Episode 20: Sunday November 1

Drs. Sam Jejurikar, Salvatore Pacella, and Sam Rhee welcome special guest Dr. John L. Burns, Jr, M.D., plastic surgeon. (https://drjohnburns.com/) Dr. John L. Burns Jr. is President of the Dallas Plastic Surgery Institute (https://dpsi.org/), one of the largest plastic surgery group practices in the United States. Dr. Burns is also the Medical Director for the EpiCentre Skin Care and Laser Center (https://epicentreskincare.com/), a world renowned medical spa.

"No Implant" (Fat Transfer) breast augmentation is increasing in popularity. This technique uses liposuction to take fat from other parts of your body and inject it into the breasts. We interview Dr. Burns, renowned expert in fat transfer breast augmentation, to discuss details as well as the pros and cons of this all-natural breast enhancement technique.

If you are interested in this alternative method of breast volumization, this episode is a MUST WATCH!

Full Transcript (also download PDF here)
Dr. Salvatore Pacella: [00:00:00] Hello everyone. Good morning. We're here. on our next podcast, it's Three Plastic Surgeons and a Microphone or 3plastic surgery podcast. Dr. Salvatore Pacella from San Diego and LA Jolla, California. My Instagram handle is. @SanDiegoplasticsurgeon. We have, Dr. Sam Rhee here joining us from Paramus New Jersey. He's @bergencosmetic. And we also have doctor of course, dr. Sam  from Dallas, Texas  @drsamjejurikar 
Gentlemen, how are you this morning? Doing well, 
Dr. Sam Jejurikar: [00:00:31] Doing great. Doing great. Dr. Pacella, how are you? 
Dr. Salvatore Pacella: [00:00:33] Fantastic. We're all doing well. I don't like. Got my coffee here. First thing in the morning here, it's not as big as your cup there, dr. Jejurikar 
Dr. Sam Jejurikar: [00:00:42] for all of our, for all of our, my cup has already been drained, but yet bigger. But for all of our viewers who have watched a lot of these shows before you'll know that a recurring theme, in all of our shows is the quality of dr. Patel is internet and. 
And we just wanted, I wanted to take this opportunity for about the first 20 or 30 seconds, just to get a state of the internet update from dr. Pacella and why it is, it looks like he is not. He's a he's back in the 1980s, dr. Pacella, let us know what's happening over there. 
Dr. Salvatore Pacella: [00:01:19] First of all, it's it's my own personal filter. It hides all the aging. 
Okay. Now I've had some struggles with my internet connection, the at and T and whatnot. I've tried it. Internet extender, not really working in and out. And then I think now that it's a little later in the morning, my kids are on their devices and stealing my bandwidth. I should just cut them off. 
Dr. Sam Jejurikar: [00:01:40] I think so. 
Dr. Salvatore Pacella: [00:01:42] Thank you.  
let's move forward here. I just want to give our show. Disclaimer, the show is not a substitute for professional medical advice, diagnosis or treatment.
The show is for informational purposes, only treatment and results. May. Very based on the circumstances, situation and medical judgment after appropriate discussion, always seek the advice of your surgeon or other qualified healthcare professional with any questions that you may have regarding medical care, never disregard professional medical advice, or delay seeking advice because of something in the show.
And with that, I would like to hand it over to, dr. Jejurikar in Dallas, to introduce our, our next podcast 
Dr. Sam Jejurikar: [00:02:20] here. Yeah. for our viewers, we're always trying to brainstorm on topics that we haven't talked about before and things that patients find interesting. And one of the things that we all see a lot in our own practice are patients that are looking for alternatives to breast implants.
there is, a growing movement out there. The, for women who want to have natural augmentation where they'll get breast augmentation, with their own fat and fat transfer to the breast is something that's still relatively new within plastic surgery. When I say relatively new something over the last 10 or 15 years, I think today we're really fortunate to be joined by one of the busiest fat transfer surgeons in this region of the U S and possibly in the U S entirely. And that's John Burns a little bit about John Burns. John Burns is the practice president of Dallas plastic surgery Institute, which I happen to be one of the partners of, so I am biased by my personal friendship and personal relationships with them, but I also see the board where we're we operate every day.
And the number of these cases that he's doing are truly astounding and truly more than probably, The other nine of us in the group times 10. So John, is a graduate of Vanderbilt university. He ran track in the SEC. He actually has the mile record in the, in the one mile at the high school that my kids still go to.
I think it was four 16 back when he was in high school, which he, which, think of Vanderbilt, he ran four Oh three off the correct me when he's on, he's still an elite level runner. he, runs in New York. Boston every year with his personal best time, two minutes and 45 seconds only plastic surgeon I know that actually has an endorsement deal with a shoe company. but beyond that, he's an incredibly talented surgeon. he is one of the, one of the nation's expert on laser. and in the last five years has really become at the forefront of fat transfer to the breasts. in addition to patients seeking primary breast augmentation, with fat, he also has an expertise in patients that are getting what are called explant removal of their implants and fat grafting. So with that, let's bring on John. 
Dr. John Burns: [00:04:22] Hey Sam. Welcome. Thank you for the introduction. Yeah. The only thing I really care about is running. thanks.
Dr. Sam Jejurikar: [00:04:29] Yeah. I was telling these guys before you came on the, the story of when you had a sacral fracture and I got an emergent. So I got an MRI that I ordered, for when he was having some back pains. And I got an emergent call from a radiologist saying your patient, John Burns has multiple fractures of his sacrum, which for the viewers out there as the lower portion of the table needs to be on strict bedrest.
And I called him and he was running in a pool. He was like, no, it's fine. I'm just going to not run on regular.
Dr. John Burns: [00:04:55] Oh my gosh. Thank you, Sam. I really appreciate it. it's fun to be here. I think you guys have a great podcast and it's been fun to watch you guys breaths. Is it quite an honor for me? Thank you. 
Dr. Sam Jejurikar: [00:05:05] thank you. the reason we, we brought John here today is to talk about fat transfer to the breast, which in all of our practices, it is something that we do, but it's probably not.
The number one, number two, or even one of the top five things that I'll see in terms of your practice, how many women do you think you're seeing per week that are looking to have this done train fat transfer specifically to the breast? 
Dr. John Burns: [00:05:28] Yeah, that's a, something that's really grown, exponentially.
I think that, and this day and age two factors have really driven, Sort of a, an awareness of, , which I think in the media. Has it been a bit over-exaggerated in terms of a risk factor and the fact that I don't know many people doing, textured implants to right now. I think that, I hope that we have a handle on that.
The other thing, being the concept of breast implant illness and where that is, I think it's a primarily internet driven thing right now, but. The science I think is lagging somewhat, but behind there, but, in my practice, there's just a huge demand for non implant based breast augmentation.
I would say that I do as many breast implants as fat transfers, so it doesn't dominate my practice completely, but it's been an important part and a growing part of my practice. And something that I've enjoyed doing. And I think that, as I've done more and more cases, I've learned more and more about the procedure and how to make it work for different types of women.
So with that being said, I think I probably did between one and 200 cases a year, breast augmentation with fat transfer. 
Dr. Sam Jejurikar: [00:06:37] Yeah. it's a remarkable number for sure. So one of the things that I always struggle with when someone is coming in and they're trying to. to, to inquire about breast augmentation, utilizing their own tissue, what their expectations should be.
let's say you're seeing a young woman or a relatively thin fit woman. Who's, an, a cup breast, relatively flat chested. What's realistic. if she says dr. Burns, I want to be two cup sizes, bigger with my own fat. Is that something that you can do? 
Dr. John Burns: [00:07:04] I say this to the patients, I say, there's two methods of breast augmentation, one it's implant based, and one is fat transfer based.
And I tried to get a feel for their expectations and what they want, if they want a round. Dynamic impressive volume increase. they're probably not going to be happy with fat transfer implants. I tell patients are reliable. They're reproducible. You have a 300 CC implant and you get a 300 CC results each and every time, the two things about fat transfer, number one is, the graph take.
And it's I find it to be highly variable. It depends on the quality of the donor site. Fat. A lot of the problem is that whether women who want fat transfer breast augmentation or rail sin, that's why they have small breasts. And so you have to be a really slick liposuction surgeon. in my opinion, not to give them contour irregularities, it's a very, it's a very big struggle.
And a lot of those patients, I have to turn away because they're too thin. not many but some, and then the recipient tissue, if they have a nice, solid B cup with a glandular tissue, I think that they're a much better candidate than those patients with a very tight skin on the lip of a small, a cup and very little breast tissue to graft into.
I hear a lot of talk, Hey graft into the chest muscle. I don't do that. I just graft into the breast tissue itself. and I think the results, and on a great case, I might get two cut sizes on the very. Average case I'll get one. And if I'm lucky, I'll get one and a half cup size increase.
It's a much different look to, I think patients need to understand, they're not going to have a leather upper pole fullness. They're not going to have a lot of cleavage. It's a way to augment their natural breasts. If you take what they have, you add a stick liquid of which about, 50 to 70% will take.
and that's the result that they're going to get. One of the things I have to talk to patients about is, post fat graft, expectation four days after surgery that they think you're awesome. they think, sorry, Sam. 
Dr. Sam Jejurikar: [00:09:10] Oh, I'm sorry. 
Dr. John Burns: [00:09:11] You have fluid. You have fat, you have swelling.
You have an amazing looking breast. I say, wait a month and then take a mental picture of yourself for the month. And then you'll lose it by the third to a half of that over the next six months. And that's the realistic expectation. Jeff. 
Dr. Salvatore Pacella: [00:09:28] John, why is, why do you think there's such a push towards injecting fat into the muscle itself? What are your. What are your thoughts on that? What's the controversy, 
Dr. John Burns: [00:09:38] I think it's better blood supply probably. I think the muscle itself in most women is fairly Ken. and I think he risk, puncture of the, of the long, if you're really aggressive with it, this is a blind procedure.
It's just like fat grafting to the, you think you're above the muscle, but who knows? 
Dr. Sam Jejurikar: [00:09:56] two questions. one, there are a lot of surgeons out there that advocate pre expansion of the breasts. Before you do fat grafting there, their rationale is that the breast skin envelope is pretty tight.
So they'll put patients and, special suction bras for the viewers, like a Bravo bra or something that's been used quite a bit. Do you do 
Dr. John Burns: [00:10:15] that? Yeah, I think it's a, probably a fair app. I think it would help. I think I spent some time with Tom Baker. I think that was his idea. way back when, it's a really tough device to wear it.
It's uncomfortable. It's awkward. You really add where it, around the clock for a long period of time, it's very expensive and very hard to find it. You just can't. I have patients on Amazon they're trying to find it. I think, from a practical standpoint, I've had a rather trouble finding these devices.
so much so that I don't think it's practical to place patients at them. The other thing is just ease of use. you've got to do this for a significant period of time to get it stretched, to get the skin envelope in the muscle. So I don't know. I don't use it in my practice for ver very often, unless a patient is motivated and their sounds whine and they really want to do it.
Dr. Sam Jejurikar: [00:11:12] What about multiple stages as you find that you have a lot of patients in your practice who you're doing repeated operations on to achieve their desired volume? 
Dr. John Burns: [00:11:20] Yeah. No, that's, I'm probably different in that regard. I think probably at least half, if not two thirds of my patients are from out of the state, they're flying in to see me.
it's a very expensive to come in and have surgery and then go home. And I can't imagine them having to come back three and four times. I think your best shot is your first shot. I think once you've done the best you can do with every subsequent operation there's less and less. bang for your buck, so to speak.
So the vascular beds is going to be the most robust, I think, in the first operation as you place fat, the fat becomes, vascular rise to a certain extent. It's probably not as vascularized as fat, or as the breast tissue. initially was. And so to ask a patient to come back four or five, six times put in a hundred seats, you seize any at a time.
I don't think that's practical. Although, in a dream world, maybe that's better. at least at my practice, I would say my reoperation rates probably around 5%. The other thing you have to think about is how much fat can they dump, once you, if you've given and I'm your best shot, and you're going to get 800 to probably 1600 CCS.
Of liposuction aspirin. Once you drain off the fluid, you have about 802 years on most patients, they come back a second time. I don't think you're going to get that. You're going to get half of that. So you're not going to get the same operation. Yeah, I have a question for you. 
Dr. Salvatore Pacella: [00:12:48] in my practice, I do quite a bit of a fat transfer for breast reconstruction, after an implant exchange say, and, rippling over the top of the implant.
Prepec and invariably I experience. on occasion, some issues with fat necrosis. I, I may have probably less than, I don't know, maybe 20% of patients may develop some fat necrosis and  it's oftentimes a, A big, concern with, the oncologists and the primary care doctors, obviously have a breast cancer patients.
they present with a lump, I would usually order an ultrasound and determine that it's not, not a cancer per a lump. So I was just curious your experience with fat necrosis, your workup after the fact, what do you tell patients? 
Dr. John Burns: [00:13:32] Sure. It's a great question.
Post-mastectomy fat grafting on top of implants. That's a great procedure. but you're right. fat necrosis is a real thing. it's just a goal for all of us, especially for a guy like me, who does a lot of that. I used to use, more concentrated fats with that graph.
one of the great things about being a practice with a big group as we watch each other work. And one of the things I watch, Sam has a massive. Fat transfer gluteal augmentation practice. And so some of the equipment Sam, brought to the practice and used I've embraced for abreast when one of those being the Wells Johnson, system.
And so it's, it's a way to harvest that and then you can pull out this much fluid, and as I've done more and more, I've used a more dilute, fat transfer product, so to speak, it goes in much easier, but that was using a more concentrated product. Like for example, the evolved SIS system that fat's pretty concentrated and it's, you don't exactly get it in the right spot.
You over graph a certain area. I think you're going to get some fat necrosis there. it's too concentrated. It's too. it's too thick. And so I think when we have a more dilute fat. and you overexpand the breast. Once the fluid dissipates, you have a much more even distribution of fat. So that's helped me a lot, but I tell my patients, I said, you have to expect some level of fat necrosis.
It's not a hundred percent. Absolutely. But I want to prepare them for that. And they have to understand going into the per procedure that they moved there, that they very well may say, you know what? There sounds. MRI scans and even biopsies to clear up the issue. I think it's very similar to the issue of capsular contracture with breast augmentation.
it's an unfortunate side effect that we all say, and with fat necrosis, it certainly confuses the issue on screening. So if you have a patient that has a very strong family history and they're very reliant on screening, I don't think that's a good candidate for a fat transfer.
Dr. Sam Jejurikar: [00:15:35] what I'd like to do is I'd like to share some before and after pictures, which I have from, dr. Burns his website, just to talk about its approach. I can find it where it is. Okay. are you seeing this right now or? 
No? technic. Oh, there we go. Oops. no, I want to do that. Okay. Hopefully you can see dr. Burns his before and afters. Can you see these?
Yes. Okay, perfect. 
Perfect. So John, this is, an example of a case that I got, and was really impressive, that I got from your website that, Basically is showing a woman that's reasonably flat chested doesn't appear to have any sort of previous history of implants at all. who clearly is thin doesn't have a lot of fat excess on her.
Had I seen this patient, I would have told her she was not a great candidate for a fat transfer, and I would have discussed doing a breast augmentation with an implant. But this is a really impressive result. This is a, almost a two cup size enhancement, if not more. So in this patient, talk to us about what the breast feels like, how much volume you put in, how far post offices and just your approach to this case.
Dr. John Burns: [00:16:44] So this is a. On the far and on the end of a spectrum, this would be a more difficult case. And so if I saw this patient today, say you're a better candidate for an implant than fat. She was adamant that she did not want an implant. She was willing to accept, whatever result that can get for her.
on 10 patients, I think you have to do a technique called scamming where you just basically, liposuction on a deep plane level. so you're not near the skin taking fat as best you can from the abdomen. The love handles the back, the arms in a circumferential thighs. And so with this particular case, I think I was able to get about 420 CCS.
I looked it up last night, of graphable fat. Of that, there was some fluid in there. this is her six month, results. I was pleased to get the take that I got. I don't think I could get this every single time to be perfectly honest with you. but yeah, you look at her lateral, she's not, you didn't have the upper pole fullness that you'd probably see with the breast implant, especially a higher profile implant.
And I certainly don't think she has. as much cleavage, but, the skin on the lip was nice. it held tight and, I think she's going to have a, she was happy. So 
Dr. Sam Jejurikar: [00:17:59] yeah, this is, yeah, this is a fantastic, very natural result. What does this feel? Does breast feel like, does it feel soft and supple or is this a big ball of fat necrosis?
Dr. John Burns: [00:18:10] I think if it was a ball of fat necrosis, you would definitely see dumpling of the scan. it's it. It's gonna feel like that. It feels softer, I think, than a regular breast would probably seal. my best guess is she's probably got a few, hard areas, almost like a fibrosis stick, a thing where some of the fat may have gotten hard.
I can't remember exactly what hers, but they typically fat transfer breast is going to feel much different than an implant. If you don't have the solid, you've got a more squishy spongy feel to it. 
Dr. Sam Jejurikar: [00:18:42] Yeah. And then, sorry. 
Dr. Salvatore Pacella: [00:18:44] how long would it take for you to do a case likethis versus how a primary?
Just, 
Dr. John Burns: [00:18:50] yeah. When I first started doing a lot of these, it takes, it took about four hours. I probably could do this case in about an hour and 20 it's quick. I think speed. I think it's, I don't know. Not, I don't want to say speed. I think efficiency is really important. Yeah. I think the longer the fat is out of the body, the worse, your results.
And I see a lot of guys, six, seven hours to do a fat grafting case. And I really wonder, how much of that fat sitting at room temperature exposed to the air is really viable. 
Dr. Salvatore Pacella: [00:19:24] And for our viewers, how long is a. Is an average breast augmentation. If you were to just use implants in a patient like this, want 
Dr. John Burns: [00:19:32] maybe 30 minutes, something like that.
Dr. Sam Jejurikar: [00:19:36] Yeah. 

Dr. Sam Rhee: [00:19:37] I think it can't be understated how you have to be good at liposuction in a thin patient like this, Dr. Burns said in order to get fat from all of these areas enough without causing issues, as you mentioned before. So that's, that also is a skill that is, that can't be understated.
Dr. John Burns: [00:19:55] It's really tough. And I think that, the smaller calculus I've got, I'd love to know about Johnson. I don't mean that. Via Homer for those guys too much, but that they have a cannular that has no section port on the backside. So you can turn the camera. I said so that you don't have the section tort facing the skin.
And then I think, multiple passes, but very deep, on I'm these patients. Yeah, but it does hurt because you're close to the muscle. you're not close to this gun. And I tell the patients, I say, Hey, you have to be willing to accept a divot here or a divot. There you are.
So Stan, I'm going to do the best I can, but, postoperative lymphatic massage, and thermology helps. I keep them in garments a little bit longer. so there's some things there too. That's 
Dr. Sam Jejurikar: [00:20:43] great. Yeah. I think this is a remarkable result and I couldn't agree more too of the need to go quickly to get that fat back in.
I think that efficiency that you're showing contributes to how good your results are. So the next one, another, hold on another, case, which I took from your website real similar to the first one in terms of just a much more, of a, enhancement than I think I could've achieved in one stage and when I'm really drawn, but to this one is the upper pole fullness that you have in this patient as well.
this looks, if you were to tell me that this was a moderate profile or a moderate plus profile, Result, I would believe you. So how are you able to do this in a case like this? 
Dr. John Burns: [00:21:23] I have to say that the same goes for the other. I think on the, the wider will you have her, Probably more upper pole fullness that I would typically expect.
I think I grafted her. I think I put in, I tried to look last night. I think it was a 450 CC per side case. occasionally if the upper pole is not giving way, I'll use a pickle fork and that, and I'm able to expand a little bit better. And the upper pole, I think you have to be careful doing that there, that you don't create dead space.
And then you graft into the dead space. thank you for picking my best cases.
We always like to show the best rounds, but we rarely get to pick. So thank you for that. But I think that's it, a better than average results for me. Definitely.
Dr. Sam Rhee: [00:22:14] I know that we talk about, diet after in terms of, Fat grafting, especially for a Brazilian butt lifts. do you do anything specific with them in terms of, managing their diet afterwards?
Dr. John Burns: [00:22:25] I think long term, five, 10 years down the road, everybody has a fit physical elastic set point, and I think we're all gonna find our way back to that weight, whether we diet, exercise or not. I think the don'ts are more important than the do so I'm not real big on diet. I'm real big on net smoking.
no diet pills, no. amphetamine based, things. there's weird things that people do to, one of the hot things and the X client world is infrared saunas. So I had several patients do that and lose considerable amount of fat during these infrared saunas. I think they're like 140 degrees and it just it's supposed to melt fat and I'm sure it did.
the other one is cryotherapy. and so a lot of these patients, for inflammation purposes would go and get cryotherapy. I don't think that's good for a fat graph either. the fruit. So quote unquote, freeze the fat. there are some things that people do that I don't. I don't ask them to do.
I think there's some people that believe in, hyperbaric oxygen therapy, posts, fat graft, and I think that's probably a waste of money. I don't know that would have a real significant impact. but those are the don'ts. and I just asked them to maintain a stable weight. and don't do anything stupid, do a fasting diet, for example, or a keto diet or some, something like that.
I just tell them to enjoy their life. 
Dr. Sam Jejurikar: [00:23:51] I think those are all great bits of advice. I want to just, work we're coming close to the end, but I do want to show a couple of explant cases because this is a common case that plastic surgeons will see now, patient who comes in, who has breast implants in place, and either.
Past symptoms of breast implant illness, a fear of breast implant illness has something, a capsular contracture, which to our viewers is basically pathologic, scar tissue build up around the implant. But the bottom line is they want their implants out. They don't want implants back in and they want to have fat.
And this is a difficult operation. Cause one of the things you had mentioned before when you were talking about using a pickle fork is not creating dead space. And to our viewers dead space is basically a large cavity. That won't support fat. If you're injecting fat into this area and it can ball up and turn into fat necrosis.
So I struggled with these cases quite a bit to get an adequate volume of fat. Into, into the patient. So talk to me about, what's different about this case versus a primary restaurant mutation, what steps you might take differently, the order in which you might, you might inject fabrics taking out the implants.
If you think it's important to take out the entire capsule, what's your basic philosophy of this sort of case. 
Dr. John Burns: [00:24:59] Yeah. so I do a lot of these cases. you have women that come in and they have breast implants and they want their implants out. And I think one of the devastating consequences of an exploiter and that's what happens to the skin post-docs and.
What typically happens if you have a positive tissue in the lower pole will tend to stick down. It's hard to get that muscle back to its original insertion point. They're usually subpectoral implants. And so you have a sort of a window shading effect, and then you have the breast, without.
Much tissue that we'll hear to the chest wall. Once that process occurs, it's extremely difficult with the fat transfer further re-expand that skin on the lip. And so I've developed sort of a technique for fat grafting, the immediately postdocs plant and people think. There's a lot of different opinions on that.
most people I think would not fat graft immediately, but for me, the advantage is that you already have a skin uncle up in the shape of a breast implant. So in my mind, what better time to create a beautiful breast that when the skin is in that shape, because once it scarves down, you have a really tough challenge ahead of you.
And really the only way to do that is to create dead space. Again, because you have to release that scar tissue. in this case, you, most of these women also are going to want a capsulectomy, with the operation. And XPLAN capsulectomy first, what's you're left with I go ahead and close the incision.
I tried to recruit some tissue if possible to the lower pole. I typically will make a, a more dilute fat transfer. ask her at. in these cases, what I'll do is as a close first. And then I'll take a medial approach and then I'll take the fat and I'll thread it first suit through the, the subdermal plane.
It does expand the tissue. it's a very odd, but it's almost like a sponge. So as you expand the tissue, you can start grafting deeper and deeper into the breast. I'm creating new spaces and you can certainly feel it's a very tactile operation, but you can feel when you've punched through and you're in that dead space where the end used to be.
when you're in the wrong space, you take your foot off the pedal because you certainly don't want to fat graft and into the space where the implant was. I used to loosely close the breast to, use a three point Vicryl pop-off to put the breast back onto the chest wall, but because I've, as I've done more and more cases, I'm just able to grasp.
And to the breast itself and expand the breast, above the muscle. when you're in the upper pole, it's much easier because you have the pectoralis, you have the breast gland and the scan, so that's in much easier expansion. I think the challenge in these cases there's really, 
Dr. Sam Jejurikar: [00:27:52] yeah, that's our, Really a, an interesting approach, and the results speak for themselves.
This one last case, real, similar to the previous one, just very impressed with the natural assault and how much expansion of the lower pole you're actually getting. 
Dr. Salvatore Pacella: [00:28:05] John, John, I have another question for you. so do you have, so tell me about your experience with, doing an X plant.
Potentially doing a mastopexy and fat transfer at the same time challenges related to the skin flaps and, placed plain of the 
Dr. John Burns: [00:28:22] fat. Yeah. That's a scary operation. it's not necessarily, always the fat transfer part that's the challenge. So you go to X plant, you need a capsulectomy.
Yeah, the stern woman, you really worry about blood supply to the nipple. So I think the question is where do you get your castle out? So I do an inferior pedicle. I raised my flaps, basically between the subcutaneous fat in Nebraska, and then I basically split the pack. And so I, I leave the pectoralis muscle as much as I can.
Attached to the breast itself. And then I peel it back, to expose the capsule. And then I take out the capsule. I used to do it where I cheated on either side of an inferior pedicle. And I went from inferior, after several rounds of nitro paste on some patients, I just, it was too much stress.
I always repair the pack, once the capsules out. So that's my approach now. So once you're closed, then I think that the, I either do a secondary fat transfer because, there's just not much space in there. or if there is, I graft into the, if I had a real solid blood supply, you can just look at the nipple and see if.
if you feel like the blood supply is great, I'm very gentle, but I will graft into the pedicle. and then I'll graft into the upper flap. If I have a nipple that, that looks dusky or it's compromised in any way, I will not graft into the pedicle and I'll just graft it into the upper part of a flap.
and I'm more conservative when I grasped on a taxi than when I grasped and. and to abreast. it's a scary operation. It's something I do not infrequently, but I go home, sweating a little bit on those cases. great question. 
Dr. Sam Jejurikar: [00:30:15] Yeah. I'm, I speak for the other tunes.
I really impressed with the results. And I've learned quite a bit from this John. So thank you for taking some time out of your schedule this Sunday, and showing us these cases, and explaining your approach that transfer the rest is here to say it is a huge thing with patients. And I think we all have a lot to learn from you.
So thank you for spending time with us. 
Dr. John Burns: [00:30:37] Thanks guys. Yeah. 
Dr. Sam Jejurikar: [00:30:40] All right. Bye everyone. Take care.