Explants FAQs Myth or Facts! Breast Implant Illness (BII)

So I'm here with Dr. Rob to finally debunk many myths going around about explant. So we're going to. We are going to ask Dr. Rob whether or not this is a myth or a fact. All right, so first one, you ready?

I'm ready.

All right. Capsules do not need to be removed at the time of explant.

Well, so that's a myth. And so I've done cancer surgeries for a long period of time. And when we're talking about, as was recently highlighted in the FDA update, there's a new cancer, and it's breast implant associated squamous cell carcinoma. So we already have breast implant associated anaplastic large cell lymphoma. Lymphoma. And now they added breast implant associated squamous cell carcinoma. We just need to make these a little bit simpler for me. And there's things that I've personally had, in my experience, that aren't even listed because they're rarer than those two. So the reason you want to take things out intact is so that you don't stand behind someone, like I did at the FDA hearings, who had only a partial capsulectomy, had implant capsule left on or had capsule left on their ribs and had alcl in their ribs. So that person can never recover from that. That's a. That's an untreatable event at this point. So I stood behind her, and I was the president elect of the aesthetic education Research Foundation. And I said, as president elect, you know, one of our goals will be to research and obviously avoid what happened to this woman. So things like that, you know, when I see that a partial cap selectomy is equivalent in terms of a complete or total capsulectomy or whatever we're going to refer to it, that would be in the setting where maybe there's not a concern for cancer. But I guess I'd have to answer the. Ask the question, when is there not a concern for cancer? I don't think anybody really has the numbers. I've done over 600 explants, and I have a pretty good sense, in my experience, what it is, But I treat them all equally so that there's not a person in front of me with a problem that I should have been able to take care of.

So definitely a myth. So that leads me. I think you might have just answered that explants should be done in block or total capsulectomy.

Yeah. So when I think about it, I did a lot of tumor surgery, especially for sarcomas and sarcomas are these rare tumors of fat and muscle and tissues that like bone sometimes. And so when you spill them, you expose the patient to unnecessary risk. So whether you're doing a cancer surgery for colon cancer or sarcoma surgery or a breast surgery, you don't ever want to be inside of a tumor. I think if you think of that logically, that sounds stupid. So we don't want to be inside where the cancer is, so we want to be away from it. We want to, you know, protect the patient from what could harm them more. So I always try to take everything out intact, and I like to explain it to patients is I don't want to break the Easter egg and find the candy. I just want to keep the Easter egg intact and take it out entirely.

That makes sense. Great. So that is a fact. All right. Explants can be done awake?

Yeah, yeah. So under. Not under general. Is that what you mean?

Right, yeah. So total capsulectomy or en bloc?

Yeah, I did one recently with just sedation.

You can do those. But typically, most doctors that are doing explants awake and not under general anesthesia probably are not removing the capsule, correct?

Yes, yes. Yes.

Okay. Myth or fact? You cannot use your arms after explant, and you must adhere to T. Rex arms.

The T. Rex solution or the T. Rex posture. Yeah, that's total, you know, myth. So your. Your arms are not the problem in breast surgery. Right. You're. You're operating on a ch and say, for instance, this implant's above the muscle, then. Absolutely, there's no reason why the patient can't use their arms completely normally. The actual concern is when you're behind the muscle and you're moving everything. It goes back to what I said about not disturbing everything or causing the least amount of disturbance. There's two muscles, pec minor and pec major. Pec minor is a very small, short muscle that's higher on the chest wall. And then pec major, obviously, we all know it's the big muscle. Depending on where that is released by initial surgeon doing the augmentation, it may need to be repaired and put down into a position. So if that position is going back down to where it's inserted, which is lower where it came from, then I would just keep somebody at 90 so they don't put too much stress on that repair. And that would be six to eight to 12 weeks, depending on what I thought of at the time of the repair. But in terms of, say, I don't repair muscle, and it's just a function of their healing afterwards. My patients can do whatever they want with their arms. I did entire extremity fellowship of the upper extremity, and when I operated on them, I didn't put them in a T. Rex posture or anything like that. So that's a myth.

Myth. A lot of women will be very glad to hear about that.

You can wash your own hair.

Nice. Okay, great.

That helps if you have the right nerve block. I didn't. I didn't mention that. So my patients don't have a lot of discomfort in that area because of the nerve block. Maybe I should highlight that. I've done several thousand nerve blocks, and it's easy for me to make that area pretty numb. And that makes it easier to avoid what. What could be a problem with movement and. And discomfort. And ice, of course, for the muscles, so they don't swell as much. So.

But as far as causing any damage by using your arms, that's not a concern. Myth or fact? You cannot get a fat transfer at time of explant.

Sure. So it's. It's a myth that you can't do that with some qualifying factors. So I just did a consult on a patient who is far too sick to have a fat transfer. Much like we discussed in your case where you had liver problems. This patient has such severe inflammatory issues that doing a fat transfer. 1. If someone's severely inflamed, think of like a wet dish sponge. If I'm trying to get fat out of them, I'm getting a lot of fluid in addition to fat. So I'm really not providing them the best situation. So I try to decrease that patient, patient's inflammation, or in your case, your liver problems, and get them back to a very normal baseline, whether, you know, GI tract is functioning. They're having good absorption of their nutrients. We've checked their hormones and balanced them out. So the estrogen, progesterone, testosterone are all balanced out. Their thyroid's functioning, their detox pathways work, and maybe they've lost that fluid weight. It's going down on exam. Their tissues are soft, and I can tell that on exam. Then they're optimized for that. So that's part of my holistic accelerated recovery program where we start treatment, you know, maybe 2, 4, 12 weeks out. Depends on the nature of the issue. If that's their goal, then I would do that up front to see if I can decrease their inflammation so they can have that desired procedure. I prefer to do that if I can. I think providing that for your patient really helps them From a psychosocial standpoint, in that you're removing what may be a very large implant on somebody who may be, you know, frame wise, small. So you're causing a lot of change at one time. So I try to offset that change by, you know, whether we're doing a 360 rejuvenation of the abdomen and the waistline and the bra area and inner outer thighs, you're trying to take somebody, I always say, from a 6 to a 4, 4 to a 2, 2 to a 0. And so that when the dress size changes and the bust size changes, it's all okay, myth or fact.

Breast skin will not tighten or change after explant.

So it depends on ethnicity and how you picked your parents. So if your parents have poor skin to begin with, they gave that to you. Some people genetically are more prone to wrinkle formation. We find that out on genetic testing. But certain ethnicities have more elasticity in their skin, so they'll contract more. If someone hasn't had children, it's easier for them to contract down. You'll see this often if someone comes in with a ruptured saline, they didn't notice it went on for a week or two, and all of a sudden it's flat, and immediately the skin is contracting. Now, if they've had stretch marks because they went up and down in pregnancy, and a stretch mark, remember, for the audience, is it's a tear in the dermis. It's an unrecoverable event of the dermis, so that prevents anybody from contracting as well. But coming in the fourth quarter at a. At a theater near you is a new stretch mark. Treatment will change it forever. I'm.

I'm standing in line, first in line, because there is currently not anything that I know of, and I have done a lot of research that substantially makes a difference.

Oh, it's coming. It's coming.

Myth or fact, you must. Must have drains with an explant, right?

So this comes out of the tradition of if there's. Think if there's an infection and you don't know what it is, and you're trying to drain the pocket so that you provide the patient the most relief. Think of, like, if you had an abscess and you cleaned out the abscess, but it was a closed space, you want to drain that space to help relieve the patient from any undue, you know, bacterial burden or fungal burden or whatever we think that is. So when we do this. Now, I don't drain anybody intentionally. If I'm in the operating room and someone has a severe rupture and there's leakage into the breast tissue or into the other tissues, then it's really hard sometimes not to utilize a drain in those patients. But I'll still go through my proprietary process where I don't drain anybody and think of like a drainless tummy tuck. There's things we do called progressive suturing technique and tummy tucks to limit the drainage dead space. What we're doing here is opening the space internally so it'll drain, but only after we've actually sterilized the pocket. So we do that with a more acidic solution, a lower PH solution, so that any organism, bacterial, fungal, it doesn't matter, can't survive. So, and in terms of safety, everything's taken out. If I've done like an entirely intact operation where I've removed everything intact, not spilled anything, and we're just looking at exposed tissues, we're going to clean everything out with a couple different solutions and then drain it internally and then go on from there. And whether if I'm doing a fat transfer, I absolutely don't drain anybody ever.

All right, let's see. Myth or fact? You have to take antibiotics with an explant.

So based on my previous answers, you don't know what's in the pocket. We figured that out forensically in my program using PCR testing that is going to look for 150 or more different types of bacteria, fungus, mycobacterium, based on their DNA. So if there's one copy, meaning one organism, you'll find it. So that's a solid technique that I'm very comfortable with. Now, I don't place people on antibiotics because according to the Skip protocol, which is a standard of care in the United States, you're supposed to give a dose of IV antibiotics 30, 30 minutes prior to skin incision. And that' just to reduce skin site infection. So putting women or anyone on oral antibiotics after surgery is really, really old and unnecessary. It creates, as we all know, more microbiome disruption. And we already have enough patients in my practice with dysbiosis digestive issues. We don't need to provide any new ones. So that's a myth.

A myth or fact. Explant can be done through the areola.

Yeah, so that's a fact. You can do that. So it depends on the size. If it's a super big wide implant, it's going to be very difficult, may end up not working properly to take it out entirely. So if I had somebody with like a 450 or 500cc implant. I would tell them, like, I will do my best to do that through the areola, but if in fact I cannot safely do the posterior aspect, I will have to make either a vertical, and it's easy to do and do like a little vertical lift at the same time. So you add, you know, enough exposure to go ahead and help that patient get a really, really nice vertical lift as well as an explant. But I have done it through periareolar incision entirely intact without problems.

Okay. But generally that's for someone with like 300cc or less.

Definitely a smaller implant. Like, think Danica Patrick had a really small implant, about a 250 or 275, I think. And so you could see it when you look at her posted pictures. It's really small.

Okay. Okay. Myth or fact, you can tell what size breast someone is going to have after explant. So you can judge based on tissue whether or not they're going to be an A cup or B cup or a C cup.

So it's really dependent upon how much inflammation. Like the patient I had today who I saw super inflamed. You cannot tell what she's going to be afterwards because if there's fluid buildup in the tissues, I always use that dish sponge analogy. If it's full of fluid, you're pinching stuff, you know what that is? So that's the. The devil in the detail, if you will.

So that's really interesting because I had seen several explant surgeons and they all had stated that I would be at least a very big B cup, which I was so surprised at. You like? Yeah. Oh, yeah. They're like, they could feel so much breast tissue on top. But I was severely inflamed. Yeah, I had, I had put on, you know, weight. That was water weight and inflammation. And so I was rather shocked after. And as I continued, as that inflammation went down to be. Not even an A cup, not even a double A.

Yes. I always, I always tell people, like, what were you? Or I'm sorry, I asked them. What did you start out as? I'm gonna say, oh, I was an A. Well, if someone's telling you that, you better listen because that's what they're gonna go back to. Because you don't magically gain breast tissue in life. And if you're a fatty layer. So think of the concept of the gal who grows up and gets older when they gain weight. Maybe their breasts get really large and so when that person loses weight, they really deflate. That's somebody who has a thicker fatty layer over the breast tissue. Remember, just so the audience knows, breast tissue is not fat. Not until you get older, like sixth, seventh, eighth decade of life, does breast tissue get replaced by fat. When you're younger, breast tissue is usually denser, firmer. The fatty layers above it. Think of the pocket on a shirt and the skin is covering the fatty layer which is above the breast tissue. That's where fat transfers go. Not in the breast, not in the pocket where the implant was. Those are no no's, don't do that. So if somebody has fluid buildup in that fatty layer and the breast layer, it's super disconcerting to figure out, like, what, what does the person really have? And so if someone comes in with kind of tense or swollen breasts and they asked me, like, what do you think I'll be, I'm say, I'm sorry, I don't know. Based on this amount of inflammation, what I perceive is his fluid retention. Same thing when I just was asked by a woman, can, can she have a fat transfer at the same time? And it's like, I would have to work for you, with you for several months in order to get your inflammation down and examine you in month over month to see if I feel like I could really do that. And I've done, you know, over a thousand fat transfers. So when I examine someone, I know the difference between swelling and, and, and fat. On exam. The breast part you have to be very careful with, especially in a low BMI patient like you. I would never think you would have a big B based on just your bmi. Especially, you know, as sick as you were before, you would be, the person I'd be like, no, you just get an explant done and just wait and you'll see, you know, how, how it will work out. And that's hard to hear, but that's the right thing in that situation, right?

Right. Well, that answers a question that I've often wondered. So, okay, myth or fact? All of your BII symptoms will resolve after explant.

So that's actually both. So it's a myth that they'll all go away immediately. I think it's a disservice to patients to ever tell them that it is a fact. They will get better. But if in fact your practitioner, whether it's me when I work with you, or if you have a functional medicine practitioner or nutritionist, they really have to help you do the work to figure out your Pathways and get them working. We do a lot of functional genomics, as you know. My practice to look at detox pathways. We work with patients to adjust diet, balance hormones, check toxicity and address that. So there are lots of things that go into it. I have a practice in Texas that sees a lot of people with mold exposures, significant mold exposures. So if you come from an environment where you got exposed to mold, it doesn't. Obviously there's mold outside of Texas, but I'm just using an example. You have a lot of work to do, especially if you genetically don't detox well and you have that exposure. So mold can mimic a lot of BII symptoms. Lyme can. We've, we've talked about this before, but you just have to know so that it's not just an implant based problem. Like there's, there's gotta be some other things happening typically. Right. And if you don't look at them, you're just, you're gonna be, you know, upset or dissatisfied because these things didn't get addressed. So I used to do all this on the back end providers and now I just do it on the front end myself. Except for thyroid, we have somebody who helps us with thyroid.

Got it. Great. So explant is a good place to start, but there could be other root causes going on that need to be addressed.

Yeah.

Myth or fact? Implants have to be ruptured in order to have symptoms or have BII issues.

Well, that's a myth. I've, I've had several people have significant symptoms with no ruptures. Quite a large experience with that. So if someone has an implant infection, they certainly don't need to have a rupture to have those symptoms. You already have enough immune system activation from the biofilm or, and, or infection to stimulate that response. And coupled to bad genetics or a bad diet or hormone imbalance, super high amounts of cortisol, big, big kind of sympathetic response. You'll have extreme fatigue, mold exposure, you'll have light sensitivity, sound sensitivity, headache, fatigue, fluid retention. I mean, list goes on and on and on.

Myth or fact, you have to sleep upright for an extended period of time after explant.

Yeah. So. So once again, this is just. I'll tell you how I do it. So obviously no, you don't have to do that. So that's a myth. The first day or two. This comes out of doing head and neck and anything related to the upper will say above the belly button surgery. So you just want things to drain because gravity always works. Right. So if you're upright, those things will drain downward. So say I did hand surgery. If you elevate the hand above the heart, it always drains towards the heart. If you did foot surgery or ankle surgery or knee surgery, if you get all of that above the heart, it'll just drain by gravity. Same thing. So you want to be upright. If you want to drain the head, neck and the breast. Unfortunately the breast hangs off the body, so it's not so easy just to drain the breast. So the first night it may be more comfortable from a, you know, positional swelling type standpoint to be wedged up at 30 degrees or what have you. After the first night, I basically tell my patients, you find the most comfortable position you can find and that's okay with me.

You can do it. At the same time, it's, there's not an either or, or better. If someone is, if someone is having no symptoms, they don't have inflammation, they're doing great, but they've decided they want to remove their implants and do a fat transfer, they can do that at the same time.

Yeah, absolutely, absolutely. So that, that boils down to what we call as just a holistic mommy makeover. So if someone comes in and they want a fat transfer, if, if they don't have implants, I still do the same things to make sure that they're optimized to have a fat transfer in the implant based situation, heavy symptoms and you're going to work with them or delay that to a later time to make it safer for them, like in your, your case. And then if you can do it at the same time, you're really going to work hard to optimize them, to make them like their, you know, 35 year old self. As I always, you know, go back to where hopefully everything was more balanced with hormones, stress levels, diet wasn't bothering you. There wasn't as much, you know, environmental or heavy metal or toxins just in your system. And that should be very favorable to have an extremely good outcome.

Wonderful. Great. If, if a woman has had an explant but she is not sure whether or not she had the capsules removed, is there a way for someone to determine whether or not the capsules are still within their body other than surgery?

Yeah, I've had this question a lot. And so I go back and I will help that client by looking at their old operative reports because typically the operative surgeon will say this was a total capsulectomy because that's a different, you know, wording versus I remove the partial capsule from the anterior surface, something like that. You know, typically I can glean from the note what I think actually happened and, or the operative surgeon told the patient, like, all right, Candace, I had difficulty here. And so this is still there. And I've had cases like that. And in those instances, I've went back where someone just removed an implant through an incision under local, which is what you asked me earlier, and left everything there. So in those instances, of course, not much changes in terms of symptoms because all the, the interface, even though the cap, the, I'm sorry, the implant's gone. But everything that was actually there, if it was biofilm, is still there.

Right?

Especially if they didn't, you know, quote, unquote, sterilize the pause the pocket. So I will go back and put like a little temporary saline device in the operating room, blow it up slightly and then take it out like a little. You have to have enough room to work around it. It makes it easier. It's harder when it's just a partial, like a posterior one. Then you have to get off the wall or you have to go on a mission to figure out like what pieces were left where. So you have to recreate the whole operation, which I've done, because people still had pain or they still had symptoms or partial symptom relief, and they're told they had a incomplete resection of this tissue.

So I have women who reach out to me who don't remember who their surgeon was or they had their explant surgery in Dubai, and so they don't have access to those records. Is there, would mri, would an ultrasound, would you be able to feel it manually? Is there any other ways that there are to determine whether or not a capsule is still there?

I would say not in my judgment, would I be comfortable with just any of a high definition ultrasound or looking at an. Mr. Because remember, the thickness is, you know, it's not a half millimeter. It's not 0.2. It may be like 0.1. And you just can't see that clearly definitively on. Mr. In fact, you know, they don't even call lymph nodes that aren't of a certain diameter on scan because they don't feel comfortable with saying that's a problem.

Right.

So on high definition ultrasound, you can look at the shell of an implant and see it. It's a bilayer, it's two strips, looks like railroad track. And so when you see that it's intact. Right. But it's super hard to see the posterior surface sometimes. So you don't really know. But to see the capsule above that is a no.

Okay. So it would just have to be like an exploratory surgery.

That's what I've told people. I know it's not what anybody wants to hear, but I've. It does no good to tell somebody something that it makes no sense. Right. If you can't back it up.

So that leads into. If they were interested in doing fat transfer but wanted to confirm that they did not have any capsule left behind, would they be able to combine those surgeries into one?

Yeah, that's fine. I've done that before.

Okay, great.

Yeah, you simply go in there and you got to reopen the pocket and look. But it would be just, you know, so for everybody in the audience, when I do a fat transfer, you know, for holistic mommy makeover with no implants, or for an explant patient, or for this patient who presumably had an explant done but needs to be reevaluated surgically, you would start everybody prone. Because I always do four or five areas, typically, to help get the best overall aesthetic results, like bra area, lower back area, inner outer thigh area from a posterior approach. So everything's well hidden in the buttock crease or in the cleft of the. Of the buttocks. So, like, a thong will hide it all. I don't ever really want things that are visible and then flip over. And we would do the left side first in an explant patient or a revision explant patient. And once that's confirmed, taken care of, we would lipo the rest of the anterior abdomen, didn't do the second explant, let our fat weight do our, you know, treatment of that. And then at the end, if we're doing a lift, we'd finish the lift. If we're not doing a lift, we would then do the fat transfer for those mommy makeover type patients or these revision patients, presumably, or they already had things done.

Okay. Wow, that's amazing. That's really great news, because I am getting a lot of women who had removed their implants for one reason or another without being aware of. Of any issues with implants. And now their concern is that they have left the capsule behind. Yeah, they're starting to pop up and they're not sure.

So, yeah, I would just strategically say, like, if it's. If it's unknown, you would approach them like, okay, they just remove the implant under local, and that's obvious. If they say it was done under local, there's no capsulectomy 2 if they had a sedation partial is more likely because they would not typically be advanced enough in repetitions or experience to go ahead and do that under IV sedation. I mean, I've done over well, well over 600 for BII, but I've done tons before that. But so that's just made it easier for me to do that under local with sedation. I don't have a issue. I'm not uncomfortable doing that. The, the patient who, who basically had an explant under general has no idea what was done. And there should be a record at the surgery center or the facility it was done and they can always request their records if that's a certified facility. Typically in any country, depending on the certifying body of the facility. That's, that's kind of like in our country it's quad A or double ha the body. The certification process is you have to maintain the records of Candice Morley at your center for X number of years. So that's basically a no brainer in this country.

Okay, all right. Well that's very good information. So maybe some women didn't know they could track down their records and that'll be very helpful.

Yeah.

Myth or fact, you have to consume large amounts of fat post fat transfer in order to retain your results.

So I think the important thing to remember is what we've discussed earlier. The closer you are, and I always mention 35, but your younger self when hormones maybe were not an issue, where digestive issues weren't a problem, you absorb nutrients really easily. Your adrenals worked, your thyroid worked well. Everything was balanced out. So I'm trying to take people back closer to that time. And so when someone comes in who you're, you're typically describing a low BMI person. So you have somebody who has to gain weight to actually have the procedure. And I don't ask people to gain unhealthy weight. So healthy fats are important. Checking their hormones, getting those organized are important. Maintain maintenance of a result is an, is a balance of hormones and diet. And it can't be a bad diet because a bad diet's not going to help you physically live your best life. It's not going to make you feel good. So although we're trying to really get the best aesthetic results, we have to be very honest with the clients and ourselves and not dress up something that we can't actually provide. So a lot of I'm not everybody's cup of tea because I'm really going to be straightforward about What I think you can have and what you can't have, and you don't want to hear it all the time, but I will in the most polite way tell you whether or not I think it's possible or practical. And if I say go, you know, gain 5 or 10 pounds so you can get in Candace's situation, 100, 150 cc's of fat that's usable, that's what she needs because she's a smaller person and that's going to help her. If someone's larger, that's going to be like throwing sand at the beach. It's not going to help. And so you explain that and it's got to be a larger fat transfer to help them. So, you know, each person's going to be treated, you know, specifically on their physical makeup and what we feel like they can do. But that's where doing our heart program and trying to understand functionally their genomic patterns, their food sensitivities, their hormone balance, make sure their detox pathways are working and make sure they're absorbing their nutrition and detoxing through, you know, the pathways, right? You gotta urinate, you gotta have bowel movements and you gotta sweat. Those are how we survive. So those things all have to be working. And I think most people just take for granted when those things don't actually happen, they're just, eh, whatever, it's not a big deal. But you know, I've come to the point in my career where I don't really want to or need to operate on anybody who can't like get on board with that process because it's in their best interest that they follow that kind of plan to get the most accelerated, efficient, safe recovery possible for them and maintenance of results. And then they can use that information for the rest of their lives to live as hopefully as healthy as possible. And we'll keep pushing the envelope to make you look better. If I can do that all the time.

Amazing, amazing. Well, I think that wraps up the most commonly asked myths or facts and. But absolutely, I know I will get more questions and Dr. Rob is always a wealth of information.

So thanks for having me on. I always like to provide a little clarity where I can absolutely.