#8: Is Breast Implant Illness Real?

Is Breast Implant Illness Real? Learn the Facts and Myths Regarding BIAI and BIA-ALCL

You are listening to the Natural Plastic Surgeon Podcast. I'm Dr. Daniel Barrett, a board-certified plastic and reconstructive surgeon located right here in Beverly Hills. I specialize in cosmetic surgery of the face, nose, breast and body. This podcast is dedicated to those deciding if plastic surgery is right for them and revealing all the latest beauty secrets. New episodes premiering every Monday at 10 am. Let's get started.

Dr. Barrett: Hey everyone, so we've got an exciting guest for you here today. It’s Dr. Ritu Chopra, board-certified plastic surgeon here in Beverly Hills, probably one of the top plastic surgeons in Beverly Hills. You are a clinical faculty, you are a clinical faculty at USC. You're a regular correspondent on The Doctors TV Show. You have an incredible amount of credentials in terms of working here in Beverly Hills but also with Pink Lotus Breast Canc...Breast Cancer Center, as well as director of some other medical facilities. Your training is impeccable--general surgery, plastic surgery. I'm really excited to have you on to, to talk about some of the stuff we want to talk about today. So thanks for being on the show.

Dr. Chopra: Thanks, Dan. You know, I've been looking really forward to this. I see you a lot when we operate together. And we talk about a lot of things about plastic surgery. And this is a great, sort of, forum where we can get great information out.

Dr. Barrett: Yeah, absolutely. Dr. Chopra actually operates here at IV Surgical Center. So we share some of the same operating rooms, you know, obviously at different times. And so we, we've, I, I really, I've seen the amount of surgeries that you've been doing. You're an extremely busy, dedicated, talented plastic surgeon. You're doing a lot of surgeries right now, in terms of explant surgeries.

01:42 EXPLANT SURGERIES

Dr. Chopra: Yes.

Dr. Barrett: And that's a big topic that's going on right now. And I'd love to, kind of, dive into that and, and, and see what's going...what's driving this...what's driving this, this want or this need to, for people to remove their implants.

Dr. Chopra: Right. I think it's twofold. Like, I'm, I’m sure a lot of your listeners know, one, because textured implants have been recalled by Allergan.

Dr. Barrett:  Okay.

Dr. Chopra: So that's one big topic in itself.

02:09 TEXTURED IMPLANTS

Dr. Barrett: So tell me about that. What, what's, what is a textured implant?

Dr. Chopra: So there's two types of implants as we know. There are smooth-texture where there's no, nothing on top of the implant--just completely smooth versus textured. The textured in, back in the day, was thought to prevent capsular contracture. We found out that that is not necessarily the truth. So we've gotten away from using that. However, the shaped implants, we use texture because they wouldn't rotate, it’s actually having like sandpaper on the bottom of it.

Dr. Barrett: Okay.

Dr. Chopra: That’s essentially the texture.

Dr. Barrett: Maybe like a, like a Velcro almost.

Dr. Chopra: That's exactly right.

Dr. Barrett: Yeah.

Dr. Chopra: And even that didn't prevent them from rotating. They still get a rotation percent, two to seven% of these implants are still rotating.

Dr. Barrett: Okay, so these are implants that are shaped like a teardrop or, like, you know, not completely round.

Dr. Chopra: Exactly. That's exactly right. And we used to start using them with reconstruction.

Dr. Barrett: Okay.

03:05 BREAST IMPLANT-ASSOCIATED ANAPLASTIC LARGE CELL LYMPHOMA

Dr. Chopra: When patients had no upper pole fullness that would give them that. The issue is completely separate now. The issue is that these implants have been associated with breast implant-associated anaplastic large cell lymphoma.

Dr. Barrett: Okay.

Dr. Chopra: It's very, very rare.

Dr. Barrett: That's a mouthful. Hold on. Let's back that up. So breast so, BIA ALCL, breast implant-associated anaplastic large cell lymphoma. This is not breast cancer, right?

Dr. Chopra: Absolutely right.

Dr. Barrett: Okay.

Dr. Chopra: It's a T-cell lymphoma.

Dr. Barrett: Okay.

Dr. Chopra: Nothing to do with your breast. It has to do with your capsule.

Dr. Barrett: Okay. Have you seen this?

Dr. Chopra: I have not seen this in my patients. I have diagnosed one that went somewhere else, but I have taken out several textured implants and sent the capsule for a specific immunostain called CD30.

03:49 CD30 IMMUNOSTAIN

Dr. Barrett: Okay.

Dr. Chopra: That CD30 can pick up your ALCL.

Dr. Barrett: Now is this, is this, like, should we, should we ring the alarm bells? Like, what's...you know, this is...you know, we thought, everybody thought implants were safe. What's, what's the lowdown on this?

Dr. Chopra: That's a very interesting question. And I think its objective and also subjective. We know that smooth implants are safe.

Dr. Barrett: Okay.

Dr. Chopra: They've never been associated with ALCL or anything. So we know smooth implants are safe. The question now becomes what do you do with the people who have textured implants in?

Dr. Barrett: Yeah.

Dr. Chopra: So what is the rate of getting ALCL from textured implants? And that's anywhere between one in 1000 to one in 3000. So it's very rare.

Dr. Barrett: So the one in 1000 that's for polyurethane-coated implants, right?

Dr. Chopra: That's right.

04:36 POLYURETHANE-COATED IMPLANT

Dr. Barrett: Because that, you know, I, I've been doing a lot of research on this and, and I don't do as many explants as you do. And that's why I'm glad to have you on. So what is a polyurethane-coated implant? Do, is that a particular company, or is that overseas, or is that in the United States?

Dr. Chopra: Yeah, so those are older implants that use to have polyurethane in them.

Dr. Barrett: Okay, so they don't make those anymore.

Dr. Chopra: That’s right.

Dr. Barrett: Okay. So if someone has a polyurethane implant, coated implant, should they get those removed?

Dr. Chopra: So...that's, it's such a dicey subject. So I'm going to, I’m going to sort of...

Dr. Barrett: Because if they're old, right, then shouldn't, shouldn't they, I mean implants...I tell my patients every ten years, you should probably get them exchanged. Right?

Dr. Chopra: That's right.

Dr. Barrett: Yeah. So, so polyurethane implants. Are they older than 10 years now?

Dr. Chopra: Yes.

Dr. Barrett: Okay. So these people should probably think about getting them removed, not for the lymphoma risk, but just, hey, you know, this might be a good idea to get them exchanged.

Dr. Chopra: Yeah, and so when do people develop this lymphoma, right? It’s usually between seven to ten years.

Dr. Barrett: Okay.

Dr. Chopra: So the implants have to be in long enough for them to actually generate this, this disease. We're not sure why they're developing it. Two hypotheses: one, low-grade inflammation to the silicone for some reason. It’s chronic inflammation causing a change, antioxidants causing a change in mRNA. Right, causing a change in sort of your...

Dr. Barrett: So mRNA, so messenger RNA. So that's the cell signaling that's going on in these cells.

Dr. Chopra: Absolutely.

Dr. Barrett: That is exposed to this textured implant.

Dr. Chopra: Right, the chronic inflammation. And then the second could be a biofilm. They've done good studies on capsules on patients who don't have ALCL and do have ALCL. These have complete distinct, different morphology. Most of the ones without ALCL have Staph. Most of the ones with have a bacteria called Ralstonia.

Dr. Barrett: Interesting. I've never heard of that.

Dr. Chopra: So yeah, so they're distinctly different species.

Dr. Barrett: Yeah.

Dr. Chopra: However you can treat this bacteria by coating or bathing your textured implant in Betadyne.

Dr. Barrett: Interesting, do you do that?

Dr. Chopra: I don’t put textured in.

Dr. Barrett: Okay. So I actually still…so I still use textured...I use them in very isolated circumstances. And I fully inform all my patients that do get the textured. I, I actually use a brand of the textured implants that's not associated with the recall. Their current association with Anaplastic Large Cell Lymphoma is 1 in 86,000.

Dr. Chopra: Right.

07:14 THE PATIENT HAS A CHOICE

Dr. Barrett: So your chances of getting struck by lightning in your lifetime is about 1 in 3000 so I kinda, you know, I kinda have to break down the statistics for people. I do, I do notice some advantages when I do textured implants for dramatic lifts or for very difficult revisions where I need just a little more stability with the implant. Now I give them that choice. I can say look, I'm, I can, I can get you a better result with this textured implant. We, we kind of roll the dice more if we do a smooth in those very rare particular situations. But I actually do coat it with Betadyne and triple antibiotic solution when I do that.

Dr. Chopra: So, so I think that's smart. And I think the most important thing that you said is “informed consent.” If you give these patients informed consent, they can make their decision an educated decision.

Dr. Barrett: Yeah.

Dr. Chopra: It's the ones that you aren’t giving them informed consent.

Dr. Barrett: Right. Great. So, so, so again, so what, what, what should somebody do if they, they have these, if they have a text…so let's say it's not polyurethane. Let's say it's, you know, one of these typical brands, and these, in the past few years, that they actually have a textured implant, what, what should they do?

07:58 MOST COMMON SYMPTOMS

Dr. Chopra: So, what are the symptoms? Right. What are the symptoms that someone needs to be worried about…is generally swelling.

Dr. Barrett: Okay.

Dr. Chopra: So someone will come into your office say you know, Doc, my breast just started swelling. So it's likely fluid. That fluid needs to be tested.

Dr. Barrett: Okay, so this is like one side, we're not talking like a couple weeks out after surgery we're talking...how far out?

Dr. Chopra: That’s right. At least a year out.

Dr. Barrett: Okay.

Dr. Chopra: At least a year out, when you know you're healed completely. Patients come in and say, Doc I have unilateral swelling or bilateral swelling, doesn't really matter. You test that fluid, and you need at least 50 cc's.

Dr. Barrett: Okay.

Dr. Chopra: And you send that for the same stain CD30 and you see what comes back.

Dr. Barrett: Okay.

Dr. Chopra: That's one of the main symptoms...as well as there can be cutaneous manifestations because it is a T-cell lymphoma. They can have some weird strange rashes that you are not sure where they come from. You can actually scrape those and send those for CD30 too.

Dr. Barrett: Okay. So if, if you were to drain, would you ever drain just the fluid, by itself, and not do the surgery to remove…

Dr. Chopra: Absolutely. So you can drain that fluid. If it doesn't come back positive for CD30, well then you’re okay.

Dr. Barrett: Okay. Now what if it does come back positive?

09:04 CD30 POSITIVE

Dr. Chopra: So what do you do when it comes back positive? That's a great question. You’ve got to get a PET scan first, to make sure that there's no spread. Once you do that, the treatment is what we essentially do anyways, take the implant out and do a total capsulectomy.

Dr. Barrett: Okay. So PET scan is basically, it's not a CT scan, it's like a magnetic resonance where it's checking for spread of these particular types of cells.

Dr. Chopra: Absolutely right.

Dr. Barrett: Okay. That's, that's very interesting. You know, I know some of the statistics. As of June of 2018, there were 560 confirmed cases of breast implant-associated ALCL. And of that only 16 deaths.

Dr. Chopra: Right. I think that...number has gone up a little bit.

Dr. Barrett: Okay.

Dr. Chopra: To about 30 deaths.

Dr. Barrett: 30 deaths. Okay. Yeah, this is, this is an older statistic. That's June of 2018. So that's, like, last year. So that's, so it's gone up to 30.

10:00 BUTTOCK IMPLANTS

Dr. Chopra: Around that, yeah, I'm pretty sure around there. What's interesting though is that, I'm sure you know that, one case of ALCL has been shown with butt implants that are textured.

Dr. Barrett: Interesting. I didn't know that actually.

Dr. Chopra: Buttock implant, one buttock implant that had been textured...

Dr. Barrett: Yeah.

Dr. Chopra:...has now been associated with ALCL.

Dr. Barrett: Wow. Do you do buttock implants?

Dr. Chopra: I do not.

Dr. Barrett: Okay. I don't either. I do fat transfer.

Dr. Chopra: Yes.

Dr. Barrett: But I don't use the implants. They’re kinda, it’s kinda a dicey area.

Dr. Chopra: I agree. High rate of infection, pain, all of the above.

Dr. Barrett: Yeah.

Dr. Chopra: So I try to stay away from those. But this just shows that, that it's not necessarily because of the breast. It is the implant and the chronic inflammation.

Dr. Barrett: Yeah.

Dr. Chopra: That something's going on.

Dr. Barrett: So it's interesting, the, the disease progression of, of this, of this rare lymphoma, it doesn't happen right away. What's a typical onset? Do we have enough data to know when this would typically present, when someone gets it?

10:50 TYPICAL ONSET OF LYMPHOMA

Dr. Chopra: Yeah so I mean, generally it's an eight to ten-year period. So women who have them in for eight to ten years, like you were saying, should probably get them changed anyways.

Dr. Barrett: Yeah.

Dr. Chopra: But that's sort of the sweet spot of where you can start to develop these symptoms.

Dr. Barrett: Okay. And it's interesting that there's been a lot of confirmed cases and a lot of women have just had the implants removed, capsulectomies. And is that the definitive treatment? Is there any other thing, anything else that needs to be done at that point if there's no spread?

11:16 TREATMENT OF LYMPHOMA

Dr. Chopra: Yeah, so if there's no spread of a total capsulectomy, you need to get all the capsule out.

Dr. Barrett: Yeah.

Dr. Chopra: That's the most important thing. And then obviously send it for CD30. If that's positive, and the PET scan’s negative, there’s no further treatment. And the survival, ten year-, I think, five year-survival is between 85 and 95%. It’s very, very high.

Dr. Barrett: Okay.

Dr. Chopra: If there’s spread, you probably have to do chemo first.

Dr. Barrett: Oh, wow.

Dr. Chopra: Yeah. Chemo first, get the chemo done. Take the implants out. Take the capsules out.

Dr. Barrett: Got it. Okay. Well, yeah, I mean, you know, this is, it's, it’s alarming because, you know, back when implants started, you know, there was all kinds of concerns about breast cancer and FDA did a lot of tests and they are, you know, breast implants are safe, and this has kind of been a new thing. And it's kind of, you know, I feel like I tell my patients this a lot. A lot of people try to demonize breast implants because…you should be happy with how your body looks and we're plastic surgeons, you know, we know people want to do things to make them feel better, you know. And as long as it's safe and reasonable. And so I feel like people have always been trying to demonize implants and with this information I feel like people are making broad assumptions about all implants. Is this, is this, I mean...does this apply to all implants? Or is it just...

Dr. Chopra: Absolutely not.

Dr. Barrett: Okay.

Dr. Chopra: I think we know Allergan took these off the market voluntarily.

Dr. Barrett: Okay.

Dr. Chopra: So the FDA didn't tell them to do it, they took them off voluntarily because of the data.

Dr. Barrett: Okay, now Allergan is the, the one company that uses the bio cell implants? Is that correct?

Dr. Chopra: Yeah, the macro texturing.

Dr. Barrett: Okay, macro texturing.

Dr. Chopra: As opposed to micro texturing which Mentor and Sientra use.

Dr. Barrett: Okay, so the, the recall applies to women who have had Allergan bio cell implants.

Dr. Chopra: As well as tissue expanders.

Dr. Barrett: Okay, so some, so that'd be rare for some women to have just a tissue expander left in there. I actually have heard of some women that just, they don't feel like coming back and get their expander out for permanent implants. So that's, that's actually interesting information. What's your advice for women out there that are, that have textured implants right now? What would you suggest?

13:13 ADVICE FOR PATIENTS WITH TEXTURED IMPLANTS

Dr. Chopra: I mean, going through this in my mind, this sort of algorithm of what I say. I don't want to cause any hysteria, like you don't want to cause any hysteria. So I always try to relate it to my family. Right. So if I pose a question to you, if your mom had these textured implants in...

Dr. Barrett: Yeah.

Dr. Chopra: What would you tell her?

Dr. Barrett: I would be, like, just exchange them in 10 years.

Dr. Chopra: Yeah.

Dr. Barrett: That's what I would tell, I’d say, you know, get go see your doc, make sure everything's cool. And, you know, if there's any problems, any, any of the symptoms that we talked about...skin rashes or swelling, then you know, we need to take a closer look.

Dr. Chopra: Yeah, I mean...

Dr. Barrett: And it's pretty rare. It's not like it's, it’s 50%, right?

Dr. Chopra: Well that's the thing. It's...

Dr. Barrett: Yeah.

Dr. Chopra: It's, it’s very uncommon. And so I do the same thing. I do tell people that...

Dr. Barrett: Does your mom have breast implants?

Dr. Chopra: She doesn't. You might have put them in. But, I, I do, I do wrestle with this a little bit.

Dr. Barrett: Yeah.

Dr. Chopra: Because the patients that have these implants in were not giving the correct informed consent of telling them that these could possibly cause this rare lymphoma.

Dr. Barrett: Yeah.

Dr. Chopra: That's the one thing I struggle with. So I feel like...

Dr. Barrett: Well, you know, it's, it's, it's not necessarily a fault because we didn't have total...

Dr. Chopra: Totally.

Dr. Barrett:...information on it. Right. So it's not like we were misleading. We went with the risks that we knew at the time.

Dr. Chopra: Absolutely.

Dr. Barrett: Yeah.

Dr. Chopra: And so now we know that the risk exists. It's just like, knowing different drugs cause different things. They come out and we think they're great.

Dr. Barrett: Yeah.

Dr. Chopra: And then a year or two, they're like, oh, you know, they're not that good for you. Right. And so what do you do with those patients that have been on it and have these...perhaps a chronic disease going on?

Dr. Barrett: Yeah.

Dr. Chopra: Right. So I think if patients are worried they should follow up with their doc for sure. And if they're super worried get them taken out, get the capsule taken out and then they can put smooth implants in if they still want smooth...implants.

15:04 OPTIONS TO AVOID IMPLANTS

Dr. Barrett: What about, is there any other option besides putting another implant in?

Dr. Chopra: I think there's several options. So we're talking about reconstructive patients because they have a lot of textured implants.

Dr. Barrett: So reconstructive patients, like a woman who has had breast cancer or has had a mastectomy.

Dr. Chopra: Yes. So those patients who have no breast tissue and have textured implants in...I think taking them out and either doing a deep flap, tram flap, something like that.

Dr. Barrett: So, like, taking abdominal tissue, basically, and making a breast out of it.

Dr. Chopra: Yeah, I think that's a great option for those patients.

Dr. Barrett: Great.

Dr. Chopra: And I know the microsurgeons at UCLA are gonna be happy with that. So...

Dr. Barrett: Yeah. They're quite busy over there.

Dr. Chopra: Yes.

Dr. Barrett: Yeah.

Dr. Chopra: So I think that's a great option for them. And I do think fat transfer, if they have enough breast tissue, take the implants out and do a serial fat grafting.

Dr. Barrett: Yeah. Because it's tough. You know, it's like, where we have that predictability of an implant, we know it's going to see the same volume...fat has, it's got a mind of its own. You know, I tell my patients all the time, I’m always like, you know, manage your expectations, because sometimes we get great take, and then sometimes we're, like, hmm, we lost that 40% of that graft, you know?

Dr. Chopra: Right. So I tell patients that, exactly what you said. I said most of the time you have to do more than one.

Dr. Barrett: Right.

Dr. Chopra: And so if they're up for that, I think that's a nice option to get the implants out.

Dr. Barrett: Awesome. Anything else you want to, you want to chat about with? Because I want to move on to a topic that is less defined?

Dr. Chopra: Yes.

16:22 TRUSTED EN BLOC CAPSULECTOMY SURGEON

Dr. Barrett: And I know it's, it's, it's…I was actually doing research on this. And I went on several websites and your name was popping up left and right as a trusted en bloc capsulectomy surgeon. But anything else you want to touch on with Anaplastic Large Cell Lymphoma.

Dr. Chopra: I think we touched on it, but the main things are, it's uncommon...

Dr. Barrett: Yep.

Dr. Chopra: And make sure you're following up with your surgeon.

Dr. Barrett: Okay.

Dr. Chopra: And make sure they are board-certified.

Dr. Barrett: Yeah.

Dr. Chopra: You know, so there's some charlatans out there that aren't board-certified and will tell you the wrong information. All of us have taken an oath to do no harm.

Dr. Barrett: Right.

Dr. Chopra: And so go to a plastic surgeon that is board-certified and they'll take care of you.

Dr. Barrett: Yeah, so both of us, both of us are actually board-certified by the American Board of Plastic Surgery. That is the certifying body that you want to make sure that your doctor is associated with. That's really key because we actually have a very active society that updates us and does active research. They do research on, you know, all types of things with implants, independent of what the FDA wants them to do. And so, I think, we're, we’re very proactive with trying to make sure that things that we're doing are safe and that we know all of the information that's pertinent to be able to give informed consent for patients. So my hat’s off to our society for doing that.

Dr. Chopra: Absolutely.

17:33 BREAST IMPLANT-ASSOCIATED ILLNESS

Dr. Barrett: Yeah. All right, so let's switch gears. Breast Implant Associated Illness...what the hell is that?

Dr. Chopra: Well, as you know, I do quite a few of these a week.

Dr. Barrett: Yeah, what is it that you do, you do, you do these, you remove these implants? And you do what's called en bloc capsulectomy.

Dr. Chopra: Yes. Let's, sort of, dispel that myth...

Dr. Barrett: Okay.

Dr. Chopra: Of the en bloc capsulectomy.

Dr. Barrett: Okay.

Dr. Chopra: So these patients are coming in and they want their implants out because they're feeling that they're causing them illness. We don't know why, but they're reacting to these implants. So we take the implant out and we also take the capsule out, because, as you know, some of these implants have a low bleed-rate, meaning that some of this silicone from the shell will get out into the body. So by taking the capsule out, we get essentially all of that silicone out. What’s an en bloc capsulectomy? En bloc capsulectomy is when we get the implant out along with the whole capsule in one piece.

Dr. Barrett: Yeah.

Dr. Chopra: As you know that's very difficult to do when they're under the muscle because of the ribs and the thinness of the capsule.                                              

Dr. Barrett: Yeah.

Dr. Chopra: So oftentimes, I try to do an en bloc. But most of the time I'm ending up to a total capsulectomy, which I take out the implant, and then I have to take out the capsule in pieces, but I get the...get the capsule out 100%.

Dr. Barrett: I routinely do these operations that typically, I've actually had a few come to see me that have complained of Breast Implant Associated Illness. They think they have it, they have symptoms, like fatigue, hair loss, tired…help me out. What are some...

Dr. Chopra: Joint pain.

Dr. Barrett: Joint...

Dr. Chopra: Rash, fibromyalgia, autoimmune, Hashimoto’s.

Dr. Barrett: Right, yeah, so there's some, some, strange constellation of symptoms. There's not like a...there's no test that I can give these people. I'm like, I don't know if this is going on but they have already come to me. They're like, I want my implants out. I'm like, all right, you are determined to do this. I'm a good surgeon. I'm going to do this for you. And it's...I, I can do sometimes I get lucky, I can get en bloc. Most of the time I get as much as I can. And then I take out the implant and I just get that little last piece on the back wall, but it takes about an hour per side. It's, it's...

Dr. Chopra: At least.

Dr. Barrett: Uh, yeah, it's, it's hard work.

Dr. Chopra: Yeah.

19:42 CAPSULECTOMY

Dr. Barrett: I feel like I've done…and, and capsulectomies on patients that have had previous ones, and there's like two or three layers of leftover from some other surgeon who left them in there. And I know that wasn't done right the first time. Where were those…where I typically, where we traditionally have done this is people that have capsular contracture. And this is actually a different entity than Breast Implant Illness. That's when you get that scar tissue that develops around the implant gets hard firm. I think Victoria Beckham might have had that. You can see photos of when she had that. And she had, it looks like she's gotten that fixed. I'm not her doctor. I don't know who it is. But that's, that example, that characteristic firmness of capsular contracture, which is a real thing. We know it, we can document it. One in 20 incidents of that nationwide with any breast augmentation surgery. That's been the majority of my capsulectomies and they are very, very challenging. But, and I know this because when I go in there, and I'm sweating, and I'm getting this back wall, and I see the two to three layers that the previous surgeon didn't get, but it's super important to get all of that.

Dr. Chopra: I agree with you 100% and you know how difficult it is scraping out the ribs. There's only a millimeter between you and the lung.

Dr. Barrett: Yeah.

Dr. Chopra: Right. So it is tedious. You got to be careful. And you gotta be patient.

Dr. Barrett: Yeah.

Dr. Chopra: So what you were saying we don't have a test for these patients. And that's absolutely right. So my analogy is someone who has celiac disease. Celiac disease, we know it's gluten problems, right? They have an antibody to gluten. We know out there there's millions of people who have gluten sensitivity. We give them gluten, they'll have bloating, they'll have cramping up, all the symptoms, but we can't test those people.

Dr. Barrett: Yeah.

Dr. Chopra: That’s very analogous to the people who have Breast Implant Illness. We don't have a test for these people who may react to the silicone. Who may react just to a foreign body.

Dr. Barrett: Right.

Dr. Chopra: We don't have any test for that. All we know is that after years, you may react.

Dr. Barrett: Yeah, you know, but I, I've had some patients that, my own patients, I've done the surgery, just a couple, and they immediately started experiencing certain symptoms and wanted to have their implants out. And you know, I'm like, okay, well, let's, let's do it. Let's see if it helps you, because these symptoms are really affecting them. But it's, it's tough because I sometimes will do this. I'll remove the implants, and then their symptoms don't get better. And it's frustrating because we've just now removed a beautiful implant and now we're, we haven't really solved their problems, you know. So this is a, this is a very challenging unknown that we're, kind of, dealing with.

But you know, it's, it's there's other things that happen with surgery too...Like we give our patients antibiotics, you know, and a study recently came out that talked about a, a normal course of antibiotics can alter your gut, you have a higher incidence of depression six months after just from the loss of gut biome, right? So is it other things that we're doing from surgery that's causing some of these symptoms that people might be feeling? I'm just wondering, you know?

Dr. Chopra: Yeah, I think it's going to be multifactorial. I think implants are just part of it. I think…when I'm looking at this disease process of what's going on, there's a low-grade chronic inflammation. And so these patients will react. So you look at their ANA titers for lupus, they'll bump. You look at some Hashimoto’s, it’ll bump. Sometimes their C reactive protein will bump. And we're not sure why, except they have chronic, low-grade inflammation. If this chronic, low-grade inflammation goes on for a while, it can cause some vague symptoms. As you know, chronic, low-grade inflammation anywhere, in any cell, can cause change and then their DNA and RNA, can lead to cancer, can lead to inflammation, can lead to different symptoms. And I think that's what's going on. We just don't have the test for it. And I can tell you, the hundreds of women that I've done, I can put in the confidence interval between 95 and 99%. Most of them feel better.

Dr. Barrett: Really?

Dr. Chopra: There's outliers who don't feel better. And so is it some of it placebo effect?

Dr. Barrett: Sure.

Dr. Chopra: Is it some of it, we're getting the implants out, and those are the patients who really have some chronic inflammation or just not candidates for implants? Sure.

Dr. Barrett: Yeah.

Dr. Chopra: So they're sort of…

23:51 WHO SHOULDN’T GET IMPLANTS

Dr. Barrett: So let's talk about that. So are there people that shouldn't be getting implants like, you know, if you have lupus, if you have rheumatoid?

Dr. Chopra: Yes. Absolutely.

Dr. Barrett: If you have, like, an irritable bowel syndrome or, or Hashimoto’s which is, Hashimoto’s is, is when you get autoimmune attack of the thyroid. Are these people that should think twice about getting implants?

Dr. Chopra: I think 100%.

Dr. Barrett: Yeah.

Dr. Chopra: I think anybody who has an autoimmune disorder should not get implants in.

Dr. Barrett: Okay.

Dr. Chopra: And I feel strong about that. And a lot of people may not agree with me.

Dr. Barrett: Yeah.

Dr. Chopra: But for my practice, if someone has autoimmune, I say I don't put them in.

Dr. Barrett: Are you studying these explants that you're doing?

Dr. Chopra: Yes.

Dr. Barrett: Okay. Because I’d love to know how many people that are feeling better after explant had some pre-existing autoimmune dysfunction.

Dr. Chopra: Right. So we don't know that. So we, patients get these implants in, generally, and then they get their tests. Right.

Dr. Barrett: Yeah.

Dr. Chopra: So we don't know if they had it before or not.

Dr. Barrett: Okay.

Dr. Chopra: That's really the issue.

Dr. Barrett: Yeah. Wow.

Dr. Chopra: But it’s a, you see, it’s a big problem...or big issue--not a problem--to tease out the symptoms of what’s coming from what. Vitamin D deficiency in women can cause a lot of the symptoms of fatigue, hair loss, not feeling great…having three kids. Right?

Dr. Barrett: Yeah.

Dr. Chopra: And all these symptoms are vague.

Dr. Barrett: Yeah.

Dr. Chopra: But...and I'm just gonna put it out there. If I wasn't doing so many of them and seeing so many women get better.

Dr. Barrett: Yeah.

Dr. Chopra: I would be a little bit, like, wow, really? The implants are making them sick?

Dr. Barrett: So, yeah, so I mean, so should, should we ban implants?

25:27 MAJORITY OF WOMEN CAN GET IMPLANTS

Dr. Chopra: Nope. So I don't think that at all. I think for the majority of women, they can take it. Yeah. So I have good friends who’ve had implants in forever.

Dr. Barrett: Yeah.

Dr. Chopra: And they're doing wonderfully.

Dr. Barrett: Yeah.

Dr. Chopra: I've had people that have implants in for six months and are doing horribly. So right? So there's a huge difference and we just can't find those patients. Once we're able to, and I think we are going to be able to, with all the genomic stuffs going on, we're going to be able to find the people that are sensitive to different things.

Dr. Barrett: Yeah.

Dr. Chopra: Then we’ll know.

Dr. Barrett: And then, you know, I also wonder if there's a surgical technique component, you know, if there's a low-grade inflammation caused by additional contamination that we can somehow prevent with certain surgical techniques, that would be great. You know, I just, I just wish we had more of this information.

But I tell you, Dr. Chopra, like when, when I've got my patients...they’re six weeks out from their breast augmentation and how happy they are, you know? This is something they've been like self-conscious about, they've never had breasts, they don't, they can't fit into…I, I, I’m like, I tell people, look, we can fight societal norms about what breast proportion should be, and, and the rest of the female body. Or you can get breast implants and feel good about your body. And that's a total personal choice, and I don't push it on anybody. But when I see these women that come in after a breast augmentation, they're so happy. You know?

Dr. Chopra: Well, I, I've seen your work and you, you do beautiful work. I think the key is, like we talked about, is the informed consent.

Dr. Barrett: Yeah.

Dr. Chopra: If you can tell the patients, hey, listen, there's a small chance that you might be one of the patients that react to these implants, we might take them out. If you're okay with that risk, then by all means...

Dr. Barrett: Yeah.

Dr. Chopra: Let's put them...but I think it comes down to informing these patients that there is a chance.

Dr. Barrett: Right. And, and if it happens, the treatment, there's a treatment, right? It's not like we're dooming these people to something, right? Because the, the incidence of capsular contracture, which is a nightmare in and of itself as we know, it's, like, one in 20 nationwide.

Dr. Chopra: It’s high.

Dr. Barrett: Yeah, that's a big problem like you’ve got a firm, painful breast. I mean, that could ruin your, ruin your month, you know?

Dr. Chopra: Yeah, your year.

Dr. Barrett: Yeah, you could ruin your year, right? And that's a, that's a real palpable, palpable complication that happens routinely, to my patients, too. I think my rate’s a little bit better, because I'm, I’m trying to make it zero, with a lot of the different things that I'm doing with irrigation and keller funnel and all these different things. But, you know, the, we don't ban implants because of that. And that's, that's a real thing, you know? That can cause major problems.

Dr. Chopra: Well right. The bottom line of both of these entities, the women aren't feeling good. And how are we going to make that better for them?

Dr. Barrett: Right.

Dr. Chopra: I think screening, like you said about the autoimmune disease. And I think being very meticulous of how you put implants in is the key.

Dr. Barrett: Yeah.

Dr. Chopra: And informed consent. With that triad, we're doing the best we possibly can do. And that's what we have to do for our patients.

28:05 IMPLANT MANUFACTURER’S RESPONSIBILITIES

Dr. Barrett: Tell me about the responsibility of the implant manufacturers.

Dr. Chopra: It’s interesting.

Dr. Barrett: Because…yeah, you have a little bit more of a, you have a relationship with Allergan.

Dr. Chopra: I do.

Dr. Barrett: Okay. So you, you're, you…tell us, give us some insight about what the, what the implant companies are doing. There's three big implant companies in United States, right?

Dr. Chopra: Yes. Allergan, Mentor and now Sientra is back again.

Dr. Barrett: Okay. And what are they...because, you know, it's like, a lot of patients are like, oh, well it's the implant companies, they’re covering up all this stuff, and they're hiding this stuff. And, you know, I know back 50 years ago that was going on and maybe even more recent. I'm, I’m kind of newer in the game than you are. I mean, tell me, tell me about that. What do you think?

Dr. Chopra: So there's a lot of misinformation on the internet. And, and that's the issue. There's a lot of people saying, oh, there's arsenic. There's...

Dr. Barrett: Platinum. I read a study on platinum...I read this website that your name was on…talking about platinum being leached...

Dr. Chopra: It was probably my website.

Dr. Barrett: No...platinum being leached from implants. I'm like, whoa, wait a second. Let me check this out. And I looked up research studies on it and they found actually some women without implants had higher platinum, then women with implants and I'm like this is totally debunked. It's like, how are people, why are these websites putting this crazy heavy metal toxicity stuff out there? It's, like, that, you know, there's no substantiation for some of these claims.

Dr. Chopra: I agree with you 100%. That's the issue, right? There's hyperbole on the Internet, of what's going on. With platinum, with arsenic, with these different things, and none of its truth, right? So you're right. I do speak for Allergan at times. And I'm actually doing study with Allergan about Breast Implant Illness with a couple surgeons all across the country. So we're giving, sort of, surveys to these patients to see what's going on, like you were saying, do you have autoimmune disease, did you have it before...and we're tracking the symptoms to see if it's getting better. Patty Maguire is actually doing a study on patients doing a total capsulectomy versus doing only a partial capsulectomy and seeing how the patient's fare afterwards.

Dr. Barrett: But taking the implant out.

Dr. Chopra: Yes.

Dr. Barrett: Okay.

Dr. Chopra: And see if the capsule has anything to do with it.

Dr. Barrett: Okay.

Dr. Chopra: You know, I think all of it’s going to mesh together. Capsular contracture, we think maybe a bacterial biofilm, right? There may be something to that with Breast Implant Illness. And as well as giving patients antibiotics and screwing up their digestive, you know, bio...

Dr. Barrett: Their gut flora.

Dr. Chopra: Yeah. So it's all related. We just don't have the pieces of putting them all together.

Dr. Barrett: Yeah.

Dr. Chopra: And I think that's where the research needs to be done.

Dr. Barrett: So Allergan is actually actively looking into this.

Dr. Chopra: And I commend them for that.

Dr. Barrett: Yeah.

Dr. Chopra: Right, because they want to get out on the forefront. Because like you said, most women that have Breast Implant Illness or textured implants, distrust the implant manufacturers wholeheartedly.

Dr. Barrett: Yeah.

Dr. Chopra: So now they're trying to get out in front of it. And be like, listen, we're going to do a study, we're going to try to find what's really going on. They've been reaching out to the people on the Breast Implant Illness website to talk to them so they can, sort of, do a collaboration with everybody. Because I think, I mean, I'm naive because I always look at the good in people...I think everyone in general doesn't want to do something that's hurting somebody else.

31:18 BRAZILIAN BUTT LIFT DEATH RATE

Dr. Barrett: Right. No I certainly don't. And, and that's one of the reasons why I love breast augmentation is because it’s one of those low-risk operations. You know, you..there…for a Brazilian Butt Lift, which is a fat transfer to the buttocks, the death rate is, like, one in 3000.

Dr. Chopra: Yeah.

Dr. Barrett: Isn’t that crazy?

Dr. Chopra: It's the highest rate in plastic surgery.

Dr. Barrett: Yeah, yeah. I mean, it's just like I hesitate to do that one, and now we have guidelines that, kind of, help us with where we inject the fat and stuff like that that’s hopefully going to reduce that. But that's one of the risks..I…one of the reasons why I like breast augmentation is because everybody's happy, very, very low risk. And I think what you're doing is great where we can, kind of, further understand it and make that risk even lower. Informing patients so they can make the right decisions and have access to all of the information so...

Dr. Chopra: I think you nailed it. I think an educated patient is a good patient.

Dr. Barrett:  Great. Well, anything else you want to add about Breast Implant-Associated Illness?

Dr. Chopra: No, I think, I think we covered it. I think this surgeons that are seeing these patients just need to be empathetic. They may not believe in it, but they need to be empathetic and listen to these women.

Dr. Barrett: It's true, it doesn't mean that their symptoms are not real.

Dr. Chopra: Absolutely.

Dr. Barrett: It's, they are experiencing something. It may not be caused by the implant, but they are, they're definitely experiencing something, and you, and I learned that a long time ago that you just have to stop what your, your medical school mind is trying to tell them and just listen to them. Because maybe you figure out something else. But you, you have to, kind of, listen to patients and, and hear what they're saying and I… I, you know, I've been getting a few more people that have had some stuff and the ones that I have taken out and they've done better I feel great about. But then I will say you know the majority of my patients that get the implants even five, six years out. They're super happy. I mean no problems...

Dr. Chopra: Right. So if you look at, say how many implants are out there? Let's say there's 5 million implants out there.

Dr. Barrett: Yeah.

Dr. Chopra: And say even 10% of them have breast implant-associated issues. Right. That's 500,000 women. That's a lot of women.

Dr. Barrett: Yeah.

Dr. Chopra: Right?

Dr. Barrett: Yeah.

Dr. Chopra: So even if it's 5%. That’s 250,000 women.

Dr. Barrett: Right.

Dr. Chopra: That's a significant amount of women that are reacting to this implant.

Dr. Barrett: Do you have any additional resources that women can, kind of, or people that have implants can kind of look into.

Dr. Chopra: Well, so I mean…I think there's a website Healing Breast Implant Illness.

Dr. Barrett: Yeah.

Dr. Chopra: On Facebook, there's a group, which is good. There's also Breast Implant Illness on Instagram.

Dr. Barrett: Okay.

Dr. Chopra: Those are great resources. And my Instagram has some, you know, pictures and videos.

Dr. Barrett: What's, what’s your Instagram?

Dr. Chopra: @DrRituChopra.

Dr. Barrett: Okay.

Dr. Chopra: Yeah. So I mean, there are, and my website has things on Breast Implant Illness. It’s just, you know, you need to make sure your information you're getting is vetted, like you were talking about.

Dr. Barrett: Yeah. So start, start with your basis of your, your research should start with going to a board-certified plastic surgeon.

Dr. Chopra: I think that's important.

Dr. Barrett: And then next, somebody who does breast surgery, right?

Dr. Chopra: I think those two, you hit it on the head. Because you want to go to someone who can do the operation if you need the operation.

Dr. Barrett: Yeah. Great. Well, Dr. Chopra, thank you for coming on to the podcast today. You're truly amazing. You, you really, you enlightened me a lot on, on this. And I think the viewers are really, really gonna appreciate all the extra advice that you put out there for them.

Dr. Chopra: Thank you for having me.

Dr. Barrett: All right.

Dr. Chopra: Pleasure.

Dr. Barrett: Yeah.Thanks.

Thank you for tuning into our podcast. If you liked today's podcast, don't forget to share, rate, review and subscribe. Join us every Monday at 10am for upcoming episodes. Also find out if plastic surgery is right for you by using our virtual consultation at Dr.DanielBarrett.com/virtual-consultation. See you soon.

‍