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    Dr. Sam Jejurikar: Pioneering Auto-Augmentation – A New Frontier

    Dr. Sal Pacella:  Good morning, everyone! I’d like to welcome you to our next podcast. I’m, of course, Dr. Sal Pacella from San Diego, California, and @sandiegoplasticsurgeon, that’s Instagram. I’m joined, of course, by my colleagues, Dr. Sam Jejurikar , who’s in Dallas, Texas. It’s @samjejurikar on his Instagram. And, of course, Dr. Sam Rhee out of Paramus, New Jersey, in the New York City area. And it’s @bergencosmetic.

    So we are joined today by a very good friend and former colleague. I’d like to introduce my good friend Dr. Andrew Trussler. We were interns together at the University of Michigan. He was in general surgery. I was in plastic surgery. And then, shortly after that, because of my influence, of course, I convinced him to join plastic surgery. He ended up doing his fellowship at UCLA. He was one of the top stars at UCLA and then did a cosmetic fellowship at UT Southwestern.

    Shortly after that, he joined the faculty at UT Southwestern and was there until 2012 and then decided to go to private practice in Austin, Texas, one of the greatest cities in the country, from what I hear. And he does a tremendous amount of cosmetic surgeries. He’s a great guy, super entertaining. Prior to introducing him for the very last time, I’m going to hand it over to Sam Rhee, who’s going to give us our intro disclaimer.

    Dr. Sam Rhee: Thanks, Sal. This show is not a substitute for professional medical advice, diagnosis, or treatment. The show is for informational purposes only. Treatments and results may vary based on circumstances, situation, medical judgment. After appropriate discussion, always seek advice of your surgeon or any qualified health care provider with any questions you may have regarding medical care. And never disregard professional medical advice or delay seeking advice because of something in this show.

    Dr. Sal Pacella:  Andy, welcome. It’s been a long time, been many years, since we’ve seen your face.

    Mastering the Art of Auto-Augmentation: Dr. Andrew Trussler’s Journey

    Dr. Andrew Trussler:  It’s great for great to be on here. It’s good seeing you guys. I hadn’t seen some of you guys for years and years, so it’s cool. Thank you!

    Dr. Sal Pacella: Andy, we’re going to talk today about a really interesting topic that you’ve done a tremendous amount with, and you’ve evolved through your practice since. You’re going to be talking about auto augmentation for our listeners out there. What is auto augmentation? Is it shaping and reconfiguring the breast without an implant? So if you’ve ever decided to get a breast lift or get some augmentation, this is an interesting way to do so without using a silicone breast implant. So Andy, why don’t you take it over?

    Dr. Andrew Trussler: Yeah. This is a subject that’s near and dear to my heart, and that’s something that I started actually at UCLA. The influence really for it was Peter Rubin’s article in ASJ, probably. I think it was 2005 in the massive weight loss population. And those patients presented to me not infrequently. And I feel like that population alone with an implant, even though you think that they need an implant for volume, which a lot of them do, you can achieve quite a good breast shape and quite a good amount of volume just based on de-epithelialized skin and thin glandular tissue.

    And so I worked in that population then translated over to a cosmetic population, then more recently to the revision population or implant revision population who may need or want their implants out. And so from a primary perspective, I think we have a couple of examples of patients who presented to me who basically wanted a breast lift and didn’t want an implant, and or patients that presented with a C plus volume that want to maintain volume, and that I feel those patients are the most challenging mass specs.

    The Augmentation patients, I do a ton of mass specs Augmentations, but that operation is fraught with a lot of control issues, and I really worked on that operation as well to control the position of the implant long term and things like that. But the larger-breasted patient who wants to maintain volume, who needs and could benefit from a lift, these are the perfect candidates. And they’re not all massive weight loss patients. I think those patients somewhat few and far between in a way, and it’s an operation that’s based on a central mound. And then I don’t base my structure on dermis. I think that’s where those results probably fail long term.

    Dr. Sal Pacella: Just for non-plastic surgery viewers and listeners out there. So what you’re referring to is when you’re talking about doing a breast lift and placing an implant at the time, the implant and the breast sometimes act differently, right? We can usually control the position of the implant reasonably well, but sometimes what happens is that breast tissue sort of falls off of the implant, and it may bottom out preferentially because it’s soft tissue compared to an implant.

    Maybe you want to tell us a little bit about some of the challenges you may have had throughout the years. Or let’s open it up for discussion about what you guys do to help control that issue.

    Dr. Andrew Trussler: For mass effects of the Augmentation patients, I feel like you’re managing two different forces. You’re managing adding volume and then somehow repositioning and lifting breast tissue as well. So I always think of that as melding the two and having those structures stay together. Often you’ll see the implant too high or the implant too low. Implant too high is probably related to the breast falling off. Implant too low is just too large of an implant with too little of a lift.

    And that’s the battle. When you have a lot of breast tissue, and you’re putting an implant behind it, you just have too much going on there. And those are really challenging patients in the literature. Those are the patients that are fraught with issues, and that’s why this operation is a really nice option.

    Dr. Sam Rhee: Yeah, I think we’ve talked about this before briefly, and when you’re trying to tighten up that skin envelope, and then you’re also trying to expand volume. Like Andy said, you have two competing forces. And I always likened it to trying to stick £10 of potato in a five-pound sack. And then Sal said, “No, I’ve only heard that comparison with resident.”

    Anyway, so to keep going, basically every time you’re trying to stuff this implant in, and you’re trying to tighten up the skin envelope around it like you said, it’s fraught with challenge and difficulty. And the fact that you can actually take a breast lift patient and use their tissue in a way to shape and augment their volume with their own native breast tissue is something that I think a lot of patients could actually benefit.

    Dr. Sal Pacella: Yeah, you’re absolutely right. I think what we tell patients is we have four dimensions to control in surgery. There’s length, height, depth, but we can’t control the fourth dimension, which is time. And that’s where I think it’s oftentimes really challenging on the table. You can get a great implant, a great lift, it can look absolutely perfect, and then the forces of contraction will take over, the forces of gravity will take over, and sometimes the best late plans in the operating room just don’t turn out exactly correctly later on. So curious to see how you attack this problem.

    Dr. Andrew Trussler: Yeah, I think one of my mentors used to tell me the lower pole of breast is likened to a lizard’s tail. It’s the only thing that grows back, it seems. So really, that lower pole control is tough, and I really work at that with mass effects yards. I really have to work at providing support to the lower pole so that the implant just doesn’t bottom out. And then, the tissue and the implant are all protected and enabled to heal well as well.

    Yeah, it’s a tough one, and I think patient realization that it is a tough one is hard. Everyone thinks it’s an easy operation, but it’s just not. So I think this is a really nice option. So this is a typical kind of patient who doesn’t want an implant benefit from a breast lift but wants a little bit more shape. And so I think if you really look in the lateral and three-quarter view, you can really see where that volume is maintained. It’s above. You have upper pole volume on that.

    Ironically, there is an article where they really said that you can’t achieve that without a small implant. And I think with this you can. And I think the terminology gets a little bit skewed in this day and age with fat grafting. These are not fat-grafted patients. This is all breast tissue that’s on a central mound. So it’s on a blood supply that I just refashioned around the nipple, and it actually forms almost an implant-like shape that’s attached to the periosteum and to the upper PEC as well.

    And I use an absorbable suture on everything. This is only three months. I think she’s lost a little bit of weight as well. But I see patients back for a long period of time. I think I’m honest with patients as far as telling them, hey, there may be some scar vision type stuff in the lower pole, things like that, but nothing that would necessitate reoperation.

    So I do see patients back for scar care well over a year. And I think the results do last. I think there’s maybe habitual changes in the patient that I’ll see. Sometimes with a breast lip, functionally, there’s improvements. So patients may be a little bit more active and things like that. So you’ll see some weight shifts and weight fluctuations. But long term, I think I saw this patient back a couple of weeks ago. In the long term, they’re good. In years out, I think having follow-ups over a year is important.

    I think these are fairly short results, but they do last for as long as the patient wants them. And I’ve had one patient come back for an implant for more volume or for volume augmentation in the upper pole. And then, a year later, we took that implant out. I think it was like a 190 CC implant, too. So it’s not like it was huge. And that’s one out of a series of probably closer to 1000 patients, probably right now.

    Patient Selection: Who is the Ideal Candidate for Auto-Augmentation?

    Dr. Sam Jejurikar: This is a gorgeous result. Imagine this patient said to you, Dr. Trussler, I want to be just a little bit bigger than I am, kind of how you were, sort of alluding of all the complications that you can have. If you were to use an implant in a case like this, would you think there would be a role for fat grafting for a little bit of volume addition to this patient? Or would you just tell her you’re going to be a little bit smaller, and that’s the way it is?

    Dr. Andrew Trussler:  No, in the consultation, I give them, hey, this is your option long term, too, and fat grafting is in the cards. I have done that. I have done that in combination with, more importantly, the patient who comes in for implant removal, auto augmentation, I may call it, and say, hey, you don’t have a huge amount of volume, but she doesn’t want an implant back in. Right? 

    So you could add some background into that. So I think this patient, sure, that would be an option. And a smaller implant, like a lower profile implant, would be another option as well. And that’s on the table. I usually have, if we’re going to do that, wait at least a year to consider that. But as I said, those are few and far between.

    Dr. Sam Rhee: This is a great result. The first time I ever saw something where there was an auto AUG with a massive exit was James Grotting, who described something with a superior pedicle and then taking the inferior tissue and sort of hiking it underneath, but I don’t know about how long that would last. 

    Amy Alderman, when we talked to her last year, if you guys remember, she talked about something similar to this that she developed with Hall Finley, and I think she did the same thing you’re describing, which is securing it to periosteum or something really stable. And so I thought maybe you could describe that a little bit more and see how that contributes to the longevity of this.

    Dr. Andrew Trussler:  Yeah, so if you think about this, I wish I guess I should have had a pre-operative marking patient. But what you’re getting the augmentation from is basically the inner and outer dermogular wings that comprise a wise type pattern. These are wis8 type patterned skin incisions. And then everything within the wis8 pattern is wrapped on itself.

    So the upper triangle of that wise pattern, that’s what I’m securing to the periosteum into the pack. I use OPDS for that. And I use three points. I used to just use one point, but I felt like it medialized. The nipple a little bit put a little bit too much tension on it. So I think if you go almost true superior have some stabilization throughout the medial aspect of the breast, it can really secure that. I know it lasts for quite a long time because you can actually feel a little bit of it may, be some fat necrosis and or just a little bit of scar tissue at the upper aspect of the pedicle. Sometimes that softens over time.

    But yeah, you can usually palpate the periosteum of the 4th, 3rd rib on the inner aspect. And this work laterally immediately on that; you have to elevate flaps. That’s the thing. You really take things apart and put things back together. This operation, I’m more aggressive with the upper pull the section, and my skin flaps now than I was a little bit hesitant to really rewrap the skin over the mound. But that really works.

    Dr. Sal Pacella:  Yeah, I think that’s the key here for an operation like this. And when I do even a breast reduction that’s on a smaller patient, I think the key is really elevating the superior skin flap all the way up to the PEC because that allows you to sort of really get tissue up really high because as you mentioned, it’s just going to always go down again. So, yeah, I think oftentimes, if you don’t do that dissection all the way up, you’re just going to get an inverted slope to the upper pole.

    Dr. Andrew Trussler:  Yeah, and I saw Amy’s presentation, and the literature is out there, but it’s not as complete as what you would think. And try to get this stuff out there within a readable kind of manuscript. But you’ll see that Sal said is you’ll see that flat upper pole, then a projecting breast, and that’s just because things aren’t dissected as far as and then the lateral aspect. 

    I am doing the skin flaps are attacked to the lateral chest as well to periosteum. You have to be careful with where the PEC vasculature comes out and things like that. So you navigate around that, but the skin and creating that lateral breast folds. Not with the actual mound, but that’s really with the skin. And I’ll do that on majority of patients.

    Dr. Sam Rhee: Do you leave drains in?

    Dr. Andrew Trussler:  No, I don’t use drains in the breast. The goal is to have no dead space in there, and there’s really not they’re coming out. They look very accentuated. Upper pole volume is very accentuated because if you don’t have that doesn’t get better. Things go lower, not higher.

    Dr. Sal Pacella:  One thing I’ve done before in a patient like this that didn’t want an implant is utilizing some ADM just to support the actual breast mound. Very similar to how you would do a pre-pectoral breast reconstruction or at least three-quarters of the way. And I found that to be moderately successful, it does have some expense to it. Patients do have to pay for an ADM or an Acellular Dermal Matrix or some sort of mesh to hold things into position. But I’ve been pretty happy with that operation. So do you have any additional slides, Andy? You get some other befores and afters?

    Dr. Andrew Trussler:  Yeah, we have plenty more, but that’s a good point. I have a couple of patients, I think maybe one or two patients that I have, not primarily, but there can be a little lateral descent in the breast tissue or in the mound. And so I have gone back, I believe, on just one patient. I use GalaFLEX on her. I don’t know if I should use a trade name on this, but I have no financial implications on that. So I’ve used that. And I like that product.

    I think it serves all the purposes I need it for. But for reinforcement, especially on the outer aspect, that lateral aspect on a rounded chest, I think it can help reinforce things. But I don’t do things primarily on that. I don’t feel I need it on everyone. It is an added expense. It’s a foreign body, so if I don’t need it, I’m not going to use it. Yeah!

    Dr. Sal Pacella:  Keep it organic, yeah.

    Dr. Andrew Trussler:  Keep it green.

    Dr. Sal Pacella:  So this is a great result.

    Dr. Andrew Trussler:  Yeah. So this is actually a patient who wants to maintain volume. Okay. Dense breast, too. I think that’s the other thing. Just like on noses, you underestimate what the cartilage strength is. And firm breast tissue is going to be unforgiving. But firm breast tissue is great long term, so this result holds true. And this is probably a six-month result or maybe an eight-month result, something like that. And there you go. There are no implant volumes up. This is what the patient wanted. Sure. I could say there’s a little bit, maybe a little bit large, but you can see from the lateral view that the upper pole stays true.

    Dr. Sal Pacella:  That’s great.

    Dr. Sam Rhee: Super impressive!

    Dr. Andrew Trussler:  And this is a patient this is a pretty early result out of town patient, but you can see where volumes down a little density to a breast. I think this patient would be really challenging you to even consider putting an implant behind. And this is a result from lateral view and three-quarter view.

    Dr. Sam Rhee: It’s impressive because if you didn’t tell me, I would have guessed possibly that you had put implant in. It looks like…

    Dr. Andrew Trussler:  Sometimes, I’ll trick the office staff.

    Dr. Sam Rhee: You’ll show them this, and they’ll think that they’re…

    Dr. Andrew Trussler:  Do you have the implant information on this patient?

    Dr. Sam Rhee: I would totally believe it, actually. Do you ever do any liposuction in the lateral aspect of the chest wall in order to?

    Dr. Andrew Trussler:  Yeah. So all that see that indentation on the outer breast? I have a series of OPDS sutures that really go right down to the rib right there. So that’s a little bit more accentuated than what it will be long term, but I actually utilize a lot of that tissue. If you look at the auto augmentation in the oncology oncoplastic literature, they’re really harvesting outer breast flaps. So I really do harvest quite a significant outer breast flaps. I actually use that, but you can see that scar extends onto the outer chest. So I really don’t do any liposuction in that area or feel like I need it, I guess.

    Post-Operative Pain Management and Recovery Expectations

    Dr. Sal Pacella: Tell me, Andy, tell me a little bit about the pain patients have after this with those deeper sutures to periosteum and things like that. How do you manage that? How bad is it?

    Dr. Andrew Trussler:  Yeah, so all counsel patients is not uncommon, where that will be the point of a discomfort, not the upper chest, but the outer chest. And I’ll counsel patients beforehand. Hey, that can hurt. I think sometimes it doesn’t. It’s not just uncomfortable right away, but as those sutures dissolve, sometimes two to three weeks, you’ll have this kind of they’ll actually hear a pop, and I’m like, well, that’s probably one of those sutures breaking free.

    And so I do a series around four sutures out there just because I feel like it needs a little bit of support. So at around ten days, they’ll feel a little bit more discomfort, inflammation, things like that. I’m a big proponent of anti-inflammatories. I don’t use a huge amount of liposomal bupivacaine, but I always inject in that area directly in that area with a bupivacaine. And that seems to get them through at least the initial kind of discomfort.

    But long term, I haven’t had any long-term issues in that area, but it can be uncomfortable. But it’s usually this delayed discomfort that doesn’t require anything other than maybe just increasing maybe a little bit of ibuprofen.

    Dr. Sal Pacella:  Right.

    Dr. Andrew Trussler:  So another patient, large-breasted, doesn’t want doesn’t need an implant. Long chest, too. You can see where the chest hits, probably a longer IMF. I’ve tried to lift IMF. I think that’s really challenging. And I think those are the patients that could benefit from some reinforcement, maybe some agile flex or something like that. But this is an auto augmentation patient maintains volume as a look of an implant in maintain.

    Now, this is actually an interesting slide. This is a patient who presented to me that had implants. She had saline implants, I believe, like 430 CC saline implants, didn’t want them anymore, felt she was too big, and just wanted a little bit more. And I felt like it’s interesting when you remove the implant, you actually see the ptosis, the true laxity of the breast, because I feel like that capsule around holds the breast up.

    So once you take out the capsule, take out the implant, I put the PEC back down, and then so all the auto augmentation is pre pectoral and same wis8 pattern tissue mass that’s wrapped on itself. And then this is what you can gain a lot. She didn’t have a huge amount of breast tissue. This is a 400. I think 440 CC saline implant. And then this is her without the implant with an auto augmentation, no fat grafting.

    Dr. Sam Rhee: That’s very impressive because if you’ve ever seen, I mean, we’ve seen it, but a lot of patients obviously haven’t. If you take out a 400 CC implant, you get nothing. It looks like a completely deflated balloon. And for you to take that existing tissue and refashion it into a very natural and nicely lifted breast volume is very impressive, especially because you save them in operation. You basically did it in one step. You didn’t delay it, which is great.

    Dr. Andrew Trussler: That’s a hard one on that because the literature on that one’s out there, too. And yeah, I think it’s one of those operations where patients really present, say, I don’t want an implant, and this is an option. It’s not an option for everyone. It’s an option if you see through where she’s going to be after you remove the implant and use everything you can without deforming the lower pole or making it too tight. I think this is a really nice option, but it’s a challenging surgery.

    And on these patients, I do superior pedicles and then an inferior mound underneath of that because if you think about where the incision is, if it’s subareolar or IMF, you’ve really delayed the nipple, and you’re not really going to have a central mound, obviously. So I do superior pedicles on here. It’s a different type pattern, but same principle of I do anchor that lower mound up to the periosteum and then refashion it too.

    Dr. Sam Rhee: How much Ptosis are you willing to tolerate in terms of these patients? Like, how much Ptosis will you say this is not something that I would?

    Dr. Andrew Trussler:  Feel comfortable doing with a central mound. I feel like I do breast reductions. I do a lot of superior breast reductions. So I push superior pedicles a little bit in central mounds as well, I guess I don’t want to put a limit on it, but I have a pretty broad I don’t have a number to give you. And I think if you look on one of those patients, I think the third example, she had quite a bit of Ptosis, and that’s a central mound.

    And I think the blood supply to the central aspect of the breast is fairly secure. And so there’s no undermining under there. And I really have limited. I’ve had a couple of inferior aspects of the aerial or a little bit of necrosis, but they’re few and far between, not any nipple loss or anything like that. So I feel really good about that pedicle and feel like you can apply that to a lot of patients.

    Dr. Sal Pacella: That’s great. That’s great. Well, Andy, these are really great results, and I think it really represents an operation that is somewhat under the radar that we don’t necessarily offer patients very frequently because, quite honestly, it’s a lot easier to just put in an implant. But obviously, the potential for implant-related issues are high. So this is a really great option for them. How many patients would you say you’ve done in your career with this operation?

    Dr. Andrew Trussler:  As I said, the numbers probably, if I take like, implant removal, AutoAg, primary AutoAg, things like that, I’m going to say it’s approaching probably 1000.

    Dr. Sal Pacella:  Oh, it’s great.

    Dr. Andrew Trussler: Yeah, it’s a lot. It’s big. I do them not infrequently in my practice, and initially, when I first started doing them, they’d be in the massive weight loss patients. But now I’ve expanded to, as we said, implant removals really common, to see the patient who comes in that has already done that experiment where someone has put a big implant into a Todic breast to quote-unquote, fill it out, and a year later they’re in my office with enough breast tissue.

    It hasn’t been sacrificed. They haven’t done a lift, take the implant out, do an auto augmentation with a superior pedicle. I think that operation is probably what I see a little bit more frequently. But the primaries are great, they’re predictable, but it’s taken some time, that operation, man, it’s taken some time to get to where you can really call your shot on it.

    Dr. Sal Pacella:  Yeah, great.

    The Future of Auto-Augmentation: Contributions to Oncoplastic Surgery

    Dr. Sam Rhee: This is definitely something that is very technique specific, and I would say there’s probably a pretty good learning curve associated with it. And you’d really want to know exactly how you’re raising those flaps and how you’re positioning them in order to achieve that really nice result there.

    So I’m looking forward to seeing you publish this because I think a lot of people will benefit. But we really need very, like you said, there’s stuff out there, but not as much that would be very helpful from a very practical, specific, technique-oriented perspective that would help more surgeons achieve these kind of results in these patients.

    Dr. Andrew Trussler: Yeah, I think right now, if you look at the literature, it’s really veering over to Oncoplastic. I ran into Mike St. Sierra a couple of months ago, and he was really intrigued by it. And I think we’re going to put our ads together. I have this during the pandemic. I actually started writing it up, and it’s kind of been one of those things I just pick up and put down and things like that. But I feel like it’s an operation that’s going to need some explanation, too, because there is that learning curve. They do take me roughly around three and a half hours to do that.

    The other thing, it’s not a short operation; it’s not a quick operation. The recovery is very equivalent to any really, breast surgery. But, yeah, there is a pretty steep learning curve. I think hopefully the contribution would be such where I’ve experienced, hey, here’s how you graduate into doing this. But, yeah, I think there are patients that I’ll do challenging patients that don’t have that have a thin breast envelope with an implant, too. And just like that last result, I think there’s definitely a need for it. You can definitely get more than what you think, and the patient satisfaction with that, in particular, is through the roof.

    Dr. Sal Pacella: That’s great.

    Dr. Sam Jejurikar: The results are amazing, Andy. I can’t wait to see this in print because I think so many plastic surgeons would from learning your technique. They really are amazing.

    Dr. Andrew Trussler: Yeah, thanks. As I said, you work on this stuff, and I think one thing that I found is I’ll find things throughout this technique that don’t work, or if I have some scars, some bottoming out, I have had that. And so it’s just how to prevent that, but it’s approaching this in a really individual way because there are all these variables in there with breast tissue density, skin quality, all these things you have to take into account. And yeah, I think that’s all part of it.

    Dr. Sal Pacella:  Well, Andy, thanks so much. This has been great. It’s been great to see you. And we’ll have to have you on again to talk about some other things. And we’ll leave you with this, the Texas Longhorn. Okay?

    Dr. Andrew Trussler: No, man, it’s fight on. We’re coming back. They have been a sleeping giant.

    Dr. Sal Pacella:  Is it this, or is it this? How do they do it?

    Dr. Andrew Trussler: Fight on.

    Dr. Sal Pacella:  Oh, I thought the longhorn thing was this.

    Dr. Andrew Trussler: That’s longhorn. We don’t do that. Not in my household. In my household, Victory – V for victory. That’s good.

    Dr. Sal Pacella:  Sign it off, guys. Well, thanks. Alright, take care.

    Dr. Sam Rhee: Thanks, Andy!

    Dr. Sam Jejurikar: Bye!




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