Fat Transfer and Stem Cells in Breast Explant and Breast Reconstruction.Drive to Explant Episode 3

All right, welcome to episode number three of the drive. This is the birthday edition because tomorrow's my birthday. I'll be double nickel tomorrow. So woohoo. For me, I wanted to talk about the evolution of fat as a filler in my clinical practice. So I started training in 1996 for all of you folks. I did general surgery training because I was going to be a heart surgeon initially. We worked tons of hours and in our program. After the first two years you went and did a research year. This could be in a variety of labs around the campus where I trained at the Indiana University Medical Center. I ended up working in the vascular lab, but I also ended up part time assisting and helping out a clinical project on leptins. So you look up leptins, there's a nice paper in my resume about leptins. So I would take fat from patients abdomens under local anesthesia and then from that harvest they would do leptin research on that. So that was done under local. So I was doing liposuction on these patients under local. And I want to say it started in 97, 98, the evolution of that. Throughout my general surgery training, fat was more or less encountered in the operating room taking out visceral fat of patients who were having other surgeries. And really not what I do now in plastic surgery, which is removal and then repurposing the fats in transfers for holistic transformations or rejuvenations of breast scish volume. So in plastic surgery you're obviously taking fat out for body contouring. And then fat transfers became more and more vogue as a technique to return volume back. And that certainly was, was beginning in the late 90s, early 2000s and then for the first, really the first 10 years in the 2000s, there was a ton of work and research done looking, oh, spinning the fats and what was the, the right amount of pressure to use to obtain the fat and what were the size cannulas used to obtain the fat? Just a ton. A ton of work was being done. Most of it was being done by Roger Curry out of Miami. I went and took his course. He was also a guest lecturer when I was teaching. And I mean we used fat all the time. So I would do 100 to 200 fat transfers a year for my cancer patients. So for everyone, a cancer patient would need a fat transfer after a mastectomy and reconstruction in many instances to provide better volume in a autologous fat transfer like a DIEP free flap fat transfer or if someone had had an expander Implant reconstruction, it would be important to typically contour it better, meaning they may have a upper pole step off, they may have a ripple, they may have some contour issue that just makes their reconstruction not as aesthetic, not as smooth for them as they would like. And once again, these are, the majority of these are cancer patients. In my practice, that's what I did predominantly for 20 years, was cancer reconstruction. And one of the years, Certainly in the 2000, probably 2012 to 2015 time frame, I had to give a talk regarding the concerns over cancer recurrence. And my specialty talk was given about sarcoma recurrence. So when we're doing fat transfers, especially in cancer patients, I wasn't doing them in lumpectomy patients. Typically what we would do is after mastectomy. So I was not concerned about fat transfers after mastectomy. In my reconstruction cases, the stem cells transferred in the stromovascular fraction basically are the adipose derived stem cells and the vascular cells and other cells that are transferred in just a regular transfer without any centrifugation or any spinning. Similarly, our adipose derived stem cells, the cell type specifically is mesenchymal stem cells. So those cells, They're going to differentiate into fat, obviously bone, muscle, cartilage, they're not going to differentiate into breast cancer. So I gave the talk about not breast cancer occurrence. But then what would happen if you put it in a sarcoma defect? And that would be something I would never do based on the cell type, because tumors of muscle, bone, fat, tendon, those are the cell types that could develop from a fat transfer from the mesengual stem cells and fat transfer. So I would not use those for those clients, ever. Those patients understood that. I explained it to them. They, they totally knew why I wouldn't do that. For those patients with those types of problems, I would do a flap reconstruction, typically depending on where one of the first patients had a very, very large, their knee bone to almost down to their ankle. And I had to cover that with a large free flap that I took from the thigh so that everybody understands what a free flap is. It's a tissue composite. So it has to have skin, usually, obviously skin fat. Sometimes it contains muscle, sometimes it doesn't. Sometimes it contains a thin layer of white material called the fascia. So it's either skin and fat, skin, fat, fascia, skin, fat, fascia, muscle. We could also add bone to it. So there's fascia and bone flaps. Of course, we would use those to reconstruct these defects to really close the skin barrier when large tumor resections were done. So whether the defect was a sarcoma defect dictated, you know, whether I would do a fat transfer on it. So in my sarcoma patients, I would not do any reconstruction on those with fats. In my breast cancer patients, I was always doing reconstruction on those patients and then using fat transfer as a secondary procedure once or twice to go ahead and restore volume. It was very hard in those patients because they were on a lot of therapeutics like chemotherapy, estrogen blockers. Those are, those are the hardest patients to go ahead and treat and get a fat transfer result. But we still were able to get good results in those patients. So now fast forward, I'm doing explants and we're doing a number of fat transfers on patients after explant. That all started not when I started doing explant seven years ago, at this point, almost eight years ago, but actually started by a patient who came to me. She just wanted her implants removed. And she knew a cancer patient of mine and she said, you did my friend's fat transfer, why won't you do mine? And she did not have the signs and symptoms of what's termed breast implant illness. So at that point, I didn't have any real specific reasons that I could, you know, not provide fat transfer for her. So that's one of my holistic transformations with fat. And when I do and contour the abdomen and around her thighs, I do it for, for patients as a rejuvenative procedure, especially after having children. It's called a holistic mommy makeover. But in this case, we're actually going to take down the previous implant augment. And so depending on the numbers of surgeries, some people had a lot of different surgeries. And it seems like lately I've had a number of those cases in my practice where more than one procedure has been performed. So anytime you do more than one procedure, certainly we know from oncology reconstruction, the more surgeries you have, the more infections you can have, the more complications. Complications develop over time in that population. That's just, that's been known for a long period of time. So when we weren't doing a implant based reconstruction, we knew the patient. If we did everything properly with the tissue reconstruction, they would have less surgery over time. And so that was really my specialty. I did become very adept at taking care of problems. So I was referred people to convert implant based reconstructions to tissue reconstructions. So back to the patient who wanted the fat transfer. I had already stopped using drains in My practice, because I was doing fat transfers, and then I really. Drains are such a problem when you're doing explants and body contour because you've got patients in different garments and different wraps, and it's just a lot to deal with. So we started doing fat transfers. The issues with fat transfers and explants vary, but some of them will make sense because anybody who initially got a fat transfer got. I'm sorry, anybody who initially got a breast augmentation got it because they didn't have a lot of tissue going to begin with. So some people gain tissue volume over time. As we age, our fatty layer will thicken. That occurs on the breasts, just like all over the body. And it will allow me to do a more efficient fat transfer because that layer is thicker. So the fat goes between the skin and the breast, and that is the correct layer to place the fat in into. The issue then becomes how much fat can you place strategically to help the patient, you know, revolumize the breast. And so when I'm putting it back, I think of it as an upper two thirds and the lower third. The upper two thirds has the most volume. So if you just draw a horizontal line across the nipple complex and divide the breast into an upper two thirds and the lower two thirds, the upper two thirds always, obviously has more opportunity to fat transfer because that is a greater amount of tissue and area to work with. The lower third is typically stretched out either through having the implants, having other surgeries. It's a lot less tissue to work with, put fat into. In. In the explant situation. If it's a situation where somebody's having a fat transfer, breast augmentation, which is totally different, that tissue is not thinned out. And then you can use it more effectively to expand the breast and add more volume to the breast. So started doing, you know, more and more fat trans transfers. And now, you know, many people come to Austin and stay, you know, seven to 10 days. And the reason they're they're coming is they want to have a simultaneous fat transfer. And so I get asked, well, what about toxins and everything? So I did several shows recently about this. So the. We all get faced with exposure, exposures. And the goal for our patients, we're trying to get them in better balance because they're going to continue to have toxicity. We all get exposed all the time. I'm no difference air, we breathe fluid, we drink foods, we eat products, we use places we travel to. We're going to get exposures no matter what that's not going to stop. It's trying to get our bodies to work more efficiently given our genetic capability and those exposures, like I mentioned, to be balanced out. So certainly I'm never going to completely detoxify someone prior to any procedure or after any procedure. I continue to see patients for the year after I operate and then I have a detox team that works with them for a whole year. So there's lots of opportunities for healing. And we start that as soon as we can meet with the clients and understand, you know, from their interviews and listen to them and hear their story. In fact, yesterday I met someone who's definitely got a lot of toxicity. Asymmetry was the reason they got an augmentation. And so now fast forward, they've gained 30 pounds. They have lots of muscle and joint pain, lots of fatigue. They sound like they've gotten an exposure of mold and or environmental toxins based on where they grew up, up. So really, you know that that client's going to need a lot of work. They're going to have to do detox pre op. They're going to have to continue to do it post op. Got to get their liver working more efficiently. And I told them that it'd be better, they'd be better suited to have a fat transfer later. Depending on their tox burden tests and their ability to detox genetically. Many times we are doing a prep a detox, then an explant, fat trans her with or without a lift and then continue more detox afterwards. Fat transfers are a very powerful tool in my hands and we're going to continue to do them.