Gonna introduce Alex, er, ask him to come up to the stage to er.
Conduct the final session on reshaping the brass.
Thank you, Alex. Good afternoon, everyone.
Uh, what a, a humbling honour to speak after Doctor Nahai.
Um, one of the things that I, I learned from some of the greats in our specialty is humility
and, uh, isn't it interesting to hear someone who wrote really the Bible of,
uh, blood supply on flaps, uh, at one point in his career he had little familiarity with
pedicles. It was really fascinating to hear that.
So talking today a bit about 3D simulation for aesthetic breast surgery,
friend or foe. Uh, again, these are my disclosures.
So you may recognise Doctor Nahabidi in here.
Uh, this is kind of a, a, a fun little picture that one of our PAs,
uh, generated, um, just AI, and it's a 3D picture which you know you could potentially
pass off as something real, so kind of a cheeky transition to,
uh, 3D imaging.
Uh, so we, uh, in our practise use Vector 3D by Canfield.
Uh, there's essentially simultaneous photographs by 6 different cameras,
and it'll give you a 180 to 360 degree images of the face,
breast, or body, and then these generate 3D virtual models which we can then see at
multiple angles. This is our setup, it's our photography room
and we simply have the machine there with a monitor that the patients can evaluate
themselves on. And so we use it for aesthetic and reconstruct
the breast imaging, facial imaging, and, and mostly rhinoplasty in my practise.
What do we know about uh 3D imaging data? Uh, well,
there's there's some out there. There's both for reconstruction and for the,
uh, aesthetic. Um, on the recon side, uh,
there's 3D imaging which was used to assess pre-mastectomy volume,
uh, to guide the reconstruction choices and help us achieve symmetry.
Ultimately they decided the value of absolute breast volume calculations from this 3D imaging,
uh, was limited. On the aesthetic side, this was a study that uh
was a prospective evaluation of 3D imaging on patient reported outcomes using the breast cue
and also on mammometric outcomes and so they had a randomised arm of tissue based planning,
uh, cohort and a 3D simulated cohort and then a non-randomized cohort specifically,
uh, which were uh choosing 3D simulation.
What was interesting is that their significant finding was that over time more patients
refused randomization and demanded simulation.
Uh, and, uh, that the stimulation did not significantly impact either the patient
reported outcomes or uh mammometric parameters and so ultimately this was not clinically
meaningful. So I don't think technology will really ever
replace uh our judgments and our examinations so biodimensional planning is still a very
important uh part of the process. So breast width and base width,
those are distinctions which uh we've all learned about and so we're assessing for
discrepancies in volume and projection. We use implant sizers in our practise.
Of course, what are the patient's goals and desires and then 3D imaging which we use to try
to align the patient's expectations with, I think realistic possible outcomes and where I
also find it very useful is for kind of assessing breast volume differences in
asymmetry which in many cases the patients don't always realise they have.
So it will help you actually choose round versus anatomic implants,
smooth versus textured, and it has a selection of the currently available implants in the
United States with really the full range of implant profiles for every single manufacturer
and I don't want to belabour the the point here, but.
During the consultation process, I actually hand the patient's implants,
saline implants, smooth and textured implants textured implants are still available in the
United States, but what ends up happening is we also, it's an FDA mandate that we have to
discuss ALCL and things like breast implant illness and quite simply detection implants
they always pass back.
So my practise is really a 100% usage of smooth round implants even though I don't always love
the results that's just kind of how it is.
So we'll start with a quick first case. It's a 27 year old who was seeking a primary
augmentation, seeking the subtle enhancement and she's bothered by the lack of medial
fullness and the lack of uh opropole volume.
So these are 3D assessments again, they're never replacing our own measurements,
um, but one of the things that it actually showed is that her right breast is slightly
larger. And she's got reasonable symmetry of the
external notch to nipple and the nipple to breast folds,
and on my exam we kind of found a 12 to 12.25 centimetre base width.
She had about a 2 centimetre uh pinch thickness and if you see here on on the uh virtual
assessment, it's about a 14 centimetre or so wide, uh,
width if you were to subtract again 2 centimetres or so,
uh, it's actually quite accurate with what my own exam was.
So this is the first simulation with kind of low plus profile implants at 265 ccs.
Uh, the system will automatically highlight, uh, the base widths which are very close,
uh, in, in measurement there.
So a nice enhancement, but it still lacks the medial fullness which she wants.
And so what we can actually do is, is reposition the implants,
uh, to kind of give her an idea of what, uh, more medial fullness would look like.
And so this is kind of showing um uh without changing the implant sizes that with one
implant size she's gonna have a larger uh result members about roughly 50 cc's larger on
the right, but it does show her what potentially more medialfulness would look like.
And then I'll also show her kind of a a subtle simulation and then a more significant
simulation to give her a better idea and help her kind of uh choose what size she may desire.
You can also see multiple video views.
So she's sitting there on the monitor really evaluating herself uh with different potential
size implants and in different positions.
So this is her postoperative result.
Alright, reasonable result.
And then interestingly these are the actual implants that we use only 45 cc difference,
which is not far off from the assessment, uh, from the 3D simulation.
So our next patient again another primary augmentation, um,
slight volume difference which you can see the left breast does appear slightly,
uh, bigger, obvious nipple asymmetry, uh, and our goal is again moderate enhancement and
improved cleavage. And so one of the nice things is that often
times patients don't realise certain things even though to us it may seem that there is a
lot of nipple asymmetry, being able to visualise it on a monitor often can be helpful.
And so this is showing a roughly 25 cc volume difference.
Uh, you can also see it in different angles which helps her appreciate a bit more,
um, again showing side by side comparisons, one kind of more of a moderate augmentation than a
more significant one just to give her a sense of what it would look like and that if we use
the same size implants, how, uh, uh, much asymmetry may be developed again,
side and horizontal views for the patient to compare.
And then this is something that they also often quite appreciate is what would it look like
with a bra or bathing suit on, um, if they like leopard, if they like pink or blue,
they can all kind of auto select for that and this is really one of the favourite things that
that patients enjoy and it also kind of lightens the mood of the consultation and it's
uh typically this is kind of the point where I feel like I just converted the consultation.
So she did end up with a low profile plus implants slightly different just like the uh
volume assessment predicted.
Um, this is a kind of a pre and postoperative vector analysis.
If you actually look at the volume differences based on the implants we place,
it's actually very, very, uh, close to accurate, and this is her with the implants kind of
settling in nicely. Next patient, another primary augmentation,
she actually presented initially seeking a rhinoplasty, but when we did her 3D morphing,
she inquired about the breast portion of it, and her goals were to be as big as possible,
so very different from the first couple of patients.
She also did not like the idea of different size implants.
It was kind of a very confusing concept to her.
These are H 3D assessments. You can see there's a pretty,
uh, considerable difference in volume almost 90 ccs or so.
And so for the first simulation we did a full profile 450 cc implant,
the goal of showing really more potential for the the asymmetry if we were to use the same
size implants. So we did one simulation showing if we use the
same size implants versus actually changing them she was actually able to appreciate that
there's a pretty significant asymmetry and finally came around to uh allowing me to use
different size implants.
This is a really kind of a useful tool. It's called an image overlay where the
patient's preoperative image is overlaid with the simulated uh potential implant size uh and
they really seem to like this and appreciate what the potential augmentation or enhancement
is. Uh, this is her 4 weeks post-operative, but
obviously the implants are, are still quite high and will settle in nicely with,
with time. So next patient, uh, she was kind enough to
send this picture off of her, uh, social media, uh, which looks like a,
a reasonable augmentation, but you know, 3D, uh, sorry, social media always tells a different
picture. So this is how she presented.
She's a 25 year old swimwear designer. She's complaining of asymmetry,
ptosis, and large areolas, and she came in seeking an augmentation and a lift.
So obvious things like external nogen nipple asymmetry, volume differences,
uh, lack of upper pole fullness, and she also had prominent stray on the breast.
And kind of see how that shows in in her own swimwear line uh in these in these images so
this was her 3D assessment, all the obvious clinical findings which we discussed including
the larger right breast.
So we discussed the mastopexy with her, um, what we did was kinda show her a mastoexy
without any volume enhancement in one width which only really a very moderate augmentation.
And it actually kind of backfired because not only now does she refuse a circum vertical scar,
uh, she demanded a circummeolar scar which I think would be very challenging on her,
and she also desired larger implants than we, uh, uh,
actually had simulated and based on that I essentially guaranteed her a scar revision,
but that's how she wanted to to proceed.
So here she is 18 months post op, which as we expected very poor scar outcome and and
widening of the areola. These are the implant sizes that we chose,
but ultimately she is improved, uh, with symmetry in her upper pole volume and the plan
now is for a scar revision.
So really did the 3D simulation help in this case?
Well, certainly we had uh improved symmetry, uh, volume enhancement,
and we got some moderate ptosis correction.
But ultimately I think her actually seeing her circumvertible scars on 3D simulation uh may
have hurt the, the ultimate result.
So in summary, um, 3D simulation and breath aesthetics, friend or foe,
um, the published data really indicates minimal clinical utility.
Um, the actual imaging calibration is not always ideal and can lead to distorted pictures,
but I do think the volume analysis is actually fairly accurate,
um, the patients appreciate visualising, uh, visualising themselves with various implant
options. It really helps them understand their
preoperative condition.
Also I think it can drive consultation demand especially if colleagues in the in your region
or area don't offer it, so this ultimately is my conclusion.
thanks very much. OK, let's, let's get Charles up
as well, thank you. It's gonna talk to us about immatia.
Correction perfect thank you.
So this lecture will be slightly similar to the previous one because Both of them are
handing mal position.
Um, so I'm having a a little bit slightly different take on this one though.
Thank you. So I've been assigned and and share my
experience with Sebastia and what I think about that, so these are my disclosures.
Um, This is a patient that was sent to me, Asher from Australia.
And um the question is why?
Why does this occur?
Because the surgeon most likely did, poor planning.
Or for surgery.
So everything starts with the question why?
Or both Then, followed by how?
How do we solve this problem?
One word education.
This is really one of those complications that really don't need to happen.
Uh, in primary breast dogs.
So education is about dissecting a tight pocket, if smooth,
less than 1 centimetre of implant width.
No touchstone on sternum recommended to be 4 if subglandar 3 if submuscular.
Preserve cooper's ligaments if subglandular.
Don't fall into the trap of trying to please your patient with a very tight cleavage.
They come in and they show these very tight cleavages and they say,
yeah, I wanna have 0.5 centimetre, a very fake look.
That's when you start getting into trouble trying to please them.
And obviously less is more.
Of course if you try to put a big implant in you need to size the pocket and the chances of
having that problem with a high profile implant if it's big is even higher because what
happens is when you go very close to the sternum, the pressure would raise that tissue.
However, reality is that due to multiple reasons this complication might occur.
So what, what might be a surgical solution?
The most predictable way is to remove the implants and let it heal for at least 3 months.
And I've learned that the hard way. I've tried basically everything.
One of the things with age is that you have a lot of revisional surgery patients coming.
Both your own but mainly I have to be honest from outside having to have problems solved,
and I tried a lot of different things and one of them is of course trying to stitch the
capsule together put different type of techniques pushing down the medial aspect.
And honestly, the best way in my hands is to remove the implant,
remove the capsule if necessary, and just let everything heal and then go back.
However, If a patient doesn't go want to go for a two stage,
I combine this with popcorn and a texture device or a smooth with a
mesh. So this is that popcorn technique once again so
what it does is with that isolated forcep white teeth, so it doesn't
cheese wire you take that thin capsule, which mostly is the case in these symethia patients.
You take that and you basically shrink it.
And that's the whole concept behind popcorn.
And don't be afraid that you'll create, well.
With decent surgical skills, you won't create capsule formation or seromas or necrosis.
Now the alternative is.
If you combine this popcorn and mesh in one stage, using a smooth implant,
if you decide not to use a textured one, this is the planning.
I'm using um.
Gala flex hammock concept here, so what you want is this is in the lower pole,
but I'm using the same concept of course immediately I'm just shifting at 90 degrees.
But the thing is, I'm shrinking the pocket, and at the same time I'm stabilising it even more.
And why is that?
Because there very often isn't enough stability.
If you try to put that the patient puts on the bra, and just the mechanical factors will
create a scenario where you might get into trouble again.
So that's why I'm using a mesh in those cases.
And I end up using that mesh immediately using these pellets in the same way.
I removed those stitches after 4 days.
And that medial portion then is protected.
Due to the mesh to create a new cinemasia.
So this is a case where I did before surgery 1.5 kg.
I removed the implants.
I did the popcorn.
I shrank the pocket and I went back 6 months, uh, uh,
3 months later, and this is 6 months after the second surgery without any master Pixyar.
So what I'm trying to say is lesson learned.
Very often the best surgery is the one we don't perform.
Have patients convince the patient of the benefits and you'll actually be able to avoid a
lot of unnecessary surgeries, like in this case mastopexy or with the simastia,
maybe a 2nd or 3rd procedure.
Make them understand the benefits.
And this is with an implant of 350 going from 1.5 to 350,
just by doing this.
So my conclusion Avoiding Semetia.
Dissect -1 centimetre of implant weight if you go for a smooth.
No touchdown on sternum recommended to be before if subglandular preserve Cooper's
ligaments, avoid violating and cutting, and if you need to reinforce,
detach and reinforce, use a like ate stitch and less is more.
If surgical intervention two stage.
Safest alternative, popcorn, combine that with a mesh or with a textured without the
mesh, use a textured or polyurethane implant.
And the second time definitely less is more.
So with this side if you ever come to Stockholm, this is the clinic.
At the hospital in the archipelago, you're more than welcome to get in touch with me and I'm
gladly share some of my insights and with that said, yeah,
all the faculty all colleagues, thank you very much for having me here.
Thank you very much, Charles.
Uh, we're a little bit over. Have we, have we got time for questions?
Yeah, just uh, just one question each.
Um, Alex, very nice presentation thank you. um.
I just I just don't kind of get it, the vector, um, and I,
you said it right now, this is not against you, but I mean none of those images look like your
post-op images, and I see so many of those presentations, and they never do.
And um it's a lot of money, it's a lot of time.
Is it worth it? You know, I, I consider just an adjunct.
um, there's, there's always a disclaimer on the screens as well,
and we always tell patients whether it's rhinoplasty, uh,
or for the breast that that we, we're not guaranteeing certain types of images.
So it's really for a patient to kind of just get a better idea of of what does it look like
with a, uh, increased projection, uh, or what does it look like with a scar and a nipple in a
different position. So by no means is it meant to be an exact
representation of what the postoperative result is.
Going to be, but you know, sometimes putting sizers on and they're they're wearing a vest
it's really kind of uh not exactly representation either,
right? There's always more projection than the end
result will be, so I think visualising themselves, uh,
with, with a certain type of result is is a bit helpful.
And do you think it lengthens your consultation or shortens it?
Um, I, I, I think it probably lengthens the consultation a bit.
Um, they, they often want to see different types of sizes,
um, but I, I do think it helps convert the console in,
in many cases for me. OK.
Um, Charles, do you use, uh, imaging?
I don't, but my staff do.
OK, so in that sense I'm using it within the practise.
I think it's a helpful educational tool personally for me and and with the doctors I
have, they don't use it really to.
To help them select the implants, however.
I believe it is a very helpful tool. I did a study many,
many years ago due to the position I had and Allegin having that,
uh. These devices and they said as a KOL you have
to, so I did a study on 170 patients and the most stunning thing that I learned with this
well there were actually three things was that um we,
we have a talent, we can see things in our heads three dimensional.
Patients don't. So when they see this 3D image it gives them a
picture and clarity, so the conversion rate doubled.
It's, it's interesting. The second thing is.
Uh, uh, some of these patients, uh, very few thought it was too big,
but actually some of them had the, the, the image that it was too small,
and you all know having that discussion afterwards with the patient that's not happy so
by seeing that and getting back we actually maybe size them up slightly to satisfy them.
So it avoided some of the problems, so uh uh I don't work with it because I think it's time
consuming, but from a financial perspective because I heard your question,
I think it's worth its value in in assisting patients, understanding the education you're
telling them about the procedure and the results of that procedure.
Claudia. But
Aren't you afraid that the patient captured the, the image and says after the post-op
period is not equal what what you showed me before?
Uh, it's, it's a very real possibility. I actually,
uh, especially my rhinoplasty patients, I, I welcome, uh,
the fact that they can take a picture of it, um, but we make it very clear these are not meant
to guarantee any type of result postoperatively. It's just as Charles mentioned,
it's just an educational tool.
Um, I mean, I, I, I, I think, you know, imaging is, you know,
you kind of either like it or you don't like it. I don't think it's a right or wrong.
I never got on with it. I didn't like the vector,
I didn't really like the crystalix, didn't, didn't really add anything to me.
I used to look at the predicted images and think, God,
I can't show them that.
Um, you know, I know I can do better than that.
Uh, I'm gonna lose the patient if I show her this, you know,
so that, that was my, you know, and, and I said, I, I do look at these presentations.
I don't think the images look particularly like the postoperative images,
but I can see how visualisation and volume, you know, is,
is, is a concept which they might find useful. But anyway,
it, it's interesting. One final question.
And yeah, just elaborate, I absolutely agree with you and I,
I, I have the same ego as you have believing that my results are better than the machine,
but they actually are, and I tell the patients up front,
listen, this is a machine. It can never produce what I as an artist can
create with your breast, and that's a fact.
You'll just get a vision. So I'm very clear about that.
However, when it comes to rhinoplasty, I don't use them.
I do not use them for rhinoplasty.
I early on did, and this is many, many, many years ago,
I took that away because rhinoplasty patients is a,
it's a different thing.
I'm using the crystalix and I'm not using the I'm using the the Allergan,
what's it called? I don't even know the name anymore of this.
Well, I'm using it to give them a picture. The rhinoas patient though,
they come back and they tell, so I removed that within my practise.
Sorry, you were about to ask me just one question on your Samastia with your nano
smooth, do you think there's a higher incidence of Sebastia compared to other devices that
you've seen? Yes, absolutely, with any smooth,
uh, if one uses a conventional technique.
Yeah, of course your adaptation.
Precisely, but with, with the, with the nano in particular because of that very thing,
absolutely. I mean, the thing is, for me they're magic
bullet, but as a magic bullet, they're also extremely dangerous if you don't know how to
handle them. So yes, because there is no interaction.
And if you go too tight, whether it's sub muscular or sub glandular,
you get into trouble.
It is and over time, but if you use them precise like I showed you a couple of cases,
you know, you have to know your surgical technique.
It's like uh um some of these cars, you know, you think you can drive them,
you get out there and you crash them immediately.
It's just the way it is. You don't know how to drive.
Good, well, I think that brings us to the last session, so thank you very much,
thank you.