BII 01 Transcript:


Speaker 1 (00:03):
Welcome to The Breast Implant Illness Podcast with board certified plastic surgeon, Dr. Robert Whitfield, Austin's natural choice for plastic surgery and the expert in smart laser and energy treatments.


Dr. Whitfield (00:20):
So my experience both with general surgery, plastic surgery, microvascular surgery, over a decade of reconstruction, I've done thousands of microsurgical cases. I've done over 500 explants now. In about 2016 a client found me on the internet and came for a consultation regarding her breast reconstruction. She had an existing breast reconstruction of a implant. So I believe this client put me on a forum or discussed me somewhere. And that's how I became to be someone who was getting referrals for breast implant illness, complex breast problems related to implants. She was from Georgia. She came, she had mostly complaints about fatigue, just didn't feel well. She no longer was interested in having her reconstruction, which I had faced time to time over for my career, and certainly helped patients with that process of either removal or adjusting reconstructions. And she had a large amount of laboratory testing regarding both her hormones and heavy metal toxicities. And she had one specific request that I do her reconstruction removal with an en bloc technique. And so that was an unusual request.


Dr. Whitfield (01:39):
I knew about en bloc technique because mostly I'd done oncologic reconstruction during my career. So I thought these things were really reasonable. We did her workup and basically her laboratory analysis was normal and physical examination was normal. She had no evidence of capsular contracture or fibrotic changes and hadn't had radiation therapy in the past. So we developed a surgical plan for her that would help her move forward. A lot of people want to know how I ended up doing complex breast reconstruction or why that was my avenue, especially if they knew me starting out when I was younger. Basically going to college and volunteering in ICUs in Las Vegas, I became very interested in surgery, working in the intensive care units and specifically the surgical intensive care units and got to observe all sorts of different types of surgery, orthopedic surgery, oncologic surgeries, cardiac surgeries, and really became enamored with cardiac surgery.


Dr. Whitfield (02:34):
And so once I got into medical school, I thought that would probably be my avenue. And it was about two, three weeks into medical school, I got a call from my sister and she had been diagnosed with breast cancer and wanted to know since I was her little brother in medical school, what should she do? And having been a medical student for all of three weeks, I immediately went to my professor who that day actually was a oncologist who was teaching us. So he was a clinician and I spoke to him after class and he said he would talk to one of his colleagues where my sister lived and arranged for her to be seen. And that was very gracious of him. And I was able to fly home and be with her for her first chemotherapy and infusion, which was quite interesting experience.


Dr. Whitfield (03:25):
So early on, we had challenges with taking care of folks in my family with breast cancer and other forms of cancer, actually. Toward the end of my third year of medical school, I got a call from my mother. She was having difficulty, had abdominal pain. And so she was going to see a GI doctor and have a workup and that didn't really show anything, but she kept having pain. So I implored her to get a CT scan and her doctor helped to get her a CT scan and she had, basically, metastatic cancer. And she had a hysterectomy, when I was very young, for a cervical cancer. This is a recurrent form of that cancer. It was biopsied and there was nothing more... A surgical problem at this point, it's more, "Will it respond to chemotherapy and radiation therapy?" So she began those during my fourth year of medical school and didn't do well in the first three or four months. So I moved back home and stayed with her and had all of my surgical and other clerkships changed to be at home in Las Vegas with her.


Dr. Whitfield (04:35):
And I got to work with probably one of the preeminent plastic surgeons in the United States, definitely at that time, if not the world. His name is William Zamboni. Phenomenal plastic surgeon. At that point, the only chairman of a surgery program who happened to be a plastic surgeon. Phenomenal in terms of technique, brilliant problem solver. And I was a fourth year medical student learning from him and he was literally the number one role model you could have as a plastic surgeon if that's what you aspired to be. But back then I was pretty stubborn and I just wanted to do heart surgery. I went into general surgery training, which was the traditional route in 1996 and I trained at Indiana University for six years. About halfway through that period of time, in training, it became apparent that cardiac surgery was not exactly what I wanted to do based on what was happening with both fields of cardiology and cardiac surgery. And my most favorite aspect of it was pediatric cardiac surgery.


Dr. Whitfield (05:33):
So one thing led to another and I did a year of really vascular laboratory training. And in that lab year, I really liked working with an operating microscope and under a microscope in general in the lab. And then it just became a natural evolution actually in the microvascular surgery, which was commonly performed for oncologic reconstruction in plastic surgery. So it became the field of choice for me was plastic surgery. I could perform oncologic reconstruction with microvascular technique. You could perform reconstruction for trauma and other serious injuries or infections. And I stayed at Indiana University for another two years and trained under Dr. Coleman. And then as I was leaving, I wanted to get additional microsurgical experience so I went and spent another year with Dr. Zamboni back in Las Vegas.


Dr. Whitfield (06:28):
And so to bring it all full circle, once my sister was diagnosed with breast cancer and elected to have mastectomy, Dr. Zamboni did her breast reconstruction and I stayed with her in the hospital during that time. And so I've always had and always will have a very big spot in my heart for breast cancer patients, breast cancer survivors, just were shaped by our experiences and that's certainly a big one in my life.


Dr. Whitfield (06:52):
After I completed my training with Dr. Zamboni I took an academic position, helping train medical students, residents, started a perforator flap fellowship, and then elected to go into private practice here in Austin, Texas, and joined a group to perform microvascular breast reconstruction. And so the kind of clients I would see or routinely find me were for complex breast reconstruction, revision of breast reconstructions using microvascular technique, evaluation of complicated breast problems or capsular contractures.


Dr. Whitfield (07:24):
So we took her to the operating room and performed an en bloc technique to remove her reconstruction. She had a medical history that required her to stay in a hospital overnight due to cardiac condition for monitoring. And so that was done in a hospital and in her planning, she reiterated how she wanted to en bloc and capsulectomy. So, once again, en bloc just means taking everything out like an Easter egg undisturbed to me. It's not a common way to go about removals unless you're doing things in oncologic terms, which I had done, obviously many, many years in my career. Now, every time I take down a reconstruction, traditionally, all the material gets sent for evaluation, both pathologic examination to make sure there's no recurrent cancer. This could be in the scar most likely, where the mastectomy was performed, but certainly could be on the surface of the capsule that was surrounding the implant. And I would take swabs or quantitative cultures with small pieces of the capsule scar around the implant and have those evaluated.


Dr. Whitfield (08:31):
And so I did this patient's case in the hospital. She was discharged the next day. She had drains in place, as I traditionally did at that point when I'm taking down a large reconstruction, and after this was performed I followed up on her laboratory analysis. Because it's done in the hospital it took a little bit of time to get things back and saw her postoperatively to get her drains out and reviewed her laboratory analysis prior to that visit and she basically had an infection. And so much to my surprise, this is on a CLIA based lab, and I'll differentiate those from what I do now shortly. But in a laboratory analysis like this you have to have over 100,000 bacteria in a specimen for the lab to be able to call it and then give you sensitivities. And this organism happened to be E. Coli which is typically found in the urinary tract or the GI tract. Taken aback by this information I shared it with the client and I treated it with antibiotics based on the sensitivities.


Dr. Whitfield (09:33):
And so after a two week course of antibiotics she returned, she was doing much better and her number one symptom was gone, which was fatigue, which makes sense because the entire time she was combating and dealing with an infection. For me, it was complicated and certainly I feel as a very experienced plastic surgeon that I had missed this, but I didn't know why I'd missed it because there weren't any physical findings. There weren't any laboratory changes. It was just her symptom of fatigue. Basically, I didn't key in on that. Moving forward, I never wanted to miss something like that. You can't really afford to be unable to recognize problems like that. Even vague things need to be evaluated and certainly listening to your client and trying to make sure that you're not missing something like this is incredibly important. So this experience shaped how I took care of all my future clients when the complaint was evaluation for breast implant and whatever the technique used for, or diagnosis they have is irrelevant. It's just what symptoms did they have and should we be evaluating them for something like this?


Dr. Whitfield (10:52):
So when you're removing a reconstruction, typically the patient's obviously been explained the risk and benefits of initial reconstruction and not having reconstruction and the psychosocial aspects of that. So when they arrive at a decision to take down a breast reconstruction, I've found that they're far more at peace with this from an aesthetic standpoint. This will be a flat...The chest wall will be flat. We take down and reconstruct the insertion of the pectoralis major in this setting. It is different than in a cosmetic setting. Typically, the releases are different with respect to a tissue expander or implant based reconstruction versus just a cosmetic replaced implant. So the pec is easily or should be more easily attached back down to its origin. Also, because this patient ended up feeling so much better afterwards I think it became less of a aesthetic concern. Bottom line is after her reconstruction was taken down, she felt better and can move on with her life. Aesthetically, she was comfortable with the appearance and that's the most important thing.


Dr. Whitfield (11:57):
So after this case was performed, I began to have patients slowly come to me asking for this technique and referring to their diagnosis or what was wrong with them as breast implant illness. Having had this experience where I did not, or could not identify an infection on this patient until it was subsequently removed and examined, I wanted to make sure I didn't have this experience again. So if anybody came in with these complaints of really debilitating fatigue, even if they had completely normal blood work, I was suspicious. And you always have to have an index of suspicion in order to find something. You'll miss a hundred percent of things you don't ever look for.


Dr. Whitfield (12:48):
So if that's not in your differential that they could have an underlying infection because they have extreme fatigue. Maybe they're suffering other malaise, joint pain, muscle pain, hair loss and these are not attributable to anything. All the laboratory analysis of the blood work, including hormonal levels, both thyroid and sex hormones are normal. All these things can be normal and they can still have these symptoms and it leaves them at a loss. And many, many times I think clinicians are frustrated because they can't find the answer. Even though sometimes it's, as I found, staring me in the face.


Dr. Whitfield (13:28):
As I've already detailed, my experience is unique in terms of how I trained. My intent was always to be a complex microvascular reconstructive surgeon. I liked to solve big problems, do big cases, and regardless of the challenge, with training and creativity and I loved to solve problems, I was up for it. And I did that for just a large portion of my career. So when I got asked to start helping with clients doing en bloc capsulectomies, of course, I didn't think it was out of my ability. Just recently I had a patient with a radiation fibrotic area and she came to me from Florida to be evaluated and, basically, she came for my opinion to get it reinforced of how it should be done and whom should do it. And if you've not ever taken care of somebody with radiated tissues and don't understand technically what you're doing you can cause a great deal of harm.


Dr. Whitfield (14:27):
So my experience both with general surgery, plastic surgery, microvascular surgery, over a decade of reconstruction, I've done thousands of microsurgical cases. I've done over 500 explants now. Regardless of the need, we're just trying to do the best and take care of the patient. I think it is helpful to have someone with more expertise to do this so that it's getting done properly, doesn't have to be revised or redone, which I've done several of those as well. We certainly, in the experience over time, we're trying to achieve the best results and provide the highest quality and return to wellness as well as overall aesthetics. These are very complicated situations and I've pressed the envelope to really provide the most benefit on both aspects. And we're always trying to learn more and get better.


Dr. Whitfield (15:22):
On our next episode, I will talk about several more patients who were pivotal along the way and how their cases led me to look more closely at labs and rethink how and what we were testing for. This is the first in a series of new episodes about breast implant illness. New episodes will release every Thursday so please make sure to follow the show wherever you're listening and subscribe to our BII email list. Those links are right there in the show notes for you. Please help us get the word out about our podcast. The best way you can do this is by sharing it and writing a review on Apple Podcasts or wherever you are listening. I'm Dr. Robert Whitfield and you're listening to The Breast Implant Illness Podcast.


Speaker 1 (16:11):
Take a screenshot of this podcast episode with your phone and show it at your consultation or appointment or mention the promo code PODCAST to receive $25 off any service or product of $50 or more. Dr. Robert Whitfield is a board certified plastic surgeon located in Austin, Texas near 360 and Walsh Tarlton in Westlake. To learn more, go to drrobertwhitfield.com or follow Dr. Rob on Instagram @DRROBERTWHITFIELD. Links to learn more about Dr. Rob's smart procedures and anything else mentioned on today's show are available in the show notes. The Breast Implant Illness Podcast is a production of Team Podcast at www.teampodcast.com.