E184: Breast Implant Illness and MCAS with Breast Surgeon Eva Nagy, MD as part of the Mast Cell Matters Series

Episode 184 January 02, 2024 01:14:31
E184:  Breast Implant Illness and MCAS with Breast Surgeon Eva Nagy, MD as part of the Mast Cell Matters Series
The POTScast
E184: Breast Implant Illness and MCAS with Breast Surgeon Eva Nagy, MD as part of the Mast Cell Matters Series

Jan 02 2024 | 01:14:31

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Hosted By

Cathy Pederson Jill Brook

Show Notes

Dr. Tania Dempsey interviews Dr. Eva Nagy, a breast surgeon experienced in all sorts of breast surgeries, who has developed special interest and skill in treating breast implant illness (BII), which she believes can be related to mast cell activation syndrome (MCAS).  Dr. Nagy describes BII, how she removes problem implants, and the effects this can have on a wide range of symptoms.

You can learn more about Dr. Nagy and her practice here.

You can read the transcript for this episode here: http://tinyurl.com/potscast184

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Episode Transcript

Jill Brook: Hello Mast Cell Patients and lovely people who care about Mast Cell Patients. I'm Jill Brook and this is Mast Cell Matters where we go deep on all things related to Mast Cell Activation Syndrome or MCAS. We are here with our wonderful guest host Dr. Tania Dempsey, Mast Cell Expert, Physician and Researcher Extraordinaire. Dr. Dempsey, thank you for hosting. Who is our guest today? Dr. Tania Dempsey: I'm so thrilled to be here and I'm thrilled to have Dr. Eva Nagy here with us today. This is going to be an amazing conversation. Dr. Nagy is a, a plastic surgeon over from over in Australia. And I'll give you a little bit of her bio. After obtaining her medical degree from the University of Melbourne, Eva's medical career began in Melbourne and Singapore. She subsequently began formal surgical training in Sydney and completed rotations in various hospitals around that area. Upon completing her training and becoming a fellow of the Royal [00:01:00] Australasian College of Surgeons, Ava embarked on subspecialty training in breast surgery. These stints saw her receive comprehensive instruction in advanced surgical techniques relevant to breast conditions in North Sydney and in various areas. Actually, a class leading Breast Cancer Treatment Center in the United Kingdom. Dr. Nagy's professional interests include advancing the use of breast conserving surgery, lumpectomy, for patients where mastectomies are not a necessity, and the use of reconstructive techniques to help restore appearances after cancer surgery. She's continually mindful of patients emotional well being and quality of life when discussing treatment plans and always ensuring that patient health is never compromised. She is she has a incredible She has an incredible resume of, of degrees and she is really passionate about breast implant illness and its connection to Mast Cell Activation Syndrome. That's what we're going to talk about today. Thank [00:02:00] you for being here, Dr. Nagy. Yes, Dr. Eva Nagy: for a long time. Good morning to me, good evening to you. I Dr. Tania Dempsey: coordinating the timing, right, was not, it was not easy, but thank Dr. Eva Nagy: know we got there in the end. Dr. Tania Dempsey: We did. Thank you for being here. So, so let's let's get started and talk. I'd love, I'd really love to hear more about your work as a breast surgeon and the types of issues and problems that you're typically seeing patients for. Dr. Eva Nagy: So my background is actually in general surgery. So I went through general surgical training and then over time I realized that really cancer surgery of the breast is being revolutionized. And whilst in the past it used to be all about mastectomies and axillary clearances, at that time when I was a registrar I had no interest in it whatsoever. I thought it was a very barbaric way of doing things. Prognosis was really poor. And I thought I don't really want to be part of [00:03:00] that. And then over time oncoplastics came in. So a way that we can actually preserve the remainder of the breast reposition them and use local flaps around the breast. So whilst, you know, the mastectomy rate for in Australia is probably about 40 60% the further you go out into the regional centres, the more mastectomies there are. My mastectomy rate is about 12%. I'm really, I really dislike mastectomies. I think, you know, cancer always trumps and when we have to do it, we have to do it. But we know how good breast conservation is in terms of psychosexual function, how we view ourselves, the pain tolerance, getting back to work, you know, it's so far better. And we now realise that breast conservation is far better with mastectomy than with any form of reconstruction, whether that be implant based or even autologous. And we also know the way that we do it here in [00:04:00] Australia is that breast conservation plus radiotherapy is equivalent to having a mastectomy in terms of recurrence and overall survival. And there's actually data now coming out to say that if you have breast conservation with radiotherapy, your local recurrence and prognosis actually, so local recurrence is lower than if you have a mastectomy, and prognosis is higher because you have a sterilization with the radiotherapy. So a lot of people are worried you know, I've had cancer, I don't want to have it again, I'm going to have mastectomies, and you know, in that instance when you have a diagnosis, it's all panic stations, and you feel very much in limbo, everything goes really fast, and you don't think, well what's going to happen in five, ten years time, you're not thinking like that. And there's no real correlation what you do in the breast, in terms of overall survival and longevity, if you get the cancer out. So as time went on, and I did my fellowship in Nottingham, [00:05:00] they're very pro conservation. We would see about 3, 000 patients a year, operate on about 1, 000. Most of them are NHS patients or public patients. So, you know, I as a first surgeon did well over 1, 000 patient cases. And so you get very used to how far you can push the breast. So the patient that I had the other day, she had a 9cm cancer, big enough breast to do a breast reduction, so we took out the cancer, reshaped her, she had a breast reduction at the same time, and she's you know, really happy because she always wanted a breast reduction, and now she got it all in one, and you know, if we can put a positive spin to it, that's great. So as I got back and I started to do those type of surgeries, there was a whole niche of women that came out. It was about 2019 and this Facebook group came out talking about how they feel that they're sick because of their implants. [00:06:00] And you know, as doctors we're always told implants are great, they're inert, you can't have any problems with them. You can do them cosmetically or corrective surgery, reconstruction. So, it was news to me that all these people could potentially get sick and I had my first patient and you know, you always remember your first patient as being the highlight and she was so sick, so, so sick. She lost her job, she couldn't function she was a single parent looking after her child. She looked to me when she walked into my rooms like she just went through a chemo. She was skinny, she had lost her hair. Not all of it, but patches were coming out, rashes gut disturbances. I thought, what on earth is going on here? So, of course I screened her for everything, came back with nothing. I said, well, you know, you want your implants out, why don't we do it? And so she had her implants removed, we did an en bloc [00:07:00] capsulectomy, which is really important, we'll talk about why later. Fixed her muscle, because it was under the muscle so we have to repair that, did a little lift for her to make her look normal, because she was only 35 years old, she's not old. And she was, she had such brain fog that she kind of forget what we were talking about just 10 minutes previously. So anyway, we did the operation, I went to do the rounds the next day, and I walked into her room, and I swear I nearly did a double take. I didn't kind of recognize her at first because she was sitting up in bed reading a book. And she hadn't been able to focus on anything. Books, or television, or anything. And I said, oh my gosh, you're reading a book. And she goes, I know, and I've read like three chapters this morning. I haven't been able to do that in years. Her bloodshot eyes were gone her fibromyalgia was improving, so she would have very stiff joints. She was moving freely. And I thought, can this be a coincidence? Can I [00:08:00] really, can we do something so quickly and so beneficial? Is this sort of, supratentorial is what we get taught in medical school. I said, well, she's better anyway, that's a good thing. And we did the two weeks, three months, six months, nine months, she's back working, she's living her best life. Okay. So that's N equals 1. You know, that's, you can't really publish anything on that one, one patient. And then the second one came in, and then the third one came in, the fourth, and we've done well over 100 now. And the story stays the same. People just generally get better. And the more I delved into it, I interestingly I went to a dinner, a fellow medical oncologist dinner, he was turning 50 and I was seated next to him, a lovely GP, and she was talking about her work and how her and her husband, who's a cardiologist, they delve into POTS. And I said, I've kind of heard of it, but I don't really know what that is. And she was [00:09:00] telling me all the symptoms that they get. And I said, hang on a minute, your patients sound exactly the same as my patients. What is going on with yours? And she was talking, talking, and she goes, well yeah, this is what I'm really interested in. And so we parted ways and she was really lovely. And then she texted me a few days later and said, hey, there's an MCAS podcast. Or MCAS conference an online conference with Larry Afrin. I hadn't heard of Larry before. And I said, okay, well that's really nice. And I had a look at the program, and I said, I'm on it. So as soon as I got it, I, you know, put up my reservation. I said, yep, all good. So I spent the Saturday listening. I had company that evening and I thought, sorry, you have to wait, this is so amazing. And I thought, oh my gosh, maybe my patients have MCAS. Because that would make sense. Because it's a very fast on, fast off thing. You know, as soon as you remove the foreign substances pathological, they get [00:10:00] better relatively quickly. And so, um, I was doing more patients, operating on more patients, and then I went to SABCS, which is San Antonio Breast Cancer Symposium in December last year. And Larry and yourself, you're, you're located close to New York, and I was visiting my sister in law after that, and I said, oh, can we please catch up? And you were so lovely, and we all went out to lunch. Dr. Tania Dempsey: That was, that was a very lovely Dr. Eva Nagy: It was lovely, it was so nice. And I think I just bombarded both of you with like a million questions and I was like a little Dr. Tania Dempsey: It was great. It was great, we loved it, because you're just the way you were thinking about it. It just, from a surgery perspective, right, a surgeon who's doing that kind of work, but thinking the way you were thinking, I mean, very impressive. Blew us away, Dr. Eva Nagy: Oh, so my background is in research actually. I've got a PhD in Short Bowel Syndrome. So my, my brain is kind of geared in a non surgical [00:11:00] way I guess. All of my past is sort of physician so, and research based. I love doing research. And so I just bombarded and I was flooded. And before I knew it, hours had gone past and I said, Oh my gosh, I can't, I don't want to leave. I want to learn more. Um, but I had to let you go. And so we had the MCAS Down Under tour and we presented in Queensland and Sydney, and then Larry went on to Melbourne and it was just like minded people coming together. And then I started to realize, okay, I think there's something really big going on here and it's not just an isolated thing. Because we know that probably about 17 percent of the population have something wrong with their mast cells. And the way that I describe breast implant illness to my patients and I kind of get down to the core of it. I say, right, so evolutionarily we're geared up to protect ourselves. Okay, anything that's foreign to us, bacteria, [00:12:00] yeast, mold, virus, synthetic materials including silicone. We just don't want them in our body. Okay, that's foreign. Get rid of them. So you have an immune system that goes and attacks these things, tries to get rid of it. When you have a substance that doesn't want to go, your immune system ramps up, gets a little bit crazy and goes too hyper and starts attacking your own system. And that's when you started to get the systemic type of symptoms, where your immune system gets confused and starts attacking you. So once we have that sort of foundation, then we can start understanding what MCAS is. So mast cells are really important cells in your immune system. Do you guys have a game called Pac Man? Did you ever have Pac Man in, yeah? So it was big in Australia in the 80s, I think. And so mast cells are like Pac Man, okay? They go along and gobble things up. And when they gobble things up, they release substances, and everyone has probably heard of [00:13:00] histamine. Dr. Tania Dempsey: Right. Dr. Eva Nagy: you know, when you have a pollen, and you get hay fever, and you're itchy eyes, and you're runny nose, and you take an antihistamine. Okay, so we're kind of really familiar what histamine is, but can release many, many substances, hundreds probably, of interleukins, and thousands cytokines, and interleukins, and pro inflammatory stuff. And so, when it works well, and it does its job, it's really important. So think, think of a mosquito bite, right? So you have a mosquito bite, the mosquito injects a little toxin into you, you get itchy, and red, and sore, and swollen. That's the histamine acting locally. What it does is it activates your nerve to say, oh, oh, something's wrong. It dilates your veins, your vessels, and becomes really permeable. To increase the blood supply to the area, to bring in white blood cells, and kill any infection that's there. And then once it's all resolved, it's all well and good, it goes away. [00:14:00] So that's when it's doing its job properly, super. Now there are some people whose mast cell is a little bit hyper, too crazy, okay? And when they sense something that's really not part of us, it will release too much histamine, too easy, too frequent, too much. And if you have a look at where mast cells are, they're in the interface between the environment and us, which is a good place to be, in our nose, in our gut, in our mouths. So if we have anything from the environment, these are our front guys to say, Oh, I'm going to gobble it up like Pac Man and make sure it doesn't get into our system. But actually they're also sort of interlocking between nerves and blood vessels. So when you release histamine, the histamine can directly act on nerves. And it can also go into our bloodstream and circulate throughout our body and this is where we start to get systemic symptoms all over our body. So your hair falling out, you get rashes and migraines and [00:15:00] gut problems, chronic fatigue, fibromyalgia. Anything and everything you can possibly think of you can get a symptom for. And this is the problem with Breast Implained Illnesses, it doesn't fit into any type of box. A good, nice, medical box where we get taught in medical school. And if it doesn't fit into any box, we kind of say it's the patient thing. We don't get it, it's probably in their head. They're thinking of something, they're too anxious, they're not sleeping properly, go exercise, go see a psychologist. And we kind of victimize patients over time because they start to believe that they're crazy. So we have a huge duty of care to these patients that say, no, no, no, no, actually it's not in your head, just because it doesn't fit into any box, you actually genuinely have an illness. And probably what you have is a baseline of MCAS, and if you go back through a thorough history, and you know, even though we're surgeons, everyone thinks that we like to just cut, cut, cut, you have to go [00:16:00] back and do three quarters as a physician, and one quarter as the surgeon, and say, tell me all about your childhood, tell me what rashes you had as a childhood, did you have asthma, hay fever, what about your gut, do you have sensitivities in your food that you're having? And then you start to realise there's probably a syndrome. The more that I start to ask questions, there's actually a syndrome that's becoming part of it. It's not just MCAS, that's where your POTS comes in. So they, I said, do you stand up, when you stand up, do you feel dizzy, do you feel like your heart is racing for no reason? Oh yeah, yeah, yeah, I've had that since I was young, but it's really getting worse. Alright. Are you a bendy type of person? Yeah, yeah, I can do, put my fingers this way, that way, I can put my leg above my head. You know, I used to be more when I was younger, but not as much now. I'm like, yep, yep, that all fits, so that's hypermobility. Or if they say, yeah, my kid's got Ehlers Danlos Syndrome. Okay, well, [00:17:00] yeah, you've got connective tissue then, right? And so what about what is your surgical history? What surgeries have you had? Oh, I've had like five laparoscopies because I've got endometriosis. Like, oh, that's fascinating. And you've got PCOS as well. That's also fascinating. And what about your gut? Oh yeah, bloating, cramping, anything I eat, I'm just, I'm not good, I'm on gluten free this, and low histamine that, and FODMAP that, I don't know what's going on. Okay, so, they've got IBS, which is the most nonsense term. I hate the word, or the description of IBS, because it doesn't mean anything, it just means we don't know what it is and we're just going to label it some nonsensical term. But you probably have MCAS and it's affecting your gut. And then ADHD type symptoms. And I call it ADHD type symptoms because I'm not sure if it's true ADHD. I think because the mast cells are so close to the nerves, they're acting on it with histamine, I asked them, so you've been on Ritalin, [00:18:00] has it worked? And they said no it doesn't really work. So I think it's sort of like a an ADHD like symptom. As opposed to true to ADHD, and it tends to get better once we sort of calm down those mast cells by removing the implant. And the only way to do that is to remove the trigger. We can dose you up with antihistamines and things that suppress your mast cells so they calm down. Unless you remove the trigger you're just not going to get better, which is why it's really important to do the surgery the way that we do it. Dr. Tania Dempsey: And so, let's talk a little bit about, I have so many questions, but I want to talk a little bit about the surgery because I do understand how important it is and so tell, tell us a little bit about how you go about doing it. Dr. Eva Nagy: Okay, so what a lot of people don't understand is when you put them in, it's a very simple, straightforward surgery, day surgery, 30, 40 minutes, 60 minutes, you're up and out, right? [00:19:00] But when you put in an implant in a petite breast, you are now distorting the anatomy, okay? So that's the first part of it. You've gone from probably an A cup, you put in a 300cc implant, you've gone on three cup sizes, so you've stretched your breast, you've stretched your skin. It's throwing a bomb into a house and it explodes and then you say to me, fix the house and I want the house to look exactly the same as it was before. Okay, so now you're talking about reconstruction. So I always tell my patients, don't think of this surgery as cosmetic surgery, this is now reconstructive surgery. So, I mean that's the cosmesis part of it, but the even though it's not cancer, I look at it as an oncological surgery. So any, any time we do surgery, we want to remove pathological tissue. And you know, even if we have a mole, don't just cut out half a mole, even if you think that it's [00:20:00] benign. You cut out all of it. And that's the same with cancer. Whatever it is, surgically, we want to remove pathological tissue. So I don't understand the concept of just removing the implants. You can have a really tiny scar, you open it up, you pull it out, 15 minutes you're done and dusted, but we know for a fact that there are patients who have implants that have gel bleeds who have silicone left behind in the capsule. So we did an audit on our patients and about 70 percent of them will have silicone in their capsule even if their imaging is plumb normal. And that's ultrasound, mammogram, MRI. No matter what sensitivity we look at, you can't see small amounts of leaking gel that comes out of it, that comes outside the implant and is housed in the capsule. Now the capsule is the scar tissue that forms around implants. Everybody gets it. It's a variable thickness.[00:21:00] But 70 percent will actually have a leakage of some kind without a rupture. So think of it like a teabag. You look at the teabag, looks all fine and well and good, you put it in the water and it leeches out. So something like that. And that can happen very early, you don't have to have it in there for 20 years for that to happen, and I don't care whether you're talking about cohesive or non cohesive and all that kind of stuff, that's gobbledygook, you can have it 3 years after, the earliest I've had is 2 years after, and you can get bits of silicone leaking out, or the casing of the implant that disintegrates over time. Dr. Tania Dempsey: I'm so sorry, just really quickly, what about saline, if it's saline in, in the middle? Dr. Eva Nagy: So saline can do that too, in that, you don't have gel silicone inside, but the casing is still made of silicone. So whilst we find BII is much more common in gel implants, you can still get them with saline implants because the casing, which disintegrates over time, is made out of silicone. So yeah, there's a lot of people who say, look, I can put an implant here, I can cut it in half, it doesn't leach anywhere, it [00:22:00] sits like that, and I can come back in 20 years and it looks exactly the same, which may be true, but what happens inside the body is very different because it's continually being activated and trying to be broken down by your immune system. So don't assume that what happens outside, ex vivo, is going to be the same as in in vivo inside your body. It's very, very different. So the way that we do it is we make an incision and you have to take it out en bloc. So why do I do it en bloc? En bloc in French means in totality or all of it together. And it is applied because I know patients who, when you do the surgery, often get this slimy fluid around the implant, and if you test that slimy fluid, often it will have silicone within it. And so if you open up the capsule and you just yank out the implant, even if you take the capsule out after, you have now contaminated your operation field, [00:23:00] and you're potentially leaving silicone behind. And we do a lot of sort of, second opinion, I've had my surgery, they've pulled out the implant, they've taken some capsule, not all of it and I'm still sick. Well, it makes sense, right? You're still leaving bits of foreign material behind, you're still activating your immune system, your mast cells, the capsule is often thickened, inflamed, and with acute or chronic inflammation, you're still leaving disease behind. So it's important and imperative to remove all pathological tissue as you would for cancer, as you would for something benign like a mole. Now the second thing is because I wear loupes and it's magnified, I'm starting to see a second layer that a lot of people don't see. So there's a second layer of capsule that is formed on the chest wall, on the muscle, on the breast, and if you go back you actually have to start peeling off and separating that as well. And sometimes there's silicone in that too.[00:24:00] Dr. Tania Dempsey: Wow. Dr. Eva Nagy: So you have to do it well. So that's another thing that we do is we take out everything. Now you have to fix the muscle. Why is it important to fix the muscle? Because What a lot of people don't know is that when you put in implants underneath muscle, you have to sever the connections of the inferior border of the muscle from your chest wall. Okay? So now that gets elevated, you put the implant under it, and that's why you call it a dual plane, two planes. The top part is underneath the muscle and the bottom part is just underneath your breast. So, the problem arises if you just leave the muscle there, you're not having the appropriate tension, so if people want to look up Starling's Curve, I'm sure if you remember back in the medical school there, Starling's Curve says you have to have an appropriate tension of your myosin and actin fibers of your muscle in order to get proper function. If [00:25:00] it's too compressed together, you can't do it. If it's too far apart, it can't do it. You have to have an appropriate one to get the maximum function. So if you want the proper function in your shoulders and do push ups and all the rest of it in the gym, you need to put it back where it was anatomically. The second thing is, if you have petite breasts and you leave them there, you will see the lower border of your muscle which is usually at the level of the nipple, so you can get this sort of like a looks like a curtain, you know like a blind, sort of half way, and you get this line across your breast which is cosmetically not very nice. More prominent if you have petite breasts. The other thing is, you want a nice plush bed for your, your breasts to sit down on. So when you return the muscle back down, you don't have the top part that is nice plush muscle and then the bottom part which is just your chest with the ribs and the intercostal muscles because then you start to get tethering of scar tissue and then you can have inversion of your breast tissue and that [00:26:00] looks really quite ugly. And so we've had patients where it's all tethered down onto the chest wall, the top part looks great, the bottom part looks like someone has pulled in your breast and your nipple. And it's not very nice, you know, you're 30 years old and you don't look like a 30 year old woman. And the final thing is animation. So, when you activate your pec, and you've got your implants and your capsule in place, when you flex your pec, often women will find that their breasts and their implants move up and out. Okay, that's called animation. So you can look at cartoons, you know, they're animated, they move. So when you remove that, and you don't fix it to the chess wall, that animation can persist. Because it's not fixed to the chest wall in the appropriate position. And then you can get abnormal movement of your breast even though the implants and the capsule is removed. So you go to open the door and your breast is up here and then [00:27:00] you do your push ups and they're all over the place. So anatomically it's very important to remove, to put it back where it belongs. From a functional point of view, from a cosmetic point of view. Then because I do a lot of cancer work and we know how to do local regional flaps, I will actually use tissue around the breast, fold it into the cavity and give you some volume and projection and tighten the skin and the breast tissue around it to remove the excess skin because now that's been stretched. So there's a lot of work that goes into actually doing the part where we make the patient better but also to make them look normal. And whilst it's not cosmetic work, I'm just trying to make you look normal again. Yeah, and so we have to be realistic what we're aiming for because you, I can't get back to the unexploded house, but at the same [00:28:00] time I can make you try to look like a house. And I give them the apple strudel analogy. If you want me to make you an apple strudel, you give me the eggs and the flour and the apple and the cinnamon, and I can make you beautiful apple strudel. You give me some egg and water, well I'm gonna try to make you an apple strudel, but it's not going to be fantastic. Yeah? So if you give me really good tissue around it, what your body can give you, then I can give you something that's really nice. But we get a lot of patients with body dysmorphia, and so even though you can give them a good result, they, they see something that we don't, and even though they look wonderful, you can ask anyone on the street and say, you look absolutely beautiful, they will still need to have a lot of psychological work to get them to the point to say, oh actually no, I look normal, I look beautiful. Even though I've got petite breasts, I look beautiful and I'm healthy. I'm now going to the gym, I can look after my kids, I'm going to university, I can do my job, I've got good [00:29:00] relationship my libido is back. So, it's a really important part of being a woman. Why I don't like mastectomies is because, you know, people just say, well just lop it off, why don't you just do a mastectomy? Well, why don't you just cut your nose off if you have a mole in you? Why don't you cut your whole face off? It's important. Don't just assume just because it's an attachment for breastfeeding it doesn't have any other function. It does have a function. So, putting them in up to an hour, taking them out, capsulectomy, especially if they're under the muscle, the capsule, especially if it's a textured implant, will fuse to your periosteum of your ribs. Fused to your intercostal muscles, and your intercostal muscles are only a few millimetres thick. So if you don't do it carefully, you don't do it slowly, a millimetre at a time, you'll have, you know, a big hole in your chest wall, and I'll be looking at your lung and heart, and we don't really want to see that, and we have to take the periosteum off the rib, [00:30:00] return your muscle down, do a lift, do some local flap reconstruction. It's not unusual to take over eight hours. So that's why we do probably only two patients a day when it comes to the really complicated stuff. Because we just have to get it right and we have to be really, really careful how we do it. I've had cardiothoracic surgery training in my past so it doesn't really matter to me whether I create a little hole or just close it or do a flap reconstruction. It's not a problem. But we try and avoid it as best as we can. So, people have to understand that putting them in is is very very easy. Taking them out and doing it properly is very difficult and a lot of people don't want to do it, right? So, you know, why would you spend eight hours making the same amount of money as you would by doing a 45 minute operation, and it's much more simpler. So, you have to be vested in this to make sure people get better and to be involved in the MCAS group and the POTS group and the [00:31:00] hypermobility group and all these people to understand and to, to gain knowledge through research, how we can improve things. And I've actually, I'm very, very lucky because one of my colleagues introduced me to a gynecologist who does lots of endometrial work in South Australia. And so we're now looking at samples of endometriosis to see what's happening there. Because I think it's all tied. It just has to be all tied. It just, just makes sense but we just don't have the data. And wouldn't it be amazing if we found what was wrong with these women who had severe endometriosis and PCOS with infertility, to say, how about we give you some naltrexone, or some H1, H2 blockers, or whatever the case may be, and they don't get endometriosis, or it's a much, much lesser, they don't have to go through IVF and have all these PCOS problems. Dr. Tania Dempsey: Well, that's what we're doing. That's what, that's what I do with my patients. That's, I mean, we need research, but that's, that's been my [00:32:00] approach. Absolutely. Dr. Eva Nagy: Yeah, this is such a big field, it's easy to get lost in the detail, but the more that we educate people, and I think we have to educate patients and we also have to educate the doctors because it's not uncommon for patients to come in seeing specialist after specialist for years. No one's ever heard of it. You know, the doctor hasn't heard of it. Or, even if the patient says, look, I think I've got breast implant illness and be told, no, that doesn't exist. Nah, it's in your head. Go see a psychologist. Right? It's not helpful. And if we can educate and say, actually no, Look, it does exist. Let's go see someone to get the implants taken out and to reconstruct you. Most often than not people get better. Jill Brook: Well this is just absolutely incredible information and I would love to hear from both of you if you think that other kinds of implants can do similar things because I bet there's a lot of listeners right now who are saying well I match those [00:33:00] symptoms but I don't have breast implants I have this other kind of implant for whatever reason. Do you think it would extrapolate to that? Dr. Eva Nagy: I think any foreign body can produce these type of things, but we have to be very careful, right? So whilst I'm not a fan of mastectomies and implants, I'm not anti implant per se because of the fact that we do have young women who have BRCA, who have mastectomy requirements. And it would be amiss to say, look, I'm not going to give you implants, because not everybody develops breast implant illness. So I think it's important in corrective surgery, reconstructive surgery, after breast cancer, so it has its uses. My issue is when people are not consented. And so my consent process when you have these things is about 9 pages long. We go through the ins and outs of everything. And if they develop a problem after that, that we cannot explain, it may be Breast Implant Illness and we're [00:34:00] fully aware of it and then we'll look for other options. But yes, I mean, synthetic materials like mesh, why not? Joint replacements, cholecystectomy clips. These all are foreign material and evolutionarily we don't want them in our body. Now we have to be realistic and say, well, you've got a metal plate that's holding your bones together. Right? It's not an easy fix to just remove that as opposed to having your implants removed. It's a very different concept, so we will try exponentially to, to suppress your mast cells and to get you to the other side, to have a happy life, but anything can cause it, and it, it doesn't it make sense like your body doesn't want other stuff that's not you in there? Dr. Tania Dempsey: It's not just even these foreign materials, right? It's inside our body. It's about the foreign materials outside our body. It's about infections. It's about all these things that we acquire, it's about all these things that our immune system is really just trying [00:35:00] to help us with, right, that, that then backfires. And, and listen, if you can remove an implant, implants and get better, right, that's, that's an amazing thing, right? But there are going to be cases, absolutely, where you can't remove the implant. Or, or right, maybe that implant is in their hip. Maybe that implant is somewhere where it cannot be removed. We've had patients with cholecystectomy clips that we think may be causing a problem. It's not that easy to go in and remove those clips. So what else can we do? So I'm always looking for these other ways of helping the immune system stop, stop fighting these things that they're, they're meant to fight, right? Sort of like teaching tolerance to our immune system because otherwise there's no, there's no other way around it. Dr. Eva Nagy: Well, you're asking, you know, thousands of years of evolution to change very, very quickly. I mean, our Industrial Revolution was what, 1960s or [00:36:00] something? Mid 1700s, sorry, 1760s. Mid 1700s to mid 1800s, right? So you're asking your body, which has been geared over thousands of years, to change within a couple of hundred years. Yeah? It's not going to happen. So all the things that we have around us, electricity, our phones, pollutants, foods that we have, preservatives, anything and everything, right? You know, it's all geared to act against us and all the immune system is trying to do is its job. But sometimes it can get confused. So, but unless you want to go off grid and live in, you know, in the wilderness, it's just not going to happen. I'm not going to put my phone away, it's attached to my hip day and night. So we just have to kind of put up with it, but if there's things that we can avoid, and we don't have a magical test at the moment, that's the problem. We don't have a blood test or imaging to say that you've got Breast Implant Illness. [00:37:00] But I would say for any patient who has any form of autoimmune disease. So Sjogren's, Rheumatoid Arthritis, Lupus, Thyroiditis, whatever the case may be, avoid implants. Because these are the people that actually probably will develop it. And actually, if you have a look at the FDA, so even if people say, right, my doctor told me that BII doesn't exist. Well, the FDA recognized it in October 21. They've listed it as a black box warning. So, any patient that has a cosmetic implant or whatever implant, breast implant put in, they have to actually initial and say, yeah, I know about this. Yeah? So, stop telling people that it doesn't exist. If the FDA recognize that you should too. And I see it day in, day out. It's kind of taking over my practice. So we probably have 60 percent as being BII patients and 40 percent being cancer. That's really taking over because people [00:38:00] just don't want to put in the work, I think. It's a very big, long day. You know, start at 7, finish 10 o'clock is not, at night is not uncommon. That's my Fridays, usually. But it's really important that we do it properly and we get patients better. And if you cut corners You'll end up in my hands again, because you know, you, you got bits of silicone and capsule left behind, and that is a massive undertaking, because you don't know where the pocket is. You have to find the pocket, and often the capsule is very high. Much higher than what you think. It's usually just a few finger breaths below your collarbone. So you need to really go very high and take everything and take it, take the periosteum off the rib and the fascia off the intercostals. Dr. Tania Dempsey: How often do you see patients who had their implants taken out by another surgeon, surgeon but are still sick, and you [00:39:00] have to go back in and figure this out and figure out maybe they didn't have the capsule removed correctly or all the pieces done correctly. How often does that happen? Dr. Eva Nagy: I would say it happens more often than I like to say, but I would, you know, a few a month. it's very difficult because a lot of patients would have spent their entire fortune just trying to get the operation the first time. And so, to try and get it out is another ordeal. But I have, at the top of my head, I have five patients in the last few months. Three of them, they're really young, they're in their 30s, and three of them are now pregnant, which is just a delight because they had problems with pregnancy, trying, you know, infertility, and they had partial capsulectomy or some, not much, and then they remained sick. They really looked quite botched, so their breasts were abnormal shape, and it was just, you know. Not very nice. Anyway, we took out the remainder of the capsule, we sent it off, there's [00:40:00] silicone in there, it's chronic inflammation. And then they slowly get better, and then the body goes back to doing what it wants to do, which is procreating. That's kind of the aim of the game, is passing on your genes, and it wants to do that, and you know, fertility comes back, and three out of the five are pregnant, carrying really nicely. And I follow these patients up, so we have quite a number of patients who have rupture of the implants, and you've got to remember there's the, the capsule is, is live tissue. It's scar tissue, but it's alive. So, you have blood supply and you have lymphatics. And lymphatics take up the silicone particles and it goes to your lymph nodes so you can actually see them on imaging. So if you have a look in ultrasound, they're called snowstorm. It looks like a snowstorm. Like this hazy, greyish white, and you can see them on MRI too. Now we [00:41:00] don't know the long term consequences of this. So I, the patients that have obvious silicone in their lymph nodes, we monitor yearly with MRI, and actually, I was thinking, what about these patients? Why don't I set up, which sounds a little bit morbid, but I think it would be very interesting research work, is that patients who have this, when they eventually pass, would they allow us to collect organs as part of their autopsy and to see if silicone travels. So as I thought about it, I did a literature search and actually they did it already in 2016. Somewhere in the Netherlands, I think. And they found that a lady who had passed away for unrelated reasons, but she, they knew that she had in the past had ruptured implant, silicone in her lymph nodes, and they collected all different types of organs. And when they assessed them, they found silicone in her brain, [00:42:00] spinal cord, colon, kidney, so it travels. So the silicone can actually travel to other parts of the body. Now what does that mean? We don't know. But I can't imagine silicone in your brain being good. So, I monitor these people quite closely because what's going to happen to them, I don't know. We don't do at this moment, there's no reason to say we should do PET scans and, and you know, staging and make sure they don't develop sort of systemic cancer. And I've, I've spoken to Larry about this and he says at this stage, maybe just an MRI would probably be best. But we know that inflammation is a key feature required to develop cancer. And if you have silicone floating around, does that increase inflammation? Does that suppress your immune system or heighten your immune system? Does that lead to increased risk of cancer? We haven't seen that [00:43:00] in implant based reconstruction. So if you have implant based reconstruction after breast cancer, we haven't seen an increased risk of you having cancer, which is why we continue to use it. But it's contained, so what about the ones that are not contained? Not sure. But I can't imagine silicone disseminated in your body is a good thing. Dr. Tania Dempsey: I guess that's the question. Are those the patients that do have an improvement, they see an improvement after surgery, and I want to talk a little bit about the timeline of what you see in terms of getting better, but are these the patients that get better to an extent, but continue to have some symptoms because they still have silicone in their body? Dr. Eva Nagy: That's the fascinating thing. So Dr. Feng, she's probably one of the first two surgeons in the U. S. who started doing this and she published a paper where she used to do used to clear the axillary nodes that had silicone [00:44:00] in it, which can be quite morbid actually, right? So, you know, we, we reduce or de escalated axillary surgery for cancer patients. So not everyone gets an axillary clearance. We just take out the central node. Because we know that you can get lymphedema, you can get cording, which is sort of inflammation of the lymphatics in the arm, and axilla you know, pain, chronic pain, these sorts of things. So we know that it comes with morbidity. And she realized that even if you don't clear these lymph nodes, patients get better. So you would be doing the surgery for, well, you would increase morbidity without the benefit. And so we don't routinely do that. The only time we do that is if you can feel it, like this big, hardened ball, and it's pressing on your rib. I've had a patient like that and she said, look, I have a rib tumour. She's quite slender. When she lay on her side, she could feel the ball rubbing on her rib. So I took it out for symptomatic reasons, but not [00:45:00] because you don't get better. And actually, whether you have them in your lymph nodes or not, the trajectory is very similar. So, I actually pondered this with Larry and I said, well what's actually happening is the micro environment in the lymphatics different to the environment outside, in your organs or in your circulation, what is actually happening there, can they hold onto the silicone and it doesn't get activated, it doesn't activate your immune system in the same way, don't know. But we know that we, that people will get better whether you remove the, the, Lymph nodes or not, it's really fascinating. Dr. Tania Dempsey: So, so what is the timeline like? So let's say you're doing the surgery, you do it the way you want it, the way that should be done, right? Very thoroughly, eight hours. What's a typical course of recovery for these patients. Dr. Eva Nagy: It is so variable. So, so, so variable. [00:46:00] I would say the longer you've had it, the greater the MCAS symptoms you had even before the implants were put in the longer you're recovering. But I've had patients wake up from the anaesthetic in the anaesthetic bay, in the recovery bay, and they open their eyes and the injection, you know, that red erythematous injection that they've gone to see the optometrist and ophthalmologist and no one could figure out what it is, is gone. It's clear, white, beautiful sclera. So it can happen within hours, minutes, hours. Then you have patients who, you know, take weeks, months, years. But I do work with a couple of integrative specialists who are very MCAS savvy, and if they have lingering symptoms we start looking at other problems such as mold allergy seems to be a big one [00:47:00] and fructose intolerance, we see quite a lot of fructose intolerance and low iodine. So even though the thyroid function seems to be normal, they have low iodine. So there's little bits and bobs that we can improve. So I would say to patients, look, if you're not the magical one who wakes up feeling glorious, don't lose hope. Because everyone's journey is very different and may take weeks, months, years to get better. It is rare not to get better. I haven't had, well, I've had one patient, she's very, very complex who just is really struggling even though we did the best surgery for her. But, 99 percent of patients will get better to some degree, and over 80 percent will do really well. So the paper that we've submitted to be published, I think we got 85 percent reduction in symptom, symptomatology, whether they have it or less a degree in the vast majority of patients, [00:48:00] 85%. So, we're doing really well remove it. Yet there's lingering symptoms, don't lose heart, there's still things to do. And the biggest thing is we've removed that trigger, the biggest trigger, which is really aggravating your mast cells that don't like it. So it can only get better after that, but you may need a little bit of help thereafter. I've actually paired up with a compounding pharmacist, so we talk a lot about excipients. That's my new favorite word that Larry told me. Excipients, I love it. Preservatives and fillers and binders and all these things. And so, when we did the Sydney part of our MCAS Down Under tour, he came to the speech that we were doing. And he's a compounding pharmacist, which is about five minutes away. And he does compounding pharmacy for our patients, so he gives me samples. And so I've been giving out H1, H2 blockers and Naltrexone, just to try post op. And the Naltrexone seems to be doing amazingly. You know, it's a [00:49:00] stabilizer, and people who've said, I'm caffeine addicted, and sugar addicted, and I had this, that, and the other. And I said, try this, and we have about five days worth. And they're right back in three days going, Oh my God! Oh my goodness! I don't crave anything. It's been years and I'm not craving it because it settles in mast cells, I think there's a lot of the GLP 1, GLP 2, insulin, glucose, all of that settles and you don't get this spike that really craves for your sugars. So they don't seem to have that postprandial sort of feeling of bleh, you know, it's much more level. So these medications are so amazing and they don't have really any side effects. So I tell people when we, initially I started them on Zyrtec, which is cetrazine, off the counter, and these patients were, oh, I had the worst nausea and vomiting. I'm like, what is wrong with these [00:50:00] people? Like, it's just Zyrtec, you can't, surely, what's, it's just H1 blocker you know, what is going on? And then excipients came along and like, oh, okay, how about we compound it? Oh yeah, it's much better now. I'm like, okay. So, you know, my simple mind, I'm still learning. All of us are still learning. Dr. Tania Dempsey: We're all learning, we're all learning, but that's why we have to do things like this. This is why I'm so passionate about having this podcast and having someone like you on because this is, we've got to get the, this information out there for, for patients. Number one, right, because they need to be armed with this. They, they need to advocate for themselves. But then also what I hope is that, yes, other, other professionals, medical professionals are going to listen to this and maybe other surgeons are going to start to, to think about BII in, in, in patients that they previously discounted, right? That's what I would hope, right? Dr. Eva Nagy: For doctors to take it seriously, I had a patient come in the other day and she saw a surgeon, a local [00:51:00] surgeon, and he said, ah, I've taken out two implants and, you know, didn't make any change in their symptoms, it doesn't exist. I thought, well, alright, N equals 2 is not a good number, and did you take out the capsule and do it properly? So, you've got to take it seriously. So, I say to patients, I mean, not everyone can travel to Australia, of course, when you're in the U. S. or internationally, but, although we do cater for interstate and international patients is to find a surgeon locally, first of all, that really genuinely believes in BII. Not just a word that, yeah, yeah, yeah, yeah, we'll tell you, yeah, yeah, yeah. No, they genuinely believe in it, and ideally, if they do research in it, that would be a bonus. Number two is to find someone who will take photographic evidence. All of my patients get photographic evidence of the implant and the capsule together taking it en bloc front and back. Some people, a little bit sneaky, will do photographs at the front and then you flip it over and like, the back part's completely missing. [00:52:00] So, the capsule is still on the chest wall. And three, someone who genuinely understands that this is reconstructive surgery but the look matters. Okay, so have training in how to do reconstructive surgery to make women look natural again. Because a lot of people, I mean I don't care if you're 60, 70, 80, people still want to look the best that they can. So aim for that, with realistic expectations and to really do your due diligence. Because if you get it wrong, if they get it wrong, and they don't remove everything you don't know, If they've done the right surgery or you're just sick from something else and then you're going down the rabbit hole trying to find exactly what's going on and you may need to have more extensive surgery to remove any pathological tissue that [00:53:00] remains. So just just do it properly really really do your your research and ask to see photos, before and after photos, I've got a whole file where we talk about before and afters, and I actually show patients so the one that I showed in, in the MCAS Down Under was patients on the table, so I, I, for patients benefit, I will take a photo while they're on the table, seated upright, to show what they look like with and without a lift, and without, with and without the flat reconstruction, so they understand what they would, look like without the reconstructive part. Because most women worry about scarring. Okay, so a lot of patients will have the anchor scar. So, the scar that goes around the areola, down and underneath. And that's really important because you want to tighten the skin. That's one of the biggest things. You can imagine if you have a sock and I filled it up with you know, [00:54:00] sand. And then we stretch the sock, and then you take out the sand, it remains stretched. So you have to actually remove some skin. And make the areola smaller, so when you have implants, that gets stretched too. So if you're going to have more of a petite breast, but really large areolas, the ratio's wrong. And I say to them, don't worry about the scarring. The scarring heals over time. Most people, you can barely see it. Around the areola, you barely see because there's already a colour differentiation between the areola and the skin. The one underneath the breast is usually hidden by the breast. The one that you probably see is just the one up and down. That tends to fade over time because that's less important than the shape of it and the contour. If you get the shape and the contour wrong, it is exceptionally difficult to correct that. I'm not a big believer in lipofilling, fat transfer. I find that they're very variable. It can [00:55:00] work in some patients but most of the time people will just reabsorb it, so you're spending money on very little benefit. And that's why using tissues such as a flap, it's one big piece of tissue that doesn't get reabsorbed. And so what you see after the operation is usually roughly the same as what you will be like in six months to a year. You don't, you don't lose the flap because it's an entire tissue versus if you put droplets of fat in there. Your body can just reabsorb it, and whilst you may look great a few days after the operation, by one year, it's like nothing stays. So, it's not a good way of doing it. For people who have had reconstruction post breast cancer, we do do it into the skin. Into the dermis and just between the dermis and the capsule to sort of buffer the implants so you don't get so much obvious rippling and the take off at the top is a bit smoother So it can have benefit, but when you're looking to have [00:56:00] sort of reconstruction with adding volume, it's not that great and it's very variable. Dr. Tania Dempsey: So, this was, this was incredible Dr. Nagy. This was really, really so, such important such important work you're doing and I'm so thrilled to have you sharing that with us today. Is there anything that, that we haven't covered that you want to make sure... Dr. Eva Nagy: Oh look, we can talk about this for five hours. I could be... Dr. Tania Dempsey: I know, I know, I know Dr. Eva Nagy: I would say the biggest key factor is don't think you're alone. I would say to patients, you, it's much more common than we think. We don't know how many people get it. But I would say that people who come to see me, whether they think they have breast implant illness or not. So there are some patients who will actually come in and say, I don't have a breast implant. I've just, I'm done with them. I've had my fun. I just want to be natural. I'm gonna lie on my tummy again. It's just uncomfortable. And get them out. When they fill out the questionnaire that I give them, which is sort of like a BII [00:57:00] questionnaire, they're ticking boxes left, right, and center. And they think they're just getting older. Oh, I've got a bit of back pain, I've rashed once in a while. Yeah, I've got hay fever for no reason whatsoever. So I would say over 90 percent of our patients, whether they have identified that they've got breast implants, actually have a variable amount, whether mild, moderate, severe. So it's much more common than we think. So it, it, women just need to do their research, find people. It'll become more common, it'll be much more aware. Don't assume breast pain is going to be one of those symptoms. Usually breast pain is not really a BII symptoms per se. It's usually related to the capsule which gets thickened and contracted over time. So that's called capsular contracture. Or, the implant placed underneath the muscle and the muscle is stretching. Because muscles are very heavily innervated and have lots of [00:58:00] blood supply. And so that can cause twinges and pain and ongoing, so breast pain per se is not one of the really big ones that is a red flag. So it's going to be all the other symptoms that you just can't explain. Why am I so tired? Why can't I sleep properly? What the hell is with my hair falling out in patches? Why is my gut bloated and I can't you know, I can't eat properly. So as a, as a final thing I would say to patients, we are starting to do more and more gastroscopies and colonoscopies. So I'm getting biopsy samples that they had previously. We've got a good hands sample now and they've got raised mast cell counts in their biopsies from their small bowel and their large bowel. Which all integrates together, so I think IBS is really MCAS and it all ties in really beautifully. And sodium chromaglycide is, we're starting to use a lot now to suppress what's happening in the [00:59:00] gut. But yeah, lots of research and lots of work. I got so excited I sent an email to Larry the other day going, Oh my gosh, this patient had a 39, 39 mast cell count in their small bowel. Dr. Tania Dempsey: Anything over 20 we consider suspicious... Dr. Eva Nagy: Yeah, so we've got, you know, 33, 39, 28, you know, they're all just sort of coming through. Dr. Tania Dempsey: And this is pre, this is, these are, these are patients who have implants in, who are sick, who are, they're going to the gastroenterologist because they have GI symptoms, or they're going to another specialist because they have other symptoms, right? And you're finding these, yeah, these increased number of mast cells. Dr. Eva Nagy: And so actually it's all part of the same story. And the actual H&E, the hematoxylin and eosin stains are plumb normal. Textbook, maybe a little gastritis, a little bit of inflammation, nothing to talk about. They get a PPI. But actually when you have a look at their mast cell counts, it's very, very high. And it all just makes sense, right? So we, we, if any patient who's had a [01:00:00] scope in the past who comes to see me as a BII patient, I'll ask them, where did you get it done? Can we get the samples? Because in Australia we have to keep them for seven years, as in a, sort of like a wax block. And we can get them, and we're starting to do them more and more now. And when we have that data, I pass it on to the Integrative Specialist so Mark Westerway is one, and Krista Balliare. And they're like, aha, okay now we can act on even more things. So it's just so exciting. Why don't we have five hours to talk about this? Why have we only got an hour? Dr. Tania Dempsey: You know what? Let's keep going. That's fine. No, no, we're going to have you back. Because we have, we have so much we have to talk about. There's so many other questions I have. But we can and we should keep talking about it. Dr. Eva Nagy: Hopefully the the paper that we submitted will be accepted because that would really be able to, so I promised all my patients once that gets published I'll send it to them because it shows all the mast cell counts and the breast capsules and the symptomatology, the resolution, it's a really good little pilot study that [01:01:00] we did just to show how important and how obvious it is. And then, you know, doing the gastrointestinal samples, that'll be another paper, and oh, the other thing I wanted to tell patients is regional anesthesia. So, we give regional anesthesia to all of our patients. So a little injection into the muscle at the back of the erector spinae. And this is where your nerves come from, that supply your chest wall, so it comes from the back and supplies your chest wall. And so, even though you get general anaesthetic, when you wake up from the general anaesthetic, you're quite numb. And you don't have a lot of pain post op, and so you don't need all the morphine and the fentanyl that makes you vomit. So, because people are comfy, they're up and around the same day, they go home the next day, they take their drains home, they're in touch with us. And their post operative recovery is much more smooth sailing. So we're publishing that too. So if your [01:02:00] local surgeon does that, that is a real game changer. So we, we found that 6 to 8 out of 10 for pain, even though you've got Panadol, Celebrex, Pallexia. With the block, it's about 2 out of 10 for the post operative 10 days. It's phenomenal. We do it in cardiothoracic surgery all the time, so all of my patients, cancer, implants, whatever, we all give them regional anesthesia, and it's very good. So if they do that locally, that's even a better bonus. Dr. Tania Dempsey: And if they can't find anyone to do this, they have to come out to Sydney. Dr. Eva Nagy: Unfortunately, yeah, so we have we've been very lucky with the Quest Apartments which are lovely apartments. It's sort of like a hotel, but people can stay for long periods of time. They have a kitchen, beautiful bathroom, one to two bedrooms. We have a lower discounted rate. We get a lot of interstate patients coming and I ask them to stay for two weeks. So if anything happens, they're with me. so they stay for two [01:03:00] weeks and so they have a discounted rate. But we see interstate, international, we see patients everywhere and anywhere. We do lots of Zoom. So the first consultation we do Zoom and if they're happy to, they can show me their chest on Zoom when they're alone. And then I can actually see, you know, do I have capsular contracture, what's the problem, just lay my eyes on them. And then they'll come a few days in advance, then I'll physically examine them. We usually do MRI for the breast, which looks at signs of rupture, where it's placed, breast pathology, silicone and lymph nodes, full serology and autoimmune screen. So we're seeing a lot of people with positive ANA and ANCA. Which we don't know what to do with at the moment, but we're seeing a lot of patients actually revert from positive to negative. Dr. Tania Dempsey: Well, do you know why? Do you know why I think it is? Have we talked to Larry about this? Because we just [01:04:00] published on this, by the way. Larry and I, and and another, another colleague Gerd Molderings we, we looked at mast cells as a driver of mimicking or spurious antibody production. And so I think that when you take out the trigger and their mast cells get better, they stop making antibodies. Dr. Eva Nagy: Yeah. But interesting, we have patients who get very, very well, that become so better, but their ANA and ANCA remain positive. So, you know, we still see patients who get better. So they have serology, autoimmune screen, chest X ray and ECG to make sure they're safe for the anesthetic. For and then we have a great day in theatre, I get to play my music, and we have a... Dr. Tania Dempsey: And what kind of music, what kind of music do you like? Dr. Eva Nagy: It's things like Skrillex, which is sort of like a techno heavy metal, R& B, um, 80s, 90s, you pick it. Probably not. Sorry for anyone who's a [01:05:00] sort of like a country fan, I'm not really in the country things and no real opera, but it's usually quite it's a very good list most of, all of my anaesthetists are hand picked so they do regional blocks, they're cardiothoracic trained, so they're very highly skilled, I have three to four surgical assistants who are very, very important. And we all work together. It's a very, very good team. And everyone is hand selected, so they're at the height of their game. I'm very protective of my patients, so we just have to have perfection all the time. And that's what we aim for, but we have to be realistic in terms of cosmesis, what we're looking at. Because, you know, it's a, it's a bomb in a house that we're trying to make look like a house again. But sometimes, actually, we, we do really good work, and they look better after the operation than they did when they had the implants, so that's something that we strive for.[01:06:00] Jill Brook: Dr. Nagy at one point I had seen some before and after photos that you had made available at some presentation, and first of all, they were mind blowing. Absolutely mind blowing. And so I'm wondering if we could just take a quick moment to describe what you see in those photos, and I don't even know what I'm looking at, I just know that It's amazing. And then second of all, I don't know if those photos are online anywhere or if people can just find you online. Is there a website where people can find... Dr. Eva Nagy: So, in Australia we're not really allowed to put up sort of before and after photos like that, but any patient that has a consult with a Zoom or not, I can show them before and afters. The other thing is a lot of them are intra op, so if people are a bit squamish about blood, it's, it's very difficult to put it on the internet. But essentially what you would see without in many patients would be an empty sac, I would think of it so if you have a sac with sand at the [01:07:00] bottom, so the majority of the breast tissue will be at the bottom and sort of caving in, hollowing in the centre, and just very saggy with the nipples usually quite low. When we do the reconstruction I will use a flap, so that gets folded to the inside to give them volume, and usually if they have a really good donor flap we can put it up as even a cup size. Then we make the areola in proportion to their new breast size, but also do a lift. So that comes part of it that the lift and the reconstruction we put it to a higher position to be in keeping with their, with their youth and to make it a little bit more sort of natural and higher and then we tighten the skin so we remove all that excess skin. So they're usually more more perky, they're lifted, they have volume and like I say, the scars will heal. It's the shape and the [01:08:00] contour that's really important. And I always say to patients, you know, breasts are sisters, not twins. And so there's always a little discrepancy between the two, and that's just natural. But we try to make them as similar as possible. And actually, most of the time, There's a lot of asymmetry even when they have implants, so we try to correct for that. So sometimes they'll have a bigger implant in one compared to the other. So in the smaller breast we'll use a bigger flap, in the larger breast we'll use a smaller flap, and we try to match them as best as we can. But there's always a little asymmetry, that's just natural. You have it, I have it, we all have it. But it's just such an important part because you go through this operation, a lot of women are very scared to have this op. Because they think, well what am I going to look like after? The reason why I got it in the first place is because I wanted to be a little bit more fuller, or, you know, more symmetrical, or whatever the case may be. So, um, I haven't had anyone say, you know, they're not happy. But it's just a readjustment of what is expectation. You're not going to have that full [01:09:00] cleavage that you had before, because that's not a natural breast. You know, that's the vast majority of women have a teardrop shape, so less tissue at the top, more at the bottom, and that's what we're aiming for. But they all look really pretty. In my eyes, I think that every woman is so pretty, and we're just trying to put them back to normal. Dr. Tania Dempsey: Great. So where can people find you? What's the best way for people to? Dr. Eva Nagy: So, our website is sydneyoncoplasticsurgery. com and I'm very, very super lucky to have the practice manager that I do, who is the best man in the world, who is also my husband. So we run the practice together, and he used to be in banking, so, you know, he crosses the T's and dotted the I's, and I can leave everything to him. I can just concentrate on the patient and the surgery. So he runs 95 percent of the business. His name is Fred. And on the website you can actually [01:10:00] send a message to say hi, I'm from here, can we do a Zoom, I have Breast Implant Illness, I have this problem, that problem and we'll set up a meeting, we can do a Zoom, and then if you would like to come we can do your surgery here. Dr. Tania Dempsey: Thank you. Thank you for that information. This was, this was incredible. And like I said, yeah, we will definitely have to have you back. We could talk for hours about this. I think that we're, we're definitely seeing things the same way. We need more research. And so thank you for publishing and doing that, that work. That's, that needs to get out there. People need to read it. Dr. Eva Nagy: I'm looking for, it's such a lovely group of people that we have with the Masterminds and it's just so collegial and so supportive and you and Larry are doing such amazing work and Jill, amazing, like this is, it's, it's, you know, in surgery it's not always this way. It's just a lovely group of people who I'm just honoured to be part of [01:11:00] and I look forward to seeing you soon and hopefully if you're coming out to Australia, got lots of good seafood, come, we'll take you on the barbie, you know how it all goes. But it's, I'm looking forward to any time you want to have a chat and hopefully the next time we talk that things were published and we can talk a little bit more about the the endometrial stuff, I'm very keen, I'm really hoping to see some positivity come out of that one. But we'll just have to see, we're only starting to do it now. Dr. Tania Dempsey: And I'll send you an abstract that I was a co author on looking at endometrial tissue and looking at other actually vestibular tissue and looking at mast cells and actually a condition known as neuroproliferative vestibular dynia. It's a little bit of a mouthful for me so the, the, these are urologists, urogynecologists, people who are really interested in the, the women's sort of sexual health issues, and so anyway, we're looking at this stuff, and I'm looking at it with some colleagues, so [01:12:00] we'll have to connect, I'll have to connect you with them because I think... Dr. Eva Nagy: it's all a lightbulb situation, isn't it? It's like one to the next to the next and it's all integrated in a way. So, I tell patients there seems to be a syndrome. You know, the MCAS and the POTS and the BII and the hypermobility and the ADHD type symptoms, etc. It's all a syndrome, because I would say that the vast majority of my patients have most of those symptoms. And so, you know, I have a little checklist and go, so, have you had ADHD type symptoms? Have you tried this? Have you tried that? And most of the time, I'm ticking that box. So, I'd be surprised if it's not rooted in MCAS and really has a huge potential to, to help many, many patients in the future. Jill Brook: Dr. Dempsey and Dr. Nagy thank you so much for this information and for all that you do to help MCAS patients. This has been some amazing information today. Some connections, some connecting dots. Wow. We are [01:13:00] so grateful for your time and your expertise. And hey listeners, that's all for now. But we'll be back again next week with a normal episode of the POTScast. And we'll be back again soon for another episode of Mast Cell Matters with Dr. Tania Dempsey as our special host. So thank you for listening. May your mast cells be good to you, and please join us again soon.

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