Speaker 1 (00:00:00):
Hi everyone. It’s Dr. Towfigh. We’re here another Tuesday at Hernia Talk. Welcome to my Hernia Talk Live. My name is Shirin Towfigh. I am your hernia and laparoscopic surgery specialist. Many of you are joining me on Facebook as live at Dr. Towfigh. Thanks for those that are also following me on Twitter and Instagram at Hernia doc. And at the end of the show, I’ll make sure that this is a available for you to watch and share on YouTube. So I’m super excited because I get to introduce to you one of my favorite plastic surgeons, Dr. Kevin Brenner. He is board certified practice in Beverly Hills, I believe,
Speaker 2 (00:00:41):
Across the street from me,
Speaker 1 (00:00:42):
Across the street from me, right? You can follow him on Facebook at Kevin, at Kevin a Brenner MD, and on Instagram and Twitter at Kevin Brenner MD. So welcome Kevin.
Speaker 2 (00:00:58):
Thank you. Nice to you. Yeah, what, this is fun. This is not my usual Tuesday afternoon, so I’m excited.
Speaker 1 (00:01:05):
It is my usual Tuesday afternoon. So he’s across the street, not because he’s special, but I would say that I’m special to be so close to you in practice. But we practice in this golden triangle. Is that what it’s called? Yeah. Yeah. Lot Golden triangle. Yeah. It’s kind of like an exclusive between
Speaker 2 (00:01:30):
Santa Monica and Wilford Boulevard and I guess Rodeo.
Speaker 1 (00:01:33):
Rodeo Drive. Yeah. A lot of plastic surgeons, most
Speaker 2 (00:01:37):
Of them plastic surgeons. Not only in the triangle, but on the floor of my building and upstairs and downstairs and across your building
Speaker 1 (00:01:46):
And my building too. But you are here because most plastics really do not do what you do. And today’s topic is really on how my audience and I can learn from you and your practice. Because as a plastic surgeon, you’re trained to do all different types of aesthetic cosmetic type surgeries and reconstructive surgery. You’re board certified that you do extra training. In addition, you did full general surgery training. Is that right?
Speaker 2 (00:02:19):
I did, yeah. I did five years of general surgery. I did boarded in general surgery. I did a year of tissue engineering research at uc, Irvine, and then three additional years of separate distinct plastic surgery residency.
Speaker 1 (00:02:33):
You look great for all
Speaker 2 (00:02:34):
That. My math’s not good, but it’s nine years of residency and thank you.
Speaker 1 (00:02:39):
Yeah, it’s intense. Plastic surgeons don’t get enough props for the amount of training and education they have to do for, I don’t think people appreciate that as much. So part of what you do is augment breasts, and part of that is to use implants for that same way that I fix the hernias and a lot of the times we need to use Mesh for that. So I remember back in the day, there was this controversy of breast implants causing fibromyalgia and there was whole Dow Corning, right? Like FDA was like, maybe we should stop making silicone breast implants.
Speaker 2 (00:03:20):
And they did for a period of time. Well, so first of all, we use breast implants for reconstruction and for cosmetic purposes, augmentation, et cetera, and also for what I call cosmetic reconstruction, which we can talk about later. So yeah, I mean there’s a lot of what we do as a plastic surgeon is to try to avoid using any type of implant and just use your own soft tissue, kind of the reconstructive portion of it. But there are times when that’s not possible. I mean, everyone is a candidate, like a, let’s say breast cancer patient. Not everyone is a candidate for a soft tissue repair for various reasons.
Speaker 1 (00:04:07):
They just don’t have that much soft tissue, for example.
Speaker 2 (00:04:10):
They don’t have enough tissue. They don’t want the morbidity of losing their latissimus muscle. They don’t have enough tissue in their admin for trans flap. I mean, they don’t have access to a microsurgeon. I mean, that’s another reason. And so when we were training, we learned both. I actually trained in a very microsurgery heavy program down at UC, Irvine, just about every, I don’t think I did maybe a handful of implant-based reconstructions when I was there. We did a lot of cosmetic surgery, but not a lot of implant-based reconstruction just cause we had many free flaps. Microsurgery. But I mean, implant-based reconstruction, there’s definitely a place for it widespread around the country. A lot of plastic surgeons do it. It’s not even something that I kind of went into practice to do. That’s not, wasn’t my focus. I was more of a mommy makeover, breast reconstruction, breast lift revision.
Speaker 2 (00:05:13):
And my practice just sort of very quickly developed into, not exclusively I do everything, but a big chunk of it is revision breast work. So that that’s implant complications, breast lift, complications reduction. I just did a redo reduction complication today. So the breadth of what we do is pretty significant. But I also realize that there are a lot of, I mean, there’s a lot of implant complications and can happen a lot of times that people do great with them and they have amazing results. But apart from breast implants, there are a lot of, different things that can and do happen with breast influence, rupture, capsular contracture, malposition, where it’s not in the right place, rippling every everyone’s breast is different. But as my practice developed, I started seeing people trickling in saying, my implants are making me sick, which I thought was very strange. It was like their exam’s normal, the implant’s soft. If the implant’s soft, then they probably don’t have a capsular contracture.
Speaker 1 (00:06:32):
But they weren’t complaining of the breast. They were complaining of their whole body. Right.
Speaker 2 (00:06:37):
Well, we, we’ll get into that there. Yeah. There’s about 40 plus different
Speaker 1 (00:06:43):
Speaker 2 (00:06:44):
Symptoms that people have complained or associated with. And the sorry thing is I initially, I thought the patient thought it didn’t make any sense, but I have a big cosmetic practice and I said to myself, if someone can come in and request that I put in a breasted plan, they should be able to come in and request that I take one out.
Speaker 1 (00:07:16):
That’s very open-minded,
Speaker 2 (00:07:18):
Right? So if that means we
Speaker 1 (00:07:20):
Don’t think that way,
Speaker 2 (00:07:21):
Speaker 1 (00:07:22):
Most Mesh surgeons don’t believe that. They don’t believe that if in fact they feel they know how to put it in, but they can’t take it out or it can’t be taken out or shouldn’t they, there’s a lot of resistance towards it from Mesh
Speaker 2 (00:07:37):
Because with a hernia repair, just like with a breast implant, when the anatomy changes just by virtue of you putting it in, and so when you take it out, you now are left with a deficit, whether it’s relative or real. There’s a soft tissue deficit. There needs to somehow be filled. And whether for a hernia, that’s a kind of soft tissue repair for a breast implant, that could be a breast lift, that could be fat grafting, that could be a very multitude of different things or nothing at all.
Speaker 1 (00:08:17):
So what I recall is that, I forget what year it was. I was much younger. I may have been in college or maybe medical school where this whole breast implants were making people sick. It was take, the silicone implants were taken off, FDA stopped. And the whole thought was either, these women are crazy, there’s no such thing. That was really the talking point. And then they said, well, maybe it’s the silicone, so let’s make breast implants without silicone or encapsulated. So it’s two layers of tissue of implant before this. There’s silicone, so even if there’s a leak of silicone, the body won’t see it. And so now breast implants came back with saline and other sorts of hybrid type breast implants. But I feel that over time, maybe even that’s been debunked. It’s not really necessarily a silicone issue. Right. And now you’ve named it, it’s called breast implant illness or BII.
Speaker 2 (00:09:16):
Well, I don’t know who they are.
Speaker 1 (00:09:18):
Well, not you,
Speaker 2 (00:09:19):
But No, I’m just saying they are, I dunno if they’re patients or they are patient advocate. They are probably not plastic surgeons who came up with that term.
Speaker 1 (00:09:30):
Speaker 2 (00:09:31):
I don’t know because I, it, it’s just sort of has landed in my lap kind of thing. Yes. I didn’t create this, but you’re absolutely right about breast implants. So breast implants go back to seventies and eighties, and initially the only implants were silicone. They were very different in terms of how they were made. The shell integrity was different. The crosslinking of the silicone internally within the gel itself was different. And you’re right, that what happened was it similar to this, although in the late eighties and early nineties, there was no social media, right? So the ability for patients to communicate with one another, share their stories, and be vocal about it was much less. And a lot of these patients, I, like you was in college at the time, high school and college and training when most of this was going on. So I was kind of peripherally aware of it, but it was never front of mind. And there was a point at where they started describing very similar systemic type of symptoms, which they called silicone syndrome. And the thought was that it was the silicone in the breast implants that was either as a result of a rupture or leakage of an implant, that it was getting into bloodstream and causing these systemic symptoms
Speaker 2 (00:11:12):
Or just what we bleeding through an implant, even if it wasn’t rupture, what we call gel bleed. And just the exposure to the silicone, silicone was causing various symptoms. Now it’s it. So that did in fact happen, the FDA did impose a moratorium on silicone implants for cosmetic surgery. And basically they were only available to us in breast reconstruction for a period of time.
Speaker 1 (00:11:43):
And then also cancer patients.
Speaker 2 (00:11:46):
Cancer patients. And I mean, there are other types of reconstruction that we were able to use it for tuberous breast, other developmental deformities, and also failure of saline implants. And what that means is sort of not well defined, but it wasn’t up until 2006 when the big implants at the big implant companies at the time, which were Mentor/ Allergan re-engineered their silicone implants and with the FDA we’re able to get conditional approval for cosmetic surgery that we started using them again, which was basically right when I finished, I went into private practice out of training, which was in 2006, a few months later, boom. I hadn’t been using silicone implants for breast augmentation, and suddenly I was able to. So most of my career has been in the zone of silicone implants.
Speaker 1 (00:12:46):
And is that the most common cosmetic operation that’s performed? Is it breast?
Speaker 2 (00:12:52):
Breast augmentation specifically? There’s about, give or take, 300,000 breast augmentations every year, breast augmentations and just over a hundred thousand breast reconstructions with,
Speaker 1 (00:13:04):
Speaker 2 (00:13:05):
There’s a lot of patients out there. But what happened was when they reapproved the implants in 2006, the FDA did mandate what was called a post-approval study so much as whatever patient was to get an implant, they had to be kind of enrolled, not by the plastic surgeons, but by the implant companies. They had to have certain degree of follow-up, if you will, in terms of symptom development, any problems, complications, et cetera. Now, that was the writing. Those were the directions in reality where the rubber meets the road. I don’t know that it necessarily happened. And the reason why I don’t think that necessarily happened is because both Allergan and Mentor a few years ago, which are two four breast implant companies, and two of the only three of the four make silicone implants. But they were both sort of, I don’t know if they were officially sanctioned, but it was determined that their follow up on this data was so low that it didn’t even make that decision. So
Speaker 1 (00:14:30):
That’s going on with Mesh in that. So pelvic Mesh has been the, I don’t know if there may be one company that still sells pelvic Mesh, but that’s kind of off. In the US there’s no phase four, which is post-marketing surveillance for hernia Mesh. But in Europe, in the European Union, the European Commission has mandated that. They just can’t figure out who should do it and how to make sure that it’s done. That’s the problem. Which sounds like in the US for breasts, they had the companies do it, but then having people, companies self-regulate themselves and that doesn’t work.
Speaker 2 (00:15:07):
Speaker 1 (00:15:07):
Speaker 2 (00:15:08):
I would imagine that, yeah, I Well mean it all comes at the end of the day for the companies, it all comes down to dollars and cents in terms of
Speaker 1 (00:15:19):
Speaker 2 (00:15:20):
They, if we can’t use Mesh, can’t use breasts, the companies can’t make them and they can’t make money off of them. And that probably sounds awful to most patients, but it’s just,
Speaker 1 (00:15:35):
Speaker 2 (00:15:36):
Just a simple reality of business in this country. And which is the same critique I hear for surgeons like, oh, well, you’re only putting in breast implants because you’re making money off of it. Or you’re only fixing hernias because you’re making money off of it. Or this person has a deal with Allergan, this person has a deal with Mentor. This person has a deal with, they’re getting paid endorsement. So of course they’re going to keep, I, by the way, have no financial interest in any of these companies.
Speaker 1 (00:16:11):
Speaker 2 (00:16:12):
Which is not the reason that I do this. The reason that I do this is because I really think that there are some people, a lot of people who are suffering from it, and I’ve physically seen them get better.
Speaker 1 (00:16:27):
So we have some questions turned in to try to help figure this out. And you’re the expert. They’re very few plastic surgeons. Actually, let me discuss that. There’s very few plastic surgeons that do what you do, which is see, treat, evaluate women with potential breast implant illness the same way I’m one of very few hernia surgeons or general surgeons that treats or addresses, well, I, I’ve been calling Mesh reaction, maybe we should be calling it Mesh implant illness just to keep it all the same family, because I think it is. But we were discussing this before the hour started. We’re the minority, you’re the minority. Your colleagues do not all agree that there is such a thing as breast implant illness or needs to be treated, right?
Speaker 2 (00:17:22):
Yes, that’s true. That’s probably absolutely true. Yeah. Now I’m not the only one that does this. Correct. That’s very clear. I mean, there are probably a handful of other people, surgeons that I’m aware of in Southern California, the LA area that do it. I do a huge volume of it now. So that’s a little different. I now, I have, this will probably take more than an hour, but I have created kind of a breast team in my practice because surgery’s only a small component of it. So I have other practitioners who do other is things, and we can get into what those are all about and whether or not they’re valid in work or whatnot. But I think I’m definitely the only one that has kind of a breast team that’s like this, that’s kind of man managing globally all that can potentially happen or most of them.
Speaker 1 (00:18:29):
So perhaps you can just define for us what is breast implant illness?
Speaker 2 (00:18:36):
So in 2021, my understanding of breast breast implant illness is that it’s a constellation of symptoms that patients get that they attribute to having a breast implant placed in their breast. So no two patients are identical, number one, right? Symptoms vary. Now have an intake symptom list where I have patients kind of rank what symptoms they have, the severity of the symptoms so that I know what it is when I meet them for their consultation. I know what, it’s a week, a month, three months, six months, one year. So that I can actually have something tangible to hold onto. Because there really is nothing tangible about breast illness at all.
Speaker 1 (00:19:32):
Speaker 2 (00:19:33):
Completely subjective. It’s all in the patient’s mind and experience in terms of what they’re going through, what symptoms they’re having. Now, part of it, the other thing is that they’re, because the most of the symptoms are symptoms that you and I learned in medical school and in residency are attributed or attributable to other disease process, other legitimate disease processes that are often serious or can be serious if left I’m treated there, there’s a lot of crossover. And so to the objective physician, whatever the specialty is, to look at someone who comes in and says, oh my God, I’m tired all the time. I can’t have brain fire. I can’t think I have shooting pain down my arm. I muscle aches in my legs. I’m losing more hair than ever in my life. By the way, I’m 30 years old, I can’t get out of bed. And oh was before I had my breast implants and this started a year or two after I had my breast implants. So is it related? So this is what I’m dealing with every week.
Speaker 1 (00:20:57):
Speaker 2 (00:20:58):
In terms of patient experience. And back in the before breast B I was a thing, a lot of, patients that would get chalked up to having fibromyalgia, which when we were in medical school, was sort of a waste bin diagnosis.
Speaker 1 (00:21:20):
Yeah, non diagnosis. Yeah.
Speaker 2 (00:21:21):
You’d rule out everything else. And if you can’t figure out what is causing their symptoms, it must be fibro. Right. So
Speaker 1 (00:21:31):
You have your own survey or is there a nationally acceptable survey for this?
Speaker 2 (00:21:38):
There may be a nationally acceptable acceptable survey. What I was going to say is I, we, we’ve been doing periodic phone calls with part of my breast team, but with other surgeons around the country who do a lot of as do I actually, the survey I have is a modification of one that I got from another surgeon who I believe is in Chicago, if I recall correctly. But yeah,
Speaker 1 (00:22:09):
The symptoms sounds similar to what I see and it’s not all of it. It’s pick bits and pieces, but it can be everything. I’ll go from head to like hair loss, headache, brain fog, inability to concentrate, memory loss, double vision, ringing in the ear, chronic fatigue, joint pains, joint swellings, arm and leg swellings. We we’re shooting pains in their arms and legs. Bloating. Do your patients get bloating, nausea?
Speaker 2 (00:22:41):
Well, I don’t know. I don’t know about bloating per se, but I have some patients who have unexplained weight gain. I have others that have weight loss.
Speaker 1 (00:22:51):
Speaker 2 (00:22:51):
Some patients with Hashimotos. I have some patients who are thyroid. And we didn’t even talk about autoimmune phenomenon, which is sort of the big thing. I don’t know if it’s as big a thing with hernias as with hernia, Mesh as it is with, or it has been with implants. I mean, the whole thing about the moratorium on silicone breast implants was that a large number of women were claiming that they had developed autoimmune phenomena as a result of their implants. People get autoimmune phenomenon, no doubt, who don’t have breast implants. So Sjogren’s syndrome is a thing, is a thing. Scleroderma is, I mean these are all real diagnosis that people get who don’t have breast implants.
Speaker 1 (00:23:46):
Correct. Rheumatoid arthritis. I even have a patient with vitiligo, which is an autoimmune disorder. But let me ask you this. So I remember there was an article early on, this is during the first wave of, before the F D A, this put a moratorium. There was an article that said, we’re going to look at the whole population and see how many people tend to get all these autoimmune disorders, rheumatoid arthritis, lupus, psoriasis, Hashimotos, ulcerative colitis, et cetera. And then look at all the breast implant patients, see how many of them get autoimmune. And they said it was exactly the same and therefore there’s no higher risk with breast implants. But now, within the past, I think four or five years, there is an article that says, no, actually there is a slightly higher risk of autoimmune disorders among patients that have breast implant illness. So it’s all evolving. We’re learning with time, it seems.
Speaker 2 (00:24:49):
It’s funny. So just in preparation for this hour, I actually went back and reviewed a lot of papers that I’ve read before. A as well as some new ones. I mean, when I started a couple years ago, I had a piece on KTLA and I said, we don’t have any data. There’s no studies. And that was time. Now that’s not true. I mean, there have been a handful of studies in the last few years, whether you agree with the statistical analysis on them or not. They’re there. I mean, they’ve been published. Okay. And not every article that’s published is necessarily, doesn’t necessarily make it the gospel just because it’s published. There are people that debate it back and forth. But the very fact that people are publishing about it means that there is definitely a trend and a build. And when I was at, I attended, albeit virtually our society’s spring meeting,
Speaker 2 (00:25:57):
It was just this past spring. It was the first time that I actually saw sort of a change change in the tide in terms of people talking about it. Studies being done by our societies, by our educational foundation. And maybe not everyone was on board. I’m sure a lot of people weren’t board, but they were discussing it. Whereas prior to that, it was like, true, don’t touch it. That’s landmine. So right before the whole COVID shutdown, I went to, I think it was Cedar Sinai plastic surgery meeting and started and was giving a presentation about my experience with breast implant homeless. And I, it’s a group of just local plastic surgeons. And I thought I was going to have tomatoes thrown at me because I think I’m a quack. But the reality is, is that I’m not a quack. I’m, I’m as legitimate as plastic surgeon as any other plastic surgeon in this country. And I just happen to believe my patients that they’re feeling this way. Yes. Cause they definitely feel better.
Speaker 1 (00:27:13):
I think that’s a very strong statement where you believe your patients, first of all, these patients aren’t all gathering together and coming over the same exact story. That’s not what’s happening. And yet they’re coming. There seems to be a similar story. And we just don’t know enough as physicians, I feel like physicians are very uncomfortable when they don’t know. So it’s very easy to say it doesn’t happen or it doesn’t occur
Speaker 2 (00:27:39):
A hundred percent.
Speaker 1 (00:27:41):
And so if you just listen to the patients and admit that you don’t know and you’re learning, and unfortunately we’re in this stage right now where we don’t know enough and there are patients that need our help and we kind of think we know what we’re trying to do to help them. But there’s no science behind a lot of what we do because we’re in the learning stages of it. And yeah, I feel like, yeah, I mean they probably think I’m a crack too, because I do treat patients with potential Mesh reactions. Let me ask you this. So in my experience, the Mesh reaction patients react within days, weeks, months, maybe a year or two, but really not after that. Is that your experience too? It’s kind of early. They don’t come 10 years later with a problem.
Speaker 2 (00:28:24):
Speaker 1 (00:28:25):
Speaker 2 (00:28:26):
No. I mean now mind you, the patients that I’m seeing, I look back at this, I’ve only had I, I’ve done a lot of breast surgery primary revision just in the last 15 years. Yes. Had one patient of my own come to me requesting to be implanted because she thought that she had BII. She also thought, by the way, she had a L C L, which is a very rare lymphoma that’s been associated with some textured
Speaker 1 (00:29:00):
Speaker 2 (00:29:01):
Varieties of implants. Two separate entities. But the question is, is there any commonality to it? Is there any sort of unifying theme? So most of the people that I see, it’s a delayed phenomenon. Now, sometimes that delayed phenomenon is six months, sometimes it’s a year and sometimes it’s 20 years. And this will come out when I crunch the numbers on patients. But it seems to be, and I don’t have data on this, so don’t hold my feet to the fire on this, but it seems to be that some of the newer generation of implants have a, seem to have a quicker time to development of symptoms than older patients. I mean, have patients who’ve had 30 years with no problems.
Speaker 1 (00:30:01):
Speaker 2 (00:30:02):
Saline implants, no problems. One thing, the other thing is that I don’t think this we, you’ve touched on it before, we’ve got sidetrack, but I don’t think this is a silicone phenomenon. Even though in back prior to the moratorium, people were thinking that it was a silicone.
Speaker 1 (00:30:21):
Yeah, that’s what they were blaming.
Speaker 2 (00:30:23):
And the reason is that, the reason I say that is I see a lot of patients with saline implants that have the same symptoms. And while the shell of a silicone implant and the shell of a saline implant are the same, it’s a solid silicone elastic. Right. It’s not like the shell is dissolving. Some people think that, well, there’s tons of different chemicals including
Speaker 1 (00:30:54):
Speaker 2 (00:30:54):
Heavy metals like platinum that are used to make the shell. And that perhaps that’s leeching, and I don’t not familiar with the biochemistry behind hernia Mesh, but perhaps the whatever’s making the implant is leeching in the body and causing these toxicity, causing these symptoms. I don’t necessarily ascribe to that. I mean will admit it as soon as I see evidence to the contrary. But what I think is that it’s just an immune immunologic response to having a foreign body.
Speaker 1 (00:31:31):
And do you see that that’s increasing? Do you see we’re seeing more of this problem, it’s becoming more of a problem, not because we’re seeing it more where there’s actually more cases of it.
Speaker 2 (00:31:42):
Is there an increasing incidence of it? Yes. I probably not.
Speaker 1 (00:31:49):
Speaker 2 (00:31:50):
It’s probably not that the numbers are changing. I think the biggest difference is a social media. Everyone’s talking about it together. And so they come, it’s almost like they’re, they come together in groups of people. So it seems like there’s more patients than maybe it did 10, 15, 20 years ago that that’s one thing. Patients are much more vocal about it as a result of
Speaker 1 (00:32:15):
That. This is true.
Speaker 2 (00:32:16):
I think a lot of patients were reticent to say anything, number one. Number two, when they brought it to attention of their physician, whether it was their family practitioner, their internist, their cardiologist, their neurologist, rheumatologist, whatever, plastic surgeon, whoever it was, they were dismissed.
Speaker 1 (00:32:36):
Yeah. Yeah. That’s true.
Speaker 2 (00:32:38):
I can’t tell you how many times I’ve had patients say, I can’t believe you’re listening to me. I went to my plastic surgeon, I went to my internist. They said, everything’s fine. You’re crazy. Get out of my office. Nothing wrong with your implants
Speaker 1 (00:32:51):
All the time. And
Speaker 2 (00:32:53):
There may be nothing wrong with their implants, but there’s something wrong. And what I think it is, is that it, some people just are kind of prewired to have this immunologic response and immunologic response. Everyone’s very familiar with immunologic response since COVID. But immunologic response happens in more than one way. It’s not just antibodies. It’s not just bodies. Right. I mean, there’s a whole cascade of cells in our bloodstream that can cause immunologic reaction. And I think it’s just the immune system’s going haywire and just willy-nilly hitting different systems. My hypothesis, I don’t have any proof of that, but there are definitely studies that are going on. There are surgeons. And by the way, I kind of noticed that a lot of, the studies that I’ve seen, even though there’s a handful in the us, there was a very good study recently out of the Philadelphia area. There’s one out from a surgeon in Ohio, which are start starting to show that the benefits of removing implants, et cetera. But a lot of, the studies I’ve seen are outside of the country, primarily in Australia. Really? They do a lot of, lot of breasts in Australia. So there’s a lot of out after.
Speaker 1 (00:34:21):
Yeah. So I see similar population. They’re told it’s in their head, psychological problems with their anxiety. If it’s a female, which it often is, they are asked, are you having, okay, sexual relations, how’s your relationship with your husband? There’s a lot of that going on, which is very disparaging. And then they lose hope because no one’s listening to them. And they legit, I mean, have patients have rashes? Do you have patients with rashes? They see, do you see rashes
Speaker 2 (00:34:49):
Speaker 1 (00:34:50):
Yeah. Yeah. I mean, you can’t make up a rash and you can go through a whole dermatologic workup, which they all do. And then at some point you have to figure things out. Now I have a question for you. So you mentioned in neuroplastic society this year, you started to see that there’s a little upswing of interest in breast implant illness and studying it. We just had one of our meetings this past week, and then also two weeks prior to that. Also, very noticeable industry and surges are both talking about less synthetic Mesh, more tissue repairs, removing of Mesh. And also there’s a new interest by industry to bring in what’s called absorbable meshes. So things that kind of come and go. I have a question for you on that, because it’s posed here by one of our viewers. So one of the absorbable meshes is called phasix. It’s P4HB, I think is the chemical name for it. It’s also sold as GalaFLEX for breast. So when I saw surgeons on social media putting galaflex in for every single breast they were doing, I freaked out because I’m like, why are you doing that? It’s like a highly inflammatory potential. We weren’t doing that before. And they claim they have had no issues. And yet I’ve had people with Phasix Mesh, which is the galaflex equivalent, but on the hernia side, who have reacted to the implant.
Speaker 2 (00:36:23):
Well, cause that’s how anything that’s absorbable, that’s how it absorbs, is inflammation. So
Speaker 1 (00:36:31):
Do you see people with galaflex coming to you with problems? Have you seen galaflex problems? Just curious.
Speaker 2 (00:36:37):
No, but I also, I will use Mesh and breast surgery. The Mesh that I prefer is a cellular dermal matrix.
Speaker 1 (00:36:49):
Speaker 2 (00:36:49):
Variety. Other. I’m not.
Speaker 1 (00:36:51):
Speaker 2 (00:36:53):
I have no financial interest. I like AlloDerm. Cause I’ve been using it for so long. Yes. But when I need it, I mean, it’s ridiculously expensive. Especially since they used to have a cosmetic component to
Speaker 1 (00:37:07):
It. Yes. I remember
Speaker 2 (00:37:09):
Cosmetic arm to it. And it was a more affordable, and now it’s either that and it’s like an arm and a leg, or there is a pig variety called strattice, which all it is acellular matrix.
Speaker 1 (00:37:25):
Except it seems to be more processed than, don’t you think
Speaker 2 (00:37:30):
Speaker 1 (00:37:31):
I think stratus is a little bit more processed. It just seems to act more synthetic. And for Mesh at least, I don’t know, even those biologics.
Speaker 2 (00:37:41):
Yeah. Well anyway, my point is I have used absorbable meshes before I, I’ve used other, there’s been a lot of things that have been coming on and off the market. And I’ve had bad, I have had in the breast bad reactions before, and I’m blanking. The name of it was a biologic mash, and I can’t think of the name of it at this time, but it was
Speaker 1 (00:38:07):
The silk one that was taken off the market.
Speaker 2 (00:38:10):
Not no, not silk one. No. Well, silk silk’s, not absorbable. It
Speaker 1 (00:38:15):
Was marketing as being absorbable biologic. I remember that. That came and went very quickly. But
Speaker 2 (00:38:22):
Yeah. Yeah, you’re absolutely right. I mean, I’ve gone to meetings before where people are talking about using either Vicryl Mesh or GalaFLEX in their breast lifts because they think that they get more permanent lift. More permanent contour. I’ve never done that. I’ve never had a need to do that. Maybe it helps. I don’t know. I just find it unnecessary.
Speaker 1 (00:38:48):
Speaker 2 (00:38:49):
You blood tests?
Speaker 1 (00:38:51):
Yeah. Do you check blood tests or labs?
Speaker 2 (00:38:55):
I don’t check blood tests or labs necessarily at the time of consultation. Yeah. I’m almost kind of the end stop for a lot of patients. So both of them have already been to the rheumatologist or their primary care or bone or cardiac, whatever the specialists that they need to go to for whatever symptom they’re having. So a lot of times, they’ll come in with it. And so I’ll review everything. However, before we go. Before I put patients to sleep, I checked kind of routine CBC chemistries. I did this year start checking in addition to coagulation, I started checking in ESR and CRP, which are inflammatory markers. And thus far, I haven’t think I’ve had one patient where they’re elevated.
Speaker 1 (00:39:43):
Speaker 2 (00:39:45):
But I’m doing it because I was curious. Yeah. I used to, my initial thought when I started seeing this is that much capsular contracture or a L c, that perhaps there’s an infectious etiology behind it. Right. Cause the one thing, which probably true for hernia rash as well, is that with rest implants, if an implant gets, any implant gets contaminated. Like it’s contaminated until you autoclave, which you can’t do with a breast implant without ruining its integrity. It’s contaminated you, not like you just wash it off with antibiotic ointment or betine or whatever and decontaminate. Because yeah, some of these bacteria create this slime layer which sticks to the silicon. And it’s interesting, a lot of people think that, well, if my breast implant was infected, I would know it because just like a pimple, it would be red hot, swollen, puss, et cetera. Not the case with breast implants. Cause because there’s a breast capsule that’s around the Yes. Just like there’s a capsule around any implant. And that space is a privileged environment. Right. So things can’t, your white blood cells can’t get in there. They can into your soft tissue.
Speaker 1 (00:41:01):
Yeah. We’ve checked blood tests too. And they’ve always been normal, even though clearly the patients are eliciting some type of inflammatory or autoimmune reaction. But it is not enough to show, at least on the normal labs that you can order. Now, if there’s a research lab, they can check HLAs, another kind of fancy stuff. Cytokines maybe that will show. But yeah, haven’t also not been able to show a difference.
Speaker 2 (00:41:25):
I mean, I started by swabbing. Every time I took would swab inside the capsule. The yield was so low that I stopped doing it
Speaker 1 (00:41:37):
Speaker 2 (00:41:38):
Yeah. I mean, I got to think maybe I got two staff that grew out one ProAct, which are all normal skin flora it. And then patients were getting all these bills for these microbiology bills from UCLA because they’re expensive to run those tests. So it’s like, unless there’s a reason for it, I don’t do it. I don’t really do it routinely anymore.
Speaker 1 (00:42:05):
So I’ve discussed on hernia talk that my practice has changed. And in fact, I’m hoping to present this change in my practice at next year’s American College of Surgeons, Southern California chapter meeting. I hope if our abstract gets accepted to show how over time, because of this kind of experience that we’ve had with patients reacting to Mesh and then looking and seeing how they tend to be women. They tend to be really thin patients. They tend to be people that already either have an autoimmune disorder or have a family history of it, or have known to have breast implant illness already. So I probably will not put a Mesh in that person. Or they’ve had reactions to dental implants or have shown some propensity towards reacting to implants. Do you feel that your practices also change? Are you less likely to talk someone into getting a breast augmentation? Or do you talk them out of it? What’s your take on that?
Speaker 2 (00:43:06):
It, it’s definitely changed. Your question on the screen. Are there subsets of patients that I choose, that I choose not to implant? And the answer to that is probably no.
Speaker 1 (00:43:17):
Okay. Because they’re all young, thin females.
Speaker 2 (00:43:22):
Yeah. No, just they’re not all young, thin girls. I mean, I see kind of the full spectrum. The reason for mean, first of all, I’m doing so many X plans that the percentage of implants tolan in my practice history changed drastically.
Speaker 1 (00:43:37):
Speaker 2 (00:43:37):
That’s number one. Number two is, wow, I do do some revision surgery and will do removal and replacement, ruptured implant fixing. There’s various reasons for it. Yes. I will do breast augmentation, primary breast augmentation on someone. The difference that I have made, the change that I have made, I should say in my practice is my consent process. And whereas it was never on my radar before. Now b I is front and center in my mind every day, all day. And so it’s part of my consent process. That’s amazing. And my consent process starts during my consult. So I mean, a patient comes in for a breast consult, I usually spend about an hour with them. So Wow. Cause there’s a lot to go over. And part of that, if they want a breast implant, part of that is you can get a capsular contracture depending on which study. It’s between eight and 20%. Yes. You can get malposition. Yes, you can get rippling. Yes. You can get an infection, you can get a device rupture. It’s going to happen at some point. You can’t get a L C L if you have a texture device. You can’t the AI with any device. And that’s part of my conversation with them. I mean, we don’t have a lot of statistical data to give them.
Speaker 2 (00:44:54):
And it’s just my kind of anecdotal experience. And now there are studies that are starting to come out. But yeah, I, I think I’m doing a disservice to people to not tell ’em. I mean, think any plastic surgeon that’s putting in a breast implant today, that needs to be part of, I’m not saying that you shouldn’t do it, people are still going to do it. It’s not going to go away completely. It’s just the reality. But a good plastic surgeon will be informing their patients about the, but whatever risks they’re aware of. And if a plastic surgeon at this point in time is not aware that breast implant illness is on the horizon right now, then they got their head in the sand. Seriously, that’s how much noise has been made in the last couple years.
Speaker 1 (00:45:48):
There’s a question related to breast implants proposed. Have you seen capsular hemorrhage in breast implant patients as they age? Especially those who need anticoagulation for let’s say atrial fibrillation. Have you seen that?
Speaker 2 (00:46:04):
I myself haven’t seen it. One of my associates I know has seen a patient who had a bloody seroma. And so someone presents with late what we call a late seroma, which is usually like six months after. Six months or later after their implantation. Any seroma at that point in time, you have, we in your back of your mind, you have to rule out a lymphoma. So I have seen it. And usually I’ll send ’em to my radiologist over on Brighton. And if there’s a seroma, they’ll aspirate it. We’ll check it before we go to, I don’t want to find about it, find out about it after the fact. I want to know ahead of time. I personally have never seen spontaneous hemorrhage from any coagulants. But that post-op and hemorrhage, I mean that happens.
Speaker 1 (00:46:58):
When you’re treating patient with BII. What’s your experience once you remove the implant? They, do they get cured? Does it linger? Is it everyone A little bit different? What about their symptoms?
Speaker 2 (00:47:12):
Everyone is a little bit different. Yeah. I hesitate to use the word cure because I mean prefer to say Rives. Rives, excuse me second. Sorry. Resolution. Resolution of symptoms.
Speaker 1 (00:47:32):
Speaker 2 (00:47:34):
Not remission. Because it’s not a cancer. I notice that I see all my breast patients. I see all our patients, most of ’em. Anyone who has a major procedure I see the next morning for surgery. I see a difference in these patients.
Speaker 1 (00:47:54):
Yes. The more you observed her, they’re like a new person.
Speaker 2 (00:47:57):
It not everything’s gone. But I feel like the brain fog has lifted.
Speaker 1 (00:48:04):
Speaker 2 (00:48:05):
I feel like their eyes are brighter.
Speaker 1 (00:48:09):
A more energetic, they’re like more attentive, more
Speaker 2 (00:48:12):
Energetic. A lot of people say, I don’t know if it’s the Percocet talking, but I just feel better. And maybe it is the Percocet talking in the next morning, but I legitimately think that patients feel better even starting it the next day. It’s not going to be a hundred percent. I have some patients who start feeling better. I have some patients who get a hundred percent resolution. Sometimes I have some that don’t get any. I mean that does happen.
Speaker 1 (00:48:37):
Speaker 2 (00:48:38):
But then maybe they didn’t have breast illness in the first place.
Speaker 1 (00:48:42):
Yeah. You’ll never know. Cause we don’t have any objective data. It’s really just syndrome symptoms.
Speaker 2 (00:48:48):
Although interesting. And you’ll, you’ll be interested in this or maybe not since now all you do is hernias. But I had a patient this past year who, amongst her other myriad of symptoms had unexplained pancreatitis. Idiopathic had seen the top pancreas guy over at Cedars. He didn’t know what was causing it because she was relatively young, I don’t know, 40 otherwise healthy unexplained pancreatitis. Did ER admissions in and out for abdominal pain, pancreatitis, lipase in two hundreds or whatever. And in fact it he, she had her on medication just to keep it quiescent. Never went away completely. She had a recurrence right before her scheduled surgery. I pushed her surgery two months just to get it under control. Cause I didn’t put something sleep for big operation in the
Speaker 1 (00:49:57):
Middle of pancrea pancreatitis.
Speaker 2 (00:49:59):
So she, we kind of calmed her down an eight weeks postop. Her lipase was back to normal.
Speaker 1 (00:50:08):
So was autoimmune pancreatitis potentially. Whoa, that’s a big deal.
Speaker 2 (00:50:15):
Speaker 1 (00:50:16):
Right? Yeah. We’ll never know. But I don’t
Speaker 2 (00:50:18):
Speaker 1 (00:50:19):
Temporally, it’s correlated
Speaker 2 (00:50:22):
A hundred percent. Wow. That’s one person. And you can’t generalize and extrapolate from one person, but, but it happened. I mean I saw that. So I don’t, don’t, an endocrinologist that I know around here who told me that also anecdotally, he seen many patients who’ve been explained who had Hashimotos.
Speaker 1 (00:50:50):
Speaker 2 (00:50:51):
And they’re any thyroid antibodies tempered off to zero after explanation.
Speaker 1 (00:50:58):
Yeah. I’ve talked to many endocrinologists and they’re all seeing some shady stuff going on. There’s these new, like you said, Hashimoto’s thyroiditis or this kind of lupus like syndromes, but it’s not really lupus. And then you take out their Mesh, let’s say, or their breast implant or they send it to me. Do you think this is possibly related because these operations are very common. We have a million hernias done a year. You have, what’d you say? 600, 700,000 breast in milk.
Speaker 2 (00:51:31):
I think that means that you’re going to be busier than I am.
Speaker 1 (00:51:34):
I am busier than you are, but I do other fun stuff. You do.
Speaker 2 (00:51:40):
Yeah. No, there’s probably about 4,000 patients who get implants every year.
Speaker 1 (00:51:46):
Yeah. It’s just crazy.
Speaker 2 (00:51:47):
Well, and for breast implants, most of ’em are bilateral. So
Speaker 1 (00:51:53):
This is true double
Speaker 2 (00:51:55):
Thousand patients. That’s somewhere between six and 700,000
Speaker 1 (00:51:58):
Implants. Yeah. Yeah. It’s so crazy. I feel like one day we’re going to look back. You’re going to tell your grandchildren. And when I wasn’t in practice, we were putting the stuff in, people we’re putting plastic in people. We thought it was okay, and then everyone got sick. I’m just exaggerating. But there’s going to be some
Speaker 2 (00:52:16):
No, but you see what I mean. You and I had very similar training. I mean, I put Mesh in people all the time when I was a general surgery resident. Didn’t even think twice about it. I mean, unless it got infected from intestines. Yeah. That’s what you worried. You were worried about ulcerating intestines. You didn’t worry about systemic illness just from the Mesh.
Speaker 1 (00:52:38):
Correct. Not something we learned in residency at all.
Speaker 2 (00:52:42):
Yeah. One thing, I don’t think it was ever mentioned once to me as a resident.
Speaker 1 (00:52:45):
No, never. I would agree never. If it were, which was the BR implants were, it was poo PDA is like a conspiracy theory. Real.
Speaker 2 (00:52:58):
It still is to some
Speaker 1 (00:53:00):
Degree. Yeah. Unfortunately. I agree with that.
Speaker 2 (00:53:03):
At least in my world. It is. I think my world
Speaker 1 (00:53:06):
Speaker 2 (00:53:07):
For every article I I’ve read, there’s like, there’s a rebuttal from someone who’s like, that’s a bunch of BS. There’s no proof a few people doesn’t make for everybody. And this article is won. Well, yes, articles. These articles may be flawed. I don’t know that you’re, first of all, I don’t think you’re ever going to be able to do a prospective blinded study with this type of thing in order to find out whether or not B II is real or hernia match for that matter. Right. Number two is how long do you want to wait to take care of people? I mean, you going to wait another 10 years to take care of people before you decide you’re going to wait for the studies before you start operating on people to help them.
Speaker 1 (00:53:57):
Speaker 2 (00:53:58):
I think that’s nonsense. I was watching, this is going to seem like a red hearing. I was watching John Stewart has a new TV show on Apple TV.
Speaker 1 (00:54:10):
Speaker 2 (00:54:12):
And it’s not the Daily show, it’s not nearly as funny. It’s really more doc documentary. But his premier episode was about pits in Afghanistan. Do you know what burn pits in Afghanistan are?
Speaker 1 (00:54:30):
Speaker 2 (00:54:32):
Burn pits. So our fabulous military, who I love and I have an obsession with special forces and everything in Afghanistan and probably Iraq in this modern Afghan war over the last 20 years, near every military base, they get rid of all their refuge by burning it. So they will dig a burn pit adjacent to the base and put everything in it. Used tires, closed, amputated body parts, feces, food, trash, everything goes in the burn pit and they burn it. So every week they’re burning, there’s black smoke. So all these soldiers returning home are having these bizarre cancers. Shocking. All these bizarre at 30, 20, 30 and 40 years old, they’re getting the most bizarre respiratory illnesses in cancers. And the VA system is denying it as not being service related because there’s no studies to prove that it’s service related, even though a anecdotally temporally, it’s related. Right? Sound familiar?
Speaker 1 (00:55:53):
Speaker 2 (00:55:55):
So I’m like, what? What’s everyone waiting for? I mean, I understand the financial implications of it for a lot of people, and there’s always probably going to be a place for hernia Mesh for some people. And there’s always going to be a place for breast implants for some people, but not everyone should be getting it.
Speaker 1 (00:56:18):
Yeah. Well, there was also the one, I think it was during the Iraq war where they had all the bur things were being burnt like oil fields, but were being burnt. And so many of the American military were exposed and they came home with all these weird illnesses and they figured out it was all the I On that note, my personal feeling is that we’re doing something different now than we were doing 20 years ago. That the Mesh that we’re selling now that we’re putting into patients has a different chemical component and maybe more is cheaper or maybe has more impurities in it than the one that was being made 20, 30 years ago. And maybe the same is true for breast implants, that whatever the encasement of those implants is made of is a different, maybe not as pure. What do you think about that?
Speaker 2 (00:57:16):
Maybe I’m not a biochemist. I really don’t, don’t never gotten into the nitty gritty of how the shells are actually made and stamped and whatnot.
Speaker 1 (00:57:25):
Speaker 2 (00:57:26):
I suppose that’s possible. I don’t have any proof I’m going to get lambasted by all the implant companies. If I said that, I mean, I really don’t know that the whole thing is that the, there’s supposed to be better. I mean the whole, with each subsequent generation of silicone, it’s, it’s better cross length. It’s more cohesive. It, there’s supposed to be less silicone bleed. There’s supposed to be lower rupture risk. Right.
Speaker 1 (00:57:56):
So I will share with you a 60 minutes. You watch 60 minutes?
Speaker 2 (00:58:01):
Wait, I can stay up. Yeah.
Speaker 1 (00:58:04):
At seven o’clock at night. What do you mean? So no,
Speaker 2 (00:58:06):
I came, I say by seven o’clock at night, I’m like feeding my kids
Speaker 1 (00:58:11):
60 minutes. I think 2016 did an expose on pelvic Mesh. And they showed exactly that. Where they went from the FDA-approved polypropylene resin to a cheaper China Chinese based company that was making also polypropylene resin. But it wasn’t equivalent and it was not intended for human use. And they didn’t tell the Chinese company, they bought it, they hid it from the F D A, and they used it to make human grade pelvic Mesh and all these poor women were having brittle meshes and it was breaking and then causing these really massive reactions in autoimmune and inflammatory reactions, and they got shut down. But I mean, it happens.
Speaker 2 (00:59:00):
I, I’m sure it sure it happens, but you would think that these big reputable companies in the US would not go that route. But I think there’s a lot of things that we don’t know that happen in our government, in the FDA at the
Speaker 1 (00:59:19):
Speaker 2 (00:59:21):
Which is why our country is so polarized right now on so many different levels.
Speaker 1 (00:59:27):
And that’s why we have all these haters that call us quacks because we talk about this stuff.
Speaker 2 (00:59:32):
I mean, yeah, I’m not injecting ivermectin in people who, I’m just taking care of people who don’t feel well. Call em what you want. I, I’ll say this, I think China needs a new publicist because between COVID and now these crappy hernia meshes, they’re not doing very well.
Speaker 1 (00:59:57):
Yeah. Yeah. Kevin, I always enjoy working with you. Thank you. Thank you for taking care of my patients. We share many patients. You’re actually removing an implant from a mutual patient of ours that
Speaker 2 (01:00:13):
Well hope. Hopefully I’m removing both of them,
Speaker 1 (01:00:15):
Hopefully removing both of them, and in efforts to maybe treat or improve an autoimmune disorder. So this stuff as real, it’s every day and I really appreciate you sharing your time with us.
Speaker 2 (01:00:26):
As do I. You thank you so much.
Speaker 1 (01:00:28):
Speaker 2 (01:00:29):
Happy to do this again. And so have a great night.
Speaker 1 (01:00:33):
I will. And thanks. Go back to your family. I appreciate your time on this.
Speaker 2 (01:00:37):
You need so Shirin.
Speaker 1 (01:00:40):
I enjoy what I do as a problem. Thanks
Speaker 2 (01:00:45):
Speaker 1 (01:00:46):
Thanks guys. On that note, I’m going to say goodbye. Thanks everyone for joining us on Hernia Talk Live, our weekly Q&A on Tuesday. Tune in to my YouTube channel to make sure you watch and share this hour, which I’m sure is going to be very helpful to more than just my audience. Thanks everyone on Facebook at Dr. Towfigh and see you on next week. We have a lot more interesting guests coming up. Thanks everyone. Bye bye. Bye.