Dr. Alan González on Breast Implant Risks, Safe Explant & Fat Transfer | Dr. Robert Whitfield, MD

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Guest on the show, Dr. Alan Gonzalez, who is a leading plastic surgeon in Colombia and Latin America with 25 years of experience performing over 20,000 aesthetic and procedures. Renowned for pioneering cutting edge techniques, he prioritizes natural results with novel scarring and swift recovery. A dedicated educator, he advises major media outlets and speaks at global conferences, blending his expertise with a vision of beauty and well being. His current research focuses on the link between Asia syndrome breast implants, collaborating with multidisciplinary teams. A member of prestigious societies, ISAPs, ASAPs and FACs, he also serves as scientific director of Care Me 360 Institute. Welcome to the show today, Dr. Alan Gonzalez. I have a special guest today, Dr. Alan Gonzalez from Columbia who happens to be in New York and he's, he's taking time out of his schedule to speak with us today. He has a long history with aesthetic surgery, reconstructive surgery, and he's really put forth over the last six years quite a bit of effort in education of patients and plastic surgeons regarding breast implant illness, probably explant surgery as well. And so welcome to the show, Dr. Gonzalez.

Oh, Dr. Whitfield, thanks for inviting me for this very important program and I think it's a very good opportunity to talk about what happened in Colombia with the plastic surgery, how I can fill these devices and the results for the patients during the time. And I think it's very important for the people to understand what happened in this moment with the implants, with the helplessness of the people.

Right. I think we were talking a little bit offline about, you know, training and I'll chime in on how I, you know, got involved in this. I mean I was doing microsurgery and doing D flap reconstruction for breast cancer patients. And then like you would imagine, I have, I had patients referred to me that had device problems, so capture contracture, radiation, injured tissues, they would have problems with scarring. And I'm sure you experienced this mechanical problems where they couldn't breathe as well or they had difficulty with pain just from scarring. So I would take all the scar tissue and device out and do an autologous reconstruction, usually the patient's own tissue. And of course that works to one restore blood flow to the area. I mean principally that's how I always thought about it. So whether it was radiation injury or a device related scarring phenomenon, that was always nice to do an autologous transplant of tissue, revascularize the area. And those patients you deformly did better as you would imagine. And that was my introduction to, you know, implant problems. I did not characterize anything as breast implant illness back then. I just knew some patients had responses that I couldn't explain. It made sense to me that some people were sensitive to the devices. Of course that makes sense because some people can't even wear certain types of earrings. So, you know, everybody's got different sensitivity patterns. You know, fast forward now the last, you know, you've spent the last six years, you know, I kind of became more problem wear in 2016 from a cancer patient. But nonetheless, doesn't matter how long we've been doing this, we all, you know, both you and I now recognize the, you know, problems associated with this and the chronic inflammatory, inflammatory symptoms, the poly, you know, autoimmunity problems that patients face, the, the different challenges they face. So maybe describe to the audience, you know, when you became problem aware of this and, and then started working on it because you're curious about the problem. Just like Kaya.

Yes. Well, you know, Amplify from 25 years ago. I studied medicine in Bogota in Colombia, is the capital of Colombia. And then I made my studies in plastic surgery in Cuba. Okay. In 2000 I returned to Colombia and all the time in Colombia during my practice in these 25 years in the first time say, okay, the implants is the perfect solution for the breast surgery. For everybody knows the breast is one of the most important parts in the women's because it depends everything. The auto perception and the mirror, the sexuality, the clothes, everything she, she thinks about it. And during this life has many, many changes. And this is all of us now is the most, one of the most important surgeries in plastic surgery. With the lipo is the number one procedure. And during my practice I put implants for 1800 patients in 22 years. But always I think, okay, it's biocompatible. My patients never will have any problem. But. And they say, hey, don't worry, doctor, it is perfect for the patients. You don't have any problem. The patient have the wellness always perfect. But when described the anaplastic lymphoma and when described this squamocellular cancer, I say, hey, no, it's not safe here we have a problem. And I start to study the problem and understand about the immunological problem. And I start to understand the chronic inflammation and I start to see the patients with many, many problems, but they don't know what happened. Many symptoms, many situations. You say, okay, yes, the contracture. We see many patients almost, I think almost 70 to 80% of patients has contract capsular Contracture. And they say, okay, I feel pain, my shape change, I don't feel good. Okay, come on, we replace the implants. Always we think about that. But in this new reality, we know about the immunological response, we know about the chronic inflammation, we know about the relation with the symptoms. We start to say, okay, now, come on, take it out the implants. But everybody has afraid about the results. Oh, no, you will see like a man, you will see with a very big deformities. No, don't do this, please. And I say, no, it's not real. We can make it. And we, at the same time, we can make a reconstruction of the breast. And patient can feel safe after the surgery. Because everybody thinks, oh, reconstruction deformity. I say to my patient, now, aesthetic surgery, you have a dream and you go to the doctor and he made the dream for you. But in reconstruction, you have a problem, you go to the doctor and the doctor made the best work for you. And you have the less scar, the less problem in the future. And in this kind of surgery, it's very important for our patients understand this is a very big possibility to recover the wellness. Because many patients are very happy, are very happy with the volume. And when I talk with them, they say, doctor, I feel safe with the volume. I don't, it doesn't matter about the shape. I put my bra and I feel perfect. But after the surgery, they say, no, doctor, I was wrong, really. I feel safe with the shape and doesn't matter the volume. I'm feel very good. And I say to my colleagues, I say, what happened? Come to the, come to the past. Not, not to the problem. The past. All the breast surges are without implants. Now all the surges is with implants. I think it's not necessarily the implants for all the breast surgeries and mastopexy in breast reduction, in reconstruction, in breast augmentation, all the topics I think is not necessary. And patients say, oh, perfect business for the doctors first and then make the plantation. I say, no, it's not the business. This is our profession. We think about the wellness of the people. And we don't know what happened with the implants years ago. Now we know. And in the past three years, I never put any implants for my patients. And in the future, never we use the implants and I start to make a very important education for the patient. And I think, doctor, this is a new problem. This is a new situation. Everybody say, hey, the scientific articles and the scientific publications, you can say, you can say that I say no, this is a new problem. It's necessary, we understand, have a big data and start to make our own publications for all the community. That said, I think it's very, very, very beautiful situation because we can help many people. Millions of Women's has implants. Isab says almost 50 million around the world have has implants. Last year, 2 millions of people. I think it's a very big problem like a pandemia because we have many patients very happy but with symptoms. They don't know what happened and they lose day by day the wellness. And it's very important to understand for all the people. I think it's not good people and bad people. Good people, you don't use implants. Bad people, you use implants. Now it's real. You can choice. But the most important thing is, you know, what happened if you use implant.

Yeah. I want to go back to something you said in particular about capshock and track stroke, because I was reviewing a paper and I was very interested in, you know, and maybe you can discuss in your training how it was explained. But I trained in plastic surgery from 02 to 04 and in surgery from 96 to 02. And a lot of things changed during that time. Laparoscopy came into the, you know, standard of care. Lumpectomine sentinel lymph node came became the standard of care for breast surgery. We no longer did modified radicals. That all happened kind of as I was training. And it was just assumed that you were going to put a device behind the muscle. And you know, I was reading a historical paper and it was reviewing 20 years of breast augmentation from 1962, when Cronin injury placed the first set of implants in Houston, Texas, and kind of recounting what they had gone through. And at that point, to your point, almost 75% of the patients had capture contractures per just studies that were being reported observationally, of course. And for everybody listening, that's just an exam where Dr. Gonzales and I feel like the device feels firm. Patient reports their feelings of tenderness, pain, you know, all these things. And it's very subjective. I think you would agree. I just found it, you know. Okay, so the reason devices got placed behind the muscle was really to avoid capsule contracture. And I don't think, and you may comment on this, it doesn't really avoid capture contracture. It just makes it less obvious to both the patient and the examiner, to me, because many times when I do explants, I find contractures that, you know, on exam don't feel that way because there's too much tissue between the examiner's hands and the device and its scar tissue capsule. Because it just struck me when I read the paper, I'm like, oh, okay, that makes a lot of sense. Because when I take these things out many times it's a struggle. Not because it's hard for me to do, but because the thing is so tightly wrapped around the device. And I'm sure you probably will say the same thing. Thickness of capsules is not really so much the sine quinon in this. I mean, it can be tight and be really thin versus something that can be, you know, from the 70s and 80s, which is just calcified and hard as a rock. Those are very different problems. But I agree with you. Like, the capture contracture is a really underappreciated phenomenon because these devices are retropectoral behind the muscle in the majority of the cases done, certainly in the United States, by far. And it makes complications, you know, or how do you want to. Not complications. Like it creates this fear that something's going to happen to the chest when someone like you or I goes to explant, you know, the materials. And I mean, my gosh, I mean, I used to replace chest wall for cancer patients. There's nothing about this operation that, to me that's complicated. There's nothing unsafe about the operation. To your point, I'm sure we could all do this operation very easily. And you have cases probably multiple times a week or a month that you say, why did the patient get an implant when they simply could have had a mastopexy or a breast lift and they were told one thing, when in reality it could have been an entirely different procedure with similar results without any device related complication. Because everybody who gets a device, hip, knee, breast, dental, cardiac, neurologic, is susceptible to an infection. You know, whether it's a bacteremia from a uti, a cold, GI problem, skin infection. You know, you're old enough and I'm old enough. I remember listening to mechanical heart valves and hearing the horror stories of people getting endocarditis and dying. So, like, everybody knows these are problems, but I don't think, you know, from my perspective, it's dealt with kind of how we would. For the heart valve patient, right? Those patients had standing prescriptions. They were taken care of a very specific way by the GI guys or anybody who was going to instrument them because they knew if they made them bacteremic, their chance of getting endocarditis and dying was Very high. I don't think we do the breast patient.

Well, I think the situation is we never understand what the patients feel. And when we put the implants in the plane, okay, sub glandular, facial, submuscular. We don't think about what she can feel after the surgery. During the arms movements and the pain of the breast, the pain of the chest pain, dorsal pain, cervical pain. Many pains are mechanicals associated with surgery. But she looks day by day, feel normally, normally, but she feel pain. And she say, I'm happy, but I feel pain. Okay, but is the first problem is necessary to understand what we change in the anatomical situation of the chest during the surgery. In this moment, I have an experience like 1500 patients in the last five years. All the patients has a capsular tissue and more than 80% has capsular contraction. Okay, different degrees. And I agree with you, it's very hard for me. Only we touch the breast. I say, oh, you are a first degree, second degree. No, when we make the explanation, you we know, okay, she has a very big contraction. She has a normal contraction or she doesn't have contraction. But what is the problem? I said for my patients, all the patients, all the patients has immunological response and chronic inflammation. 24, 7. Okay, you don't feel symptoms. Oh, perfect, Congratulations. But maybe you make a normalization of your symptoms. You think, oh, the eating process is normally, I have a headache, normally I am, I have fatigue, normally I don't remember the things. Normally I have a pain in my joints. This is normal in the aging process. I say to my patient, no, this is not normal. The normal situation is you have the wellness during the aging process, but no sickness or symptoms. And this is very important because many patients, things with the implants don't. Don't have any problem. And really is you have always a problem because you have an immunological response and a chronic inflammation. Well, what happened with the reconstruction? Well, when you, when you make a reconstruction, you say, well, it's a very, very hard surgery because a very big movement of the tissue and we, we make a very big and very aggressive movements for the tissue. But we can make the reconstruction with the patient's breast tissue. After you take out the implants, what's the problem? You need experience, but the problem, you need to know how to do it. I think breast surgery is one of the most difficult surgeries in plastic surgery. Because we need make a reconstruction in 3D. We need to put the upper pole and the lower pole in the perfect position. The areolar nipple complex in the perfect situation and the less scar possible. This is a very big and very hard surgery. But many people say, oh, no, it's so easy. You just take out the implant and you can make a capsulectomy or not. No, for all my patients, I think it's mandatory to make a total capsulectomy. And I think, Dr. Wilfeld, at the same time, it's very important to make the differentiation about the total capsulectomy versus unblocked capsulectomy, because many people say, do you do my capsulectomy on block? Dr. I say, no, you don't have anaplastic lymphoma. You don't have cancer. Total capsulectomy, always. You take out the capsular tissue and you can make included or not included, total capsulectomy included when you have the implant inside of the capsular tissue. But in many patients, in my case, well, I say have a very important bending to the ribs, and I prefer first take out the implants and under direct vision I can make the surgery and never has a pneumothorax or something like that. What do you think about this, Dr. Whitfield?

Yeah, once again, this ends up being the conversation because of one certainly there's a perception that everything has to be done that way. Now, with your experience or with my experience, when we operate, you know, when something's abnormal. And so I had a patient who obviously had an abnormality from an Allergan 410 implant. No seroma, none. Grade 4 capture contracture, both sides. So that's very firm, very obvious changes. And the patient had pain. And so but when I started operating and I got onto the capture tissue, the capsule appeared abnormal. And so for everybody listening, that's not going to make a lot of sense to you. But for Dr. Gonzalez and I, he knows exactly what I mean. It's not a normal capsule. And if you operated around a cancer environment long enough, you know what I mean? Cancer is, you know it when you see it. And I immediately, I was like, oh, this is going to come back and it's going to be abnormal. And I told my team, I told the husband, you know, I took all this out. I'm 100% convinced this is going to get a call from the pathologist that it's not normal. Now, it's not necessarily alcl, but I don't know what it is. I can just tell you it is not normal. Having done in my career, you know, thousands of sarcomas and head neck cancers and breast cancers, I mean, it's not normal. So about you know, three, four days went by and I got the phone call. You know, my office says, hey, the pathologist is on the phone. They want to talk to you. I'm like, okay. So I, you know, I get on the phone and I'm like, yeah, I presume you think this is a lymphoma from a breast implant. And they're like, yeah, but we can't characterize it. It's not staining the correct way. And so I was like, well, that's great. So, you know, once again, Dr. Gonzalez and I both know, like, when things are abnormal, they're abnormal and they're bothersome to us because we've seen enough over a number of years to know that they're abnormal. And of course, in that setting, I did an on block resection, but it was much easier because one, it was very firm. And he knows, like I do when it's firm, it's a little bit easier for us to complete the resection in a way and move it around and just adjust it to, to get the best angles and take it off the, the surfaces without violating the capsule. And that's what I did in this case. And so I was 100 convinced the way it came out, the margins were going to be fine because nothing was extending. There was no extra capsular invasion. There could always be microscopic disease. But this was all contained. So I will tell you what they did with this. I won't tell you who did this, but I got a phone call and they're like, we're not going to characterize this as a breast implant associated lymphoma. We're going to call it a breast lymphoma. I'm like, it's not in the breast. You know, it's not in the breast, right, because it's inside the capsule, up against the implant. So they didn't characterize this as a lymphoma of a device. And I was like, oh, my word. So you're going to really subject a patient to surveillance, like they have a breast lymphoma when they don't? That makes no sense. And this is where I get bothered by all of these things, because, you know, this was a non anaplastic large cell lymphoma, basically was a B cell lymphoma, one of the eight in the world at that point. And I was like, okay, so, you know, when we're doing things on block, that's for a very specific indication, which is cancer. And if you don't know how to do cancer surgery, you shouldn't talk about it, Just say you're not comfortable with it and send it to somebody who is. That's my complete and, like, final statement of this stuff. Don't scare patients because you don't know what you're doing or you're not comfortable talking about it. Just send it to somebody who has the experience to take care of it. I've done like, you've done thousands of cases for cancer patients and reconstructive, you know, procedures. So I'm very comfortable all over the body. I'm not going to get into somebody's chest. And if I do, for whatever reason, I know how to take care of it. And that's just the nature of it. Right? You either have a skill set and you're comfortable or you don't. And that's fine. You just don't scare patients. You don't need to scare a patient because you're not comfortable. Just say you're not comfortable with it, you don't want to do it, and send it to Dr. Gonzalez or send it to me. And that is fine. That's 100% professional, collegial. That's great. Just don't scare patients. And, you know, the rest of it. I agree with you. Doing a total capsulectomy in every case. I just published a paper last year about biofilm. I mean, a third of them basically have biofilm in our study. So, of course, we're always going to take everything out. That makes no sense to leave anything behind. You know, the incidence of cancer, like we know, is very low. And then this one was ridiculously low. It's eight in the world when I did it, you know, several years ago. And now they have this squamous cell carcinoma, which I don't know what you think about that. That was. That was a little shocking to me when I first saw that reported. I mean, that's, you know, for you and I, that was like a margins ulcer from a burn scar or something, you know, or a pressure sore or something like that. But that's how it was explained to me. I was like a squamous cell is just. That's really odd.

Yes. Look at. In my experience, only one patient from the 1500 patients has lymphoma. And this patient, we, you know, you. You say, I don't like this many vascular tissue, very big inflammation inside the big seroma. I don't like it. I prefer to make a more aggressive capsulectomy. And all our patients, we send the tissue for histopathological studies. All and all the capsular tissue has problems, logical cells. And for me it's impossible. The doctor says, oh no, I don't take out the capsular tissue because I can use this tissue to increase my results. When I put again implants, oh my God. I say it's impossible. We continue this practice. Sorry. The surgeons understand you like to make breast implants. Okay, perfect, do that. But now in the, in this new real situation, please take out the capsular tissue and put your implants again and explain to your patient all the topics. I think it's very important the education in these topics for everybody. But people don't want to listen. And I say if you don't want to listen, you can understand and you never know. But it's necessary for our patients. They start to study. They I don't know if you have the cases. The patients know many topics about plastic surgery, many topics about breast surgery, many topics about the cellular inflammation. I say, oh, you are like a doctor. Yes, doctor. In Google I find, I make a research, I make, I think it's perfect. But many doctors say, hey, what happened with the patients? They're coming with the diagnosis and they say us what is necessary to do? And I say it's perfect because your situation is very important. Just playing what happened, just playing what you can do and both define what is the way to make this surgery. And I think this is a new future and very interesting problem. And well, Dr. Whiffle, this is our problem because nobody wants to know the real situation is better. You say, well, we don't have any problem. My patients are always healthy. But we know in the future you will have a big problem because your patient don't know what happened in the future.

Yeah, I find it interesting that the, the discussions about augmentations or lifts or. Well, I guess we can just break it down and say if they came to a plastic surgeon with the idea that they wanted more volume and this is something again that boils down to experience. If you had a 34 year old who had two kids and breastfed them but was not happy because they had some postpartum breast involution, you know, the, the breast is not necessarily sagging, it's just kind of a little bit deflated now and they have a B cup now, I was taught all day long that's a really easy breast augmentation. But I think of it very differently now, many years into practice and I think about, well, if that person's BMI is X then they're really good fat transfer candidates and or Fat transfer, mass Pepsi, whatever. There's a lot of different options for that patient rather than just breast implant. And I had this, you know, patient, to your point, come to me recently, and they said, you know, I don't want a breast implant. I'm very convinced I don't want one. What other options are there? And they had learned a little bit about autologous fat transfer, but didn't really understand the nuances of it. But since I've been doing fat transfers since 2004 for cancer patients, it's very simple for me to, you know, talk about and walk a patient through. And being in South America, obviously, you know, autologous fat transfer has been done for ages, or buttocks, predominantly. I mean, that's been around forever now. But you don't ever hear anybody go, oh, my God, I'm not happy with my butt. Og I didn't get enough, you know, fat in my butt. But somehow the, the breast is this kind of un, ungraftable area based on somebody's opinion, where both you and I know that's very simple to do. It's not hard to do. And I'm always kind of perplexed about why it's not discussed. I know one. Technically, it requires more equipment, right? So you have to have the equipment to do it. Fine. That's an investment of either the surgery center or the surgeon. If you want to do it, you'll do it. I mean, I have all that equipment, probably like you do, so I, I can offer that service. I have thousands of cases of experience doing it, and of course it works. I mean, the patient I just described is, is just as easy to do a fat transfer. It's actually easier, less risk. I did it under local in the office, Dr. Gonzalez. So the patient just got up and left afterwards totally fine. That's. I mean, probably as good as it gets, right? I mean, easy, easy, you know, local only procedure, low risk for everything, Infection, dvt, pe, anything. Because it's only just a few access points that are 3 millimeters. And that's it. There's no device. It's all autogas. It's all your own genetic material. It's not going to get rejected. So it's like, why, why are we not discussing that a bit more? I mean, it should lead the discussion instead of being something that somebody doesn't talk about.

If you want more volume, you can do it again. Worry you want. Come on. I'm very thinner, doctor. I'm very fit. Okay, our neutralologist will explain you the new Meals and you gain five pounds and do again. But you say, a very interesting topic. When the patients come to our offices, patient don't know what want. She want to look like after the pregnancy, like. Like before the pregnancy, sorry. And she wants to see the breast again in the place, the upper pole projection, the cleavage. But she thinks, because everybody talk about this, the solution is the implants, right? You don't know. Okay, and when I talk with the patient, what do you want? Shape or volume? Doctor, I love my volume before the pregnancy and the breastfeeding. But now I don't like the volume. I say, no, you don't like the shape because your volume is the same. But it's very sagging skin. If I take out the laxative skin and make internal techniques to put in the correct position your breast tissue, you will feel the game very good. And you recover your shape, your cleavage, your upper projection. And you are very happy without implants. I say, okay, doctor, I want to do that. I think it's very important in our practice to explain all the topics for our patients. Okay, you have implants, you want implants or you have. But you have another option without implants is with fat, is with the technical flaps. You have different options, what do you want? And she can say, okay, I want to assume the risk or not, I don't want implants. Okay, I think it's very important, this little change in the practice, in our practice, explain all the topics for the patient. But if I don't know how to do breast surgery without implants, this is impossible to explain that. I say, okay, the best solution is the implants. Come on. And I think it's necessary all the doctors develop this sensibility about this topic step by step, you know, step by step. But the fat, I love the fat. But I say always for my patients. Well, I make this plantation. And in the same procedure I will make the reconstruction. But my reconstruction is only with your breast tissue. Because I want to have the result like the seeing the future, the projection and the correct position of the breast. And if she wants more volume. After six months in my practice, I make the fat grafting. Because many patients look at. We make a cut in December 2023, 1,000 patients. Only 6% of our patients put fat graft. After six months. They say, doctor, I feel very good and very safe with the shape, no matters with the volume. And this is important topic because all of us know about the resorption of the fat. All of us know about the chronic inflammation of the breast tissue and the Situation about the recovery on the healing process of the tissue after this kind of surgery. It's very hard. The competition, the fat graft and the ombre tissue for the oxygen and I think we have a very big resorption if we do at the same time. What do you think about this?

Yeah, I agree. It's a complicated situation. So we look at genetics and toxicity, burden and gut health and hormone balance. And in our post operative program, when I do simultaneous fat transfers, as I did one yesterday on a patient with a lower BMI who was going to have a really difficult aesthetic result if you didn't do something at the same time, I, I will opt to prepare them preoperatively in three to six months and then do a simultaneous transfer. And then in my office I have hyperbaric oxygen therapy and lymphatic massage, all in my office. So we offer that to all of the patients, not just the fat transfer patients. But to your point, those patients will probably derive the most benefit from that sort of treatment because you're providing a better environment for the graft. I always have the same discussion with patients about this. I mean if you are of the BMI and we'll say, you know, closer to 20, then fat transfers are always going to be easier. And if you're closer to 80 then fat transfers are always going to be more difficult because of our metabolism, our hormone balance. If you want to think of just chronologic age and all the things that are affected. I think, you know, if we all just operated on young people, life would be a lot easier for both you and I because young people are much more resilient. They just are. So of course, you know, when I do that case yesterday I did a simultaneous transfer, low BMI patient. I did a very specific technique, single sided cannulas only, you know, four. I always use fours for everything. I don't ever use a circumferential hollowed out, you know, or cannula for anybody who has a low BMI ever. Because I can't, you know, even bring myself to potentially create a contour abnormality on a patient like that because they're already very small and you're taking fat out. And so I transferred about 225 per side yesterday, which I took out a 265 and it was a poorly placed implant. I don't know if you run into this, but I find in lobby in my patients some of the worst surgical outcomes because of just technical misadventures mostly. And those patients don't have A lot of maybe their surrounding tissue structures not going to accommodate a device very easily. There's a lot of things that go into placing devices and I don't, you know, not to go into a technical discussion about it, but the device on one side was severely displaced into the axilla and inferiorly. And so, you know, it was going to create a big visual problem for this young person. So I feel compelled in those instances, whenever possible to do fat transfers and not delay them just to, to help them, you know, because they've never really had a pregnancy or breast changes. Their, you know, skin stretch is not that, that much. So you and I both know skin stretch is, is nice to have when you're going to do fat transfer. But. And I'll see that patient, you know, here in a little while in the clinic. But those are specific instances where I leverage a lot of years of work in that environment and using what we have to your point, just to help them post operatively in those situations. I always like hyperbaric oxygen for, you know, post op. And all my patients been around it for a number of years. My mentor, Bill Zamboni was a big proponent of it, published a bunch of work in the 90s and 2000s about it. And I don't think we leverage it enough, honestly.

Well, I always. And during this, during this time, I think day by day we understand more topics about this situation, this new reality. And I think it's come back to the past because you, I don't know if you remember in 1992, 94, 96 in the United States have a warning dog corning implants and many, many situations associated with the symptoms of the patients.

And.

After that return again, return again. And now we have again the problem, the same problem. I read the different articles in the papers, I say the same problem. Now we have millions of patients with the problem. That's the difference. That's a little difference. And it's necessary anybody do the work. And I think you and me and many other doctors start to understand more deeper about the problems and work together is a perfect time. Yes, for me it's very important to stay here with you because you can understand what happened in Colombia. In Colombia we had the same problem. Like around the world. Before the COVID my patients, 20% foreign patients, 80% local patients. After the COVID 80% foreign patients, 20% local patients. Why? Because we make a virtual consultation or telephonic consultation and people around the world comes to make the surgery. And I say in all the countries have the same Problem. This is like a pandemia. But it's necessary. People understand and I'm very happy. First they say, Dr. Allen say always lie about this situation. Asia syndrome. This matter doctor is crazy. Dr. Schultz will say that now say, oh, Asean syndrome. Yes, yes. Asheville syndrome. Yes, it's possible. And in the future, breast implant. Never now symptoms associated with the implants. Yes, it's possible. And I say, oh, don't worry, we have a new sickness for the patients. I say that be sad. Breast implant, silicone, autoimmune disease. Because the silicone is the problem. And I say to the industry, hey, what happened? 60 years with profits. Please develop new materials, develop new choices for the patient. But silicone is not the choice, not in these years. It's necessary. You work, but not versus the doctors like Dr. Wilfield or like me. Say lie. No, it's necessary. The doctors make another educational program to make surgeries without implants. And at the same time you develop new materials. That's the reality. This is the future. And I don't know if you think the same.

Yeah, it's interesting because like I said when I was reviewing those historical papers, if you read the history of augmentation, how it developed, what was used, materials, etc. It is, it is. I don't know, I was kind of shocked by it to be honest when I read it. And you know, by the time I came into training, you know, they had form stable device. I mean all these things were, were better. I didn't experience the quote unquote, worst of the worst cases. And you know, we were always educated that no, the, the shell technology was better and all these things. And to your point, it's, it's still extremely inflammatory to tissues. Anytime you put anything in anybody, it's inflammatory. It's just the nature of it. So some are probably less than others, you know, whatever. I mean, I'm not gonna, I've taken care of. I don't know if you did this, but if you're a surgeon who puts in a device, you have called someone like me to help take care of that device, once it got exposed, infected, you had to change it out. And these are like, they can be life threatening, right? If you have an infected pacemaker or if you have an infected hip prosthesis or a knee prosthesis or I did a lot of sarcoma reconstruction. I mean, these are all complicated issues and we're not trying to, I'm not trying to make them less complicated. I just from a choice perspective, like Dr. Gonzalez has pointed out, you want to explain all the options to the patient. That allows the patient to make their best decision that fits and aligns with them personally and it shouldn't be affected by our professional ability. Like, like I said, if you can't do something, just say you can't do it. Doesn't mean you can't talk about it. But you should be able to explain the options to the patient, and then the patient can decide whether or not that makes sense to them and what they want to have done. And you don't. I always have no problem saying no to people. It's not, not a big deal to me. If I don't, like, you know, what their vision is, it's okay. I mean, I don't. I've never had a problem with saying no or if I don't know how to do something. I mean, I would tell you. Yeah, but I mean, my whole career is based on a very, very long, extensive experience clinically like yours and doing a lot of. A lot of reconstructive surgery. So there's really very few things that can, you know, bother me or that I don't have experience with, you know, at some level. At this point, I've been operating for almost 30 years, so it's not really any things haven't dramatically, you know, changed to your point. Like, are there. Are there really better products right now? Not so much. Pretty much the same.

Yes. But, you know, this is one choice. Okay, well, many people love biomaterials. Okay, perfect. But the silicone is not the choice. Okay, what do you want to do? All you love might be on biomaterials. Okay, you do that. But understand always any biomaterial produce immunological response, inflammatory situation. And look at this. I think it's very important for the people understand this kind of surgery is necessary. And expert, why I say that because the decision is a very big decision for the patient. Oh, I have volume. I will lose the volume and the projection. I will have a secondary deformity after I take out my implants. But if the doctor knows how to do the reconstruction, I feel safe, I feel good. When I see to the mirror, I feel better. But if the doctor don't do that, I say why I take out my implants. I'm crazy with this deformity. I don't want life. This is very important for the patient to understand It's a very big decision and make a consultation with the expert and the doctors during this time. Start to study and start in the practice how to do That I don't know is your case. But in my case, the doctors don't call me. Hey, Alan, I want to visit you and I want to see how do you that they say, Alan, only take out the implants. I say, no, doctors, you are wrong. It's necessary you start to make the surgery without implants. I say in Colombia, when, when? When I start with this plantation, I say, I have a problem. It's necessary to take out the implants. But I have the solution. This is a technique when L shape is L shaped incision. We come with the breast of the patient. We can make the movements, safe movements. We preserve the nipple areola complex. We can really change the anatomical position of the tissue and good shape for the patient with less volume. Absolutely. But it's important doctors just start to make the surgery without implants. The lift, the reduction, all the topics without implants. And if you want volume, fat is the choice too. And in different steps. Maybe if the patient want more volume. But I think it's necessary to change our mind and understand we are in the new era of the breast surgery.

I think that's a great place to end. Because I agree in full disclosure, you have to offer all those different options. And whether it's in Columbia with you or in Austin, Texas with me, that's probably the way to at least start and get an explanation so that it helps them make a better decision. So I really want to thank you for joining us today. I appreciate it. I'm glad you're doing work like this. I think it's extremely important in your contribution to the scientific literature as well has been very important. So thank you for joining me today.

Dr. Whittle, it's a pleasure to be here and thanks you for your job and I'm very proud for you and well, we will keep on touch. Okay, thanks for the time.