Great, so we're gonna pass on to the next session.
Um, and, uh.
We'll talk about er breast reshaping.
Um, we've got a whole series of, uh, fantastic speakers, lots of different topics,
and we are going to start off with Lazaro Cardenas, um,
who's gonna talk to us about breast reduction.
That welcome. Well, good, good
afternoon. I want to thank uh London Bridge meeting for
the invitation to this presentation.
I'm Lazaro Carnes Camare. I'm from Mexico and plastic surgeon.
And I'm, I, I have no conflicts of interest and I'm going to talk.
About uh.
Breast reduction.
Uh, with the lateral dermoglandular pedicle, do we need sutures?
Do we need, uh, to use sutures or to do glandulloplasty in a breast reduction?
Well, we're going to talk about it.
When we do a breast reduction, the most important factor as are the vascularity,
the sensitivity, and the functionality.
So our preferred technique is the superolateral dermoglandular pedicle.
Why? Because we use this technique because.
There are reports that the lateral thoracic artery is present in almost 100% of patients.
So when we do this technique, we have a very good vascularity.
We have a very good sensitivity because the sensitivity comes,
uh, from the deepness of the of the.
Of the gland.
So why do you prefer this technique? Well, we prefer it because of the muscularity,
because of the functionality, because of the sensitivity.
Uh, so we have published this in classic and reconstructive surgery and also we have a,
uh, on a chapter in a book.
So how we do, how do we do it?
First of all, we have to mark the, the lines that we're going to use for,
for the breast reduction, and we have to put the new nipple areola complex position and we
use a pattern that we have, uh, designed for this type of surgery.
And we might the patterns and we we put the lines that we are going to use it for remove
the the tissue. So we designed our pedicle.
It's a lateral pedicle, and all the blue marking that we have in here,
we are going, is going to be removed during the surgery.
So this is the pedicle and as I said, all this is going to be removed in blocks so it's a very
simple a very, a very simple technique to to design a very simple technique to to do.
So what we do is we remove all the tissue that is around the pedicle in a block,
and it's very important to leave uh dermo glandular pedicles as you can see the dermo
glandular pedicle is attached to the the chest, so we have all the nerves and we have the
artery and we have the lacteria for ducts here.
So we are preserving the sensitivity, the vascularity, and the,
and the functionality.
And what we do is a pedicle rotation and it's very, very easy to do it.
And so we, we made the, the nraola complex lifting.
This is our pedicleiccation and we have it right here and with the pedicle lication we,
we, we make a, a glandulloplasty at the same time but also we have to make a faation to the
chest wall. So we're going to give you the shape and we're
going to give you the form that we're looking for.
This is one finishing, the other one without finishing, and this is the results before and
after during surgery.
Uh, this is a patient that we present on the, on the slides one week after surgery.
This is a the video, a video of of a surgery, uh, it's a little bit dark.
I don't know why, but this is a pattern that we use.
No, don't put the, don't put the, the sound please.
This is the how, how we mark it and as you can see, uh,
this is the lateral pedicle that we use is around 7 to 8 centimetres in in white,
and here is the patient mark for surgery.
And all the tissue that is around the, the pedicle is going to be removed during surgery.
So what we do first, we remove the skin that we are seeing right here.
And after we remove the skin, here's the pedicle, and all this tissue is going to be
removed it in block.
So it's a, it's a very simple technique to do, uh, and as I said,
you have to be very careful to leave this pedicle attached to the chest wall,
so all the, all the nerves and all the blood supply is coming through the pedicle.
And after we remove the breast tissue, we can rotate the pedicle and
and the nipple. To the new position and then we do the,
the, the landloplastic with with stitches.
As we can see right there and when we finish uh doing the glandulplasty and the then we attach
the gland to the chest wall.
We know that it's not going to maintain the, the breast shape for,
for, forever, but it's a way to maintain the shape during surgery and to have a symmetrical
results for a long time.
So you can see how it is is is the the the nipple complex is after surgery before surgery,
and this is before surgery and after surgery.
We're going to see some clinical cases in this in this uh uh July you will see
how many months or years the patient has and how many grammes were removed from,
from each breast.
There are going to be around 8 to 9 cases, uh, as you can see we have different shapes,
different sizes, different volumes, uh, and different types of follow up.
One year after surgery, around 800 and 770 from from one another breast.
One year after surgery.
2 years after surgery, also another patient 2 years after surgery.
A little bit more follow up time 3 years after surgery.
So you can see We, we remove different volumes depending on each,
on each patient and the size of each patient and finally this is the the the final case.
OK, we can have complications and we can have eventuality in this type of surgery like,
like, uh, any surgeries.
Our, our main, uh, complication is or a more frequent complication is one distances,
but we can have any other complication as you can see here,
but, but the most important complication that we have had is total nipple areola necrosis
that we are having in in 3 patients out of 550 breast reduction that we have done with this
technique. One complication can be a hyperpigmentary scar
like in this patient.
After 2 years after surgery, one thing that can happen is fun necrosis.
Fa necrosis happen because when we do stitches on the on the gland,
if we tie it to, if we, if we put it to tie, they can produce fun necrosis and when we have
fun necrosis, we can have a symmetry like this.
But the main problem that we can have is, is in neoa complex necrosis.
It's not very common. We have only 3 patients out of 500 and
something of patients.
So this is one of our patients that have that problem.
This is the other patients that have a problem.
They are very big, uh, reduction, and we have this problem,
so we can have problems.
anybody have complications and we have to share complications also.
In conclusion, this is a very simple technique to design,
easy to perform, it's very safe.
We have excellent innovation and function after this type of surgery,
and it's very useful for and toastia, but we have to be careful when we do the technique.
We have to design the pedicle in the proper position to avoid force of rotation.
And vascular problems because these techniques is useful when it's a big breast if it is small
breast is not useful because with the rotation we have,
we can have vascular problems.
We have to, uh, make all the incision perpendicular to the rib cage so we can have,
uh, all the, the ves the vessels and, and the nerves on the pedicle.
And finally it's very important to make placation and facation of the mammary gland to,
to give the shape that we are looking for during surgery.
Well, thank you very much again for the invitation.
Eric, thank you very much. Well, thank you very much and thank you very
much for being here. Thank you.
We'll have the discussion at the end. We'll get all the speakers to join us on stage
after they've spoken. Very good.
So um, yeah, my microphone on? Yeah, so we're gonna go ahead with the next
speaker, uh, so we call on stage Doctor Adel Barra who's gonna talk a little bit about,
uh, mastopexy and how to individualise this procedure.
please. Welcome, Adele.
Morning everybody.
Thanks Marlin, Eric.
It's a great pleasure being here and we'll talk about the multiplane Oscar Mastoexi and the
multiplane rising of the IMF.
These are my disclosure as a creator of the techniques that are published on various.
Of course I have a personal conflict of interest and we also hold a breast surgery
course that takes place in Brazil and online with a little more than 400 surgeons that.
Took the course and I will show a concept is just a different way of seeing the breast
of performing the surgery and that's the that's what we believe and we think that we all
surgeons can partially or completely use the multiplying concepts in his in their own
practise. And what is the, the multipla about?
It's a plateau breasts. We got simple markings.
We have an L shaped scar for all our patients.
We do an anatomical treatment treating the, the skin and the parent on a completely different
pattern. Uh, we use a triple pedicle that's superior
media and narrow for the neck.
Uh, we also do an internal mastopexy which we the raising of the IMF.
We can put theme and and compensate the products.
As we don't have enough time, we'll focus on three pillars.
That's undermining the skin of an inferior pole of the breast.
Giving stability to the implant and through the perchema.
So, uh, we start the surgery and they're mining the whole inferior,
uh, pole of the breast, so we have the skin.
Uh, complete separate from the parenchyma. So with that,
and also, uh, undermine the the pachema from the muscle we can completely print the pachema
on a completely different way.
Uh, stability to the implant is the basis whenever we use implant we talk about surgery
without implants in the next lecture, but, uh, to give stability to the implant we use both
media and Laros links.
And they, they should always keep a low plane 1 or 2 with both medium and laterus links.
We just by the end of the surgery we leave this, this the width of these links a little smaller,
but the idea having these links to hold the muscle down and to prevent the muscle from
going up and causing bottoming out and expansion of the part of the breast.
And we do a customised internal mastopexy, and with that we mix concepts of vertical and
horizontal mastopexy.
What is that? A vertical mastopexy is a circum vertical short
scar whenever you raise all the tissue.
It's safe for the neck, but we got a problem that it may go down with gravity and lose shape.
Horizontal mastopexy is a wise pattern.
You can use technique.
You pull everything down, but you have a problem to raise the neck.
So with this internal mastopexy, we lift the neck and we pull down both medium and later
breast columns.
And that's how went our surgery.
This is the amount of parema resected and the amount of skin in this patient,
we have 26 centimetres of parenchyma would be my scar if I don't dissociate skin from the
parecuma. We have, uh, 26 and uh 14 centimetres in what
would be the BC on our marketing and the same is 14 centimetres at the level of the neck.
And PRS whenever we publish, they put on the Instagram that the scar is the cholera effect
of the mastopexia and as doctors we must try to reduce this cholera effect.
So we have two different patients, no implants, and how we finish our surgery.
The idea is to have the breast reshape the skin redrape.
Uh, we limit our scar to the anterior axiliary line and we even delivering,
delivering a a scar, we don't have to over resect around the rela and can we
give the stability and a small scar for all patients.
We have this massive weight loss patient, very low IMF.
Very loose tissues.
And that's by the end of surgery and the patient sent pictures to us in 15 days,
3 months, and we're supposed to have 6 months, but it didn't open,
but with 10 months post-op, what to have stability of the implant,
stability of the parmichema, and roundness of the infra middle pole of the breast.
And this is essential whenever you're delivering the scar to have the roundness of
the inferior. Inframed bone of the breast, and this is a 205
cc breast implant.
And even for bigger breast we use the same principle we can customise this curvature.
I I can exactly precisely determine the curvature that I want for the different middle
pole of the breast and considering that I'm not.
Uh, dealing with the skin and parachema in the same way,
I can completely resect the pachema from the stern to the interior or middle exterior line
if I want to, and we start with simple markings.
All the concept is from up to down.
We have the purple.
We have the position of the neck, and that's it.
The rest is just, uh, midline of the breast MF.
And even even for huge breast whenever we react 2.5 kilogrammes from the patient,
we can deliver a a scar.
Uh, carnaton thorax is a problem with, uh, with the multiplying concept,
we can compensate the patient still got the carna on thorox,
but whenever you look from forward, it looks like a plan thorax.
But we're just using this constant treatment of symasty another difficult thing.
We can treat sematium on table one year after surgery.
Other patient, other patient, even without the implants, we can go with just undermine the
skin from the right breast to the left one with resect the tissue and with a barb suture to sew
the skin to the sternum.
That's basically the principle in this patient.
I think that's just like 14 days postop.
Uh, it's a almost uh 750 kilogrammes resection from each breast we raised the IMF with Red and
mastia without the middle scar and it's still early postoppe.
Uh, we can change the shape of the inframedial pole as we see in this patient we can
treat the medial block ears internally so we don't have to extend the middle incision.
This is the early postoppe, and we can raise the IMF,
but we're not doing a reverse abdominal plas. Instead of starting the surgery at the level of
the regional IMF, we start the surgery at the level of 6 rib where 80% of the patients get
the region of the PEC major.
And the inferior pole of the breast with the bulk we resect the vertical excess and we
convert the inferior pole of the breast without any attention,
uh, into talk abdominal wall and this will be delivered this December on PRS I think on PRS
first it's uh available. So that's the idea we don't start the surgery.
On the patient's IMF, we start the level of 6 rib and all this inferior part of the breast is
converted into uh to abdominal wall. With that,
we can completely change the footprint of the breast without any extra tension and we
also want the major.
at level 6th grade we can have our dual plane one otherwise we'd have the back measure too
high and for the muscular implant expansion of an in pole of the breast,
and we do this for basically all for patients. So fixing the IMF at the level of 6 rib gives
us the confidence to get, uh, less one thing to to put on the breast
count. So the IMF is always at the same level and we
can have the fullness of the upper pole.
And stability with smaller implants. What's much safer for the muscle and prevents
the laros placement bottoming out.
So 6 months, uh, this is really part early pre-op, uh,
15 days and after 6 months when the, the implant settles.
We can see how we we we raised the IMF, how it gets a bit of an implant perchema
small L-shaped scar for all four patients. Window shading is something pretty difficult to
treat. Once it's difficult to lower the muscle,
we can raise the MF give proper coverage, use a small implant.
And not completely but partially with window shading as well,
uh, explanation whenever we do explanations or breast reduction,
we can also raise them up with that a little more bonus of purple and as a bonus we
get the elongated torso, what makes the patient looks a little thinner,
a little more elegant.
Uh, we like, uh, intramuscular effect rafting during, uh,
explanation whenever it's possible when you have surgery.
Uh, the result.
Uh, stable. Uh, switching for a smaller implant,
raise IMF, we should do a Doctor Andrea Abo Emothetic net external.
Now, now we do it internally.
More upper pole andogele torso and instability and roundness and if you see most of our
patients the oh gotta a leader here.
The roundness that we deliver on the on the inframeal pole of the breast is basically the
same because it's customised was bariatric carnaton on on right,
even more caronnaton on left, look.
Like a plain thorax, but it still can not. This is the compensation of the thorox.
Hopefully it's gonna be published soon and we'll share with you.
And on a long term how it stays whenever we have a proper coverage,
whenever we do our internal muscles, so we saw the pare much to the muscle that's something
that you can do in every technique just do that.
We can get stability 3 years nono tax rising plants.
7 years post-op and of course, long term results depends on the surgeon and on the
patient. The patient gain weight, loses weight,
they don't have this kind of result on a carna on thorax,
uh, 50 years old.
Female 24 breast implants.
And, and keeping the basically the same curvature.
And of course on secondary cases, uh, this is really interesting low implementation breast.
The implant too high.
This area with no implant. This is the early post-op.
It's gonna be better, but we've risen the IMF 3 centimetres.
We use the small implant to get stability and now the IMF and the implant are at the same
level, so that's the idea of raising the IMF.
The muscular to the muscular high rising laro placement dog ear from her previous surgery and
that's one of the disadvantages of the technique whenever you raise the MF you leave
her previous scar behind.
You don't try to do a reverse abdominal plastic rate a new IMF with this extra,
uh, caudal tension of the, the reverse of abdominal placelero placement bottoming out,
uh, low implantation breast.
With uh some muscular implants generally leads to a high muscle,
a low plane tree, and bottoming out.
And this is exactly what happened here. Carry on thorax,
low implantation breast, 325 cc breast implants, that's the perfect storm.
Patient came after two previous surgeries with recent IMF a lower implant,
and with that we give this stability and we know that it's gonna long last because we
lower the muscle with its broad technique, uh, now the muscle is over here.
Not giving proper coverage.
And this is a breast chat where we discuss about the multiplayer.
Everybody is more than welcome. Thank you again very much.
Sorry. Next, uh, speaker is Roy De Vita from Rome,
who's gonna be talking about mesh, the use of mesh in mastopexy.
Thank you so much. First of all for inviting me.
Thanks a lot. I'm really honoured to be here and I guess I,
I think that with three of us on the same time and on the stage,
I think that could be considered really a mafia session this one.
Let's go. And First of all, by disclosure, I'm a
temporary consultant for BD mentoring and politic and actually answering the questions by
my speech.
What are we looking for in a heavy phototic breast actually we want to look at stable upper
performance. That's our final goal.
Then the we tried in the past several options.
Um, one of these was the, uh, the orbi shape and, uh,
micro screws, uh, on the ribs with a sling of silicon just to keep up the,
the, the lower pole if it could be logical from.
Uh, just thinking about the, about the, the, the thought that was behind the idea,
uh, but actually, uh, it works we can see well, but just for
some patients, uh, you need to have quite fatty patients, uh,
to, to, because the, the, the link was quite palpable and,
uh, was so unnatural when the patient lies down.
And uh and then we were obliged to to stop to use it and um as you can see 3 days and uh 3
days and 3 months, uh, the result is definitely stable but unfortunately impossible to use uh
with the tiny patients and, and generally um was much better to to move towards
something different and uh uh one option it could be very,
very useful could be using mesh uh to try to to to keep them.
Uh, um, stable position, uh, uh, petigo and, uh, and the,
um, the glanderer and adipose tissues that we have in the lower pole.
I use Galloflex.
Galaflex is something fantastic for many, many reasons.
First of all, it is, uh, monofilament. It means that it's very,
very strong against the, the, the, the infections.
I sometimes it, it happened to me, uh, that the, the, the T junction,
um, uh, opened and, and, uh, it just needed to trim, uh,
the, the portion of the, the, the mesh is exposed with no problem,
no infection, no other.
Um, complication and post is a very quick integration is reabsorbable is very important
along the time is length, uh, very low, but is a reabsorption of the,
of the, uh, the mesh and, uh, stimulate a very, a very,
um, soft inflammatory process.
Then what I, what I do usually I, I prepare the, uh, um,
the in the inferior portion of flap.
Uh, that needs to redistribute the volume in the breast,
and I keep in the from the lower to the upper pole and,
um, I, I just, um, fix the, uh, the, the totic breast,
uh, using this flap that I, I, I, I put in the, I can show him short video.
Uh, after I prepare the flap, I, I just remove the, uh,
the superficial portion.
Um, skiing and, uh, and I use the old flap.
I go to the dermis.
When I prepare the flap, I just remove the skin.
And I put a flap inside.
What I think is a good position as soon as I, I finish to,
to rebuild all the memory core, and I fixed with a couple of stitches the flap on the
chest wall, and then I use my, my mesh.
That that's the, the flap on, on the wall and then, uh,
as you can see, I usedal flex its many, many times because once was,
was not BD like now I was Glaia and, uh, that did this video,
uh, I showed it at that time.
And But usually I split the uh the mesh in two pieces, the long the long one,
and I fix on chess wall.
Just to to to keep in uh uh the flap, and I, I trim and I removed the the the portion of
me is in excess.
Just go and see a couple of clinical results in front of you on on long
term and and laterally you can see how it it's still very very
good the uh the shape and the upper pole lateral and profile.
And once again start to have a breast in front of you and and profile two years
later I must say that I use also in reconstructive when I need to to do the
reshaping of the controller outside and I need to do a mastopexy it's so useful to use it
because you know the the patient.
Uh, after if you do an implant based breast reconstruction on one side and you have a
natural breast on the other one, the upper pole immediately goes down.
After a couple of months, you will lose it and the patient is a little bit upsetting because
can see from, from both the difference and they say is the my,
my upper pole is, is, is empty, it goes down again and,
and it's not true we say that I, I, I love to use mesh to to keep in place the uh uh the
lover. Um, the lower pool and to keep up the,
the volume, uh, on lateral and and profile.
Well, I, I think that this is could be a very good option using using mesh for help,
uh, ourselves in a very simple procedure, um, especially if you use a non,
um, uh, a reabsorbable uh device because I think that the long
term is much, much better to don't have foreign body inside if we can.
Uh, and then my, my, my experience is very good. I, I can tell you that I suggest you use a mesh
always when you do eptodic when you correct eptodic best.
Thanks a lot. Thank you so much for your
presentation. So we go to the next speaker, Mr.
Mark Pacifica.
Hello, Mark, good to see you, please.
Thank you. Thank you very much for having me and thanks
for inviting me. This is a big topic to cover in 10 minutes.
Um, so can I have my slides up, please?
And I have to on explant and master effects out please.
Uh-huh, good. Um, so I'll try and cover this as best as I can,
uh, going through what I think of the salient points, and this is really uh a key different
operation cos by definition, first of all, every patient has had previous surgery.
Uh, that affects blood supply, you've got to consider the previous scars,
both externally and internally.
You've got to consider the expansion effects of the implant over time.
And you've got to consider that most of these patients, or many of them will have a degree of
ptosis or pseudatosis, and of course time will have passed since their original operations,
so the effects of ageing and life events mean you need to be flexible,
you need to be able to think on your feet, and you need to be able to adapt because what you
think your plan's going to be when you go into theatre may not be what it needs to be.
And don't forget, there are a lot of psychological con uh considerations because in
a way you could think of this as a downgrade. The patient who's lived and got used to her
breast with an implant is going to have, by definition, a smaller breast afterwards.
They're going to have added scars if they've not previously had scars,
and you've got to consider that sometimes a patient will come in knowing and requesting
that operation, but sometimes it's us who tells a patient for the first time that really a
mastopexy's indicated, and that really can throw the patient sometime.
So of course there are a variety of indications for this.
It could be due to the patient having a complication from the implant,
effects of the ageing process or effects of life events,
and patient wishes.
Um, they may have come to the end of their implant journey,
they may want to downsize their breast, but as I said.
It's really important to recognise that the patient may be unaware of any of these,
and you're giving her the news for the first time and she needs time often to process that
and come to come to terms with that, particularly if you're suggesting this as this,
the purpose of this talk is a one stage procedure.
So decision making and planning is ever a key, and as Patrick alluded to in his keynotes
earlier, volume distribution is really important to analyse,
and here we've got the patient on the left who's got a bottomed out breast implant with
double bubble, who needs either the implant out or relocation.
The middle patient has got far too much. of course in the upper pole,
and it might be that by either removing the implant or lowering an implant if she were to
maintain it, that would rebalance the breast, whereas the patient with an implant in on the
right side um has a uh a pic breast which is going to become more ptotic once that
implant is removed.
So a few concepts that I think are really key and I think are really key as part of the
patient education process and the first is to estimate how much of their breast is breast and
how much is implant, and very crudely and very simply, I do this with the patient in front of
the mirror. I simply er displace and separate the breast
from the implant. To educate the patient so they know what the
likely future breast volume they may have will be.
It's very crude. It's a vague yardstick, but at least it gets us
in the right sort of ballpark, and I give them a percentage.
I say, well, look, about 20% of your breast is breast, the rest 80% is implants,
so you're going to have an 80% size reduction.
The other very subjective sort of um assessment is feeling the breast tissue quality,
and we all know that sometimes there's a very very lax loose breast that will be very mobile,
and other times you have this almost brick-like fat that's very immobile,
and that will have implications as I'll explain on choice of pedicle,
both the automation auto augmentation pedicle, but also the,
the nipple pedicle. So you've got to consider a variety of planning
uh aspects that we do in every breast case. The nipple position is key.
The uh pedicle, as I said, you've got to think about the skin resection,
and you've got to be prepared for this to change during the surgery,
and therefore be flexible and have an armamentarium of techniques at your disposal.
And you've got to, I think, counsel the patient cos often these patients need a little
adjustment, a dog a correction or have a little fold in the future,
or certainly you should prepare them for that so it's not considered a problem,
it's considered just uh the final touch up if they need it.
So the key marking, of course, of a lot of breast surgery is where's that nipple going to
be, and I use a very crude technique that has held me in brilliant stead for many years now,
and it's to pinching and lifting, looking at what looks aesthetic,
hovering my pen over that area, allowing the breast to drop and marking that.
It seems incredibly. Simple and basic, but it's amazing how well
that works and how you can evidence it works is you independently can do it on the other breast,
and what I find still extraordinary is how it's often within 5 millimetres or so of the first
breast when you've not looked at the first breast, and you can adjust a little bit as
needed. On table, once the implant's out, I will always
tailor tack, I'll set the patient up just to assess my markings and adjust it if I need to.
Um, and here you can see the patient tailor tacked on table and this patient is going to
have her augmentation subsequently done and she's going to have some fat grafting.
We've got to think about capsule decisions and we've got to think about peg major decisions if
the implants under the muscle.
For, so for a capsule, if it's a pathological capsule, I'll usually remove it.
If it's um a soft capsule, I will usually keep it, and I think it's really helpful,
it's our friend. A lot of the time it helps provide structure,
it helps support the blood supply, and it's something you can actually get a suture safely
into um, and I will, as uh, in the video here, I'll often popcorn the um er the
capsule if it's very thin.
With regard to the peck major, if they've got a substantial pec major and you can separate it
and it's a sub muscular implant, then I'll aim to relocate it on the chest wall.
However, if it's a very thin atrophic pec major, I will,
I will ignore it and it can be um superficial to the pocket that my auto augmentation flap
will be in, and I've never found that cause a problem.
So that's uh just popcorn in the pocket, which will come onto in another of my talks,
uh, tomorrow.
Um, tissue quality, it's very subjective. This, this thin lax tissue,
which is very easy to move, is very helpful on one hand,
but of course it's got a more precarious blood supply.
Um, that thick, dense tissue is very hard to move, and I think that's going to lead me more
into a more medial rather than superior nipple pedicle and probably a more cordially based
flap than a superiorly based flap.
And these factors are very subjective and I really think they're hard to teach.
They come with experience.
So you can see the top picture or the top video is some very thin lax tissue,
and the bottom video or the picture was somewhat very thick tissue.
So in terms of auto augmentation options, my.
The majority of my cases will be a superiorly based in continuity turn under flap,
um, which is probably better for maybe more supple tissues,
but in other cases, I will do an inferiorly based advancement flap,
which may be better for thicker tissues, and I've not,
touch wood to date, found that despite an in mammary crease incision,
that the cordially base flap is much of a problem.
So the cranially based superior flap will turn under and the cordially base flap will advance
superiorly. In patients who've already had a mastopexy,
you've got to consider uh the blood supply and it's very difficult sometimes because whilst
it's an easy decision to do the mastopexy cos they've already got the scars,
it can be a difficult decision and an unknown with respect to the blood supply,
particularly if they're an implant cripple or had multiple previous surgeries.
So a few results. Um, this is a patient we saw earlier,
42 year old, large implants, been in for 20 years, subglandular plane,
and she's had a superiorly based, um, uh, turn under flap,
and here you can see her with well-heeled scars, she's maintained an excellent breast volume
despite large implants coming out.
56 year old patient who's got ruptured 30-year-old implants,
uh, she's had a medial nipple pedicle, and she's had an inferiority based auto
augmentation, um, and here you can see her, uh, the results post-op.
55 year old, um, inferiority based augmentation with a medial uh uh nipple pedicle.
Uh, you can see in the intraoperative picture the both sides have the implant out.
One of course has had the mastopexy and one hasn't, and you can see that troublesome,
slightly annoying fold that you sometimes get that you might see sometime down the line,
which is easy to adjust if, if need be.
Small breast volume cases, there are many of the patients whose,
of course, the stimulus for having their augmentation in the first place was a
hypoplastic breast, so they have never had much breast volume.
Um, and these, I think, take a lot more adjustment psychologically,
uh, to approach. There's a 54 year old who'd had implants in for
13 years. Um, here she is afterwards, um, and here she is
at 8 months. What's quite interesting is to see her
pre-breast augmentation pictures and to compare them, and I think her shape's almost better now
and it seems as if over time she's gained a little bit more volume,
um, without putting much weight on.
Here again, 17 year old large implants that are contributing the majority of the breast volume,
and a significant size adjustment at 11 months, but making the best shape possible.
And again, here, a 6 year old with 23-year-old implants in,
um, and importantly, I think, as we know, you can never go wrong if you're in doubt,
putting the nipple a little bit lower, that will always look natural rather than overly
raising the nipple. Skin challenges, I'm gonna just finish on a
couple of points. Um, these sorts of small dog ears can be a
nuisance. You can see if you look at her AP view on her
right breast laterally, she's got that little bit of excess,
uh, that I adjusted at the same time as inverting her left nipple,
and that's just something you've got to be prepared for.
And I think it's interesting as a rule always to look at your patients from the back,
as we can see here, you can see her scoliosis and asymmetry,
which can contribute an impact on the um uh the breast morphology as well.
Complications exist and this is, by definition, more complex high risk surgery because of the
guarantee that they've had previous surgery and particularly if they've had multiple surgeries,
so that has to be counselled carefully with your patient.
My final slide, really, the take home messages. Of course it's gonna be challenging surgery.
It can be unpredictable, you do need some flexibility and some experience,
and I think that analysis preoperatively is really key to take a step back and take a view
on things and manage your patient's expectations as as best as possible.
Thank you very much. Well Thank you, Mark.
Um, we're now gonna move to Klaus Uberreiter.
Um, welcome, Klaus. Yeah. So.
Dear Male, thanks for the invitation here with auditory.
And I don't have much to disclaim.
I use only The body's own material fat craft.
And I maybe I can explain you by.
If you have tuber breasts severely constrictions, it's not always solved by
surgery. In the lower line, this girl has been operated
already 13 times in renowned plastic surgery units, university units,
and everything, and that's the result she had.
Fat has a great advantage that you have rarely any complications.
Skin is growing.
Many people don't know that, but under the influence of fat,
you get new skin.
Therefore, you have to do body lifts after the people lost weight.
There's simply too much. It's not only stretched like in the pregnancy,
but it's new skin.
You don't have to destroy glandular tissues and you don't have to.
Put uh Exchange implants.
I've designed this protocol for fat graft and tested it from 2008 on
with MRI control.
They can see exactly how much fat is left and we test it again after
5 to 9 years and seeing a very good relation.
To the body weight, it's about 80% of the fat which survive permanently.
So if you have the prior repairs, you can resolve it with fat graft.
The only thing the patient here complained that afterwards she found her breast too big.
You can improve if you have an implant repair, which is not so favourable,
you can put some fat around.
You can replace implants. One of my patients,
uh, who had came 8 years later with a capsule contracture
and I replaced the implant for fat.
You see, it's a very natural result. That's something we do quite frequently in our.
So how do I do it?
You mark the areas for liposuction and Usually about 10
centimetres below the new line.
And And then I show you a short video.
Marking the area, then infiltrating a basic two sense solution and also in the
breast. In every case to avoid bruising.
And this is a water beam.
You can always control the tubes sense flu fluid entering the body while you do the
liposuction. So it's.
The fat is floating out.
Collected in a lipo collector.
And at the end, the oily debris and water is removed, and I refill it
in 10 syringes.
And from only one single incision, I fill up the breast here you see the old fold and the
new fold. Again
So it looks afterwards. It's important to fill the fat also in the very
subcutaneous layer to help the skin.
Growing Yes, a former sub memory fold that will not disappear at once completely.
It will be visible afterwards.
But At least after the 2nd intervention, it usually it's
gone. Another patient About to
see the millilitre size of the graph I put never.
Do too much fat in the breast.
If you think, oh yeah, you can still fill it 300, 350,
400, it will be necrotic and it will be a disaster.
No chance. Better several times.
After one, then we do the areola correction if necessary.
After the second operation, they put a suture of 20 silk round to
keep the rela tight.
Silk has a big advantage. It's very easy material to suture,
and it will be reabsorbed by the body within a couple of years.
That's the patient from the video you've seen.
To injection after the 2nd graft, we do the repair.
Oh, again, The great thing is they have never to think of
capsive contraction of implant exchange and nothing.
This was a young patient for almost 30 years when she came to me.
Said, I had my breast, but I never wanted silicone.
You must always think that there's many patients who simply refuse silicone.
So I did one graph, you see the sub-memory folders lowered a bit.
I did the 2nd craft.
And finally a certain and yet this is a picture.
5 years later, I wouldn't have thought it was the first severe case I have treated this way.
I would never have imagined that it works. Yeah, but she sent me lately a picture of a
baby breastfeeding and was very, very happy.
So also with uh To this correction, you can do it breast lift.
I personally, I don't do breast lifts with, uh, implants, only with fat.
Again here. So I've treated more than 250 tourist press in
the last years.
In the average, it's 2 to 3 cat grafts under there, but they always can decide
if they want more after 3 months' interval and the satisfaction is very high.
Much lower complication rates silicone, I must apologise to the industry.
And very easy and safe to perform if you remain modest.
There's, there's the booth down there Lipolastic is not human made.
Sometimes they have some literature if you're interested.
So this is my part of the hospital. I rented this,
this entire building.
And keep it and it's fueled only by craft. I can tell you.
Thank you.
We're gonna move along to the next speaker please we welcome on stage,
uh, Patricia McGuire.
Good morning thank you for the invitation.
I'm gonna talk about my evolution on uh trans feminine breast augmentation,
my disclosures.
Going back to my first case in 1994, maybe before some of you were born,
my first patient was a 50 year old patient who I had known actually as a physician when I was
a general surgery resident.
She had transitioned after I finished general surgery, had been living female for.
5 years have been on oestrogen for 3 years she came to see me for an augmentation told her I
had not done any at the time what we call transsexual augmentations but didn't think it
could be that much different. This is 12 years after a dual plane
augmentation with smooth saline implants is what we were using at the time.
My second case was an interesting one. This patient came about 6 months later,
was using he, him pronouns, was with his wife. He said he always just wanted to have breast.
I tried to find a reason not to operate on him, couldn't find it,
so did his procedure. He had not been on hormones.
This was a much more difficult operation, the first one.
So at the time there really weren't any clear guidelines that I was aware of.
I realised that it was a lot easier to do if the patient had been on hormones.
We were using saline implants, dual plane, uh, at the time.
We now do have standards the World Professor Association of Transgender Health,
uh, these are the newest ones. I do follow that and that I have a letter from
these patients more for their psychiatric stability.
These patients have a lot of, um, comorbidities.
Um, I get a letter. I'm not as strict on this as I am for the
female to male patients.
Um, I require one year of hormone therapy. I won't do an augmentation I want.
Stable psychiatrically check these patients for a history of silicone injections.
They won't always tell you that.
A lot of them are smokers, and physical exam and the planning is not any different than my
cisgender patients, but the surgical considerations are different.
These patients' anatomy is different.
They have a lateral nipple position, a short nipple to fold distance,
thick pectoralis muscle with a wide chest and wide sternum.
So take these one at a time, the lateralization of the nipples on these,
um, using an appropriate width. I use moderate projections so I can get a
little bit more volume, um, with, with it, um, not being too,
too much volume for the width, uh, textured implants were great for these because of the.
Position stability. I stopped using them in 2016,
uh, but the main thing is centre the implant on the nipplelorear complex,
not on the, uh, uh, breast prancuma.
They will have a little bit wider set breast, but it camouflages this appearance of
lateralization of the nipples.
For the short distance, treat it like a constricted breast.
Choose the right implant so you're not lowering the fold too much.
You will have to lower the fold some.
Um, I use moderate profile implants. This is probably controversial,
but do not score the lower pole. These patients have thin lower poles.
You always see that score to expand it. It will expand with time from the implant and
expanding it, you just thin it out. You give them a risk of bottoming out carefully
managed with super. Uh, the infra memory fold suture repair and
support. I now do all of these subfascial takes,
um, the muscle out of the equation and then keep them in a supportive bra for six months.
Uh, this is managing the inframmory fold. I put the sutures.
It's just a 30 monoryl from the chest wall, uh, preserving the,
uh, um, uh, scarpus fascia, and then suture this very carefully to support that lower pole.
Um, this is why you don't score the lower pole is 3 weeks after surgery.
It looks very tight, flat in the lower pole, uh, over 6 months,
that rounds out.
The nipple to full distance is short early on that relaxes down with time.
That distance will get longer.
Another one flat 3 weeks after surgery at a year that has lengthened.
Implant selection you can use any implant that you and the patient are comfortable with,
uh, but they need to be as wide to accommodate their wider base with and again I use low to
moderate projection.
We use three dimensional imaging more to show the patient their anatomy.
It's a great education tool, um, so it asymmetries that they have and um they see how
and why you're choosing an implant.
This is her 2 years post op. This patient has that lateralization of the
nipple. Need to see that ahead of time to know the
limitations on what you can do for the thick pectoralis muscle,
um, even on hormone therapy, the muscles are still very thick,
um, so be careful with your implant selection.
Never divide the medial sternal attachments. These are patients where it's a big mistake to
force cleavage because it'll be very obvious if you once you divided the muscle,
and I take the muscle out of the equation by using a subfascial placement.
I used shape textured implants for a long time. I did those dual plane.
The position stability was good. They got nice long term results.
Older patient 5 years post-op, 10 years post op. But then I changed the smooth.
I got concerned about ALCL.
I changed the smooth implants. I was still doing dual plane.
Here's the same patient a year post op. She's bilateral inferior mal positions,
so I. Started thinking well maybe I'll do
subglandulid so I did this was probably the wrong patient to do as the first case
subglanduloid. She had a capsular contracture on the right
side. So then I, but she was happy she could wear a
bra and was fine with it. And then I thought well subfascial approach,
will that make a difference?
This is a patient, uh, in her 60s. She's been female for 6 years,
been on oestrogen for 5 years.
My markings are nothing to write home about.
Uh, these are the instruments that I use. I use a,
uh, um, a long boy direct visualisation of what you're seeing.
I have a fibre optic light on it just because I don't like to wear a headlight,
double ended breast retractor and a long, uh, wider retractor that I actually got when I was
in, um, South Korea that works well for this.
Subfascial, I wondered when I first started doing this,
is there actually a subfascial plane? There's a very well defined subfascial plane,
especially on the transgender patients. Be careful when you start the dissection that
you don't end up under the muscle, um, so you always know where you are and then just follow
that plane. There really is a well defined plane um you can
follow it. It gets more well defined when you get to the
lower level of the arela uh be careful not to over dissect the pocket,
especially laterally and inferiorly to leave the fascial um structure intact.
I do use scisors. I use an inflatable sizeor.
This is just with air. This is not for sizing.
It's to check the pocket.
The sizers the same with the implant that I'm planning to use,
and I do sit the patient up.
Here she is, um, 3 weeks post-op and 2 years post-op.
Another patient, these have good she has good skin coverage,
easy decision for subfascial, but even on a patient like this is a 72 year old with not
great tissues, thin tissues does fine with the subfascial placement,
tight, uh, pocket, uh, full do fine with it. Patients with these kind of herniation of the
areola, um, tends to stretch out with time, so I don't do anything to address that.
The other options fat grafting is very useful in these patients,
especially if they want a tighter cleavage with their wide sternum,
um, and I do use soft tissue support if I need because some of these patients want bigger
implants for their inframammary fold. There are,
um, either ADM or P4HB is off label use in the United States.
So this patient, I just suctioned that, uh, pre-axillary fat and use that for the lower
pole and medial cleavage.
Uh, this patient had no infra memory fold. I use P4HB support.
Just take a strip, the 10 by 15 of the light, divide it and,
um, suture the fold, and then lay this over to support it.
This is a massive weight loss patient, uh, using, uh subfascial placement,
perureolar mastopexy, and a P4 HP mesh wrap for the risk of capture contracture and position
stability. Uh, complications, a hematoma is the most
common reason for unplanned return to the operating room on transgender patients.
Uh, they're no different than than, um, cisgendered women.
Uh, size change and malposition are the other common reasons.
The other thing I've seen this since I changed the subfascial,
this redness of the skin, it scares everybody to death that they have an infection,
but they look fine. They have no symptoms.
It's not even itchy. It's just this bright red.
Leave it alone and it goes away.
In mposition. This is a patient I had to re-operate on.
I just overdissected the pocket and malposition is a surgical error on this patient,
I just overdissected the pocket, didn't fix the fold well enough,
so I took her back and um did a capsulory put P4HB.
I wanted to lower her left side a bit, and she didn't want to do that.
Um, I've had no size changes. I've had one malposition repair.
The other patient I showed you declined surgery for her malposition.
I've had one patient detransition requested implant removal,
but she hasn't followed through on that.
Uh, breast cancer screening is recommended on these patients if they've been on oestrogen for
more than 5 years, over 50 biannual, um, uh, mammograms.
ALCL has been reported in transgender patients. There's been at least 4 cases.
Breast implant illness, it has been reported, but it's much less common in transgender
patients than in cisgendered patients.
Uh, this is very satisfying surgery. They're very grateful patients.
Um, you have to consider the differences in their anatomy,
the thick muscle, the lateral position of the nipples, size your implants appropriately and
carefully control the IMF just like you do on a cisgender augmentation.
Thank you. Take my seat.
Oh, we've got one there. Oh yeah, OK.
Yeah. OK, so later on we'll, uh, uh, last talk of the
section and then we'll, uh, open to discussion.
So thank you. Thank you very much.
Thank you, Patrick. Well, uh, our talk this time will be about
refinements on transgender surgery female to male.
I'm Lazaro Carnos Cabarela. Like I told you,
I'm plastic from Mexico and I have no conflict of interest to declare.
When we're going to do this type of surgery, you have to know the difference between the
male and the and the female mammary gland, and the male breast is smaller.
It's atrophic and very important thing is the nippolora complex is smaller and lateral.
So our goal in this type of surgery is to eliminate feminine characteristic of the chest,
making it masculine with minimal scarring.
We, we have described this in in an article around 6 years ago,
and we have to think about 3 areas of the brain when we are talking or when where we're doing
this type of surgery.
We have to know about the fast tissue and the glandular tissue,
but most important, the skin quality and quantity.
So we have to think about this, and we designed this flow chart to to to think about the
surgery that we're going to do.
And when almost all, all this type of, of patient has this type of of problems
with minimal or moderate or severe skin excess, so when the patient has minimal moderate skin
excess, we have to think about gland removal uh combining or not combining with liposuction
like this patient all these patients have already been in in hormones for a long time,
so that's the reason that they have hair in, you know,
in, in, in the chest, you know, on the body.
So these patients in this case what we did is only only uh gland removal,
a mastectomy, and the reshape is very well after surgery is one year after surgery,
but there are another patients that they have uh breast tissue,
but also they have fat so we have to combine the treatment and in this case as we do
liposuction at the same time we remove the gland and here's the patient some weeks after
surgery this is before and this is after.
And when the patient have uh skin and we can do a perolla skin resection we do at the
same time in in this patient so we remove the gland and we can have a periareolar resection
uh and we, we close it like a Benelli, uh, technique and this is a patient or we did
liposuction and we removed it.
59:58.610 --> 01:00:03.379 The breast gland and we also did a resection, a peroral resection very early.
01:00:03.590 --> 01:00:07.739 It's only 1 or 2 weeks after surgery and this is the shape that we can have.
01:00:08.229 --> 01:00:14.350 This is a patient that that is a bit a bodybuilder, so uh he had a uh a surgery this
01:00:14.350 --> 01:00:17.840 is. Two weeks after surgery this in 1 year after
01:00:17.840 --> 01:00:21.830 surgery, so you can see some weeks after surgery still a lot of swelling,
01:00:21.840 --> 01:00:28.510 but with the uh peroral resection we have a good shape after a year after surgery like as I,
01:00:28.570 --> 01:00:33.479 as you can see this is before this is uh 2 weeks after surgery and 1 year after surgery.
01:00:34.189 --> 01:00:39.979 In some patients when we do a peroral resection, we can do it on on two surgical times like this
01:00:39.979 --> 01:00:43.590 patient we did the two surgeries on the first surgery, we remove some,
01:00:43.739 --> 01:00:46.810 some, uh, lip suction, and the second surgery we remove,
01:00:47.159 --> 01:00:52.040 uh, the breast gland, but on both surgeries we remove skin,
01:00:52.580 --> 01:00:55.780 uh, from the perioal area. So this is the first surgery we're removing the
01:00:55.780 --> 01:00:57.949 fat and the second surgery removing the gland.
01:00:58.320 --> 01:01:03.979 And this is before after the first surgery and after the 2nd surgery as you can see right here,
01:01:04.189 --> 01:01:08.860 we still have a little bit of excess skin, but after the 2nd surgery there's totally flat.
01:01:08.889 --> 01:01:13.459 This is a very good option because the patient only has a per scar.
01:01:13.600 --> 01:01:16.709 And, and, and, and he, and he had a lot of skin around the,
01:01:16.750 --> 01:01:22.840 the breast and finally you have the most severe cases where we always use uh neroliola complete
01:01:22.840 --> 01:01:28.350 graft because it's this type of breast that we have to resect and the only option is to do
01:01:28.350 --> 01:01:31.429 that. This is a, a, uh, a video that we made.
01:01:32.020 --> 01:01:36.879 And the she masculinization, the, well, the markings we have to know that the areola is a
01:01:36.879 --> 01:01:43.000 is lateral to a normal areola and we are designing this type of resection that we're
01:01:43.000 --> 01:01:46.840 using in the last surgeries 3 or 4 years from now and,
01:01:47.000 --> 01:01:53.189 and, uh, what we do first of all we do or we put to methane infiltration to remove the gland,
01:01:53.689 --> 01:01:58.189 uh, we, we obtain a nipple or areola.
01:01:59.050 --> 01:02:02.409 Graphs on the previous areola we're going to put it after surgery.
01:02:03.300 --> 01:02:06.570 So we remove, sometimes we can use a tattoo, but we,
01:02:06.649 --> 01:02:11.300 we normally use a graph that we remove before we, we remove the gland,
01:02:11.610 --> 01:02:13.409 and then we remove the gland.
01:02:14.199 --> 01:02:18.050 We don't do a a big undermining only they needed to remove the gland,
01:02:18.620 --> 01:02:25.219 and what we do is to mark or recheck what we're going to resect and this lateral adjustment
01:02:25.500 --> 01:02:30.179 that we have to do at at the end of the surgery because first of all we remove the gland and
01:02:30.179 --> 01:02:36.129 then we close it and then we resect the lateral part and as you can see the uh the final on on
01:02:36.139 --> 01:02:41.050 on the end of the of the of the day you can see that we resect this area.
01:02:41.669 --> 01:02:46.439 And we adjust the skin better than before because before we extend the,
01:02:46.449 --> 01:02:51.969 the scar to the back and, and we have a longer scar and in this manner is a new,
01:02:52.060 --> 01:02:58.860 the new thing that we're doing that we put the scar on the uh anterioral line and it's more
01:02:58.860 --> 01:03:02.580 hidden and looks like a a male breast.
01:03:03.189 --> 01:03:07.590 So that's what we're accepted and after we finish the surgery you have to determine where
01:03:07.590 --> 01:03:10.050 we're going to put the the new nipple areola.
01:03:10.489 --> 01:03:15.580 So what we do is marking it outside the the previous one is around 14 centimetres for the
01:03:15.580 --> 01:03:20.449 middle part, but this is the previous one, the middle middle midline of the breast,
01:03:20.860 --> 01:03:25.310 and here we're going to put the new, the new nipple will have to be symmetrical,
01:03:25.860 --> 01:03:28.780 so we use stitches to to determinate where it's going to be.
01:03:29.770 --> 01:03:36.239 And we remove the skin and we put the graph there like I told you before we can use or it
01:03:36.239 --> 01:03:39.989 can be used uh tattoo for for making the new the new nipple.
01:03:40.320 --> 01:03:42.709 The yola nipple is is is a is a good option.
01:03:43.030 --> 01:03:46.500 If we put a tattoo uh a a graph that's the way they use it and,
01:03:46.530 --> 01:03:51.550 and you will see how we make the, the new nipple and the formation we put stitches around
01:03:52.159 --> 01:03:53.479 this mark that we make.
01:03:53.929 --> 01:03:58.310 And then we tie it and when we tie it, we make a little protrusion of the middle and,
01:03:58.350 --> 01:04:03.860 and, and looks like a nipple and it looks very good and it works very good also.
01:04:04.790 --> 01:04:08.560 This is the final surgery and here's how it looks.
01:04:10.739 --> 01:04:13.260 Sometimes we have to do some liposuction on the lateral area.
01:04:13.340 --> 01:04:17.129 Patients have a lot of of of breast tissue and also a fat.
01:04:17.500 --> 01:04:24.020 This a patient we didn't have any, any, any fat, so we only a graft and and resection of the
01:04:24.020 --> 01:04:27.129 breast. This is some, some days after surgery,
01:04:27.139 --> 01:04:30.870 and the patient and so photograph because a lot of my patients are from the United States or
01:04:30.870 --> 01:04:35.620 from Canada, so they send me pictures after several weeks or months of,
01:04:35.659 --> 01:04:37.379 of the surgery. There's another patient.
01:04:38.050 --> 01:04:41.050 See the, the nipple that we made on the technique that we showed,
01:04:41.090 --> 01:04:44.239 this is one week after surgery.
01:04:47.439 --> 01:04:51.060 Bigger breasts and bigger breasts sometimes the, the, the,
01:04:51.070 --> 01:04:54.300 the scar joints on the middle is something that we cannot,
01:04:54.510 --> 01:04:59.699 we cannot avoid and we did liposuction on the lateral area and this is how it looks.
01:05:00.110 --> 01:05:05.270 This is the area of the of the joining of the of the scars on the middle part of the chest.
01:05:06.709 --> 01:05:12.179 And well the way we have to tell patients that they can have hypertrophic scar like this way
01:05:12.179 --> 01:05:17.620 because we are removing a, a lot of tissue and you can see some some days or some weeks after
01:05:17.620 --> 01:05:22.300 surgery looks very good, but after one year they can have this type of scar.
01:05:23.629 --> 01:05:27.790 The, the biggest mistake that we made when we begin to do this is the position of the nippo
01:05:27.790 --> 01:05:29.090 areola graft.
01:05:29.379 --> 01:05:34.330 So this we did it on the first on the first, uh, uh, patient that we had.
01:05:34.780 --> 01:05:39.219 Now we have to put in more lateral, so we have to avoid this because it's something that it
01:05:39.219 --> 01:05:43.899 can happen. So in conclusions, there are 3 characteristics
01:05:43.899 --> 01:05:47.129 that must be considered to determinate the type of treatment.
01:05:47.340 --> 01:05:49.979 We have to see how much fat tissue and glander tissue we have,
01:05:50.020 --> 01:05:53.209 but most importantly the skin quantity and quality that we have.
01:05:53.629 --> 01:05:58.219 So the, the surgery is, is a combination, uh, doing liposuction,
01:05:58.300 --> 01:06:02.929 doing mastectomy and how to manage the skin excess that is different,
01:06:03.100 --> 01:06:05.370 uh, as you saw on the on the presentation.
01:06:05.739 --> 01:06:10.379 We have priorities, the thorax shape we have to, uh, position the,
01:06:10.419 --> 01:06:15.449 the, and, and be uh a small scar as possible and most important,
01:06:15.699 --> 01:06:20.189 like I told you is the position of the new nipple aa complex.
01:06:21.149 --> 01:06:25.050 Thank you very much. OK, OK.
01:06:27.790 --> 01:06:28.870 Jo, you wanna take a seat yeah thank you um.
01:06:33.590 --> 01:06:38.870 So thank you very much for all of those talks. um, and we're on time also we are,
01:06:39.030 --> 01:06:43.080 yeah, perfect. So any questions from the audience?
01:06:43.189 --> 01:06:45.659 We have somebody right at the top.
01:06:46.270 --> 01:06:49.939 Do we have a microphone here maybe then you, yeah, of course.
01:06:52.409 --> 01:06:59.320 Thank you. I Um, Georgeiaulermo
01:06:59.320 --> 01:07:02.379 from Cyprus. I have two questions for Mr.
01:07:02.520 --> 01:07:03.649 Roy De Vida.
01:07:04.120 --> 01:07:10.270 The first one is, do you have any reactions to the mesh like redness of the breast and,
01:07:10.399 --> 01:07:16.149 uh, or complications like seroma and especially late seroma or infection?
01:07:16.479 --> 01:07:20.399 And the second one is, do you use drain after the operation?
01:07:22.120 --> 01:07:25.030 So I sat for the second one. I used drains, yes,
01:07:25.050 --> 01:07:29.399 for a couple of days actually, uh, in all breast surgery,
01:07:29.989 --> 01:07:34.570 um, I must say that for if, if I don't use implant, it's just the overnight.
01:07:35.250 --> 01:07:40.060 Uh, if I use implant this for a couple of days, um, when I use,
01:07:40.189 --> 01:07:43.250 uh, because I can, I can use mesh also with implant actually,
01:07:43.879 --> 01:07:49.070 um, no talking about, uh, as I said before, infection, uh,
01:07:49.080 --> 01:07:54.830 I must say that um, for, um, 4HP is, is the great, uh,
01:07:54.840 --> 01:08:01.760 4HP is a great, um, device, um, it works wonderfully a
01:08:01.760 --> 01:08:07.040 very. Small inflammatory process as a reaction and
01:08:07.040 --> 01:08:10.520 then we don't have seroma, no less seroma at all, but,
01:08:10.840 --> 01:08:17.490 uh, neither in the short term seroma and talking about infections I said before,
01:08:17.520 --> 01:08:23.120 more than once I was obliged to to trim the portion of the the the.
01:08:23.669 --> 01:08:28.490 Device that was exposed because the, the, the T junction, uh,
01:08:28.529 --> 01:08:33.689 hold it and the and and was the uh out the portion of the.
01:08:34.509 --> 01:08:39.009 The mesh I just cut it. I trim it, uh, with no other problems.
01:08:39.060 --> 01:08:44.049 Then I must say this is from this point of view it is very strong and very safe.
01:08:44.580 --> 01:08:48.060 Thank you. So I think we have another question here on the
01:08:48.060 --> 01:08:50.189 front row. Andrea Moreira from Pittsburgh,
01:08:50.330 --> 01:08:53.870 thank you for this wonderful, wonderful panel. I have two questions,
01:08:53.959 --> 01:08:56.189 one for you, Roy, and one for Lazaro.
01:08:56.410 --> 01:08:58.049 Um, I'll start with your Lazro.
01:08:58.290 --> 01:09:03.600 I really enjoy your presentation on the lateral, uh, niparola pedicle for breast reduction.
01:09:04.120 --> 01:09:08.160 Um, I have a question for you about managing of the lateral excess tissue.
01:09:08.200 --> 01:09:12.359 In US we have very large patients and it's something that we wanna address during the
01:09:12.359 --> 01:09:17.959 surgery. When you do your pedicle, um, using a lateral
01:09:18.120 --> 01:09:20.770 perforator for the blood supply for the nipple.
01:09:21.330 --> 01:09:28.009 Um, it, it showed on your cases, it seems like that lateral fullness gets distributed into the
01:09:28.009 --> 01:09:32.609 breast, so maybe you have less of that. But if you have to address excess tissue on the
01:09:32.609 --> 01:09:37.319 lateral chest, um, what's your approach for that so you don't injure that perforator that
01:09:37.319 --> 01:09:39.310 it's providing blood supply to the nipple.
01:09:40.279 --> 01:09:45.750 Well, normally, normally, as you said, when we pull the the lateral pedicle to the middle,
01:09:45.830 --> 01:09:48.959 we pull the, the lateral tissue to the middle and, and this,
01:09:49.029 --> 01:09:52.459 uh, allowed us to have less protection in that area.
01:09:52.750 --> 01:09:57.390 We can do a little bit of liposuction there because, because all the blood supply come from
01:09:57.390 --> 01:09:59.629 the from the deepness of the of the gland.
01:10:00.009 --> 01:10:03.930 So normally I, I don't do liposuction because because we pull the,
01:10:03.939 --> 01:10:09.520 the tissue to to towards the meal, but I think it's a good option to do some liposuction and I
01:10:09.520 --> 01:10:11.490 don't think it will be any problem with that.
01:10:12.200 --> 01:10:15.120 Thank you, thank you. This is very beautiful results and Roy,
01:10:15.279 --> 01:10:18.910 I love your technique with the mesh and the demo pose flap.
01:10:18.919 --> 01:10:21.470 I use that a lot actually on reconstruction.
01:10:21.740 --> 01:10:24.830 My question for you when you use the thermo pose flap,
01:10:24.959 --> 01:10:28.910 I like to say liai hivero because he described it like 1000 years ago.
01:10:29.359 --> 01:10:34.169 Um, do you also, you, you showed cases that were reductions.
01:10:34.419 --> 01:10:40.140 Do you do that for all your reductions in mastopexy or if you have a patient with severe
01:10:40.140 --> 01:10:41.140 micromasia.
01:10:42.779 --> 01:10:46.439 I'm assuming you don't need that flap, but you still use the mesh.
01:10:46.689 --> 01:10:49.149 How can you support the mesh on those cases? Are you talking about the patients or generally
01:10:53.370 --> 01:10:58.089 no, I, I use always the, I use always the panicle if you panicle flap because I think
01:10:58.089 --> 01:11:01.009 it's the only way to keep the up above fullness actually.
01:11:01.115 --> 01:11:05.214 Then I have, I, I, I keep a portion of flat.
01:11:05.464 --> 01:11:10.424 If I do a reduction, I don't need a sewage flap just in the central portion and,
01:11:10.464 --> 01:11:16.174 and I, I, I, I try to, uh, to redistribute the volume in the upper pole,
01:11:16.384 --> 01:11:20.625 and I, I, I use the, the, the mesh always.
01:11:21.439 --> 01:11:23.189 Very, very nice cases thank you.
01:11:24.640 --> 01:11:27.189 Any any more questions? Yes, we've got a question at the front.
01:11:28.720 --> 01:11:30.830 Hi, thank you. I'm Fleur Blueman from the Netherlands.
01:11:30.939 --> 01:11:35.569 Uh, I was asked to have to have a question for Klaus on the lipo filling of two breast.
01:11:35.680 --> 01:11:37.660 Thank you very much for sharing your results.
01:11:38.069 --> 01:11:43.180 I was wondering up to how much Lipo filling per breast do you dare to go?
01:11:46.299 --> 01:11:49.850 I don't. No.
01:11:51.049 --> 01:11:57.990 Well, I can. the only one that they
01:11:57.990 --> 01:12:00.160 have is that one. Yeah.
01:12:06.459 --> 01:12:12.879 included in that if you're centrifuges it would be only.
01:12:21.430 --> 01:12:22.620 20% of course yeah it's it, but I think.
01:12:23.609 --> 01:12:30.290 3000 I can do if I exchange very large implants for fat and there is already massive
01:12:30.290 --> 01:12:31.290 tissue, but
01:12:38.049 --> 01:12:39.399 usually you are safe if you remain below 3 OK and I have one more question.
01:12:39.649 --> 01:12:45.319 What do you do with the Cooper ligaments? Do you release them with a special technique?
01:12:45.459 --> 01:12:52.290 No? OK and my last patients I I
01:12:52.290 --> 01:12:57.720 did. I tried to cut the ligaments and whatsoever
01:13:09.810 --> 01:13:10.049 and she got again. OK. We do this and it's it's amazing but skin will
01:13:10.049 --> 01:13:13.359 grow and you inject and you need only. Well thank you for the alternative treatments.
01:13:14.770 --> 01:13:16.600 Alright, we have another question at the front.
01:13:16.979 --> 01:13:21.919 Uh, this question comes from our online attendees and comes from Yildirim Ozadogan,
01:13:21.930 --> 01:13:26.649 who asks, do the female to male patients require breast cancer screening down the line?
01:13:28.810 --> 01:13:31.750 The female to male patients, do you, do you follow up?
01:13:32.089 --> 01:13:35.430 Yeah. Do they need screen, do the female to male
01:13:35.430 --> 01:13:38.089 patients need screening for breast cancer?
01:13:38.770 --> 01:13:43.200 Well, normally, normally this, this type of patient come from out of,
01:13:43.209 --> 01:13:47.000 out of this, uh, our country, but when they arrive, all,
01:13:47.049 --> 01:13:53.290 all the tissues that we removed are sent that to to to have a uh test and to have a
01:13:53.290 --> 01:13:56.250 histological examination to see if they have any problems.
01:13:56.410 --> 01:14:00.729 The World Professional Association of Transgender Health for patients who are on
01:14:01.009 --> 01:14:07.479 testosterone, they do not require mammograms, but they do they do recommend chest.
01:14:07.705 --> 01:14:14.645 Exam if they feel any lumps it has to be I tell all of my um patients that um anything
01:14:14.645 --> 01:14:18.935 that they notice on their chest has to be evaluated uh with time because it's not a
01:14:18.935 --> 01:14:22.854 cancer operation you're not removing all the breast tissue and even a mastectomy doesn't
01:14:22.854 --> 01:14:23.895 remove all breast tissue.
01:14:24.720 --> 01:14:27.390 Thank you. So do we have any further questions from the
01:14:27.390 --> 01:14:29.180 floor? Not for the moment.
01:14:29.229 --> 01:14:33.279 So yeah, oh yeah, another one, OK, another one online.
01:14:34.029 --> 01:14:39.089 Yes, this comes from Sascha Der who asks for the last speaker on creating the purse strings
01:14:39.089 --> 01:14:42.229 in your graft. Do you take much sensual necrosis?
01:14:43.140 --> 01:14:46.859 I think that's for you. OK, tell him again because I don't understand,
01:14:47.850 --> 01:14:49.959 so we're talking about the graft.
01:14:50.390 --> 01:14:55.729 The graft, when you do the purring, do you get any necrosis of the of the graft?
01:14:55.770 --> 01:14:59.609 Well, it can be we can have some necrosis because it's a,
01:14:59.649 --> 01:15:04.959 it's a, uh, a graft, but normally we don't have any problems because when the necrosis is,
01:15:04.990 --> 01:15:11.089 is, uh, corrected by the their own tissue, it's on the same tissue of a graft.
01:15:12.740 --> 01:15:15.439 I think we had another question somewhere up there.
01:15:15.689 --> 01:15:21.839 I have a question for uh Doctor uh uh uh Lazaro Cardenas Camarena.
01:15:22.169 --> 01:15:26.850 I'm a plastic surgeon from Colombia and uh thank you for sharing your technique.
01:15:26.930 --> 01:15:31.009 I really like it. I have personally not seen a lot of people that
01:15:31.009 --> 01:15:35.919 use the lateral pedicle for, uh, breast reduction, and I wanted to ask you,
01:15:36.049 --> 01:15:40.810 uh, a question related about sensibility because I think sensibility is something that
01:15:40.810 --> 01:15:42.609 is very important in breast reduction.
01:15:43.029 --> 01:15:47.939 And I want to know if you use an objective scale to measure if patients are actually
01:15:47.939 --> 01:15:54.609 preserving sensibility or you just ask them to compare pre-op or how do you actually
01:15:54.899 --> 01:16:01.660 know that sensibility is being uh conserved? OK, we have to to to to answer for
01:16:01.660 --> 01:16:05.140 this. One is how the sensitivity is coming through
01:16:05.149 --> 01:16:11.500 through the breath so uh when we when we leave the middle part of the of the pedicle always
01:16:11.500 --> 01:16:17.180 towards the the chest wall, the, the nerve is coming to that that pedicle,
01:16:17.430 --> 01:16:23.069 and we always ask patient how do they feel so normally we have a very good sensitivity after
01:16:23.069 --> 01:16:25.620 the surgery because of this, OK.
01:16:28.299 --> 01:16:30.609 Any other, another online question?
01:16:30.939 --> 01:16:33.859 Hi, this question comes from Kishmore Mackam, which says,
01:16:33.979 --> 01:16:37.049 is there any evidence for doing a 2 year screening for breast cancer?
01:16:37.100 --> 01:16:38.450 Is it American guidance?
01:16:40.500 --> 01:16:45.740 Any evidence for doing what what was it 22 year screening, 2 year screening for breast every
01:16:45.740 --> 01:16:50.339 other year, the Cancer Association in the US has changed over 50.
01:16:50.419 --> 01:16:54.180 I disagree with that. I believe in yearly mammogram screening for
01:16:54.180 --> 01:16:57.265 patients, but. Um, that this was the World Professional
01:16:57.265 --> 01:17:03.225 Association Transgender Health said says every 2 years the American Cancer Society has been
01:17:03.225 --> 01:17:05.774 saying older women don't need to be screened as much.
01:17:05.935 --> 01:17:10.305 Personally, I still recommend my patients get yearly mammograms.
01:17:10.950 --> 01:17:14.779 Right, so, uh, Patricia, can I ask a question just, you know,
01:17:14.899 --> 01:17:19.250 out of my curiosity, you, um, showed in one of your last slides that,
01:17:19.660 --> 01:17:24.939 uh, the risk for complications for transgender women is basically the same as non-transgender
01:17:24.939 --> 01:17:27.939 women. And then my question is being a non-expert,
01:17:28.080 --> 01:17:33.810 uh, and you know, like what's, you know, born as a male chest is by definition as,
01:17:33.939 --> 01:17:39.180 you know, constricted or like let's say short, uh, lower pole so I think of a double bubble
01:17:39.180 --> 01:17:43.569 deformity. Uh, do you have many of those, or do you limit
01:17:43.569 --> 01:17:47.089 the size of the implants in order to avoid that? What, what's your,
01:17:47.419 --> 01:17:51.169 uh, what's your approach if, if some patients ask for large volumes?
01:17:51.660 --> 01:17:55.839 A lot of these patients will ask for large volumes, and it's just like when my cisgender
01:17:55.839 --> 01:17:58.209 patients come in, they have to understand their anatomy.
01:17:58.419 --> 01:18:03.129 I always tell them the most, I respect their request, but I respect their anatomy more.
01:18:03.299 --> 01:18:07.683 You are gonna have. Lower the fold um on on these patients I think
01:18:07.683 --> 01:18:13.643 going subfascial, not taking the muscle out of the equation makes it better for the patients
01:18:13.643 --> 01:18:20.283 who want larger implants then I will use um some P4HB something to to really
01:18:20.283 --> 01:18:24.562 stabilise the fold on them. I have not, when I did change from texture to
01:18:24.562 --> 01:18:29.056 smooth, I did have um some. Bottoming out on the patients,
01:18:29.065 --> 01:18:32.536 uh, they're very grateful, nice patients. They don't complain.
01:18:32.746 --> 01:18:36.346 That may be why the reoperation rates are a little bit lower on these patients.
01:18:36.386 --> 01:18:38.295 They're so they're like breast reconstruction patients.
01:18:38.306 --> 01:18:44.295 They're so happy to have something, but, um, I think going subfascial,
01:18:44.496 --> 01:18:48.576 not oversizing your implants, giving the patients reasonable expectations,
01:18:48.746 --> 01:18:50.815 and managing the fold is the whole key.
01:18:51.810 --> 01:18:55.060 Well, yeah, quick, quick question for Mark Pacifico.
01:18:55.680 --> 01:18:58.109 I think Murray's not, by the way, Washington.
01:18:58.520 --> 01:19:03.750 I think what gets some people into trouble when doing explantation and mastopexy is,
01:19:03.759 --> 01:19:07.720 uh, what to do around the nipple areolar complex because you're worried about the blood
01:19:07.720 --> 01:19:10.160 supply, especially if somebody's else done the operation.
01:19:10.520 --> 01:19:14.790 So do you just routinely deepithelialize? Do you score the dermis?
01:19:14.799 --> 01:19:19.350 Do you undermine the skin flaps in order to cinch down around the nipple?
01:19:19.520 --> 01:19:24.149 Just because of the blood supply issues, just wondering what your kind of approach is to that.
01:19:24.399 --> 01:19:27.479 Um, I don't. Can this microphone be turned on,
01:19:27.490 --> 01:19:30.279 please? Um, I don't undermine the skin.
01:19:30.330 --> 01:19:34.810 I'm not afraid if they've got decent thick tissue thickness of scoring the dermis for a
01:19:34.810 --> 01:19:37.959 better insect. If I'm, they're very thin tissueed,
01:19:38.049 --> 01:19:41.120 very mobile tissue, I will preserve the dermis, just to be cautious.
01:19:42.779 --> 01:19:44.450 Can I, can I have a follow up for Mark?
01:19:44.700 --> 01:19:45.810 Yeah, I wanna keep you busy.
01:19:46.459 --> 01:19:49.419 Um, so I, um.
01:19:50.620 --> 01:19:57.069 I mean, less and less do I do mastopexy at the time of implant removal.
01:19:57.970 --> 01:20:03.669 Um, and, and I'm just interested in your views, and, and two reasons.
01:20:04.209 --> 01:20:11.049 Um, first of all, you do get over a 6 month period, a degree of recovery once the implants
01:20:11.049 --> 01:20:14.080 removed. And, and I've, I've seen, you know,
01:20:14.450 --> 01:20:16.729 quite, quite significant recovery in terms of, you know,
01:20:16.810 --> 01:20:20.479 the, the, the implant's gone, the weight's gone, and there's a gradual sort of,
01:20:20.569 --> 01:20:23.399 uh, you know, back, you know, back up again and, and.
01:20:23.779 --> 01:20:27.250 And I've seen uh you know that there a few times.
01:20:27.459 --> 01:20:30.180 And then secondly, of course, uh, you alluded to it,
01:20:30.620 --> 01:20:32.220 it's much easier to plan.
01:20:32.640 --> 01:20:37.919 Um, you know, when you've taken the implant out, you know exactly what you've got left and what
01:20:37.919 --> 01:20:42.279 kind of masturb, and I slightly worry, particularly in the smaller breasts,
01:20:42.359 --> 01:20:48.359 is that we are committing people to more scarring than they might need by doing it as a
01:20:48.359 --> 01:20:49.839 one stage. Just, just a thought.
01:20:49.959 --> 01:20:52.020 No, I think you made really good points. I mean,
01:20:52.479 --> 01:20:56.129 life for all of us, I think would be much easier if every patient was happy for a two
01:20:56.129 --> 01:20:58.560 stage operation. I think that's the first thing to say.
01:20:58.990 --> 01:21:05.029 Few patients want 2 payments, 2 recoveries, so immediately that does limit things.
01:21:05.259 --> 01:21:07.939 But you're absolutely right, and we see this all the time with explantation,
01:21:08.000 --> 01:21:10.169 the way the breast does change over time.
01:21:10.379 --> 01:21:14.540 So if they're borderline, I would rather have a way forward with them and not commit them to
01:21:14.540 --> 01:21:15.819 the scars, I totally agree.
01:21:16.189 --> 01:21:19.290 Um, if they've already got the scars, cos they've previously had a mastopexy,
01:21:19.359 --> 01:21:22.069 then you're, you know, sort of it's the perfect crime in a way.
01:21:22.319 --> 01:21:28.819 Um, but if there's cleartosis or if it's going to be clear that they are highly likely to have
01:21:28.819 --> 01:21:31.790 a toic breast, then again, that makes it easier. But I,
01:21:31.879 --> 01:21:35.029 I agree with you, for the, particularly the borderline patients,
01:21:35.259 --> 01:21:40.589 I would encourage them to stage it in case that second stage is never needed.
01:21:41.149 --> 01:21:45.299 How do you determine, Mark, because the intramammary folds sometimes you have no idea
01:21:45.299 --> 01:21:49.040 where it is and it always reestablishes itself. That's where Patrick said,
01:21:49.100 --> 01:21:54.580 I've had patients where took the implant out they had a terrible inferior malposition and
01:21:54.580 --> 01:21:58.020 all of a sudden the the the fold has completely recreated.
01:21:58.220 --> 01:22:01.569 I've done mastopexy on those patients guests and like you said,
01:22:01.660 --> 01:22:06.259 and get some weird crease in the wrong spot. So how do you determine where you're going to
01:22:06.259 --> 01:22:08.490 put the fold? Well, I think that that's crucial.
01:22:08.580 --> 01:22:12.899 I think we, they've already got scars to start with, so you can access the implant through
01:22:12.899 --> 01:22:16.060 those scars. And then that's the point I was trying to make
01:22:16.060 --> 01:22:21.100 about being flexible and and open minded because you have to reassess the breast once
01:22:21.100 --> 01:22:25.310 the implant's out. And if I'm pretty sure that that patient will
01:22:25.310 --> 01:22:27.089 have a good result with the mastopexy.
01:22:27.680 --> 01:22:31.540 I won't do it, I'd rather come back to fight another day and deal with the patient rather
01:22:31.540 --> 01:22:33.569 than commit her to something that may be a mistake.
01:22:33.819 --> 01:22:38.029 But you're absolutely right, I, there are cases that totally throw you when you take the
01:22:38.029 --> 01:22:41.259 implant out and you see the anatomy is not what you predicted.
01:22:42.770 --> 01:22:46.200 Eric, hi Adel, I have a question for you.
01:22:46.490 --> 01:22:49.919 I enjoy very much your presentation and I really, uh,
01:22:49.930 --> 01:22:55.140 um, like the idea of stabilising the upper pole with your technique.
01:22:55.410 --> 01:22:59.479 My concern is about the elevation of the inframammary fall.
01:22:59.649 --> 01:23:05.009 I noticed that in some of your patients, the scar actually is not at the end in the
01:23:05.009 --> 01:23:07.720 intramammary fall. How often you need to revise that?
01:23:08.609 --> 01:23:11.689 Um, this is probably due to a, a miss.
01:23:12.299 --> 01:23:18.330 Means planning of the position of the IMF in some mess weight loss patients and we saw
01:23:18.330 --> 01:23:24.009 sometimes the layer sagging of the skin may may put the scar all over and other times the
01:23:24.009 --> 01:23:30.970 muscle, uh, might have a, a too white las link especially that post implants too
01:23:30.970 --> 01:23:35.129 high. Uh, and that can be corrected once the,
01:23:35.149 --> 01:23:36.660 the IMF is established.
01:23:36.970 --> 01:23:43.689 So raising IMF is something that we started from the way we do from zero and we got
01:23:43.689 --> 01:23:44.790 our learning curve.
01:23:45.310 --> 01:23:50.029 Now I would say that the technique is pretty pretty established and and I don't think that I
01:23:50.029 --> 01:23:56.149 don't think that in the future I'm gonna have much more of this mis positioning of this car,
01:23:56.189 --> 01:24:02.870 but this was part of our our learning curve to to really stabilise the the
01:24:02.870 --> 01:24:05.549 position of the MF and the this car at the same time.
01:24:06.830 --> 01:24:10.310 Good. Thank you.
01:24:10.319 --> 01:24:13.879 So yeah, we have another question there. It was a great panel,
01:24:14.379 --> 01:24:17.939 uh, congressional panel is uh I have a question to you,
01:24:17.950 --> 01:24:21.549 Roy. Uh, for patients in post-pyotic surgery,
01:24:21.700 --> 01:24:23.689 mastopex in this case are very hard.
01:24:24.140 --> 01:24:28.810 Uh, what's your approach to this case? You use a mesh for all these patients and what
01:24:28.810 --> 01:24:33.589 you do. Usually I was also the implants because quite
01:24:33.589 --> 01:24:40.549 often the the the the the pocket is so large, the amount of skin is so wide that it's not
01:24:40.549 --> 01:24:45.620 enough just to to reshape the skin that you have and to use the the the tissue is very
01:24:45.620 --> 01:24:51.134 atrophic then I, I. Use the implant I use the mesh,
01:24:51.234 --> 01:24:53.944 but sometimes I use another technique in a different way.
01:24:54.194 --> 01:24:59.115 I use something as an ammo just to keep the implant in position because the quality of the
01:24:59.115 --> 01:25:04.504 tissue is very poor and then I try to avoid the implant goes down and having a bottom out.
01:25:05.140 --> 01:25:07.430 I described this tech this technique as a balcony.
01:25:07.600 --> 01:25:11.259 I use a dermal flap, sorry, not a dermo flap, a choro flap,
01:25:11.560 --> 01:25:16.089 uh, um, removing the, the, the dermis, uh, like an MO to,
01:25:16.169 --> 01:25:19.919 to keep the, uh, implant in position, and then I, I re-draped the skin.
01:25:21.359 --> 01:25:23.790 We've, we've got time for one more question.
01:25:24.390 --> 01:25:26.790 Oh there we go. Hi, it's Andreas from London.
01:25:27.000 --> 01:25:29.680 Uh, it's Mark, um, and thanks for your presentation.
01:25:29.759 --> 01:25:32.080 I've got a question about how you counsel your patients.
01:25:32.120 --> 01:25:36.759 Obviously there's going to be a dramatic change after the implant is removed and you've already
01:25:36.759 --> 01:25:40.169 mentioned the unpredictability of the result.
01:25:40.879 --> 01:25:43.439 How much time do you spend with them? What things do you discuss?
01:25:43.520 --> 01:25:47.250 Do you use any adjus, any imaging or 3D kind of.
01:25:48.140 --> 01:25:50.689 AI to, to show them what the result will look like.
01:25:51.060 --> 01:25:53.410 Um, so it, it's difficult.
01:25:53.700 --> 01:25:57.970 We have a consultation process, so I will have two consultations with the patient.
01:25:58.180 --> 01:26:01.370 My nurses will always have a separate consultation with the patient as well.
01:26:01.859 --> 01:26:08.669 Um, I will show them many examples, and I think what I found most helpful is just
01:26:08.669 --> 01:26:12.950 that simple, um, examination with the benefit of the mirror to show them,
01:26:13.100 --> 01:26:14.700 and I find it kind of surprising.
01:26:15.209 --> 01:26:20.290 How few patients are, have a concept of what part, how much of their breast is implanted and
01:26:20.290 --> 01:26:24.290 how much of their breast is breast. So simply by doing that manoeuvre and giving
01:26:24.290 --> 01:26:27.330 them a, it's a guesstimate of what percentage it is,
01:26:27.439 --> 01:26:32.640 I, I find that the most powerful, helpful, reliable thing to do with the patient.
01:26:32.770 --> 01:26:37.700 And then I can say right, let's look at some other patients examples with a similar
01:26:37.700 --> 01:26:40.850 proportion of uh implant to breast ratio as you have.
01:26:42.419 --> 01:26:46.450 Thank you very much to all of our panellists, wrapping up a great session,
01:26:46.819 --> 01:26:48.910 great questions, keep it going.
01:26:49.299 --> 01:26:51.049 Have a good lunch, and good lunch.