Hello and welcome! We have prepared an exciting session for you. Before we begin, we want to remind you that the material shown here is the property of ASPS or the presenters. Copying or distributing the content in these presentations without specific consent from ASPS is prohibited, including screenshots, photography, live streaming and video recordings. Also, please note that this session has a corresponding forum discussion taking place right now on the PSTN 23 conference platform. If you have questions for our faculty, please feel free to submit them there. Please note that chat records may be recorded. Thank you for your participation and enjoy! Hello and welcome to this on-demand session entitled And You're Out! Explantation and Secondary Breast Surgery. My name is Diana Yoon Schwartz of New Street Plastic Surgery in Huntington, New York. This program has presentations from Dr. Carolyn Glixman, clinical assistant professor at Hackensack Meridian School of Medicine and current president of the Aesthetic Foundation. Dr. Mary-Jane Grass, private practice at the Plastic Surgery Center of Nashville in Nashville, Tennessee. Dr. Ruth Graff, professor at the University of Paraná in Brazil, who also performs breast and facial procedures in a private clinic. Dr. Sarah Metz, sole owner of Sarah Metz Plastic Surgery Center and MediSpa in Columbia, Maryland. We have prepared an exciting and informative session for you covering topics such as capsulectomy, plane change, mastopexy, fat grafting and salvage flaps after explantation. Thank you for your participation and enjoy! Good morning and thank you for inviting me to this panel. I'm going to be talking about revision breast augmentation, texture to smooth implants or explantation without any replacement. These are my disclosures. So what is the most common indications that I see patients coming into my office for an explantation or revision? Well, most of the time it's my aging patients, my patients with aging implants or they come from other offices with older devices. I see patients with ruptures usually between 9 and 13 years after they've had an augmentation, and I confirm that with high-resolution ultrasound in my office. I do see patients with capsular contracture, late seromas rarely, hematomas from trauma or post-surgical, and size change. We do see patients with that over time, and the occasional patient who's been hurt or has an athletic injury. So the first question really that I ask my patients is, do they want or need their implants? And I certainly see patients who have very little breast parenchyma, have no desire to go back to where they once were, and all those feelings coming back to them of not being able to dress or wear clothing, and they want to continue to have their implants. But I also see patients who absolutely don't need their implants anymore. They've gained weight, menopause, aging, divorced, not with that husband anymore. There's a lot of reasons that patients just don't want their implants anymore. There are also patients who are on social media who have health concerns, but more often I see patients who just don't want their implants anymore. The question is, what's in there? If they're not my patient, or they don't come with any medical records, there are patients who, as I say, just simply don't have a clue. High-resolution ultrasound has been the most brilliant thing that I could have added to my office, because it provides me with the opportunity to look inside. The patients may not remember exactly what they have. I can determine the age of that implant, or whether it's ruptured, whether it's intact, the fill of the implant, the surface of the implant, the pocket location. I can tell, possibly, if there's a double capsule that I'm feeling that's firm, and it's not necessarily a capsular contracture. I can also take a look at an implant right away, and in a few minutes have a conversation with one of my own patients or somebody else's patients, who may not have had their mammograms, or may have missed it, or have not had adequate radiological imaging, that they actually have a ruptured gel implant on one side or both. And that certainly changes the conversation. So I have a surgical algorithm that I use in my practice, and I do vary it. I can't say I follow algorithms all the time. But with a textured implant, I'm going to be removing it. In general, I try to perform a total precise capsulectomy. However, there is currently no clear consensus on the removal of the capsule in all textured patients. I do want to consider it in patients who have anxiety over a risk of ALCL. Obviously, if there's capsular contracture or a calcified capsule, rupture, history of infection, or a benign seroma, or in the past that may not have been adequately worked up. Replacement without a capsulectomy must be a consideration as well, though. If there's been no rupture by radiological examination or in my ultrasound, there's no history of any known pathology. I go into the operating room and add to that a very thin and translucent capsule. And the patient's fully informed of the current known risks of ALCL. The other reasons may be because the patient's happy with their look, the pocket location is ideal, we're doing a minimal size change, and they really need no capsule or work for a malposition. The patient also needs to have their expectations managed. Because patients who've had a textured device in for a long period of time, they may be used to that look or feel. It's the same with patients who have a capsular contracture that may like that fuller upper pole. It may be due to a contracture. You must manage their expectations, especially with shape and size change and a change in shape and feel. I just want to present a quick case. This is a patient of mine who had a textured and shaped implant for a chest wall deformity 11 years ago. Actually, it's 14 years ago. It was 11 years post-op. She had no evidence of a rupture, stable position. She had stable weight. Her breasts were soft. She was not anxious about texture, but I had been following her every two years, and I was concerned about rupture. She knew that her implants were aging, but she wanted the same look, and she was hesitant to get rid of her textured implants because she liked the shaped texture that corrected her chest wall deformities. So I went back to my preoperative Vectra 3D imaging, and I looked at our simulation from 2009, and we looked at possibly replacing her shaped implant with a round implant. And when I looked back and I looked at I had done two different size implants in height and projection, and now I was able to change the implants to two different projections and volumes, we were able to achieve a similar look that basically gave her the confidence to move ahead and not be so concerned. And here she is at 11 years post-op with her textured implants, which was pre-op for the revision, and here she is three years post-op revision. So just the simulation really managed her expectations and helped me move this patient along to get out her textured implants. Transitioning from textured to smooth round gels, you want to control the IMF. If you're going to do a capsulectomy on these patients, you're taking out a stable pocket and potentially a healthy capsule at the cost of possibly having malposition over time with the implant being smooth and in the same pocket under the muscle. So you want to control the position of the IMF and perform a layered repair, and consider changing your routine. I put my patients now in post-op bras for an extended period of time, and I change their exercise routine until we develop a new capsule. So explantation without replacement, I think we're all seeing more of these in our office. These are patients who want their implants out. Again, they may have SSBI and anxiety. They may be that group of patients or ALCL anxiety with their textured devices. But more often, I'm seeing aging patients, aging implants, postmenopausal patients. They just don't want or need their implants anymore. And again, the algorithm for these patients is similar in that I would try to perform a capsulectomy when necessary. However, there are times when I do leave the capsule behind on these patients. If it's thin and translucent, I'm not taking it out. Mastopexy, again, I may do it immediately or stage it. These patients might need a possible small reduction, and we might want to add some fat. If I am adding fat to these patients, they must have sufficient donor fat without any donor site morbidity. A lot of these patients are thin, and I'm not so sure where I'm going to get enough fat. And I certainly don't want to mislead them to thinking that I can build up a 250 cc breast with fat in a single stage. The grand mommy makeover is another one that's very big in my practice as we all age. So do my patients age. But in-office deflation is something that I offer a lot of patients. I know that we're all doing this now. It gives the patient who hasn't looked at their breast in 10 to 15, 20 years an idea of how big their breasts really are and that they don't really need an implant anymore. In this patient who had a terrible mastopexy and weight gain over the years, we deflated her preoperatively. She lived with that for a few months, and then we went in and did a mastopexy on her. It also provides really good breast imaging for the radiologist if you take out that implant and take a look at the breast preoperatively. And I really strongly advise this technique. For the patients who attribute systemic symptoms to their implants, we know that removing their implants and the capsule is part of their journey. But there are more and more patients who are considering removing those implants without a capsulectomy. We know there's no statistical difference to the time the implants were in place or the number of symptoms at baseline that they report or the improvement by any method of explantation. And we're currently undergoing a no-capsulectomy study, which has similar enrollment criteria as our previous ACERF study. And again, we're seeing the same statistical improvement of these patients, despite not removing any of the capsule at all. So the patients will usually and generally want to do a total precise capsulectomy on the patients who request it. I may leave the capsule behind on patients on the chest wall or when it's thin and translucent and it's not indicated to remove it. You just have to talk to your patients. I can tell you that I can try to do this with a thin, small incision. It could be a little bit more difficult. But these patients may not want to have a large incision. And I'm certainly no explantation expert. I don't call myself that. But this is one of the tricks, if you guys are interested. This is called an AMT max vac. It is an amazing trick. This is Pat McGuire removing the new max vac. But you're certainly welcome to try this. It really cuts down on a mess in the operating room. But explantation, because the patients don't want them anymore, we can certainly do an immediate mastopexy or a stage mastopexy. That's basically nothing new that I'm telling you, except that I tend to not find a lot of fat on these patients. And they have to accept a smaller breast with some scarring. So basically, I want to educate my patients. I want to get as much information as I can preoperatively. I utilize high-resolution ultrasound every day in my practice to know what that implant is and whether it's intact or ruptured. It gives us a lot of information preoperatively. I get old records on these patients and then have conversations with them. What are their expectations? What are you going to do with that capsule? Do they need their implants anymore? And really try to convince patients who are on the fence that they don't need their implants to live with it for a short period of time before they make any other big decisions. Thank you. I'm Ruth Graf from Brazil. And I'm going to share with you about explantation and secondary breast augmentation. I have this disclosure that I'm just responsible for the medical education for the establishment labs. Let's talk a little bit about complications in subpectral breast augmentation. You see this animation, the deformity that this patient has. The implant goes upward and the breast has ptosis. During the procedure, I depitalize around the skin marks and I remove the implant from the subpectral pocket. I do a lot of popcorn in the pocket to remove the anterior capsule. And here I undermine the new pocket that is subfacial. You see the fibers of the muscle. Inferiorly, you have inferior muscle flap. And here is the inferior flap. I spread some muscle fibers, so these fibers are going to protect the implant superiorly. I don't undermine too much laterally. And inferiorly, suture the muscle to the inframammary fold. After putting the implant in, I suture the muscle flap to the fascia superiorly. We have more stability for the implant mainly if you use a smooth implant. And just after that, I suture this inferior flap in order to close the pocket. And then after that, I suture and do the mastopexy. So you see the final result with the breast. And here we can observe that you see that the muscle moves, but there is no displacement, no animation deformity of this patient. Here is the patient, nine months post-op. You see how was the breast before and now very natural. This is another patient that had the animation deformity, subfactorial pocket. I switched to the subfascial. And you can observe here that the fascia has a firm adherence to the muscle. So it moves, but it's not as animation deformity. Here is the surgery. You see the implant under the muscle undermines the subfascial pocket. How is the difference? Subfascial on the left side and subfactorial on the right side. You see, we can give more stability for the implant, perform a smaller pocket in the right position. So here is the patient that there is no animation deformity. Another patient, two years and four years post-op, switched from the subfactorial to the subfascial. Here is the animation deformity that the patient had. And on the right side, subfascial, there is no animation deformity. Very natural result, switching from the subfactorial to the subfascial pocket. Another patient, eight years post-op. She had capsule contracture, very long lasting result. You see eight years post-op with the natural result. I performed dual plane in the first part of my career, but I switched to the subfascial since 24 years ago. And now for the smooth implant, we need to perform flaps to stabilize the implant. As I showed you, I maintain some muscle fibers that is going to cover the implant superiorly. And also inferiorly, I perform this inferior myofascial flap that is going to give stability for the implant. You see the inferior myofascial flap, and also I maintain this inferior dermaglandular flap that I can use at the end of the procedure. So now I'm going to talk about removing the implant from subglandular or subfascial to the intramuscular. Why I do it, I'm going to show you here. The muscle has spaces between the fibers. So instead of use all the thickness of the muscle, mainly superiorly, you can use a thin flap that is going to avoid the animation deformity. I elevate the posterior capsule together, partially the muscle. So the implant is going to be inside the muscle. It's a very well vascularized tissue. I'm going to show you here how I perform this. I depitalize as inverted T I did here. Then I maintain this inferior flap in order to use at the end of the procedure. And I go until the anterior capsule, and I undermine from the glandular tissue. I remove the anterior capsule. We open the muscle in the posterior capsule at the areola level. And you see here how is the intramuscular pocket. So you see that the muscle is below, and we undermine at the middle part of the muscle. So put the implant inside, and you have here implant intramuscular. So you suture to avoid that space, suture to the inferior part of the muscle, suture this flap to superior part of the muscle. We can close the pocket, and then after that, we do the mastopexy. Suture the columns, and you have here the final result. So here you can see posterior capsule together with the muscle. We have a muscle at the anterior part of the pocket and posterior part of the pockets. The implant is going to be in a very well vascularized tissue. After that, we suture the inferior part of the breast tissue to the muscle inferiorly in order to avoid that space. Also in order to avoid that the implant coming back to the former pocket. So you see that we suture. This is a patient that I use intramuscular one-year post-op. Another patient, very hard capsule contracture like Baker 4, and here she is two years post-op. And nowadays we have the ALCL that in stage one, we remove the implant through the capsulectomy, and you can use the smooth implant. And also we have another pathology that is the BII. So the breast implant illness is a term used to describe a variety of symptoms by patients with breast implants, for which there are no normal physical or laboratory finds to explain their symptoms. Self-reported BII at social media, asking for a block capsulectomy, but we don't need to remove a block capsulectomy. We remove only for cancer or at the ALCL. So it's very important to explain for the patient. And I'm going to show you here that I do the mastopexy with breast lipofilling after the explantation. So here is the lipofilling. We publish this technique. And in this case, I remove an implant, 208cc round implant, and she doesn't want a new implant. And then I perform the mastopexy and lipofilling with 200cc intramuscular inside the pectoral muscle, plus 200cc under the belly, subcutaneously. So I perform the inverted T technique. I dip the lice all inside the drawings and have this inferior flap in order to help us to reshape the breast. So we remove the anterior and posterior capsule. So after that, we inject fat inside the muscle. As you observe, we can get more upper pull fullness. And then we suture this flap superiorly until the second tercostal space. We start laterally, finish medially. So you see that we have the upper pull fullness with that. And after that, we perform the mastopexy. This is the stitch that I suture the breast to second tercostal space, then suture the columns and then the skin and subcutaneous tissues. And just after that we use the fat sub-dermally. So we don't use the fat inside the glandular tissue, just inside the muscle and sub-dermally. So in this patient I use 200 cc sub-dermally. So here is the patient at the end of the procedure. And here is the six days post-op, two months and two years post-op. Two years post-op. And here at the profile the same patient. And here she came back to three years post-op. You see in three years post-op a very natural result. And here is her MRI pre-op and post-op without the implant. Another patient that implant was to be glandular. And I remove the implant and the capsule. We did the same technique using the fat inside the muscle and then the flap and use the fat intra-dermally. Here is the patient, a very old patient, so it's interesting to remove the implant for this patient. Her MRI, you can observe the fat inside the muscle. And another case, four years post-op. When it is under the muscle, you see that we cannot remove all the capsule. Try to remove as much as possible. Again we use the fat inside the muscle and use the flap as you observe here. And then at the end we use the fat sub-dermally. Here is the patient four years post-op without the implant. Again you see the implant that we could remove totally. After that we use the fat inside the muscle and then sub-dermally. It's important that we use very high the fat because superiorly the muscle is very strong. Then you can use more fat at the upper pole of the muscle. So I use 200 cc normally inside the muscle. And then you suture the flap over that muscle as high as possible until the second intercostal space. And then after that we use the fat sub-dermally. And you can observe how is at the end of the procedure that was almost like a mastopexy. And here is her final result. It was just fat together with the flap. And here another case that was under the muscle and now four months with the lipofeeling without the implant. You see how was sub-pectoral and now very natural with fat. In breast reconstruction you can do the same. Two years post-op we could remove the implant in both sides and use fat to obtain this result. And the same patient. And we have some complications but the only complication is oasis. You can remove or we can follow at the post-op with the MRI. Then here is the patient three years post-op. So in conclusion I use sub-fascial pocket to avoid animation deformity. I use after ALCL I use smoothing implants. We have to perform precise pocket, release some muscle fibers supermedially, perform the inferior fascia muscle flap to avoid implant displacement, use hybrid surgery if necessary. When I exchange implants from sub-pectoral I use sub-fascial or sub-glandular to the intramuscular. And we know that aging process brings thorax enlargement. Patients do not want to change implants forever. There is good indication for ALCL and BII and lipofeeling is a good option of implant removal instead of implant replacement. Thank you very much for your attention. Hi my name is Mary Gingras. It's a pleasure to participate in this explantation panel. I have been assigned to talk about to lift or not to lift. For those of you with agenda anxiety I'm going to tell you a few tips on planning the right procedure for an explant patient and maybe some tips on mastopexy techniques. Other panelists are going to be talking about capsulectomy, fat injection and maybe some salvage procedures so I'm going to kind of stay away from that. So the patient usually comes in tells you I want my implants out and usually the next couple things they say are well what are my breasts going to look like and will I need a lift. So to kind of address those questions you would really like to be prepared to tell a patient if she's going to look like this with explantation which is pretty reasonable. Whether she's going to be look like this which is you know might might like to have a lift or some other secondary procedure done or whether she may actually have some deformity. So I think some tools are taking a really good history and physical exam. Weight changes since the augmentation and pregnancy or nursing history since the augmentation are really important. This patient shown here said oh but doc when I had my implants put in I was in a cup I don't have any breasts at all and so when you take these out I'm going to be I'm going to be thin again and you know she only has 300 CC implants. So a lot of education is often required. People who have had multiple breast procedures also should raise a little bit of a red flag. You also want to try to get a history of whether they had any kind of deformity like a patient like this had a tuberous breast and multiple procedures. So first thing you want to start off with and while educating the patient is what's how much parenchyma do they have, what's the size of the implant, do do they now or did they have glandular asymmetry. Previous incisions can be really important. I've definitely learned to take the periareolar incisions. Capsular contracture can definitely cause significant problems especially if it's long-standing. I used to think that sub glandular versus sub pectoral placement of the implant made a big difference but I think there are actually it comes down to how much parenchymal manipulation was done when they had the implants put in or at other surgeries. So the more parenchymal manipulation probably the more potential distortion there is of the breast. So the periareolar versus inframammary fold incision I find to be a little bit more telling of how much the breast may or may not have been manipulated. Inframammary fold generally speaking you're not necessarily disrupting much parenchyma and you're just going through the fold and putting the implant behind the muscle. Periareolar incision is can be either put in along the subcutaneous plane or potentially straight through the parenchyma and I found that these incisions can and do cause a lot more disruption especially the bigger and bigger the implant is the more and more that parenchyma is is split and some of it may be above some of it may be below or if the incision came right along down here all the parenchyma is up here and there's little to no parenchyma down here. A dual plane can definitely have an effect I mean I think in a perfect world a dual plane one which is most of probably what most people do for most average breast augmentations doesn't disrupt the parenchyma all that much but the dual plane three was actually designed to have the muscle ride up above the nipple areola complex and it was specifically to allow parenchymal manipulation for glandular ptosis or constrictive lower pole and of course the worse the capsular contracture and the more long-standing the more potential for glandular disruption. Photos are an excellent tool that we have touch MD on big maxi pads in each in each patient room and I will go through multiple examples of implant removals and talk to them about what what potentially their breasts may look like and and a lot of people really have no clue how much breast tissue they have or what they may look like. Deflation of a saline implant I've also found to be extremely extremely helpful. It's just a fast video showing piercing the implant with an 18 gauge needle and pulling off the saline that can be done in the office. I usually show on a video first so that they know kind of what they're getting into you got to get informed consent blah blah but it can be really helpful in giving people an idea what their breasts are going to look like so they can make a little bit more informed decision. High-resolution ultrasound many of us now have in our offices. I find it to be a great tool. It can help you distinguish if there's a lot of calcification of the capsule itself if there's things like extra capsular rupture. I just used it recently and found a big seroma and so it can be super helpful. So once you kind of educate the patient you're going to help them make a decision do we want to do removal alone or do we want to do removal with some sort of mastopexy. Fat injection I'm going to leave for I think it's Dr. Mess is going to talk about that but I think it's also important to let people know that they can always later do a mastopexy, do an augmentation mastopexy, put an implant in later or do a series of fat injections. So focusing now on just a few examples of deflation. Here's someone who came in, gained a lot of weight, had three children since her implants were put in and she is then able to make a decision about whether she wants a lift or not and she decided against. Here's another patient immediately post deflation. Another tool I use in the office frequently is I'll tape the breast up to give them an idea of what it will look like with a lift versus without a lift and this can be very very helpful. This particular patient decided on removal with a lift. Another patient who's really not sure if she wants a lift, this is deflation, she decided on a lift and here she is five years later after a lift. You do have to be prepared for some surprises. In the 28 years I've been doing this, I've only had this happen once, but I deflated this woman with 40 year old subglandular implants, put in through a perireolar incision and got some fluid that I obviously sent off, maybe betadine. This probably was long-standing calcification and there was probably, the implant had probably been ruptured a long time. She decided on capsulectomy and removal and I think in retrospect she had had a perireolar approach, manipulation of especially of those lower poles, probably approach along this plane and it can really result in deformities like this and physical exam can but you do need to be prepared for this. Here are some examples of after good history and physical you can decide we can just remove these under local in the office, you're going to do fine. Other examples of removal under local. One another picture that I show people is here's someone who has a classic waterfall deformity, long-standing subpectral implants. If you really look at these breasts before and two weeks after deflation or removal, I don't even remember which, but really with waterfall deformity and a good physical exam, you can give them a really good prediction of what that breast is going to look like. It really is going to look like what it does in the lower pole and the breast tissue does recover with time. Here she is at two weeks after removal and then at a year. The breast really does fluff up. Moving on to just an example or two of later augmentation. Here's a patient I showed you later had had four surgeries, multiple capsular contractures, autogenous breast, and here she is with removal. She's doing does fine and then later presented for re-augmentation. Another example of subglandular again through these dreaded periareolar incision. She's almost in a panic. Her daughter's just been diagnosed with breast cancer. We do a capsulectomy and removal and she had significant deformity. Again, pretty predictable on physical exam when you examine how much or if any tissue is below that nipple areola complex. Here's someone who I took back later and put in a subpectral implant and she was much happier. Moving on to removal with mastopexy. Again, lots of options here. Here's someone who comes in requesting capsulectomy because of the EII concerns. She's got subglandular silicone, currently had had some other operations before. Just moving on to a bit of a video you can approach. I think if you can go ahead and plan your mastopexy before removal, you've got a lot more options for a nice big incision. Otherwise, just make an incision that is not going to be in the way of your potential mastopexy. Moving on to technique, here's a video showing the capsulectomy, subglandular, just getting rid of the implant. Folding that inferior parenchyma up to give yourself as much superior fullness as possible. I find that a vertical, just simple vertical incision here, just doesn't give you any volume in the upper pole and accentuates the deficiency. Here's the pedicle already, closing the inframammary fold, inverted T, and stapling her up. I find this technique on a superior pedicle to be very reliable and it's usable in many, many circumstances. This patient, here she is shown on the table, I did not commit to my periureal or nipple placement until I have the mastopexy completed. Here she is with the nipple areolas marked and cut out, again on a superior pedicle. And here she is, I think this is about a month or two post-op, I'm sorry, I just made this video for the, for this talk. So here's some another, some more examples of that technique. Here's a 55-year-old comes in just kind of over it, she's got capsular contracture, a very similar technique. You can do the capsulectomy through any incision except a full inframammary fold here, obviously you're going to go through your dermal blood supply inferiorly. And fold that upper flap, the more tissue you have in the lower pole, the better. And here she is at six months and at five years. Another example of recurrent capsular contracture, similar procedure, did a little bit of fat grafting, here she is on the table, and here she is at a year and at three. Another example, two years after a lift. Moving on to patients who do come back in. So just to show a few of the later options in case someone decides to have removal, does a mastopexy and want some later options, they can, they're not, they can decide to either do fat injection later or put an implant back in. So here's an example of someone who deflated in the office. She wants her implants out no matter what. I go ahead and do the technique that I showed you, very, very deflated, not much upper pole fullness. You can see there's very little or no fat available for fat injection. She came back about five years later and we did a subpectral aug with the 195cc implant. And when you've been around as long as I have, she came back another five years later and wanted a little bit more implants. So they do have options and this does make a lot of people feel better. Complications do happen. And if you're going to move a pedicle, move a nipple areola a long way, based, I think superior pedicle is more reliable, but this is a long way to move the pedicle. She also wanted to be significantly smaller. I did a lot of liposuction and obviously this nipple areola had some trouble healing. So here's her long-term outcome. She did move to Florida. So if anybody out there took care of her, I appreciate you. Some people do instead of when they see the deflation or when they talk to you decide, eh, maybe I just want to downsize or exchange my implant. So this is an example using very similar technique. Someone comes in with a very obvious long-term sequelae of an 800cc saline implant. I did a similar technique, but just use that inferior de-epithelialized dermal tissue as basically as, as ADM. So I replaced this, the, this with a 600cc smooth round silicone implant, kept all the capsule, didn't do any capsule work. I put the new implant sub-pectoral and sutured the inferior border of the pectoralis major muscle to my dermal glandular flap inferiorly, basically using it as an autogenous piece of ADM and then close with the Weiss pattern. So here she is at six weeks post-op with a lot better upper pole appearance. And here she is eight years later. So thank you very much for your attention. If anyone would like to email me, my email is listed below and I hope you enjoy this panel. Hi, I'm Dr. Sarah Mess talking about explant and FET transfer. I have my own surgery center in Columbia, Maryland. My disclosures are that I am a speaker and trainer for Allergan and Cyton Consulting for BD and husband has stock in AbbVie. This is my first case of explant and FET transfer. And I learned through this experience, as well as reading articles and attending conferences, just like this one, that simultaneous implant exchange with FET is a better way to do this procedure because you get a lot of scarring and funny wrinkles with staging it. Bottom right corner, I have the original article of CEEF by Delvecchio in 2012. I did my first CEEF in 2014 and here she is. She had an explant and FET transfer. It corrected her semastia, her pain, and also she had translucent skin with a visible implant tab. And that was very unnatural looking. She actually had two transfer sessions and I have 60 cases where there was an average of 333 cc's of FET transplanted. Majority of the cases between 200 and 450 cc of FET was used to replace the implant. And in four of these patients, I had two transfers. Complication rate was one seroma requiring re-operation, which was done in the office, I found that I have more seroma issues when I leave the capsule intact than when I remove it. I have started to remove the anterior portion or checkerboard it to try to avoid seroma formation. I've had two infections requiring oral antibiotics. One did require two debridements and packing of the implant cavity. I've had one revision liposuction and six oil cysts. I check for them with physical exam as well as ultrasound in the post-op appointments. Very easy to aspirate with a 16-gauge needle. The exponent fat transfer corrects a lot of sins of the implants such as the scalloped over-released unnatural cleavage and the waterfall deformity where the implant is up high and the breast tissue is hanging off the bottom. The tissue, the fat and the breast tissue are one unit unlike the implant and the breast tissue. Exponent fat transfer also corrects asymmetric development. This patient had an augmentation decades prior and some revision augmentations and finally wanted the implant out because it was almost in her armpit and you can see how the fat transfer corrected her skin envelope. Exponent fat transfer also is a solution when there is a one-sided deflation of a saline implant. A lot of women decide they don't want to put implants back in when they have one side deflate. It's also a solution for ruptured implants. This patient has severely ruptured bilateral implants and underwent a fat transfer and largely abdominoplasty at the same time. Exponent and fat transfer can restore the inframammary fold and it's highly successful in younger patients. The percentage of volume that remains seems to be higher in younger patients although it is still successful in older patients too. The exponent fat transfer resolves capsular contracture. This is a 60-year-old woman. I do warn these patients that the breast will be significantly smaller and the upper pole will disappear. The fat is much more subject to gravity so there's a ski slope with the fat as opposed to a rounded top with the implant. If the patient will allow me to deflate their saline implant prior to the surgery, I will do that. This will help us decide on secondary procedures such as this patient was decided to do a mastopexy at the time of the fat transfer. I usually take a picture of the fat. I aspirate with an 18-gauge needle and 60 cc syringe and collect the saline for documentation. Here she is. She actually had two procedures. The first one, the exponent fat transfer mastopexy and the second one, second transfer revision of scar on the right ergola and abdominoplasty. She had a very successful result. You can see that the deformity of the implants, capsular contracture, snoopy breast was corrected and she has fantastic volume and symmetry. You can also do an infomammary fold skin excision. The mastopexy does increase the risk of the procedure as well as complexity. The skin excision is quite easy to do. I did not take a photograph of her original skin excision but I did end up doing a revision. You can see that marking on the top left. Here is her final result one year after surgery with some significant weight loss. She went back to running because she no longer had the pain from the implants. This is really ideal in the long nipple to fold distance with pseudotosis. Weight loss does affect results. This patient was one year out in the middle and then three years out on the far right with a 75 pound weight loss. She came back to me to discuss implants as well as weight gain affects results. This patient had explant 700 cc of fat transferred and gained 40 pounds at four years later after COVID. She underwent a breast reduction. I found that the transferred fat had a lighter yellow look to it. There was no liponecrosis and the pathology showed benign breast tissue. I removed a significant quantity from each side 500 on the right 400 on the left. Some patients missed their implants. I've had two patients subsequently have me put implants back in. You can see this patient. She essentially has a composite breast augmentation on the right. She had larger implants pre-op 325 and she had 300 of fat and then 250 of the implant finally. So you can see she has a nice rounder larger shaped breast with this final composite result. My pearls for the fat grafting are to use the safe lipo technique described by Simeon Wall with the pre-tunneling and using some post-tunneling as necessary that will allow the fat to be removed smoothly and optimally. I generally use a four millimeter diameter cannula which is connected to the power assisted liposuction and I'll harvest with either a three or four and I'll put the fat back in with a four millimeter tri-port bent cannula. I also try to concentrate the fat and remove as much to mesenbladen oil as possible and to maximize the volume that remains and I use tissue turgor as an end point so I avoid that poterange look and that is the end point for the recipient site or when you see the fat flowing back out the incision. This video here shows the use of Poloxamer 188 wash and this is a detergent that will separate out the blood and the oil from the fat then that will be suctioned off and the bottom of this container has an absorbent sponge in it to get some extra liquid out. I used to jerry-rig my own system with ABD pads using the micro air three liter canister and I would add the ABD pads at the end. I would also remove and I still do need to remove virus tissue that gets suctioned up with the fat, use a cannula, swirl it around to get those fibers out so they don't clog the cannula when it's being put back in so this demonstrates the use of the Wills Johnson pump to replace the fat using the expansion vibration lipo filling technique. This picture on the right shows you the before and after of the patient in this video. She's had an explant capsulectomy. I do put drains in when I do a capsulectomy and you can see me using the four millimeter bent cannula doing a reverse liposuction technique to pump the fat back in and you don't see many videos of this offered out there on the internet and I believe this is because this is watching how the sausage is made and everything but the pig squeal. So here I am suctioning out any free fat in the pocket and the incision will be closed with the drain coming out at one week. I wrote an article exploring lipo augmentation preferences over implant. I had a questionnaire for plastic surgeons and the general public using Mechanical Turk. They had before and after pictures and they had questions to rate the breast on attractiveness, naturalness, size, femininity, and symmetry. And the fat was preferred over the implant for all these before and after sets and that was statistically significant. The findings cannot be extrapolated to women seeking primary augmentation but it is very helpful for women and their decision for implant removal. Thank you very much. My name is Diana Schwartz and I'll be discussing secondary salvage after explantation. No disclosures. In my practice, I perform both autologous reconstruction such as deep flaps as well as implant-based reconstruction. Therefore, I sometimes see implant-based complications with significant capsular contracture, deformities, and breast asymmetry that may require autologous salvage. These patients, a lot of them have had prior procedures with some disappointments so it's very important to be compassionate about their situation and offer hope when possible. So for my capsulectomies, they're not removed because the implants are textured or not necessarily because they're saline or silicone. The capsules are removed oftentimes due to the thickness or the shape of the capsules that may alter the final reconstruction. As you can see, they're significantly thickened and acquire a particular shape and the secondary salvage cannot always mask these capsules. If the capsule is removed, it's then for pathology whether the implant is intact or whether the implant is not intact. So this is an example of a patient who had been reconstructed fully by another surgeon with a implant sub-pectorally. The patient came to me complaining of pectoral animation, very tight skin, and a thickened capsule. She had this small nipple areolar or nipple reconstruction along the incision. She also complained of asymmetry compared to the contralateral breast that was significantly more tautic. So when given options with regard to this patient, obviously autologous for the right was a consideration, but the patient was also interested in a prophylactic left mastectomy. So for her, we performed a bilateral deep flap and in performing the right side, the entire capsule as well as the implant was removed. The mastectomy skin flap was re-elevated particularly medially and a very large and extensive skin island was created to match shape. The nipple areolar complex position on the left side was also elevated by the skin island. After second stage nipple areolar reconstruction, the patient has a nice improved abdominal contour and better symmetry. This patient had previous explantation of her procedure after a failed immediate reconstruction. The other surgeon had not secured the pectoralis major, and as you can see, it was curled up in her left axilla. The patient had been left this way for about six months, so this deformity bothered her quite a bit. And as you can see from mastectomy defects where the pectoralis is not sewn back to the chest wall, due to the absence of any other breast tissue, you can see the deformity significantly. Particularly in this thin patient, you can see it in this left upper chest. So if the patient is going to be left flat for a significant period of time, it may be worthwhile to tack that pectoralis major down. So for that explantation patient, she opted for a unilateral deep flap on the left with a reduction on the right. And as you can see, compared to her prior explantation defect, she achieved more symmetry and due to her large right breast, a breast reduction allowed her an improved contour as well. Now as you can see, compared to the other two cases, this patient waited over five years for any reconstruction, so her explantation defect appeared much flatter as the other surgeon had sewn the pectoralis to the chest wall. Now this particular patient opted again for a left deep with a large skin island, and then I performed a secondary nipple areola reconstruction. Not all patients have enough tissue for a deep flap. This patient had a right latissimus flap with an implant and a left implant reconstruction, and this was her after her bilateral nipple areola reconstruction. In a latissimus, when a patient has a radiation chest defect, it's an elderly patient, a latissimus flap with implants allowed correction. Now some patients have a radiation deformity that you can't always see very clearly, but there is some sort of misshapening of the breast contour, and she also complains of significant pain and animation. She had right chest radiation. For these radiated cases, the use of spiolete is very helpful, and it's not only helpful for elevation of the abdominal flap. The elevation can tell you which zones to use. For example, in this patient who didn't have a significantly large or thick abdomen, the use of multiple zones was required, and I did go to the past the midline, and you can then see how much of that left flap could be viable, and certainly zone four was not at play, but a good portion of zone three cross midline was able to be used, and as this part appeared a little darker, a portion of zone two was also removed for this particular patient. And the SPI software system, SPI Elite system, is not only great for the elevation of the flap, it's also very helpful in determining what portion of your breast skin flap needs to be removed. Now, if you kept the original entire skin island of the mastectomy flap, and it did not excise this large area, you may have been left with a necrotic flap, because this was a subpectoral reconstruction, and so the mastectomy flap was re-elevated, which may have decreased some of the blood supply of that skin flap. But if you had not re-developed that flap, the pectoralis major muscle may have been too restrictive, and would not have allowed the type of shape that you had desired. So it's really important sometimes to figure out what portion of the existing skin island you want to remove. And as you can see, this very large skin paddle was removed from her right radiated breast, much in line with this area of puckering and distortion, and then this is her with the use of zone one, part of two, and part of three for her right deep flap, and she kept her implant reconstruction on the left side with a lower profile implant. We will now begin the discussion. So in my presentation, I spoke about suturing the muscle back down when you know you're going for a secondary reconstruction. Dr. Glick-Smith, in an explant-only case, what's the role of suturing the muscle down to the chest wall after explantation? I think one of the things is we're talking about suturing the muscle down, which might be different if you know you're going back there to do a bigger reconstruction. But when we see these explant experts that are suturing down muscle, and then puckers, and they have no soft tissue coverage, whether or not that's really necessary if you're just going to an explant only, and not going back there to do something else. So that's kind of different than what you're doing where you know you're going back there or you're going to be bringing in soft tissue coverage. So that just might be something that's a little bit different in an explant only when these guys are suturing down. And there's really nothing to suture. There's nothing to suture. Yeah, these patients are just tethered and look even worse. Thank you, Dr. Glick-Smith. And moving on to the role of capsulectomy. So there are some experts who discuss the need for an on-block capsulectomy in all textured devices. Can you elaborate on that concept and explain to us when it is absolutely necessary and when maybe it isn't absolutely necessary? So there's a couple of different points there. Number one, I would try whenever possible in a biocell patient to perform a capsulectomy or convince them to do so. But there are other texture devices such as the Mentor Cil-Tex devices and Cientra surfaces that we see. And occasionally the devices from outside of the country that you see as well, some polyurethane implants you may see in your practice. So I try to convince a patient, but there are times when that implant has not been in for that long. The patient has no history whatsoever of any abnormalities, never had any changes to their breasts, no history of a rupture. And you get into the operating room and it is a tissue paper thin fine capsule that you probably couldn't take off that chest wall anyway. You're talking about increased morbidity, possible pneumos, possible chest pain, rib pain, for what? Because we actually don't have any evidence that you really changed their lifelong risk from the papers that are published to date. There is some literature out that's coming out, some papers I have reviewed that may sway us one way or another. But there are times because if the patient has no other problems, no history whatsoever, no problem with rupture, seroma, any issue in the past, you are adding to your transition from texture to smooth. If you're doing that and the patient's not concerned, possible changes in shape, possible malposition, possible increased palpability, visibility, and the other surgical risks I mentioned. So it's a consideration. And I do let the patient who really has had no problems, if they say, I really like my shape, I can tend to guarantee it more. And so if there more evidence comes out that says this is an absolute indication, you will, you know, we have evidence now, I will change and take it out 100% of the time or try to. But at this point, there's no evidence to say you absolutely have to, especially in the other manufacturers' devices. I don't know what anybody else thinks on that. And is that in keeping with their kind of voluntary recall on those devices from Allergan? Yeah, the voluntary recall from Allergan does not say anything about what you have to do with the capsule whatsoever. There's nothing on that at all. Their lawyers are different than that, yeah. And do you send your capsule specimens for any pathology? Anything I take out of the human body goes to pathology. Yeah, I send all capsules to pathology. Even if I'm doing a partial capsulectomy, any piece of capsule, I don't wanna find out two years later that I do have a seroma or you missed something. And there's other malignancies now in the capsule. There's other problems. So I send all capsules. What about the rest of the panels? Does everybody send all of the capsule, whether it's done in your office or in any other setting? I mean, for myself, because they're reconstructive cases and oftentimes the patient has had cancer, I obviously send all of my specimens as well. But how about in Brazil? I'm just curious. Yes, I send always to the pathology every tissue that I remove. And I try to remove the capsule as much as possible. And if it's impossible to remove, I maintain the capsule only if the patient has ALCL or something. But send to the pathology is essential, yeah. And if there is no specific concerns, do you routinely ask for any special pathology studies with regard to the capsule? Let's say there is an associated seroma or you have some sort of suspicion, do you alert the pathologist or you just send it for standard pathology? Yeah, I would definitely say rule out ALCL. And they're pretty much knowing now what to do with that capsule. If it's a routine pathology, if the pathologist finds something abnormal, they go on, they alert you that there's something abnormal and they go on. But routinely to ask for all of that is really a waste of time. But if there's anything, obviously you see a mast, you see anything abnormal, you encounter a seroma, but you shouldn't really, with my ultrasound, we're really not gonna go to the OR and find surprises. That's the beauty of having an ultrasound in your practice. You know, if there's a seroma, I'm not opening up the patient or I would get PET scan in advance. You do all the proper protocols first, but you should not encounter something. But if any capsule, I just send for routine pathology. I agree with that, yeah. Okay, all right. And so moving on, I'm going to ask Dr. Graf. Yes. Hi, Dr. Graf. I really enjoy your talk about the change of, I guess, the home for the implants. So if you could just elaborate on probably the ideal patient for that subfascial and intramuscular plain position cases, because I think those were, as we had previously discussed, very complicated and technically challenging, and certainly not a case to go on and do after watching your talk. And, you know, I just wanted to see if you could share a little more detail about, you know, who are the best patients and sort of maybe technical pearls on that. Yes. I use the intramuscular only when I change the pocket. So when the pocket was subglandular or subfascial and the patient has capsule contracture, I switch to the intramuscular because I don't go totally under the muscle because I try to avoid the animation deformity in the future. So, and also because the muscle is a very well vascularized tissue. So if you use the implant inside the muscle, it means that you have less capsule contracture in the future regarding the infections, regarding the bacterial inflammation. So, and the muscle has like a fascicles and it's very easy to find these fascicles. And they go with the electrocautery and then it's, you have no bleeding because you cauterized before cut yet. And I open the muscle at the areola level. So I don't close totally the muscle during the procedure. I use the inferior flap to block and then to close the pocket. So this is my way to do the mastopexy to change the implant. And always I try to change the pocket because you don't have the new implant in contact with some silicone particles, some body reaction, antibody. So I think it's important to have a new pocket, virgin pocket to avoid capsule contracture earlier. Yeah, I mean, I really enjoyed the videos as well as the results, but I think, you know, in your hands, it seems like it's an easy procedure, but I think it appeared a bit technically challenging and requiring a bit of expertise and certainly precision with regard to bleeding. Have you ever had any situations where you've had a late bleed in that pocket, which, you know, then we would worry about that being a concern or a nidus for future contracture? Oh, I don't use drain. So I have no hematoma. I didn't have a hematoma until now. I do this technique since almost 10 years. Do you put them on, I guess, activity restrictions for an extended period of time or what other measures or magic do you add to that? The patient, they can move the arms, but they don't do a strong exercise for three weeks. So I try to maintain for three weeks, just moving slowly, not do a strong exercise. But after three weeks, I allow them to do exercise. All right. And Dr. Jen Grass, I really enjoyed your very, I would say the journey of various patients that you've been able to take care of and particularly those sort of very important discussions with the patient about removal and, you know, like their decision process. So if you could go through your sort of discussions with these patients, because it seems like at least through your presentation, it's definitely a journey for them. And I just would want to see what your approach was or your simple approach, it seems, but. Yeah, I guess I just try to take each patient individually and really go through and try to make sure that she's educated on what, how much breast tissue she has at this point in her life. I have a fair, I have more people that come in just because of body changes than necessarily systemic symptoms or concerns about systemic symptoms. So I was doing a lot of this before the BII situation sort of presented itself. And just because I've been in practice almost 30 years and it's, I think it's wonderful when you see somebody 20, 25, 28 years later, and they, you know, you put their implants in and then they've had their children and now they're perimenopausal or gone through menopause. And I mean, that's sort of the joy of being in practice for a while. And so a lot of those women, their bodies have changed and they don't always really realize what, how much breast tissue they have. You know, they may have had an A cup or almost no breast tissue and now they have a lot of breast tissue. And so it, to me, that's important that they make an informed decision. So, you know, the deflation of the saline implant, I think is just a really powerful tool. Some people look at me like I'm crazy when I suggested but a lot of people decide to do it. And I think it's, it can be very helpful especially the people who are just over their big breasts and they've maybe gained weight, maybe haven't but they're just kind of done with their journey and they know they want their implants out. And they're thrilled to know that there's an option. Oh my gosh, you mean I can go home without these big water balloons? And it's just, it can be a really happy thing. Yeah, so I mean, I think for the cases where you have the opportunity to do a sort of stage saline deflation and you can show them. I think, you know, the more difficult situation would be the patients who have an implant showing them their possibilities. So how do you discuss or determine staging their mastectomy? Or doing it immediately? Because I would think for those cases if they have a lot of breast tissue and they're very tautic you kind of already know what you would want to do. Yeah, I mean, I would say most of the time if I think your really breast isn't going to look very good I'll tell them that. I mean, but some of them are ready to hear that. And some of them aren't and it can take a fairly lengthy discussion. And I've learned as I've gone along and taken some implants out and there's nothing like that panic on the operating table. Like this isn't what I thought it was going to look like. And I didn't, you know, that you may have a little more to do than you thought you were planning to do. So, you know, I think I try to do a really good physical exam and tell them and then break it to them. You know, you really need a lift. And a lot of them come in and they know they need a lift. And just like a lot of the people that come in for a breast augmentation, they really need a lift. You know, you've got to have a lot of those discussions. Most of the time, a lot of them do need a lift and I'm just taking them. It also depends a little bit on like sometimes like you said, Mary, if they were my patient 15, 20 years ago, I have their images from those years ago. And I think if they were a small implant under 300 CC implant, didn't add that much they put on their own breast tissue. I just show them, I say, you'll most likely go back to this and possibly now just be sure you want to have some scars and you want to change it or do you want to live with it for six months or so and decide. So I do a lot of staged because, you know, I guess my income is lower because I don't book the, you know, the mastopexy at the same time but they come back to me. They've been coming to me for 20 years. So I think I just trust and let them recover a little bit. And some women really just want to spend money from here up, you know, they're really done with this. And they're in their fifties and sixties now and they really want to do something with their faces. They're kind of over that. And they don't want to spend the money on the mastopexy. I don't have very wealthy patients. So they kind of pick and choose. So I do look back at their old photos and look at their old body. And if I didn't put something so big in and they never really bottomed out or stretched I say you pretty much go back to what you had just older. And if you didn't do the procedure, I've got, you know, literally hundreds of just plain explants pictures to show them. And that is very, very helpful. Cause you know, I can scroll through that. I know where the ones are that look similar to what this patient that's in my exam room right now looks like. And so I can give them an idea. And some of them are horrified by how they're droopy. And others are like, oh my gosh, that's not bad. Let's just take them out and be done with it. And, you know, move on to something else. So I just think that you just have to be prepared to have those conversations so that the women are making an informed decision about their body. I'm pro-choice when it comes to breast implants. And Sarah, Sarah, are you online? Oh, okay. All right, so I'm gonna, I really enjoyed your talk about explantation and the secondary procedure of doing fat grafting. So for your fat grafting sessions, what's the average transfer volume? 325 CCs is the average grafting volume. And the range for most of my cases is 200 to 450 CC. And is that determined by just the sort of donor volume of fat that you have, or is that sort of based on the tightness of the pocket to which you're grafting to, you know, because there's obviously been some investigation into the viability of the flap when there's too much pressure, for example. So what is that volume determination based on? Primarily donor site. And I do charge per harvest area. So if I'm harvesting from more than one area versus two areas, so it could be finances at the patient's end. And of course, what you're saying, I avoid too much turgor on the tissue. So if I'm injecting the fat and it's starting to come back out the little incision, I'm putting it in through, I'll stop filling. And can also be what the patient wants, if they want to be smaller, then I don't feel the pressure to add as much. All right. And one other question I had for the entire panel, does everybody use ultrasound in their office? Yeah. Yes. I use it primarily for looking for oil cysts, since I do a lot of fat transfer to the breast and typically find them in 10% of my fat transfer cases. And I take care of the oil cyst in the office myself and would only send the fluid if they had a history of breast cancer. And I do look at the implants too, but primarily for oil cyst. And anybody else wanna comment on the use of ultrasound? I think Dr. Glipson, do you give certifications? Can you? Well, we actually do through the Aesthetic Society. We now have a course that everyone, we just had it at a breast and body meeting. We do it at the national meeting. We have educational, didactic lectures and then hands-on, and then we award a certificate that at least they've had certain number of hours of training and also perform an informed consent, which a lot of people need to use in their offices. I mean, I just use my ultrasound all day long. It's the most fun I have all day. And I think for any patient that gets hurt or has any injury or breast pain, it answers the question so quickly. You just look right at the implant. And then I start, I follow my patients at five years, five years, seven years, nine years. I start to ultrasound them every two years as we're getting towards the discussion of replacing and just peace of mind and kind of, especially for older devices and patients that come to me, like I said, they have no idea what their implant is. You can tell where it is, what it is pretty quickly when they have no card and no history. And I don't go to the OR with any surprises. I know if I need to book that case for an hour or an hour and a half, if it's ruptured or not ruptured, there's no more opening it and worrying in the operating room. We know the left side's ruptured, the right side isn't, start on the right side. So it's just really, it's one of the best things I've ever added to my practice. We lost your volume. Oh, anyone else want to comment on the use of ultrasound for these explantation cases? I feel like it's like the microwave. Now that you have it, you can't believe you ever lived without it. Right, right. It's in my back pocket every day. We use ours all the time. Just phone, it's based, phone-based and can carry room to room. And did you have to get special training or certification or you just started incorporating it into your practice as you saw the need? I mean, Carolyn, and I think I've learned at some course, it was before it was kind of formalized, but you know what a great way to do it is just take it to every patient and ultrasound them before you open them up. I mean, that you've got an immediate information of if you're making the right call or not. So I would say that's how I learned. It's just taking it to the operating room with me and ultrasounding the patients before I opened them up. And then I know. We just published in ASJ on the learning curve and looked at Pat McGuire and myself and my daughter is a medical student actually wrote up our data looking at how many cases it takes us to, we got to 97% accuracy after the 30th patient, which the standard of care in radiology is about 69 to 70% accurate because they've never seen an implant. And it's just doing the ultrasound, going to the OR, doing the ultrasound and going to the OR. So it's very simple, but we can't encourage that enough with our courses that we give and trying to get everybody on board with ultrasound. Great. Well, I wanted to thank everybody for helping with this on-demand talk as well as engaging in this very interesting and collaborative discussion. I wanted to thank you for your time, all of your expertise, and it was really an honor to both share this panel with you as well as be able to observe and study all your work. So I look forward to seeing you live at the meetings, but thank you so much for this on-demand discussion.

breast surgery

explantation

revision augmentation

capsulectomy

subfascial placement

intramuscular placement

fat grafting

ultrasound assessment

patient lifestyle changes

implant deflation

fat transfer

surgical techniques