Do You Need a Lift After Explant? Surgeon Explains Scars & Healing

So what happens to the nipple and areolar complex during explant? I want to go over the incisions, the nipple position, and scar planning. I'm Dr. Whitfield. So let's get rolling tonight. We want to answer— I get these questions all the time from women who come see me and we have calls with, and they're nervous to ask if they remove the implants and do a lift, do I actually remove the nipple complex and take it off and on? And I don't. In the explant and lift procedures I perform, the answer is obviously, as I just alluded to, no, we don't do that. I keep the nipple areolar complex attached to the tissue source and reposition it rather than removing it and putting it back on. That is my standard way I preserve the blood supply to it and minimize risk to sensation changes that way. We want to explain how we go through this decision-making process, and this is for education only. Everybody needs to be seen if they're going to get a procedure done like this. I can't determine that from a live stream. So we gotta just clarify how we're going to speak about it. The nipple areolar complex is the pigmented central structure. The areola, like I said, is pigmented with the skin around it. There's varying sizes and shapes. Now, we'll just refer to that as the NAC or the nipple areolar complex. People sometimes use the phrase nipple core, but the NAC or the NAC or the nipple areolar complex is what we're going to refer to it as. So, the complex for me personally to avoid any worry is never disconnected from its blood supply, and that allows us to avoid problems with both wound healing and sensation and should give us more favorable scar patterns. The external scar obviously is not the, uh, entire picture when you look at it. That's what you visually see outside versus What we're actually doing. The scar tells you really where the skin excision was performed. It then allows us a window to open and then divide tissues in order to get to the anterior surface of the capsule. And so once we're in that area, the thickness of the tissues and the surrounding circulation, of course, the implant capsule, becomes visible to us who are operating, and then we can start clearing the tissues off those areas. Once again, you're trying to preserve really all of the soft tissue, breast tissue, the fatty tissue, as much as possible around the scar tissue that is around the surface of the implant, which can be typically 1 millimeter to 2 millimeters thick. So, I think it helps to think of the nipple-areolar complex as part of this entire 3-dimensional structure if you want to think of it the way we view it in the operating room. It's not something that's like a sticker that comes off and on the skin. Its position is obviously very visible on the surface, but its circulation, nervous supply, tissue attachments continue below the surface. And, as a surgeon, when I'm planning the lift, It's not simply cutting a circle around it and just kind of moving it or popping it, like I said, off and on. We want everything in continuity, and that's also why photographs don't completely answer questions. You can certainly have some thoughts about them, but it doesn't show you the skin quality, obviously the amount of breast tissue, especially in a case where you're doing an explant, and you can't Because of that, assess tissue thickness. You can't have any idea about the underlying scar tissue typically. You can see obvious like capsular contractures sometimes if they're really significant. So I do visualize those a lot in 2-dimensional photography. But all those details require history, exams, sometimes imaging. Just to be complete. So now we're going to talk about the almost how we kind of parse things out, right? So everybody can always have an explant alone and do absolutely no lift. That is their prerogative. We simply explain what opportunities exist given each patient tissue characteristics. An explant is meant in our practice to remove the scar tissue and the implant, and we want to do that intact as much as possible because we've shown that 29% have bacterial contamination. So we try always to remove the tissue. We want to remove that signaling from potential either biofilm or debris in the pocket to the breast tissue and surrounding tissues to decrease what we consider is happening at the B-cell, T-cell, plasma cell, and mast cell levels. So when we're doing the lift, we remove excess skin, preserve breast tissue, which allows us to reshape the tissues themselves, redrape the remaining skin, and that helps us in addition reposition the nipple areolar complex. Fat transfer in my practice has another role, which is adding volume back. When we're taking volume out. So it's never going to be a 1-to-1 procedure. So if you're taking out a device of any amount, you're never going to typically put back that same amount of volume in fat. And it's not 1-to-1 anyway. The densities are very different and they do not go in the same places. Where you take an implant out of is a pocket created by placement of a device. That is never where I put fat back. Fat belongs beneath the skin, above the breast tissue in the fatty layer. Now, what determines whether someone may want or need a lift after explant is obviously going to be different from case to case. We look at the nipple position. We look at the volume of tissues, the distribution, the size and position of their existing implants. There are obviously skin quality, the stretch of the skin. Are there preexisting asymmetries side to side, which normally are either in volume Or skin or breast or all of them. Any previous incisions, you know, skin stretch or looseness usually follow suit with pregnancies or nursing history or changes in weight. And those all have to be accounted for. We also ask, you know, obviously each patient how they feel about scarring and indicate where the scars will be, either around the circle, down the front. Underneath, or a combination of those. Now, some patients have enough skin recoil and acceptable nipple position not to need any kind of lifting procedure, and those patients are always obviously just like anybody available to just do explant alone. The the kind of desire to remove the device, heal, and allow the tissues to settle is always within everybody's. Own decision-making process. All we provide is the information so you can make a really, uh, what you want to consider is the best informed decision. So in patients who have really, really low set nipple position, they are obviously maybe more concerned about it right off the front, and they will bring it up to me and ask, hey, you know, I'm really worried about this. Is this going to get worse? And usually when you take volume out Obviously the tissues will settle lower, sometimes up to a couple centimeters or over an inch lower. And so that can be something that you have to obviously upfront help explain to the patients. And we have general examples and they're not recommendations for any individual. They're just how we think about it conceptually. If someone has a relatively small implant, limited skin stretch, and a nipple position that's already good, then obviously they typically don't need a lift. They wouldn't want a lift. And if there is confusion about it, we'll just explain that so they can better make an informed decision. If someone has a progressively larger implant or more stretched-out skin or a nipple areolar complex that's sitting well below the fold, then removing the implant in that position changes the characteristics of both volume and skin, and then the nipple position can suffer and become lower as well. So those patients typically may require more vertical lifting. Third, someone who has thin tissues, several old scars, asymmetry, and uncertainty about volume. That may require very, very careful consideration and staging if necessary. We don't create a wound healing. Problem. So once again, all the things are always the same in terms of what we're trying to do is we always want to help, but we want to do it in the safest possible manner. So we can talk about our access incisions, and one common route is through the fold, of course. So when I'm doing explants, especially the first couple hundred I did, I routinely went through the bottom of the breast and just did the explant procedure. Now, That gives you direct access to the implant and the capsule. And most patients, especially in the United States, have had their procedure through the inframammary fold position or beneath. And so that usually provides adequate access. Another route may involve incision around the areola with the vertical extension. This is done Probably more often in my practice because I deal with patients who have typically gone through pregnancies, had children, and/or had other operations with or without weight loss. And so the skin needs to be adjusted, and that leads us to use the vertical incision many times. I will add separately at that time, depending on the base or the bottom of the breast, Especially if it's really stretched out, some skin excision there. I rarely, uh, perform an anchor-type incision. It's really uncommon because people get compromised blood flow in those positions, and I don't ever do that in combination with a fat transfer. Um, those horizontal components, you know, for patients who've had bottoming out or skin stretch of the lower pole, That becomes important for them not to develop as many stair-step deformities. Those can be managed under local later if necessary. And no scar is invisible. Obviously, they fade with time. It takes typically the— we'll give it a year and let things fade. And when areolar scars, the circular scar is healing, we always make it circular, but then— The healing is different because of the movement of the shoulder and the chest, and those will pull and tug on the scars in a different— we call it a vector, but just how you move your arm around affects it. So a vertical or a fold scar can heal differently from one side to another because of our hand dominance or how much work we're doing on a side. And scar behavior is individual. It's not equal on each side. Every side is going to be different. That's very hard for everybody to understand. But if you think about it, many people start out asymmetric, and having breast augmentation does not make them symmetric. And having explant surgery cannot make you symmetric. We can do things to help offset some of that with adjusting the skin and/or adding volume. Here is a key point too about the nipple and areola. In the procedures I perform, the nipple areolar complex, like I said before, always remains attached. We do a de-epithelialization procedure, which is— I try to explain it like it's removing the top layer of skin, like you're peeling a vegetable. You don't want to be deep because that will injure the blood supply, compromise the sensation. So once again, we're not removing it and then sewing it back on. That's an entirely different procedure. We are not doing that in these cases. The tissue attachment is important and it's imperative to just be careful and preserve it at all costs because that's the circulation, that's the nerve supply, and we want to preserve the attachment so that it will create absolutely as little risk in this operation as possible. Obviously, the blood flow is going to be affected. We just want to minimize that and minimize any changes in sensation. Many people who come to me already have lots of trouble with sensation, and we, we don't want to ever make anything worse. Now, we are very careful and don't want to, you know, create healing problems like we already talked about. So we're careful with where we position things. How we position the scars, what we'll do at one time. And we already know, and we've discussed, the breasts will heal differently from side to side. One side will definitely stay swollen longer. That's very normal. And then every side is a little bit different anyway. Everybody obviously who who comes to see us, we talk about if somebody needs a revision of skin, that's. That's okay. Many of those are managed very simply. If someone needs a volume addition, we prefer to do that with fat transfers. So all these are obviously explained to patients. Um, now obviously we talked a little bit about, uh, position. We talked about preservation of blood supply and nervous supply for sensation. And when we're trying to change the heights, We're trying to be careful with all of those so the attachments all remain intact. And just because you're not doing a lift doesn't mean that sensation can't be altered. It can. It can't, you know, it, it's not obviously as typically risky in that situation, but it can be affected. And, you know, A more central nipple position does not guarantee perfect symmetry. We're trying to get everything improved, provide better symmetry. We definitely always have to preserve blood supply and sensation. So at the end of the game, you want a well-healed scar. And, you know, the planning helps with this. Obviously, discussion helps with this so that everybody's on the same page. And when we're trying to restore volume, Obviously, that's how we utilize fat transfers in my practice. So fat transfer may restore a select amount of volume. We typically think of a cup size. It can definitely help with any kind of contour abnormalities or transitions in contour. It can address asymmetries. So typically people are a little bit different side to side. So fat is a good tool when we're trying to provide better symmetry. I encourage everybody to go and I'll give a shout out to my patient, Jessica Brassington. She really was focused on getting that done for an explant and a natural augmentation. My patient, Jenna, is a great example of that. So in those settings, when I'm doing fat transfers without a lift, no skin removal is performed and it can't improve projection like implant can because the density is very different. Fat is not even remotely as dense as an implant, whether it's silicone or saline. Saline is the densest. So obviously we've, we've on my previous shows discussed how to improve and decrease risk of fat resorption, fat necrosis, oil cysts, other problems. We don't overgraft ever. We try to be extremely respectful of how much graft we're putting in. We try to prepare each patient very, very well prior to the procedure to improve outcomes and maintain a high higher amount of the fat transfers. When we harvest fat, we're very specific about that. We use very specific donor site areas. And, you know, if we are doing cases where we're going to remove fat, we'll always offer skin tightening because we're not getting tighter as we get older. So we know that, we offer that, it can be done simultaneously, no additional incisions are made. All the same openings that used for fat harvest can be used for skin tightening. So, depending on what series of steps someone needs to take and what state of health they start in, that dictates a lot of what we're describing. We don't ever create plans for patients who really would benefit most from just improving their health first and foremost. Had a call with a patient today who we look forward to taking care of very soon. Has got a lot of problems, and their plate is already very, very full. They would be best served to have their procedure done in terms of explant, whether without a lift, and then get healthier and come back for a fat transfer later. End of story. As many of those as I can do simultaneously, I'm happy to, but this case I had today is definitely not one of those. For some patients, as I just mentioned, the staged approach is going to serve them better, and that's what we always want to do. So, and obviously waiting is obviously not doing anything. We have an entire functional medicine team that works with our patients over the course of a year, preparing them, helping them with certain either genetic detox issues, supplementation issues, binders, things to really help them. We already have a very comprehensive program via my book, The Sharp Method, that we employ for all of our patients, and we have our providers who work with them on that during the course of the year after the procedure. Um, you know, the, the prep phase is extremely important to me. It's, it's really how I've changed and, uh, adapted my practice. And I feel like having, you know, as much information about their history of where they've lived, where they've worked, where they traveled to, in addition to How their state of health is now, what workups have they done, in addition to what implant type do they have in? Is it smooth? Is it textured? Is it above the muscle? Is it behind the muscle? Have they had more than one procedure? Have they had other lift procedures? Have they had problems with weight gain, weight loss? Have they had pregnancies and breastfed? Have they had any other problems that would compromise them from a wound healing standpoint, or do they take medications or have habits that would compromise them? Have they had any imaging? So a patient needs to disclose all of the, obviously, things that they can remember. Sometimes we have to prompt them 'cause a lot of our patients have neural inflammation, they have brain fog, they have trouble remembering some of these things. But that's how we get our information to make plans. Recovery is for us, you know, one of the, I think, big differentiators for us. And we have all these treatment modalities. In office, including hyperbaric oxygen therapy, including the Human Regenerator, Flopresso from New Zealand, red light therapy, NanoVi therapy. And all of this is meant to help us really give our patients a head start on recovery. We want there to be, um, you know, as, as easy a recovery as possible. You know, recovery for us is, you know, as much as I try to give everybody A very standardized approach. It's all very individualized in terms of how patients can really stack their nutrition, supplementation, proper sleep hygiene, and rinse and repeat all those because swelling lasts longer, bruising lasts longer, and that leads to kind of other issues. So you really gotta ramp up the things I just said in your program, the way we run it. To get the swelling to go down quicker, to really help yourself get on the right track with healing. That decreases pain; it decreases problems with drainage. It really gets you on the right track quicker. And scar planning—we're always like going over this so that patients understand. Anytime we create a scar, it's going to take a period of time to. To fade, but it's going to be a visible reminder of everything we need to do. And so we really try to go over this carefully so everybody's on the same page. And we need the access to do the procedure regardless. And the thing we're always going to do is the safest approach for the patients. And we always, once again, confirm all those Uh, where is the scar going to be? What's the access? What are we— what are the goals of this? How is this going to help us? And if there's a patient who's uncomfortable with having a lift, well, then we defer it. I don't encourage anybody to have something that they're not comfortable with. And, uh, I try to explain always how these previous scars can affect planning. Um, and those are just like our main kind of thoughts and And takeaways from how we approach this with our patients. You know, like in closing, I would say an explant always can be done without a lift. No one has to have a lift. What's important is the reasons why someone would want to have a lift. And then how does that help them? What does it do? Is it going to serve them? Does it align with what they want to have? We obviously have discussed this ad nauseam, but we're going to say it again. We do not ever remove the nipple complex in this operation and then sew it back on. It stays intact throughout the entire procedure. Third, obviously there's going to be a visible scar pattern if we're doing a lift. If we're going underneath and taking the, the tissues out, everything will be hidden underneath. And the more tissue you have, the more, more well hidden that will be. And whether you're doing a periareolar or a circle-type lift, a vertical lift, a combination, we obviously want everybody's scarring to be the best as it can be, thinnest possible scar, least visibility. Fat transfer for me adds volume but never projection. It does not do that. It is not an implant. It doesn't have the density to push out and project, so it's not going to improve nipple position, and it's not going to always fill out skin excess sensation changes. We really try to avoid these by being super careful around the areola. They still can happen. Super rare in our practice, but it can happen. For my patients wanting everything done at one time, explant. Fat transfer with or without a lift. Obviously we gatekeep that. We want everybody to be in the best possible position I can get them in. So we have a really aggressive upfront prep program. We look at all your toxicity, all your gut health, all your food sensitivities. We really want to know how you're doing and how much balance you have overall to provide that service for you, because we think that's a very strong option for many patients to really get this transition and transformation they want. Um, I hope this discussion has helped everybody. Make sure if you're interested in getting a discovery call, go to the links in the bios or go to drrobertwhitfield.com, book a free discovery call with my team. You can go into the circle, drrobscircle.com/live. I'll put it in the, uh, chats. We're going to go into the circle, we'll have a live Q&A, and then we're going to call it Tonight I have to travel. I'm speaking tomorrow at a meeting out of town, so I got to shut it down tonight. But what I will do is put this in. It's forward slash live, not backslash. Sorry. All right. We've got to put this in everywhere so everybody can see it and go to the circle once again. If you need to get in and see us, You got to go visit one of the sites. Every site has all the information, and we'll be happy to help you as much as we can. Once again, today I had a really, uh, a patient who's went and tried everything literally around the world, and they're gonna come and, and we're gonna take care of them here in Austin, Texas. So I've operated on patients from I think 40 states, from South America, Central America, Mexico, Canada, Asia, and Europe. So we're happy to help everybody. We're all set up to do that. So once again, we're going to go to the circle, putting this in everybody's comments now. It's drrobscircle.com/live and. If I didn't type it in right, then you heard me say it. All right, I think I've done everything. And all right, what do we got here? Oh, Jess, I don't use drains because I don't like them. I find them to be just a thing from a time where we were all taught to use them. I try to prepare my patients really aggressively and get them in and out of the injury phase fast. So the cortisol goes down, the fluid that's being built up goes down. We leverage the body's own lymphatic system, which is far more effective than drains. And that in combination with diet, rest, upgrading the nutrition like we talked about and really concentrating, you don't need drains. Okay, everybody. Can everybody get into the circle? Because we're gonna go in there. And I'm going to expand my view. I'm going to let everybody come in. All right, everybody hop into the circle or go book a discovery call or go sign up for the circle, but we're going to go in there and have a live Q&A. I have a few questions here. Um, oh, I'm sorry to see this, Lisa. Um, yeah, did you have an implant-based reconstruction and fat grafting or a deep flap and fat grafting? Let me just ask her that question. Oh, you did say you got implants. Okay. Uh, yeah, I mean, it's harder to do that. There might be less and less space to do it. That's probably part of the issue. So that can be, um, a more difficult case, um, to be honest. Excuse me, I got an itchy nose. All right, I have Nicole— I'm sorry, I have Nancy and I have Danielle. Who else is in the circle? All right, let's get this shut down. And now, all right, any other questions on Instagram before I take off? All right, if y'all need to get set up, then, um, go into my Instagram bio and hit the new link. It'll show you if you're traveling what you need to do. If you need to get a discovery call, it'll show you what to do. Um, whatever you need, it's all there. And then of course you can get to the website and have full explanation information. All right, take care. Oh. Hi, Jolene from Idaho. Awesome. Thank you for hopping on. Oh, Keiko's on. Keiko, am I saying it wrong phonetically? Because I don't know how to say your name. Keiko or Keiko? I don't know. Hi, Cassandra. Hi, Denise. Thank you all for hopping on. Hi, Nancy. All right, fire away. Oh my gosh. Y'all have to spread the word. We are, um, opening up the schedule. We're going to add more days for operations. So anybody who really needs to get taken care of for the end of the year, we're going to be able to do that. So I need y'all to share with friends and family who may be experiencing problems, um, so we can get everybody taken care of. I know people have been trying to make this, uh, more difficult. Denise, no, we don't remove nipples during the lift. Nobody should do that. That is, um, it's just the point of, of confusion. What you do is think of when you peel a vegetable, you remove the top layer of the vegetable skin off to get to the underlying surface. We do that in the operating room, is— and the way we do it is very careful to preserve the blood flow in what's called the dermal layer. So, you take the very top layer of the skin off, which is the dead layer that prevents us from dehydration, desiccation, and then the blood flows in the dermal layer, which is deeper. And, you preserve that always. Thanks, Kiko. If I remember right, what is it, 6:30 in the morning there, Kiko, or is it 7:30 or 8:30 in the morning? It's probably Early morning for you. All right, for everybody on, I need y'all to put a question in for me. I've had a long day and I'm excited to have everybody on. I just want some good questions so we can help everybody out who's got questions. That is my, my big ask for my time. And then also, if you would just share with somebody who needs help, that would be great. It's been very hard for us to get the word out. I don't know exactly all the reasons why. It's really frustrating to me, but we just keep doing and moving forward as best we can, but it's definitely not been made easy lately. All right. Nobody has a question. Oh, you guys, come on. Oh, yeah. It's 8:30. That's right. I checked that last time. What if you're not sure if you need a lift and then during surgery it appears it would help? Yeah, I, I'm experienced and been doing this for 30 years. I won't let you get that far. I'll make sure you understand all of those things well before the operating room. You actually can't do that in the operating room without informed consent. That is part of the consent process, and we don't ever do that without discussion pre-op. I got to give a shout out to 3 people on TikTok: Angelina, Laurel, and KS. They watched for 32 minutes. That's pretty aggressive. It's pretty awesome. Cassandra says, I had my implants put in through the nipple areolar complex. The doctor told me it would not affect breastfeeding. My first 2 kids prior to implants, I was able to produce a lot of milk, and after the implants, I wasn't able To produce enough milk to just breastfeed. Is it possible the surgery did in fact affect my ability to produce milk and breastfeed? I think that's a hard one, Cassandra, because a lot of studies have been done about this, especially with breast reductions, and they haven't shown that to be a problem. Sometimes it's just a function of the ability to produce enough. And I'm sorry, is it the same? Um, I guess where it says member, I see the same person. Okay. I went to a surgeon near me in SoCal and it's up to me, but I'm not sure. Okay. Um, you know, that's something we could help with, of course, and then maybe just give you, um, our thoughts about it. That's absolutely, uh, We're happy to help with that. We could do that in a consultative, you know, process to give you a bit more, um, maybe a better idea, if that helps you. Okay, Denise, if that helps you, I mean, that's something we could help, uh, provide. I do a fair number of second opinions, so that's totally fine. I don't know what I did. Yeah, Denise, you can go to the link either, um, on the bottom of my home page for the circle, or you could just go to the website or Let me see. I can just pull up the discovery call link. Hold on a second. We'll make this easy for you. I've got so many windows open on my computer. That's the problem. Sorry about that. All right. Let me see here. Kind of scared myself. I just opened my computer window and I saw myself streaming and it's okay. I will get you the correct link here in a moment. Maybe. I'm trying. All right. I'm gonna put— uh, hold on a second. I'll put the link in the chat and that way you can do it. All right, hold on a second. There we go. Okay. My breasts have several scatching after Enbloc and I cry every day. I have nerve pain on the nipple. Do you think I could have pain again? So, Kiko, there's a medication, um, that's called gabapentin or pregabalin for nerve pain. That's what you should ask for to help with nerve pain, like scratching or itching or feeling like things are crawling on you or pins and needles, and that will help. All right, these are good questions tonight. Did I get everybody's Jolene, do you have a question? I appreciate you hopping on. My friends from Boise were just here. I gave a talk at Cellcore in Boise at their meeting recently, or I'm sorry, not recently, 2 years ago. I didn't go this year. I keep doing stuff on the different channels, and I tell you, the one that baffles me is TikTok, but I'm going to get better at it. I will, I will get better. It will definitely take me time, but I will get better. Well, when they're under the muscle, Cassandra, it depends on the amount of breast tissue. So if you have a really low-set breast, a lot of times I'll do the lollipop lift to help reshape and lift that breast, especially if it's wider and low-set. If it's not and you don't need a lift, I'll do it through the bottom. I don't do them through the areola That tends to have more scarring difficulties. So those are the 2 most common routes. All right, who else do we have? Miss Danielle's being quiet. There's Miss Nancy. Is that all we have on? I know we have more than 3 people. I find it confusing, like on my chat, it doesn't tell me all the people. It's very strange. So, so textured implants have, um, Allergan textured implants are more closely associated with more, um, problems with breast implant-associated cancers, but it's a really low percentage. I did a talk about this, uh, I think it was 2 weeks ago maybe, and then, um What I've noticed personally is people seem to have more symptoms with textured implants, and some of them are pretty, uh, inflamed. Um, short of that, about the same. Kiko, you have cold intolerance. Um, you feel pain when you touch cold stuff. Okay, that is a little— that's different. I don't know exactly what's causing that. We're gonna take a few more questions and then we're gonna Close it down for tonight. I gotta get ready and fly out of town in the morning. So everybody can and should take advantage if they're trying to get on this schedule. Use that link. If you want us to help you with detox, then we do and can get you hooked up with my team to run it remotely. If you have friends or family who are explanting elsewhere, that's totally fine. We totally understand that. Not everybody can come to us, obviously, because of logistics and family and work and all the things. But, you can still work with our detox team headed by Chelsea and Gina. I'll be speaking with Chelsea tomorrow afternoon in San Diego at the Hicks Conference in San Diego at the Hyatt. So, um, yeah, thank you all for hopping on tonight. Have a great night.