Robert Whitfield MD is live!

All right. Hi, everyone. Gonna get started in just a moment. Everybody can chime in. We are going live on Facebook, Instagram, TikTok and YouTube. Now, I'm Dr. Whitfield. We'll get started here in just a moment. We're gonna let everybody hop on here. So just give it a couple minutes. We're gonna do a little bit of a deep dive in terms of capsule capsulectomy and what I've learned recently about motifa implants and just going to. Give it a few more minutes. We have a lot of COVID a lot to cover. So I just want to make sure that I give everybody enough time to hop on it. In a couple more minutes, we'll get started. All right. All right. So once Again, this is Dr. Whitfield. We're doing this live today to discuss capsulectomy and why I in particular, perform capsulectomy in every case. And then I get asked a lot of questions about what implant is safe. And so we're going to discuss. I've taken every type of implant out of patients from literally all over the world. Just operating on somebody from Germany actually yesterday. And on my table, I have several types of implants, and basically implants themselves. And we'll go into it here in just a minute, are going to cause a response, and everybody's going to have a little bit different response. The. Sorry, I have one technical thing that I need really quick from my team. Okay, sorry about that. Now we can get going. So we're going to do a brief intro. We'll go through basically some of the things about capsule capsulectomy, and then we'll get to the. More of the what we found in our experience. So in terms of understanding breast implant illness for us in particular, I had a patient come to us in 2016. And so our journey with this has been to date, it's going on the 10th year. I consider breast implant illness to be a chronic inflammatory process, one in which a breast implant plays a central role. This is a process that's not unique to breast implants. There's all sorts of medical implants placed that have a reaction, and some of them create more and more inflammation. What we know without a question, is that breast implants create acute inflammation when they're placed. Now, think about it this way. If you step off a curb and twist your ankle, your ankle will swell. The swelling is acute inflammation. That same thing happens when a breast implant is placed. It can be even more pronounced when it's placed behind the muscle due to muscular swelling. Patients will experience soreness and swelling later on, that should subside. Once that acute inflammatory phase subsides, the actual, you know, if you want to think it, it's healed, then that that signaling stops. Now, there is scar tissue around every implant. Now, the thickness or the thinness of the scar tissue will vary in each patient, but every single patient forms a scar capsule primarily made of collagen around it. And as the swelling decreases in the acute inflammatory phase or signaling shuts off the bodily, you know, that part of the inflammatory phase ends. And then, you know, the more important question is to me, like, if everybody gets out of that phase and they're fine, what is the trigger or what makes them become, you know, chronically inflamed or what restarts that process? And recently I Talked to someone, Dr. Jabin Moore, about this and he, he, he said it's like the burden of time, and that's a good way to think about it. I always say, you can't pick your parents and you can't outrun a bad diet. And then to his point, there's this burden of time. So as I mentioned, in 2016, I had a patient who I was caring for who had breast cancer. Primarily in my career, I've done cancer reconstruction, had neck cancer, breast cancer, and sarcoma. So this patient came to me and wanted to go flat. Now, aesthetic flat closure has been done for a long period of time. And of course, I accommodated her request. I did her workup personally, as I do all my consultations in person, and found nothing abnormal on her exam. She had no evidence of abnormal scarring, pain, redness, swelling, tenderness, nothing. She had no laboratory abnormalities. So that patient in particular asked me to do a en bloc capsulectomy. And for everybody listening, en bloc means you take all the capsule out intact with a margin, and that's what you would do in a cancer resection. Now, I had always taken out of cancer patients all the capsular material and performed a complete capsulectomy. It wasn't always intact, and in instances where it's thick, it's actually relatively easy to take the scar out intact, especially in a cancer case. So I did that for this patient. And so as the patient recovered and saw us on follow up about a week later, we looked at her reports. Her pathology report shows she had no evidence of recurrent breast cancer, which is paramount, right? We don't want a patient to have recurrence, whether it's in the skin, the scar, or in the pocket itself. However, at that time, as I always did, I checked for any evidence of Infection. Now, at that point, point, we were using a very standard method for that. And it think of like using a Q tip and doing a swab. Then you place it in a vial, you send it to the lab, and they would incubate that on certain growth media to look for a different bacteria. Now, if you had suspicion of fungus or something called mycobacterium, you would have asked for very specific steps to be taken to look for that, and you would have done different cultures. Now, this patient happened to have an E. Coli infection. So to be infected, it has to have 10 to the six bacteria. There's, there's a benchmark for this. Now, this patient didn't have any abnormalities in their labs. They had no elevated white blood cell count. They had no over what we call elevated neutrophil count. And once again, no physical findings. She did have fatigue. And many patients who've underwent cancer treatments have fatigue due to bone marrow suppression and their treatments. So I treated this patient with oral antibiotics, and ultimately her fatigue result. And then in 2018, I had another patient come to me because now I had been placed in different groups as a plastic surgeon who would do explant. So I had people coming routinely for explant surgery. And I had a patient in 2018, she had wanted to have us do her surgery. And so she came and we did her surgery. But she had a very, very abnormal finding on her. Her tissues. It was almost as if she had a, you may have heard of gel bleed or a rupture and was very slick or slimy feeling. So when we looked at the implants carefully, there was no evidence of a rupture or anything like that, and we couldn't ascertain anything. So we felt these were most likely infected, and we sent off cultures like we had talked about previously. Now, in this instance, the cultures didn't reveal anything, and I was very suspicious of that. So we started investigating new ways to look for and evaluate just bacterial contamination outside of culture techniques that were traditional. And in 2019, we switched to only doing PCR analysis of all of our scar capsule specimens. In September of 2024, we published a paper of over 690 consecutive PCR tested samples to show that 29% have bacterial contamination. Now, that's important because in some papers that had been published, it was upwards of 48%, which I felt was very, very high relative to what we had seen in our clinical experience. So that's one thing that was always concerning to us is, you know, capsulectomy not being performed, especially in Light of these findings, where in some patients you had found upwards of 29% in this large series that we published have bacterial contamination. So if you left that in, that's a source of immune system stimulation, that would have not been removed. And I don't think anybody would do that. If every patient who showed up had redness or swelling or pain on exam that was consistent with and accompanied maybe with a laboratory finding of an elevated white blood cell count, and then everybody would think, oh, well, that that's clearly, obviously an infection. So now we know that 29% of the patients we explant have on PCR analysis, predominantly staph epidermidis and Cutibacterium Agnes. With that knowledge, we're trying to understand better how patients have symptoms. Papers have been published in particular by Dr. Muthoon Sina at any university medical center that show that that bacterial contamination can interact with the fatty acid in the breast tissue called oleic acid. And that forms a reaction that creates Oxylipin 10 home and other Oxylipens. Long story short is those will ultimately lead to symptoms. Now, you cannot commercially check for those right now. That was done in his laboratory. But that just adds credence to what we said. So if 29% have this bacterial contamination, and we know that in those patients that can affect the fatty acid in the breast tissue and lead to more symptoms, that also reinforces, you know, thinking about doing a capsulectomy because that removes that from the patient and takes it away from activating their immune system and, you know, these symptoms that they experience. So let's take it a step further and explore, like, what has been shown recently. And there was a paper published in July 2025 in the prominent plastic surgery journal about. They call it the Transcriptome. And so the title of the paper is Transcriptome of Capture Contracture Around Breast Implants Mimics Allograft Rejection. A matched case control study. So that's a very, you know, that's a mouthful of a title, but let's think of it, you know, simply. If an implant is placed, the traditional thinking was it forms a foreign body reaction. Think of like getting a splinter caught in your finger. You may get a bump around it. So that's more of a foreign body reaction. On examination, looking at pathology, it'll show signs of chronic inflammation. So when the pathologist looks at it under the microscope, they'll see cells like giant cells and histiocytes. And those are the traditional cells that form when you're looking at a foreign body reaction. But in this paper in patients they were looking at with, we'll say thicker, firmer, or maybe more tender scar capsules, and using the Baker classification from the 1970s, that is incredibly subjective. But nonetheless, that's what we have in this study to evaluate and other studies, they found that the scar tissue is creating more of a organ rejection picture. And so instead of a foreign body reaction where you have histiocytes and giant cells being formed, they're actually seeing more of a T cell, a B cell, and what's called a plasma cell response, actual antibody production in this setting. So that is the first paper to ever show that in the literature. But it makes perfect sense. The only time you wouldn't have or mount a rejection to get something that was implanted would be if it was from your genetically identical twin, if you had one. And that's how the first kidney transplant was done that didn't require any medication because it was from a genetically identical individual. If you are a non identical twin, which was the next step in organ transplantation done by Dr. Joseph Murray, who also ends up was a plastic surgeon, that required whole body radiation. And then when they started cadaver transplantation with kidneys, it required azathioprine and prednisone. And that was all meant to help block the patient's immune system response to the transplanted organ. Now, obviously, a breast implant is not going to be recognized as your own tissue, because it can't. Also, it makes sense that any debris that is left inside of a pocket, especially if there's a rupture or any debris coming off the capsule, there would be a T cell receptor recognition of that, that would show it to the immune system, that would activate your immune response. So that all makes perfect sense. And, you know, I've been asked routinely, like, what do I think are safe implants? And there are implants that are marketed, and I have different implants on my desk right now. This is a textured device. It's shaped. There's a smooth, round device. Here's an ideal implant put in by a famous plastic surgeon around the country that I took out yesterday. And then we have a device that, you know, we've tried to mimic kind of what scar tissue would look like around it. And we'll take the scar tissue and cut it. And the point is, when you take these things out without capsulectomy, it's very hard for me to believe that you're relieving the body of all the things that could be interacting with it, because the capsule itself does not go away. So if we take out this Motiva implant, which I explained it from a patient previously last month. Here's the implant. We took the implant out, but if the implant had bacterial biofilm on it or debris from the implant shell were to break off and get stuck in the capsule on the inside, we represented this with just some black dots. And the point being is if something's ruptured and leaking inside someone, even if the plastic surgeon were to take it all out, you wouldn't be able to see with eyes if you got it all out, because at the microscopic level, you can't see that. So leaving that in leaves a source of immune system activation. So leaving the capsule in is what I mean. The other thing is, if there's biofilm stuck to the tissues, you're just leaving it in there. So it acts as a continued source of inflammation. So whether it's a Allergan device, the Intra device, Mentor device, Motiva device, all of them will have a reaction. In particular, I get asked about Motiva, and it's, you know, marketed as something that has a really decreased capture contracture rate. So, once again, capture contracture is extremely subjective. There's not objective criteria about capsular contracture. And much as I'd like to say I hope that it does have a decreased rate, your body's still going to form scar tissue around an implant. And saying that it doesn't is not factual. It's not genuine. Anybody who reoperates on patients for various reasons for cancer or. Or any other revision would know that they have a scar capsule. Sometimes it's very thin, but typically it's very visible. And it doesn't just go away with time. Now, we're kind of taught that in training those things dissolve, but that's not been my experience. And I've done several thousand explants and thousands of reconstructive procedures for cancer patients and reoperated on them when needed and seen the scar tissue. So capsulectomy is. Is something that we do routinely. We try to do it intact. We feel like getting all the tissue out that could then potentially, if left behind, react to your immune system is important. The reasons are the following. 29% have bacterial contamination that we've shown on PCR testing. And with this new paper that we just discussed, that you're getting more of an organ rejection picture. So I just had a patient actually in the office who had a ruptured pair of implants from the 80s exchanged to a new set of implants in 2017, and ultimately it was her null neurologist, Dr. Thalgonda Praveen, who encouraged her to evaluate breast implant illness as a reason for her ongoing autoimmune type symptoms. Because she had had everything else medically worked up and to, to date, they hadn't determined the cause. So I, I think we just need to give patients, and if you're a practitioner listening, we want to give them the best possible information. So the literature reflects that 29% have bacterial contamination. These new studies show that there's ongoing immune system activation mimicking organ rejection at the tissue levels with activation of T cells, B cells and plasma cells. So. We, we want everybody to be armed with the appropriate information. And so with that, you know, I will say in the future we'll do a live about simultaneous fat transfer and explant, which I do routinely given a certain set of circumstances. And, and that will be our next live. So with that I will, I'll take some questions. My team is looking at all the comments now and we'll try to go through a number of these questions. Give me just a moment. All right, so now I'm gonna have to start reading these. So in the comments I have. Should your implants be replaced every so many years? So traditionally we did those. I started having discussions at the eight year interval because we had been taught the rupture rate goes up a half percent per year after 10 years. So it's important always to be followed up and make sure that it's being evaluated. Doctor, do you believe. Let me see. I just. Sorry. Doctor, do you believe that subvascular breast implants could be responsible for the high volume of fibroadenomas, nodules and cysts in both breasts? Fibroadenomas predate implants. Implants started in 1962. Could implants be affecting getting pregnant? I'm trying to decide if I should explant and get a lift after I'm done with kids. I've had a number of patients come to me prior to undergoing fertility treatment because they've had difficulty getting pregnant. Now that's a very specific set of circumstances that each person, you know, should get counseling about. I don't have specific guidance on that or can give you specific information on that. Are there specific probiotic strains we can potentially take to be protective in heading off biofilms? We don't have any specific literature to support doing that. And you can't eliminate a biofilm off of a device that's still in place because the device itself does not have a blood supply. You need a blood supply to deliver, we'll say, any of the, you know, effect that a probiotic or an antibiotic or an antifungal would actually provide. All right, who else. Had my explant 3 months ago? After 17 years, symptoms are still there. So we didn't discuss my program. Program, which is the Sharp method. I have a book about it. Basically, we look at genetic testing, toxicity testing, gut health, food sensitivities, hormonal balance. But in particular, we look at a total toxicity burden test to evaluate environmental toxins, things like mycotoxins, things like glyphosate, phthalate, any kind of chemicals, herbicides, pesticides you could have got exposed to, because those can continue to give you symptoms despite an explant. All right, who else is there less risk of capsular contracture under the muscle versus over the muscle? Oh, that's a great question. So. So, my. Oh, wow. I'm glad you brought this up. So I don't think the actual capture contracture rate changes. I think because you change the position of the implant, it makes it harder to determine whether there is a capture contracture. So when it's behind the muscle, there's more tissue between the examiner, me, and the implant, and when it's behind the muscle, there's more tissue between you feeling that and the device, if that makes sense. When it's above the muscle and just behind the breast, I think it's much easier to both have the patient say, oh, well, this feels tender. This is sore. This is changing. And the examiner then can confirm that more easily. All right, I have 10 new messages on TikTok. Let's see, let's see, let's see. I can see all these. No, I can't. Who else? Oh, Megan, you're asking me if my daughter, who's 17, wanted implants, would I talk them out of it? So my daughter's a LEO like me, and I can't talk my kids out of anything, so I would explain to them the risks and benefits. And that's all you want to do? You want people to make the most informed decision? That's most important to me. It's not talking someone in or out of something. Have you seen patients with PancyToPenia related to BII? No, I have not. No, the most common thing I've seen is either decreased white count or I've seen people come to me for elevated platelet counts, but those are just very few and far between. Can intracapsular rupture increase the risk of developing BIA alcohol? So BIA AlCl is most common with the texture devices. And I don't know that they have any information on that specifically Brandy, so I can't answer that. All right, what else do we have? Is this all? Trying to get all these answered. Oh, here we go. Implanted motiva. Could I take any supplements to help ward off biofilm from forming initially? So a supplement to ward off biofilm? No, I, I think, you know, maintaining appropriate levels of supplementation. So if someone gets tested as a low vitamin D level, then supplementing for that would be helpful. If there's absorption issues, then we recommend liquid based supplements. I have a lot of patients with absorptive issues, so we use a lot of liquid based liposomal supplements. So the question is, if you currently have textured implants, should you explant? So I don't actually ever tell anybody to explant. We simply provide I, I think the best, most up to date information so everybody can make their decisions. The textured implants of course have to be followed because they have increased incidence of bi. ALCL. Have had implants for 21 years now. I feel burning sensation around implants. Is that a symptom of bii? So a burning sensation is typically nerve related. And the 12th intercostal nerve is one of the nerves that runs from the back into the armpit. And we do see that involved in the scar tissue. And so that can be responsible for that. Especially if it's like one sided. But it can be on both sides. Why is the term en bloc understood by most surgeon surgeons only in the cancer situation? Because that's what the term is. It's a pathology term. Capsulectomy is the term most commonly used when communicating about work around breast implants. How long of an explant do you have to wait to do a fat transfer? If I don't do the fat transfer simultaneously, we usually do them around six, six months. Kitty cat. I have double lumen implants from dow Corning from 1990. I am 69. Think it's safe to get new ones? Well, those implants are definitely past their prime. So you should see your surgeon get those evaluated. Decide what works best in your situation. Brandy says I can't wait to explant. I have intracapsular rupture with recalled allergan. Highly cohesive 410. Yeah, I don't recommend anybody have a rupture device or if someone comes to me with a rupture device, I recommend they have that removed. I would not watch that. Yeah. Wonder Woman 6227. It will be posted later. Yes, it will. We recording everything. Becky is asking, can implants make your thyroid antibodies elevated but normal thyroid function? So if your. Your TPO is high, I mean, there's all sorts of reasons for that, I think, you know, there is a lot of work done as it relates to just thyroid. So people have elevated antibodies who don't have implants. So I would go through and check all the boxes, and then, you know, if that workup revealed itself to be negative, then you can consider, you know, the implant. I do explant and lift routinely together. Yes, Carol. Yeah, that's fine to do. I'm a certified FDNP practitioner. Do you have any openings for health coaches on your team or should I inquire on the website? Well, we're always looking, you know, to. To expand the team. Currently, right now, we'll just take note of your CV or resume, and when we have openings, we'll let everybody know. We'll post them. All right. What else? Had explant but. Got back. I have high red blood cell count. Do I postpone? Yeah, little red. I don't know. I don't postpone people for having a high red blood cell count particularly. That's common in people taking trt. I do not do explant, lift and tummy tuck at the same time. I do explants and lifts, and I do something called a holistic mommy makeover where I do a fat transfer and I dress the tummy, but not with excision. I do it with something called body tight, and we perform liposculpture. Michelle says is detoxing necessary after explant? We found it to be be important to preoperatively look at a patient's toxicity level and burdens and then help them develop a plan. We use cellcore for detox, typically. And that's a homeopathic, if you're not familiar with it. I have a whole team that runs that. They run my Sharp method. And for folks who don't explant with us, we have a group program for Sharp as well. So anybody can go to the website drrobertwitfield.com you could get a discovery call about Sharp. Or if you're interested in learning more about X planning with us, you can set up a time to speak with me. Is it crucial to replace implants every 10 years, even if nothing wrong, fact or myth? No. So once again, I addressed this earlier. We started having discussions about that at year eight, typically, because the rupture rate goes up a half percent Per year. They just have to be surveilled. You can do that with your surgeon or another surgeon. There are a number of ways to do that. Well, we're glad you're feeling well. A N o o V. All right. Should someone with POTS or autonomic dysfunction avoid getting breast implants? Carol, I find POTS to be a very challenging thing to deal with. I've had a patient recently, we explained with pots, and it got a little bit better but did not resolve. So I would be careful about that. I don't have enough information to guide you on that. I just be careful. All right. What else do we have here? Do I have other questions? I guess I can run all these. I talked for a long time. No, I haven't performed a breast augmentation over five years. I take implants out, I don't put them back in. I do autologous fat transfers. So I do fat transfer for augmentation or do explants and fat transfers. Or explants and lifts and fat transfers. But I don't put implants in. No. What do you do in case of tethered tissue on the side after explant? In other words, the nipple is stuck to the chest wall and doesn't heal. Hard to pull away after six months. So that's something that we would do a scar release and fat transfer for. You don't need a lot of fat. So even if you're a very thin person, you can have that done. I'm sorry you're experiencing that, but that can happen certainly in thinner patients. Yes. Brandy, we do preserve the natural breast tissue. We don't take breast tissue out. That's not part of the program. We reshape a breast mostly with just re draping of the the skin tissue after excision of excess skin from stretching or just having excess skin. I'm trying to make sure I get all your questions answered. All right, Anybody else got a question for me? I heard fat transfer is risky. Ed, fat transfer is not risky. No, that's not a thing. So fat transfers work very well. That will be our next live, so we'll have to tune in for that and learn all about fat transfer, but it's. No, it's not risky. It's not risky to perform, and the results can be extremely predictable. You just have to pick the patients and prepare them properly. Oh, I have eight new patient or eight new questions here. Okay, hold on. Is sudden cardiac arrest in a 23 year old rare? I'm not a cardiologist, so I can't give you the exact numbers on that, but I would consider that rare. Yes. If someone's very thin, is it better to go under the muscle? That would require an in person exam. And did I get everybody covered? Going to go to all the phones here and make sure that we got all the answer questions answered. Let me see. Okay anymore. Beth, you're showing up late here. Do you have a question? Compared to getting implants, is it worse pain for explant? Ah, I'm glad you asked that question. So pain control is something that we take very seriously. I have a group of very devoted anesthesia providers who do ultrasound guided nerve blocks before we ever operate. So it's done before the patient goes back and that helps create a nice level of pain control before we ever start. And then we do nerve blocks as we complete an area of the work and then in recovery, because we've done all that and prepared the patients very well preoperatively, they do experience really, really low levels of discomfort when it comes to just explants and explants and lifts. Especially in some cases, patients do not actually take narcotic after the surgery because we use short acting and long acting local anesthesia and we also have an anti inflammatory and something for nerve symptoms. So most patients in my experience don't want to take any narcotic and my patients in particular are very sensitive. So I think on a whole we have a very good system for that. Oh, someone's asking if we do virtuals. Yes, I do virtuals for people all over the world. So yes, you can have a virtual with me. Of course. If you have an explant and you have a lump, would you remove the lumps at the same time as the explant? So you, you don't want to go wandering around into the tissues taking things out at the time of explant. That's not something I do. I don't take out lymph nodes and I don't take out other areas of tissue. Question is, what if someone's taking narcotics already for a chronic pain management? Then we just work with your pain management physician. We don't increase or change what they're doing. If you've had seven surgeries and don't have much tissue left from multiple contractures and remove scar tissue and are very thin, can you still reshape the breast enough? So that is a very specific question. We would have to review your case individually, but that would be one where if I could do a fat transfer, that would be ideal. So I think that would be without seeing everything that that would be what I would try to do. If implants become a health issue, why would this not be covered under insurance? So I haven't had anything to do with insurance since 2019. And cosmetically placed implants are usually excluded from policies. But you can certainly file a claim with your provider regarding any surgery that you have with us. We give everybody all the information. I just don't work with or deal with insurances at all anymore. So for general. Oh, somebody's asking the question. No general anesthesia. So the patients can have what's called a teva, which is IV sedation. And then patients can have general anesthesia via gas. So it really depends on the, on the, the patients and their needs. Each person can get their case individualized depending on what their. What best suits them. All right, I think we're going to wrap it up, everybody. So we'll follow us on social media@drrobertwitfield.com is our website. I'm sorry. @robert whitfieldmd. Just type that into either Tick tock, Instagram, Facebook or YouTube. Follow us on those platforms and you can subscribe to our YouTube channel. We'll put this whole thing up in long form once we've had a chance to go through it and edit it. Are implants under the muscle harder or more complicated to remove there? You know, honestly, Jennifer, that's like 90% of the things I do, so I'm pretty used to it. All right, take care, everybody. Bye bye.