The Fastest Path to Natural Breast Rejuvenation | Dr. Randall Feingold

Your mention of radiation is so important to me because my earliest experiences with fat grafting, working breast reconstruction patients who have radiation therapy typically around an implant, no matter what you did with the capsule solution. But one of the problems we had to treat was the impact on skin that's been radiated where it gets thickened and firm and it develops vascular or surface markings and hyperpigmentation and it becomes woody and it loses its viability and softness.

Welcome to the show. Today. My guest is Dr. Randall Feingold. He is the founding partner of New York West Reconstruction and Aesthetic Postum Surgery.

In Great Neck, New York, where he.

Is the medical director of ITS Quad ASF. He has 31 years of experience with cosmetic and reconstructive surgery. With expertise in microsurgical respiratory structure. He draws patients nationally and internationally for.

Surgery with emphasis on capsulectomy and aesthetic respiration of the breast with autologous fat graft. He is the director of flustering at St. Francis Hospital in Leslie, New York, and goes as a professor of surgery in the Zephyr School of Medicine at.

Hofstra and a member of the patient.

Safety committee as the American Society of.

Plastic Surgeons Aesthetic Society and the International.

Society of Aesthetic Plastic Surgery.

I let everybody hear. Constructive microsurgery. So I really appreciate that. I didn't want to like squander the conversation because method us have have been up early. Dr. Kingold's already been to the hospital, seen patients, and now he's in his office giving us precious moments of his valuable time. So, Dr. Feinkle, from my audience, they've heard how I got in to do an explant surgery. Can you relate your experience maybe through what we just discussed and other. Any other stories?

Certainly. And good morning and thank you for having me into this conversation. Dr. Whitfield, you know, I know of your reputation as well and I respect your work and I'm happy to share my experience. I've always had a breast centric practice. Breast reconstruction is very important to me, treating women who've had mastectomies for breast cancer or gene mutation or strong family history. And I've had a strong cosmetic breast augmentation practice for many years, up until recent years. In terms of moving away from breast implants. In the breast reconstruction world, I favor natural tissue solutions. People call that autolycus fat solutions or autologous flaps. I'm a microsurgeon, so I transplant deep flaps from the abdomen and occasionally inner thigh or buttock flaps to provide natural tissue solutions for women. When it comes to the long term, follow up of my reconstructive breast implant patients. There have been so many instances of patient symptoms related to implant ruptures and textured implants that have been recalled from the marketplace, symptomatic contractures and systemic symptoms from their implants that I frequently explant those patients with total capsulectomies and restore them with usually deep flaps. And this was as recently as yesterday. And in practice, when patients come in seeking augmentation, my preference is autologous tissue, meaning autologous fat transfers, fat grafting. And I see that commonly in young girls that have asymmetry or women who've had pregnancies deflated, they want a breast lift, they need some volume. They don't want an implant. I'd rather not put an implant in either. I show them the results of fat transfer, and they're happy. And because of the reconstructive and cosmetic backgrounds, I seem to have attracted patients that seek explants. And they want doctors that are willing to listen to their symptoms and their concerns and not have them minimized. And being able to offer them diagnosis and treatment and aesthetic refinement of their breast after the explant has really solved problems for many women. So now I have an explant practice locally and regionally and nationally, sometimes outside the country, of women who have these concerns and they want to be treated by someone who's sensitive to their concerns and understands and believes their symptoms and can provide them with the technical solutions involved in explant surgery, which are unique and important. And for many of these women, restoration of the breast, because just because the implant didn't work out doesn't mean we've lost value, you know, in the breast. The breast is still important to these women. And so an equal component to my concerns is having them come out of their explant with a breast that they love, whether they're in clothing or out of clothing.

Some of the most challenging cases, obviously, are low BMI patients, which we'll get into. But you brought up a really, you know, salient point, is you're in a unique position with your background and experience in reconstructive surgery to have a discussion with whether it's a cosmetic patient or a patient who has found out they have breast cancer to lay out a series of options that other, other people can't. And I think that I get asked a lot why a fat transfer, like you mentioned, is not offered to patients as frequently. And I'm sure as you understand having your background with breast reconstruction in general, your experience level as a Practitioner in that arena. It provides so many more repetitions, I guess, when I think of it like that, because you would experience so many more opportunities to provide that for patients in a, you know, post mastectomy situation. Because you would, you would see that more frequently. And I often describe that to patients like if, if, if the patient I first took care of who had bilateral capsular contracture after a post mastectomy implant based reconstruction that I then converted to a deep flap, if that was a patient who was experiencing, you know, symptoms, you know, back in 2005 when I started doing that. And for you, around those times with deeps or earlier even that was a. You probably intuitively knew that when you took that product out and removed the capsular material that you had an autologous reconstruction and you knew intuitively that it would heal. Due to your history of taking care of patients with problems with radiation injury or infection or trauma and doing a flat reconstruction. Maybe you can highlight that because I don't think really most people understand those. We understand them. And it's very difficult if you don't have that level of appreciation for that technical ability and that kind of decision making.

So you've brought up many different points very quickly there. But before we talk about issues of capsules, for example, your mention of radiation is so important to me because my earliest experiences with fat grafting were in breast reconstruction. Patients who had had radiation therapy typically around an implant. And no matter what you did with the implant or the capsule, they're never going to have a great result if you don't convert them into a non implant solution. But one of the problems we had to treat was the impact on skin that's been radiated, where it gets thickened and firm and it develops vascular surface markings and hyperpigmentation and it becomes woody and it loses its pliability and its softness. And the early experience we all had in fat grafting was taking body fat from a non radiated area and injected it into a radiated area of skin. And then watching improvements in the skin color and texture and softness. And I believe now everybody understands that there are factors in non radiated fat that improve the environment, Adipose derived stem cells and other regenerative factors that are within the soft tissue of our body. The body is smarter than the doctors are. And if we learn how to harness these intrinsic components, we can do a lot more healing with that sometimes than we can with a knife or a suture. So fat connecting for me came from treating radiated patients and then in later years an appreciation for problems with Implant capsules, not just in the reconstructive patient, but definitely in the cosmetic world. And how to properly manage capsules for patients that had implant related complications.

I know it's a big bucket when I say that. I guess I got a little excited because it's rare that I get to discuss that with somebody who understands that so well. You know, we talk about, probably amongst ourselves, you know, the work that Rigodi did out of Italy and how quickly that changed our interpretation of what you could do with fat. And, you know, I've been just like you have been moving fat around the body and getting it to heal for over 20 years without any issues. And when I hear someone describe fat grafting as a risky or difficult maneuver to do for a patient, it's a little confusing to me because it does work. It works uniformly well given some specific factors and situations. But to your point, you could put it somewhere that's been extremely damaged through radiation treatment and get both, you know, improvements in vascularity and texture and pigment and everything, including, you know, the scarring that may exist.

So it also took a while for me to become a believer because as a microsurgeon who transfers flaps of tissue, which are pieces of, say, fat that have an artery and a vein and have established blood supply, you know, in contrast, when you inject fat, these are grafts, meaning they have to get blood supply from right the neighborhood that you inject the fat into. So for a microsurgeon to move from vascularized fat transfers to, to avascular fat grafting, you know, I needed proof of concept for a long time. And using it not just in radiated patients, but to kind of blur the boundary deformities around breast implants and thin skinned patients and then augment my deep flaps with volume and then learn to replace implants with body fat, you know, that was a big learning curve. And now, you know, I give lectures on how fat grafting has fundamentally transformed my practice. And I'm still a microsurgeon. I still believe in microsurgery. But fat grafting is a very important tool that we use in all these different types of patients.

Yeah, absolutely. It just, it's the skill set I always like, you know, you can have a discussion and I can have a discussion about things. Because of the experience you had in each of those different technical areas. It is, it's always fascinating to me when I get patients coming in that had such a. I think that's what the, the rub is, right? It's hard to make an informed decision if you don't have all the information.

And you also mentioned, you know, technique. I change the way I harvest fat or prepare fat or inject fat because the goal is to get higher and higher percentage takes. And, you know, in my training and in the continuing education we get, there was a movement toward filtering fat, centrifuging fat, adding things to fat. You know, my thinking has, has evolved. 360. I kind of like to take it straight out of the tap and right back into the body. I want minimal manipulation. I want to keep it at body temperature. I'm not looking to spin it at thousands of rpm. You know, I want to harvest fat without too much blood and fibrous components. So I tend to emulsify fat with an ultrasonic tool called the vaser, which comes out like a fine milkshake and doesn't have clumps of fat in it. For uniform harvest and uniform deposition of fat, I only use small cannulas, meaning small tubes that are no more than 3 millimeter diameter to harvest fat because again, I want fine particulate fat material to transfer. And I put it into a sterile collecting system and then immediately transfer it to syringes and then inject it by hand under low pressure manual injection technique with continuous motion through the body area that I'm injecting to lay it down in a very uniform way. I don't like when I see people use giant diameter cannulas, taking chunky fat out and then using a pump to put it in under pressure. You know, that scares me. And I don't think that you can get as thoughtful a deposition of that to get the kind of sculpting or shape, you know, or volume augmentation, you know, that you want with those kind of techniques. And I want the highest percentage take. So technique is important. And, you know, I'm constantly, you know, learning and changing what I do based on patient outcomes. But it is a very safe and fairly reliable technique. And patients shouldn't be scared about dangers related to it because it's safe to harvest it, it's safe to inject it. Nobody's getting cancer from injecting fat after all. The population that we've done so much fat grafting in is in the breast cancer population. And we study those patients, they get so many imaging studies for years to come. And there has never been a case, you know, a fat graft associated, you know, cancer development.

I know that was. I, I remember when, because I did a lot of sarcoma reconstruction and that's, that's the cell type where you can get a problem. So you have to be cognizant of that because of the mesenchymal origin. I, I totally agree with you on particle size. I do 3 to 4 millimeters. Always nothing above and really nothing below. And I have adopted a low pressure reinfusion system and I am happy with that. But I, I did hand for 19 years, 18 years, so I've kind of transitioned out of that. But I agree, like all of the things that you can do to optimize for the patient to give them the, the benefit of an autologous, you know, transfer is hugely important. And I guess, you know, as we transition from both, you know, your flat brick construction career and autologous fat transfer and kind of explain for the audience your, you know, how you got involved with doing explan for quote unquote, I guess ASIA systemic symptoms, ssbi, breast implant illness, whatever we're going to call this, you know, entity now that's been around for a very long period of time and has grown in I guess, recognition. You know, we were at the breast implant hearings in 2019 where I testified about it. And then we've gotten some research done, some of which we helped fund when was President Acerf. And then now there's more papers coming out that are more basic science papers which I find very interesting maybe that we can get into. But what was your kind of sentinel experience with a breast implantolis patient?

So, you know, for many years I had heard about reports of symptoms related to silicone and yet there were so many papers that seemed to, you know, refute it or rebut it. And in fact I lived through the era of the Dow Corning implants when they leaked with high frequency and had severe contractures. Because I went into practice in 1994, I got to inherit complicated patients who had their implants placed in that first generation of implants from then retired plastic surgeons you had put them in the 70s and the 80s and then the period where implants, the silicone implant was banned in the United States and we can only use saline implants. And then the period where textured implants appeared to allow us to use shaped implants, which we thought were so great until there were problems with inflammation and malignancy associated with certain types of macro textured implants and the removal of that from the marketplace. You know, and I was kind of blind through all of that about, you know, is there some basic intrinsic risk here, you know, using implants? Until patients started explaining more and more about their symptoms and I have to credit, you know, patients with teaching me about what they were experiencing. Part of it was being minimized or rejected or demeaned by maybe an originating plastic surgeon who told them it was in their head. And then I started to see commonalities amongst patients and it wasn't simply brain fog or symptoms that might mimic more psychiatric type of symptoms. There was genuine hair loss, there were skin rashes, joint pain. I've had patients come in with pulmonary conditions and, you know, listening to them and giving them the opportunity to explain what they felt in their gut was going on, I started to operate on them. And frankly, you know, nobody knows your body better than you. And if you trust patients to inform you that something's wrong or, you know, and they've gone already for general medical workups and endocrine workups and rheumatologic workups and infectious disease workups and they're all coming up negative. And then after you explant them, their symptoms improve or resolve. Maybe not 100% of them, and maybe the mechanisms behind their symptoms may not be identical on every patient, but I began to appreciate that there was something there. Now we know at this point the FDA acknowledges systemic symptoms related to breast implants and resolution of symptoms in some patients with explantation. It's on their website, it's mandated in the patient decision checklist. The American Society of Plastic Surgeons has, you know, produce their own website information and printed materials that align themselves with current fda, you know, opinion and recommendations. But, you know, this happened very organically in my practice by just paying attention to patients. And then it wasn't just a question of explanting them, they were requesting removal of the capsules, which was a different concept, you know, for me to digest because it takes a bigger operation. And fortunately, because of my background and treating so many of the ruptured Dow Corning implant patients in the 1990s, I was already accustomed to doing total capsule removal because there was no other way to treat those patients. When they had densely calcified, rock hard capsules that were like big dinosaur eggs in their breast containing just liquid gel. You know, opening those capsules to take the gel out was a mess and the calcified capsule could not be left behind. Whether you did nothing or whether you put another implant in because you could feel it, it was pathologic. So I disappointed those patients by telling them they needed an incision in the crease of the breast that they might not have had originally. And then I would lift the breast and skin up like opening the hood on your car and expose that capsule and do a total capsulectomy. And I never saw the ruptured contents that was in it until it was on the back table. I didn't have a name for the operation. I didn't call it on block. It was really just what was technically necessary to treat those patients. So you fast forward 20, 30 years in your practice, and I'm not inventing a new operation today. This is something that's been in my skill sets for the entire duration of my practice. But I'm implying I'm applying it now for so many different patient populations. It's definitely the safe, clean way to remove a ruptured gel implant in any patient.

And I just pause you there for a second because you took care of this first generation of implants that were problematic, if not the first two sets of. Of generations of implants. And the other day I took out set from 1986, and it was as you have described. And I try to tell everybody the same thing. It is like taking out a bag full of syrup. There's just nothing more difficult. If that stuff starts going everywhere in a pocket that we've created with that type of gel, maybe you can, you know, for the audience, give them the visual of, you know, hey, this is a really bad actor. If in fact, I let all of this go in the tissues, you know, without a doubt.

You know, we're doctors and we can't ignore some, you know, obvious facts here. Silicone gel that's evolved for decades and being heated at 98.6 degrees for all those years was never intended to be left behind in the soft tissues of the body outside of a silicone envelope and or its capsule. And so, you know, conscience drives you to do the right thing for the patient and remove that capsule and not have leakage of it into their body. And it's what patients nowadays request. They may request that type of operation merely for systemic symptoms. Some of them have symptomatic contractures. Sometimes they're calcified, sometimes they've undiagnosed ruptures. And the patients with textured surfaces, we can get into that, you know, later on in the conversation. You know, there's a commonality of approach in managing the implant within its capsule for all of these different indications. So once you become comfortable doing total capsulectomy, then it's a natural extension to be able to offer it to patients with all different scenarios. You know, what I wasn't prepared for many years ago when patients were coming in with Systemic symptoms was that they had knowledge of this ahead of time. They were talking amongst themselves. They were requesting capsule removals. They were suspicious of whether it was going to be done properly. They wanted photo documentation that it was being done. You know, there's no other type of operation I've done where patients come in with these really specific requests of technical performance and evidence, you know, that it was done. I wasn't really concerned about the technical performance because it's something that was already, you know, steady state in the background of my practice. I just didn't understand why they wanted it initially, because it's a bigger operation and it takes longer and implications of how it affects the remaining breast and managing the pectoralis muscle properly and whether there's a drain tube involved. And then how are we going to take care of a breast that's had total capsulectomy explant in terms of its aesthetic appearance. But I've worked through the evolution of these operations and their outcomes and seen the aesthetic outcomes and then developed protocols for how to do the operation and how to maximize aesthetics if the patient wants. There are always some patients that say, I want out, and I don't want anything more than that. I'm not looking for a lift. I'm not looking for a fat graft. I want to feel healthy. I want to know that this was done a certain way and I'm going to abide by the patient request. But majority of women, if they placed an implant, they had a certain concern about their breast, whether it's size or shape or symmetry, and it goes to the sense of femininity and sensuality and motherliness. And just because the implant didn't work out, as I mentioned before, doesn't mean we forget about the breast. And so it's really important for a lot of these patients to be able to offer them aesthetic restoration or refinement at the time of explant to the degree that we can. It may or may not always be perfect, but we don't forget about that. So I do hear about explant surgeons that will not offer breast lifts and. Or fat grafting at the time of explant.

Very strange.

I really don't understand that concept. The patients are uniformly told, wait a year, there's inflammation, the blood supply is going to improve, you know, come back. And when I ask those surgeons, how often do those patients come back, they don't say, like, yeah, 5 or 10%. Yeah, I'm doing breast lifts or fat grafting on, you know, maybe 75% of my explant or 80% of my explant patients. And some of them say, if I knew the breast would be this good with this approach, I never would have put the implant in.

Right, right.

You know, I'm learning from them. Not to mention the, you know, we can talk about scenarios of symptom improvement and, you know, how we do capsulectomy and how we restore breast. But, you know, this is really important to women who have had problems with implants. And I'm not saying that of the 10 million women walking around the country with breast implants, they're all. They're all suffering. Many of them are famously happy with their implants and oblivious to them. But there are enough symptomatic patients that we have to take care of them. Right. And tell them that this is the way it's supposed to be, or just accept it.

Well, let's do this, because I, like you, hear a lot of feedback about what is being said to any given patient. Like you said, there's these absolutes, like, you can't do things simultaneously, which obviously, in your experience, know is not the case. My experience as well. So let's just say, you know, a lift obviously can be done in almost every instance that there is any issue regarding a width issue or a height issue or a ptosis issue or whatever for everybody listening. Basically, if you have a saggy breast with a device, you know, Dr. Feingold might do a lift for you and help address that. At the same time, I do get told a lot that people are informed of how this is a very dangerous type of surgery to do. And I'm gonna. I'm gonna let you fill in the back. I'm just gonna take the easy part, which is the. Just take the, you know, plastic Easter egg approach and open it up and have the top half of the Easter egg shell. That's the top half that Dr. Feingold and I always see in the operating room. It's. It's very plain, and it's not difficult, typically, to separate from the breast. It becomes a little bit more challenging on the muscular plane between the anterior capsular surface and the actual posterior surface of the pectoralis major if it's behind, which in our country, the majority of them are behind. But really it becomes like, how, doctor, how does Dr. Feingold protect the chest wall? Or how does Dr. Whitfield protect the chest wall? And you get all. You'll get asked about your. The danger of a pneumothorax and all these issues. And I hear, especially plastic surgeons, I Think with different levels of experience. I try to describe this and I don't know if their intention is to fear monger or it's just a lack of experience in reconstructive surgery or dealing with the chest wall that makes them uncomfortable. You know what I mean? Like their comfort level dictates how they respond to a question.

Well, I think you're spot on there. If any of us as surgeons want to talk a patient out of an operation, we can elaborate upon risks and dangers and accomplish our goal. And if it's an operation we don't do routinely in our practice and we don't feel comfortable with it, that doesn't mean we should malign the operation or exaggerate the risks. Maybe we want to find the right practitioner who does this on a regular basis and has developed skill sets and reliability and a better safety profile. You know, these are operations that definitely require paying attention, taking your time. I may spend an hour plus on each side doing careful total capsule removal. For those patients that have implants under their pectoralis muscle where the back surface of the capsule is adherent to their rib cage, I think there is a little bit more pain associated with it taking it off the ribs. There may be some additional bleeding concerns as opposed to taking it off the pectoralis muscle if it's just a sub glandular implant and capsule. But I could count on one hand the number of patients I've taken back to the operating room within the days after these surgeries for bleeding after total capsulectomy in the last, say, 10 years. Oh yeah, I think the bleed risk is relatively low. The pain is controlled with intercostal nerve blocks. You know, I use long acting anesthetics and inject it into the interspace when I do this. When it comes to getting into the intercostal muscles, into the chest cavity and introducing air, which is called a pneumothorax, or actually damaging the lung where you have a leak and would need a chest tube. I hate to say this, but I haven't encountered that yet in countless cases over many, many years. You don't like asking plastic surgeons about these, you know, their complication rate with these things because, you know, with karma, you don't want to have your first one next week. But I have to say it is reliably a very safe approach. And if somebody doesn't feel comfortable developing those skill sets, taking their time, that's fine. You know, if someone came to me today with their child and said, you know, my baby had a cleft lip can you repair it? I could say, yes, I can do it. I was trained to do it in my residency, but it's not what I do every day. You know, that child deserves to go to somebody who does cleft lips every week of their career and focuses on it. And they're going to do it not just more efficiently, they're going to do it far better and far safer with better outcomes. And the same can be true of patients with complicated implant scenarios who seek, want, or deserve or need total capsule removals. You know, if you're comfortable doing it, do it. And there can be very good safety profiles. If you're not comfortable doing it, don't change the operation that the patient deserves to have to suit your technical skills. You know, tell them that this may be the right operation for you. It's not what I do every day. We have a colleague who does this, and all of us should put ego to the side and just find the best solutions for each patient.

When I hear the probably just like you, I get frustrated when I hear the discussion that someone had. So I just. I think, you know, what I try to explain? The patients are, if you're talking to Dr. Feingo, just like you said, and you said you want a cleft done because you're Dr. Feingold and you trust Dr. Feingold, but Dr. Feingo says, I'm not your guy. You know, that belongs to somebody who does those all the time. Where Dr. Feingold does press reconstruction or breast procedures, predominantly, that's his wheelhouse. That's what he does all the time. He can't do it. But you don't want to ask somebody to do something they're not necessarily comfortable with. And I just tell patients the same thing. If you're having that discussion with your plastic surgeon and they don't feel comfortable or they start giving you reasons like you said, of why this is not safe or xyz, then it's fine just to go different, get a different opinion.

We recognize that for what it is, and apparently increasing numbers of patients recognize that also. I think there are scenarios where total capsulectomy is absolutely the right procedure for the patient. I'm not making that statement based on an FDA guideline or a society guideline or what's printed in a textbook. It's from taking care of real patients for over 30 years and seeing so many different problems come up with implants that need to be solved and just not being afraid to get to the right solution or to tell patients, I think you should do it this way. If they say that's more of a procedure than I want to have, then I may say that's fine. You will find any number of practitioners that will accommodate you. But I don't do partial capsulectomies in these scenarios. I do total capsulectomies. And there are reasons why, and I've seen it help so many patients. So, you know, I let my conscience guide me in terms of, you know, procedure selection.

Yeah, I agree with you too. I have been doing this long enough and understand the ramifications of contamination, pathological findings. So there's no reason, you know, to do a partial if there is enough capsule, obviously, to remove. There are some people that, you know, come, that have a very cellophane type capsule. That's a, that's a different scenario that each of us has to face, you know, surgically. Let's transition to like, you know, and I appreciate from learning from you and hearing from you, discuss your thoughts of your process in the operating room and we'll just go outside of the, you've done the capsulectomy and now what are you going to send things off for? What are you interested in learning more about? To understand and help your patients.

So this is on the diagnostic side, you know, because patients come in with various symptoms and we may not fully understand what's driving those symptoms. Is there autoimmune, is there an inflammatory response that's not autoimmune, but yet stimulated by the implant content or the implant shell or something that's in the capsule itself? So I do total capsulectomies. I photo document them for my patients. I send them to our local university hospital laboratory for pathologic analysis and they will look at inflammation and in certain scenarios they will look to tell us if there's malignancy there, particularly if they had the now recalled biocell macro textured surfaced implants that have a, you know, likely causative role in breast implant associated anaplastic large cell lymphoma. I've treated that disease. I've treated breast implant associated squamous cell carcinoma. I have inadvertently found B cell lymphoma, inadvertently found T cell lymphoma in breast implant capsules. What I don't want to tell a patient is we found this in your capsule, but unfortunately half of it's still in your body. So when you see enough of these things happen, it gives you pause and it makes you grateful that you took the whole capsule out. But it's like a bacterial colonization and in rare cases, a fungal colonization that I Identify that I think may have causative roles for certain patients. And we can talk more about that as well, because I take biopsies of the lining of these capsules and I send them for bacterial cultures that take about a week to come back and fungal cultures that typically take 28 days to come back. And I was shocked when I started doing this at the high frequency of positive findings. You know, probably a third of my patients have bacteria and there's maybe only one or two a year that come back with fungus. But you know, for all the conversations about biofilm on implants and plastic surgeons accepting that as if it's just the benign reality that we don't even have to consider in any way, I started to think, well, you know, maybe this is not a good thing. And you know, even the people who focus on preventing capsular contracture now have a multi step plan for minimizing contact with implants to minimize the introduction of bacteria during the initial index operation when the implant was placed to have softer long term results. But I think the presence of organisms that produce inflammatory products, enzymes that they secrete, can certainly you can imagine that that would predict symptoms and maybe not classic symptoms or appreciable, like classically appreciable symptoms in patients, but. And all you have to do is start to correlate, you know, capsulectomy explant with symptom relief. And you know, I'm not saying I know how to connect the dots in every single patients, but the goal here is to make people better. So when you start seeing these reports coming back, and I'm talking about, you know, the common agent is cutobacterium, which used to be called propionibacterium. When you've got that bacteria in your skin, those inflammatory enzymes caused like pustular acne. It certainly got no business living in a woman's breast for a decade. But all types of staph varieties, including mrsa, mrsa, streptococcus varieties, including unusual varieties that are in oral flora, in our mouth or in vaginal flora. I have no idea how these could possibly have gotten into breast implant capsules. But there's an expression, if you don't take a temperature, you can't find a fever. If we never looked, how would we know if there's something there? And the more you look, the more you find. And then you can't look away anymore, you can't avoid it. And so my standard protocol is every capsule gets removed in its entirety. They all go for pathologic analysis. The yield May be low, but it's not zero. 100% of them get bacterial and fungal cultures. The yield is high. Then you have to have conversations with patients. If they were symptomatic and they had colonies of organisms in their capsular tissue, we're not talking about swabbing the implant, we're talking about embedded in their capsular tissue. If they've got colonies of organisms in there, if they've got symptoms preoperatively, do they deserve to be on an antibiotic for a more extended period of time? No, they're not classically infected. They don't have 102 fever, they don't have pus coming out, you know, but perhaps it's traversed the capsule, perhaps the microbiome, the bacterial flora of their breast has been altered and they've got some of these pathologic organisms in their breast that the average woman wouldn't have. So, you know, the protocol and the management of this has grown over the years, at least for me.

Yeah. And we don't differ dramatically in terms of our understanding of there's a contaminant. I mean, we will agree that that contamination rate, just like you said, and I felt strongly about published reports where it was 48% and it was kind of just brushed under the rug, was a real problem for me. So we in our audit knew it was about a third like you were describing in your series. And so we published a paper last year using PCR to show that at 29% in over almost 700 samples. So we totally are in alignment with, you know, there's a contaminant, it shouldn't be there. Obviously, you know, the, you know, both you and I have been around implants from other providers and probably I would say orthopedics is like the, you know, standard bearer in terms of when they place devices, their behavior around the device and the operating room. They're in, you know, specific, specific airflow designed rooms, they're wearing suits and all these extra precautions are taking. So, you know, to your point being as cautious as possible when placing a device, you would obviously do just like I did. Placement of a breast implant after a tissue expander for an implant based reconstruction. When you started doing that many, many years ago, you would take great care, but you always knew that that person was at a much higher, had a higher risk of problems postoperatively due to the number of procedures they had had. It was not like placing a cosmetic device. I guess the, the thing you mentioned about cancer is very, resonates with me. My Sister passed away this past year with breast cancer after a very, very long time of dealing with it. And you know, if there's one person that you or I miss that had a cancer that we didn't find because we didn't send something that would be one too many. And that's how I always feel about that problem. And so just like you have, every single person I've ever taken capsule out of, I've sent because I was trained that way and I would never deviate from that. I find it appalling that I hear patients tell me that their capsule wasn't sent because you're going to miss a handful of, you know what breast cancer, not just really the lymphomas, it's. It's more routinely going to be a deep lying breast cancer that's missed in my experience. And I find that extremely frustrating to hear about.

And there are plastic surgeons practice explant surgery and promote and develop having an explant practice that will say they don't routinely send the capsules for pathology for reasons that I don't understand, such as yield is too low and there's an expense with getting a pathology report. The patient may have to bear that expense if insurance doesn't cover it. So I can't relate to that type of thinking. This is just simple principles of being a good doctor, I think.

Yeah, I'm not aligned with the concept that you shouldn't send things to. I guess you miss 100% of the things you actually don't look for. So that would be one reason not to do that.

And you don't regret the patients you don't operate on?

Yeah, I mean it's very.

I do capsule removal for these obvious reasons that we talked about. The ruptured implant, the textured implants that, you know, are, they're not really. There's really no recommendation for removing textured implants by the fda. They recommend monitoring people. My, my gut doesn't feel right with that because there aren't a lot of scenarios where we know there's a risk and we'd rather wait for a patient to develop the symptom of a developing cancer to treat them. I just don't think it's that morbid to a patient to remove a device that may be putting them at risk. Although I don't understand surgeons that take out the textured implant and leave the capsule behind because when you remove textured implants you find that they are adherent to the capsules. And pulling the textured implant out of the capsule is like peeling apart two pieces of Velcro that are stuck to each other and they shear apart. So I have to believe you're leaving some particulate of that textured surface behind in the capsule. And the capsule is the biologic material that forms the lymphoma. Someone's going to get sick. So for me, if you're going to remove a textured implant because of those reasons, the risks, you should be removing the capsule. And people say, well, we don't have proof yet that it's going to prevent cancer. Well, we do know that these cancers don't form in people who don't have these implants. You know, I just don't know what the big fear is of taking them out. If people want implants, they can have them replaced with smooth implants, but get the capsules out. And I also treat patients that have, you know, such bad contractures. Some of them are reconstructive. They can't take a deep breath. You know, that capsule is so stiff on their rib cage. You know, it's almost like having a plate of metal armor tacked from rib to rib to rib. And when you remove that back wall, the capsule, you immediately see their rib cage expand. You know, the, the ribs can separate from each other and the intercostal muscles can expand. They've got excursion again in their, their chest wall. And people with capsular contractures, whether they're radiated or not, whether they're cosmetic or reconstructive, you know, they, they learn that they can, their breathing's improved and association between chest wall restriction and anxiety and, and people feel much less anxious when they can take deep breaths again and they can walk up and down stairs more readily or participate in, in gym or sport activities. You know, so there's, there's advantages when we do capsule removal that are mechanical. For certain patients, they may be preventive or therapeutic. With certain types of cancers, they may be therapeutic with regard to bacterial contamination or fungal contamination and systemic symptoms. You know, this is not one operation for one reason. There are many reasons why we offer it to different types of patients and they each get assessed as to their motivations. And once you're comfortable doing it, then you do the capsulectomy and it's usually very uneventful. Then you have to move on to the cosmetic part of it, which may or may not involve lifts or fat grafts or both. Or as in the case I did yesterday, a deep flap after capsulectomy in a patient with 12 year old reconstruction that she had pain and rippling and animation deformity from. So these operations are here to stay. More and more plastic surgeons are developing the skill sets and embracing them and we're going to help more and more people.

I think the thing you brought up about chest wall restriction, Both you and Dr. Fang have discussed it and it's a real entity. I think going back in the literature. You can remember when they did all the reduction studies and showed increased lung capacity basically after a reduction. And then you're, you're adding to it, right? So you're taking volume off, so you're taking weight off the chest and you're restricting the scar tissue that's restricting the excursion to your point is being removed. So like you're getting even more improvement than you would have thought of in the reduction, reduction study. So I think of them, obviously it's not the same, but when you're removing, you know, weight, that's one component for sure. And then you're taking it a step further where you're actually quote, unquote, removing the scar tissue that's restricting the expansion of the cavity.

And this is in the patients that by and large have the sub pectoral submuscular implants. Right. The capsule is plastered rib cage and they appreciate that improvement even if they're not the radiated cancer patient who's in a worst case scenario, who feels they haven't been able to take a breath in years and have chest wall pain. They're highly symptomatic. So, you know, we have mechanical benefits from these procedures. We have symptom improvements related to being able to take deep breaths. You know, I've seen, you know, all types of other improvements related to resolution of migraines, restoration of hair growth, the absence of skin rashes that were plaguing patients, improvements in joint pain, patients with pulmonary bronchospastic conditions that have been weaned off of biologics. You know, there's so much we don't know about the presence of implants and long term, you know, symptoms in patients. You know, I'm thrilled if the majority of women with breast implants don't have symptoms. If they're, they're happy with them. God bless. Right. I think that we, we don't minimize, you know, patients who have symptoms and try to relegate them to, you know, a bucket of people that, or somehow psychosomatic, which they're really not, and just offer operations that can be done very safely and be prepared to handle the aesthetic outcomes when we do these operations.

I think I want to ask a Couple questions of your thoughts. Since you found so many people with bacterial contamination and there's a growing amount of literature to support both the interaction of the biofilm and the breast tissue leading to kind of downstream what we see in terms of symptoms. So like fatigue and dry eyes and myalgias and things like that which both of us see resolved after, after explant. And then some of these newer concepts of things like fibroblast growth factor 19, where that's been something that is elevated and then returns to more of a normal state. Because you and I both would like to have a biomarker to be able to follow our patients and know that that is getting better, or identify them pre op and say, oh, hey, well, this is what we find when someone has cutobacteria agonists or if they have staph epidermidis, this biomarker is relevant. What are your thoughts about the. You know, what is a growing amount of evidence supporting these biomarkers?

I mean, I would love to have a tool like a diagnostic tool, screening tool, or a tool that allows me to follow patient response over time, both before and after surgeries. You know, in the old days, we had very little to go by. There was the erythrocyte sedimentation rate, the esr, and then there were complement factors that were looked at and then certain clotting factors. And now there's more significant understanding about inflammatory pathways in the body and drugs that we use to treat inflammation. And perhaps there are going to be precise markers that we use in the long term. I'm not a laboratory scientist. I don't know all of the potential markers that are being studied out there, but I do believe there are going to be answers in that universe ways that we can say this patient with symptoms has an elevated biomarker and that gives us more confidence that if we do this procedure, they're going to get symptom relief. Because I don't know how to guarantee that to patients. I just knew that many patients are improved for any number of reasons. But we definitely need to invest more in this type of research because the immune and inflammatory pathways of the body have much greater impact on our sense of wellness and health than we understand and that we appreciate. And it has, you know, not just diagnostic implications, but therapeutic implications, you know, with agents that block certain inflammatory, you know, or immune pathways. So that's an exciting field and they look forward to, you know, hearing more about consistency, you know, and application of those markers. Because we don't have like a perfect diagnostic test yet or a perfect way to follow someone other than their symptoms.

Right. I mean, that's these potential options I'm going to interview. I interviewed Dr. Mathun Cena about his work with Oxylipin 10 home. And then we look forward to interviewing the group out of the Netherlands about fibroblast growth factor 19, because that seems to be a promising biomarker. So I think more and more of these obviously will come to be studied. And like, to your point, it'd be so nice to have something to follow.

I look forward to hearing those interviews. How does somebody you know, do you, do you catalog these interviews? Are they available on the web? Is it physician only? Is it available to the, the lap community?

Yeah. So I interviewed Dr. Cena on my podcast and it's on the podcast and it's also on YouTube and it's a. He's such a bright scientist. I think you and I can have a conversation because you and I are kind of the same in terms of levels of understanding of problems and things like that. When a super sophisticated scientist talks about things, it gets to be a little challenging. And I interviewed him and tried to summarize it as easily as possible for the audience listening to keep it so it's understandable and relatable. The take home points are the interaction between the bacterial contamination and the fatty acid in the breast. The, the breast, to your point, is very lipid rich and the oleic acid is oxidized and that oxidative process forms a molecule, oxylipin tinho. Now that is something that can be looked at by a laboratory. And currently we've introduced that scientist to a laboratory to help commercially develop a test that is not gonna, you know, for both Dr. Feingold and myself, that's not going to resolve every single patient's question about what is causing what, because not every single patient is going to have staph epidermidis, which was what was studied in this scenario. But there are other oxylipins. He published a paper where there's five that he found that had higher amounts in patients with breast implant illness, symptoms, SSBI symptoms. So that's an option. And then that group out of the Netherlands, I have not formally interviewed them on my show, but I've reviewed their paper once again, like Dr. Feingold and I talking about surgery, it's easy for us to do, but when we read these papers, sometimes it gets a little complicated.

Yeah, that's, that's true, of course, but we need those people out there doing that basic science research. Oh, yeah. So that better applications, you know, to help our patients one day.

Yeah, for sure. Well, thank you for coming on today. I really appreciate it. I know you have patience see us do. I so really appreciate you coming on.

My pleasure. Every time I have these conversations, I learn something as well. And I thank you for the opportunity.