Explant, Fat Transfer, Skin Tightening, and Rejuvenation

Going live in 2 minutes. 2 minutes. Tonight we're going to talk about the real questions I will provide you some honest answers. Okay. Explant, fat transfer, skin tightening, and rejuvenation. I'm Dr. Whitfield tonight. Those are the points we're going to discuss, and we'll get right to it. When women come to see me about removing breast implants, the question is really just, can you take my implants out? There are typically deeper questions. What are my breasts going to look like afterward? What will happen to the skin? Can I restore shape without putting another implant in? Do I need a lift? I often get, you know, told I think I need a lift, and then can I help them better understand that? For revolumization, many people have come to know that I prefer fat transfer. It's an autologous product. It is not a product that is from cadaver fat. And they want to know if they're already having a procedure, is there another way to address any kind of facial concerns or another area at that time, whether it be an area of loose skin or extra fat, textural problems, indentations, anything really? And those are all important questions and they deserve more than just a quick answer or a simple You know, menu of what we offer. Tonight I want to talk about skin tightening and breast shaping, how we reshape around the time of explant surgery, breast lifts. When we're doing breast lifts and fat transfers and/or other operations like natural augmentation with fat transfer, we always want to explain how other areas can be treated at the same time if that is the patient's area of concern, or can we coordinate it with them? Because many of my patients come in from out of state and spend about a week in Austin, Texas, where I practice. And we want to coordinate things. More treatments are not necessarily obviously better. We just want to make everybody aware of what we can offer and how we can help. Every combination should follow a full, obviously in-person individualized examination. And detailed discussion of, you know, what can we do, what can we offer, what are the risks and benefits, are there alternatives to it, I mean, what are the patient's specific anatomy issues they want to take care of, what are their goals. Most important for me, obviously, due to what we wrote about in the Short Method and what we put forth in all of our care plans, is the the patient's health and wellness, their ability to heal, tolerance for other procedures if needed or if wanted. And after implants are removed, the breast does not simply return to the way it looked before augmentation. It can't. Many times patients have had weight loss, weight gain, pregnancies. They have had previous breast revision surgeries or other issues. Breast tissue may have changed, obviously, with Age, like I mentioned, nursing, weight change, hormones, and just aging. Many times the implant pocket affects the shape. There's concepts— think of like bottoming out or stretching or displacement into the armpit area. The nipple position will change. One breast may behave entirely different from the other. That's very disconcerting to patients, but that is very common. Implant size placement, the duration of implants, scar tissue, and the quality of the issues all matter. That is why 2 women who both want explant surgery may need obviously very different plans. One may have good skin elasticity or recoil and enough natural breast tissue to accept a smaller size without a lift. Another may benefit from a lift because the skin is just too loose and the nipple position will be too low if not raised. Another may want a lift plus carefully planned fat transfer to restore upper pole volume. Someone else may prefer explant alone, allow the tissues to heal, and decide later whether or not another procedure is worthwhile. As you can tell, like, there are no right answers. There's a series of options that we try to explain, and then patients have to make their best informed decision. I don't ever make that decision for patients. It's one of those things too, it also helps to separate, if you will, all those different ideas we mentioned. Obviously, removing an implant removes the volume of that implant. A lift reshapes the breast, and the more breast volume or breast tissue there is, easier it is for the surgeon to reshape. And we need to do something with the excess skin. You know, fat transfers add a selected amount of volume using the patient's own fat. Other skin tightening treatments may support contraction or improve selected areas of laxity or textural problems with the skin. Stretch marks— think of like stretch marks as they're just tears in the skin, and they're very Frustrating to deal with because they compromise how skin will tighten. So we do a lot of microneedling for those, and we'll talk about that a little bit later. And I don't use tightening devices on the breast itself. That does not substitute for what we need to do with the skin laxity facing most patients. It would be too inconsistent. A breast lift can help reposition the nipple and reshape the skin envelope around the patient's existing breast tissue. So the wider the breast, the more tissue there is. And the— think of like the best-case scenario is somebody who really didn't necessarily need an implant but got an implant because they were told or The impression was given to them that would help give them a lift. Those patients are the more simple patient to help achieve good shape with, especially a simple vertical lift, because they're wide and you can make them narrow and higher. And then as you get bigger implants or smaller amounts of breast tissues to work with, that's harder on the surgical side. There is always going to be scarring with any of these procedures. Obviously, if we do everything underneath, we can hide that relatively well. And we just want to choose the best series of executable steps to help patients achieve their goals. You know, some patients ask me a lot whether energy-based tightening can help reduce the need for a skin lift on the breast area. And I said, you know, previously with With these cases that I'm doing, we don't do that for the breast. We do it in other areas, especially where we take fat from. So if we need to change nipple position, we always do that with a skin excision pattern and giving a vertical lift. And that is the best way, in our opinion, to do that. Whenever, you know, we're going to do a transfer, we're trying to be very thoughtful of how we do this. But everywhere we take fat from, we offer skin tightening and skin treatments externally to help with those areas because we don't want them to get looser. We are not getting younger. Obviously, we lose collagen and elasticity over time. We prefer to use BodyTite and Morpheus8 for these. BodyTite is a minimally invasive radiofrequency-assisted option used In the same areas where I take the fat out of, through the same opening, I can treat those areas with BodyTite, which is bipolar radiofrequency. It's a very safe, very effective treatment. And then we use for textural treatment over the top on the skin surface Morpheus8, and that helps as well. And I mentioned previously stretch marks, but skin laxity in general is That's a great 1-2 combination therapy. So anatomy, skin quality, donor sites, treatment overlap, the procedure length, of course, risks, recovery, patient preference, and obviously whatever they choose after giving consent is really how we develop our plans. Technology themselves don't substitute for skin excision. Don't ever think that. If the patient is better served that way, we'll always let them know, especially in any of the areas we work on. Morpheus8 obviously works differently. It combines microneedling with radiofrequency energy delivered at different depths. We're always using superficial depths when we're on the skin. It may be used to address these textural changes, like I said, and my laxity, but it's not going to be a big visual changer. That's, that's not it. And we do it all over the body. And if patients want their face treated, we'll do that for them as well while they're under anesthesia. It's very simple, efficient treatment, doesn't take long. And once again, it's obviously going to be better tolerated when you're under anesthesia. There can be quite a bit of discomfort with energy delivery from radiofrequency treatments. So we still have to consider obviously what we're doing, the condition of the patient, the tissues, blood supply, swelling, what are we doing in the areas, and we don't want to ever compromise wound healing, so we won't do things that would do that. We did touch on stretch marks previously, but we'll go back to it. Morpheus8 may be really helpful in those textural areas. The texture of skin can be really difficult to manage. That's weird. Um, sorry, it looks to be like a problem with the, the feed we had on Instagram. I'm just going to let it reload. I don't know what happened. It dropped. Pause for a moment. Okay, I don't know if it's gonna allow Instagram to rejoin. All right, Morpheus8 may also be discussed for texture concerns after pregnancy or weight change, including the appearance of some stretch marks. The language obviously here needs to be careful. Stretch marks are changes within the skin. They're tears in the dermis. Their appearance may soften or improve in selected patients, but they are not going to be erased, so it should never be interpreted that way. These are to help shrink them. They will not erase them. Another technology we have, which is office-based technology we have, is Softwave. It's one of the additional treatments that are available in the office. It's a non-invasive ultrasound option for Skin tightening. It does not remove fat, add volume, or perform a specific lifting type procedure. We have Evolve or Evolve X and Evoke. Those are all office-based in our practice. These treatments obviously may be planned separately. The surgery, depending on the timing of it, we can work out before or after. Because people are staying in the office the week after, it's a little Simpler, obviously, after a few days of recuperation and coming back to the office. Once again, these treatments are for remodeling, and those treatments obviously take time for that to occur, but they can be started while you're here. And so that actually brings us to an important part of the conversation. A woman may come in focused on obviously the explant surgery, the breast surgery, and, you know, just entertain or want other options. Sometimes that answer is we can do that in the office, or sometimes obviously we will do that in the center. We try not to get into very lengthy treatments in terms of facial procedures in the OR. Plus the breast procedures because they become too lengthy. But once again, we make that decision after discussing everything with the patient. For facial planning, obviously we start with our basic same principles. What are the main issues? Is it skin laxity? Is it deeper tissue descent? Fat loss? Is there other volume issues, skin texture, wrinkles, or true excess How healthy are the tissues? What prior procedures has she had? How much swelling and recovery can she reasonably manage while also healing from breast surgery? FaceTite is a minimally invasive radiofrequency-assisted option that we use quite frankly for the lower face and neck. We've coupled that in my no-cut facelift as well. It may help contour and support contraction when there is appropriate anatomy such as in early jowling or mild to moderate laxity or selected fullness beneath the chin in combination with liposuction. But it is not and cannot be parsed out the same way as a facelift would. It is not powerful enough to do that. If there is substantial skin excess or deeper descent, FaceTite is not a good option. We also have Ellacor, which gives us an office-based or surgery center-based microcurrent option for specific facial or body concerns. It removes small amounts of skin without leaving a scar. It is FDA cleared. We've used it extensively in our practice and are happy with it. And because it addresses the skin differently from FaceTite, there are carefully selected plans for patients in which the approaches may complement each other. We do that as part of my no-cut facelift. But that does not mean the combination belongs obviously in every plan. Evoke is a non-invasive radiofrequency platform for selective facial remodeling. It definitely works. I have to be careful with patient selection always. And you could do a series of these depending on the patient's age relatively easily while they're here. Evolve or Evolve X extends, and think of like where the The body contouring ends in the hip thigh area, the abdominal area, the love handle area. These systems are the applicators once planned to work on the skin and localized fat in those areas. Those targets obviously must be distinct and planned out, but this localized fat treatment is not a weight loss treatment. Skin treatment In this case, obviously, it's not excisional. This is all non-invasive. Evolve or Evolve X may be useful for a patient who prefers a non-invasive treatment program. And so we're not like parsing out or doing a checklist here, and that's intentional. Technologies obviously are tools. I have a lot of them in my practice in addition to all of our treatment modalities like the human regenerator, the hyperbaric chamber, The Juve Red Light, the Flopressor from New Zealand, and NanoVi. We have all these other tools to help with skin treatments or fat treatments. So the question is, what tissue is causing our patients concern? How much change is realistically possible with these modalities we have? And what combination offers the most benefit? Sometimes the best answer is just obviously do the procedure we're Set up to do no add-ons. Sometimes obviously it's better to stage some things out depending on their ability to come back and forth. And you know, one of my favorite things to talk about is fat transfer. So let's approach that now. I think it's a really underutilized way to augment the breast. I know there's all of this talk now about cadaver fat, but it really. is not going to become part of my practice. This is a natural autologous treatment, so I prefer it. Fat transfer begins with obviously removal of fat from the donor areas, and these are kind of standardized for us, but they include the abdomen, the love handle area, the mid-back, the bra fat area, the inner outer thighs. You can do arms, you just have to be very careful with them. It is not placed after you acquire the fat back into the old pocket. It's placed beneath the skin, above the fat. Think of breast augmentation and buttock augmentation. Subtract the breast tissue out, and there are fatty layers over muscles. Here in the breast area, we have to be above the breast, not in it, and we don't want to be in the muscle in either of those operations. We should never inject anything into the breast gland. You know, we use this fat to really augment the fatty layer. The donor fat available, the breast skin capacity, its circulation, existing breast tissue, imaging history, and other operations all play into how much I can place safely and effectively. Fat transfer can help restore selected Fullness, obviously, after explant. Soften contour transitions, address some asymmetry, or create a modest natural breast augmentation in the right patient. It does not tighten loose breast skin. It does not lift a low nipple. Adding too much volume to loose envelope may make heaviness or descent worse rather than better. That is why a patient may need a lift with a fat transfer. A lift potentially first and a fat transfer later, or none at all. Not every transferred fat cell obviously can survive, and the final retained volume can vary. We concentrate on preparation with the Sharp Method, doing DEXA scans, working on toxicity burden in preparation for our patients to have fat transfers. The breast changes as swelling resolves and the transferred fat And the tissues will settle. Sometimes you will have oil cysts, you'll have necrosis, that can happen in any case. It should be limited if you follow some basic tenets. Future screening should not be impaired by this at all though. When we combine explant lift and fat transfer, that's one of the preferred things I offer. The operation is designed around this patient's tissues, Their blood supply, their toxicity burden, gut health, food sensitivities, how they detox, you know, what is on their tox test, trying to get them ready. Any additional things like prior scarring, previous procedures, implant malpositions, current positions. I mentioned thickness of tissues. All those things play into how we do it. In some patients, a single stent plan is Great. And others, they need to be staged given their state of health or their tissues. And that's fine. We allow, you know, totally staging of those when necessary. And this is where other procedures like my Smart Tummy or Smart Arms can be done because then the patient's already had a larger procedure, typically at 6, 9, 12, 16 months, they're doing better. And it means just being strategic. Maybe they wanted their arms done at the same time as the other procedure, but I couldn't do it, and now I can. Maybe they want another fat transfer, or maybe it's their first fat transfer. It doesn't really matter. We can sequence and stage these things however we want. And that leads us to, you know, one of my favorite things I came up with and felt very comfortable with doing for many, many patients is a holistic mommy makeover. Where you just take all of the excess fat that is created through pregnancy and nursing and aging and weight change and all the things from those stubborn areas and use that to augment the patient's breast. And it's using their fat, so it is very holistic. It means we're looking at all the parameters, you know, that are highlighted in the Sharp Method. Their overall health and wellness, nutrition, sleep, stress, inflammation, toxicity burden, gut health, food sensitivities, all those things, giving them counseling about obviously nutrition and how we want them to exercise, looking at a DEXA scan pre and post and keeping that top of mind for them. And, you know, a patient may need an explant with a lift or skin excision and other treatments. Those are typically going to be spaced out because the recovery from those can be much longer. Another may choose obviously just have breast surgery and then consider all the other options later, whether it be Morpheus Softwave, Evoke, Evolve X after healing. And another may want to add additional facial rejuvenation treatments at the same time. And those are fine. We, we don't operate for extended periods of time in this outpatient setting we use, and we always want to be safe and effective in what we're offering. So combining facial rejuvenation with breast surgery requires obviously attention to how much time, the positioning, swelling, aftercare, any other considerations in the medical history and the patient's ability to recover should be addressed. And the patient obviously will need help. Many people travel here, they have a caregiver, or they will contract with a nursing service for help. We don't want to put anybody in a compromised position ever. Safety is always paramount. And obviously, the final decisions are made after addressing all the concerns and getting informed consent. Minimally invasive doesn't mean there's no risk. Obviously, energy-based treatments can involve, you know, some changes in the skin. They can result in some contour problems and swelling and scarring like anything. And surgery brings its own risks, of course, including bleeding, infection, scarring, delayed healing, fluid collections, changes in sensation and symmetry. And there's anesthesia-related concerns, of course. And the purpose of discussing the risks is not to frighten anybody. It's just to better explain them so they can make their best informed decision. Healing also changes what we can judge and when breast shape evolves as swelling decreases, tissues settle, Scars mature over a year, and then over that same year, the fat, if we transfer it, will stabilize. And facial swelling from any procedure can be temporary and make contours look irregular, but collagen remodeling is really a 6 to 9 to 12 month process. It doesn't happen in a day or week. If you are considering an explant, a lift, a fat transfer, or natural breast augmentation, ask your surgeon to explain what each part of the plan is intended to do. Ask what it can and cannot do. Ask whether a device is being used for the skin, fat, the texture, any other targets, and what is that device and its risks, benefits. Ask whether if you have significant loose skin, is it better just to have a skin excision at a later time? And ask how fat transfer can affect the volume. If there's no skin tightening, ask whether combining treatments improves the plan. How much time does it increase in the operating room. And so the goal is not really to convince anybody to do anything extra. The goal is just to explain these exist as options to provide like a different treatment in an area that may have been concerned. And while we're taking care of one, provide options for the other. The goal is always just help understand that these are choices and how they fit together. But planning and discussion and obviously Allowing patients to make the best informed decisions is all we want. All right, as always, our discussions are always educational only. None of this determines anybody's candidacy. They're giving you the the way to ask the questions. So at this point, we're going to go into Dr. Rob Circle. If you signed up, it's free to sign up. Go to drrobcircle.com/live. You can go right into the circle. We're going to do a live Q&A. But thank you all for joining me on Instagram, TikTok, and all the other platforms. We're not going to go in the circle. All right.