Part 1 Capsulectomy

There we go. Everybody remember to unmute when you're inside the, um, app. I have not been reminding people, so we gotta turn on the live on Instagram because, uh, my stream key did not work. So we're going to talk about capsulectomy, uh, tonight. I'm going to start, uh, from everywhere, and then we will take it into the private community, go from there. Once again, I apologize The, uh, Instagram stream key was not loaded. Welcome everybody! Hi Leah! How you, Danielle? Hi Jody! Is it Connie? All right, filter in. I gotta see if I'm doing— I'm live on all these other ones. Can't see my mouse, but so All right. I am live there. Good. Let me know that I'm live everywhere. Chime in. I don't know how it's done. Oh, there I am. Yeah, you can live stream on all these platforms very easily through StreamYard, so that's what we're using tonight. We're going to talk about capsulectomy. I get asked a bunch of questions about it, so we're going to try to demystify the capsulectomy, uh, question. I didn't run off, one of my props escaped. So I'm going to try to make this very simple tonight, try to keep it all really simple. I want you to see my props. All right. Do you need to request to join? No, you can just join the live. Now, if you want to follow along in our community and get live Q&A with me, then you have to go into the community. So when you go into drrobcircle.com, you got to remember to unmute it. There's actually, um, there's no fee to join or anything. We just I get censored a lot for almost everything I do and say now, so we're not going to say dude too much where it's going to get me in, in, uh, more grief. So trying to avoid the grief right now. Got enough of that. Enough grief. Perfect. Everything is working. So I'll put a question out and then I want you to kind of think about it and chime in the comments. Needs to be interactive. Oh my gosh, Jess, what is going on? Jess, why can't you get on Dr. Rob's circle? Oh my gosh, Jess, where do you live? If you're in Austin, Texas, we're going to have to have you come by the office. We're going to have to load this on your phone. You're in Dallas? Come on, you got to be able to do this. All right, uh, I will post all the replays, uh, in the community. And then, um, I am working in the office tomorrow. If I have to have a call with Jess and like troubleshoot for you. I'm going to get you in the community, but I can't say all the normal things because it's just going to get me more grief. The reason y'all can't see me online very much anymore is because I'm getting censored. So that's the way it is right now. So I'm looking at my YouTube channel, which has one video with 6 million views, one with 2.8 million, one with 2.1 million, one with 1.8, and another one with 1.8. And you can't even see those videos online. Isn't that interesting? So if you go to my YouTube channel, videos, 1.3 million, 941,000, just goes on and on and on, but you don't ever see them 'cause they've taken 'em down. Yes, we're going to help you. I want you to get in so you can ask me whatever you'd like. And anybody who wants to come in, um, after my little spiel about capsule, I'll, I'll go over it. But I'm not gonna do more than just kind of educate you about what a capsule is, and everybody can chime in the comments and tell me what you think a capsule is, and then we can answer those questions. Happy to do that initially. That would be a good starting point. All right, I'm gonna check the comments here. Yeah, so capsulectomy, they're different types. Today I did what is referred to as a total intact capsulectomy, or an en bloc capsulectomy. En bloc just means you're taking it with, uh, a little margin of tissue around it. Everybody makes a big fuss about this, but it's really not very hard to do. All right. Anybody— gosh, who is on Substack? Let me see who it is. Just one person. It's probably my friend out in Las Vegas, Chris. Is it you, Chris? Are you the only person watching on Substack? Oh, that's pretty funny. All right, that's right. Uh, somebody said capsule is a scar— is the scar tissue. So what's the scar tissue really composed of? That's really the point of it. And then in part 3, I'll tell you like more of the very steep science about it. We're just going to introduce the, you know, the concept about it. And so any breast implant that's placed for cosmetic or cancer purposes forms a scar capsule around it, and if I don't hit my face or glasses. It's composed of collagen and some other cell types, mostly fibroblasts. And the, the nature of it is like when I see it in the operating room like I did today, they can be transparent like cellophane, they can be hard like a really calcified shell. Think like an eggshell but a really hard one, and kind of everything in between. So it depends on— yeah, there are different types of collagen, 1 and 3, but the point is it's just like a collagen sac. Your body makes this collagen sac. That's the scar. So there's all this, um, action or, or dialogue about the scar and etc. So your body forms scar tissue virtually everywhere I operate. And then when we place the implant for cosmetic or cancer reconstruction, it forms around there. And in the '70s, they created this system to describe the capsule, scar capsule, becoming tighter and causing changes, patients having pain. It's called the Baker Classification System and it was presented, I believe, in 1975 for the first time. And capsular contracture was a big problem with the initial placement of implants above the muscle. And when you review the literature, lots of things were tried to solve for capsular contracture. Or the tightening or firmness or thickness or hardening of the scar tissue, however you want to describe it. It's a really subjective set of criteria. So the, the way I think of it is they tried different solutions of antibiotic, they tried steroid, all sorts of things, and nothing really, uh, solved that until they put the the implant behind the muscle. And I have this theory that the actual kind of rate of contracture probably didn't change substantially, but the examination or findings that were— it was really subjective. The classification system is just 1 through 4. 4 is the worst. Painful malpositions. Um, and I took, uh, a patient's bilateral grade 4 capture contracture, uh, out today, and each of the implants was ruptured and leaking silicone gel, but it was all contained in the, in the cavity itself. Now, I've taken those out and they've not caused any of that calcification that I was talking about. Some of them have been very thin, flimsy capsules versus hard calcified, like rocks. So you can have any of this and everything in between. And these today were above the muscle, but many, many times, uh, in fact, the majority of the times since the moratorium, implants were placed behind the muscle because at one point all you had was smooth saline implants. And, and then with the reduct— reintroduction of silicone gel into the marketplace in '06, you had more silicone and then widespread use, especially in 2013 with the introduction of Sientra implants. So the The kind of capsule formation has always been there. People have always got tightness, firmness of capsules, and the way I was taught initially was it could be secondary to bleeding, infection, and then scarring sometimes is a function of just how someone heals. They can have more fibrous tissue when they are not good scar formers, things of that nature. So there was a lot made about the operation itself, and certainly you had a higher rate of capture contracture in patients who were having cancer, cancer surgery because they would have more extensive surgery. It was harder to just to do a, a more controlled operation where there was very limited blood loss because it's such a bigger operation. And then they had other treatments, other factors involved. So they, they just had more opportunity for problems. So excluding them and looking at the cosmetic patients, the thing that really changed the rate, quote unquote, was putting it behind the muscle. But I'm not convinced that really actually changes the rate. It changes the ability to identify whether or not someone actually has a capture contracture. So that being said, I have one little prop. And so if If you had blood in the pocket, that was always thought to enhance the formation or lead to a thicker, firmer, harder scar and a capsular contracture. So you always wanted to do the operation, especially in a cosmetic patient, with, uh, little to no blood loss if at all possible, with very little disturbance of the tissues. And then that gave you the, the best chance. And then obviously you want to avoid infections, so taking all the precautions about handling the devices carefully. Using— is, uh, before there were Keller funnels or any kind of funnels or devices, you could change gloves before you got the device. You always got it with new gloves and then protect the skin. Use, uh, different types of skin barriers. One common one was called ireband. And those were multiple ways to avoid contamination of the device. So got to diminish blood loss or any bleeding in the pocket to avoid a capture contracture. That was the big one. And then avoid obviously an infection, taking all those precautions. But throughout life, someone can get bacteria in their bloodstream, and that can lead to attachment to an implant? Hip, knee, breast, dental. Here we're talking about a breast implant. Now it, it can attach to an implant because the implant doesn't have a surveillance system. The actual elaborate system your body has to protect us is not going to work on an implant. It can't. There's no blood flow on an implant. What it can do is it can attach to an implant. So I happen to have an implant. Somebody's asking me about Motiva. This is a Motiva implant. And see there's a little yellow sticky inside this white wrapper, which represents the, the scar tissue. So if that yellow is bacterial contamination and this is not sealed, then what you can do is basically Oh, thank you, Connie. So the signaling can happen between the bacteria and the tissue over the top. So that's a really important concept because if you have that ongoing signaling back and forth between the bacteria and the tissues and it stimulates a reaction called think of like oxidative reactions. When we have more oxidative stress, that's like if we were working out harder, the tissues are, you know, quote unquote working out harder, they're building up free radicals, things are oxidizing, and the fatty acids in the breast tissue can oxidize. And there was some great work published by Dr. Mathun-Singhna. There's an interview on my YouTube channel with them with over, I believe, a million or 1.8 million views. I would highly recommend checking it out, and we've done some blog posts about it. Dr. Mathun-Sina, great scientific work, showed that that oxidative reaction can lead to macrophage polarization and more symptoms in patients with breast implant illness who report breast implant illness. So I thought that was a great piece of work and research that he did. And then what I did was when I was president-elect of the research foundation, I gave testimony at the FDA hearings in 2019 that I had helped fund research about breast implant illness and tried to better understand it. So that happened, and one of the papers that were published showed that there was 48% bacterial contamination rate in the study. The study was kind of smaller. And so in my own personal experience, I didn't feel that number was appropriate. I thought it was too high. So we published a portion of my experience, 694 consecutive explant specimens to look at the scar tissue. And it showed that 29% had bacterial contamination, predominantly with Staph epidermidis, and the other dominant bacteria were Klebsiella magnus. Both of them readily form groups together, which basically is biofilm, like little communities or villages of bacteria. And then they're hard to eradicate. Your body, like I said, can't do a good job doing that. So that's some like preliminary ways to think about capsule formation. And I've given several talks about capsule on my YouTube channel. I believe some of the blogs are up too. So you can go to DrRobertWhitfieldMD.com. You can check out my YouTube channel, Robert Whitfield MD on YouTube, to find those capsule talks. Maybe we'll put up a special collection of those. I did 3, I believe, in a row. I believe that's right. I've done so many of those videos, I can't remember all of them at this point. But that being said, so that, that's kind of like the beginning of, you know, your body forms a capsule. What are we trying to do to protect patients when we, you know, use an implant for cosmetic purposes or for reconstructive purposes? We'll table, you know, the different strategies for reconstructive patients as they are very different than the— basically, we wanted just a one-time initial operation for a patient who's undergoing a cosmetic augmentation. The other things to think about are avoiding, you know, things that could potentially contaminate, so not using things like drains. So this would be in the pockets. These are cosmetic cases, so cosmetic patients, you typically— there wouldn't be a reason to use a drain typically because that's another potential way to get a problem. Problem with an infection because the tube that comes out, bacteria can go inside from the opening in the skin. The other is folks who have more problems with wound healing, like doing surgeries where they're doing more simultaneous lift surgeries. The incisions sometimes can break down. That's another route to get a problem with an infection. So those are all things that, you know, can lead to in my head, you know, over my almost 30 years of, you know, taking care of patients, increase problems with capsule formation. So this is basically part 1. Now I'm gonna stop on the other platforms and just stay on my, my stream in my community now. So if you want, I would come into drrobcircle.com. It's free to join. We're gonna carry on the discussion. I'm gonna let everybody ask me questions. And then tomorrow, I believe we're gonna come on at, I believe, 2:00 PM. Let me look at my calendar. At 2:00 PM Central, I believe I have time tomorrow is what we described, 'cause I have folks that want me to livestream during the day for other parts of the world, and then other people just want it because that's a better time for them. So we're taking care of our folks in Europe and then folks who have more time in the, in the daytime. So tomorrow we are going to go live at— I believe it's 2 PM. I don't know. Yeah, 2 PM we're going to start. And so I'll do part 2 tomorrow. All right, hit me with a couple questions. I'm gonna end some of these and go into private community. I get asked bunch of questions about it. Sorry, that's my, uh, Substack just going off there. And it's fine to ask questions. Don't, uh, hit me if you got a question before we shut down and go into the community.