our team now. So they run programs to help heal the gut and continue to detoxify patients. So we just, that was something that we wanted to have more supervision for the patients because I was getting a lot of people running different protocols and having, as you would expect, variable results. And so much like anything in surgery, I'm sure you're probably like this as well. You don't like variables and you want to control them as much as possible. That just makes us feel, feel better surgically. So I've transposed that philosophy onto my, you know, practices in my office and my, in my other providers so that we can know. I try to get the variance out of this very complex problem as much as possible. But gut healing and gut brain axis, you know, improving that connection and stabilizing mood and hormone balance and, you know, getting enough sleep and the glymphatic system working and washing away all the amyloid that, you know, can affect us. I mean, oh, there's something that I, I don't make a big enough deal about, but I have Dr. Fang on, so I'm going to talk about it. You know, I have sleep apnea pretty bad. I'm not overweight. I don't have a specific, you know, jaw problem or neck issue. I just have a narrow airway. And I think what I try to impress upon, you know, patients is you don't have to snore to have sleep apnea. And I encourage all my patients, like, number one thing is, and I'm sure Dr. Fang will reinforce this as well, if you don't sleep, you can't recover after surgery. So, you know, principally the way I think about it is, and if someone hasn't had a sleep apnea test or doesn't measure their heart rate variability or has no idea about their sleep metrics, I try to get people interested in this because women are particularly susceptible to brain health issues like Alzheimer's. And I don't want any of my clients who already suffer from chronic inflammation from this problem to have brain health issues. Like, I don't want to have brain health issues. I have a 19 year old and a 16 year old. I'd like to be fully, you know aware of and available if they have children to be able to be a grandparent, as odd as that may seem to me. But I, I want my mental health, my clarity because that helps me take care of my, you know, team my patients, myself and look forward to the rest of my life. So I've made a big deal about sleep and sleep apnea and maybe let us know your thoughts about that. I feel like it's an underappreciated problem.

Yes, I have several measuring device. I use the Oura ring when I go to sleep. I do use the Apple Watch and the Apple Watch has a health app as well as apps. So I basically compare three parameters, the Apple health Watch, the Sleepwatch and the Aura ring, their sleep metrics. And I tell people I do take a lot of supplements to make sure I get deep enough sleep. So I figured I have to work on myself in order to help others. So basically the kind of supplements that has supplements that have helped me, one is melatonin, higher dose melatonins, slow release. The other is revitalizing sleep formula that has valerian root or deep sleep L theanine and magnesium glycinate. So you know, as, you know, you know, you don't, I don't get seven hours every night but I hope that when I do have six hours, five hours that I get enough deep sleep in them. So I use these devices and paired it with the supplements to make sure that I have enough deep sleep. So that's what I encourage my patients to do. And in the, in these apps you can tell if you have sleep apnea because they, they look at the oxygen saturation and whether you sat down, you saturation goes down. Part of, as part of your sleep.

Yeah, I think it's, it's a good point. I've used the whoop strap and I've used what's called the ultra human ring now because it's a more advanced ring. And I would suggest looking at the ultra human ring. I bet you would like its metrics in terms of sleep support with supplementation. I totally agree. A longer acting extended release melatonin, something with bisglycinate and then of course a combo with adaptogens like valerian root and Ashwagandha. That has worked for me. I basically do the same type of thing. I routinely can get 7 now but really not much more. And if I don't go to bed early enough, it doesn't really matter because I'm always going to wake up at like 4:45 or 4:30 or 5:00 clock, because that's. I'm so used to getting up and operating. That's just the way my body works. So maybe once I'm retired, that'll. That'll get better. But I. I completely agree that one. You have to check it in order to talk about it with us. Because I'm going to ask and you're going to ask. I'm sure you do this. I want to know, like, are you sleeping? And how many times you get up at night to go to the bathroom. And all these things where if someone in their 30s is getting up, they go to the bathroom. That's like way too much sympathetic activation. You got to get that person on a. On a regimen to calm them down and get them into sleep, because there's no chance they're going to have the surgical experience they could have if they can't get that remedy right.

The other, the other activity, lifestyle modification that I find very helpful. I exercise quite a bit, and I do a pretty intense cardio with spinning and the night. See, I exercise at the end of the day and the night that I do two times a week, the night that I do the intense cardio, I sleep much better. The sleep, I really can go through a whole night without getting up, I mean, and I fall asleep much faster, like within five minutes, three minutes. But this cardio I do, it's about 45 minutes. You really sweat profusely, I believe. I bet that there are parts of it. It's not just in zone two, but it's in zone five at times. It's the. We use a spivvy app. I'm actually, I got trained in spinning instructorship, but Linda is a great spinning instructor because she, She's a. She's a great dj. So she uses music to get your. To get your motivation up and go faster and faster so that you're constantly on the edge of being out of breath. I don't know if you. I'm sure you do exercises, but I find that the cardio is incredibly helpful. And I used to do running. I can't do running anymore. I think when you do running, you're relaxed, but in this class situation where you're competing against your baseline and your ranking in the class is dependent on how far up you are from the baseline, those kind of exercises, for me, really help sleep. Don't know how you feel about that.

I've had folks who really concentrate on cardio, and I just. From a patient perspective, because for. For women, I'm trying to make sure that they avoid osteopenia and osteoporosis. I want them to do more with weight or, or movement with weight in addition to any cardio they do. So I try to get it more balanced because I have some, some folks who are way too much cardio and not enough in terms of weight. And that's just gonna, from a skeletal perspective, lead them down the path of, or potentially down the path of osteopenia and osteoporosis. So I certainly try to get them working, especially on their lower body, more that way. You know, thinking of worst case scenarios of us getting older and more frail and falling. So lower body strength, you know, I think is key to, you know, maintain. Maintaining lower body strength is, is to me a key factor in just as we get older. Because I think, and I want, you know, obviously both of us on this call, live a very long time. We don't want to fall, we don't want to get hurt doing that. I too don't. I had to stop running and stop doing a lot of things. I had five knee surgeries and a, an Achilles tear. So I've had too many things go on. From a biomechanics standpoint, I have to be thoughtful about how I do things with my lower body, but it's still very important to me to maintain lower body strength and then do things like I don't do 45 minutes, I'll do burst. So it's more, you know, burst training with an echo bike or something like that to really stress my heart. And I'm always trying to figure out how to increase v2 max and fiddle with my heart rate variability. And you know, for everybody listening, you know, I. This is just us talking out loud about how we think about these things. So I don't. For instance, I know my HRV gets affected if I eat too late and if I have alcohol, if I have alcohol in the evening, there's no chance I get a night of sleep that's worth a darn. So that's correct. And you know, for the last, I don't know, whatever month it is, October, something. I haven't had anything to drink in the last few months. And it's, it's not because I don't mind and, and don't like to have a drink with my wife or, or whatever. It's just I'm trying to not wreak havoc with my sleep and recovery. That's basically why I'm doing it. It's not a stance or anything, but it's, it's A, it's a physical thing that I'm looking at carefully and checking and trying to make sure that if I can make it better for myself, then ultimately that's what's most important.

Yes. So alcohol has a two phase reaction. One is initial relaxation and a longer period of excitation. Personally, I don't drink and I try to eat less at night because if you eat late and a lot, it's going to disturb your sleep, your HRV is going to be low and you're going to have more increase heart rate because you're still digesting when you're sleeping. But I do agree with you on the exercise. For women, I think they're more weak in the upper extremity. So balance is very important, flexibility is important. So I try to work on my upper extremity and lower extremity strength training in a week. I do two of those with just a phenomenal trainer that does a lot of isometrics. As you know, isometrics really help with blood pressure control. So even though I do do intense cardio, I also do intense strength training. I think it's critical because it's. Because as we get older, the more you, you need more exercise. You need everything. You need flexibility, balance, strength and cardio. So.

And don't you find it like a very. I, I find it really concerning when people tell me all they want to do is hit or peloton or, or something so specific. And I'm like, look, you, you, you don't need anything to get exercise. You can go outside and do air squats or push ups or planks or sit ups. You don't need to do any. Your body weight is more than adequate, right. To do just about anything you want to do, you may need to do more of it. But if you could do, you know, whatever, what's a good movement, air squats or lunges or. I mean, these are big movements and you can do them with your body weight. You just have to do them.

Right?

So what.

Oh, one thing I wanted to tell you is that one of the things that I work on is, is pull ups. Pull ups from a standing position, either using your fist in a palm facing you or, or ext. Or pulling up with the extensor surface facing you, which is harder. But that's something I always try to do in addition to the free weights. I think for women, especially if you have your implants placed under the muscle and the muscle cut, most people cannot do a pull up. Even though you could do a pull up before the Implants. So I. One of the things that I notice is that the loss of upper extremity strength when you have either big implants or implants placed under the muscle.

Oh, now you segued in. What I was going to get to here. So my practice is in Austin near several military bases. So I have this group of patients who will come from the military after they pass their physical training test and want to explain and. And you can. There's going to be a lot of variation in being able to repair things based on how they were released by the original surgeon. So just like you, I get faced with a attenuated or really thinned out atrophied fibrotic pack. And yesterday I did a patient who had been radiated. You know, kind of going back to our reconstructed days. So there's a couple things that both of me. When somebody gets on and says they can repair every single person, I just think that person surgically either hasn't done enough cases or they're not being incredibly honest about what's going on, because you and I both know that that's not possible in every case. So from a perspective of somebody who did reconstruction for a long period of time, and you know, yesterday I did this radiated case. There was no chance I was going to do anything with this pec. It's just fibrotic. And so I was trying to figure out, you know, can I stabilize it more for the patient. But they had had breast cancer on one side, a lumpectomy, whole breast, radiation, implant placement, capture, contraction, the usual kind of scenario. And on the opposite side, they had an augmented breast with a lift. And so now, you know, you and I both know that's never going to be a great situation when we exploit it because it's very hard to get anything like that to match because it's been radiated on one side and it's forever changed. So I did the case and a reconstructive surgeon had done the augmentation on the normal side. And so I'm sure, and I'm going to let you comment on this, but I, I was like, I was waiting to. You know, you're. It's like Christmas. You're always trying to figure out what you're going to find when you go open this up and look inside and I open it up and. And the insertion is intact. And about 2 inches of the insertion as we go laterally is intact. So it's basically not window shaded at all. And it's very easy to. To repair. I'm sure, as you Understand, when you think about that, but that's a fraction of my cases. That is not the normal situation. And by training, I know how I. First of all, I know who it is. And second of all, they, for 30 years did reconstructive surgery. So they know intimately all of the problems and things with taking things in and out and then dealing with things on the back end. So I will let you, Dr. Fang, give your philosophy about repairs and how you think about them so that, you know, patients can understand and maybe we can chat about that for a bit. Everybody likes that chat.

Yes. So I think the muscle repair is critical because aesthetically it changes. It shortens the superior inferior base of the breast. So when you have the implants in, it's like an accordion stretched out, meaning that distance between the bottom of the nipple, real or complex, to the fold, the implant fold, is much longer than initially or what you're born with.

Right.

So in order to restore that, that muscle repair becomes critical because you're pulling up the aponeurosis to the edges of the muscle. The muscle has to be freed up first. It has to be freed up from the capsule and, as you know, from the breast. And then you have to see whether. How flexible they are. And when I see a flexible muscle, I know we can repair it, but if the muscle is tight, forget it. You can maybe repair a little bit of the medial, a little bit of the lateral, but somewhere in between. That muscle is not going to travel that distance, say from the third rib to the fifth or sixth rib. This is not going to happen. The most I could do is just to, if there is rib cartilage close by, just attack down the muscle to the rib cartilage. And you have to be.

Just to stabilize it.

Just to stabilize it. Yeah. And then. And then move the breast around so that it's not tethered to the muscle or that it has a more medial fullness. But you're going to. It's not going to be, you know, good, because you're going to have some missing spots. You're going to have spots that are sitting on the ribs, and it's not going to be as ideal as if you had a thicker muscle that you can completely repair.

Yeah, that was just like the case I'm telling about you. Telling you about from yesterday, basically is the ideal setting to then avoid all of the downstream complications of just lower pole issues and. Or exposed rib cages or palpability or, you know, having somebody with too thin of a lower pole. Like all the things like we Want to avoid them, of course, all the time. And, you know, I'll get just like you in a week, there'll be like whatever, three, four, eight cases. They'll all be all over the place in terms of, you know, the pec thickness and, you know, what can you do in terms of positioning it? It's just there needs to, I think, be some understanding from both patient and surgeons. Like one, obviously you want to do this and reposition it and stabilize it when at all possible, provided there are a couple things, you know, from a factor standpoint, is the, is the PET going to move?

Right?

It. Does it have enough, you know, quality of tissue to actually suture? Because muscle does not like suturing. It's just not that type of tissue. There's no, you know, beautiful fascial covering of this that's going to allow us to just stitch it together and make us all really comfortable. So I'm glad we, we, we talked about that. I find that to be something that, you know, patients have difficulty understanding it and then I, I've heard several versions of it. So I, I'm, I'm glad we're on the same page. Yes, I, I always want to provide that service, but I tell patients like, hey, it really depends on the quality of the muscle. I, I just. Like Dr. Fang, we could do a lot of things if in fact the quality of the tissue allows us to do that.

Right. I think the patient who's had multiple surgeries for contracture, that's another scenario where the muscle repair may be difficult because either because there's too much open capsulotomy so that muscle is denervated so that all you have is just a scarred, thin muscle that has many holes in it. So those are, those, those situations are in addition to the radiated patient that contribute to these inability to repair the muscle scenario. And that's part of my, in the risk informed consent. I tell patients there are times when I just cannot repair the muscle or can just only do a partial repair.

Right. More like just stabilizing it, you know, making sure the, you know, I've tried to, like it depends, you know, sometimes I'll show up and the insertion has just been released up until like 3 o' clock on a clock face. And you know as well as I do that is not a good situation.

Right.

And that's exactly, that's always going to be a challenge. And sometimes you can get an inkling of that preoperatively when you ask them to put their hands on their waist and animate and, and see where the, where it is and try to highlight that and say this is not going to be a good situation based on how it's been released. It's a good thing. You know, I was taught probably as you were, not to over release that insertion. This was, you know, drilled into my head by, you know, my mentors in training and we did so many cancer cases and placements and all the things that I'm glad I was taught to avoid a lot of the things we're describing, I mean, it goes a long ways to preventing these problems that we now, you know, face routinely. Now maybe we should talk about something else that gets a lot of attention is kind of draining people and how to manage that and what's your, what's your philosophy or thoughts about draining and how to get that sorted out for patients? Because you have a lot of patients travel in as I do.

Yes. So I do drain. So I do drain in the capsular space because I want that space to close. If I do do a breast lift, I also drain the area between the muscle and the breast. So I put in. So if I'm doing a capsulectomy under the muscle and a breast lift, I do drain. I do. I put in JP for the capsular space under the muscle and I put in an axiom Y drain for above the muscle. And so in those situations, they have to be less than 30 cc's per 24 hours per breath for me to take out those drains. Typically the people, typically we can take out the drain and fulfill that criteria between day three and day four of the post op. People who are a little bit overweight, who have a big space, who have a rupture, they tend to take longer. But what I tell them is that, you know, the drain does detox you because there's a gradient of chemicals that extend from your capsule to the rest to the surrounding space. So if you're draining that, and that would include both fat soluble and water soluble liquid. So I tell them if you're still draining a lot, that means that you're, that, that is good because we're detoxing. So those people, they stay longer or they go home and they come back or they just stay until the drains are out. And I don't want to go past a week.

Yeah.

So some, you know, I just take them out even though they don't fulfill the criteria.

Yeah, philosophically I differ a little bit. I agree totally with, you know, talks. I try to work on all that pre op because it's usually it Varies. It may take three or six months to get here and, and people do a lot of work in that phase. Even though I stopped doing tummy tucks a long time ago, I hadn't done a tummy tuck with a drain for a very long time that didn't have additional liposuction just with suturing. But I deviated away from draining the breast space just through work of like Simeon Wall and Constantino, Constantino Mendieta because of suctioning through the pocket to the abdomen. So I tend to make it contiguous with the subcutaneous space and allow lymphatic drainage to do the, the lion's share of the work. I do agree that obviously there's a lot of different toxins. We try to identify as many of these pre op and get work done on them. But suffice to say that I do have cases where I will end up using drains. I use it, you know, relatively infrequently now and I've rarely had trouble with seromas. But that can happen whether you use a drain or not, as you know, and certainly drains don't prevent bleeding. I think, you know, to your point, you know, being meticulous and taking precautions and people will argue whether PAC repair helps, you know, alleviate some of the space where a potential hematoma could develop. All of it. It's still surgery. The biggest complications always going to be bleeding. That's what I obviously explained to every single patient and that's, they all should understand that anyway. But that's the number one thing that you and I, because we operate, you know, for a living, that's what we constantly worry about when I, I'm glad that you adhere to, you know, principally and have a philosophy of why you're doing it. Like, I don't, I don't, you know, disagree with, with anybody's actual philosophy as long as they're, you know, I think explaining it well to the patients, the patients understand it and then, you know, communication is always key. Why we're doing things that just helps patients better understand what's, what's going on. I did want to ask, like, because you're doing or recommending some dietary programs, let's give like your tips and tricks for your patients for maybe diet, what you suggest for them pre op and then post op so that it helps them if they have drains. Obviously you're trying to get those drains out sooner and things like oncotic pressure and dietary protein are important. So maybe highlight a few of those tricks, if you will, for your patients.

Sure. Well, maybe I can just react to what you just said and then I'll go into the diet. I don't put drains. After abdominoplasty I do the progressive tension suturing. So oftentimes it requires over a hundred of these progressive tension sutures. But I don't put drains because in the abdomen you can really, you can anchor them in the breast. The breast is free flowing, so you can't anchor anything in the breast because otherwise you'll create deformity when you stand up. Right. You know, laying down. Yeah. So on the. So that's my, that's my philosophy now in prevention of bleeding. What I do is that I really look at the preoperative baseline pressure and figure out what is their baseline. If their baseline is too high, I will put them on clonidine. And during surgery I get the blood pressure up to their baseline so I can see the bleeding. I do use txa. If after numerous hemostasis I still could not get the bleeding under control, patients will get a thousand milligrams of IV txa. And there are times when the capsule is so vascular and just not able to control, not able to get a very, to get a very clean field. After you stop all the bleeding, then TXA I find is very helpful. Regarding the diet, I think preoperatively at least no fast foods, at least up your vegetable and fruit intake and make sure the animal protein or vegetable protein you eat is clean. In our facility we provide afterwards because in our recipe we are very aware of the sugar, the macronutrients, that the sugar content is lower and that the salt content is lower. So the sugar content lower helps with not increasing inflammation. And the salt content, a lower salt content will help with the amount of drainage. So if they like pizza, you know, that's really a no no. If they like cured meats, that's a no no. You know, sausages and things like that. So we try to get them to eat the salad and our dressing and whatever animal protein they want. Make sure that it's, you know, water based cooking. Because I talk about the advanced glycation end products. When you use too much heat in cooking meat, that a water based cooking, like chicken soup or some kind of a soup based or crock pot based cooking for meat is probably less inflammatory than if you were to do a barbecue, high heat barbecue. So those are the kinds of dietary advice that we give. I don't know how you feel about that.

Oh yeah, I mean the. We want to avoid the Maillard reaction as well, because cooking it too high heat creates that problem, which is, you know, many people are using Carnivore as a principal diet now, but the Mailer reaction and the increased glycosylation is what Dr. Feng is referring to. We want to avoid that. So cooking at the proper temperature in the right oil is imperative to avoiding that. I do like the fact that you're incorporating txa. We use it on each case now and then. Clonidine, just like you're using it is case by case. It's centrally acting. It's been used for a long time in plastic surgery, began, I believe, if I'm correct, with facelifting, just controlling pressure as a way to avoid postoperative hematoma. And I think Dr. Nahi presented his experience over a long period of time with reducing hematoma by use of preoperative clonidine. So I agree those are all tips and tricks that should be and can be utilized by plastic surgeons performing explant surgery. What I agree and wanted Dr. Fang to share her philosophy with about which you could go to her website and see she really cares about your diet, just like we do at our practice. And I've become more and more rigid about who I'll work with because neither you or I can afford to have delays in recovery for our patients. Because that's not, I, I call that not a problem, that we can diminish that problem in our practices so we can work harder on diet and nutrition way up front and nutraceuticals and lifestyle changes and decreasing inflammation and toxicity burden by just making choices. Like we use Jasper air filters, we use echo water filtration, we, you know, I'm fortunate I live near a farmer's market. I can go to a farmer's market and get higher quality, whether it's meat or produce or vegetables or what have you. So we try to really educate our patients. Like, you have to start doing these things. You have to start lowering your inflammation before you ever have surgery. Like surgery is not the impetus to start this process. It starts many, many months beforehand to get you into a better position. If in fact you come to see Dr. Fang or I for surgery.

Yes. So I know you have hyperbaric oxygen therapy. So I have invested in two big chambers, multi person chamber. Just about every patient after surgery, I put them in there. We give three hyperbaric treatments. And I also invested in these red light lasers that we use after the drains are out. And so I use that for both facelift, tummy tuck, breast reduction, breast lifts, so that they heal better and that I'm really amazed at how much pain reduction this does for the patient. I know you also use hyperbaric oxygen treatment. I strongly believe in that and I use that extensively after fat grafting. Whether it's fat grafting to the face or fat grafting to the breast. Yeah.

Dr. Zamboni was my mentor and he had NIH funding for hyperbaric oxygen research for ischemia reperfusion in muscular tissue. And, and so if you came to work for him or if you were his fellow, you were going to go to the lab and you're going to be in the lab and they were going to, you know, talk about the experiments, you're going to go to lab meetings and you know, it's, I would say you, you don't appreciate your mentors, unfortunately, until many of them have passed. Dr. Zamboni passed very early in his career from metastatic renal cell carcinoma, kidney cancer. And it's quite, you know, I'm older now than he was when he passed, which was very difficult. He has a son my daughter's age. So he impressed upon us all at a very early part of our career and training the therapeutic benefits of hyperbaric oxygen. Before they were as commonplace as they are now. Both you and I have chambers that was unheard of when you trained or I trained for huge, huge devices that seemed like impractical to have. And now we have a vertical chamber so all of our breast patients can just sit and relax and have a treatment. We have a 6 foot tall vertical red light from Joovv that we really like to improve hormone balance and decrease inflammation. And then I'm a huge, huge fan of lymphatic massage. I have a lymphatic therapist and I have three lymphatic massage devices, Floppressos from New Zealand and I, I implore every patient listening or prospect listening. Those are important things to have as part of your armamentarium, you know, in the recovery process as well as the things that we've already discussed. So I think Dr. Fag and I will agree, like behavior modification is always the hardest thing for us to take care of. But if you sleep better, eat better, drink better fluid, breathe better air, you'll do better.

Yes, I agree. I'm amazed at how similar our approaches are to health. That's really good because, you know, most good things people will agree on if you have enough experience doing this work. So I'm just so happy, so happy to hear that you're doing all of that and that just Confirm you know what I'm doing. So, you know, this is, this has been a wonderful, wonderful chat and I really appreciate that.

One of the reasons I wanted Dr. Thing on the show and I'm going to have others on the show in the space we're in, but I wanted you to be the first person I really extended this invitation to because, one, I respect all the work you've done, but two, many of the things that are extremely important to me we're in alignment with and how patients take care of themselves and how we want them to take care of themselves and promote a more efficient recovery process. We may differ on the specifics on some things, but that's not the point. We're all very motivated, in alignment with the mission of helping our patients recover faster. So I want Dr. Fang to tell us where you can learn more about her clinic and her programs. And I'll have her share that and I'll put it in the show notes as well.

Great. Well, for food aspect, I mean, you can go to our website, fangfitfoods.com we are in the process of exploring, expanding. We're going to get a. We already signed the lease for an 8,000 sq ft commissary to prepare salads. So we typically at this point sell about how many salads? 1,000. 1,000 of our salads. There's about five salads that we sell a week. And we also have soups. As you know, you don't really make much money from food because the profit margin is very low. And but, you know, it's for me, that's part of my mission. So it doesn't really. As long as we can pay our bills, I'm satisfied. But I want to make our community healthy. And there are people who walk up to us in restaurants in Cleveland that tell us, you know, I really depend on your salad. And because it's just labor intensive to make a salad and there's like our salads most popular salad has about 13 superfoods in there. So if you were to buy 13 items in the grocery store, you're going to have a lot of waste. But if you buy a prepared salad that was well thought out, I think it saves you money to do that. So I know I'm not supposed to be plugging any commercial entity, but this one, I just feel like this is our contribution to our community for health. Thank you for letting me plug this.

You're my guest. You can plug whatever you want. This is my shift.

Thank you.

All right, now, what's your URL your website so they can find you if they want to learn more.

Yes, it's fanclinic.com it's www.fanclinic.com all one word fangclinic.com we'll put it in the.

Show notes as well so everything will be there available. I want to thank you again for coming on the show and I look forward to our next chat.

That's great. Thank you for the invitation. I thoroughly enjoyed being with you on this and was so amazed that you have the same similar philosophy that I have. And I don't feel so alone anymore since since food, nutrition, genetics was never part of our never a part of our medical education.

Unfortunately it wasn't. Yes.