Speaker 1 (00:04):
Welcome to The Holistic and Scientific 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.

Candice (00:21):
Yeah. Well, I hadn't really discussed that I had pretty severe adhesions, and I went back for, I think, two or three sessions of adhesion release where-

Dr. Robert Whitfield (00:34):
Oh, no.

Candice (00:35):
Yes. Where they numb you up, so more lidocaine in the area, and then take, I don't even know what it's called, it's a needle that looks like a blade.

Dr. Robert Whitfield (00:47):
Rigotti knife.

Candice (00:48):
Yeah, and just would stick it in there and go back and forth. And the snapping and the crunching and the pain, I mean, and it would help a little bit, tiny bit. And then it would be like, go back and cup. So, I had the big inappropriate looking suction cup things I'm doing at home, and then had holes from where we did that, so it would just look like ... I mean, it was bloody and messy. And all that to say, none of these things really helped with the adhesions.

Dr. Robert Whitfield (01:18):
Right. What Candice is describing is called a scar release. And basically the Rigottomy's, famous surgeon in Italy established one of these. Technically you're doing scar release and you're supposed to do fat beneath that scar release in order to prohibit the scar from forming as dense or in the same position. So, think of it like you have a depressed or tethered area, and then you release it and you put fat beneath it, so that it cannot tether again. So, that's a very standard reconstructive technique for both radiation injury, adhesions from surgery, or in our case, we did it a lot for cancer reconstruction cases. So, what she's describing is a very commonly utilized technique to break down scar.

Dr. Robert Whitfield (02:07):
But the next step is to place something as a filler between that. So, think of fat as one of the oldest fillers we have, it's the oldest natural filler really, and fat brings with it its own adipose derived stem cells. So, those stem cells are what helps support and develop the ability for that depressed area to not stick back down. So, she had poor blood flow and what she brings with it when you add fat to it in the right setting, is a way for new blood flow to develop in that area so it doesn't adhere back down. So, when you do it without, you can have a result, but remember she's had three operations. Now, this is a fourth intervention and a fifth intervention. And however many interventions you do without changing plan A, plan A doesn't work, if you don't change it.

Candice (03:02):
Yeah, it didn't. Maybe 10% improvement, but the issue was that that area would just adhere back down. Eventually, I knew fat transfer was going to need to be an option. And so, I found a fat transfer doctor. I didn't want to go back under general anesthesia, even though my liver was well. And I just have had so many surgeries at this point that I wanted the least invasive way to handle this. I had realistic expectations. I only wanted to be an A cup and to just have uniformity. If I leaned forward, you could see that my skin was adhered to my chest wall.

Candice (03:43):
So, I found a fat transfer doctor in LA that had excellent reviews as far as fat transfer to the breast, and the bum, and awake. My mistake was in not asking, or not even realizing, the importance of someone needing to have extensive experience in fat transfer after explant, because obviously there's a matrix of scar tissue there.

Dr. Robert Whitfield (04:14):
When you have those percutaneous releases, those areas develop more scar. Each intervention without a filler placement, or fat transfer, or something to buffer it, you get more scars. So, what you're going to describe next is pretty predictable.

Candice (04:33):
Right, so proceeded with the awake fat transfer, about 300 CCs of fat was placed.

Dr. Robert Whitfield (04:41):
Which is a large volume for you.

Candice (04:43):
It is a large volume. I was surprised because again, I just wanted to look natural, normal. So, they sat me up. When they looked at all the fat they had placed, I don't know what it looked like, but they said, "Lay her back down," because I'm awake, but I'm highly drugged. But essentially what the issue was, was I guess it just looked like pintucks everywhere. So, they'd placed this fat, the scar tissue then once they sat me up, pulled in all of these areas, causing deep dimples where the scar tissue was. So, then he went back in with a smaller cannula and started to just ... I had 150 holes all over my breasts as they went in individual in each one of these spaces, trying to break up the scar tissue at the same time as injecting small amounts of fat all over.

Candice (05:39):
So, my best friend was taking care of me again and I was doing okay. And then the next morning I texted said, "Does this look okay?" Looked red to me but of course, I had surgery, it's probably going to be red. And I never saw him again before I left town. I was there another three or four days, had just virtual check-ins. So, at a week I said, "I'm larger than after surgery." And he said, "Great. You're keeping the fat. That's great." And I'm like, "How is it possible that I'm larger?" He said, "Well, you probably still have swelling." And so, a few more days go by and I'm like, "Yeah, I'm not feeling good."

Candice (06:26):
I wear an Oura ring. And so my temperature before this had dropped really, really low, extraordinarily low for three days. And my respiratory rate was really high and all of these things, but he was like, "You don't have a fever, right?" I said, "No."

Candice (06:43):
And then I got a fever and they just kept getting bigger. I sent pictures. He said, "Okay, yeah. Again, this is to be expected, you had a lot of scar tissue. Start on this antibiotic." Didn't get any better with the antibiotic, fever kept going up. , did the breasts. At this point, they are bigger than my implants ever were. They were red and shiny and awful looking. I kept saying, I said, "They feel like they're filled with air, like helium. They're not heavy. They feel like they're blowing up with air." It was so weird because they felt bouncy, like a balloon.

Candice (07:24):
So eventually, another round of antibiotics. By this time, we're three weeks in. I'm so sick I can't get out of bed, super red. It gets passed over to a different surgeon who sees it and says, "You need to get on a plane right now. You could go to the ER, but they're not going to know what to do with you." So, this was Christmas Day, so I had to get on a plane and fly back to California. I meet the surgeon at the office and he tried to aspirate with large needles and we did get a substantial amount of fluid, but not enough. So he said, "Let's see how that does." And then sent him pictures the next morning. And he checked in with me every hour. He said, "You need to come back in." And at this point, he made two little incisions on each side and it just poured out liquified fat and infection.

Dr. Robert Whitfield (08:22):
Just for the audience. So, a couple things Candice said, was her temperature got really low and she kept getting asked if she had a fever. So, the prelude to getting a fever, you get chills, right? And then her respiratory rate was going up. So, had they checked her blood work at that time she would've definitely have had [inaudible 00:08:42] blood work. So, her white blood cell count would've been higher. It would've been pretty obvious that she had an infection. These are things in a hospitalized patient, you would recognize pretty quickly because the nurses would be like, "Hey, Dr. Rob, the temperature's really low. Her heart rate's elevated, her respiratory rate's elevated." She has an Oura ring on, so she knows this anyway. So, she's got her own monitoring device on. And basically now she's describing a closed space infection.

Dr. Robert Whitfield (09:08):
So, what I tell folks, try to envision a honeycomb and this honeycomb has been broken up, but you still can't get everything out. So, when the surgeon tries to get things out, he doesn't know where it is. It's a huge maze to get stuff out of. And they're fortunate that they got enough out, so that she could actually then with the help of the antibiotic, I hope, get healed up because this can become a life-threatening condition for someone, if it's not taken care of.

Candice (09:37):
Yeah. That was the issue with trying to do it a with large needle, was it was a honeycomb. So, we couldn't find where the pockets were, even though we knew that there was a lot in there. So, we ultimately, creating a large hole and incision and then manually ... First of all, a lot poured out. But then he had to manually express the remainder of the liquified fat. And then of course, took samples and swabbed all of that and said that to the lab and then was able to determine what kind of infection it was, or bacteria. And so, then I was put on another two antibiotics there. So, I was on four antibiotics within three and a half weeks. And then after that point, by having to manually mash out that fat and infection, it somehow created ... My skin felt like there was literally a sponge stone in there, it looked ... They called it orange peel skin, it was just ...

Dr. Robert Whitfield (10:31):
It's called peau d'orange. So, the dermis is got fluid stuck in it and it feels boggy or soft. So, we've described this on the show before, but where you put fat is between the skin and the breast tissue. Now, in a really thin patient like Candice, there's not going to be a substantial layer there. So invariably, you're going to be rubbing up against the breast and that space. You're going to be in the dermis, just beneath the skin so that ... The skin is composed of layers, epidermis, dermis. The dermis is where the blood flow is, so you actually want to be very close to that area, but that's when you have an infection from fat transfer or just when fat transfers are healing. We see it in revision lipo a lot, where we have to undimple skin that's been contracted down from scarring, you'll have this bogginess and it'll look like peau d'orange, which is orange peel, basically.

Candice (11:32):
Yep, that's exactly what I had. That has been a process to heal that, which I talk about a lot on my Instagram account, and how I found something that really helped me with that, and helped restore the blood circulation to that area. And so, at least everything looks better, substantially better, from where we were at. I would say I probably retained like 15, one, five percent of that, which ... The only place it retained was at the bottom, the only area that had breast tissue anyways. So, lesson learned.

Dr. Robert Whitfield (12:11):
Yeah, that's a complicated thing. And maybe we'll just do a simple physics lesson here on the show. So, we're going to use a couple ... We'll use some Sharpies. Those are easy. So, when you're doing fat transfers, there's some just basic things to remember. We're all taught how to do them. Remove fat with one instrument, a liposuction cannula, put it back with another instrument called the fat transfer cannula. There are varying sizes, but just for illustration purposes, if you take something out with something that big and put it back in with something that's smaller, you just have this disparity and pressure that it takes to put it back. And the smaller that device is that you put it back with, the more pressure you exert to put it into the space.

Dr. Robert Whitfield (13:08):
And the more pressure you put on things, the less control you have. And when you don't have control, no matter how good you are, no matter how talented you are, you can't get it exactly where it needs to be evenly distributed. So, what I tell people and what I've showed you in the past, is whatever you take it out with needs to be the same size as you put it back. That gives you your best chance to evenly distribute the fat across the area that the ... In this case, I want it to go. And I, a long time ago, used to use the technique you described. It's a hard technique to get just right. But I did that over a thousand cancer patients, so I was very versed in doing that.

Dr. Robert Whitfield (13:56):
And then we have Wells Johnson fat transfer equipment now. So, we have this very posh system that holds it. And as I remove the fat, it's collected and kept safe, and then we're able to with a nice little roller pump, put it back in with a fat transfer cannula, so that we're in ... We always are hopefully going to be evenly distributing the fat. Of course, we're not in there with a camera looking at it, but you can feel it. And you're not applying extra pressure to push it in where you're trying to put it, which is ... When you use small cannulas, especially in scarred up tissue, you can extrapolate how that happens very easily.

Candice (14:38):
So, do you think it's because maybe the fat was damaged as it was going in there, so then it didn't have a chance to take, and then because it liquified it grew an infection? Or what do you think happened there?

Dr. Robert Whitfield (14:50):
I think anytime, you know, you described it, when you have a heavily scarred area, I'll just use the most extreme example as a scarred radiated area. If you release it, no matter how much you release it's still like a trampoline and then you put fat in there. There's only so much expansion tissue can have. And as they sat you up and looked, some of the areas didn't expand. I think that's probably a time to pause and reflect and say, "Maybe don't need to put more there. Maybe just need to release the scars it's been released in the past." Because that's the moment where I would probably change my tact.

Dr. Robert Whitfield (15:29):
I have these numbers that run through my head, along with the voices, and they tell me what I should do and shouldn't do over years of doing these. And I will stop as some of the best people in the world have taught me, is it will only expand so much and the more you expand it ... This is not lip filler. Lip filler and cheek filler is not dynamic, fat is, but it's also highly compressible. So, you can kill it and that will create more problems for you.

Dr. Robert Whitfield (15:58):
So, you get yourself into catch 22 when you add more and more fat. Many, many clients ask me to over fat transfer them in order to get them a better result. Which, if you just follow what I said, doesn't work, you can't. You only have so much tissue expansion and when you reach that, I mean, you stop. Doesn't matter how much fat you have, that's not the point. The point is to safely transfer that. So, although I think there's a lot of very qualified practitioners. I would not say it's always that easy to get that and know when to stop. I think that's just something I've been fortunate with over time. I've done so many of them. I know by tactilely, how it feels, how it looks. If you see the skin get peau d'orange in it, you know it's time to be done.

Candice (16:53):
And from my understanding, in order to avoid fat necrosis, or oil cysts, or things like that, and I may have those, I'm not sure. After explant, there was areas where I felt like maybe fat got ... or breast tissue got stitched in a weird place close to the scar. And luckily, I had a baseline ultrasound before this procedure, so that I have that to at least have as baseline. And then I will do another one soon.

Dr. Robert Whitfield (17:26):
Well, she brought up some very good things. So, I get asked a lot, what's my take rate with fat transfer? How often do I get fat necrosis? How often do I get cysts? In terms of take, which is , you know, you want to say how much you have over time, I'll qualify it like this, between the ages of 20 to 30, you should be upwards of 80%. I'll highlight why I say that. So, fat works really well in premenopausal women. So take, for instance, one of my holistic mommy makeover patients, they don't want a tummy tuck. They don't want breast implants. They just want me to do body contouring to give them the best shape. They want to go from a four to a two and they want their breast size to improve. And fat is a very good tool, very good filler, and you can get really nice results. But you have to have the protective effect from estrogen and you have to counsel them on their diet, and they have to have hopefully a lifestyle that they don't smoke and drink, and have other issues that make it complicated for them to take care of themselves. Because all those things, you can have wonderful surgeons and nurses and anesthesia, and everybody can take really good care of you. But you mentioned it before, you have to take responsibility for maintaining their results.

Dr. Robert Whitfield (18:51):
Now, when you get into the 30s and 40s, depending on have you had children? Have you had some other disruption in your endocrine system? Have you developed food sensitivities? Do you have leaky gut? I mean, there's a host of problems that seem to develop quite quickly in the, we'll just say the 30s, and you can get yourself into a little bit of a pickle with those if you don't look carefully. And I will say, that people don't like you looking and asking them about these things, most of the time. They find it to be a little intrusive. But I basically lay it out like, if you want this procedure, this is why I asked these questions to get these results, which I feel are better than most.

Dr. Robert Whitfield (19:40):
And so, I think if you can get good results in cancer patients who basically have their estrogen blocked, which I did over a long career in taking care of cancer patients, I think in the healthy patient, you better dot your Is and cross your Ts and make sure everything's checked off, so that when you do that, you're giving that woman the best opportunity to have the result. When people say fat transfers don't work, I just say, "Really? Have you ever seen anybody's Brazilian butt lift?" Now, I will say in the breast, it's under a lot more influence of estrogen than it is your butt. Butt's different. In your butt, you could put a large amount of volume in and it seemingly does very well.

Candice (20:32):
What you said is profound. I don't know that many doctors and women getting fat transfer have connected estrogen with the breasts because I know some women who are like, "I'm eating lots of protein, I'm eating lots of fat." Because a lot of times they're told to eat a really high fat, healthy fat, but they're doing the fat bombs or it's coconut oil, and almond butter, and all of these things to really try to up their fat so that their fat keeps after their fat transfer. But if their hormones haven't been addressed, that is why ... That's making so much sense to me because I am on these fat transfer boards and they're like, "I did all the things I ate exactly what they said, but I feel like they went down a lot." That makes so much sense that it would be an estrogen issue.

Dr. Robert Whitfield (21:22):
I want to say, it's not just one thing. Maybe they did eat everything right. Maybe their hormones were close, but not quite right. We know providers who don't like the fact that I balance hormones as a plastic surgeon, but that's okay. I mean, my entire career has been taking care of really severely injured burn patients or cancer patients. And I can tell you for a fact, there's plenty of studies to show that wound healing is improved when anabolic steroids are used, of which testosterone is one of them.

Dr. Robert Whitfield (21:51):
So, when folks want to get on me about that, that's fine. I have broad shoulders, it's okay. If you take care of people long enough and recognize the patterns, understand your endocrine system as a female is very complicated, as you know, and the better position that system is in, the more comfortable I feel that you're going to have a good outcome.

Candice (22:15):
Right, and I know many women, me included, that when your body is in an inflammatory response and state for so long, that eventually for me it turned into Hashimotos, and for many women it does as well. Luckily, I've been able to balance that. I don't struggle with the Hashi very much anymore at all. I'm not cold all the time, also all of the other things that I had just not only from my implants, but that were thyroid related along the way that no one ever connected for me. So yeah, that's really, really profound to me.

Speaker 1 (22:52):
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 Holistic and Scientific Podcast is a production of The Axis, the axis.io.