Perennial Problems and Innovative Solutions: Update on Aesthetic Breast Surgery w/ Dr. Jason Pozner

Doreen Wu (00:00):
Welcome to another episode of Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your cohost Doreen Wu. I'm excited to be here with Dr. Lawrence Bass Park Avenue plastic surgeon, educator, and technology innovator, and our guest expert plastic surgeon, Dr. Jason Pozner from Boca Raton, Florida. The title of today's episode is Perennial Problems And Innovative Solutions: An Update On Aesthetic Breast Surgery. Dr. Bass, tell me, what are some of the big issues in aesthetic breast surgery?

Dr. Lawrence Bass (00:37):
Well, there, there are a number of significant issues and common sticking points that plastic surgeons continue to endeavor to improve. One of the most common issues with breast implants is capsular.

Doreen Wu (00:52):
What is that? And how does it happen?

Dr. Lawrence Bass (00:55):
Capsular contracture is a tightening of the capsule that forms around the implants. So the body reacts to the implant, lays down collagen that looks to us as surgeons in the operating room, like a white glistening membrane. And we want that membrane to be soft and thin that preserves the shape of the pocket for the implant that we fashion during the surgery, occasionally that thickens or over many, many years even calcifies, and that can distort the shape of the breast and the softness of the breast. So we get firmness and we lose symmetry. The implant looks like it's riding up or the shape at the edge of the breast. Contour is no longer the nice curvy shape that we like. There are a number of thoughts about how this occurs, and if we go back many years, uh, one of the contributing factors was gel bleeds, silicone gel leaching out of the implant, even with an intact shell. And that was a promoter of capsular contracture. Now modern implants are low bleed implants, and that's probably helped tremendously to stem the tide of that issue. And people also thought that blood in the pocket at the time of surgery was a promoter of capsular contracture. And it probably is. But more recently, data has come to light that is pretty persuasive that bacteria not free floating, but in the form of a biofilm or colony are probably the major contributor to capsular contracture.

Doreen Wu (02:46):
Well, that does not sound like a pleasant experience, what can be done to prevent it.

Dr. Jason Pozner (02:52):
Okay. You know, so let's go back a little bit to capsules. So everyone says, well, why do I have a capsule? Do I need a capsule? And the issue is whenever you place a foreign body in a person, be it a pacemaker or a hip joint or a breast implant, the body's reaction is to form a thin film around it. And that's called a capsule. But as Dr. Bass said, as it thickens up or becomes misshapen, it can cause tightening around the implant and basically squeezes it like a balloon to the point that the breast is misshapen. So I think in terms of what to do for this, I think the first thing is we, we talked about a little earlier is prevention and I, the ways and steps we do to place a breast implant in 2022 is different than what I was taught in the mid 1990s.

Dr. Jason Pozner (03:44):
So just to kind of go from, start to finish with this, it is some perioperative antibiotics, as we always gave a clean in incision and dissection with minimal blood in the pocket. Because as Dr. Bass said, bacteria are probably the cause of contracture. And guess what bacteria like to eat and grow on it's blood. That's how you grow bacteria in a lab. You put them on blood agar plates. So meticulous dissection, no ripping millimeter by millimeter dissection with basically minimal handling of the tissues and atraumatic surgery. A typical breast augmentation for me, there's three drops of blood. I mean, there's almost nothing you would think that you could brush your teeth and get more blood out than we would placing your breast implant.

Dr. Lawrence Bass (04:32):
Well, because you're probably doing it mostly with electrocautery, right?

Dr. Jason Pozner (04:36):
Yeah, of course, with electrocautery. And incision makes a difference. If you want to talk about incisions there's data that suggests that an inframammory incision that's an incision at the fold of the breast has less problems with contracture than an areola incision. The areola incision cuts through a lot of breast tissue. The breast ductular tissue is open to the air, has bacteria in it. We find cysts in it all the time. And when you place it through an inframammory approach, you avoid cutting through the ductular tissue. And I believe it's a cleaner approach. And I think most surgeons in the country are using an inframammory approach these days because of this data. Um, the other thing is no touch technique. We, we don't put our hands all over these implants before they're placed. I use a Keller funnel to place the implant we wash with triple antibiotic betaine solution, our close friend, Larry and I friend Bill Adams did most of the seminal research on this.

Dr. Lawrence Bass (05:34):
Now, now let me stop you there for a second and ask, what do you think is going to happen now that FDA has, has taken bacitracin off the market? Because that was one of the antibiotics that was used in, in the

Dr. Jason Pozner (05:48):
Solution. Right. But actually it wasn't. So, um, so what happened was the original, the original triple antibiotic solution was betadine gent and ancef. That was the original triple antibiotic solution. The FDA thought that betaine was having, causing some shell problems with the implant and put a recommendation in that you should not use betaine in your washes with breast implants. So his formula was changed to gentamycin, ancef and bacitracin, but the original triple antibiotic solution does not contain bacitracin. It's ancef, gentamycin, and, um,

Dr. Lawrence Bass (06:31):
Betaine

Dr. Jason Pozner (06:32):
And betaine so that's what, that's what I currently use. So hasn't affected me.

Dr. Lawrence Bass (06:36):
All right. And you're not going back to, you're not going to, to hypochlorous acid or something like that,

Dr. Jason Pozner (06:43):
I actually like hypochlorous acid in my capsule contracture cases. So, um, when I'm, we're going to get into that. Right. So,

Dr. Lawrence Bass (06:52):
Yeah. And so these are just different ways that, that we try to create a pocket and in the implant that is as clean and protected against biofilm and therefore capsular contracture as possible. And there's good data that shows this has a major impact on capsular contracture rate

Dr. Jason Pozner (07:12):
Major. And, and this is on the prevention side of things. So if you ask me, what's changed in the last 20 something years, since Larry and I both were in our training programs, all of these steps have played a role. I can't tell you there's one step that played a role. It is the no touch. It is the aseptic placement of the implants with, with washing with triple antibiotic solutions and meticulous tissue handling and no blood in the pocket. Each one of these has added up to a significant reduction in risk of perhaps contracture and most experienced breast surgeons probably have an under 1%, um, rate at this point in their practices.

Dr. Lawrence Bass (07:52):
So that, that covers prevention, which was the question that Doreen asked. But regardless, there still is an incidence of capsular contracture. It's not common for it to be major, but it's not our rarest potential problem with breast implants. So if the contracture is mild, usually it's treated with massage or with ultrasound treatments in some people's hands. Some people actually give, uh, medicines that are used for asthma, like accolade, to Luca, right? Luca inhibitors inhibit, you know, a, a proliferation of the capsule.

Dr. Jason Pozner (08:37):
I never had a res good response to any of those medications. I've never once in 20 something years seen one work. Yeah, maybe you have. I have,

Dr. Lawrence Bass (08:45):
I, I have not. I have not. And I don't use them, but it, it is a,

Dr. Jason Pozner (08:50):
You gotta be careful. You have to follow liver functions, they mess up your liver a bit. You gotta be careful with that. But I do like for early capsular contracture, the Aspen ultrasound technology, it's a big ultrasound probe, uh, specifically made for this, that goes on either side of the breast and for mild capsular contracture, or early positional problems where you have a high riding implant, it does a miraculous job. And perhaps it's breaking up the biofilm, if there's a mild biofilm and allowing the body to come in and take it away. Not sure, but it does work in mild cases. If you have significant contracture, it won't do a thing.

Dr. Lawrence Bass (09:27):
Yeah. And so that's the lesson. Mild can be treated non-surgically, but if you have moderate or severe capsular contracture with a big distortion of shape or a big change in firmness, you're probably headed back to the operating room and treatment in the operating room typically is something like capsulotomy cutting the edge of the capsule to expand out the pocket. If there's a thickened or not healthy portion of the capsule, capsulectomy, which is usually done in a partial form. So partial removal of the capsule, and sometimes in someone who's had recurrent capsular contracture, you will change planes. The implant is subglandular under the breast tissue. You'll go submuscular under the pectoralis muscle. Or if it's submuscular again, you'll flip it to subular. But where has treatment of capsular contracture gone from there? Dr. Pozner, because I know this is something in particular that people seek you out from around the country to help them with when they get in trouble with their implants.

Dr. Jason Pozner (10:44):
Yeah. Um, you know, I, I see a lot of these patients per week and I enjoy taking care of these patients because we can make miraculous changes to their breast shape and feel. So with the understanding in my mind that capsular contracture is most likely caused by bacteria in a biofilm situation. My thinking is always, you need to get that biofilm out. So I wish we had a magic antibiotic that would clear it up, but unfortunately it doesn't. So I like to, to get rid of all the capsule in significant capsule cases. So that's called a complete capsulectomy. There's some data where people talk about on block and not on block and how you take it out. I don't think that makes a damn bit of difference. And there's some recent data that says that there's no difference in types of capsulectomies that's performed, but I like to take out the capsule then I like to try to sterilize the pocket. So I will use hypochlorous acid there after the capsule's out to sterilize the pocket as best as possible. I then wash just to have a belt and suspenders approach with the triple antibiotic betanine solution. So I don't have a, I don't have a horse at either one of these races. I use both. Um, and then as Dr. Bass said, I like a sight change. If they're over the muscle to under the muscle, I way prefer an under the muscle implant to an over the muscle implant for prevention of contracture

Dr. Lawrence Bass (12:15):
And the data and the data on that is pretty clear as well.

Dr. Jason Pozner (12:18):
Isn't it, it's pretty clear, pretty clear pretty clear. I mean all of these steps have been, well, everything I'm talking about has been studied and I don't think any one of these is a controversial topic, new implants. You don't put the same implant in cause there's biofilm on the implant. So you gotta change the implant. You can't clean it, you can't sterilize it. You put a new one in, I use a drain in these cases because these capsulectomy cases drain like crazy. I don't like drains and tummy talks. I don't like them in my primary surgeries and lifts and things, but I do use them in capsular contracture cases. I also place an ADM, um, which we learned from the cancer patients and ADM is a Stratus is what I like to use, which is pig skin, porcine dermis, or skin that has no cells left in it.

Dr. Jason Pozner (13:05):
You can also use human tissue or if you want to use a synthetic there's some evidence that GalaFLEX mesh also has some antibacteria properties. And I usually will place the implant under the muscle with the mesh underneath it so that the implant is completely separated from the breast tissue where the bacteria is, because the bacteria's in the ducts of the tissue. So that's sort of my process. And the last step is we send the capsules fresh out to Texas for PCR analysis. Everyone knows what PCR is now because of COVID, but we send it to the lab. And in our studies of our patients, we found that about 50% of the specimens come back with a bacteria and a lot of weird stuff in there. It's not one bacteria it's usually multiple, which is what you would expect from a biofilm and believe it or not, the number one bacteria that we found was E coli.

Dr. Jason Pozner (14:04):
So we're thinking that a lot of the etiology of these capsular contracture comes from urinary tract infections, which many women are very prone to. So I think it gets in the urinary tract and get, see it seeds the breast implant. Um, but we did find lots of weird bacteria, including dinitrobacter reductant, which is a soil bacteria. Don't ask me how that got into the breast. Interesting. So, so that's sort of my roadmap to treatment of capsular contracture again, capsulectomy new implants, ADM wash, wash, new site, new site, and drain and send that out to see what's in there. Because if it does come back positive for bacteria in my PCR analysis, I'll give them a month's worth of specific antibiotics based upon the bacteria that we found.

Dr. Lawrence Bass (14:51):
And there are certain antibiotics that penetrate biofilms better than others. So once you know what bacteria, then you pick an antibiotic that's gonna penetrate and, and a good long course of it, as you said,

Dr. Jason Pozner (15:05):
And the company we use MicroGen out of the labs in Texas, they're based of Orlando, um, they provide you with analysis of bacteria and the antibiotics that they suggest based on those bacteria. And if it comes back negative, I say, look, there's no current bacteria in there, um, that we've found or it's below a certain threshold to be detectable. You're good with just your perioperative, antibiotics and massage and perhaps some ultrasound. So I mean, there's a roadmap, it's, this is information that we have now in 2022 that I'm able to use to help prevent recurrence. And I think our recurrence rates are very low back in the day when I was just taking out the capsule and putting the new implant in and doing the wash. I would say that my recurrence rate was 50% with the steps that I'm taking now, including an ADM and yada yada, as I explained, I'm down to under 5%. So I think that's a significant change. So the steps we're taking seems to be important.

Doreen Wu (16:03):
So shifting gears from capsular contracture, what is your next topic of discussion Dr. Bass?

Dr. Lawrence Bass (16:09):
Well, the next topic is breast lifting. This is also known as mastopexy. This has been an area with a lot of tinkering and aesthetic breast surgery with techniques to improve the, both the degree and durability of improvement and in the effort to reduce the length of scars. So if we look at the classic mastopexy, basically it's a skin brassiere, the skin is being used to hold the breast up in its lifted position. And the problem with that is skin stretches out when it's placed under tension. Simple example of that is if you put the abdominal skin on tension, like when a lady is pregnant, that skin will stretch out over a few months, quite a bit larger than it was to start with. So that was intrinsically a limitation or problem in the way breast lifting was done in past decades, uh, attempts more recently to build a pillar of breast tissue to support the breast or even to place the bra tissue in a sling of chest muscle has been used to try to enhance the degree and the durability of the correction. So what else is happening, Dr. Pozner with mastopexy to try to enhance the results along this particular direction?

Dr. Jason Pozner (17:34):
So we it's funny because we were discussing this last night on, on a, on a call. So I learned a lot from a friend of ours, Bruce Van Natta in Indianapolis. And he was one of the early pioneers in using mesh specifically GalaFLEX mesh in mastopexy so that the breast tissue, the breast skin is not supporting the implant. The mesh is creating a scaffold and a little bit of scar that holds up the breast tissue. I do far more, um, implants with lifts than I do just lifts alone. So mastopexy with implant and in pretty much a hundred percent of those cases I add mesh just so that the implant is held up by the mesh and not held up by your skin. For example, none of us in 2022 would think to do a facelift without tightening the internal layers. Right. So why would you expect this skin on the face? Not to hold up, but the skin on the breast to hold up, it just doesn't you put a weighted implant in over time, it's gonna stretch. So I'm a big fan of support.

Dr. Lawrence Bass (18:43):
Yeah. The breast is a lot heavier of course, than tissues on the face. So there's a lot more stress there and it even greater priority to the need to have some kind of support. So what else is, is happening with, uh, more limited incision lifts, uh circumareolar lifts? What do you think in, in 2022 are the indications for these more limited incision procedures?

Dr. Jason Pozner (19:12):
You know, you know, there's I always tell the patients, there's not one patient who's coming, came into my practice since the day I started who asks for scars on their body. Okay. So nobody wants scars. Everybody wants a procedure that has no scars that gives you maximal results, but unfortunately breasts come in many shapes and sizes from mild droopiness to significant droopiness. So for mild droopiness, I find an incision around the areola can help the patient if it's a mild degree of areola, um, droopiness for a little bit more droopiness, I like what's called a lollipop incision or a circum vertical where you're taking off skin in both around the areola and a vertical fashion. And then for bigger droopiness, I use a wise pattern, which is a inverted T incision, which is the lollipop lollipop plus an incision along the, inframammary fold. So basically it depends on how droopy you are and what you're looking to achieve.

Dr. Lawrence Bass (20:11):
So it's really, you know, there's a, a stage of aging issue and uh, necessarily technique needs to be adjusted. There's no one size fits all, which is not a big surprise.

Doreen Wu (20:25):
So I guess your stage of aging figures pretty heavily in the procedure selection is breast lifting, always standalone or are there some combination procedures?

Dr. Lawrence Bass (20:35):
So let's back up a little bit and just talk about what we're trying to do in conjunction with the lift. If you want to be smaller in size and have the breast tailored and shape and repositioned back up on the chest, that's basically a breast reduction. A reduction always has those sort of lifting and shaping components as part of the procedure. If you're staying the same size lifting alone is done. Uh, and sometimes there's a lot of ptosis or drooping of the breast along with a lot of volume loss and you're trying to restore the volume loss or some people always wanted to be a little bigger than they naturally are. So in conjunction with the lifting, they get a breast augmentation, uh, this and that volume loss is very common. Volume loss occurs with aging. It occurs obviously with major weight loss, but also after breastfeeding. So breast lifting as an augmentation mastopexy when we want a sizing increase, especially if we want fullness in the upper half of the breast is very commonly done. And Dr. Pozner's already said this, uh, now augmentation mastopexy is often regarded as one of the most difficult procedures in aesthetic plastic surgery.

Doreen Wu (22:06):
I didn't realize that Dr. Pozner, why is augmentation master Pepsi so difficult?

Dr. Jason Pozner (22:11):
Well, it's, it's two operations with different vectors of force one. You're trying to lift something high and tight. And on the other side, you're trying to put an implant in to make them bigger, which basically puts tension on your repair. So your forces are in opposite directions. And that's why I mentioned that I don't do that case without mesh anymore. It has changed my practice completely. And I have hundreds and hundreds of cases cuz I've been putting mesh in and various types of mesh for a long time now. And we have women in their eighties who come in, who look like they have breasts from their twenties, sitting high on their chest, not needing to wear a bra and super happy. Whereas prior to using support mesh in these augmentation mastopexies, the patients would often come in six months later with bigger, droopier breasts, which nobody wants.

Dr. Lawrence Bass (23:02):
And I'm just curious, have you run into because you have ladies who you said have had this for some time, have you run into lead issues with the mesh or it seems to be well tolerated,

Dr. Jason Pozner (23:13):
Especially the GalaFLEX it's super well tolerated and the newest version of the GalaFLEX mesh, which I've been using since August is called GalaLITE. So it's a one step lighter and it's stretchier and it seems to the small problems I had with the previous generation were an occasional high riding implant that didn't fall perhaps a little bit excess scar tissue, but with the new mesh, it is just phenomenal. And zero infections in, um, a couple of hundred cases with me between Dr. Van Natta's office and ours, we have over a thousand cases with zero infections.

Doreen Wu (23:47):
It's very impressive. Are implants used with reductions the same way they are with breast lifts. It seems counterintuitive. If you're trying to go to a smaller size, why would you increase the size by adding an implant?

Dr. Lawrence Bass (24:00):
It is counterintuitive, but it is something that is important. Particularly if the patient desires that upper pole fullness basically volume in the upper half of the breast, making that part of the breast full is a challenge. So if that's a priority for patients, they often have to agree to have a small implant added just to help round out the shape in that area. When they're in light clothing or undressed, if you wear a pushup bra, you can get upper pole full, but in the absence of a pushup bra, it's almost impossible to get that in any adult woman without an implant in place.

Dr. Jason Pozner (24:44):
You know, I, I agree a hundred percent and what we call these cases is a plus minus case. We take out the droopiness of the, usually the bottom hanging heavy breast tissue, and we replace that volume with an implant that gives you upper pole fullness. So I call it plus minus. The other option is if someone's looking for a lift, but wants a small degree of upper pull fullness we'll put some fat grafting in. And that works very well for patients looking for a lesser amount, but some fullness.

Dr. Lawrence Bass (25:15):
So it's plus minus, but, but with natural tissue

Dr. Jason Pozner (25:18):
That's plus right,

Dr. Lawrence Bass (25:19):
Plus minus with an implant, in some ways that's the best both worlds. You get your desired size and you get better shape, but it's also the worst of both worlds because you have the incisions and, and therefore the scars and you also have delayed implications of adding an implant of some future malfunction of the device, somewhere in, in the remaining decades of your life.

Doreen Wu (25:44):
Dr. Pozner, you mentioned that sometimes fat grafting can be used to modify breast shape or even for augmentation in place of implants.

Dr. Jason Pozner (25:51):
Right? So we learned this from our colleagues doing breast reconstruction where they found that that putting fat into breast cancer patients often fix some of the radiation problems and some of the dents and on other malformations that happen in cancer patients. So we started using it on the aesthetic side and we found that we could achieve some reparable fullness and I put it in for rippling all the time, if someone's extremely thin breasted and you have a visible implant. So it's just another tool in our toolbox that allows us to achieve more natural looking better results in patients. But we do a lot of fat grafting to the breast and other areas of the body. Now

Dr. Lawrence Bass (26:32):
I agree with you completely. I think fat grafting is an extremely powerful tool for really perfecting roundness of, of the edge of the breast contour and all manner of minor sins or minor defects in perfection without doing any kind of big surgery. And if you go in and try to recontour the pocket for some little shape, uh, you know, you're risking everything. Sometimes all the cookies crumble and fat grafting is easy to do. Low recovery patients after they've done around a fat grafting are, are so pleasantly surprised at how minimal it is for them to do that. And it can really advance the aesthetic quality of the result.

Dr. Jason Pozner (27:24):
And I always tell the patients, you get a little free liposuction. So they're usually happy about that,

Dr. Lawrence Bass (27:29):
Right? I mean, what, you know, what's not to love.

Doreen Wu (27:32):
What more could you ask for? Wow. I didn't realize how many complex issues are under evolution in breast surgery as we wind down this episode. Are there any additional key takeaways you think patients should keep in mind? Dr Pozner

Dr. Jason Pozner (27:44):
I think the only thing we missed that we didn't talk about and I'll mention in just a couple sentences is, um, problems with positioning of the implants on the chest. Sometimes you'll, you'll find circumstances where the patient will come in with a two lateralized implants, two media implants, two inferiorly placed implants. So we use pocket control techniques and mesh to help support the pockets, to put the implants in a better position. So we do a lot of fold repairs and other things now that because sometimes the tissues just couldn't hold up and we use the mesh for support in those instances. But again, if you're seeing, if you have a complex breast issue, um, you know, look to someone who does this on a routine basis, you know I'm not an expert in hand surgery. I wouldn't go to me for hand surgery. I haven't done one in many years, but you know, we all sort of super specialize as we get a little older, do your homework.

Dr. Lawrence Bass (28:43):
Yeah. And I mean, I think that's really important. The experience and specialization breeds, predictability and control in the results and pocket control and the use of mesh to help, particularly for the inframammory fold. You know, once that fold has been destroyed, the ability to make a stable fold and have control over the height of the fold, which is key to the breasts, positioning and height has been a classic problem area. That's probably been very well addressed with these mesh techniques. Well, I'd like to thank Dr. Pozner for joining us today and providing so much clarity on these very complex issues.

Dr. Jason Pozner (29:31):
Thank you very much, Dr. Larry, thank you so much. Doreen I really enjoyed being on this show cause it was, you know, a lot of fun.

Doreen Wu (29:38):
Thank you so much.

Dr. Jason Pozner (29:39):
And it's always nice to see Dr. Bass smiling face. Um, because I haven't seen you in a while in person, right?

Dr. Lawrence Bass (29:46):
Yes. The pandemic has certainly interfered with so many medical meetings. They're they're taking place, but they're virtual. So the ability to see friends and colleagues in person is something we've missed in the last couple of years,

Dr. Jason Pozner (30:01):
But I'll see it as at a laser meeting first. That'll probably be our next venue.

Doreen Wu (30:06):
Well, thank you again, Dr. Pozner for sharing your insight and expertise with us, I've definitely learned a lot and thank you to our listeners for joining us today, to hear this update and learn about the evolving issues in aesthetic breast surgery. If you think of other exciting developments in plastic surgery that you would like to see us discuss in upcoming episodes, please feel free to reach out via email or Instagram. We'll see you next time. This is Doreen Wu, thanking you for joining Dr. Bass, Dr. Pozner and me for this discussion of breast surgery. Be sure to tune in next time. And don't forget to subscribe to our podcast, to stay up to date with all of the exciting content that is coming your way.

Speaker 4 (30:43):
Thank you for joining us in this episode of the Park Avenue Plastic Surgery Class podcast with Dr. Lawrence Bass Park Avenue plastic surgeon, educator, and technology innovator. The commentary in this podcast represents opinion. This podcast does not present medical advice, but rather general information about plastic surgery that does not necessarily relate to the specific conditions of any individual patient. No doctor-patient relationship is established by listening to or participating in this podcast, consult your physician to advise you about your individual healthcare. If you enjoyed this episode, please share it with your friends and be sure to subscribe to our podcast on Apple Podcasts, Google, Spotify, Stitcher, or wherever you listen to podcasts.