En Bloc Capsulectomy Explained: Drains, Detox & Toxins with Dr. Robert Whitfield MD

All right. Good evening and welcome. Tonight I want to talk through 3 things that come up in almost every explant consultation I do, and that get talked about a lot online, but often incorrectly. 3 topics, um, you know, we'll go for probably 8 to 10 minutes each. First, the en bloc versus total capsulectomy, uh, what those words actually mean and why I'm going to wrap an implant with a little paper-thin cover to show you something. Second, drains versus no drains, why I haven't routinely used drains in over 5 years. And why the real question isn't drain or no drain. Third, we'll talk about detox, forever chemicals, mold toxins, and heavy metals we test for before surgery, and what the honest science says you can and cannot do about them. I'm going to show you real evidence on screen tonight. We'll go in my private community. I'll give you an example of a lymphoma we took care of and a toxicity test, and, uh, we'll dig into that. But first, we'll start with, uh, the en bloc capsulectomy versus the total capsulectomy. And the origin of en bloc is very simple. The word itself is a French word. In origin, it just means whole, in one piece. It came into surgery basically in cancer surgeries. And the cancer surgeon, you know, as I was taught in training, as many would expect, you don't want to be in a tumor. You want to be around the tumor. And that way you're not in danger of Opening it, spilling it into the cavity where you're taking out. This is very important in things like sarcoma, but you kind of think of these principles always in tumor surgery regardless. Cancer surgery is where that concept comes from. The moment we spill cells, then we potentially endanger the patient. So en bloc is not a marketing term. It's a term used as a cancer surgery principle. To remove it whole with an intact margin. So we'll talk about what margin means shortly. So total capsulectomy versus en bloc capsulectomy, and the total means, are you taking it all out? Are you taking it out intact? It all comes out. So let's talk about that as it relates to explant surgery. And when you have a breast implant, your body forms scar tissue capsule around it. It's a thin collagen bag all the way around it. It's not completely impervious. It's not watertight. It's not quote unquote going to block anything. And there are a few ways to remove it. There's a total capsulectomy, which is what I do every time. The question is whether it's intact or not. And so when we're removing all the capsule, it's relatively easy as long as it's not translucent or like cellophane. If it's like that, it will tear or not come out in one piece very easily. An en bloc capsulectomy, Means we're moving it altogether intact as a concealed or a sealed unit without opening it, without spilling any of the contents. My goal is always an intact capsulectomy. If there's something, you know, inside there that we've shown, such as biofilm, a rupture, degrading implant, we want to leave all that material inside intact to the best of our abilities so it doesn't further effect to tissues. It's the same principle that cancer surgeons use— whole, intact, margin preserved. And so what is this whole margin talked about? I've heard a bunch of people, you know, on the podcasting circuit discuss this and try to take probably some shots at me. Most of them, when you hear them speak, don't know or haven't done very many Cancer surgeries or cancer reconstructions. RO means there's no tumor left behind, it's a clean margin. R1, there's typically microscopic disease at the edge, and R2 is visible disease left behind. Obviously, we always want an R0, and then it's about how much margin are you talking about. So basically, the reality is 1 millimeter of margin is enough to be considered negative in the majority of instances. So we wrapped up a little implant tonight, this little blue wrapper. Okay, so if we take that little blue wrapper off, it's basically about a millimeter thick. So if we consider that to be our margin, that little wrapper, that would be negative. We would have taken that intact. Okay. Now that didn't disrupt the scar tissue around this. That's represented by the white So basically, even if you're taking a millimeter of tissue around that, that's considered negative. You're not trying not to disrupt everything, and that's the best way I can, you know, visually describe that. And that's it. And that would be the margin that was acceptable in a cancer surgery if that were the case for breast cancer. So when I tell you we can remove the implant and the capsules intact or en bloc, if we're going to use that term, It's with as little as a millimeter of tissue as my margin. And I just want you to understand that, and that's the easiest way I can portray it. So we'll go into the community later and I'll show you exactly how I did this for a case of breast implant-associated lymphoma. I was hoping to have my special guest, Tiffany Blackman on tonight, but she's traveling to Montana. Otherwise, we would talk about her case specifically because it's super unique, and I like to hear her story. You know, the diseases like breast cancer, a breast implant-associated lymphoma—you know—they're real. They affect patients. Obviously, breast cancer affects more patients. My sister passed away from breast cancer. breast cancer. So we always want to be careful when we're taking these tissues out. I send all of them to pathology. So we always want to be mindful of that and not miss anything. So we're going to move off of capsulectomies and into draining versus not draining. And I'll talk about how I was trained. Obviously, when I was training, the rule was simple. If you made a big old space in the body, you put a drain in it. That tube would carry the fluid off. It'd be connected to a little bulb, and the bigger the space, the more drains you used. There were countless of very famous surgeons I would go to meetings at, and they would show their drain placement for cancer surgeries, especially in particular one I'm thinking of, we'll not name. You know, the bigger cancer operations, the ones that actually involve lymph node dissections, those really, really needed drains because you disrupted the filtration system of the body, which is the lymphatic system. There is nothing more effective than your lymphatic system, and that's why we don't use drains, is because we help enhance that drainage. Now, if you're doing lymph node surgery, like an axillary dissection, or if you're doing a melanoma surgery, and And lymph node removal, those folks require drains. Breast surgery, no. So, the shift we need to make is not, should I have a drain? But the question is, why is my body making the fluid in the first place? And so, because if you understand that, you can get ahead of it. And instead of dealing with it after the fact with a tube, We can avoid the whole thing, and drains themselves don't prevent seromas or hematomas. If you look at Open Evidence, which is the quote unquote AI platform for doctors and surgeons, the data actually shows that in most soft tissue settings—breast reduction, abdominal wall and flank work, cosmetic cases—drains do not reduce seromas or hematomas. They help in specific. Situations like formal lymph node dissections. So, a drain can, once again, a drain cannot prevent fluid formation, it cannot prevent bleeding, it does not prevent an infection from forming, as well as any of the other aforementioned issues. Your body makes fluid. The question is, why is it making so much fluid that your body can't handle it? The body Normally handles about an ounce of fluid per 24 hours. And the rule of thumb was take the drain out if it's putting out less than an ounce in 24 hours. So how can we actually just avoid that whole problem? So if the tissues are disturbed through surgery, you get inflammation, your bloodies, your blood vessels get temporarily, they become leaky at the capillary level, and then the plasma seeps into the space. Think of it like a dry sponge that becomes wet with fluid. Think of your sponge on your sink. It's dry and then you start doing things, adding fluid to it, and it fills up, and then you squeeze it out. So, the surgery sets off the stress response that creates a surge of cortisol and adrenaline that ramps all this up. Usually lasts better part of 72 hours. That's kind of peak for swelling. Capillary leak is highest in these first 3 days and then it starts to settle down. The cortisol surge climbs right after surgery and drops off around 3 to 5 days. So, most of the fluid that isn't coming from the empty pocket, really, it's really coming from your physiology in the first few days. So, how do we get ahead of it? And so, really, this is the S.H.A.R.P. method. It's what I wrote the book about. It's what we espouse. It's our methodology, which is exactly why my approach is to really lower inflammation Before we ever operate. That will lower the response before it ever happens, so there's less fluid to begin with. And the drain becomes the least of our concerns. That starts before surgery. Proper sleep hygiene, proper dietary intake of protein, not overhydration, but proper hydration, calming down the nervous system, really reducing your inflammatory load with our stack. We optimize genetic pathways for detoxification, which we'll talk about later. And the reason for all that, when we started our patients, about 83% have these genetic variants in detox and inflammation pathways. And over 500 of our patients consecutively tested in an audit had a higher than normal environmental toxin burden. Most of all, they had BPA, they had glyphosate loads, and they had, excuse me, aflatoxin. So we want to prepare them individually. So that's why we look at genetics, toxicity burden, gut health, food sensitivities, and hormonal balance. The night before and the day of, we layer in our own enhanced recovery methodology. We use a series of eRest techniques plus our localized and regional nerve blocks done by our anesthesia team and then by me personally in the operating room. Then that night after surgery, up walking around, We concentrate once again, once you're able to intake things normally by mouth, we want to increase protein intake. And then the following day you're going to come to the office. So this is very different about our program. The next day you're at my office in Austin, Texas. If you made it here for surgery, you're coming to see us the day after surgery. And then you're going to do my stack. My order is the Human Regenerator. And most of you don't know what this is. You can look it up on my site, drrobertwhitfield.com. And it's a great tool to help lower that sympathetic activity and get you in a more parasympathetic state. That's followed by lymphatic massage, which also helps your body's efficiency in terms of filtration, getting the fluid out after surgery, helping the stress response in that fluid production. We combine that with NanoVi therapy to improve protein synthesis. And then we also, after that, follow it up with a hyperbaric oxygen treatment. I really enjoy having hyperbaric in the office. Raising oxygen tension really helps healing tissues. I do a lot of revisions, and this tissue is already at risk of low blood flow. So, we want to increase oxygenation in those tissues that are trying to heal. We want to prevent bacterial, fungal, viral infections because they thrive in low oxygen environments. Then, we follow that up with a big red light treatment. We use Juve as our red light treatment device. And so, we put all that together and here's the result. I haven't routinely used drains in over 5 years. Not because drains are bad, they're totally fine in the appropriate situation, but I don't find this standard situation that I do for explant or explant lift or explant lift fat transfer or explant fat transfer to need drains. When you attack the root cause of why you're developing more and more fluid, then you can reduce that and not need the drain tube to get the fluid out. So, you know, we mentioned toxic burden, and in our audit, personally, about 83% of my patients have problems with genetic variants in their detox pathways. Everybody's heard of MTHFR, about 36%. Mm-hmm. of the population has MTHFR. It's a much higher percentage of my patient population, and so really that's the, the third piece of this. So let's talk about detox. So, you know, we talked about, or you hear people talk about detox, and it used to be kind of a strange thing for me. I didn't quite understand all of it, but we've got really quite a bit of data now on detox using a Total Toxicity Burden test. And we look at PFAS, forever chemicals, organophosphates, BPAs, phthalates, glyphosate. We look at mycotoxins like ochratoxin, aflatoxin, zearalenone, citrulline, zinn, all these different toxins. And then we look at heavy metals like cadmium, tin, aluminum. We look at arsenic, lead, of course mercury. We look at all these different levels. And so, the levels in these are what really guide us and how we should be, you know, individualizing care plans for patients. You know, everybody's got a different set of exposures, like where they grew up, where they worked, where they traveled to. And one of my patients who we did a live with recently, Ashley Kurtz, was a competitive golfer her whole life, from junior golf to high school golf to college golf. And worked at a golf course, and she had the highest levels of organophosphates and mycotoxins I've ever seen in one patient. And so, that's purely from her recreation, and then occupation. And then PFAS, you know, forever chemicals, are in non-stick pans, water-resistant fabrics, food packaging, and unfortunately drinking water. And they're called forever chemicals because they barely break down in the environment or in you. Mycotoxins are really from mold, and mold finds its way, finds its way into our environment, usually in our homes or places we work, through HVAC systems or leaks around sinks, showers, penetration of HVACs into roofs done improperly, and these aren't fringe concerns, they're background exposures almost everyone carries to some degree, and they can add to a huge inflammatory load your body is dealing with. So, I want to be as, as straight with everybody as possible, because this is where the internet oversells things. I think the single most powerful thing you can do for ongoing exposures is filter your air and your water. Cut the plastics and nonstick, you know, you got to clean up your environment and your food. And that's not glamorous, but it's the intervention with the least arguments against it. For PFAS specifically, there's emerging evidence that some of the older binders can be helpful. We use these in our practice. We can talk about those in my circle later, because you're going to get this stuff out of your system. And there are some things I want you to be skeptical of. Overheating yourself is not great, especially with implants. I shared this with my patient Lauren Bostick, who had a large amount of heavy metals in her system by doing a very aggressive sauna regimen. And things like charcoal, chlorella, random detox cleanses for forever chemicals have weak human evidence. For mold toxins, there are certain binders and protocols that definitely work better than others. For heavy metals, you have to be careful here. We don't advocate IV chelation therapy. It can be too aggressive, and we've seen some very poor outcomes with it. So, the framework is simple and honest. Reduce what's coming in, support your body's own detox systems, your liver, your gut, really work on your sleep hygiene, dial in your protein intake, and don't overhydrate, especially in the leaky phase after surgery, and use the tools that clinicians like myself and others provide you. So, none of these are extremely You know, novel. And while this ties back to surgery and it closes the loop on everything, you know, a patient who walks into my clinic in a lower inflammatory state, less toxic burden, heals differently. There's less swelling, less fluid production, and there's a smoother, easier recovery. And that's the same reason I can do a clean, intact capsulectomy and in most cases, Completely skip drains like I have in over 5 years for the majority of my cases. It's all in one system. I feel strongly that you have to prepare each patient, respect their physiology, and you need, you need tools, but you don't need drains. That's easier for the patients. There's less drama, easier, smoother recovery. So in closing, you know, in-block, I know it's been talked about. It's used in the groups all the time. It is a pathology term that means intact, undisturbed. This can be done as a total capsulectomy intact with as little as a millimeter of margin. Drains aren't a you know quote unquote question. The real question is why the fluid's forming. Is your patient properly prepared for the procedure? Detox is real. But there are a lot of things that we need to learn. We have to really reduce exposure, support your body, and use the tools that we have available, and not really succumb to hype. So, I will take a few questions now, and then we're going to move into Dr. Rob's Circle, my private community, to answer the rest, and we'll go over some cases. So, I'm going to put in the chat on Instagram, How to get into the community? It's very easy to sign up. It's not complex. All you got to do is pop in your email and you'll get a magic link to sign up. Amber, yes, toxins can affect AST and ALT. Oh my God, let me do a TikTok question here. Linda, we have people take our inflammation support bundle after surgery. I think that will help. Lower inflammation. It's been shown in our practice to lower it. So what I'm gonna do is, for everybody who's gonna hop over, I'm gonna go over a cancer case, a breast implant-associated lymphoma, and I'll go over an actual tox test in my community. So for everybody who wants to see it, you can only see that in the community, okay? I'm gonna present that on my screen here shortly. Okay, so here in this, you can see this contracted implant capsule, and here, this is actually not meant to be here. This is a pseudocapsule around the implant and another layer of tissue. So, these had, this was a lymphoma, and I took it out all complete and intact. So I took them out en bloc with this margin. And so, you know, what I was talking about, what I was talking about earlier is with these, you can take a margin of tissue. It's very, very, you know, slim margin, less than a millimeter sometimes, or 2 millimeters. And this thing had 2 different capsules. You could tell it was abnormal from the jump. So, for me personally, yeah, I knew it was a problem. I fully expected to get called by the pathology folks within a week, which I did, and I told my team to expect it because I knew she had, you know, something abnormal. I knew it was most likely a cancer, and so, you know, I've— that was one out of my first 1,000 cases. I've done a couple thousand cases now. Published the largest series in the world of PCR-tested explant specimens that show that one in three have bacteria. It's predominantly Ketobacterium actinis and Staph epi. I mean, those are the things that are important that you have to keep in your mindset, and you're you'll be best served by that. I'm gonna do one more like show and tell thing, and then we'll get out of here tonight. All right, we're gonna go over tox test. It's an impressive one. So a tox test like this is, you know, look at all this. So DDA derivative, um, atrazine, very bad actor, very neurotoxic, um, one of the breakdown products, BPA, the most commonly found Environmental toxin we see. Just a bunch of organophosphates, and then all these mycotoxins, fumonisins, dihydrocitrone, aflatoxin, M1, G1, B1, heavy metals, lead, beryllium, just a host of chemicals. Now, when I find all that, especially on anybody who wants a fat transfer, I typically just Pause because I don't feel like I can clean all that up and do the operation the way I want to. So I think it's important to help those patients with, you know, an explant or explant lift and get them in a better condition with my detox team. And so that's very valuable. So Sarah's asking a really great question. She says, Question then, if you find cancer when working on someone and you didn't realize they had it, what are the next steps? Do you just go on with the procedure as planned? Well, you don't know someone has cancer until you actually take it out and send it to a pathologist. It's not something that I can tell in the moment. Typically, all that's found after the fact, and sometimes things are more difficult because I have people come with capsular contracture, ruptured implants, Heavy calcifications, all sorts of pain and firmness and fibrosis. Sometimes it makes it difficult to examine. So sometimes the picture is really not clear, but we want to do our best in every case to help every single patient. So as much as, you know, we can do to help them, we try to. Great questions tonight. Y'all are doing a great job. I think everybody's just online. I goofed everybody up doing this on a Wednesday. I appreciate everybody hopping on. Um, we'll return to our regularly scheduled time next week, and hopefully I'll have some of the other problems worked out with, um, streaming, etc. But been great to have you all on. All right, see y'all next week. Bye-bye.