Thank you very much. It's been a wonderful symposium.
Very honoured to be here and share some thoughts with you.
These are my disclosures.
So I think all of us who work with uh breast implants in a reconstructive or aesthetic
setting, this is a chronic problem. One of the in the previous panel we're talking
about what what's an issue and uh uh one of the primary issues is how do we deal with rupture.
So we know the data, the data, uh, that's listed from the,
uh, core studies from the FDA by the manufacturers are compromised by,
uh, variations in how the rupture is measured. So that's at least partially why we get such a
wide range. I haven't included the non-US uh devices such
as Motiva, which they do have data, but it's, um, uh,
not, uh, through the FDA yet, so this is only FDA approved.
Um, saline implants, uh, generally have a little bit more accurate data,
I think, because you're not, you're able to detect when a true rupture occurs in a saline
implant, whereas in a silicone implant, you're relying upon either an examination which may be
faulty or a volunteer, uh, a voluntary clinic visit which may or may not occur.
So it turns out that there are different ways that the implants can rupture.
We know this clinically, we know this logically, um, but histologically,
there are differences between an actual needle or a puncture or scalpel cut
or fatigue wear.
And it turns out that this is not something that's been analysed quite as much as it should
be given that ruptures, as you saw, can happen in 25 to 30% of our patients at 10 years,
depending on the device.
So this is a study out of Health Canada, uh, that was cited by Doctor Wikstrom,
who I'm not sure is here, uh, but he and Doctor Handel did a study in which they looked at this
and as I was researching this topic, what was really interesting to me is the fact that
surgical instrument damage accounted for 5 to 2/3 of the ruptures.
Now, if you think about, well, when would surgical instrument damage occur in an implant,
it only occurs essentially at time 0 or if you're taking it out.
So if it turns out that half to 2/3 of them, now other methodologies like fold flaw,
that's in the previous uh histology slide, it showed the kind of wear pattern.
These are clearly distinguishable as long as we're looking.
And again, the theme from what Doctor Rehnquist and Doctor Nahai were talking about with the
last panel is sometimes the problems that we pose to ourselves are because we're not
actually looking or the data isn't uh granular or obvious enough.
So if this is true.
We look at the data that we have here, some of the data that show this Kaplan Meyer curve of,
of, of when ruptures occur. It's always this smooth,
gradual kind of uh cascade.
But if half to 2/3 of the ruptures are happening at time 0,
this is false.
What's actually happening at an incident level is that we're getting a lot of these ruptures
happening at time 0, and then the fold flaw or the wear and tear pattern is slowly,
we would assume that that's gonna accrue over time.
And the only reason we never see this is because we are not checking.
We're not checking until, as in our case in the US, the FDA asks us to get an MRI at
5 or a high death ultrasound at 5 to 6 years and every 2 to 3 years thereafter.
Or if there's a clinical need. So if you think about it that way,
this pink line which shows the true incidence of ruptures should be reflected in a cumulative
instance that peaks right around 5 or 6 years when we're catching all of those first.
Ruptures, and then it slowly goes up as we start catching the slower accretion of the fold
flaw. So I think that this is a problem.
So what the fact that we've got curves that we're seeing in our literature that are at odds
logically with what we would predict to see, I think this tells us that there's a lot more we
don't know about ruptures than we are willing to admit to ourselves.
So of course, there are other things to deal with uncertain.
just with the detection. So just because you say,
OK, I'm gonna get an MRI, it doesn't mean that you're actually detecting ruptures with a true
positive predictive or negative predictive value.
We all talk about this linguini sign. We're not radiologists,
but this is apparently the way they determine it.
There's also something called a teardrop sign.
So this is an example of what, uh, a patient of mine, the radiologist pointed out.
Yes, this is a teardrop sign, uh, linguini, there's intracapsular rupture.
Well, it turns out we went to surgery and there was no rupture.
And so this is something we have to remember when the studies quote 90% sensitivity and
90% specificity, that's not 100%.
So there are times now in this patient, she had gel bleed,
which is a different phenomenon and because of that, and the implants had been there for a
while, I think it, it was.
Presumably justifiable, but the dynamics and the logic behind when to take these implants
out, what we counsel our patients, and how frequently we're checking,
all of that calculus of risk and benefit and decision making,
in my view, is still flawed.
Now we look at ultrasounds. I think ultrasounds are really maybe a
potential solution because now in our offices instead of waiting for our patients to get an
expensive MRI go someplace else and maybe have cost prohibitive kind of economic reasons not
to get it, they just come into our office and we can,
uh. Be facile with it.
The problem with this is, so you've got in caps, there's something called a step ladder sign,
a snow storm sign. The problem with these two things is that you
have to be good at it. You, there's operator dependency,
and oftentimes you have to get an MRI to confirm it.
And even in the best hands, you're still not getting the best positive predictive and
negative predictive value.
So, how do we know that this is actually a problem?
My hypothesis that we're under uh reporting or underrecognizing these issues.
This is a nice study. Again, the Scandinavians have some really good
studies out there that are population based and. With the homogeneous demographic they can
really control for a lot of factors that we can't in the US,
but they did an MRI on all of the study patients in question at 10 years and 7 years
for submuscular. What they found was 27% true rupture rate.
So that's important because that again, it's an older generation,
it's stratified, but that's, they checked everybody.
It wasn't just somebody who had symptoms or somebody that clinically the,
the surgeon had suspicions for or there was lost to follow up.
These are the actual numbers there.
The other thing they did, which was pretty neat was they correlated this with lab study,
so they actually drew blood and looked for things that would be suggestive of connective
tissue or autoimmune disorders to see if there was a relationship and they found that rupture
versus non-rupture, there was no. Relation again this is one of the questions our
patients come to us they find out they have a rupture, they're in a panic and they think that
they're gonna either get autoimmune or cancer related issues and this is a study that can be
quoted saying definitively, no, your lab values aren't gonna change,
you're not gonna get a difference based upon that.
So this is uh from uh yesterday's slide basically showing our own version of the study
in which we looked at the RNA gene expression, so very sensitive measure of what's going on
underneath at the cellular level, and there was no uh change in that.
So in terms of the issue of timing and, and clinical scenario,
as you can tell, you know, I, I think before we even talk about when and how we should take out
these implants, I think the problem is knowing when they're truly ruptured.
And of course, with saline, that's something we can tell.
But with silicone. I think a lot of our surgical technique depends
on what we're finding here.
This is an example of something we've all seen, which is a very thick capsule around the
implant, and I think the degree to which that rupture has cascaded into a problematic
capsule um is the degree to which.
We, uh, intervene. So what I mean by that is if they have capsular
contracture with a rupture, it's long standing, greater 40 years,
then we're gonna try to do if they were pre-pectoral a pocket change.
We're gonna try to do in my view what I call an on block capsulectomy,
but I'm not doing it for symptom reasons or BII. I'm doing it to get.
Rid of the calcifications and give us a soft envelope afterwards.
Oftentimes we're not able to tell what the implants are,
so how do you do that? Well, it takes some clinical judgement.
You're gonna have to feel the breast maybe a little bit more and try to get granularity on
what the size is, knowing that over time that apparent size is gonna be contracted in that
space. Um, and then you're gonna have to order a lot
of implants. You can do the Archimedes principle,
which I've done sometimes when a patient really tells me,
Doc, don't make me any bigger than I am, in which case we,
we can put it in fluid, measure the fluid displacement, and kind of tell them,
listen, this is what we measured intra-op that we took out,
and this is exactly what we took in, uh, brought back in.
Um, is a situation where, uh, another case where there was unknown implantation here,
oftentimes a patient, the question is, do you just replace with another silicone?
Sometimes the patient will ask you this as well. Say, Doc,
is it safe for me to do silicone or saline?
And honestly, in situations like this where they've already had a ruptured implant,
if they ask me, then I, I tell them that it might be worth considering saline because the.
Issue of detection, which is the first part of my talk,
and the uncertainty around that is no longer an issue with saline implants we all know that you
should within a, uh, a couple of days know that there's a difference and we can counsel a
patient that that might be an approach to take there too.
And again, what drives this sort of, um, uh, the capsulotomy versus a capsulectomy is
strictly the degree of calcification around that uh around that implant.
Uh, this is another patient here that we're removing, um,
uh, ruptured silicone implants, but she did not have that tight capsule.
Now, in fact, it's, it's often the case that the shorter the duration of that rupture,
the less the degree of capsule, and this is what I mean.
In her case, I didn't do an en bloc capsulectomy.
Relied upon capsulotomies found, uh, again the rupture there and the question there this,
uh, you know, the question on the ruptured side is are we looking at something that was there
from day zero and that's just progressed over time, um,
and that again histologically knowing this data, I would say that chances are statistically
that's exactly what had happened, um.
And this is, uh, again, the issue that we don't have to do capsulectomies capsulotomies are
fine. Uh, this is another patient, but this is saline
rupture. Now saline rupture itself, you, you know,
we've seen saline rupture oftentimes we're catching those early,
but sometimes they are late or sometimes they're associated with a texture,
uh. Capsule as well and in this case she had
capsular contracture she also had this kind of issue here of uh chronic skin condition which
we'll come back to later.
So again if possible in this situation we'll try to uh do a pocket change um and what
was interesting is in her um.
You see this, and, and for those, uh, other kind of high volume users,
I, I, I would query, I still don't know what this is.
I sent it for pathology which was negative cultures unfortunately we're not uh.
Were actually not sent even though they were requested so that that's a problem but it
clearly looks like some sort of bacterial contamination uh in both of these saline
implants, but took out that capsule um and didn't because of what I saw.
I decided that I wanted to remove everything associated with it,
do a vigorous washout with the pulse lavage uh because I saw what clearly seemed like
bacterial contamination creating or contributing to that capsular contracture.
And you can see her this, she, she was done in the last month or so,
so this is my post-op follow up and uh better result, but look at what happened to the skin.
So what's interesting is I think that she might have had some sort of reaction to the whatever
was contaminating that that uh saline uh fluid and it was contributing because because the
skin condition has cleared dramatically and again I'm not sure.
So, what about those rare cases where a patient has a ruptured saline implant and decides not
to do anything about it for a long time?
The problem is that you get tightening and contracture of that skin.
So this is a reason if you have a silicone implant rupture,
I think you have, because the volume's not changing, you don't have this aesthetic hurdle,
you have to uh overcome and it's just a patient kind of facing issue of a patient anxiety,
which of course is important and we want to keep our patients happy,
but there's no, in my view, a, a. Pathologic or clinical reason to take these out
right away. I think with saline implants there is more of a
reason and in this case where there was such a discrepancy, this was a breast recon case that
was referred to me from another surgeon um I felt like I had to basically do what we
sometimes do, which is rupture or take out or puncture the other side,
um, and she wanted to be the same size, so I, I just.
Followed her. I waited to see when she actually developed a
similitude in terms of the skin envelope, and it took about two months where I thought,
oh, things are about the same, and thought, OK, she wants to be bigger.
We talked about everything and she didn't want to go straight,
uh she, she wanted to be bigger, and I thought what would be safer for me is to put in an
expander because I could control the position of the expansion.
I was wrong. I couldn't control it for whatever reason,
the skin envelope was different.
But of course when you put in the tissue expander, you're setting an expectation that
this is not the final result.
So I had a second chance at it, not a perfect result.
It would be nice if we could fat graft and you know I'm not gonna put this on my website,
but I think going from here to here, uh, with that approach of kind of contralateral,
uh, uh. Deliberate deflation giving time for the tissue
to settle and then either going with a small implant or in this case with an expander is not
unreasonable. So in conclusion, I think we've got rupture
issues. I think these are unclear in terms of how often
it happens, but I would counsel you to think about that,
uh, Health Canada data which suggests that many of these ruptures we're seeing we're causing
ourselves more than half of these, um, and thank you very much.
Right, thank you, John, and have a safe journey back home and now we welcome back Charles
Rehnquist who's going to give us lectures on how to stabilise an unstable implant.
I couldn't agree more with than with Doctor Kim regarding ultrasound.
I think every facility that puts implant in would benefit from having ultrasound very
good today and very efficient and actually add a lot of value not just to your patients but
also to your practise.
So with no further notice, what I'll be talking is about hopefully guiding you how to avoid
implant laterization map positioning basically.
My disclosures.
We can avoid implant mal positioning.
By finding the right balance between the anatomy of the chest,
the quality of the skin, and the soft tissue, characterises on the native breast.
In addition to an understanding of the breast tissue to implant relationship,
that's really the key, patient selection.
Find the right implant for the right patient for the right reason.
So finding the perfect balance between shape, size and weight of the implant in correlation
to the soft tissue is a true challenge.
And understanding that most likely patients with good soft tissue elicicity,
smaller and tighter breasts, will have fewer risks than those with weaker tissue and poor
soft tissue elicism. This.
We're talking about unstable implants, we're talking about smooth devices.
This accounts for all patients, but especially for these type of implants in these patients.
One of the things that we found through our data is understanding that conditions such as
pseudotardic breasts, stretch marks, and Ela Dana syndrome may require further attention
around civilization.
You have to be careful with those patients.
I hope everyone is aware what Iodanis syndrome is, but basically if you have 5 out of 9 over
extending your joints and your fingers, etc. you're erodontists.
And most likely you have a predisposition of having a stretch tissue with that.
So the challenge with the nano smooth, and those are the smooth I'm working with,
is its surfaced by compatibility.
There are pros and cons with all devices.
These are super smooth in the sense, they give a very thin capsule.
So by definition we'll have a free floating implant with minimal interaction to surrounding
tissue and we'll have a less predictable tissue stretching over time.
Now, Are we able to conquer that?
Are we able by surgical or other measurements or measures control that those.
Well, This is what we might end up with if we don't, the bottoming out.
Obviously this is a too big pocket on overtime in my position.
However, this is not with a smooth device.
This is with 1.5 kg of textured device, which obviously is stretching
over time. 7 surgeries to get here, but she was the
playmate of the year when she came to me, but it had consequences.
Now early on when I started working with these devices, um,
believing that they had a surface that were like microtextured because that was
introduction, I used fairly big implants and this is a case,
and after 5 years, and although there is a balance in that breast,
in my world, that is a heavy looking breast uh bottoming out.
I don't like it for aesthetic reasons, and it's more obvious from the very side view.
The nipple is really looking up and the balance is not there,
but. Between the upper and the lower pole.
So What is lateralization of the implant? Well, the problem with a device that doesn't
interact through friction or interaction through ingrowth is that over time they
lateralize. Now initially people talk about that's a
natural look, but when they up in the axilla it's not that natural anymore.
It's actually quite anaesthetic and as you can see, this implant is really big.
And the problem is that a lot of surgeons still believe that they should massage their implants
and maybe there is a reason. I haven't seen any scientific evidence of
lesser capsic contraction, but what happens is you create a tight pocket and then you massage
it out of its position.
And if you put that implant under the muscle even more so now I developed and presented at
the Atlanta Breast symposium. 2008.
The popcorn technique.
And as you can see, I'll just try to lower a little bit.
And as you can see what I'm doing is I'm using uh isolated forcep with white
teeth and I'm grabbing that thin capsule and by grabbing it and putting it on Colorado tape,
I'm able to shrink it from inside so it pops. That's why I called it the popcorn technique.
And by doing so I can really shrink the whole pocket and I've shrunk it more 50%.
And if I decide to do two stage, I still shrink it.
I don't put an implant in, but in one stage you can do that and put an implant in.
Now The fear I had initially was seromas and capsic contractures,
but if you do this the right way and you just grab this and put it together.
You put a drain in to lessen the vacuum to strengthen the,
the vacuum effect uh there is very little fluid and we haven't had any capsule contractures due
to this procedure.
This is the same implant in the same pocket just for educational purpose to show you the
strength of this technique.
Initially when I started working with Smooth, I had the fear of.
It won't hold up. The smooth, not interacting will give a
displacement, so I use meshes.
However, I've abandoned that today. I just put the implant in there and I rely on
the inflammatory reaction creating a capsule scar formation.
So We can avoid implant map positioning, and that's really the most important,
how do we do that? Well, and achieve implant stabilisation by.
Wet blunt cooper ligament preservation.
So I've developed a surgical technique today with the smooth devices that really helped me
create a more stable environment for the implants.
Implant stabilisation by Cooper ligaments preservation.
So the question is, what is Cooper's ligament?
Well, Cooper's ligaments are bands of fibrotic, flexible connective tissue that shape and
support the breast, and actually first described by British surgeon Ashley Cooper,
ligamenta susporia mammalia.
And how? How do we preserve these?
And avoid by avoid cutting them.
So this is a small video.
So Um, it just shows, so today, one of the things is of course that we have,
uh, I have very short scars, if the video plays.
It plays, but there is no movement, gentlemen.
Here it is. So, um, one of the advantages with these smooth
ergo 2, which are mainly the implants I'm using today, we have fairly small incisions up to 400
ccs we're able to put them in with a funnel 400 cc's.
So what I do is uh I do the incision. I go down with the Colorado tip.
Through scarpus fascia and that's basically uh the cutting I do.
And once I reach scarpus fascia, what I do then is I'm uh
identifying where the fascia and where the muscle is.
Once that's done, I have, and this is where I'm cutting so I really got the fascia,
as you can see what I then do is that I do uh wet infiltration.
So I'm basically.
Creating an expansion, a pocket dissection, a wet pocket dissection.
So I'm injecting around 150 of fluid in one point in the centre under the nipplelorela
complex. So When that's done
What I do is I go in with this instrument and I create the channel.
The first channel I go, and the pocket is very limited.
It's 1 centimetre less than the width of the device because I know these devices
don't create capsule formation, so it's a very thin so I really want.
So I go in and as you can see now that fluid comes out,
but that's the expanded pocket.
And as you could see there was hardly any red blood cells and then I've got one of these face.
Tools that we normally do the face dissection with and I just release.
The, the, the pocket, I released the gland from the fascia.
And this is actually live surgery done in Dusseldorf a couple of weeks ago.
And then with my finger 180 degrees, totally different than what I used to do or I still do
with the texture device. I'm just releasing those bands.
And with the help of the fluid, it's extremely easy.
So once that's done, And I manipulate, so I put what I call my
lifesaver in there to see if there's any blood.
And I remove it And um, guess what, it's dry.
So when once that's done, what I do is.
I will give you the endoscopic view of how the, Pocket looks like,
I'm going in with endoscope and it's for educational purpose.
I don't do that during the surgery, of course, normally, but as you can see,
I've got this beautiful plane.
There's no bleeding, it's very clean, but what's more interesting is when we go medially,
you'll see the Cooper's ligaments.
And these are stretchable ligaments.
And but they're preserved. I did not cut through and as you can see,
we're going lateral now, those are the Cooper's ligaments, you see those fibrotic bands?
I'm not cutting them, and that's implant stabilisation by preservation of those Cooper's
ligaments. So once you have that, that implant will
actually stay there over time.
Now once that's done.
I put one of these stitches.
What I call the lucky first, the funnel.
And I put the implant into the funnel.
Here you can see, so it's a fairly small incision, so it's very difficult to do this
without a funnel. And I squeezed the 3:30 implant into that
pocket. And then of course what's important is when you
do this, it's easy to flip an implant so you need really to go in with your fingers and feel
that you've got the patch on the backside.
OK, once that's done.
I put the lucky 8 stitch, which is a sharp needle with a braided stitch.
I grab the pericardium periosteum. I go from inside out grabbing scarpus fascia
and from inside out grabbing scarpus fascia.
I'm looking at my data now and most likely I'll abandon this stitch with this technique because
I don't, I don't believe it's a necessity anymore.
I think it's stable enough without that stitch.
So with that, sorry, I don't know what happened with my computer,
gentlemen. Hm.
So here we are back in business. So.
So these are some results. This is uh on a patient before this is the plan
I managed. Thank you.
This is uh 140 cc implant.
Oh, sorry, or you can't see it. How do I back?
Something happened. I'm sorry about that,
gentlemen and ladies.
Anyway, 140 cc.
A small implant Very flat I have a precise pocket minus 1 centimetre
subglandular 2 years down the road, stable, which really wouldn't be.
Very strange considering it's such a small implant.
But I think a fairly natural.
Good looking result. That's a 3D image.
This is 360.
After 6 months.
As you can see, she had some asymmetry, a lower the fold,
but even in lowering the fold, with this technique, preserving the Cooper's ligaments,
not cutting them, I was able to create a fairly stable result more symmetric.
So with the presentation 4 months ago, the rupture rate and the capsule contracture rate
are very low, and with this technique.
I'm able to control the pocket which was the dilemma which was shown in the early study we
had mal positioning.
However, there are still situations where preservation might not be enough.
And I want you to be very careful with patients with excavat men smooth implants.
What happens is you have that smooth implant, they put the bra on it and it looks like a uni
breast. And in these cases what I do is I do still use
textured anatomical implants, rotating them, using the volume distribution of that implant
medially, and I've got the stability even with a bra.
So I think it's important once again pick the right implant for the right patient for the
right reason and you'll have long term good results.
So my conclusion, avoid mal positioning by dissecting -1 centimetre of implant with with
these nano smooth implants.
No touch zone on the sternum recommended to be 4 centimetres subglandular.
Preserve Cooper's ligaments, avoid violating the IMF if IMF.
Is violated reposition and taking conservative approach and precisely infirming reposition of
the fold, and guess what, less is more.
With dad said thank you very much. OK.
Patrick So Next up,
Patrick Mallucci, kind of going the same direction.
And let's see how he does it.
Yeah, let's do that.
Really? Yeah, there we go.
So, um, thank you once again, um, these are my disclosures.
Uh, how to avoid lower pole stretch, um, I mean, a lot of it is what Charles has,
um, just said really.
I think these are things that, um, uh, elements that we need,
you need to consider, the anatomy of the patient.
Um, elements of that implant, it's size, it's weight, and also the,
the surface or the texture, all of these will be contributing factors.
As we heard with the anatomy, we've always uh you know,
you hear loads and loads of times at these meetings, you know,
do you want to stay out of trouble, just stick to the anatomy.
That's a very simple process.
Guide your patients, don't be pushed by your patients.
When patients I always say an expression that patients never understand the limitations of
their own anatomy.
That's for you to teach them.
Um, and what they can have is determined by their anatomy.
If you want to stay trouble free.
Um, so sticking to the boundaries, being respectful of the tissue quality,
etc. uh, you know, this lady clearly wasn't given
that advice, um, and has way overstepped those boundaries.
Um, and also different, uh, anatomy will allow different, um,
implant size, shape, position, and risks with regard to lower pole stretch,
etc. It's gonna be very difficult to get lower pole
stretched really on the.
On the left right of your screen, but the tissues are starting to be a little bit more
lax on the right, and this is the lady with Elosanlos syndrome who Charles mentioned,
and you can see this extremely unstable um soft tissue envelope.
Implant weight and size, uh, again, you know, for obvious reasons would seem to be,
you know, an important factor in determining.
Jan, why are you smiling?
Um, science, um, and as you can see in this less exaggerated version,
you know, as you get bigger, surprise, surprise, you distort more and you start to bottom out.
So implants size and weight of course is very important.
Implant surface, we've talked a lot about surface.
This also has a very big role, and as we know, we have a whole bunch of surfaces,
a whole bunch of implant properties that are available to us now,
and you've got to select from those which you think is most appropriate.
I can tell you, you know, what what has has taken preference in my practise and and other
people have, have different choices.
Uh, but for me, as we said earlier, the real game changer for me,
particularly in terms of stability, has been polyurethane because of this,
uh, one feature, and that's tissue adherence.
I came across polyurethane really because um I was getting fed up
of anatomical implants rotating.
And I really wanted to use them, um, you know, is it a problem?
Yes, it is a problem, textured implants rotate, but polyurethane don't.
Um, and it's this tissue adherence, which is really what led me to polyurethane,
and also understanding the other benefits in terms of uh uh tissue stability.
So you don't need IMF fixation.
You don't need to have fancy pockets, um, you don't need er ADMs or meshes.
Uh, they're a very powerful instrument, powerful instrument in terms of maintaining
implant position.
As we've heard, with less aggressively textured implants, um,
you know, perhaps those who are less experienced, you know,
you can run into trouble with instability.
You do have to undertake other procedures in order to stabilise those implants and to
prevent them from putting out. So for example,
in. Foul fixation or getting out of trouble, as in
um something like this where you see a classic bottoming out,
that's sliding out of time.
Sometimes you need some extra help uh in order to get you out of trouble,
uh, and the role of meshes, um, such as P4HB um in order to try and strengthen.
Uh, those lower poles, uh, because of that, uh, uh, surface instability,
um, as we described again, another classic bottoming out,
uh, and again using Galaflex to bail yourself out of that problem.
So that kind of um issue has disappeared overnight with the use um of,
of, of polyurethane, and I said, particularly because of my um uh uh slight
preference for uh anatomical implants.
We also talked about weight and so you can combine uh shape,
surface, um gel uh uh stability, but also, what about um potentially using lighter
weight implants, um, and you can do that whether it's anatomical or whether it's round,
you can use all of those different properties.
Um, lightweight implants or the Blight implants that a lot of you might be familiar with,
30% lighter than standard, um.
Uh, silicone and they use these, uh, air filled microspheres, um,
uh, linked into the gel to render these, um, uh, lighter, uh,
weight, um, a bit like, uh, Ed Sheeran's Maltesers there.
Um So these are just a few examples again of just that lower pole stability
using lightweight implant. This is 18 months post-op.
You can see the fold, the incisions are exactly where you want them to be.
There's been no descent over time.
Um, again, I used to use polyurethane as my sort of secondary get out of
jail card, um, but now I go straight, uh, in all of my primary cases because of that
predictable stability. Again, that's me scribbling on that.
Patient, um, and this is her one year later, pretty much exactly as we placed it
with no extreme little change over time.
Again, 18 months post-op, an implant's not gonna go anywhere,
it's gonna stay exactly where you put it.
It's difficult, tight, constricted lower poles, again, you put the implant there,
expand it there and there, and that's not gonna change over time.
You can see the effect of that lower pole expansion, which is pretty much immediate.
and again here you see a 2 year post-op, uh using that form stability,
that real grip and adherence to keep the implant exactly where you want it to be um over
time. That's the Elos Danos patient, very, very
difficult, you can use, you know, meshes, whatever you like,
um, but very, very difficult to get an implant that's gonna stay there.
Um, that's an anatomical polyurethane coated implant, um,
which is lightweight in order to minimise um all of that descent.
Obviously with very poor, unstable soft tissues, the idea of having a lighter weight implant,
a grippy surface is very attractive in order to maintain this is 2 years post-op with an
extremely stable lower pole, which virtually hasn't moved and again making use of all of
those elements, less weight, polyurethane coating in order to produce more
stable outcomes and you see the lower.
there again, extremely stable at nearly 2 years post op.
Similar scenario here, just showing progression over time,
6 months, 18 months, um, and again that extremely stable lower pole.
If you focus on that, there's been virtually no movement there whatsoever.
And then just a final case again, just trying to put all your elements together in very
challenging cases, extremely poor soft tissue quality.
So the idea of having good grip, less weight and shape to get yourself out of trouble is
an attractive thing, um, in order to er er get the best possible outcome.
Um, so, you know, that's it really. I mean, I think,
you know, avoid up or stretch, be sensible, um, you know,
guide the patients, stick to your anatomy, uh, something we've preached all the time.
Think about all of these, uh, other elements that you have at your disposal and that you can
change, uh, uh, to your benefit.
Thank you very much.
Thank you very much both.
You want to come to the front for a little chat?
Is anyone question out there?
I said, well.
Question for you both, um.
One of the patient types that I struggle with is the.
Sixty-ish 65 year old woman long term implants, loose connective tissue maybe not Ellers
Donlos who either has a rupture or contracture and we're gonna do a revision,
uh, you know, I'm only using smooth implants and as you guys have mentioned with smooth
implants it's very difficult so maybe elaborate a little bit.
On the use of P4HB to help in these cases.
I know Patrick, you mentioned it a little bit.
Charles, uh, do you, do you have any thoughts on the role of P4HB and some of these more
challenging elderly patients with real poor connective tissue?
Good question um.
If if they've got a capsule.
I tried to preserve it as a hammock.
I, I have a concept called anterior capsule flap, I'm using that because they are most
likely a bit lower on the chest wall.
I can put that flap back on the chest wall and use it.
Um, If they don't, or if I need to remove due total capsulectomy,
and I feel I don't have the stability, I'll be using different type of measures including the
Galaflex. Uh, but I'm, I'm not a big fan of putting stuff
into the breast if I can avoid it.
If I feel I can't control that pocket, I can't shrink that pocket because there is no capsule.
In those cases, I actually use a polyurethane.
I think it's a great device when you feel you're not in control of that pocket.
So maybe that would be an option in those.
Another option is of course which is difficult for a lot of patients to accept is you take
everything out you let it heal and then you go back and you start all over again and then
you've got more options of course.
But if they want to do primary, a big pocket, you can't drink it with popcorn,
polyethane is a good alternative.
Yeah, I'm gonna be very boring, Mo, and just say polyurethane.
Now the problem is, of course, is that that doesn't help you.
No, so, um, you know, you, you, you are then down to,
you know, using P4HB, um, which I think is very good in,
in, in, in some of these situations, um, you know, and there are various ways of inlaying it
along the fold and uh or hanging off the, off the pectoralis,
um. But I think you, you know, unfortunately for
you in the states you you have far fewer options and I think in those really difficult
cases I think Charles is probably right, you know, it's almost start again um if you can
persuade them to do that, which of course is not always easy,
um, but it's, it's either that or uh extraneous measures, yeah.
To to just elaborate on that, unfortunately a lot of those patients that come in that age.
They're very often oversized because they've gone through 2 or 3 procedures.
So, so the problem is if you let the breast rest and heal it's amazing how much
it retracts.
So if you can make them understand that you've got before and afters explaining that,
actually I'm able to convince quite a few. It's 3 months down the road.
So, so, and it, it's a very safe predictable way.
So question up there. Hello Al Bahia, um,
Edinburgh, um.
We, we grew up using the Allergan textured implants and then ALCL reared its head and we
we stopped using them, we started using smooth ones.
But I'm hearing an awful lot of polyurethane being used.
Are we, are we, are you worried about the possibility of ALCL with with these heavily
textured polyurethane implants?
Well, I mean, you always, you always worry about it,
you always counsel your patients about it. I always tell them there are alternatives,
um, I always tell them that they can go to see other people,
um, but then you have to, um, be confident of your data,
of your knowledge, um, uh, and you have to be confident of the advantages and the
disadvantages, because you have to put into the balance, uh,
of your ALCL risk which um.
At the moment for polyurethane it's about 1 in 150,000.
Um, you know, some people may think that's a high risk,
some people think it's a low risk, but then you have to put it into a balance.
What about the higher complication rates with round smooth implants?
What about the fact that they're more likely to be back in the operating theatre,
undergoing different risks when you put that all together,
um, that's also part of the discussion.
So, you know, clearly I have a, a view and a and a vision and and and and a confidence of
the way I practise based on that data.
Um, but you, you've all got to make your own minds up.
I agree with Pat, however, I've chosen a different path.
There is a big difference in my world between a cancer and a complication due to lack of
knowledge and ability from a surgeon.
So for me I've taken the path moving towards smooth.
But not just Ale cell like I said the day before yesterday or yesterday.
A cell or breast implant illness is not the reason today.
It was initially.
I'm, I'm not that concerned, we give our patients information and we have to follow the
role we believe on.
The reason why I'm using Smooth today are for other reasons.
I think it's more biocompatible implant that's softer, nicer,
and just easier to live with long term in a safe way with smaller scars.
That's the reason today why I'm using them, however.
For a community that built their practises with textured implants that shift might cause
a lot of problems and complications like that addressed, so it's extremely important that we
educate surgeons how to use them in the right way, and that's what I'm trying to do with
other colleagues, but I think for me at least that's the path.
Uh, Charles, well, one question, your, your video very nicely showed the preservation of
the Cooper's ligaments, um, but also another video showed you bluntly dissecting,
uh, in the pockets. So can you describe maybe what seems like two
opposing things and, uh, the distinction between them?
I, I sorry, I didn't quite follow you.
I understood the sublander, but then you said something else about some other dissection.
Uh, you were showing kind of a, a, a pocket dissection where you're doing a blunt
dissection with your finger. That was the same,
it's the same concept.
So basically what I've done is I've done a, a wet dissection initially and then with my
fingers because.
In the breast, first of all, Cooper's ligaments is not something static,
exactly the same in every patient.
Some have very soft, some have firmer, some have more in the lower pole.
That's why the breast looks so different.
So that's why I go in with my fingers and I manipulate them,
and that's what I'm doing, but it's still a blunt, uh,
uh dissection.
So it's a combo.
So I think Prof got a question.
Thank you. I have no conflict of interest with
polyurethane implants other than I wish Bristol Myers hadn't taken it off the market in the US
in 1991.
Uh, as I mentioned in the panel earlier, we've put in between 2 and 3000 of them.
I still see some of my patients Hester and Bostwick's patients.
I have a 35 year follow up that she's soft.
I've taken some out.
No evidence of ALCL. If there was any, they and their lawyers would
come looking for us.
The only paper that I'm aware of that associates polyurethane with ALCL was
the paper from Australia and then.
The question there came up who was putting in these implants and we come back to the last
panel. Was it the surgeons because they, it seemed as
if all of them were coming from one or two clinics.
So, uh, as I, as I said, I, I don't know of any evidence long term,
at least in the US, Pat Maxwell put in thousands of them without any hint or
sign of ALCL.
Can I just make a, oh sorry, I'd like to endorse his words we are using for 35
years, uh, 40 years in, in Buenos Aires without interruption of,
uh, polymethane, and, uh, we are a group of people, uh,
we have several, and as he said the only thing is a little increasing in capsule contraction
after 7-8 years since um.
Instead of being nothing at uh at 78 years, some patients develop like they if they have
eaten the polyurethane, but the vast majority.
I've never seen any liquid or seroma or just to comment, um,
I'm a relative latecomer to polyurethane. I started probably about 6 or 7 years ago.
I think polyurethane is an implant which is, is, uh, it takes a little bit of getting used to.
It's uh it's not as easy to handle as normal implants.
Um, and, and I think that puts people off, um, because you just got to kind of figure out a
few tips and tricks how to get them in. Once you figure it out,
it's, it's very easy, and I think certainly from my point of view that's what put me off
and I only used to use it in secondary situations, but particularly with anatomical
implants now, I'm 100% polyurethane, even in primary cases.
I think we're really running late, so can we have a last question from Helen then?
Um, Charles, sorry, you just kept saying that you've changed to smooth implants,
but you use the term smooth nano textured.
Um, they're not what we would classically or historically describe as smooth.
Do you explain that to the patients? Yeah, so,
so the reason why I'm using the nano, it's not nanotectured.
The industry or the company initially called them nanoteurd,
promoting that they were working like micro textured implants holding up through friction.
That's not the case.
They are smooth, but just to differentiate them from regular smooth,
I use the nano because that's still within that and and and so.
I work with all different types of implants out there.
I really try to pick the right implant for the right reason,
uh, so it's, it's a misconception that these are regular smooth.
They're not, they're nano smooth, but they're not micro textured implants.
So one needs to look at at at what they actually do and and the classification
sometimes in micro, how much is surface, etc.
makes it somewhat confusing but.
Please understand these are smooth implants.
The reason why I'm using nano is just to differentiate them from other manufacturers
because there is definitely a different type of surface with these ones which make them very
biocompatible. Does that clarify?
Yeah, it's just that they're not actually smooth.
They have a degree of texturing to them.
Well, it depends on the definition.
I mean they fall under the, the, the group of smooth just because the the surface,
the texturing does not move into that uh microtextured range,
so they are smooth. Uh.
Thank you to both of our speaker and thank you for all the questions.
I think it's a very interesting topic and but for the matter of time,
I think we've got to move on to the next sessions.
Thank you.