Why These Plastic Surgeons REFUSE to Place Breast Implants Anymore | Dr. Landon Pryor

I have a really great opportunity today. I have Dr. Landon Pryor with me. He's out of the Chicago area and Florida area now. He has two locations where he practices and looking forward to having a conversation with him about, you know, his practice now maybe, versus what he used to do and why and things and challenges probably that both of us have had at one time or another in practice, whether it's patient related, business related, or society related. So welcome to the show, man.

Thank you. It's great to be here. It's a lot to unpack there and hopefully we can cover it all in a short amount of time. But like you said, we're definitely at a point where this is an important topic that we need to be talking about. I know you've been beating this drum for a long time, but it's just so important, and I'm glad that we're getting some opportunity to talk about it.

Yeah. So Landon's not saying the quiet part out loud, but we both do explant surgery, and I do it predominantly now, when we were just kind of talking before we came on about what I'm doing specifically now. And for most of my career, I got into plastic surgery mainly rooted in an avenue for reconstructive surgery for cancer. So I did head and neck cancer and I did breast cancer, of course, and then I did sarcomas, which is like an orphan cancer. So for us, I gave this talk recently and I was in a. I don't know, it's a room of 3, 400 people, whatever, and I changed up the deck. Like they had you submit a deck and say, what are you going to talk about? I said, well, change it up a little bit. And I think the perception of plastic surgeons are, is it's facelift, tummy tuck, breast tug, lipo, and that's plastic surgeon. That was really never my career. So for 19 years, all I did was manufacture different body parts out of other body parts to reconstruct a cancer defect. And that was, to me, the most interesting, exciting thing I could do. So I spent all those years training for nine years after I got done with medical school. And so I said to the audience, I said, you never would have met me unless you had a head neck cancer, a breast cancer, a sarcoma. You're on your desk, doorstep in the icu, or you had been in a really difficult accident or home fire, or there was something really traumatic that had happened to you. I said, at any given time, there's only a couple hundred people around the world that walk around who do what I do. And they was like, I was looking around, I was like, well, that's. And that's how this has become with explant surgery. I've been doing it a long time now and wasn't really very vogue to do when I started doing it. I did it for a cancer patient initially. So maybe start there. How did you, from a plastic surgery perspective of maybe doing a broad range, get more narrow?

Yeah, absolutely. And I think probably our stories are very similar as it relates to that. I know a lot of surgeons that have really embraced the explant space and explant movement also come from a reconstructive background. Like you. Like me for lots of reasons. I think doing a proper explant requires a certain skill set that not everybody has. I think that I also did fellowship training in reconstructive surgery. Now, yours was in microsurgery, mine was in craniofacial and pediatric surgery. But there's an element, I think, of the surgeons that really want to focus on restoring health and wellness to patients, in addition to helping them look better, do it through the lens of helping people feel better and function better in society. And that's really why I went into plastic surgery. For the first part of my journey as a plastic surgeon. I started in practice in 2009. I did predominantly reconstruction like most plastic surgeons do. A large part of that was breast cancer reconstruction. So, you know, like you, I didn't do microsurgical breast reconstruction, but we did obviously en bloc capsulectomies and all kinds of breast reconstructive techniques for women with a history of breast cancer. So you get experience and the skills needed to be able to do a proper en bloc capsulectomy when, you know, the calling for BII came up. And so I was doing that in practice as I was building up my aesthetic practice from say, 2009 until, you know, call it like 2000. I went into private practice in 2013. So, you know, gradually I started doing less of the reconstruction, more of the aesthetics. And, you know, that whole time. And I know this is something that you talk about and I've talked with plenty of other plastic surgeons about, you know, we were always taught in residency and fellowship and I trained at top established institutions across the U.S. implants are safe, so no issues there. Put implants in, you're making patients happy. And so as a plastic surgeon, that was always our goal was somebody comes in with a perceived imperfection or insecurity or self esteem issue related to their body or their breasts and we want to be able to help them. And from our perspective, putting implants in was one way to do that. And what ended up happening in my career was around 2017, I started seeing patients with breast implant illness in large volume. And I got invited to speak, actually at a documentary with a number of advocates in the Chicagoland area. I invited, I think, like, all the Illinois plastic surgeons where I was practicing, and I was the only one that showed up to talk about breast implant illness. And at that point, I had done all the research, I understood the problem with bii and I just continued to kind of go down that rabbit hole of, you know, what is breast implant illness? How legitimate is it? You know, what do we see with patients that present with bii? What's the underlying pathophysiology? Cause all the same questions I'm sure you've asked yourself over the years. And as you start doing the explant surgeries, for me in high volume in 2018, it was like patient after patient are getting better, getting better, like miraculous recoveries, turnarounds. I don't need to tell you about that or anybody else that does explants in any kind of large volume. And at that point, this was around 2019, 2020, I was like, you know, I'm just not putting implants in anymore. Like, I understand informed consent, but I mean, I just can't justify putting these foreign bodies in. In patients knowing that, you know, even with appropriate disclosure, they have this chance of going on to getting something that could really be pretty detrimental to their. To their life and to their health. So I gave up putting in implants, you know, seven or eight years ago, whatever that is. And in addition to doing. Continuing to do aesthetic plastic surgery outside of explants, I, you know, gradually built up my explant practice, you know, did several hundred explants and, you know, between, I would say, like 2018 and 2022, ish, around that time period, I could kind of Fast forward to 2025 if you want, but that's kind of my history with BII and explant surgery.

So going back into. And I always, like, try to explain this for the audience, right? So we're in Texas. I live in Austin. You came to visit for this show. I always tell everybody the country of Spain fits in Texas. So unlike Europe or areas of dense population, our country is so massive, so expansive that once you get outside of an urban area like Austin, into 30 minutes from here, you're in literally the country. And your access to plastic surgery goes down. Your access to microsurgery, it goes away. And so people always ask me, why are so many implants used? Well, of course, of the folks who get reconstruction, that's going to be predominantly done with implants. Because at every community based hospital, smaller volume centers, plastic children with the appropriate training can offer that service, which is definitely appropriate. But like you said, I don't get the, the in my head, I try to track like, okay, when I was placing devices for cancer reconstruction, I always made this big deal about an infection. And I'm sure you had this philosophy as well. Like it seems like on Friday or Saturday night, I would always get a call and the patient, red breast, red breast. And you know what that meant? That meant admission, IV antibiotic therapy, if no resolution surgery the next day. And I was like, it gave me. And just. And I'm not ever anxious, I'm not a nervous person. But God, that always used to drive me nuts, that component of it. And because I did microsurgery that predominantly, that's what I did. I, I couldn't as, you know, it takes a lot longer to do micro cases. So just by sheer amount of time, I could never put in as many devices as I could actually do micro cases. So it didn't make a lot of sense. And then I had patients get referred to me who had capture contractures or, you know, the radiation injuries or maybe they had an infection on chemotherapy and extrusion or whatever. The laundry list goes on and on. So I got into this before I knew what either breast implant illness or asia or whatever it was being called at that point. In 2005, when I started doing micro, I was taking care of patients who had problems from devices because devices are inherently going to have problems or foreign bodies. So it doesn't matter if it's a hip, knee, breast, dental implant, you name surgeon, I've taken care of their problem because I did microsurgery. So when everybody is like, you know, this is a new thing, it's not a new thing. Anybody puts in a device who's a surgeon, especially an orthopod, plastic surgeon, neurosurgeons, There are a lot of high stakes with devices. Hip knee implants, like if you got an infected knee implant, you know how difficult that is for the clients, the patients who, you know, have to deal with that. And then, you know, then the orthopedic surgeon is calling you to help take care of that. You know, I got that all the time.

Yeah, that's what you did. I mean, this is nothing new for.

You yeah, it's a lot of big. How do you want to think? There was a lot of stakes riding on those devices. So I always, I guess my point is I always had a more than healthy respect for device. When I had those conversations with patients, I probably was a little bit more hanging the crepe, so to speak. Like these can always get infected and these are not lifetime and the. These should be replaced on an 8 to 10 year.

So you were setting appropriate expectations based on your experience as a microsurgeon. I definitely give you credit for that because I think that's somewhere that generally we fall short as plastic surgeons is doing an appropriate informed consent. So we can talk about that.

I think that's the most common theme that I hear out of patients. Never told it was not a lifetime device, never told they needed to exchange because of that. And then obviously because of now the awareness breast implant illness and, or. And we can go into like, what we consider that to be. I think it's kind of comical that we still use the same descriptors about infections that were derived in the 50s, given the amount of capability we have relative to 1950 to describe an infection. So infection still as we sit today is called 10 to the 6th bacteria per high power field. And it's just kind of nonsensical. So I switched away from using that basic laboratory technique in 2000 at the end of 18, when ICU nurse traveled from New Orleans, her sister lived in Austin and she wanted to get explanted here and stay with her sister and have me do it. So we took care of it. And probably just like you when you do an explant on the back table when you're done and you're looking at the device and going, you know, over that for the patient, either on video or stills or whatever, you know, everybody's preferences. I took the capsule material off and these things were all slimy. They weren't ruptured. So you know as well as I do what that means. That means a couple things in my head automatically given my device history with orthopedic devices, vascular grafts. That's infected.

Yeah.

And it's like I went out and I confidently told her husband, probably like you would. It's like, hey, you know, this is infected at that point. I use drains exclusively on my cases, which I haven't used in the last, I don't know, five years probably. And I, I said, it's gonna be fine. The cultures will come back, they'll tell us what it is, and we'll just treat her and be fine. Well, I'm sure you've seen this culture result before.

Normal flora see it all the time.

And so I was like, well, this is a bunch of. Because that's not what's going on here. This is biofilm. And I was fortunate to work around enough vascular surgeons who were the guys who published the papers about vibrating vascular grafts to get the staph to come off. And that was the biofilm, because you remember, they were the ones blood vessel grafts that got infected were.

Yeah. I mean, we're talking about saving extremities. I mean, very big deals. Yeah. People losing legs and arms and everything else. Yeah.

So I switched to PCR testing then. And so since February of 2019, I've only sent everything off for PCR. And then Methun Sina published his work about the Oxylipin 10 home found associated with Staph EPI biofilm. And then we published our series on PCR testing that shows that in our series, kidobacterium is above staph epi. But I don't. I don't really care. That could flip depending on your patient population or mine. So the point is it's there. And instead of, I think, acting like we're in 1950, that the infection.

There's some threshold that we're not achieving.

Correct. Right. So that as for Everybody listening, the 10 to 6 number comes from urinary tract infections based on studies done in the 50s in symptoms. I mean, we have to get just a little bit more accurate these days. So I don't hedge my bets on something from 1950. I don't drive a car from 1950. I don't live in a home from 1950. For all you who love classic cars and classic homes, that's great. I think we have to move forward and using things like pcr, because PCR is a very effective tool in this situation to better characterize it. So if someone were to come in with a difficult to treat UTI because your patients come in with this as well, I immediately. We're not sending that off for a standard urinalysis and culture and sensitivity. We should send that off for PCR to see exactly, you know, what is there. And. And for everybody listening, PCR is DNA fragments, dead or alive. So it's like the crime scene, essentially, analysis. So I know that's a big departure, but I think that's one of the elements that's incredibly important when describing that to patients. Because when I used to tell a patient cosmetic or Cancer, this can get infected. Like they all get inflamed. 100% of everything you've ever taken out is inflamed because it's a foreign body.

Anything you put in the body that's foreign is going to cause inflammation. I mean, that's kind of the bottom line, right? Yeah, that's.

That's like 100% the case all the time. Hip, knee, breast, dental, it doesn't. It doesn't matter. As soon as you put it in, body walls it off. Chronic inflammation. You look at it on pathology and you'll see the standard, you know, histocytes and giant cells and all the things. But then, you know, the reason we do PCR is to further. Just codify what I believe and probably you do as well. Many of these are. Have a. How we're going to define infection, because in you it'd be different. In a client with a compromised immune system, be very different. And that's something that, you know, everybody's at the end of one. Right. You're your own biological experiment, if you will, and you can't be standardized like the things from the 50s were describing with a urinary tract infection.

Absolutely. Yeah. I totally agree with you. There's not many plastic surgeons doing that level of analysis like you're doing with the PCR and really kind of analyzing what's contributing to this patient's symptoms. That I think, more importantly, what can we do about it? When you do your PCR testing and you identify that there's a bacteria that's present, like there probably is in most of these patients, how do we change the paradigm or the treatment for patients with BIIs so that they can hopefully improve more than what they're already gonna experience?

Well, that's something to get. I did this case this past week, and I mean, without saying the quiet part out loud, the texture devices are certainly much more stimulating, as we know those are most.

I got a whole story about that. I'm not even sure we should get into it on this podcast, but yeah, that's a whole separate discussion.

Well, I think. And we can keep it not. We can keep it more high level and say, like, obviously what I was going to say in terms of texturing and inflammation is far more stimulating.

Well, that was the whole point of the texturing of the devices to begin with.

Right. The salt loss texturing specifically. We don't need to name a vendor because everybody knows when I say that what I mean. But that's literally, like I tell people, smooth is like the great plains Salt loss is like the Rocky Mountains, and that's the interaction with the tissue. And then that kind of helps people better understand, like, what's going on in. In terms of. When we mentioned surface area contact and interaction, because. So that everybody listening understands this, the scar capsule is this. We'll just say collagen bag that your body forms around the device, but it's not impervious. It's not like going to block a nuclear bomb. So it's constantly allowing interaction between.

That's a great point. It's not a firewall.

No, it's allowing the interaction between the device and the breast tissue or the tissues. We'll say. And so I think Muthun Sina's work is great, and I love to. You know, Muthune is from Indiana University, and I trained at Indiana University many, many years before he ever showed up. And if you know anything about the Midwest, they don't fanboy each other. Right. So a scientist from the University of Michigan wrote a glowing commentary about his paper. Now, you know as well as I do the University of Michigan would not write some great paper about somebody's IU paper. That's a classic Big Ten matchup. We don't do that. Just like we wouldn't do that about Illinois, et cetera, and Wisconsin. That would be the other.

I did go to Illinois, by the way.

But you.

I understand. You know exactly what I mean.

Yes. So he wrote that, and it's very elegant. Right. And when you speak to Muthune, Muthun's an incredibly bright researcher and scientist, and he says, you know, Rob, the bacteria that's on the implant continuously interacts with the tissues through that capsule because it's not impervious. So maybe for everybody listening who has a nana who quilted or something, that is a good example of something that's not impervious. You spread it apart and you can see the openings or the interstices. And that allows the interaction between the bacterial biofilm and the breast tissue. So imagine you have some biofilm. Imagine you have a texture device. How stimulating is that to tissues over time?

I mean, it's a rhetorical question because you don't need to be a plastic surgeon to understand how that type of device in the body is going to create chronic inflammation.

I'm interested to ask you something because I find this question to be odd. And we trained at times that are pretty similar. So I remember starting, and it just made me think about this because all implants started out really behind the breast. And there was this Paper I read in the 80s, very famous plastic surgeon you would know of, but we don't need to name them, wrote this paper and it said, you know, these devices don't cause this problem in rabbits, mice and dogs or something of that nature, but in women. You put them behind the breast, they all, you know, 30 to 75% get capsular contracture. And then, I don't know, you know, how you were taught. But when I came up, the moratorium was in place already.

And so it was during my training is, you know, when we had the moratorium in place. Literally when I started in practice, it was, you know, I had just been lifted when I was doing my last year to a fellowship. You know, people were putting implants, silicone implants back in.

So they were putting them in.

Yeah, yeah.

So it was. I started at an 96. So it's all smooth saline behind the muscle, basically. And I, I guess, historically, did you get taught why other than it was just saline, it was going to be harder to exam or harder for us to determine the edges and palpability and all the things, because saline implants, because they're filled with water, always denser and feel firmer than a silicon device. But, like, I don't really think capture contracture incidents changed at all. I just think you put more tissue between the examiner and the device or the client and the device, because it seems to be the same.

Yeah, I think there's a number of variables. So obviously, when you're going under the muscle, you might have a contracture that isn't as evident. You know, you might have firmness around the implant, but because it's camouflaged by the muscle, you don't see that translate to the breast tissue. So that's kind of. We were always taught that submuscular devices have a lower incidence of capsular contracture. But I mean, the reality is it's probably not changing the incidence, it's just changing the presentation.

It's like, I've been duped my whole life, and I was just reading papers and I was like, it's like a bait and switch, right? And plastic surgery. I was taught you to fix it or you hide it. Right? So in reconstruction surgery, many times you're like, it's a combo because you can't, you know, I can take the fib you and make a mandible out of it, or I can take the abdomen and, you know, that use the skin and fat and make a pressure construction as a deep flap, or I can, you know, do a sarcoma reconstruction that who knows what that'll end up looking like alts or whatever you know, is done. But you can't ever do specifically all the components like for like. But I was just like, man, you put that behind there and you just made it very difficult to determine a baker grade two or three, because how could you? I'm sure you're good with your hands, you're a good examiner, but you have to have tactile feedback through your brain in order to understand whether or not that's really a problem. And the smaller the device in a retro pectoral position, you could never figure out honestly, how much is capturing tractor. You can't even examine probably a third of the device. So you would never really know.

Yeah, I mean, the interesting thing is my understanding is, you know, the texturing devices were put on the market to begin with to try to lower the incidence of capsular contracture so that they could put in shaped implants and put them over the muscle. And that obviously turned out not to be the case. And just to the contrary, I think there's probably a higher incidence of capsular contracture with textured implants. And as you know, those were taken off the market predominantly not that long ago. And now there's a newer, you know, what's called nanotextured device that's been back on the market. And you know, that's kind of a whole other story. But, you know, ironically, they, they would advocate that, you know, this textured device has the lowest incidence of inflammatory reaction compared to any other implant on the market. And so, you know, we can talk about the science. I know everybody likes to talk about the science, but it's not always as transparent as what I think you and I would like it to be.

Yeah, and I guess I would table discussion about that particular device because one, it hasn't been out very long, and two, you as well as I know all those things in the end will circle back. So devices are always going to have lots of limitations. And I don't argue really anymore about should we or should we not use devices. I think what we can all do better in terms of discussing with patients is giving them, okay, this is what I know now, and we know a lot more than we did five years ago about this and whether the topic is breast implant illness or chronic inflammation, and devices like you can have a more clear discussion with patients about those specific problems, and then they can make as they should make the most informed decision about.

Yeah, it's not hard and I don't know exactly your belief system. And I say this, I'm not trying to get implants taken off the market. I'm all about having patients make an informed decision and understanding the risks, the long term risks of getting implants included, including breast implant illness and doing our job as plastic surgeons like is required by the FDA to talk about breast implant illness so that in my opinion, patients, if they do develop symptoms months, years down the road, they know at least to get treated, to see a plastic surgeon to potentially get their device out. You know, what really is unfair to the patients is when they're walking around with breast implants, they're sick, they've got breast implant illness and they're being gaslit and dismissed and you know, put into other categories of chronic inflammatory conditions and being treated with, you know, medications and other therapies and really all they need is to get their implants out.

I feel like when folks come in now and I still get the, oh, I went and saw my plastic surgeon and they said breast implant illness was actually not real.

Right.

And I was like, well, that's not exactly true. When I was in, you know, the plastic surgery organizations, I was the co chair of the task force for the FDA meetings on breast implants. And then I gave testimony and then when I came president of the research foundation, one of those societies, I said we would provide, you know, resources to do studies and studies were done. And those in my head were always meant to be pilots for bigger and bigger studies. I think a lot of things we probably, if we studied them more carefully in larger groups, it would give us a better understanding. I think small group studies always lead to some biases and I feel like it's a little bit odd and certainly not in the patient's best interest to not listen carefully, to try to understand where they're coming from. Now I don't envy any like gp, rheumatologist, obgyn, anybody trying to understand this problem with the patient sitting across from them. Because how could they really grasp that problem if they're not really switched on to a device problem? They're just like, hell, they may not even know the patient has a device because, you know, people don't put this on their records a lot. They don't, they had it done when they were 18.

That's a really good point. Yeah, I mean, and the patients don't know enough to even bring it up to their physician. I mean, sometimes they do and they get dismissed.

Right.

But you know, I'd say to your point, very commonly it's probably not even discussed as a possibility.

That's something that I. So I try to give everybody, you know, room. Right. So, like, the patients, it's always two way street. Patients have to be like, hey, I feel this way, and be very clear on the history. And then the providers, like, you should, as a provider, if you're listening to this, you need to be aware of any device, IUDs, neurologic devices, nor plant any.

I don't. Any. Any adjuvant to what you said earlier about Asia. Right. Everything.

Everything can cause a problem.

Right.

So you better be doing. If you have a patient with chronic inflammatory symptoms, a very, very strong inventory of what surgery is that people forget they've even had surgery. I'm sure you know this.

Oh, absolutely.

How many people come in that. I've never had anything done.

Oh, it's like, I never had surgery. Well, you've got scars all over your abdomen, like, oh, yeah, I had a DNC hysterectomy or, you know, whatever.

Because they don't consider it a surgical procedure.

Right.

So you have to be like. Everybody's like, come on, man. If you're a surgeon, you've operated a long time. It's your job to do a history and understand what's going on. That's why I said the gps. You could never make me a gp. I would go nuts. Because it's a hard job. There's no way I would be good at it. I just can't, like, sit there. And, I mean, I know what I know, and I feel like that's a challenging position for them to be in. And then women with all the other things that go along.

Yeah, it's a complex topic and probably outside the scope of our discussion, but, you know, these gps and other primary care providers, depending on their employment arrangement or under time pressures, production pressures, and, you know, they generally don't have the time to be, you know, going through a really thorough history with these patients. So, you know, there's a lot of issues that are factoring into why patients with breast implants that have symptoms of BAI are not being treated appropriately.

Yeah, that's. That's more of a. More the frustrating part, I guess. And then we go back to a surgeon nowadays, and if they can't acknowledge it, won't acknowledge it, or can't steer you in the proper direction, I mean, you may just say, as a surgeon, you're not aligned with that, you're not comfortable with doing a capsulect. That's totally fine. That's totally fine. Don't Ever ask a surgeon to do something they're not comfortable with?

Yeah, absolutely. I think that transparency, again, that's paramount. And you know, to your point, maybe not everybody is comfortable doing that surgery, but I think as plastic surgeons in this day and age, kind of regardless of your beliefs about bii, it's our job to at least educate the public and the patients that this is a possibility. I think the perception that it's not a real diagnosis or entity or something that can be treated surgically or otherwise is completely absurd. I mean, there's so much information out there now by legitimate, validated, scientific sources. Maybe not as much in the plastic surgery literature, but, you know, the world literature. I know the world literature. I mean, there's a lot of people that have done a lot of great work analyzing breast implant illness and understanding what really is causing it.

Yeah, for sure. I. I do find it interesting too, that. Because, I mean, you were training and practicing during the whole advent or the. The kind of.

Re.

Emergence of, we'll say fat transfer. And I'm sure you remember all this going down. I used to have to get up at meetings and discuss the. I remember one meeting in particular. It was one of the larger society meetings. Guys were just arguing about doing fat transfers and causing breast cancer, which of course is not a thing because a fat cell is a mesenchable origin and a breast cancer cell is an epithelial origin. Not to make it too more different than that, but they don't lead to one, doesn't lead to the other. Now, because I did sarcomas, I was the guy who had to get up and talk about. Because sarcoma is a mesenchymal cancer. So you would not want to fat transfer a tumor bed that had a mesenchymal cancer because.

No, that doesn't sound like a. That could be a psychologically safe idea.

So I would be the guy that would get up and talk about that at the meeting while the other guys were arguing about, you know, the. The breast cancer. And then I've been doing fat transfers. Wow. Since probably 2004. I was taking fat out in the 98, 99 for leptin research and where we wore and training. And it's a very good tool, and it's probably been a bit bastardized for, I think, a number of the standard misinformation and disinformation kind of reasons. Like it doesn't work and it doesn't have longevity, and you can't volumize the way you would like. And I'm Kind of like, okay, well, if that was really the case, then the entire continent of South America wouldn't have done Brazilian butt lifts that wouldn't have been transported to. We'll start with Miami, you know, in our country. And I don't really see people get on the news and say one part of their ass didn't work. But I get all these questions all the time about, like, well, my breast nut. Will one breast be lopsided? I'm like, where do these even.

It doesn't. I don't think it gets a good wrap in the explant space. And I think a lot of it goes to just like anything we do, setting expectations with the patients.

Right.

You know, there's issue. I mean, so a lot of women want a natural reconstruction after explanting. There's limited options if you're not going to do some kind of microsurgical or tissue transfer, autologous tissue transfer, which there's a whole nother conversation about reasons why, you know, people aren't doing that. So, you know, your options are, as, you know, tightening the skin, massopexy, but adding volume or shape with fat transfer. And it has to be done setting appropriate expectations, like, I'm sure you do, like I do, like all of these ethical plastic surgeons do, and making sure the patients understand this is not going to be like you're swapping out your implant for the same look or shape with the fat. Like, there's definitely limitations. There's not going to be 100% survival of the fat. You know, there could be contour regulation. It might require a more staged approach. It can, you know, lead to additional layers of potential risks, you know, in the surgery, you know, cysts and those types of things. But, you know, it's definitely a tool that, you know, we talk about with patients as an option for somebody that, you know, is an appropriate patient. You know, they've got donor site fat that can be used. They've got a recipient site where, you know, a lot of women that get augmented with implants don't have, you know, appropriate breast tissue recipient site, because that's why they got implants to begin with. They've got no breast tissue, which makes the reconstruction more difficult. You know, all of this just has to be done with appropriate expectations. And even then, you might have upset patients. You know, because like I said on a podcast yesterday, women are excited to get implants. You know, it's like, it's something that they identify with, is improving their quality of life. Like, nobody wants to get their implants out. Generally speaking, from an aesthetic standpoint, I mean, they want to feel better. But, you know, it is a really big decision for patients and has to be done in collaboration with your surgeon. After setting appropriate expectations and trying to, you know, understand the risk benefit ratio of, you know, doing the explant surgery and, you know, making sure that the patients understand that this is going to be a permanent change to the appearance of the breasts. And, you know, we'll do everything we can to maximize the aesthetics, but, you know, it's definitely. We have one less tool to work with, you know, by taking the implant out. So there's still things we can do to make the breast look as good as possible. But, you know, there's going to be scars, there's probably going to be asymmetry, there's going to be size changes from taking the implants out. And, you know, it's unfortunately not what a lot of women want to hear.

Yeah, I, I think of it into like, as we were taught in training, there's, you know, usually two big blips in this. There's the, the younger. When someone finishes will say high school, college and, and they get a augmentation. Usually those are lower body fat, lower BMI patients. Like you said, not a lot of recipient sites take fat from. And then do a autologous transfer, which is a. Just for everybody listening. Autologous is your. Your own tissue. Allogeneic is the same species. So when someone is talking about getting exosomes or some other product, that's definitely an allogeneic product. Right. It's not your own tissue. Autologous, just like. And I always give the example. I like to bring up Dr. Murray because he was the last surgeon to win a Nobel Prize for kidney transplant on a Siamese twin. And I don't minimize it because it's a tremendous feat. But he literally showed that tolerance is what you need. Right. So you can do the transplant technically, which I'm sure you've done transplants and training. You know, you have artery of vein and the ureter, in this case the hookup. And it works because it was a Siamese twin. There's absolutely no genetic intolerance because they're exactly the same and everything else. And the whole field of transplant is based on affecting tolerance. So I always like autologous. I always like stem cells at the top of the pyramid for use of enhancing, whether it's the breast or the buttock. I don't really do butts. There's so many people in town who do great jobs with that. That's not my forte. Obviously doing breast is. And then to your point, I never really talked to young people because you can imagine if all I did was cancer. The youngest person I ever talked to was 24 about that. And that was a very specific, disheartening situation of poor genetics and unfortunate.

A breast cancer.

Yeah.

In a 24 year old.

Yeah, yeah. So I just never had those conversations with young, young people. And my daughter is 17 here in another week and I just tell everybody the same thing, like my daughter's a Leo like me. I could tell her exactly what I know and what you know and she's.

Going to do what she wants, create.

The best understanding of the problem. And then to your point, she's going to do exactly what she wants and there's not going to be anything I or you would be able to do about it. If you, you said, oh Rob, let me talk to her. You know, as long as I do that, it's not going to make a difference. Right. So let's just, you know, have a pretty clear understanding of what we're talking about here. Young people are going to do what they're going to do. It's just can they do it with the best information available, which, you know, that's our job. And then the second blip is obviously the folks maybe after breastfeeding who've had kids. And then there's some space now in the tissue, there's probably a little bit more body fat because usually we accumulate fat over time. And then I've coined this holistic mommy makeover, you know, because I don't obviously put in implants anymore. I take them out. So I usually get the mom who's had kids breastfed and now they've implants symptomatic and they kind of want all this undone. So then I'll do it. Almost undoing, if you will, the breast dog and doing just a mommy makeover with fat and body constraint. I like that. That's a nice set of wins. To your point that they come with certain trade offs. There's going to be scores with many of these things and maybe we should discuss what but you know, reasons and I've highlighted on my show and I'm sure you've talked about it on shows as well, why your patients have told you they got this done in the first place. I've had people bullied. As a middle schooler, I've had people see their peers get augmented in the groups. The moms were augmented. So it was Normalized. If I guess we can say that using big words now. Normalized.

Yeah. I think that that trend continues with social media and with everybody comparing them not only each other but to ideal standards, which isn't obviously realistic or healthy, but at some point it's worse. It is worse. I mean, when we were growing up, I was born in 1976. So you know, this is pre cell phone, pre Internet, you know, still had magazines. Still had magazines. Yes, magazines. We had regular dial phones, whatever those are called. And rotary. Rotary. Actually that was my grandparents generation.

I had a rotary phone. That's how old I am. I was born in six.

You actually had one of those?

Oh yeah, my parents were old.

Okay.

Older. Oh man, that's tough. My parents were born in 25 and 1930.

Okay. Yeah, that's, that's definitely my grandparents generation. But in any event, you know, going through school could be challenging. I just talked about this on another podcast and you know, everybody's got their own baggage and emotional trauma and you know, problems with your peer groups and you know, feeling like they're not enough. Coming from a sense of, of lack and needing to, you know, improve some physical appearance that's always bothered them. And that's typically what we see in plastic surgery. You know, it's not like somebody wakes up one day and says, I don't like my nose, I'm going to get a rhinoplasty. You know, Pause there.

Just. I have a good question. I don't want to forget it. Should we all be doing the BDD assessment for aesthetic surgery on every single patient undergoing any aesthetic procedure? But we'll answer that after you finish.

You want to come back to that? Okay, so, so these are all typically. And this is why I went into plastic surgery and this is why I think a lot of plastic surgeons go in to try to help people feel more confident, feel more comfortable in their own skin, meet their aesthetic goals. But it has to be done in a way that isn't focused so much externally on you're going to do this surgery and all of a sudden you're going to get the outcome or the life or whatever it is that you think that the surgery is going to do for you. It also involves, you know, making sure that the patients have realistic expectations and, you know, they understand the limitations of the surgery. You know, I'm sure, you know, Psycho Cybernetics by Malcolm Maltz, you know, he was a plastic surgeon in the 50 talks about this. It's been reproduced many times, but you know, just doing the surgery itself, even if you got a great objective result, if the patients aren't doing the inner work to really try to improve their perception of themselves, you know, they're not going to be happy not only with the result, but with the improvement in their life. So I think it's, in this day and age especially, it's important that we continue to reinforce that message. Because everybody's so focused on appearances, and I think we've kind of lost sight of really what ultimately is going to make people happy and feel like productive members of society. And I think it's important that we all take care of our bodies because that's our vessel and that's how we communicate in this world and that's how we're perceived. And we want to be able to have the most productive of relationships and lifestyle that we can. But I think it can't be done exclusively through the lens of aesthetics. I mean, there's a lot more involved that should be talked about with our patients. Right.

That's why I got on this. You can tell I've been reading a lot of old papers about augmentation and why. And it's interesting if you go back into our journals and read these papers about what they were doing and how they were assessing it, especially papers out of Hopkins, they were having the psychiatrists speak to the patients and try to clarify. To your point.

What are you trying to get out of this surgery?

Yeah, not the level of aesthetic satisfaction from the surgery, but more so the changes in mental health, if you want to say it that way. And my point was asking about the BDD assessment. So body dysmorphia is not going to get to be less of a problem, it's just becoming a bigger problem. Because now with filters and what you can do to your appearance and then what others see from influencers about appearance is really disheartening in one respect because a famous influencer just got 450cc devices placed by prominent plastic surgeon in Beverly Hills. And now that person is a role model for a lot of people around the world at a young, young age who already have a problem with maybe their body and their appearance and their impression of themselves. And to your point, that takes a lot of self work, not surgical work, to.

Yeah, and I think young patients don't have that level of really integration or emotional intelligence yet to really kind of understand the limitations and what it is they're trying to achieve. I think it's really important to have that discussion with patients and at least do our best to set those expectations ahead of time so that you've got a happy patient after surgery.

Yeah, this is the challenge like that when I said initially when I started, like it would be very hard for anybody to ever met me unless you had a very specific problem. And that is contrary to the problem we're discussing because anybody can go see someone for a complimentary consultation who's offering that for a breast augmentation in that younger age group group. So it's a really important decision for that young person coming in. But it's even more important that the provider have like the most well thought out, kind of easy to understand explanation and be very, I guess, weighted in their discussion about that rather than, yes, we can do that. And this will help you because it's to your point is that really, does that really help?

So, so to answer your question, I mean, I, I do not do like a body dysmorphic assessment objectively on everybody. I mean, obviously I'm kind of checking all the boxes in my head as I'm having a discussion with the patient and I understand very quickly whether this patient's going to have realistic expectations and whether or not I can achieve an outcome that, that they're going to be happy with. So to me and other experienced plastic surgeons like yourself, I'm sure like within 10 seconds, you know, whether or not this is a relationship with a patient that you're going to be able to be successful in and achieve an outcome that they're going to be happy with. Because like you, I don't at this point in my career want to have unhappy patients. I don't want to operate on somebody if I think there's a chance that they're not realistic or they're not going to be happy with their results. So while I don't do a formal BDD assessment, I think everybody's somewhere in the spectrum, right? I mean, it's kind of a spectrum. And, and I've got great patients that probably by definition are body dysmorphic and I've got other great patients that aren't body dysmorphic. But, you know, they've been challenging. And so it's really more about the relationship building, trust building, rapport, making sure the patients know that, you know, you're doing what's in their best interest. You're doing your best to try to set expectations, you're being transparent with them. You know, you're not taking advantage of them emotionally, financially or otherwise, and that you're going to be there and available if in the event they're not happy. With their outcome. If there's a concern, they need to be able to work with you as their surgeon to hopefully resolve that.

Yeah, I mean, that goes back to trusting what you or I can do for someone. So that's inherent in that. I think that's probably. I mean, certainly in society there's far less trust than there used to be. And certainly in our positions, it's been challenged quite a bit. It's challenged every day in social media through influencers acting like providers with no.

Training, no credentials or background.

It's very interesting to me especially, I'm sure, as well as it is for you, when you get asked these things about certain topics or things that have been said or it's a level of, I guess, like, it is odd. It's just really odd for me sometimes given the amount of work and the years in surgery specifically. And you know, about my practice now, where I do a lot of what is termed functional medicine, the practice. And outside of our traditional allopathic training and we look at other. You know, I've always, always been interested in genetics since college. So, like, for anybody to like, kind of poke at that, that's kind of funny to me because I'm old enough to remember all the different things that unfortunately, you know, cassette tapes, CDs.

I do remember cassette tapes back in the day, the old mixtapes. Right.

And you used to look at PubMed on a series of silver platter discs. Where I went to med school before the Internet was prominent.

I remember doing research in med school, going to the library, pulling out the books, putting it on the photocopier. You're copying all these papers. I'd have a stack of papers like this going through with a pen and a highlighter. And it's very different experience nowadays. Now I can just put my question in a chat GPT and literally in an instant, like, you've got the world's information at your fingertips. It's pretty unbelievable.

You have to be very careful with chat and medical information. It's interesting. And there's many publishers that have protected their intellectual property, as they should. So Elsevier is a prominent medical publisher and Elsevier has its own AI component built into its platform. And many others do the same thing because obviously they publish this material over time and you know how protective they've always been of that. You had to pay for a copy of a journal article or you had to have a academic institution log in. But as a solo practitioner, you wouldn't have that. You would just be getting the articles either that you are most interested in. And you brought up the articles from around the world that have been done. Probably the groups in the Netherlands specifically have done so much work. That's great. It's just recently published in Nature Is.

Which.

Which is fortunately access. It's open access. I'm sorry. It's just funny that these things now are becoming more and more to the fore. And it highlights some shortcomings in our training. Certainly now the pathic training, nutrition was a huge component, zero nutrition of training in medical school. But my surgical training was a big deal because I did six years of general. So that was, oh my gosh, tons of training. And we took care of burn patients as plastic surgery. So I have tons of work there. So that was always kind of not a bridge too far. Genetics. Always was interested in genetics. I will say the thing that's been the most enlightening me is looking at environmental toxicity and learning more about just things like phthalates and, and atrazine or glyphosates and all these different chemicals and things that are in the herbicide, pesticides. And when you look at patients toxicity profiles, that has been one of the more shocking things to me in terms of what could be kind of in the background of their history.

I think all of that that contribute to the symptoms of breast implant illness. Like in my opinion, it's not just you got implants and now you got breast implant illness. There's cumulative biotoxicity that we're experiencing in our environments from our food, from our water, from our products, you know, pretty much everything that we're exposed to, infections, you know, viruses, we don't need to go down that road. But you know, it's a cumulative effect over time. And to me, implants are one more thing in a genetically susceptible individual that has the appropriate lifestyle factors that. That ultimately causes the development of these symptoms. So I think it's great that we're in a day and age where you can get all this information pretty much at your fingertips. There's lots of great resources online that patients can use to educate themselves about how to feel better with or without breast implants. And to your point earlier, I agree. You got to obviously be careful and validate anything that you get online or from ChatGPT. But. But ask ChatGPT about BII. See what it says. I mean, I've gone down this rabbit hole. It's really interesting. I mean, patients have all kinds of questions and I understand with kind of limited knowledge base and resources, they may not be going to PubMed and reading all the scientific articles about breast implant illness. But go to ChatGPT, it's free, and ask your questions there and you'll see, at least from the perspective of the collective consciousness of, of, you know, the world, information on breast implants. You know, what, what does CHAT GPT think about it?

Yeah, we did that the other day. It's like a. I'm always trying to generate things for FAQs and I wanted to see what it would, you know, bring up. And it was the basic, you know, things you were describing. So it does give you that baseline view. When I've had to do like more specific, you know, through prompting, what I was looking at, then I would go to what it created and I would check it and I'm like, it's a little off. So for us, that was my point. It does give you some great baseline. It's almost like a first draft many times.

Absolutely. But I think for a patient, it's a great resource. I mean, you're looking at it from a very critical scientific perspective because you've got that baseline knowledge. You're ready to criticize, you know, the information that you're getting. But a patient that has got no baseline for what to believe, you know, they hear different things. I think it's a good resource.

Well, I'm glad you brought up that there's more than just the device because I've said it on, you know, my show a bunch and I ended up writing a book about our program because it highlights obviously outside of the device, there's all these other things, you know, going. Going on in our environments. Like you were, like, I was in the Midwest. I mean, I trained in the Midwest. I lived in the Midwest for a long time. Everybody's got different things in their environments. You know, the quality of the air, depending on where you live or where you work, or inside, outside all the things. And then the quality of the food, which is such a big topic. Yeah, it's a big issue. And then fluid, similarly, you know, you got to be switched on. There's a lot all the time. But just not to inundate anybody with like, you can't eat this, can't drink that, you can't, you know, do xyz. Just try to. I try to have the patients make some small incremental changes and that will help them.

Of course. Yeah, I just said that. It's like, you know, it doesn't have to necessarily be something super expensive or something that is. Is going to be very time intensive. Like there's A lot of things that patients can do with BII or otherwise, if you just don't feel well, you know, kind of getting back to the basics, getting back to nature, all the. Actually, the podcast I was just on with Troy Casey, you know, he's got nine pillars of health. I mean, who's actually doing those nine pillars? Like, get those dialed in, and then let's see how you feel. I mean, those are things that I've all integrated into my lifestyle over the last year, year and a half, and I feel, like, completely different. Right.

I mean, that's. If you don't make any adjustments, then you can't expect a different outcome. But if you make small ones and then they become habitual, then you'll.

Yeah, but it's work, right? It's not a magic pill, no pun intended. But, yeah, it's. It's definitely work. You got to put the time in. You got to be consistent about it. It's like going to the gym. But, you know, for me, I want to feel good. I want to. You know, I'm more about living a, you know, healthy lifestyle. I heard somebody say, I'm not looking to add years to my life, but life to my years. I mean, especially as you and I get older, it's important for what we do physically for our profession, for our patients to be leaders in the field. And you got to be healthy to be able to perform at the highest level. And so I think it's important as plastic surgeons and as thought leaders that we also embody a lot of the same principles that we're advocating for our patients.

Yeah, I talk to them mainly about if you can't sleep, you can't recover, because that's, you know, obviously we take for granted, probably going to bed, getting up, and, you know, rest and recovery in general. I see you're wearing a whoop. I've had a whoop for a long time. There's always all these ways to measure things. Some people get anxious about that. Our goal is never to make anybody anxious about anything. It's just to bring awareness to, like, what we're talking to you about. Because I'm sure when you speak to patients, they say, I have a clean diet. I don't even know what the hell that means when you say you have a clean diet, but then it's like.

What do you eat? Oh, yeah. Really? Okay. Because that's. They don't even know. I mean, it's nobody's fault. And patients blame themselves a lot, which is a whole nother topic. But they blame themselves for making bad decisions, for getting implants and, you know, lifestyle decisions. But, you know, for example, before I was more knowledgeable and I've had to do a lot of my own homework like you, I didn't learn anything about diet, nutrition and medical school or residency for that matter. And a lot of these other just kind of basics of good health. You know, I went to Whole Foods just not too long ago, and I'm, you know, go to their salad bar. You think like, oh, this is, this is, it's at Whole Foods. It's fine. It's a salad bar. And you actually look at what's in the food there and I'm like, wow, like, I can't eat most of this stuff. I can't eat most of this. It's all full of seed oils and, you know, other toxins and so it's just emulsifiers. And it's just, it's pretty challenging to really try to maintain a healthy lifestyle in this day and age.

Well, we're taking the Dr. Pryor out after this to the well for lunch so he'll have a good meal because it's gluten free, dairy free and no seed oils. But that's a good way. Obviously, surgery is a big, big decision, but all these other things end up being bigger, bigger components of a long lasting change you make in your life. So maybe for the audience, what are the kind of top things you mentioned? The nine pillars? Maybe simplify it into three or four things they could start with and then we'll wrap that way.

Sure. I mean, really the basics. I didn't come up with the nine pillars. That's Troy Casey's certified health nut. But his nine pillars are food, water, breath, thought, movement, sleep, stress, connection, and legacy. I think that's nine. And those are all really important. I mean, get those nine things dialed in and see how you feel. But then, you know, kind of outside of that, you know, I think it's really important too to, you know, do a lot of the things that you're talking about. You know, there's so many resources now. You know, everybody hopefully has access to, you know, oxygen. I know a lot of people talk about, you know, presence of oxygen is absence of disease. That's, you know, Gary Breck is mantra. And all of this biohacking stuff, which I'm very into. You're very into. You've got your whole perioperative protocol, but those are all great adjuncts that people can use, whether you've got breast implants or not. To help feel better. It improves mitochondrial function, it improves detox, sweating, all of these things helps regulate the nervous system. So I know that didn't quite answer your question, but for me personally, I think. I think sleep is number one. Like sleep has to be the foundation of good health. I mean, that's the same as the guy that wrote don't die. I'm blanking on his name right now.

Brian Johnson.

Brian Johnson, yeah. And so sleep number one, for me, stress is probably number two. You got to get your stress in check. Relationship stress, personal stress, finance stress, whatever it is that is definitely contributing to poor sleep, it's contributing to immunosuppression, it's leading to epigenetic changes. So I'd say sleep stress, and probably the third one, which is about as basic as anything, but I think we're all very susceptible to not making it a priority is hydration. And I think the lymphatic system is kind of a whole body system that's kind of understudied and under really focused on in traditional medicine. And, and we know our bodies are predominantly water. And without feeding your body water, your detox systems aren't working correctly. And, you know, you're just going to feel sluggish, you're not going to sleep well, you're not going to feel well, you're not going to sweat, which is your body's way of eliminating toxins. So I would say, you know, sleep stress, water hydration, and that's still something that I'm working on, would probably be the big three. Movement, obviously is critically important.

Yeah, I'm glad you're out of movement. I think that's something that certainly as we get older and we want to build into our patients always ways to avoid in our female patients, osteopenia, osteoporosis, maintain quad strength, grip strength, so you have a longer, better quality of life. And so if they want to learn more after the show, where do they go to find out all the good work you're doing and where to find.

So we have a dedicated website for patients looking to get information about breast implant illness. It's BII Centers of Excellence. And currently we've got locations in Rockford, which is outside Chicago and Palm Beach. Our primary surgeons are myself in Florida and Dr. Sud, who's a great explant surgeon in the Rockford community. So anybody looking to get information, even if you want to just get resources related to BII or explant surgery, happy to provide any kind of help we can.

Awesome. Thanks for coming. On today?

Yeah, it's been awesome. Thank you. Thank you for all your good work.